HOWTO IJSET}IIS BOOK

CqW 'C*gW" and Molcr traruting a triloull, be,. Ead, branl u und ,*fpd tnto {ru,, ,{hfk, algo,tilro,t *d drgr^t b Mo*o tr ortt fu g*b rytrusto ulroh bwdo in o watu ,{ lrw!
Tk
B*k, a daEndb
Tfio,ol a buulo

,{

Cpeml All,-ou

{r{ln*g

pnda

bwda

nfla

boolo,

ululo

ui,U ,rrako go,n

tttfu ilrirenbfiota/,get ..

TWEET W 6EBNA
T,rtefi of ln{o,w,oto"frotgow uag tiltlt fuing fufuug Ao b,ura/+, Ahng

u&,tow irqata$poofr frr"to lfiCQt AA frgilrrh i* o auph ,{ poput!!

KEYC TO CACEC 6,nl to tdu ol upafot$ Cliraul cata, ulatgou platfll

uu/tc h4N atout?n/t uto
iro

o {eil

uoqA

QUECTIOI/ BANK QUt u {,rr* p,,uarrl erurrl attwgd ad cafrgaizd auddtug bto u$ufb gi@ lotr on arurab ttatutnb
dnin gow

alfrfiffi b f,o upotafi

d *pfu

qutou.

TAKE YOUP NOTEC lfgr* fnd bto dra uhuatu,* ueAl, 0, *! Addtr"rtrru!!

ORTHOPEDICS

.
.

. Uppor thb . Lmr Lfunb . Bone Defiomrilies . Bone inf,srnmglions . Bonc furnoE
.

Oenoml schsno frcalmenl & Complioefions ol Fracfures

I v
2t;

gt
38 42
47

26

fwe,is, Cesee, Queetlon Benk, ilotos

UROSURGERY . fumo[t

. .

lnjurloe lnf,anrmslions

. Obslruolh/r Umpathg . Cor{Fnital anomalee . Teslis . Iweele, Cs.6, Queclim Bark, I{olog NEUROSURGERY . Heed injuries . Periphoral llowe inJurirr . OiC9. 0ku[ ]romstome . fumorc . heolurc spine, &ein abscess. Spine biftde,
.
Dlec Prohpee, Cqwrhous dnus lh fursel$, Cesss. Qusfiotr Bank, iloilee

r ebrres

5t

BI
6{)

BI
68

,6

82 88
96
97

PIASTIC gURGERY . Bulhs . 8&in closurc . 8kin. 8C lesions. go0 {lssue sarcoma . Aeslho{lc surlgorg,Bed sores . Ptgmenled skin lecions . Non-Melanotic skh fumors . fo4gue Ulcers. Cancer lotgpe . &mlhq6rs of the jaw . Clsh hp, Clef, palaile . Miece[arreous lopics . Iurests. Casec, Queslion Bank, lloles CARDIOTHORACIC SURGERY . Carfrac ansst . Fmcturee ilbs . hsrmolhorex, Hernolhomx. Empgenra . Posl-operetive pulmonarg compftcalions . Tweets, Casec, Queelion Bar*, lloles PEDIATRIC SUROERY

r(x) tr3

ll4
tl5

r8
120

ll6

2n
tzs
124

t2s l3{,
r35 r36 r39

trxl
ut6

99

I(x'

@@
.) )t a
!

(.9
't.,a
l,

/:i
a

q(46 . .!

.,.

,t

J)

ilR4-1oq'15. )rlnopedk,

aury\

?I,QY

tt

Sne
TRAO'NIA

n{Cuenlde
DIRECT,!NDIRECT
POSITION OF DISTAL FRAGMENI IN RETATION IO PROXIMAL ONE.

SfiPrilis
O Historg of lrauma O Pain O Swelling O Disturbance Of
funclion (inabilitg to use lhe affected limb)

GENERAL

LOCAL

Hemorrhage

O Shock O Associaled injurg

Tenderness

O Specific sgmptoms
accordinp to fraclure

Crepilus
Temperalure (in

Neurovascular
t.l

(, o

Shock Fal embolism Complicalions of

Prolonged recumbencg

Skin

, Visceral .
.

Blood vessels
Nerve

.Ms&
Tendons

evalualion
Vessels Nerves
,

injurg injurg Joinls . Bones

lnfection, crush

INvESNqAflONS

X ras 3 i"'#:";"H::':iJJ"J""
Definitive

ABCD Resuscilation

O Reduclion O Fixalion O Rehabililalion O TTT of complicaiions

ilRq-4)Ar1.)r|Iapedtc,.ur,zry ?lGVt 1

PFE

Fnl}IAnl/ SecoXpan*f SSoR\rEtl SoR\rEy

RED',CTPN

FrxAiloN
OFEl.l

lzAiloN) mGp
/-)'+

ffi
&
TFEatrtrlEhtroF

6.oseo

PtAstER
OF PAFIS

r{oN-nGp
rnAcrtoN

CoMpueAiloi.ls

el<rrFNAT -rRem.fau

+ffisffi,,
@e
o
@

@ Failed closed reduclion Open fraclures (Cornpound) is

besl lrealed bg Open reduclion & Exlernal Skeletal fixalion

@ lnjurg of NVB @ Non-Union

,t
fr

PRIMARY SURVEY: ABCDE

SECONDARY SURVEY

.... Airwag, brea*hing, circulalion, Drugs, exposure : Head lo loe Exarn, AMFILE Hislorg , lnvesl'rgaiions (Angio ,Doppler)

REDOCf,IoN oFTl,lE
WAIT for

rnActt

RE,

*CP:6Ps

20

rninutes

* Complicalions :
tr Wet gangrene tr Compartmenlal $
No pulse
EXPLORE

Pulse relurns
DEAL WITH THE FRACIURE

E Volkman's ischemic
coniracture

&

DEAL

OPED.I
lrr'rgale wilh saline & Wound debridmenl

Ch.oGED

tr tr tr tr tr

Skin) MS.)

Excision of l-2cm Open lense fascia Mark wilh black silk Excision of dead Ms.

t{rt{ourrEAR
SPASIrl
I

ultnrrran
PANflAU

Fascia)

CotfntstoN
I

Coiln^ere
r)

Nerve)

Blood vessel

Deal as

Painting Or

Excision of the

--r-1 <t/2
with sulure* Proline
Repair

Repair in
obl"rgue manner

>t/2

Closed injurg with lear...

lnlra-arlerial
papaverine

coniused segmeni and

saphenous graft

circurnference circumference
II

freai

aS

2) Mobilize arterg 3) Cut branches 4) Saphenous vein graft

comprele

5UP$.-T1Arr. lr&toyedic,

ffi
MClosed injurg MNeuropraxia MAxonlemesis
I

)ur*.,

?tQY

t0

OF PERITI{ERAt
MNeurontemesis MOpen injurg or Closed with failure of recoverg MPalpable Neuroma,
Tinnel's sign

NBq'E II{J'N/
lrnprove funclion if Recoverg is impossible

I
MArlhrodesis MTendon lransplanl

MSplintage MExercise & Massage

M Eleclrotherapg M Proteclion of Skin

MAmputalion if severe

(lf injurg occurs

during operalion)
I

MNeurolgsis
M Division

/ /
,/

At lime of Wound repair: Approximale 2 ends of N. bg black silk sulure 3-4 weeks laler: 2 ends are cui & Exposed & Trirnrned Apposition of Nerve shealh Repair (Epi-neural, lnierfascicular )

of Un-imporlanl

branches

MTransposilion of N.
MNerve grafting

(Saphenous'N.9 Cable graft) M Fixalion in Plaslic Cast for 3

weeks

1,R{4-jI0U.1r. )rthoqedi c, )urbary

?AqV

tb

OF
MORBIDITY
GENERAL LOCAL

MORIALITY

' Shock , Embolisrn . lnfection

. Crush $ . Due to
Prolonged recumbencg

. Skin . Muscles& tendons . Blood vessels . Nerve injurg . Bones . Joints

5UPt+-Tw,t .)rfraye&c,

rurdtl

?AEV

TREAIMENI:

M As ang Polglrauma ... M TTT. of lhe cause M Forced alkaline diuresis

CRUSH INJURY, COMPARIEMENIAL
$

/
MYOGTOBINURIA

Fluid Mant Manniiol Vilan Vitamin K

ACREATININE IN BTOOD

M a g g g g

Marked osleoporosis & lhickening of sofl lissues due lo disuse atrophg or Sgmpalhelic overslimulalion Colle's fraclure, foll's fraclure , $caphoid bone fraclure Clinical piclure : Neurolic female) pain, swelling, sliffness, vasomolor changes X-rag Palchg osleoporosis, Glass app. Of bone

g
V

Deposilion of Ca*2 in sofl lissues lhal lnvolves Bone, Periosleum, Laceraled Muscle

After ELBOW INJURY

frealmenl

. .

Mechanism:

Ms. Laceralion) hemaloma) lransformed inlo bone

Massage

Osleoblasl invade

E !l

Prophglactic

Aclive

) Exercise ofjoinis from {irsl dag Hol wax, analgesics. sgmpalheclomg

& passive slrelching of joints) Traumalic ossiffcans

EI Trealmenl:

l) Prophglaclic)earlg reduclion of fraclures & avoid Massage 2) Active) lmmobilizalion & reseclion afler 6 monlhs

M Siles: fltlE . EEMOML HEAD > after hip dislocalion, Fraclure neck femur . CARPAL SCAPHOID . CARPAL LUNATE . TALUS ) dislocalion, fraclure dislocalion V X-ru1 > NORMAL earlg, appears afler 3 months M TTI : acc. fo sile: l) Femoral head ) Auslin moore head 2)Scaphoid ischemic Necrosis ) Vascularized grafl from {ibula

ARq--TWrr.}rfroydie,lurd;1ry ?l(*t

CoMruCtnorG
g g
lmpairmenl of circulation 2rg to APressure >3OmmHg
ETIOLOGY: size of comparlment

g g

Flexion conlracture due to {ibrosis of Flexor muscles

CTINICAL PICTURE :

SIIES:

. { ' 4 Conlenls

l)

lnabililg to fullg extend Fingers

2) Fixed lenglh phenomenon of fingers 3) Extension of meiacarpo-phargngeal joinls 4) Complete Claw hand 5) Weak hand grip
IREAIMENI
:

a) 4 compariments b) Forearm )Volar

c) Hand )

of Leg: Ant, Lal, Superf, deep poslerior , dorsal comp. lntrinsic compartmenl ....lhenar, hgpothenar ,

,r'

Porphglactic ) Rapid reduclion, avoid light casi, assessmenl o{ vascular condilion of limb

Aclive:

inlerossi, [umbricals )
CLINICAT PICTURE :

Abseni pulse COMPTICAIIONS:

tr E

a) Earlg <8hrs ) reduclion of fraclure + Vasodilalors b) lf cornpartmenlal $ )Remove casl + Fasciolomg

SEITERE pain

on PAgglVE exlension of di$ts

c) lf Late cases
lransfer

with Fibrosis) Phgsiotherapg & fendon

E /

Generd) Crush sgndrome Etr Local) Gangrene, Volkman's ischemio oonlracture

IREATMENT:

7/

Prophglaxis) Avoid tight casts

Aclnte) Decompression bg
fasciolomg & debridemenl

plG
ETIOLOGY:

ilRq-{C[t\5.

orll:6.pedre'

1uryry

?W |

ETIOTOGY:

.
Due

LOCAL: lnadequale Blood supplg, lnfeclion, Foreign bodg, Tgpe of bone

. .

lrnproper fixation Premalure removal of casl

TYPES:

lo

Presence of

GAP

Due

lo

Loss of blood supplg

GENEML: Age, Nulriiion, sgslemic illness, Drugs (Corlicosteroids) ORIHOPEDIC: lmproper reduclion, lmproper irnrnobilizalion

'. . . .

Angular

Rolaiional
Mal-union with shorlening Cosrnetic deforrnilg

CLINICAL PICIURE:

CLINICAL PICIURE:

Pain, swelling, dislurbance of funclion (persislenl tenderness, abnormal range

CLINICAT PICTURE: Pain

of mobilitg)
INVESTIGAIIONS:

. . .

lnlerference wilh funclion Osleoarlhritis of Nearbg Joinl

Swelling Dislurbance of funclion

COMPTICATIONS:

INVESTIGAT!ON8:

.
.

BONE

X-MY:

TREATMENI:

'

BONE $CAN:

Uptake in Hgperlrophic

IEIEIGIE
TREATMENT:

Correclion Osleolomg

tgPe Rigid fixalion Bone Grafl & Fixalion

TREATMENT:

'. Hgperlrophic)
Alrophic)

TTT.

of lhe cause

-p12stur",

Bone Fixation

5)Pq-10U\r.)rfno7ed'ic,

surd?\

?[,hY

tt

Site lncidence
Trauma

Junction bet medial %3

& laleral l/3

Irll
Fall on oulslrelched hand , Blow to clavicle MEDIAL FMGMENT: Pulled up bg sternomasloid LATEMT [f,AGMENT: Placed downwards bg weighl of the limb ,t t*tq;0 O

Displacemenl

Sgrnplorns
lnspeclion

As Genera! Scheme ... As Genera! Scheme+

ct)
L

Palpation Movemenl Neurovascular bundle

Broken displaced clavicle

cl)

.Ep

Claw hand + loss of sensalion of medial side of forearm medial ?Yz fin$ers

)Gp , Tl) )

Complications

As Scheme

* *

+ ...
X.RAY: Resuscilation

Mosl common: Rare ) Non-union ,Sfiffness, lniuru of NVB

ABCD

lnvesligalions

o
E

Definitive

fr

o o
Cornplications

lmmobilizalion + Follow up o{ radial pulse tr Child Figure of Bandage tr Adult Arm to Neck slinq n ORIF if Non-union, NVB iniurg , Pleural iniuru

) )

O O

Most common ioint dislocaled in bodu Cornmon in Adolescents & Uoung adulis

HUffirO"
TNAUMA
CEMENT
S

MORE COMMON Forcible abduction

INCIDENCE

&

Forcible abduclion

&

rotalion Mosl common displacemenl

rolalion Sub-acromial, Sub-spinous

As scheme...

o
OPl. holds injured limb al elbow bg
other hand, with upright OUpper limb is apDarenllu shorter
Head is oaloable anferiorlu
COMPETE TIMITATION

'YMP lrcpection

As scherne...
vi

E (f
ra Movemenl
tuyE

Axillaru ARIERY (6Psl .Fracture Grealer luberositg

.Roialor Cuff lear

abducl arm

COMPLICAT/oNS

inabilitg to

'
X-RAY:

- Due lo Bankart lesion - ITI : Bankart's ODeralion

,rt

yEsrr6qrroils

. A-P view )confirm dislocalion

Lateral View Anlerior dislocation ABCD + RESUSCIIATION

Defiditive

ABCD

RESUSCIIAIION

$t

fr
!)l

Reduction under G.A. ) Kocher's Method l) Outward iracfion 2) Exlernal rotalion 3) lnlernal rolalion & adduction lmmobilization (adduction, Int Rotation) Rehabililation Axillarg arterg, Nerve Fracture Grealer tuberositg Rolalor Cuff tear
Recurrence

$t

Reduciion:

l)

Adduction
External rolalion

2)
ru = ur

E
E
ffT-oF
Complicution*

1,P4-TW\5. )rltayedie,

tuwl

?P,{fi

t l"t

Slts

lmideae
frctrtllw

Dislal rnelaphusis above Condules Comrnonest elbow iniuru in Children

Oisplooaamt

Srrmatoms

As $cheme
As Scheme

lnr*ctqt
Palpottoa

,hiliD 4
rtlovcmcat

O 3 bong landmarks (medial ,laleral epicondgles, O Supra-condglar ridge is inlerrupted

Olecranon))A is NOI dislurbed

t/eurwoccuk,t bundh

O
O
Nerve injurg

Limited

)Gps
Median N (ape hand) . Ulnar N (Parlialclaw hand) , Radia! N

(Wrisl & Iinoer drcol

Conplkotiors
Acule ischemia (Anlerior lnleroseeus) Newe injurg) + ) (cubilus valgus leads lo Delaged Ulnar Neurilis ) Muosilis ossi{icans As Scherne
.F

hrasfio;fiont:X-rw
AECO

Oellalt&e

c,

q o

Closed Reduclion & fixalion E Above elbow splinl lor 3-4 weeks in Exlension posilion of elbow Radial pulsalion observalion throughout lhe rnaneuver Open reduclion is indicated in :

tr

Tff.6
Coarylieations

Adull fraclure , failure of closure. Failure of Closed Reduclion, NVB lnjury t{ Open Fraclure : E Exlernal skeletal fixalion " DunloD traclion" As scheme .

tr

5u?14.j{i0q.15.

)r&ayad,ic,lur6Qr\

?lQ7

t+

\, o

Direcl lraurna lo elbow

Ulna

migrates

+ Fall on

fraclure of

Ulna migrates

oulstrelched hand

Fraclure of

Trealrnent:

ORIF

freatrnenl: tr Reduclion under GA)Downwards & forwards traclion fr Fixalion with elbow casl for 3 weeks !1 Exercise for 3 weeks

lnferior Radio-ulnar joint dislocalion

OPEN REDUCTION, INTERNAT FIXATION

TTT:

I
T

Comrnon in adolescents Painful Pronalion &

&

Elderlg

of forearrn

t I

TTI

ORIF or excision

lJP$-:l?Arr.lrlhopadtc,

surbQ\ ?lQY r W
I inch above dislal
end of Radius

Postero-lat. Shifl & Tilt of dislal fraomenl

Exlra-arlicular fraclure, I inch above distal end of Radius

Fall on lhe Dalm of outstrelched hand

Posfero-laleral shift &

fi[

of Lower segmenl 4tt

)*

dtzu

As scheme ....

Loss of aclive movement, Painful passive movemenl

O
Campllwtlons

is affecled (Iested bg Median Nerve injurg ) Ape hand + sensoru loss MAI-UNlON, Carpal lunnel $, Sudek's atrophg

lesls (counting

deformilg= Ulnargrowlh > radial growth

lnvestlgatlons

//

X-RAY:
A-P VIEW: Lateral shift LAIEMT VIEW: Poslerior shift of distal fragment :: To Differenliate fiom Smilh fraclure ::

z/
Definltlve

tr

Closed Reduclion

l)

ABCD, Fesuscifaffon & Fixalion bg Cast for 4-6

weeks

2) 3) 4)

fraction of hand Counler lraclion of humerus

Push dislal fragment )Anleriorlg & Mediallg Cast is below elbow except if associaled with Fraclure ulna (above elbow)

tr Rehabililafion fr N. injurg , Arterg injutg B Sudek's afrophg ) Sgmpathectomg,

E
Runlure of lendon

splinting, analgesics. Phgsio Transfer of tendon

El TRAIIMA: Fall on
is Shifted Dista! IE: tr DIAGNOSIS: X-rag laleralview to differentiale frorn Colle's fracture TREATMENI: Reduction & fixalion bg above elbow casl for 6 weeks

tr tr

tr

ffiwlDpNe
Site

ilEq-T1qr, )rlhoTed'ic,aury\

?lQ7

tt"

Waist of scaphoid

l*ideme
Traumo
D/lrprorca;rana

Fallinq on oulslrelched hand

As scherne* ... Pain in wrisl , Palient can move his hand (no (ross imDairemenl)

SWfiotrs

lnswtkn
aa

Polfutioa
Movement

As scheme+ ...
m
X-rau:

ilw

Canrplkofiorn,s

of proximalfraemenl

hwestigotions:

M6
a,

ITffiEfiEEItrElG

Eesuscitor;ba

Drftrttive

Plasler of Paris for 6 weeks

Below elbow

tr

E J

E
Conplkotlons

*abducted thurnb lnlernal fixation wilh Herbert's screw fr Bone Arafl for necrosis

FRAC'IURE SSlUIFT OU{IE RADIOS

E Most common Complication tr III: Fasciotomg
,
is

(oF
for 6 weeks

PROOESS OF RADIOS
tr
TTT: Colle's Cast

BAF{rOD{,S FRrc']T'FEL
E lnlra-articular fracture of
Radius

BENNEt'S FRAC'IURE
El Fracture dislocalion of l8t melacarpal

ilRQ-TW.l, }rfr16.yed,ie, tu

BUTIERFTY FRACTURE
ETIOLOGY: Sudden violenl musoular conlraolion - SARIORIUS)Fraclure

with posterior displacement of

A.g.t.g.
-RECTUS FEMOR,IS' Fracture A.lnferior.l.S
DIAGNOSIS: - Hx of Trauma, Acute pain

-PT. CAN L]FT THE LEG.

g g

STA]IID ON IT

X-MY: Fraclure line

TREATMENI:

Resl, analgesics for 6 weeks

URO.GENIIAL

g @

VAGINAL
DRE:

lf Clear urine passed) [\lo lnjurg

NO Clear Urine, 9uspected urelhral injurg) Gentle

lf

g V

Large Hematoma palpable fraclure line

Do PV for associaled Vaginal injuries

Relrograde urethrographg

Visceral injurg: - lnlra-pelvic Urelhra - Exlra-periloneal bladder ruplure

- lnjurg of reclum, vagina - Refrc-periloneal hemaloma) Paralglic ileus

g V g g

CT gorn, rapid evalualion of head, chesl, abdomen, pelvis and for associaled

Sciatic lrl. injury DVI, Osleo-arthrilis

Pelvic Mal-union

SeoondargOsleo-arlhrilis

TrToF coi,lPtlcffiol.ls
MUB)
Closure of be waler tight Sulure lhen Foleg Calheler

MUrelhra) Suprapubic
cgsioslomg, Dilalalion

MReotum) Coloslomg

5RI+'T0qr5. lrllopad'ic,

5urry1ry ?W l

11

IPPTS
F>M , rl Child
ol'gohgdraminss ,i 6 riili l.gglli s3g breech iUjU EJJI Palhologg : Hgpoplasia of Hip joint

ti16!! ii

l;

}GONATES
g a
timilalion of abduclion in {lexion
Difficultg in applging Napkins
Asgmmeirical gluleal creases Gaift M lf Unilateral Trendlenberg's Gail er+tl

ffi&ADOLTS
g M
Delaged walking.

a g

Limitalion of abduclion in flexion Asgmmetrical gluteal creases

Gilor.qltil fEAnrotrrl t===Fr ==ii:=E===i Ihe hip subluxes On lrial lo reduce

hip, a CLUNK is
heard

M lf bilateral )

Waddling gair.unir+{

NEW BORN: Mosl are

sponlaneouslg correcled , so wail

oul of the

lill 3 weeks before inlervenlion, lf

acelabulum) ou\b*
0\ oo
e

failed)

R.educlion bg VON-

Ix

Jdl

ui

ote

CTUNK is heard ... ,;ili

lusl s

ulyr

ull\ Jc thumb
o[e

g 6 Months-6 Years: Reduclion in

g
Plasler cast wilh Maintained abduclion for 6 weeks >6 gears: Correclive osleolomu

ROSEN SPLINT

Hip ll

a\udl

\*

Jl

irrrJ\.rlo
dimri

.... Abduslion rhri s

trrltsal,>ill

aqcaNri DDH slis d

ord\ osil1liJ\ebisi

hDlio

nucaN\b
ounrLJ\

o$l\

il?$-:lC[hl, Orllaydic,

aurry4ry

ffic
Forcible abduction & Exlernal Rotalion of flexed hio At Obiurator foramen As Scheme... Traurna
Dash board

?t{fr t

to

PD
Obluralor N. injurg
Forcible flexion * adduction *lnlernal rolalion accidenf, Fall of heaw obiecl on back of sloDDine individual Ecialic or ischial Pain, swellinq. inabilitu lo walk or sland

Disolffieillent Svrndornr
lngpsctlon

t
Limb is anoarenllu Head mag be fell Loss of aclive

I
ilEil
6

LL is

Palpatlon

FEMORAT HEAD

tg FEII,

@EE@W lnjurg of Fernoral

& obturator
NVB

&

Passive

a g|
UI

PUTSE DUE TO BACKWARD DISPLACEMENI OF FEMORAT HEADI

EEEIE@I

(DtFFrculry Passive

ro

pArpArE FEMoML

il@ernent
NeurouarcuLr

Loss of aclive

&

bundle

E@qII * Molor )Foot drop * Sensorg )Back of fhigh + ) )

asDecl

Leg, fool excepi medial

As 8cheme...

Complicadons

General Shock , Prolonged recumbencg Local Ecialic N. injurg , Avascular neuosis, irreducibililg

r .

x-rau ) A-P + lateral Cf scan

sliffness

lnvertlgndons:

I@ ' 6tkffi

ii}|J e .igsJ

iidu,
lum, associated fraclures) ctures & Femoralhead

ABCD

& Resuscilalion

B R

IIffi'TI

Reduclion (as Post) Skin lraclion for 3 weeks bg

c It c
a

Definitive

fr

Alter care

Closed Reduction bg (lf failed or associaled fraclures ORIF ) !1 lmmobilization for 6 weeks Neurolopical assessment . earlu molion. Follow uo for 2 uears

[@

Compllcatons

m Sciatic N. iniuru

A,Rq''TC[f'lr.

)r&16.ped,i e,

tuwry

?tQY

tu

NEEKffi
i,g;frrl

ii.otniii
Basdl

Trochanteric

* lnler-trochanleric * Per-lrochanleric
*
Sub-trochanleric

rranslncornplele

TREATMENT:

ORIF >DHS

fraclure

I
TR.EAIMENI: Resl in bed

TREATMENT: A/ASCO[.{R,
lnlernal bg Moore

fixalion Pins

N*O$S
According To Age

Old
*

,+\

young!

TREATMENI: onre! ous

HEMI-ARTHROPTASW Ihompson , Auslin moore

ilRq-4w\r. lrllayepc, aur*,ry

?lQV

t tL

/ /

nler

No Rolalion Limb appears to be abducted

oqijl r,r,!ri gfu1 r iii a [6J lcr.a ii

TEST

Neurovascular bundle

EUI@

lnjurg .... "Scheme"

IM: Mlloilarr.l
IN IHE ISI S MONIHS

X_RAY

iioRElDrF/

A-P with internal rotalion bg l5o r-4g+uU o1g-o

qEl.lRAt
/
Mal-union

rocAt
INrTRA_CAI>

/ /
/

PROTONGED RECUMBENCY

DW, P.E
Osteoprosis Constipalion... lnleslinal obstruclion

/ /

Gron

BLooD

Avascular necrosis No -union

NVB

ffT:

Conservative

... Rgle, Line,Catheter,

Fluids, moniioring, Decompression of Colon

5UP4|-T00N5. Or{/rtoyed.ft,

ou

ry

?l$Y

t-1

Sle
Displace-

n
Scm below inlerlrochanleric line Abduction & Fixation (Glulei) Adduction

ffiFEhNOR ;{e';
Ir[i
tn belween Forward (quadriceps)
Backwards lHamstrinol As Scheme...

[smw.rT

Prox. Segmenl Dislal Segmenl Sgmploms

9crn above femoral condules

Forward (Quadriceps) Backwards (G.N.)

menl

&

Uowards (lleo-nsoas)

UENERAL

o
o0

LOCAT

TNSPECTION: Ecchgmosis, Bruises, swelling MOVEMENT: Diminished

cl,

* *

.r PALPATION: fenderness , eepilus

NEUROVASCUIAR BUNDLE: Femoral arlerg in Midshaft, Popliteal arlerg and nerve in Supra-condglar

Complications
As Scherne

...

o o o o o o
ORIF

Prolonged recumbencg
NVB

Mgossitis ossificans Sliffness of KNEE

X-tett
ABCD

lnveslipations

De{inilive

&

o
E

lnlerlocking nail

;i[Lll r,rnrr;-lt
!1 Newborn) Crede's method tsHJ

&

Resusci{alion

!i lnfant)
!R

[tk!

ORIF ) !nlerlocking nail

Gallow's iracfion

o o 3F
Complicalions

Child) Reduclion & fixalion bg fhomas

splint

9l

Adult) ORIF& lnferlockino

Nail

Mal-union , Non-union, lnfections

m/s

DEFINIIION: Fraclure lower end

of tibia& {ibula involving the ankle ioint

'Jr

=:\\

TMNSVEREE AVUISION OF

t- + ...
oBUOUE AVULSTON

MAHFSIil{f +
DISPIICEMENI

[fifitltr

oBrcFuffiffiiloN
MAr#F$filts +
DISPTACEMENT OF

OFEEIEITE

DIBPI.ACEMENT OF

'tffiffi
IAIUg

IALUS

TREANIE}.TT
lf Polg-lraumalized) ABCD, R&M FIRST AtD) Trial of reduction for displaced fracturee
Definitive TTT:

lf Slable ) Below knee plasler casl for 6 weeks lf Unstable )ORIF bg Screw lur-i [5J;lor.,n

of grcaler lroohanler.

,ol,*-rh#

M
!f

TOPICS

offi

supine position, a perpendioular line is dropped lrom each ASl8. Anolher perpendicular line is drawn from lhe grealer lrochanler lo lhe lt is ueed lo access lrochanleric

lsl

line.

MENISCUS INJURY

girii!
Xii-f*".

at !{J

O Trauma : twisling slrain on llexed knee O Pt. can walk home, O/E : effusion,

INJURY TO THE CRUCIATE TIGAMENT

o@,

knee is rotaled in {lexion

Arthroplaetg " dialnoslic, lhempeulio" O freatmenl : Coneervalive , unless surgerg is indioated) Meniseolomg

Most common complloellone le Comparlmental $ :Faeolotomg)

()Ifi

pNe
Congenilal (Vertical Talius),
i

5UR*-+nA't,

)r&lr.pedte,luryry

?lQY

t Lb

Bilateral

>

unilaleral

o
TTI : soft lissue- wedge Tarsectorng
Tali:Tarsa-rwe

"af'
Pao, .o r

t Il Uirg

Varus:

"Plant ar fle*clan" E4ulnes. Ankle "ioinF

latjoint
Foob"

'nlnvetsbnof

TTT: excision

of Base of Proximal phalgnx

O X-rag :

. .

AP

view) lflt@Cab"nea! Angle Deueased

:

Laleralview) [l[t@calcaneal angle is @[[tr dislallo proximal

Plaster of Paris Ar Nighr
:

Trealmenl

n
vALqOi.n
(r<r{ocrrcr{re)

MANUAL REDUCTION from

VAFoi.n
(Eo$rIECS)

fr MAINIENANCE bg : adhesive strapping * fr AVorD REoURRENcE) @

. . .

until lhe age of 2 gears O Surgical treatmenl if resislanl a$er 2 Uears, or relapsing
Posleromedial release incision in soft iissue(<2gears) Bone reshaping (2-lO gears)

Arthrodesis

( >10 gears)

ilP{4-jtC[/,\r. )rlhoyad,ic,

surbQ\

?l{+

DEFINITION:

Acule nonspeci{ic inflammation of cancellous lissue of bone & ils medullarg cavitg INCIDENCE: Male, Child, Low social class JLr.jJl gLf!
ETIOLOGY:

, . .

Organisrn: Slaph.aureus Roule: Blood PDF: General , Local

PAIHOLOGY: SITE:

. .

Which bone?! ... Around lhe knee, awag from lhe elbow Where in bone ?! ... Metaphgsis

PATHOGENESIS:

lnlerosseous Abscess: ( Sub-periosleal, in medullarg cavitg) Sequeslrum formalion, lnvolcrum, Cloaca lnlerosseous Hemaloma
gYMPTOMg
General Local FAHM

&

CTINICAL P!CTURE:
stoNs
Fever. fachucardia

O lnsDeclion: Swelling O Palpalion: localized lendernese over lhe bone Sgmpalfietio e$ueion of ltre adjaoent joint

Percussion: O Movemenl: Loss of aclive movemenl

(DD: Cellulilis)

+ +

IDD: Seolic Arthrifis

COMPTICATIONS: . General: foxemia, Sepficemia, Pgemia (tF TMMUNOOOMPROMIZED) . Local: Chronicilg, Ar.thrifis, VBone growlh, Pathologioal fraolure INVE$TIGATIONS:

@ @ @

CBC, EgR, CRP

Blood Culture al lime of fever

MEIIIIIEEIIL

CT scan abscess,

@ U$)sub-periosleal

joinl effusion,

U/8 guided aspiralion

@ X-raq) NEGAIIVE< 2 weeks

ilRq

Rest, analgesics, aniipgreiics, anlibiotics

. Failed Medical TTT.> 48 hours . Lale presentalion . Abscess . Drainage of subperiosleal abscess

lndicalions:

Afler 48 hours Decide conlinuilu of medical TTT. According lo

imDrovement

Anlibiolics for

4-6 weeks

j Trealrnenl

t+

i i i i

tt ,l
zr

Saucerizalion Sequeslrectomg Sinusectomu Bone Grafl

Jr+.lor! e1 c.F,_*J*- py- Jf r,lt ;jhyt oitU a,Jl... e:t :" Glr eJl .:" C-. :-,-4s
"1"

dt

k lc j95to 4jl JGi,i9

Bone Sclerosis

&

Gi,iuJl abscess cavilg

. Trealmenl:

Saucerizalion &

5UP4'TW'lr. )rfnoTadb

rvryz\

?r,q9

10

I
,( /
lncidence
:

Eliologg:

O Organism : Staph, strept. + O PDF : General (Sepfic focus , low immunilg) , O Roule:

Local (frauma

. .

Blood

Direct: Penetralint trauma

Clinical piclure :

O O

Swelling Dislurbance

of

O O O

lnspeclion: 9welling Palpalion: Hotness, Tenderness

Movemenl:

funclion

//

Diagnosis :

Laboralorg:

4ItC, 4ESR,

CRP

o
O

X-rag: Sofl tissue shadow + VJf.

U/S: Effusion

Space

z/ Treafmenl(ll'sa

B E

):

General: Rest, analgesics, antipgretics, anliblol'rcs

Local:

2) If eroded Cafiilage ) Arlhrolomg & fraclion 3) lf Complelelg separaled Cafiilage ) Arlhrodesis

l)

Washout o{ infecled joint

/ Lhant, / ii.obtt, / Hlplolnt, VerAebrae

STTESrcRTB
11[fu: Spine

ffi

5'Pt4

?AQV

\\

t 1t

ETIOLOGY:

PATHOTOGY:

ORGANI$M: Mgcobaclerium Tuberculosis ROUIE:

SITE:

MACROSCOPIC:

. MOST COMMON SITE

MICROSCOPIC: TUBERCLES:

2RY BLOOD BORNE

FROM LUNG TB
PDF:

Ig DORSO-LUMBAR SPINE
. AFFECIS ADJACENT
PARTS OF THE BODIES OF VERTEBME WITH THEIR DISCS

. Verlebral bodg is deslroged, replaced

bg casseous malerial . Deslruclion of disc

l- Epilheloid cells 2- Giant cells

3Surrounded bg

. Collapse of lhe
veriebrae

lmmuno-suppression

&

Lgmphocgles Fibroblasts

MORE COMMON IN CHITDREN PEAK <5 YEARS

chrNtcAl-Plcrrrne
GENERAL) TB Toxernia

Clinical piclure of Primarg Focus (e"g.

T.AEORATOF!/
& CI Scan, MRI

CBC)

Leukopenia
,

X-rag:

wilh relative

l)
2) 3)

Earlg

Osleoprosis Destruction of vertebral bodies

Arnalgamaled

* *
.t

lgmphocgfosis
ESR

> t00

Tuberculin *ve Spulum cullure on

Lowenslein Jensen rnedia, PCR

intervertebral

4)

discs Kgphosis

5URfl-100N5.)rtlaydiv

CoMrutcffiol.ls oF Furr' s
Abscess collecls under anl. Long. Ligamenl infronl of verlebral bodg

DW

lvrdz\

?hW

1t-

* *

t
Cervical region )Relrophargngeal Thoracic region)Passes lnlercostal spaces & Out from Laleral or medial perforalor Lumbar Psoas abscess

I I

R,EVERSIBIE

le

OCCUR MORE WITH THE

ossEus wPE
IN THORACIC
REGION

OFFOIt'SOISEASE
* *
Sanalorial

Anli-luberculous for 9 months: O Rifampicin + INH +Ethambutol for 2 monlhs O Rifampicin + INH for the resl of course

* *

PA\AI{fG|IA
Aspiralion bg Z-lech

l)

Open drainage :

Chest) Coslo-lransverseclomg
approach

lqlq

Earlu : Arthrodesis Conservative TTT for bed-ridden Pts.

2) Abdomen) Anterior

Er{effiOnS
* Osleoclaslorna * * *
Corrunur

ilRq--fC0), lrlhopedic,1vrffry ?W t

(Giant cell tumor) Osieosarcorna Ewing furnor Multiple Mgeloma

is!s!

of Bone

Epiphgsis) Osleoclasloma (Giant cell lurnor)

ttlhst Gorunm O ln Clfl&en)oeteosarcorna O ln Adr$s ) MullQle mgelorna

leq-'Twrr. orllaydie, rurd.ry

?wt

++

o)
O X-rag:

ttlas u" singl" or pa* of

Der (

@f,1[li$!
noc)

osis )

"Bong projeclion wilh carlilaglinous oapsule"

Mefaphgsis of Upper Humerus or Femur Cgsi : filled wifh Slraw colored fluid

TTT: Excision

Site)Pelvis. ribs, proximal long bones

X-rag) Fluffg calcilicalion

ITT

Surgerg (Resislant lo radio, & Chemo)

OCenlral lumor
OENCHONDROMA OF SHORI BONES OF CHITDREN NEVER IURN MATIGNANI

SUEhl-+0A,r5. )rllaTedic,

1ury1ry

?hhY

ffi

Incidence & Age

ffi

2O-4tJ.lemale

ffi.I^ f1 mffrfl,
. ,

Mosl common primarg lumor in children

On lop of PAGET' Dis. Of Bones

fflI iN [Efinr^ F-,=

Mosl common in Age : 5-15 gears

SSllailpn$aagpjtl I

Sile

Around Knee.... , awag from elbow

tflilitEls

8O7o Long bone 8O7o around Knee

$OYO

.
tr

of Long bones . EUEEEE Flal bones

Round cell (BM reliculocules)

IIIEilIIITEIE

(,

Cell of orilin

o J o

Macroscopic Micrcscopic
Spread

UNKOWN, thou{hl lo be Osieolulic brown, areas of Hemorrhage , necrosis

Osleoblasls Purelg osleoblaslic (45%) or ourelu Osleolulic l3OT"l Malignant osteoblasls

...... Soft, gragish . brain

like lissue

Mulli-nuclealed $anl cells

ps
. .

...... Rosefte
Direcl
Blood

shaped cells

lIIgiultgiulgl4uI

. lnvades Corlex) Phanlom . Raise oeriosleum

clo
I
a a

Direcl, Blood, Lgmph Direcl: invades medullarg cavitg (NO plug)

bone

. EEIIIIEIIE
gwellinA

Similar Slowlu nmorcssive swellino Globular

I

lo C/P of acute Osleomgelilis... wilh Conslitutional sgmploms " FAHM"

Swellinp

lnspeclion

o o = 9 F
<,

Palpalion
LNg

+lil..lil

ilI|l

slrelched skin
ht

Urt l i( t
RARE

tcl-g

liLgrl It lII

Lale swellino + dilaled veins LNs Bone swellinA

Coneesled skin

9wellino

LNs

+ve

COMMON

Diagnosis

r)

X-rag : Eccenlric lumor

Thin Bioosu

2l st
SiapinE Pre-op
TREATMENT

@cortex +

l)

X-rag
ill-de{ined deslruclive lesion

X-rcg

l-

medullarg plug

o = u
z.

,/
cxR, cT

2) 3)
Bioosu

2cxR. u/s

Biopsg

cxR, u/s
As Osleo-sarcoma... Chemolherapg

g
V

. .

lmporlanl bone

,:t<rli,
:

Orpan profile (CBC, KFt, LFI ) g Operable) Ampulaliont Chemolherapg g lnoperable) Palliative chemo

Cure+lage Grafl Excision re-consfruclion Un-imporlanl) excision wilh safelg mar$n lnaccessible) Radiolherapg

M M M

Pre-operalive chemolherapg Excision * Mioo-vascular grafl from {ibula& radius

Posl-oDeralivechemolheraDu

E E M

lrradialion
Surgerg:

Ampulalion
Excision & Proslhetic replacemenl

ilPq-{C[l)r.

Orlnoped'i c,

turff\

?t$V

t tu

2/3:
Sile
lncidence

Cancer Proslate, Cancer Breast

iil-:IifUEEIiIilW;
I

l/3:
) )
U

Olhers (Thgroid, lung ,GlT, kidnegs)

MI|LTI{f]

Wr}U UIrUtCil IrlI

Roule of spread

Sgslemic lnvasion

) )

fissues which drain into SVC,IVC

Trunk bones , root bones lI {l]tl I I tl I rtrfrl n Hearl & Lung) peneirale capillaries) Sgslemic cir.culalion

.l Direct) pelvic venous plexus & verlebral veins

t
Sgmploms

3{lh\I

Tumors of reclum spread inlo Pelvic bones

{t{llillrtrl!!&"r
Proslale
:

il3{8rvrflgtr*&"ffi$$6fi
Breasl )Painless breasl lump

Pain: Swelling

fifp@ff

Frequencg , Difficultg, Sexual

Dislurbance of funclion ,r/ Pathological fraclure

,r/

/
General

Hgpercalcemia 9pread to olher fissue : hemoptgsis ...elc siqns of Drimaru lumor Cachexia Redness & Swellino Holness, tenderness lirniled ranoe of mobilitu

o
.90

lnspeclion
PalDalion Movemenl
NVB

cl,

Accordin( lo the sile...

Palin X-rag:

lnvesligalions

Osteolglic ... but ( Osteogenic) in Cancer Proslale ) Bone scan (I0'ge)) Hol spols (ro diff. frorn M.M.)
Trealmenl

Breasl : Mammographg, US, FNABC Prostale: IRUS, Acid phosphatase

tr tr

Palliative Radiotherapg Palliative Chemotherapg Trealmenl of Hgpercalcemia : Loop diuretics, Bisphosphonales

lV,-i prqJl) Ereast cancerTnormonal,cnemorneraPu +railaflve N Proslale cancer)Hormonal lherapg + Palliative TURP
PALLIATIVE TREATMENI (staoe

ilRq4Wti

)rlhopedic,

turffry

?l,hV

17

MtLm-e
Age

& sex: Mosl commonlg in Old age

oroD 1.p
C?9

.....

orir jgfr rhlt

Bones wilh hematopoietic BM : O Spine O Skul! O Ribs, slernurn

Clintcatpinwe

Marrow sDace is replaced bu diffuse Qelalinous Red lissue Sheels of olasma cells of malipnanl characlers Wide E Pain " Backache" tr Pathological fraclure

Paraplegia

tr Pallor .... Anernia tr Weighf Ioss, infeclions

E Hgpercalcernia...
Weakness, faligue,

Normocgtic, normochromic anernia mm/l*t hr. 2) 3)Monoclonal Garnmopathg 4) Hgpercalernia

l)

Treatment

M Pallialive Chemotherapg "Prednisolone + Malphalan " M Spinal de-compression M BM lransplanl EI Bisphosphonales ..... for hgpercalcernia M ITT of anemia

ffi'sDw
Definilion:
Incidence

il?14-{0Nr.)rthopeile,

iuw\

?lQV

qe

M Avascular Necrosis of Femoral head u.ito guipl 1'ril+l{ rr-il JgJl gl ii l'(rirol! gru ,",.il guipl t n,! t r ..lii,! | 6JJt ii o.! I rr Il #.JJl .-i Ul+ri g #.JJl ,--s GIS ffo rrjirir=pr

& Etiologg:
Unilaleral

V 90%

M Male Child (5-12 gears) niili JsJrJ-ri us M Recenllg : mag be due lo ihrornbophilia

*+

ul+ilg.litdl,..p pi

Pathologg:
M Site ) Hip joint M Stages : l) Stage I : r-rgall ischemia, bone dealh 2) Stage ll 3 r"rr!ll revascularization & repair 3) Slage lll : urli.tl Disiortion & rernodeling

clo:

V Pain in hip ... referred to knee M Mag lasl for 4 hrs after inactivilg .. resolve and then relurn at night M Pain mag be sornelimes in lhe unaffected limb ln,ilr.'l'iitloUl

lnvesligations:
M plain x-rag & aspiralion of abscess (if there's seplic arthritis)

Trealrnent:
M Most cases (75%) resolve sponlaneouslg within 2 gears M Non-surgical ) rninimize rnovemenl * fxalion bg abduciion brace M Surgical ) IENOTOMY, OSTEOTOMY

il84-10\'15. )r&aped,1, lury\

?lhY

' , .

Sure signs of fraciure: Deformitg, length discrepancg, Crepilus, Abnormal movement fhere is 2 tgpes of open{compound } fraclure: lrg {the lraurna from oulside cut the skin ihen fraclure the bone),2rg {lhe lrauma frorn inside ,bone fragmenl causes skin injurg) The main complicalion of open fraclure is
INFECTION

Grade l: low energg ,wound<lcm in length Grade 2:wound> lcrn in lenglh GradeS :h'rgh energg wound with exlensive lissue damage 3A:Adequale sofl lissue loss 3B:Extensive sofl tissue loss and bone damage

' . . ' .

3C: Associaled wilh arlerial injurg common joint in the bodg lo be dislocaled due to:l-Shallowglenoid cavitg & large head of humerus 2-wide range of mobilitg 3-lax capsule &weak ligamenl fhe commonest fraclure of lhe scapula involve the neck or the bodg of lhe bone Fraclure surgical neck humerus usuallg occur in elderlg palienl associaled wilh osteoporosis and ils most imporlanl complicalion is axillarg nerve injurg Blood supplg of femur head &neck:
Shoulder

! n n

joint is the rnosl

I.

Exircapsular arlerial ring

2- Relinacular arlelg 3- Arterg of ligamenlurn teres 4- Nutrilional arlerg

One of lhe mosl imporlanl complications of fraclure both leg bones is compartmenial sgndrome

il?+'T1qrr. lrfrapedic, rury\

?hh9

t *0

SURGI-

bhae/

5UP4-10q:\r.

Uro' eurgzry

?lQV

+L

URIWTRACI
. REIIALTUI,IORS
TUTIIORS

;:l [ir t;1

"Did you srvitch nry apple juice tvith a urine sarnple again?

turyery VhY 1 +1 PR$ilAFT' PAFEhICLIIhiAL REhIALTUWIONS

cilRq4W:rr. Uro-

lilr,v,ISEiII^
lncidence & Palhologg r

fTg/E-nEfliY.X^llff-{a,C
Mosl common lumor of Renal parenchgma 175%, Age:50-70 gears) Carried on chromoeome 3

,lO7o ol Childhood malignancg (3-4 gears)

Sile :
Macroscopic

. Carried on Chromosome ll . 80% Differentiated s-to% BI.ATEML

2%

BII.ATERAT

Slar shaped mass, wilh areas of

Hemorrhage, necrosis

Microscopic
Spread

EI Grauish, pinkish white in color . Mixed: Epilhelial & Conneclive lissues . ORIGIN: Embruonic lumor tr Mainlg BLOOD lo lung) CANIIION BALL
EI

Mass wilh infiltralive edge, areas of hemorrhage, neorcsis EI Golden uellow in color . Adenooarcinoma . ORIGIN: PROXMAL CONVULUIED TUBUIES Lgmphalic) Para-aorlic

tr

Olhers:
Direcl Lgmphatic (Uncommon)

tr

BrooD
.Lung (CANNON BALL)
. Liver

Para-aorlic..l.r9l

.To renal veins & IVC (FllrlGER lN OtoVEEl

Palienl

Child,

uears

Male, >4O qears

tlnusual presenlalion : 2 El Fever o{ Unknown orign (FUO) E Unexplained loss of appelile & weighl

tr tr E

Pain is lale

(40%)

(Stretch of capsule, Passage of Blood Clot, lnliltmtion of adjacenl lumbar N.)

E Hemaluria) Late, bad prognosis

*E PE

Para-malignanl $ tf bilateral) uremia

Abdominal swelling (30%) Para malignanl $ (Hgpercalcemia, polgcalhemia, amgloidosis) N.B.

lnvesligalions

//

FOR DIAGNOSIS:

// //
Trealmenl

tr

spider leg appearance (elongaled & displaced Pelvi-calgceal sgslem IVU In RCC) DEAD (Dilared, elongaled, ampulaled, dislorted) FOR 9TAGING) CHEST X-RAY (CANNON BALL) , Bone scan , U/B PRE-OPEMIIVE INVESIIGATIONS) CBC, KFI, tFI tr OPERABTE TUMOR: OPEMBLE IUMOR: Radical Nephreclomg folal radical hephrec'lomU (Trans-periloneal approach) II'IOPEMBLE IUMOR: posl-operalive lnlerleukin-2 PreoDeralive ChemolheraDu (Io thrink lumor lo be removed tr INOPEMBTE IUMOR: Remenanl of iumor is marked bg clips to Pallialive Nephreclomg IVU

o o

U/S (shows renal mass) & SPIML CT & Guided biopsg

facililale Posl-ooeralive radiolheraDul

Posl-oDerativelg: lf NO residual lumor Adjuvanl Chemolherapg (Aclinomgcin D, Vinoistine) lf lhere's Residual lumor Posl-operalive radiolherapg

. . .

lnlerfercn lnlerleukin-2

M
M M
PAfHOLOGY

lrrilalion bg Bilharzial ovum or slone

Chronic inflammalion bg EColi Pre-cancerous lesions: Brunn's nesls, Cgslilis Cgslica, Poslerior & latera! wall

@ Chemical

g
V

irrilalion bg smoking, chemotherapg lnduslrial Aniline dge

Genelic:
RAS, C-erb B,2, P-53 (lifraumini's $)

.
.

. .
.

Ul&

Fungaling, ulcerative, in{iltrative

Cell nests

ffi!$

IRIGONE Papillarg, ulceralive, nodule Superficial 1757o), Muscle lnvasive

'l9llg: SCC)
Etr Direcl

tr tr
CLINc/,L PEruNE

...

nearbg organs

Blood ... BtBt Lgmphatic ... DELAYED in SCC

clo: EI Painless lerminal hematuria (ln SCC)Hematuria is Painful) M Necroluria M Frequencg, dgsuria ..... ( tn CIS) Malignant cgslitis) El ABNORMATTY ..... Recurtent allacks of UI!, Retenlion
o/E:
General s'rgns Signs of Malignancg (cachexia, anemia, Metaslasis) Looal siQhs) Bimanual examination under GA (To assess local DIAGNOSIS: Cgslo-urethroscopg & Mulflple biopsies 2) IVU lrregulailg lilling defect ..... (if # Ascending Cusrographg) 3) U/S, Cf , Urine analgsis for cause z/ $TAGING: CXR, Bone scan PREOLERAJIVE CBC, ECG. KFT, TFT... CHEMORESISIENI, SUPERFICIAL BTADDER CANCER RADIORESISIENTI IMNS-UREIHML RESECIION Radical Cgsteclomg + MULIIPLE BIOPSIES Permanenl urinarg diversion lf Grade ll, It!, CIS) lnlravesical

EI

lfives'l8atlons

l)

//
Trcafinant

. .

chemofherapg, lmmunofherapg lf Reourrenl, Persistent CIS) Radical ogsleclomg MUSCLE INVASION BTADDER CANCER . Radical cgsteclomg (Wilh removal of the urelhra)

. .

Radiotherapg

Chemoiherapg (MVAC)

Noturr
Etiology

aiffiry
Beniqn

MaliQnanl

UNKOWN... Mag be due to

RE!-ATIVE

4Esfroeen level
Male

UNKOWN.. *ve Familg Historg, Fatlg meals, Black races

Faticnt
rihe
I I

a a

> GOuears Pathology IZ (Peri-urethral glands)) tAIEMt lobe

Posterior Lobe

CZ (Sub-ceMcal qlands)) MIDDIE lobe Yellowish Fibrous lrabeculae dividing il into lobules NO gilttg sensalion .... Diff. from cancer

) *

Ouler zone

. . .

GraUish

ln{illrative Mass
nectosis

Hge

&

GRITTY SENSAIION .

Aiict+
scqpir

ADENOCARCINOMA

(dried proslatic secrefions) clinical oiclure

)Mau

syrTrptonrs

schirrous carcinoma rarelu anaolaslic be asumolomalic . Proslalism

'

.Erggq

of micturilion (noclurnal) dag& nighf)

spns

' Difficultq lo start , mainlain , finish micluriiion ' 99Iggl: Libido... lmpotence l91l,tri,rrt pi Ugl al+l 3 Exclude complications & DD I Hgdronephrosis) mass or lenderness in renal

, Pain . Occull manifeslalions . Complicalions

(melastasis)

I
E E

I
a

ahgle

Relenlion
DRE

Supra-pubic palpable bladder

Mass or lenderness in Renal an$e Supra-pubic palpable bladder

DRE

sofl & smoolh

summelrical

hard AssUmelrical No presewalion of sulcus

ffi
belween Proslafe& seminal vesicle Reclal mucosa is mobile

or nolch rlu mobililu and lale {ixafion

Investigations
For Dlagnos&
I

ptc'
ooeratlvelv

N:O-449lml ... BPH <15, Cancer 15-30, Melasiasis Cuslo-urefhroscoDu & Biopsu ) Adenoma KFT, tFT, CBC, FBg, CXR, ECG

>30

Oth.rr

For complicalions: . laboratorg )urine analgsis, KFT . !nslrumenlal:

. .

fC99, BM aspiralion,
X-raU spine

CXR

Uro-{lowmelry )BNO

ilP$-41qrr. Uro-

our5ary

?lh? r

+to

freotment

Mild C/O

. . .

& No Complications) Medical TIT : ODerable cases

AVOID SWs Alpha blockers (Prazosin)

S-alpha reduclase inhibilors (Proscar)

Radical prostaleclomg wilh Preservalion of Bladder Neck, NV Bundle

Severe C/O

& Complications) Surpical TII:

ITI of ang complicalions

Pre-operalive : M Antibiotics & !nlra-oDeralive :

l)

hg@..casest
Palliative TURP

2)

M TURP M VLAP M Transurelhral prosfalic vaporizalion M Open surgerg)Trans-vesical proslaleclomg

Posl-operalive
:

Hormonal : . Bilaleral orchideclomg (or Orchiectomg) . Eslrogen (Phosphorglaied

. . . .

DES) LHRH

lrr'rgation bg Saline ComDlicaiions of oDeralions :

Anli-androgen
Radiolherapg

METASTASIS:
lnlernal fixalion of ang fraciures

tr tr

Retrograde ejaculation
TURP Sgndrome

Conrplcot'
ions

Hemaluria (Rupture of vesical varices) Urine Retention .... 5W (Women, wine, winler, withhold of Urine, with infeciion ) . Back pressure (Urine relenlion, over-reacfive UB, Chronic relenlion, residual urine, Bilaleral hgdroureler, Hgdronephrosis, Bladder slone, Cgsfilis)

. . . .

Acule Renal failure

Psgchological dislress

gPREAD

Direct : lo pelvic organs @ Lgmphatics : lnlernal iliac) Common iliac)para-

aorlic)lhoracic ducl)Virchow's

LNs

O
I

Blood

Bone)
Hematuria

Lower verlebrae

Urine relenlion
! I

Renal failure

Back Dressure

lhre fo over-absorplion of inigating hgpoiic fluid

E$hcts)

Hgpervolemia,

&rtional hgponalremia,

Hernolgsis

. .

Prophglaxis)
Glgcine for irr'galion Conlrol bleeding bg amino-caproic acid

ilR.q41q't . Uro-

eurgary

?lh7 r +7

URIWTRACI
. KIDIIEY ITIJURIES . URETER IIIJURIES . URIilAtrTBLADDER
IIIJURIES

' URETHRA II{JURIES

il84-1Mrr. Uro- eurytry

?p{fi

t *S

:r.E>-ll:lrrt

20%
I

lnfanls
Underdeveloped Gerola fascia

C/P:

l) Minimal shock 2) No Periloneal irriialion 3) Meteorism ....

24-48 hours due lo hernaloma)

&

closelg relaled periloneum

to kidneg
Previous pathologg

(Abdominal dislension afrer

@Mffi
I I

Anuria
Bad general condilion

. . . . .

Pseudo-hgdronephrosis Perinephric abscess Nephrotosis Hgpertension Renal arleru aneurusm

C TNTALHCrURE,

E;;il.

Hislorg of lraurna + Pain in flanks Mau be) Hematuria ................

examinalion
S'gns of Shock

+ associaled injuries

examinalion:
.

. Super{icial PalDalion ) Guarding . Deep Palpalion )Superficial tenderness, rebound tenderness

.

hgp!.!q )

ecchgmosis, Bruises, Rigidifg

. Auscultalion

@!q

)Shifting

Dullness

9lnteslinal sounds

. DRE )Fullness in relro-vesical pouch

ilRq-TM1. Uro- eur6ery ?W |

fl

SECONDARY SURVEY) Head to loe exam + AMPLE Hislorgt

Resuscilalion

& rnoniloring

FESEGI TANON

02, Rgle, line, cathelen,

I I I

& wlo{nmn{cl
US)Perinephric hematoma
CT scan ,X-rag

Pre-operalive angiographg

AFTRSTABTTIZffioT{ oF DAflET{T

. For comD)CBC, KFt, tFt . !VU) M'edico-legal for the

other kidneg

REIFoFE,IIoNEAt HAAfto}iA ii ur=lgl n i h! g Urr,;gi 0l+(

oDEr.l n$.rRy, sE\rhE sr{ocK,

INilRA+BrIONEAL I{EItiAIOiiA,
PERTTONTfiS

. . . .

Anli-shock) Rgle, line,

Calheler, fluids
Analgesics, Abs

. . . . .

Laparolomg

Moniloring of Vilal data lVU, U/g ) for assessmenl

frans-periloneal approach &

Exclude injuries

lf

srnall tear

Avulsion Partial nephreclomg Cornplelelg depulped Total nephreclomg

)Sutured

ffiOFllrtaFt/BIrADDER
ii,!+r a':h!: r_ggjl, J+U

?ilRfl-'TB*r. Uro-

eurgzry ?W | 50

20%
Acule abdomen all over abdomen Fullness in reclro-vesical pouch X-rag) Ground glass appearance

No desire lo miclurale in inlra ruplure, Calheler oan

n n,!6115

EJr iiig5l+Jl tto gss JiU

be/ /used'; )
. Emptg

. Acule abdomen in Suprapubic region

in reclrc-vesical pouch

o%

. X-iaU )Fraclure pelvis

Polg-lraurnafized

patienf) Resuscilalion & rnoniloring

frealment of R.uplure bladder tr Midline supra-pubic incision & Evacuate urine tr Bladder is sulured with single lager of Polggalaclin 9lO E Drainage) Suprapubic drain, Retro-Pubic drain - Calheter (Foleg's Calheler is lefl for 5 dags)

ttLXlmESTo T-IEORETHRA
. C/O: Acule abdomen in 9uprapubic area . O/E: Emptg in rectro-vesica! pouch . DRE: Floaling Proslale . X-raU)Fraclure pelvis

tr SC Exlravasalion in complele
Polg-lraumalized palienl ) Resuscilalion gupra-pubic Perculaneous cgsioslomg Urelhra! dilatation

ruplure EI Striclure (extra-pelvic lgpe) E Slriclure, !nconfinence,-impolence (tnlra-pelvic tgpe

. .

& moniloring

ARQ-TWW

Uro'eurgzry

?l{&

5l

llfFl.flttlliATIOtls
. PERI-IIEPIIRIC ABSCESS . PrO.]IEPHROSIS

URIWTRACI

lfrt+'Tc0!9 Uro- curgery ?W t

6L

PERI.NEP;P1
DEFINITION: $uppuralion
ETIOLOGY:

of Peri-nephric fat & Fascia

. .

PRIMARY: Blood born (rare) ... from dislanl seplic focus

SECONDARY: Direct spread (MOST COMMON) ...from Kidneg, appendix, GB, Pleura, Peri-renal hemaloma, TB of the verlebr:ae

CLINICAL PICTURE:

@ @

SYMPTOMS: FAHM SIGNS:

Pain

&

* GENEML: , Tachgcardia * INSPECTION: UAbdominal movemenl * SUPERFICIAL PAIPAIION: Guarding * DEEP PALPATION: Loin Tenderness, Rebound Tardeme * SPECIAL SIGNS: O n Loin
o

O
ole.l r1fu

Flexion of Hip

& painful

Lilk

Uflro

INVE$TIGAIIONS:

*@
*

)Diagnostic & fherapeutic

AESR

,t.,t\Trc

PLAIN X-RAY

O 9coliosis , obliteration of Psoas shadow O Elevaled fxed diaphragm O X-rag spine) For Poit's disease
TREATMENT:

fr
E

Rest, Analgesics, Anlipgrelics, Antibiotics U/S GUIDED PER-CUIANEOUS CATHETER DRAINAGE lf thick & Multi-tocular) Pus drainale through a lumbar incision* C/S *Drain

?hhe

Im

ETIOLOGY:

. '.

Ortanism.... EOoli Roule ... ascending infeclion Predisposing faclors ... Obslruclion
PRIMARY: infection
SECONDARY :
I

WPE$:

. '

Obslruclion rlloqJq\o\ais6Ail-od
urn
s

obslruclion infeclion

ge\o>\r$

lldfd

CIINICAL PICTURE:

PYONEPHROSIS IS USUALLY UNILATERAL

I

Chronic foxernia, Renal

I

- General) Acute Toxemia - Local) Throbbing pain, Tenderness, Small swelling COMPLICATIONS: . General) Acule & Chronic Toxemia
INVESTIGATIONS:
FOR DIAGNOSIS:

(swelling ie large if 2ry obelruction)

. [ocd) Perinephric abscess, Acule Renal Failurc . . . .

CBC) ATLC, AESR
Urine analgsis Pguria in open tgpe U/S Dilatation of renal pelvis & calgces Cgsloscopg ... Chronic cgslilis in open igpe, ln Closed tgpe; Ureterio catheler mag be arresled at site of obstruction

FOR CAUSE:

FOR COMPLICATIONS:

' .

X-rag

Stone
IVU

ARF) KFI,

TR,EAIMENI:

GENERAL) Resl. Analgesics, Anlibiolics, Anlipgetics

locAt

: OBSTRUCIED INFECTED KIDNEY: frealed URGENILY bg Antibiotias, Kidneg drainage

bg Nephrostomg lube or ureleric calheler

OPEN WPE:

l-

!F KIDNFT lg FUNCIIONING: IIT. of the cause 2- IF KIDNFY !8 NOT FUNCITONING: Nephroslorng 3- lF KIDNEY !9 Slltt NOT FUNCIIONING: Nephreclomg

provided

. fff

of Cause , fff of Complications

that the other kidneg is Normal

ilP$:fCfl"t . Uro'

cur6ery

?lq7 1 6+

URIWTRACI
OBSTRUCTIUE

Ont
PFEDISFoSINGFACIoRS M INCIDENCE:
Metobolic enor

5UEL4-+W)5.

Mw

Uro-

luryl

?lh7

t 00

. . . .

lO-ZOYo

Male

>

of population

T/pES

Female

. '. .
.

Common in Middle age CALCIUM STONES ARE IHE MOST COMMON WPES, Followed bu Phosphate, Urales"

ldiopalhic
Huper-vilarninosis D V Urinaru cilrale Loss of tdrmina! ileurn

(Crohn's dis, reseclion)= IOXAIATE

Cgslinuria

,.i^
aa

rRrPrE PHOSPHAIE (SRUVIATE) (Formed of Ammonium, Mg , Ca)

^ts

@ @

Minimal sgmploms Stag horn slone

' Diet O Milk) Calcium siones

Ole o

. .

ine

Hot Randall's Plaque

cJlFQ-{oUrl. Uro- ourgzry

?ttcY

I
I |

'Drll ,"hl"g pain in FLANKS

svswtprous,
C/o of
of

ffi .Tili-,
I
I

'

complicarions

SYMPIOMS: . severe

SYMPTOMS:
in

LOIN radiating
I

@IItrEIN
to

GROIN

. SUPM-PUBIC

PAIN

. Sudden onsel, Shorl

duration

(<8

hours)

t".S. Renalfailure) I. Tender Renal swelling

complications

ffi
l.

(Hgdro or

Puo-nephrosis)
|

Lateral I abdominal muscles

n-ig'airg in

-Referred to the tip of penis or Vulva -At lhe end o{ miciurilion -Aduring dag & movemenl -V bg lging down
I

. Historg of renal colic 2-3 dags ago . During last miclurition ) Sudden arrest of urine)
leads to Acule Relention

BAtt

VALVE EFFECT

COMPLICATIONS:

. Painful hemaluria (TOTAL) . lnfeclion) Pgonephrosis . Migrallon )Collo

ffi I lornr gErrrnrrrnrn

I attack

is
I I

(futrg occur afler

an

of ureleric colic)

URIA

. Renal, ureleric calculi . lnfecJion (pgelonephriiis, cgslitis with ascending infeclion) . Hgdronephrosis . Renal cel! carcinoma . Carbuncle of lhe kidneg

5U?4-100Nr.

Uro-

eurgzry

?f,qY

t 61

IMOM
' . .
!niiial...Proslalic Urelhral Nol relaled to miclurilion
PYELO-NEPHRIIIS

....

Distal Urethral

.
.

a) b) c)
a) b)

:
uria

Change

of

of Leukoplakia

Characler

o{ pain

PYO

swelling Consislulional
Painful loin

ssmproms
:

pAl1;1lL
IEII.(IERAL
I

CYSIITIS

h)'t

a) 9upra-pubic pain b) Frequencg

c)

Dgsuria

il

Coillpr.erE -l
A}.IOHA

FETHtnoN

A0frfE,

. Desire lo urinale . Full UB . Trealmenl :

Relief bg Cathererization Supra-pubic cgslostomg

Loin swelling

lf Bilatera! )ARF
frealment
:

RemoveEtone Hrr{(,nor{Nq

HrlgnoNlNq Notl-

' No urine . No desire . Emptg UB . Trealment : l- Relieve bg

Ureleric Calheler

&

2- lf Failed)
Nephroslomg

$f,
2)

Anorexia, Hiccoufh, Anemia, bleeding, Coma

Infection: Painful hematuria , Pguria Obslruclion:

0r.lt

l) plqllq;

Anuria

Nephrectomg .Nephroslorng

Obsiruction of ureter: Severe persislent pain

Transplantalion

ilPqA1N5. Uro- 5ur()Qry ?l{fi t

56

rcR
. RBCs . Crgslals

Rodio-oPogle*",.*"
'Phosphale
Cgsleine

IF RES'RRENirOR
. Serum Ca*2, phosphorus, . Stone analgsis . Uric acid

lffiFoRTtrtECAISE
Urine salls

. Slone) Filling defecl . Back pressure . Differenlial funclion

OII{EFS:

paralhgroid hormone

'

lF@liPrjem
lffiFoR
. .
KFT

@rmrC*rrotS

Urine analgsis

ilPqJw$

Uro-

OF OF$
. . . .
Admission

/sTOI.ts
!l

curqyry ?W I E

ks or accidentallg discovered stones

Analgesics)Declofenac lV (Voltaren)
Anli-spasmodics (Buscopan)

Anlibiotics

@rtlptrcAnor{s sFEclAt. -_-l I , I;"i,""-," Reculrence

ffi
FF'{At
. . .

,["

Failed conservaiive TI

".rnp1,""tt."-

lf complicaled slones lf >O.Scm

WE HAVE TO TRY INSTRUMENTAL TIT. FIRSI & IF FAILED)
DO SURGERY

TTT

of cause

Bilateral Slones funclionino kidneu -TreaT5eiler then lhe-other " afier 2-3 monlhs Mulliole slones

A[liliii:1,:r;:, I

acrortlcafion oi unne

at rnultiple levels

ORETER BIADDM. W

RENAL)Nephro-lithotomg PELVIC)Pgelo-liihotomg SfAG HORN> Exlended Pgelo-nephro-litholomg

DEFINITION: Obslruclion angwhere in the urinarg lract associated with changes in the urinarg sgstem proxirnal to the obslruction

mw
N
Ss.lr

Uro-

eur5ery ?W t tfr

PM
${ t,RerER
$.I ONETHRA
Cr{Rotlrd nergltnorl

@Mn-sre
t,NeTER.

${ oneil{RA

rb'|td ffmns,

t I
,atld

crrl[,CO!{F, A}IOR'A

ffi

HrDFoHto(|1$!
.
DEFIIIIITION:

cilPq-4Mr1. Uro-

euryzry

?fQ7

Aseplic dilalation of Pelvi-calgceal sgslem due lo intermillenl obstruclion

ETTOTOGY:

. . . .

Stones... Renal

TB

Pelvi-ureferic junction obslruclion Horseshoe kidneg, Aberranl renal vessels

Ureterocele

. . . .

BPH

Congenilal conlraclure of Bladder Neck

Bilharziasis Phimosis

PAIHOTOGY:

. .

Exlra-renal Pelvis lnlra-renal Pelvis

CTINICAL PICTURE:

. .

Dull aching loin pain , A bg fluid inlake , OlE Clinical picture of Etiologg: Stone) Colic, hematuria

>

palpable kidneg

l)

2) BPH) Prosiatism 3) IB)Toxic sgtnploms,

frequencg

Clinical piclure of Complicafions:

l)

lnfection

2) ARF) if bilaieral

Hgperlension & Fever hgdronephrosis, or Unilaleral wifh one functioning kidneg

INVESIIGAIIONS: . U/S) size of kidneg, thickness of corlex . lVU) Flattening, Clubbing, Ballooning lf IVU is # ) Ascending Pgelographg . For cause) IRU/S. Cgstoscopg . For complicalions) KFT, Urine analgsis, CBC

f.-rlllllfFrrll

IREATMENT

HrlwnoNl}lq ib.tflrr{anoNrNq HrNenoilD{q

TTT

of cause

Nephreclorng

'il;".'1,"0""',11"'
kidneg

. .

NePhroslorng
lf improved)
ITT. Of betler funcfioning kidneg

Re-conslruclion bg "ANDERSON - HYNE$ OPEMTION" or Recentlg bg "ENDOSCOPIC PYELOLYSIS"

lf nol impr.oved)
Renal Iransplanfalion

. Stones) Rernoval , BPH) TURP

. ARF)

Transplanlalion

'

Phimosis) Circumcision

Pgo-nePhrosis) Drainage. Antibiotics

ilR4-10q\r.

Uro'eur6ery ?l$t t 6t

Uo*ln^ereo
. .
Bilaleralobslruclion Unilaleral obslruclion

.
'. .

BPH

(lf olhet kidneg is congenilallg

absenl, surgicallg removed or

Slone
Ttauma

Reflex (Post-operative), Psgcholo$cal

CIIIfiALFEIIIffi, SIAGE
tfHFFofl,tS

Emptg UB No Urine, No desire SIAGE OF IOLEMNCE (3-8 dags): Pain graduallg disappears, 4Blood

. . . . .

OF ONSEI:

Ureleric colic fender Renal angle

Relenlion) Supra-pubic pain, lnabililg lo pass urine inspile of desire, Sgmploms of cause) Slone, BPH, Hislorg of lrauma

SIGNS: Kidneg) Loin swelling

STAGE OF UREMIA (after few

CAIHEIER + ... EI Plain X-rag , U/S

Ascendingpgelographg Cgstoscopg N.8.... IVU is #

DONE AFTER RETIEF OF OBSIRUCTION M Pelvic U/S

El

For Cause: Slones) X-rag, BPH)

TRUS

EI

TFEAn$Eltr

c.tr+ErER.

.iHo

l- rnetnlqlr

-l

ffTOFCN6ES: o,{rt
62,

Relbvd
I

lf NstRclteved

l!
9urgteal romovat

\,<b
)>'" tt

ETIOTOGY: . Urelhral Slriclure, BPH, BNO, Tumors

ffiOFORI}\|E

CLINICAL PICTURE: . SgrnDtoms) Painless UB swelling , Frequencg

. SiQns) Full UB. Nol tender

INVESTIGATTONS:

@ Pelvic U/S @ UREA LEVEL @ For cause @ For complications

TREATMENT:

FOLEY's CAIHETER

!f urea > IOO ng% ) GRADUAL EVACUAT1ON . TTT of cause ... DRE, BPH . fTT ol Complicalions ... Hgdronephrosis, Tender loin mass

ETIOIOGY:

. PUJ . Urelerio-Vesical junclion obstruclion . Posl. Urelhral valve . Slones

Ct!N!CAL PICTURE: . Abdominal pain
INVEgTIGATIONS:

+ Abdominal swelling (Hgdronephrosis, or dislended UB) .Clinical picture of complicalions) UTl, Hernaluria

1JE4-100.t . Uro-

ourytry

?lQY

r tA

. REJTIALAIIOIIRI.IES . UR!ilAtrf BLADDER A'll0I,lAL I ES . URETHRATAiIOTALES

FENATA{
,'iq.I,:'i

il84-1wr5. Uro- cur6zrl

?Wt

tE

.
l)

Clear fluid Flat epithelium {ibrous sepla Clinical Piclure:

a) b) c)

Eliologg: quf93.. +i6 ja,e.. rrrrL p+r.t Clinical piclure: Mainlg Asgmptomatic+@

-Asgmplomalic -Loin pain, $welling

E E E
M

Clear lluid NO {ibrous seplae

2)

3)@

Duodenal lraction Draging loin pain

EI

Loin pain *Hemaluria

-Complications: As ang cgst

EI

(Hemorrhage, infeciion, calci{ication..) Best invesl'rgalion is U/S

No Malignanl cells on aspiralion No residual mass

afler aspiralion

lf Small cgst) CONSERVATIVE TIT. lf Large or Complicaled) SURGICAI

Besl invest'rgalions is !VU: during full inspiration & Expiration ) Mobilitg > I verlebrae Besl lrealment is CONSERVATIVE (Weighf g,ain, exercises, avoidance of corcefl

lf failed) Nephropexg
TTT:

Aspiralion, Marcupilizalion, Parlial Nephreclomg

Adult tgpe (AD) lS MORE COMMON IHAN lnfantile rgpe (AR) Mag be associaled wilh cgstic changes in the bodg (lC aneurgsms. Liver cgsts)
PATHOLOGY:
-

SlfE: Alwags bilaleral

PICIURE: Multiple cgsl MICROSCOPIC PICTURE: Conlent) Amber clear fluid

- MACROSCOPIC

intramural part+ swellj Mlnvesligalions : IVU : I MTrealmenl:

CLINICAL PICTURE:

-Asgmptomalic lill 2nd -3rd decade

regular loin swellings, , Hematuria, infeclions. Multiple cgsls in bolh kidnegs Besl invesl'rgalion is U/S , Cf scan Screening is done bg US for familg members >2O Yrs

-At age of

30 Complicated
:

freatmenl

!n m

gURGICAL)Rovesing operaiion (marsupilizalion) lF RENAL FAILURE OCCURS) Kidneg lransplanlation

Can be pushed in

ALI directions & lo lhe renal angle, could be complicaied with lorsion & Gangrene

51Bfl--T1qrr.

Uro-

1urff\

?lhV

tw

Contain Muscle Fibers

NO muscle fibers within

Within its wall)Contractile

CtItt|ICAL P!CTURE: Abeence of lor,ver abdominal wall +Anl Bladder wall Widenin! of Sgmphgsis pubis Waddling gait CLINICAT PICTURE:

the

wall)

Doesn'i

Male >5o searc'

Accidentalrtffi"JffiH.,}rr"rion

Genitalia: lii;Loir! 0+:Ji''o-. O Epispadius (EXIROPHY -EPlgPADlUg coMPLDo

O O O O
Rudimentary prcslale, Seminal vesicles. penis

OF COMPLICAIINS: Frequencu, Pain, Hematuria

INFECTION. SIONES

Bifid scrolum

Bilaleral undescended lesles Bilaleral lnguinal hernia O Associaled anomalies (e.9. Spina bi{ida, Cleft
liP)

Trealmenl

TTT.

of lhe cause, Diverliculeclomg if com

Complications:

Cgslilis & Ascending pgelonephrilis Ekin Excorialion, Ulcer, bleeding, bad odour Bladder Carcinoma (chronic irrilalion) lnvesligalions : plain x-rag (Wide separalion of sgmphgsis pubis), IVU (For associaied Urinarg lracl anomalies) Trealment : E Temporarg closure of defecl al birth

. . .

l-

!t
fr

Bladder augmenlalion laler

Pelvic correciive

osteotomg + phgloplastg lf conlinence cannol be preserved) permanenl

diversion

M M Trealmenl :

Hgpertrophg of lnlernal sphincler wilh developmenl of vesical diverliculae (MARION's DISEASE) 2- Fibrosis of lissues of Bladder neck lnvesligalions: Uro-dgnamic studg) Raised voiding pressures, V Flow rate

Alpha blocking drugs "Prazosin", Surgcal

" frans-urelhral incision ofbladder neck"

f/'I?4-jf00t\r. Uro- 1urdtry

?l&Y

t"1

D-o
@

TYPES

&

ETIOTOGY:

Atl
shaft of lhe penis, Dislal part of urelhra is replace bU fibrous lissue
Failure of fusion of inner

EUM opens on undereurface of Glans penis

Urelhra opens in-belween, Penis is rudimenlarg wilhin undescended lesles

M CIINICAI PICIURE:
Clinical picfure depends on Age
:

* e *

At birrh) iltitloJliirduro )hooded prepuce 2-lO gears)ai,i 9i ) Wetting clolhes in miclurition After pubertg) Uirili+t, ) Bowed penis downwards during ereclion

urinarg obslruction Congenital or acquired ,.BALANITIS XEROIIC OBLIIERANS" TfT: Circurncision

lnvesligafions : . Hormonal assag & kargolgping ... For associated condilions . Ascending urethrogram posl-operalivelg ... to asses success of surgerg

freatmenl :

fr PRE-OPERATIVE) Rernoval of Chordae, injection of saline for ereciion fr OPERATION) Urelhral reconsfruction (recentlg: arti{icial tube)

Micturating Cgslo-urelhrolram "MUC"

(Dislended poslerior urelhra, VUR., Bladder trabeculae)

l)

2) 3)

GLANUTAR) MAGPI opetation PENILE) DUKEIIE operalion PERINEAI) UB mucosal{lap

- u/s
(Dilated, Pelvi-calgceal sgstem, lhining

of

corlex, dislended UB, dilaled ureler)

DMSA scan

POST-OP) Circumcision

ilRq,-T1qrr. Uro-

eurgen ? hq7 t 6

Organism

(anlerior > Polar) . lmperfecllg descended leslis

. Long mesochorium . High inveslmenl of Tunica va$nalis
. Spirallg aftached cremasleric ms. . Separalion of Epididgmis from bodg

EE@.I"oli.

. staph.

Mosl common sexuallg lransmifled

cause

Route of infeclion : .Along Vas , Peri-vasal [Ns , via slream

!!gg]

of

teslis
Precipitaling faclors : . Sudden strain

/ /
rr ,/

fesiicular swelling
Refllex

/
N, V, collapse

Eliologg

Dgsuria, FAHM

sgmploms)

GENEML: Pallor ,swealing ,tachgcardia Due lo imDerfect Descended Teslis: )Emptg scroturn, swollen lnguinal canal
On top of ComDlele Descended Tesiis:

GENEML: Fever

[OCA[: ,,/ Scrolum :red , inflamed skin

l)

Scrolum : swollen, lender leslis

Cord : fwisted Teslis : h'rgh, fender, associaled

l/ / /

Epididgmis : Enlarled , lender Associated hgdrocele lf abscess is formed ) Pus loculus

airB

Ccrnpk

Gangrene wilhin 6-12 hours

tr tr
Urine analgsis

tr
)
Free

E
M

Doppler, Duplex: Teslicular vessel is PATENI Urine analgsis

) @tE

EI lN THE FIRSI

HOUR: unlwisl using

gentle manipulation M Correct general condilion M Emerqencg lrealmenl in earlu cases : Untwist cord ) Orchiopexg )Eversion of funica ) Orchiopexg of olher testis M if lale cases : Orchieclomg & orchiopexg

) Doxgcgcline IOO mg Acfive IIT : l) Resl (elevation of scrofum), Antibiotic, analgesics, antipgrelics 2) !f abscess is formed )Drainage
lf chlamgdia

of olher leslis

5UP4-1W\5. Uro-

ourgzry

*,1fr,kp

10

DEFINITION: Colleclion of fluid in a parl of processus vaginalis

CoXcrrlrrlu
Due

1Hvrc,rr{Au
INCIDENCE

Encgsted hgdrocele of cord " See DD wilh sDermalocele " Hgdrocele of hernia sac Diffuse hgdrocele of cord

lo persislence of

ln fernales

processus vaginalis

E Sac connects wilh

peritoneum

tr

. .

Sac has NO

Middle aged male Fluid is Exudalive

CLlNICAI. PICTURE

tr Mother

complains thal her babg has a

tr

Scrotal Swellin( + bg dag

conneclion with periloneum Mother complains ihai her babg has a Scrolal Swelling+

tr A

DIFH'SE }gDROCFI.E OF COFD Eliologg:

Chronic lgmphalic obslruclion "FlIARIAglS"

ln inguinal canal

C/O : painless swelling in one of lhe scrolal comparlmenls O/E

. '

Clinical picture

SWELLING:

&

n'rghr

.trEENtr .
Unilateral
II{VESTIGATIONS

. EIEEEI
' '. ' ' . .
Soft
Dull

TYMPHOCELE

lnguino-scrolal

Non-lender Cuslic, lranslucenl

(No expansile impulse on coughing ) Cuslic , Translucenl lrreducible

tr S'rgns)Swelling:

tr S'rgns)Swelling:

l)

lnguino-scrotal 2) Cgstic (Bipolar lesl)

l)

tnguino-seolal
Cgslic
(Bipolar lesl)
TREAIMENT LORD'S OPEMITON: Plication of lunica vaginalis

2)

Diffuse Funiculilis is common

3)

Translucent

4) Non-reducible

3) Translucenl 4) Non-reducible

r)

freafmenl

:
TTT

Trealment
Eversion
Tunica

2) 3)

Conservalive

of

for 6 monlhs
no sponlaneous improvemenl occurs) Excision of sac lill inlernal ring

Sub-lolal excision of Tunica vadnalis in cases of calcified, loculaled, and recurrenl.

Eversion for small hgdrocele

lf

N.B. ASPIRATION lS # Except if bad general condilion as il mag lead lo hemalocele, pgocele, recurrence, injurg of ieslis

ilRq4)U\r. Uro'

lurbery

'i k

h* t7t

DEFINITION: varicosilg of pampiniforrn cremasleric plexuses of veins

&

INCIDENCE

.@
tr e

AEe: bet. Puberlg -35 gear

VENOUS OBSTRUCTION How lo differenliate frorn Prirnarg?

!NCIDENCE
,

ETIOTOGY

PREDISPOSING FACTORS: Congenital mesenchgmal weakness PRECIPITAIING FACTORS: AVenous pressure (prolonged slanding
)

tr A

slraining, venous congeslion CTINICAT PICTURE

C/O : usuallg asgmplomalic, Pain, scrolal swelling

. @.." mosl cornmoh " . Relro-periloneallumor, fibrosis

CTINICAL P!CIURE

Old male >4O gears EIIOTOGY

O/E: Swellin!

. .

Lefl side hanqs lower lhan riphl, Scrolal skin show dilaled veins Palpalion : Ecrolal neck lesl) Fullness al neck of scrolum

.
I

Course

)Rapidlg prolressive

l)

3) 4)

Associated with a small lax 2rg hgdrocele To differenliale fiom SECONDARY varicocele) Thrill on cough

INVESIIGAI!ONS Semen analqsis) Slress pallern (asthenosperrnic, Oligospermic) .. for medico-legal imporlance .. reversed blood flow bilaterallg Duplex scan Scrotal, lrans-reclal U/S) for visualizalion & Grading Abdominal U/S)exclude 2rg varicocele (Hgpernephroma)

sl
s
Z
M M
mical
fTT: RAAA, el 2rg Hgdrocele Testicular atroph Neurosis

x tr x

theorg

. .

bo-phlebitie
C/O: severe

tr

IREATMENI

tr

CONSERVATIVE) Psgchological supporl, Scrolal supporl, Cold bath to scrotum, avoid conslipalion & pelvic congestioh I approach, Reiro-periloneal , Laparoscopic Varicos-eleclomg, Perculaneous venous embolizalion

UroNCE:

eurgtry
cancer in

k{4V

t fl-

!@[E@

(Olncidence of maldescenl)

ltl fr[a-)'-\
SEltttNoriA
TERATOMA

40%

32%
Smrou CHrTrtiOF.
iiJ+.oj 1'JI J+.ojJl

Jsri

CEI,Lffi
lfrrtO
20,-25

A,EI4J0NL Uro-

surg\

h{qb

71

ri!.j lstr

, Undescended testis . fedicular desgenesis (klinefelter's . HtV @ [ar!e , firrn , smooth @ Cuf seclion : Homopenous , Pink @ Hemorrhage, necrosis
Microscopic

$)

. Carcinoma in silu . Trauma . Geneiics: " ISO-chromosome

of leslicular lumors)

12 p

"

(8O7o

@Cul seclion : Heleroqeneous,uellow @ Hemorhage. necrosis

piclure

Sheels of rounded cells with large nuclei infiltraled with lgmphocgtes (Good prognostic indicator)

Malignanl leraloma tropho-blaslica

"CHORIOCARCINOMA"

Teraloma di$erentiated (Dermoid cgst)

@ Para-aortic) o

lhoracic

duci)

Virchow LNs

Lungs are the {irst site affected

lOCnl: spermalic

cord,epididgmis,

scrolal wall
Painless swelling wilh senee of heaviness Painful in advanced cases, if Hemorrha4e occurs Tesfis is enlarped, hard, heavu , {ixed with Enlarped Para-aor}ic [Ns

M Rapidlg accumulaling Hgdrocele M HURRICANE TYPE ... fatal wilhin l-2 gears M Piclure simulatin! acule Epididgmo-orchilis M Abdorninal mass with Empfg sootal
in a patient wiih undescended festis

OCCUTT MANIFESIAITONS:

l)
2)

SEMIIIIOMA) Enlargemenf of Virchow

TERATOMA) Lung metaslasis

LNe

1JP4-10q\r. Uro'

eurgzrrl

AkV

7+

?JrrtO
lnvesligalions

FOR DIAGNOS!8: MScrofal US) mass. calcificafion Mfumor markers :

SEMINOMA TERATOMA
B.HCG
TDH

a- FeloDrolein

ZFrozen seclion biopsg (inguina! approach).. FNABC is # in leslicular lumors FOR STAGING . Bone scan, CT scan , abdorninal U/S, CXR . IVP) distortion of ureleric course (Para-aortic LNs metastasis) FOR FOTLOW UP . lumor markers PRE.OPERATIVE

LFT,
I
T

KFt,

ECG, SuEar, urine..

l)fedis

lll) LNs above diaphragm lV) Distant melaslasis

ll)LNs below diaphragm

.. HIGH INGUINAT SIMPTE ORCHIECIOMY " # Radical otchieclomu Para-aortic [Ns

Secondarg

lrealmenl

.I) . ll)
. lll

according lo lhe slage

Radiolherapg lo Para-aortic LNs As 9lage I + Radio-lherapg lo mediaslinum

. l) repealed . ll , lll, lV ) . lf
combinalion

assessmenl As Slage I + Chemolherapg

NO dislanf melaslasie) Refioperiloneal

wilh initial TTI.

, lV)Chemolherapg

LNs dissection

dsr"l
tr tr tr
Pre-pubertal iumor )Precocious puberlg Masculinization of patieni Hgpertrophg of other testis

6l.pj 1'J! J=piJI Jgri

tr tr tr
Posl-Pubertal lumor Feminizalion of paiieni Ggnecomaslia, loss of libido, aspermia

Treatrnent for both cases: ... OR,CHIECTOMY

Uro- our6e.ry ? hk* t

75

DEFINITION: Relenlion Fluid Confains:

DEFINITION: failure of obliteralion of of processus vaginalis

DEFINITION: Cgsl of vestigial slruclure "Hgdatid of morgagni" @ Conlain :

@

l)

Clear {luid

OtD MALE WITH PAINTESS SCROIAT SWELLING iiiJU iif-ai

@C/O> Painless swelling in

scrolum

orir

@OlE : mulliple lransilluminaiion

Ul

Uurrtr

@O/E

o
J

E
(!

c)

. . '

OO/E) Swelling:

SWETLING

Painless

Cgslic

: o
L

.9

'!!else@ leslis bu inlerval

Al upper pole of lestis

. Painless . Cgslic , lranelucenl . SeDaraled from leslis bV inlerval . Mobile across cord) mobilitgV
on down traclion of testis

GqnoNrC
r)
@

cHRoNrc NoN-sPEcrFrc 2) TB EPrDrDYMrIrg

epruU^ioong{rns
EPTDTDYMO-ORCHTITS

Pa
Macroocopic piclure: accordihg lo roule

Microscopic :

O O O

) Tail is lhe firsl sile affecled, Vas is thickened & beaded BOOD) Head is lhe lirsl sile a$ecled , vas is Normal
LYMPHAIIC

cenlral caseafion. Lanperhans pianl cells, {ibrcocules, eoilhilioid cells

urinarg TB
TB

@ C/O: sgmploms of TB loxemia, @ o/E:

tr S'6ns of TB loxemia , urinarg
trEpididgmis

tr DRE) fB

Enlarged, lirm, nodules in proslale, seminal vesicles

@ lnveslilalions: l- Urine analgsis) @ IREIMENI:

Slerile pguria 2- C&g on Lowenstein

media 3- IVU)Detecl
&
Epididgmis

urinarg TB

. . 3)

Sanalorial lrealment + Aili-fB drugs lf no response after 2 monlhs) Excision of Vas deferens

BTLHARZTAL MASS O Mosl common Roule) Vesico-proslalic plexus of veins @ VAg Ig INIACI, VEINS AR.E BEADED

4) F[-ARrAgrS
@

(ENDEMTC FUNICUUTIS)

CORD 18 THICK AND MATTED , VAg IS MATTED

A,W{4-jtC0{f-

Uro-

curgtry ? h** t lb

WILM's TUMOR:

. . . . .

One third of palient wiih wilms tumor presenl wilh value abdominal pain , wiih minor lrauma and hemorrhage with in lhe lumor Neuroblastoma is a childhood supra-renal lumor wilh bone Secondaries ,enolase *ve VMA

in urine and frealed as wilrns iumor ln TIT o{ wilms lumor: lhe use of chemo& radiotherapg have improved lhe overall prognosis

lo SOTo and Earlg cases are usuallg cured Urinarg bladder carcinoma is lhe most common urological malignancg in Eggpt lN BPH there is no relalion belween lhe size of the prosiale and degree of sgrnplorns ,the severiig of sgmpfoms depends on lhe degree of urelhral and bladder neck obslruclion CANCER PROSIATE: lhere is delaged spread lo lhe rectum due lo presence of fascia of
dennonvilliers

UROLOGTCAL INJURIES:

Anuria as a complicalion of renal injurg mag be due kidneg ,clot relenfion, injurg solitarg kidneg

to : shook, reflex inhibition of

both

INJURY OF

IHE URETER

Mosf common cause is IAIROGENIC (During open surgeru especiallg pelvic surgerg)
Diagnosis :

O O

UNIIATEML: SILENT ATROPHY OF IHE KIDNEY (Most dangerous), Loin pain & swelling

BILAIEML: Anuda or oliguria

INVEBTIGATION:

O Ascending relrograde urographg showing obslruclion or exlravasation O CT scan wilh conlrasl showing exlravasalion of the dge
TTT:

. .

diagnosis: Fair patienl condilion: urefero-vesical continuilg, Restored bg lsl anastomosis Poor patienl condilion: hephrostomg for drainage of utine lhen delaged repair O lf delaged diagnosis: lemporarg nephrostomu lhen delaged repair URINARY IRACT INFLAMMATIONS: Earliest macroscopic specific aPpearance of the bilharziasis of fhe urinarg bladder is bilharzial pseudo-tubercle

lf immediale

Siles of impaclion of Ureleric sione

. .

Pelvi-uretericjunction At Ureleric ori{ice, At the sile of crossing of iliac arteries At the sile of crossing of the broad ligamenl in females At the sile of crossing of the vas in males At fhe sile of enlrg inlo the bladder wall l3-9O% of small urinarg slone <O.5 crn will pass sponlaneouslg

URINARY OBSTRUCIION: Ihe mosl common cause of bilateral hgdronephrosis is BPH Ihe mosl common cause of unilaleral hgdronephrosis is stone

Teslicular Turnors
@Most oommon fedicular lumor is @Most Mal'gnant Teslicular lumor is
(Earliest leslicular lumor melaslasizing

lo

QaAA{
TUNGS)

Ell
*

@
@

@Most common presenlalion of fesficular neoplasm is a "Painless mass" @Loss of leslicular sensalion : Seminoma, Sgphilis (Earlg complete loss of sensalion) SEMINOMA) ofthe teslis respond Tumor markers:

Fournier Ganlrene
/
rr
Mag follow minor injuries lo Perineum Sudden onsel of scrolal in{lammalion sudden onset of gangrene (oblileralive
arlerilis)

. .

Ovarian carcinoma) CA 125 Teslicular seminoma) B-HCG, alpha feloprotein

. . @Alphafetoprofein Proslalic carcinoma) PSA . Coloreclal carcinoma) CEA

.Ies!!cu!ar!era]oma.2.8-H0G,LD|{

/ /

Caueed bg rnixed infeclion HEMOLYIIC $TREPI. + 9laph

Ecoli ..elc

Mag be associaled wiih Neeolizing Fasciitis) anterior abdominal wall

/ lrcalnenl) Antibiofics

& wide excision

al anornalies
V feslicular arresl is associaled wilh
urinarg

skin graft

g g
M

anomalies in 15 7o of cases Undescended Testis is prone frauma, malignancg

lo

Torsion,

Hgdrocele, Varicocele
Mosl importanl dia8noslicrfealure of
SECONDARY HYDROCELE mag be due

Most

im

ic lool in arresfed

lestis is lf teslis is nol found bg laparcscopg :

lo:

. . .

Teslicular agenesis Felal festicular torsion

Maldescended lesfis

l)
2) 3) 4)

Teelicular lumors Teslicular lorsion Epididgmo-orchilis Following Herniorrhaphg

Most common sife for

@@ @

@!E

lestis is

lurr "rp".f'"irl

inguinal pouch

a) b)

Fluid : Epididgmal cgsl Crgstal clear spermalocoele Barlg Waterg {luid

HEMATOCELE:

M
M

Ectopic leslis is due to rupture of scroial

- Iapping of hgdrooele is lhe mosl common cause of hemalocele - Old clotted hemalocele rnag simulale
teslicular lumor

tail ofgabernaculum
Best treatment for Relractile leslis is Reassurance M CRYPIORCHIDIEM: . Occurs in 5% of new bon babies . Laparoscopg is the besl diagnoslic melhod

MISCETLANEOUS:

. 4 Risk of mal'rgnancg . Associated wilh V Ferlilitg

1M-TWI'.
l.
Palienl 40 gears old presenls wilh dull achin! pain in {lanks and irregular upper quadranf abdominal mass wllh mild impairment of renal funolion. UB show mulliple cgsle in bolh kidnegs.

2. 3.

6ugw6a/ pQcystrb kAtq.

Palienl presenls wilh loin pain, swelling and fever usuallg after pelvic

surgerg'

llreter t@tr,
A polglraumalic palienl presenls wilh supra-pubic pain, He was in agong io Miclurale before the lrauma, Bul deehs afigl lhe lmuma x-rag shows ground glass appearance and UB shows {ree fluid in periloneum,

4. 5.
B.

/ntra- Ventoteal aVtre rtnrtary blafuer A polgrtraumalic palienl presenls wilh supra-pubic pain and urine relenlion wilh desire lo miclurale.Xrag shows fraclure pelvis.
E

xtra-?entottu/ rl?tilre b/d&t

Palienl wilh historg of irauma to perineum presenls wiih, Few drops of blood at tip of Penis, perineal hemaioma and urine relenlion wilh desire lo miclurale. trhra plwb rult/tre trethrd. Adult palienl presenls presenls wilh righl loin pain increases bg movemenl, respirafion and coughing& heclio fever. Plain X-rag shows scoliosis wilh oblileralion of psoas shadow elevalion& {ixalion of lhe diaphragm. Urine analgsis is slerile.

Pul-ttelhrb abscss,

7. 8. 9.

Adult pt. with Hx oI renal slones, C/P: Anemia, fever& large renal swelling. Urine analgsis shows pguria.

Opn t4pe V4onephrosb. Middle aged usuallg male presenls wilh hemaluria, markedlg increased pain & frequencg.Cgsloscope shows sandg palches or olher specilio lesion. Bilharzial anlibodg deteclion bg ELISA is posilive.
Blrharzrhsrb of Middle aged male presenls wilh dull aching pain in flanks associaled wilh nausea and vomiling. US shows radiolucenl or radio-opaque shadow.

l/8,

&ta/

co/rb

lO. Palienl presenls wilh severe agonizing pain in loin radiating lo groin of sudden onsel short duralion associaled wilh nausea and vomiling .On examinalion rigiditg of lhe laleral abdominal muscles. /,/retenb co/rb Gtond, ll. Palienl with historg of slones or BPH presenfs with mild pain in loin ihcreases bg excessive fluid inlake with dragging heaviness in loin, IVU shows palienl has a renal mass in lhe Loin
HydronVhrosb, 12. Male above 50 gears old presenls wilh painless, recurreni, profuse, lolal hemafuria. Mag be pain or renal mass or other non-speci{ic sumploms, polgcgthemia. IVU shows dislorled pelvi-clagceal sgslem Reta/ ce// carcimna Hyp.rnphnna. ) (Qrayfrtz funor) patient 13. Old wilh historg of chronic ir.ritalion lo UB or Bilharzial precancerous lesion presenls wilh exacerbalion of sgmploms of cgstitis. (Painless lerminal hemaluria, necroluria, frequencg and dgsuria).lVU ehows irregular lilling defect or jusl irregularitg in the bladder wall. 6aner ttrirtanl b/ailer (TG or 366 accorditg to Vrdispsug factoD. 14. Male above 50 gears old presenls wilh frequencg of miclurilion, Dif{icultg lo slarl, lo mainlain and lo finish, 4libido and urine relenlion. DRE showe lhal prcslale is sofl, smoofh, sgmmelrical, preserved median sulcus, noloh belween il and seminal vesicles is preserved & mobile mucosa of reclum over il,
B u,,!t Pros

tatb

hTprV/as

15.

Black old male palient presenls wilh sgmplorns of difficult to slarl, lo mainlain or micluralion. DRE shows lhat the proslate is hard, asgmmelrical, With Backache

lo {inish
Garuer

prostate.

5u?q40ar5. Uro-

eurgtry ? h+* t n

lnfant presenled wilh an ernplg poor developed scrolurn wilh or wilhoul associaled renal anomalies.

Babg with an ernptg well developed scrolurn, normal lesfis, O/E lhere's Exaggeraled cremasleric reflex

lnfanl or Uoung adult with sudden severe,testicular pain, absent cremasleric reflex, duplex shows obslruction of teslicular vessels & urine analgsis is free
SECONDARY VAGINAL HYDROCELE Middle aged male with rapidlg accurnulating hgdrocele & Pregnancg lesl is POSITIVE

\
Middle aged male with signs of congenilal rnesenchgmal weakness with or without dragting pain in leslis which disappears on lging down & elevalion of leslis.

-/t
:\

Middle aged rnale wilh Abdorninal Mass, Painless swelling

In testis

& loss of leslicular sensalion.

'{

ilRt4'-T00tr5.

Uro-

euryzry T t,k6 t U

Hgdronephrosis : Eliologg , ClP,lnvesliglalions& TTI

G4rh

s/rams,2@ - .4u s/ans'2M

,4y'rar

fi2@4 - Aztrar rll,2@ )

(,4zar rl/'zo// )

Discuss Unilateral Hgpernephrorna

OR bilateral Hgdronephrosis
Renal cell carcinorna
G4ilr

"

":

Diagnosis

&

TTT

alarr/s,2@22@52@- Kaan2@8 - ,4h starr/s'2@2-2@52M )

(

Management of renal lumors

Ailart,2@7)

Acule relention of urine

(

5u shan&2@52@5 - AZar

ril,-zozZa4Zan)
(Aushatrs,2ffi
( z4zzhr

Manalernenl of obslruclive relenlion

Causes and rnanagemenl of relenlion

f,2@7 )

Rupture Kidneg: ClP , Urelhral injurg

lll

and follow up
G4ths/ans'2@4 )
(Kasn

2d/)

Tgpes of renal calculi , TTT of Kidneg slones, TTT of lower end ureler slones G4u shans,2d- Kasr, 2@7 - Ay'rar f,2d - ,Qst 2@a - Ay'rar f,2@) Calcular anuria
Give explanalion for ihe following : Whg bilateral orchidectomg mag be indicated for advanced proslalic cahcer

(Kailzd)
ttl of
Kasr,2@6 )

BPH

Kaan2W -,4y'rar F,2@ - Kast;2M -Ailarrlr1,zml Kasn2%) Eclopia vesica: C/P, Radiological finding , comPlicalions (Kasr2M )
(

: C/P complicalions, indicalions for surgerg

Give an accounl on leslicular lumor

(

Kasnzd)
)

Torsion of lhe teslis : ClP , DD and invesligalions G4ilarf,2ob

ilR4-10A\5.

Uro'lurbQry F &** t 8l

5UR(+'T0A\5.

Uro' eur6zry

?&*5 t 6L

ilR4-10N5. tkuro-

luryzry

?fQY

t *+

ilefl-4w{rr. tQuro- 1uryry

?Wt ffi

ll -

tr \-i

-rir:,

i itl

L!/3
I
I I
hage

FRAcnne,

FISSORE

RACN'FE

s*R=--a:-r,p.rNp (eL@) (ffirl) -A-

%l-I "Tffiffi.-ffir hcrrn^ I I AlEBloR | . Trauma to chin riusqr r I GANIAL . Trauma to spine asqsgr d,. e."q | | | CA
.r

lqrtrw

lrcal
*
t
Escape

DD = black ege of sub-conj. hge I .t Escape of CSF from Nose + lnjurg of l, lll, lV, Ophlhalmic branoh of V Nerve

Masloid Pr. Discoloralion

Scalp emphgsema around lhe ear.

of CBF from Ear

qFolH lffi
deoressed fiaclurer in ir

lnjurg of Mandibular, maxillarg br. Of V, Vl, Vll, Vlll Nerve

lilOrrfgO rallrer

I]IITACI

s iteelf wilh growlh

':ffi^{ u/"
chifiben
lhr
r

-,r rL'

* *
$
CBF escape

from Mouth

lnjurg of lX, X,

Nerue

As ang head injurg ....

(see tarer)

, . !t

Rhinorrhea) Semi-sitting & avoid blowing, Surgerg (lf failure after lO dags)
Olorrhea

lie on opposile side & Clean drg dressing Antibiotios, TTT of associated brain injurg

ffi
EIIOLOGY:

ilRq-T1qrr. &uro- 1uru5ry

?&V

t a"

l\:1
Sn*lne
il

Blunl lrauma bg a wide surface area (Wall)

SITE:

(ffi^l)

Starts al sile of impaot & Runs awag from

COMPLICAIION9:

...

LESS THAN DEPR.E$8ED FRACTURES

. .

Hemaioma, Bleedirg

lnfeolion, lntracranial l{emorrhage CgF leakage, Epilepsg

TREATMENI:

l-

First aid (ABCD)

a a

2- himatg suweg 3- 9eoondarg surv6g 4- At hoepital:

a
T

CONBERVATIVE: like subdural Hemomhage

TfT. of associaled leeions if presenl

llo
is

5UP4-A0ar5. Ncuro- 5urutry

DEFINITION: Hemorrhage belween skull, dura maller.

?t{fi |

87

Mosl comrnonlg im Temporal & Parielal regions

AATSES (i])

l) Fractural Ternporal bone

2) Fraclure Parielal bonga 3) Without fraclure in Children Pupils
Vilal Data: d\ \re \n V
otr

(Equa!, Reactive)

SooRcE oF BlEEDlrc' (ll) l) Cornmon )Anlerior branch of MMA

2) Serious

3i

Venous sinus t tnsignificant Diploeic V6ii!

ferminal compression

lis

snAd+s (il)

rl_
iting
I

l)

Stage of CONCUSSION 2) Stage of LUCID lNTERyll 3)Slage of COMPRESSION

upil)

al pils

flP$-T)qrr. tQuro- turdtry

?NqV

tU

tr cr SoAN)
HBD FACW nt

ql
E

HEC -

MPDA

o$D

d\b
\

E lntracrania! Hemorrhage E Brain Edema E Dural lear

E
Abscess

tr

Headache Epilepsg

M&M ;6e si \

Etr

Cosmelic deformilies in Skull

Meningeo-encephalocele Posl-traurnatic Hgdrocephalus Sub-dural Hemaloma Aneurgsms

tr Fislula (Carotid- cavernous)

Osleomgelitis

El Cranial N. Palsg tr Whiplash injurg

E E tr
E

troLy

PffiEDIT
PRIMARY SURVEY:
ABCDE, Resuscilalion SECONDARY SURVEY:

soRc'lc{tffi

8co*rnouBI,^EEDING
Surgical Drainage lo evacuale ang Acule Inlracranial Hemaloma

& Moniloring

Exposure Head lo loe examinalion Ample Historg

INVESTIGATIONS CONTINOUS CARE

&

OBSERVATION

ilP4-T)Urr. Ncuro-

turdzry

?W t

61

wtcAtrlT

Queslion mark incision r ( rt InI'lrir;ir':'i Siij lnii riri g l^rr'i6 iTernporalis muscle Jl .-EIU Osleoplastic Flap rJori...
Saline

iihlr,^crd,,ri

I I I I I I

Jl g iibl6 rir l! a l#rir ... pJ Eill"r Itf lgd.o oI! 1-gllr ... pJl Jliri IoJ

elrrj! 1'ilti.or

gaftJq nrr^liii

tjl

Foramen dl
sPinosurn

r.r.a nosfi g'f.41qJ Ternporalis Fascia

cJc

ECA dl

blri

M Position ) Head elevalion M Anlibiotics EI Anticonvulsanls if PDF is present EIRemove drain afler 24 hrs M Rernove stilches afler 7 dags

SURq-4)grr. Nautro-

svrba\

?tQV

SoB
^

| 10

o
o

Dueto ruplureof @ (As it crosses the subdural space)

Bilateral & Severe Persislenl loss of consciousness

o cr:q@E@$ffi;il"J]
Morfalitg up to

Hr-o nin rrlJl r_.ttg+Ul Sr? af tfu Alherosclerosis orir Utol s Elderlg alcoholic " gr? I.1 .. gr1 " oJLig ortor eJ alJ or,!&19 Sudden displacerneni of brain within skull ) ruplure of super{icial cerebral veins 5h-o oJte lgnrrir 3 - gl.rLuri 3 . .!

gl,FuigiiSgJgiiIIij

!@

Trealmenl : (As Extradural Hemorrhagr lnlraoperalive, lhe Dura is:

Vague sgrnptoms (Headache, blurred vision, projectile vomiling,

. Bluish ' Tense . Non-pulsaling

W
-tr
O
ETIOLOGY:

"'+,\

personalitg changes, menlal apalhg, stupor) TTT: Evacuaiion Burrholes

W=j,

Mosl common cause i* IEEIE@ 2nd rnosl common is Rupture " Berrg's aneurgsm "
PICTURE:

O CTINICAL

o o

INVESTIGATION OF CHOICE: TREATMENT: Endovascular Coiling

Evacuation of hemaloma

5UP4-1w$ Ncuro-

tuW\

?lh7

|7

?ilP4-100'lr.

PERIWNOIW
.

&trro- 5urbQry

?lhY

. Compleie molor loss . COMPIETE sensoru loss . Degeneratio" N . Recoverg afler surgical
repair ONIY Besf prognosis with PURELY MOIOR injuries

ffi
injurg of MEDI gctATrc N.

+
Mag

PALPABTE NEUROMA
ed nerve

TINEL'g SIGN

be

(FOR FOLLOW UP) lighl percussion on course ofnerve fiom below

upwards) Iingling

nSrr
Fasciculalions
No abnormalitg detecled in Neuropraxia QUINIZARIAN POWDER

after 2-4 weeks

Anhgdrosis) No coloralion

o,:lr!:.1:aD
ln Closed iniuries ln Open injuries

lf lhere's

Failure

of nerve repair

5UR4-100N1. Munro-

lurhQry

?IQV

ffi
MClosed injuries:

PENPT{ERAtNEF\EII',N/
Or'-lr!'.0-)iiD)tU
Neuropraxia Axonlemesis
I
I

M Neuronternesis M Open injurg or Closed with failure of recoverg E Palpable Neuroma, finnel's sign

M lmprove function if Recoverg is irnpossible

M Splintage M Exercise & Massage M Electrotherapg M Prolection of Skin

g g
V

tI
Arthrodesis Tendon lransplanl Arnpulalion if severe Ulceration & infection

g
g

IMMEDIATE SUTURE

(3.1-weetaafterinjwy)

V lndicalion: lnjuries during

operations Disadvanlaqes: Thin Nerve shealh

t Al Time of Wound repair:

Approxirnale

Neurolgsis branches

2 ends of Nerve bg black silk sulure

V Division of Un-imporlanl V fransposilion of Nerves V Nerve grafring

(Sural

N.)

Cable graft)

3-4 weeks laler: / 2 ends are cul & Exposed & Trimrned z/ Apposition of Nerve sheath

V Fixalion in Plaslic Casl for 3 weeks

Repatu (Epi-neura!, lnlerfascicular )

A.)Rq-{1A\r. &t

tro- lurbQry

?rQY

1+

oF PERIPHERAL, hI. Tr{g,xEs

tr ttlnsr:
Ape Ooponens Pollicis (Iested bg counling {inger lest) Partial Flexor pollicis btevis loss of Flexion of Thumb (Tested bg pen touch lesl)

M Hupolhenar Ms )WASIING
(Loss of abduclion of litlle linger)

M lnterossi) Guflering,
c9ur{Trilo FINGER IESI

No

fanning, no abduclion

Abduolor Pollicis brevis 2Lalerul lumbricals

ctAw

I{AND!

(Extension of MPJ

Flexion of IPJ)

Arrr^pd:
M M
tesr) Flexor carDi Ulnaris ) Weak flexion of wrisl & Loss of Normal Ulnar deviafion

Lateral /z of Flexor di(ilorum Drofundus Ulnar paradox (Exfension of Terminal phalgnx of

medial 2 {ingers)

SrrrlSonl/r.GSl:
g
d

SEhUSm/ roGlS:
g
AI WRIST:

AO of palmar surface taleral 3& Yz ingerc

Laleral Dorsum of lerminal phalanges

Medial Medial

l/3 of palmar surfa l& t/2 {ingers

Ig

DORSAT SURFACE SPARED ELBOW: DORSAT

AI

&

PATMAR

Surfaces are affected

ilRq4w-15. ttunro-

,urba\

?AqY

Spira! Groove rjlr--s

qirp

rijJ

SJ

Long head of lriceps

FLEXION OF THE ETBOW l-f TricepsJl)

WRIST drop

+ {inger drop #tuirJl Usl+i ,JlL,f SJ Elbow Jlr",'tJ? g Posterior lnterosseous N.

Exlension dor,t tjlo.o ...HOWEVER

phiu

J+oJ loJ

of Elbow
...HOWEVER

PRONATION

r-s.ii Exlensor carpi radialis LONGUS

(Loss of Supinalors)
Supinalion Ja.q

@Jai'JtUeni

Ulo,

Bicepsjl1'lr

UiLi-61<

WRIST DROP

+ FINGER DROP Enfension J4q liaoo ...HOWEVER Wrist jl r i,,,t ( of Fingers

SATURDAY NIGHT'S PATSY

(Paralgsis of exlensors of the wrist)

;!

2
Radial N.

lnjurg Al
Flhow

Radialil. lnjury At
Spiral
G

ETIOLOGY: Fraclure, dislocalion, Pressure,

CL!NICAT PICTURE:

AXlttA)

Flexed elbow, Wrisl Drop, Finger drop SPIRAL GROOVE) Wrisl Drop, Finger Drop POST. INTEROSSEOUS N.) Finger Drop

INVESTIGATIONS: ....see before... TREATMENI: ...See before + COCK UP SPLINT

AR$4WI, &uro-

,urff\

?tQY 1 1b

CAFPATTUNNT-USTNDNONTE
DEFINITION: Compression of lhe median

N.

inside lhe carpal tunnel under lhe Flexor Relinaculum

M Medial )

Pisiforrn, hamale

Lale,al') Scaphoid , Trapeziurn

2Ulnar

2Palmar

@ Palmar

culaneous Br. Of Ulnar N. Palmar culaneous Br. Of Median N. Tendon of Palmaris longus

V Primarg: ldiopathic Secondarg lo

a g

Acute chronic

'.

Mgxedema

. .
9YMPIOMS:

lheurnatoid arthriiis Colle's fr.

$caphoid Fr.

C TNTIUHCilNE:
-

EARLY (pain on the hand along the hand & Lateral LAIE (Weakness, Paraslhesia, Numbness

3 fingers

SIGNS: As Median N. injurg al wrisl bul.. (Palmar culaneous br. O{ median N. passes superficial)

g
V

NCV (Nerve conduclion Velocitg) EMG (Electrorngographg)

g g

Division of Flexor relinaculum Mulli-vilarnins

1e4-1Mrr. &uro-

,urd?ry

?l{&

71

Paralgsis of harnstrings WEAK FTEXION OF KNEE

ANESIHESIA BELOW KNEE

r Aulonornic
Palpable Neurorna sr8n

. Tinel's

Paralgsis of All Leg Ms

clawing of toes, anesthesia below knee excepl media! side

.INVE8ilOAflON8. IT[:

lnjurg ie common al if

Paralg
. Aulonornic
OIHB!3
I
I I

es

Palpable Neuroma . Tinel's srgn

ANESIHESIA

ovER

EE

rel
Complele Claw hand
(Wailer's
Aneslhesia of Whole

g g
/(

lip position)

U[ excepl

M M

Aneslhesia
Along Medial aspeci of Forearrn & Medial 3&l/2 {ingerc
Mgosis, Anhgdrosis, Enophlhalmus

Media! side of arm lT2) Skin over Upper part of Delroid (C4)

M Shoulder dislocalion M Direcl blow lo shoulder

Skin of Lower parl of

EtrEI@@

Failure of abducfion From l5o- 9Oo

?ftqY

fo+i+(

diiJ{

1.1lol,t g r-tlgLDi

r:rl(Ja

!ncomprehensible Sounds Exlension lo

Flexion to

painful slimulus

painful slimulus

,flNl

^,1e

dlbl\.,1e
De-oorlicafe

De-cerebrate

C5>Delloid(shoulder movemenl, raise arm) C6> Biceps (Flexion of Elbow) C7>Triceps (extends Elbow, wrisl) C8> Wrisl, small muscles Of hand L4> Quadriceps femoris (Exlension of leg al knees)

Localized cgstic swelling in the $C

Diffuse hemaloma

Hernaloma lirniled to

DD: Subgleal

Colleclions

sulure line
DD:

DepressefS{

fraclure
Cul wound in Scalp causes
SEVERE BTEEDING
(8oalp is verg vasoular &O4 {ibrous lissues prevenl recoil)

ilF-4'40}\r. t'lcuro- 1urd1ry

?AEY

t 100

. ,
lvorg osteorna (Frontal sinus)

BENIGN:

PRIMARY: Osteosarcorna Fibrosarcoma Multiple Mgelorna Gianl cell lumor SECONDARY: , Thgroid, Adrenal, Kidneg, Proslate

. .

GLIAL IISSUES:

Liporna Papilloma

Plexiform Neuro{ibrorna Heman$orna Cirsoid Aneurgsm

Basal cell carcinorna

. . . . .

Aslrocglorna

LOCALLY MALIGNANT: MALIGNANT:

Epithelioma Melanorna Fibrosarcorna Sebaceous Adenocarcinoma Melaslasis

Ol'rgodrendroglioma Glioblastoma Epindgmoma MENINGES: Meningiorna Meningiosarcorna NERVES: Neuroma (e.g. Acouslic Neurorna) EMBRYONIC Medulloblastorna ANTERIOR PITUIIARY Pituiiarg adenoma MALDEVELOPMENT Craniophargn$orna

Ml.l'lUMo S
. ETIOIOGY: UNKOWN Exposure to radiation

ilP$4)arr' &uro-

)urbQ\ ?lQ7 t A

. CLINICAL PICTURE
(Dull aching, Peak al mornin!,

Genelic (Lu Frirnani $, Neurofibromalosis, Turcof's Hormone replacemenl lherapg Head injuries

$)

.
. . .
obg cough, Straining)
VOMITING:

. .

CER.EBML HEMISPHERES Fronlal, Pafielal Tempora!, Occipital CEREBELTO-PONIINE ANGLE TUMORS

;

(Projectile, 4 ln morning, Nol relaled Io Meals, Nol Preceded bg Nausea

PAPILTEDEMA FAISE LOCATIZING SIGNS:

- lpsilaieral cerebellar alaxia - tpsilaleral Affeclion of Srh, 7h , 8ft N. - Conlralaleral Herniparesis

PITUITARY TUMORS: HORMONAT MANIFESIAIIONS

Venlricular dilalalion Cranial N. Paralgsis (Vl) Herniafion $

Neurological manifeslations, 4lCT Bi-lemporal Hemi-anopia

INVESTIGATIONS MR.t... CL Scan Plain X-rag: (Separafion of cranial sufures, Bealen Silver appearance , Enlargernent of Sella furcica, Rarefaclion & deslruclion of the dorsum sellae & poslerior clinoids, Encroachmenl on the sphenoid air sinus)

Cerebral angioglaphu

TREAIMENT:

MDICAL SURGERY: o For BENIGN SUPER.FICIAL TUMORS o Palienls with signs of compression (After urgent Preoperative dehgdrafion) o Palienls with hgdrocephalus
PALIATIVE TREATMENT:
(dehgdrating measures, debulking. chemotherapg, radiolherapg, sgmplomalic lrealmenl)

.',t-,o

Deep Turnors, Malignant infillralive lumors, Residual, Recurrenl lumors

. Mosl common Brain lumor are SECONDARIES . Mosl commoh Prirnarg Brain lumor > GLIOMA . 2nd Mosl common Prirnarg Brain lumor> MENINGIOMA

aRq-Toa.t

t la

ETIOTOGY

'@
a

E.X.

Comptession Fr., Bursl Fr., Whiplash injurg

Metabolic (OSTEOPROSI9) , Deslruclive (POIT'S DIS)

. .
.

CLINICAT PICTURE

.@lschemiaofspinaloordduelohgperflexion.hgperexlensionoflheneck
in an injured palienl
BROWN SEQUARD SYNDROME: lpsilaleral Molor loss

Hisloru of lrauma, Pain, Swelli O/E: Palpalion of spine shows

Conlralaleral Sensorg loss

COMPTICATONS

I) Loss of vascular tone, bradgcardia 2) Loss of muscular tone ) Hgpovolemia . . . . .

INVESTIOATIONg

&

Hge

DIAGNOSIS) Plain x-rag spine, AP, laleral, odonloid COMPLICATIONS) CT, MRI ABCD+ Fixalion ol spine
Primarg surueg

TREAIMENT

(....), seoondarg surveg (..,)

Delinilive lrealmenl : l) tf stable )Exlernal fixalion (e.x. Plaslic collar, shoulder spica) 2) lf Unstable ) Decompression, inlernal lixalion

. . .

ETIOTOGY

ORGANISM) Gram*ve, Gram -ve, anaetobic ...etc

ROUTE

)Direct spread, blood

spread

PDF> lrnmunocompromized patient, sePtic focus, posl-lraumatic

CIINICAL

MASS......... 4tCP lrrilalion, deslruclion lN BRAIN INVESIIGAIIONS . LABORAIORY ......... AWBC, AESR . MDIOLOGICAL.........

. . .

PICIURE Oror;i 3
INFECTION

.........

FAHM. Tachgcardia

Hgperintesitg

TR,EATMENI ' Hospilalizalion , life support )Surgica! drainage (Aspiration, excision)

lf small abscess (<2cm)

Medical

III

DEFINITION: Failure of Felus spine

lo close properlg

l"r monlh of

. Bulging of meninges . NO nervous lissue

MENINGEOCELE
through spinal defecls

.
.

Mosllg Asgmptomalic till pubertg (Sorne cases Present with Urinarg inconlinence)
TTT

- site) Lumbo-scral , back of neck - Consislencg) Cgslic - Translucenl - Compressible - Expansile impulse on cough . III ) Repair during firsi few monlhs of life
MENINGEO- MYETOCELE
I

'

SWELLINO:

NOT REQUIRED

lf lhere's Neurological affeclion)

Culling The MEMBRANAREUNIENS
(Fibrous band connecting skin

lo

meninges)

. .

Prolrusion of spinal cord through spinal defecls Dilated UB, palulous anus
Associated anomalies Hgdrocephalus, Arnold chiari TMNS IILUMINAIION TEST) Dark TTT) REPAIR AS SOON AS POSSIBLE WITHIN 24-44 HOURB

'
. .

. Folic acid deliciencg . Posilive familg hislorg . Having a babg wilh

. .

MYELOCELE
lncornpalible with life

Neural lube defecis

Poorlg conlrolled DM

SYRINGOMYELOCELE
Dilation

, .

PRE-NAIAL: Malernal serum Alpha-fetoprolein al

2d

lffiq

POST-NAIAI:

l)

l{ rnild> X-rag 2) lf severe) MRI, Cf scan 3) lf associaied hgdrocele >

CT

som,

ilP4-4wrr. &uro-

TurbQ\

?AhY

A+

Dlsg
DEFINITION: Ruplure

of annulus {ibrosis+ hernialion of nucleus pulposus

80%

LUMBAR (Lo,L, L5,S,)

20%
WPES
LATERAL:

CERVICAL

(cu,c6

- c.,cr)

TYPES . LATEML) Unilaleral . CENIRAL) Bilaleral

MOTOR

' ' . .

Anlerior rooi) LMNL Poslerior rool) Pain, paraslhesia PYMMIDAL TRACT) UMNI below level
SPINOIHALAMIC TRACT) Super{icial Sensorg loss POST COLOUMN )Deep sensorg loss

LMNL> Weakness, paralgsis in Lower

limbs

CENIRAT:

SENSORY

. Radicular pain , relerred lo lower limbs . Hgpothesia . Loss of superficial, deep sensalions
. Sphincleric disturbances . Vasomolor chanlles

AUIONOMIC

INVESIIGAIIONS

. MRr (OF CHOTCE) . CT scan . Plain x-rau

TREAIMENI
TREAIMENT

LATERAL
.
Conservalive

(Rest, NSAIDS, Ms. Relaxants, phgsiotherapg ..)

Neck collar Analgesics Urgenl decompression

. SURGICAI) According lo pain, molor,

sensorg loss

CENTRAL
. . .
Full-lamineclorng

Hemi-lamineclog Micro-larnineclog

5UEq-4wNr.

&uro-

turdzry

?hhY

r tM

THrcMBOslS
/o
ET!OLOGY:

$l'loct

DEFINITION: ln{lammalion with Thrombosis of cavernous sinus

ORGANISM: Pgogenic ortanisrns ROUIE: Hemalogenous along

communicating veins, Endogenous infections PDF: V lmmunitg

, DANGER ,- ZONE
OF IHE
FACE

CtlNlCAt PICTURE: As Ang infeclion

......

l-

Severe Supraorbital pain (ophthalmic branch of 5'h C.N.) 2-Ederna over Masloid bone (Thrombosis of Mastoid emissarg veins)

3-Proptosis 4-Pupil Dilalation, Iotal Ophthalmoplegia (occutar motor nerves: gd,4'h,6* N.) veins 5- Fundal changes: papilledema, engorgernent of retinal ----F TREAIMENT:

HOSPITALIZATION IN ICU Resl, Tonics, Analgesics Massive doses of

sgsiemic anlibiolics Anlicoagulants Corneal proteclion TTT. OF COMPLICAIIONS

Head

POND FRACTURE: is a simple depressed fraclure in children in which lhe bone is usuallg inden{ed rather lhan fiaclured , Dura usuallg intacl and this tgpe of fraclure usuallg correcls ilself bg lime wilh growlh of the skull V lnvesligalion of Choice in a head lraurna wilh allered level of consciousness )CT scan @ Best TTT Bleeding fiom wounds or incision of

& Spine injuries:

{P(}-Toqn . &uro- lurbe\

?ffi t tAo

Scalp

)
A|CT

EI ln prolonged

Turnorg:

is lhe mosl affecled Nerve (Thin, runs a long course in Cranial cavilg) Emergencg reduclion of

M E
EI

EI S'rgns of Fraclure of Poslerior Cranial fossa ^rcT)Iml@trEE

M M

M
@

EI

Cerebro-spinal [@tE bone fraclure Spinal Cord injurg is suspecled wifh: Viclim of Signi{icanl lrauma Pain ,lenderness of Neck, Abdominal Respiralion, Priapism Oplic nerve usuallg escape in case of anlerior cranial fossa injurg as it is prolecled bg the bong canal {opfic canal} l2lh cranial nerve usuallg nol injured in poslerior cranial fossa injurg as il presenls in the condgloid foramen and protecled bg lhe condglar process ln fraclure base of lhe skull :usuallg a {issure one which runs lhrough lhe weak poinls

Olorrh

Mosl Cornmon Melaslalic lesion involving Spine is Herniation of Uncus of Temporal lobe lhrough len{orial nolch)Pressure on @)Dilated {ixed pupils Hernialion of Cerebellar Tonsils inlo Foramen Magnum in midbrain )Respiralorg irregularitg, loss of consciousness, Neck

O O

sliffness, Head tilt

Tumors associaled wilh Neuro-{ibromalosis : Acouslic neuroma Meningioma Pheochromocgloma Acouslic Neuroma O Arise fiom Neuromuscular lemma of

O O O O

Glioma

Acouslic N.
O Bilaleral, Associaled with "Caf6 au lail

palches"
O Grows slowlg in Cerbelloponline angle O Mag cause cerebral & pgramidal signs

Nenae.i4Juries:
M Pseudomolor affeclion= Loss of M M M M
Gland aclivilies

Miscellaneous:

"Anhgdrosis" Superficial peroneal N. is responsible for sensalion in 1"r,2"d,3d loes cti,e in Sfernomasloid Ms. Accessorg Complete claw hand occurs in: klumpkes palsg

Skin Manifeslalions of Spina Bifida Occulta

Ssmpathectomg
N.) Coslo-clavicular

l[!![t!![

O Tuft of hair O $kin dimple O Skin Hemangioma rolapsed Lumbar M Mosl c disc ) M The mosl imporlanl cover lo lhe brain is
DUM Mattet

include

Combined ulnar &median nerve injurg Volkmanns ischemic conlraclure, Dupuglren's conlraclure, posl-burn scat

conlraclure EI fhe result of nerve is belter in pure molor nerve conlrolling lhe coarse movemenl e.g: radial & is wors{ in mixed nerve e.g: ulnar &median E Rool of origin of - Radial netve: C5,6,7,8 &Tl - Median nerve: C5,6,7,8&Tl - Ulnar nerve: C7,8,fl

ilB+TWri.

sleur6-

ilryry

?W. W

Give a shorl accounl on Glasgow corna scale

(

kasn2@8 )

Give a shorl accounl on depressed fraclure of skull " C/P, lnvesligalions and rnanagernenl "

kasr2@A ) A--- grs old bog resenled lo lhe ernergencg roorn with historg of fall from heighf. He was cornalosed with stable vilal signs and had clear fluid coming oul frorn his nose. Whal's gour diagnosis? Describe the rest of the ClP and TTI of this condition ?
(

kasn2W )

Diagnosis of exlradura! hernaloma, Trealrnenl ( kasn 2@720/- E u s/ans, 2@2 2@52@72Ob -5 u slams, 2@2. 2@52fu ,4r'ar f/@Z 2@6ZM - Ar'rar .L|, zo/zzruz@7zoo6, 2@4Aoo2zw Ay'rar

f,2M-

,4zrar

rllzobzwzurzoa,2@42@2zw

Describe clinical piclure of cutting Ulnail Radial / median nerve at wrist / elbow (5rh shams,2M .2@2.2W2il - Alrar f,2@5.2@42O2 ) Clinical Picture , investigalions and ftt of carpal lunnel sgndrome ( r4y'rarf,2M) Spinal Canal Compression
( r4y'rar

f,2d2)

1.)EtiAw\r. &uro-

turffry

?lh7

DA

ilPq-1)qrr.futottc,

,uW\

?htfi

t lD

. CAIICERTO]IGUE . SWELLIT{GSOFTHEJAH , CLEFT LIP ATID CLEFT PAI.ATE . TiFCELIIilEOIIS TOPICS

. TOIIGIJE ULCERS

. BURTIS . SI$JICLOSIJRE . S0FTTISSUESARCOI,IA . TESTHETICSIJRGEff . BEDSORES . PIGIIEilIED SI$[I LESIOTIS . lrulGMtIT [tlEl.[tl0triA ' il0lI-IIEI.f,il0TIC S!fl ll TUIIIORS

5)Fq400\r.1aetic,
Definilion:

lvry\

?I,QY

ttt

Necrosis of lissues bg Phgsical or chemical agenls

E.x. Sunburns

gura,rfuJl

dgF
bg

tr Affects Epiderrnis tr Blislers surrounded

erglhema

E 9urface is Moisl E Painful, sensilive lo air

El Heais @E

E.x. Uilrl hil! 1,Id 1's,"r,l1il! d9J: tr Affects Epidermis EI Moist, ergthemalous E Painful, sensilive lo air tr Heats E .. bg epidermal

[[EE!@

tr tr tr tr

@of

Epiderrnis White or black escars, area is drg

derrnis

ffi

. skin grafts are needed

regeneralioh from remenants of sweal glands provided that there's no in{eclion

a@onon{Gro
18
o/o

ffiOFBOFhUS
jltl
e
9o/o

ta
fiEf,(

el$EhlT3

tq*

ta6

glf

J5

s.r,,i!l

I
< lO% Total < 15% Iotal bodg surface bodg surface

wlApn
ADUTT

CHITDREN ADULI

CHITDREN

t5,- 30 %
Total bodg surtace area

> SOTo Iotal bodg

surtace area

area

atea

ilEq41qrr.16che'

turdz\

?NcV

tW

CoMffioFBORnUS
sHoct<
/\

see Later

Z FqrcHol,clcAt
.
.
.
Mag be complicaled bg

/\

\Mor

@NsrRlaflilg
ECIIAFS
.
.
ln deep circumfereniial burns of limbs Urgenl escharolomg

sk
TTT:

FaAnoN
edema

@ilpAnraErtrlu
Due lo edema of 8C lissues ::
See Orthopedics eurgsru ::

ln burns of face &

Neck)

seplicemia, seplic
shook

r fJf;

Urgenl iracheoslomg

fff)

wound care
(See later)

(MARJOUN UrCER)

1'R4-{0arr. fitotte,

lury\

?tQ, r tb

SrSrEMtcdoMucttnotE oF
. IMMEDIAIE)Neurogenic shock . EARTY) Hgpovolemic shock . [ATE(>lweek)) Septic shock . lrnmediate) Asphgxia . Earlg ) Pneumolhorax, .

pneumonia,

pulmonarg Embolism Lale) Respiralorg failure tgpe

ll

(ARDS)

. 4Calecholamines . ACorlisol+ ADH )Na, H2O retention . AProlein Catabolisrn ) -ve Nilrogen
balance, 4Glgcogenolgsis

. Acule

LVF

. Congeslive HF . Arrhglhmia.. electrical burns

'

'

Mgocardial infarction

ACUTE TUBULAR. NECROSIS (reversible) ACUTE CORTICAI NECROSIS (irreversible) . MYOGLOBINUREA, HEMOGTOBINUREA

( Wifh eleclrical burns )

. ADYNAMIC ILEUS: Acule gaetrlo dllatallon . CURLING ULCER:
Mainlg in 2'd pafi of duodenum & treated bg EMPERICAL Omeprazole, Anlibiolics & Antifungals

. ACUTE RENAL FAILURE

(Secondarg lo hgpovolemic shock)

. LIVER DYSFUNCIION

Septic . Ufl . Burn wound sepsis . Pneumonia . Seplic shock . Seplic thrombophlebilis

OFN
tr
STOP. DROP
ABCDE

ilPfl-Tw$r.

A6rltc,

turd?ry

?W t

ll+

&

ROLL

E E
tr tr

Dlean with Betadine Dressing with Silver sulpha

.i.iril

:,i9p2 lcrr,iti, slgp

no:.o

9.t"ril

tr
El

(Remove Pi. fiom source of burn, Remove palieni's clothes)

Oinlmenl *
dressing

Vaseline Gauze

:.9rlc2 El

tr tr tr tr
tr tr tr

Analgesics & anlibiotics repeat dressing for 2 weeks till healing

,ertcgE;;GEE-

f4ilt tr

Fluids run... waler oogrni4ir'ito rrf oLlLrn=!,ilr Admission & resuscilalion (Cannula, Rgle, line, calheier) Moniloring Vilal signs (BP, Pulse, Temp, Urine oulpul ... best 30-50 ml/hour) Lab. Tesls (CBC, KFf, LFT, ABGs, serum Eleclrolgles) Eslimale Burn size & deplh Anli-lelanic lG & Vaccine, BS speclrum Anlibiolics, DRUGS Anlacids (fo prevenl Curlin[ ulcer), Analgesics (lV Moruhine)

:
trCrgstalloids)Ringer

FI..1'IDS

NornrnoN
rcRhnot.A
El0olloids+

t.OCAtTIT

PARKITADiID,S

rcFlJlorA

E/A,l'S

E Proleins

trCHO,lipids
EVilamins, lrace elemenls

tr/IFLY
microbial agenl
De{inilion Sile
Advanlages Exposure of wound under

T.AIE
E Escharolomg tr Skin gralt EPrevenl olher Late
complicalions

Laclale

ElFor lhe lircl 4U hours a) l"t I hours ) l/2 dose b) 2"d I hours ) U4 dose o) 3'd I hours ) l/4 dose d) ?d dag) /z ori$nal dose +O.Sml/kP% butnt area colloid

tr l4glx

Crystalloids Kg x

ERoule: . <20 %....Orallu

, .

2O-4OTo... Enlerallg

>

4O %... Parentrallg

percenl surface
area SALINE+

lmlxKg x percenl Surface area

. . .

il!
::i::

r, Hf
i:a

':i

Werghing palienl Plasma prolein level in blood Progressive wound healing

cotlorD
+20OO ml
Glucose

aseplic condilions
Face, Neck One side of lrunk

uove?ed bg bulkg occlusive dressin!

uircumlerenlial burhs
Limbs

& ebililg to

Monilor adequacg of lV fluids bg Vital signs & urine oulpul, Hemalocril value

tr2"d dag) Zz doses of the td dag

combal infeclion

VRepealed dressing VAnaerobic infections

\,

Utoss inleclions
Edema

U{luid loss,

5UB4-{00N5. fua*tc, bvrbery

?thv

t tt'

Segment of epidermis & dermis completelg cut off from lls blood supplg, Nulrilion Depends on DIFFUSION FROM SERUM

Tissues to be Transferred from one sile of the bodg lo anolher sile with lheir Blood supplg EWound wilh poor vascular bed E Reconslruclion of facial features trWhen sensafion is required

Epidermis

part of
Donor

ro o{

dermis

Blrunks, thighs
Upoer arm, forearm ECover large areas of
E

B B

Post-auricular

lndicaiions

granulalion lissue
ECover deep burn ECover afier Malignancg

Supra-clavicular Facial burns BCover Palm, planlar surface

E

BI.oOD SOPFI-Y

of feel
BCover Site of pressure (e.g. sole of fooll B Direcl closure of donor site B Minimal conlracture

RANDoll
A iio;-o

TISSOETI'}E .f. Skin

AXIAT

por.lon. StrE
r,.ocAnoN

.l

reseclion
Advantages

f iilrh'irrrn
A Well known Blood supplg analomicallg

Disadvanlages

Earlg separalion, applicalion B,I'IAKE bg graft E Cover wide area E Deleclion of recurrence of malionancu E Liable lo Conlracture, Pigmenlalion B V Resislance lo lrauma EV Sensalion. cosmoses
E

I Beller sensalion
E

Blood supplu is Non-analomical

{.

*
t

Beller cosmoses

A Ratio 2:l
(Excepl in face)

.f.

NO dirnensional

reslriclions tirniled donor site E Less TAKE bg grafi

B E

Fascia Ms. Bone Visceral Cornposite

(Made of several

different tgpes of tissues)

Favourable granulalion lissue

EScar al donor sile Flaps oblained within area of defecl

neqpr,lau
ThAl.lsILAI>
Flaps takEn from an area awag from defecl bul on sarne exlremilg

usrAhtr
Flaps laken

from

distance

lf,B.
:

ADV\NCNr1ENr E.AF

ffi*y,'::T

posmor{Au

Hl'::*:H H:ffi:'J,'r

breas,

FINGERFT.AF oRB/A

CR6

DlRErcr

qIFRIER

SKIN.S(!rets$orE
:: See General 9urgerg ::

L)Pq40Ar5. fla+ltc,

,urlQry

?I,QY

t Sebaceous cgsl e Dermoid cgst t Neurofiblomafosis e Lipoma t Congenilal vascular

anomalies

A Squamous Keratosis

A Basal

Bowen's disease 6 Xeroderma Pigrnentosa

cell carcinorna Squamous cel! carcinoma Malignanl rnelanoma

sbrryresAncorw\
e DEFINITION: Mal'rgnant Conneclive Tissue lumor arisin!
in lhe exlra skeletal conneclive tissue i INCIDENCE: srh &6th decade of life

lr EIIOIOOY:

Unknown bul rnag follow ...

Radialion for other rnal'rgnancies ln palient with VON RECKTENGHAUSEN $, On top of chronic posl masleclomg arm edema
Liposarcoma RhabdornUosarcoma Fibrosarcoma Painless swelling enlarging over several months (Delaged presenlalion so the lumor is large since ld presentation) O/E: Soft or firm in consislencg according to arnounl of deposited collagen

CLINICAL PICTURE:

INVESTIGATIONS:

For diagnosis: Biposg : FNABC or opeh biopsg For staging : x rau ,CXR., CT scan

TREATMENT:

OPEMBLE: l"t line: Enuclealion 2) 2d line: Ampulalion is indicaled if reseclion will lead

l)

lo

useless lirnb

II\IOPEMBLE:

l)

lst line: cornbination chernolherapg is lhe main line of palliation 2) 2nd line: pallialive sur$cal excision mag be added

flaetLc,lurda\

?Ahe

\7

DEFINIIION:

Surgeru lo improve appearance , correclion of ang disfiguremenl and il is verg imporlanl lo selecl patienls for that tgpe of surgeries as lhere is no palhologg io correcl
EXAMPLES OF AESTHESTIC SURGERY:

Liposuciion
Face lifiing Ege lid surgerg

.i. DEFINITION:

D
A localized area of lhe soft tissue injurg resulting from compression belween a hard prominence & an exlernal surface. It is a tgpe of a vascular necrosis Stages..

PATHOLOGY:

tr

l.
2.

Non -blanchable ergfhema

Pafiial thickness skin loss (epidermis Manifesled as: abrasion,blister,shallow crafer) 3. Full thickness skin loss (SC tissue is exposed) 4. Muscle or bones are exposed (lissue necrosis of ang supporting slructure) E Siles: common analomical pressure poinls
COMPTICATIONS:

General :Bacterernia ,septicemia ,loxemia Local: osleomgeliiis, cellulites, pgo-arthrosis IREAIMENT: Prophglaxis { most important} Reposition everg 2 hrs. 2) Air matters 3) Skin care &improve general condition Definilive TTI:

E E

tr

l)

tr

2) 3)

Slape Sfage

2: as l*dressin! fo prevent drgness of wound

3.4:

Debridemenl

Chernical (Srnall wounds): Saline dressing, Iruxol Surgical (Large wound): Mgocutaneous Flap

ilPti-41T r. Stch:c, surdz\

W$Y

tt9

MOST COMMON TUMOR IN HUMANS

,.DENOVO

>

ON

IOP OF BENIGN"

PREDISPOSING FACTORS:

!t"

Jeqi
' '-'l'-;"'- . Melanocules Pass lo oermls form nod"ules in Epidermis CLINICALLY: Black nodule CIINICALIY:
Flal sooi
rarseo aDove surl'ace of skin

* Prolonged exposure to Sunlight (UV rags) * 4 incidence in Albinism, Reiinilis pigmenlosa * On top of Benign melanoma
oresenl in

Melanocgtes replace basal lager of

epidermis
CLINICALLY:

iermis wiih
junctional activitg

Flat spot

TREATMENT:
Mosl cases require NO TREATMENT EXCEPT:

CLINICAT PICTURE:
SYMPTOMS:

. .

For cosmelic reasons, subjecled lo repealed lrauma, suspected lo lurn malignanl Gianl hairg naevi musl be excised

l)

Denovo presentalion

2) Mal'gnant on top of Benign naevus 3) Occull presenlaiion 4) Transit melaslasis afler removing lrg tumor
SIGNS:

r)

!! {tiii "i"! Gianl Hairg pipmenled Naevi

!!

Grei

6lj!
border

l)
2)

Nodule or ulcer, saiellite lesions

LNs enlargemenl, liver melaslasis

* Asgmmelrical, lrregular

2) Junclional Naevi 3) Chronic irrilalion (shaving) 4) lncomplele excision

* Dark color * Hard consislencg * Change in behavior * Painful, itching, LNs++

INVE$TTGATION$:

l)
2) 3)

Sraging ) Senlinel LNs Pre-op investigalions

Diagnosis) Biopsg

}iHANO,lA
. .

ilR$--T)1Nr. fladic,

aurbQry

?leY

\1

sir*[EII@

Mosl cornmon

(5o-7O%)

. @!er:,

. @, frunk, head, neck . @[4 Raised

above surface wilh

. .
. r

OID age (>60 gears) Dark skinned patienl @ SO[E, palm,

under nail Poor prognosis (Radial ihen

'. Ulcer resisfanl for healing tjlfjl+J

.
DD: BCC, SCC
DIAGNOSED BY: DOPA reaction

Old age

Sile: lesl

Face

! r=rI6.f ,rIJI fuo . ! LiEi tSUl '

raised above

surfiace with irregular edge Besl proghosis

smoolh surface

'

&

Biopsg

Worsl Prognosis
(Vertical growth)

verlical growih)

(Radialgrowth)

PREDICT PROGNOSIS

N.ODERAEIE
Surpical excision wilh safetu marQin

<O.75 mrn
O.75 -1.5 rnrn

. . .

lcm ... if thickness <lmm 2cm... if fhickness l-4mm 3cm ... if thickness >4 mrn

l)

Palliative excision 2) Chernotherapg

(Actinorngcin D)

2) For LNs :
O O

lf tNs are enlarled, firm)Radica!

disseclion lf not clinicallg apparenl)Senlinel LN studu O# Proohqlactic dissecfion

3) !rnrnunelherapg (lnterleukin 2 ) 4) Radiotherapg

Prognosb deVetds OI/ DEPTH !!

ilR4--{0q\5.fua*{c,

lurbQry ?NqY t WO

DEFINIIION: Locallg mal'rgnanl lumor from basal lager of skin

DEFINITION: Malignant lumor from skin squamous epithelium

. ' ' . .

UV rags Xeroderma pigmentosa Radialion, immunocompromisalion BOWEN's DISEASE ... single erglhemalous scalg plaque Leukoplakia

As BCC + ... MARIOLIN UTCER Prolonged exposure to carcinogenic agenls (e.g. coal tar derivatives)

. .

or sailor

Rapidlg

. ' .

ln face (9O%) (lnner canlhus,

Nasolabial folds) Slowlg growing & Painless

While with dilated

capillaries Over

il

@..

Prickle cells surrounded bg Basal cells, separaled bg fibrous slroma

ffi ffi

Cell Nests (Prickle cells

keralin in cenler)

Anaplaslic cells (no keratin) Bad prognosis)

l)
2) 3)

A)P4-jI00N5. flbttc,
Confirrnatorg .. (miooscopic picture) X-rc1 ) lnfillralion (Rodent ulcer) Sentinel [Ns studu in SCC
Excisional Biopsg

aurffry

?tw t wl

tr tr

tr Wirh safetg rnargin @@

Elliptical incision.. for cosrnetic purposes Raw area is covered bg Graft

tr Wilh safelg margin EE

tr

tr Elliptical incision.. for cosrnetic

Raw area is covered bg Graft or bg primarg closure Dissection

( in Face : lcm )

tr lf Enlarged LNs)Block
CONTRA-IND!CATIONS:

lnfiltraling bone, cartilage .. avoid irradialion necrosis EI Near the Ege.. avoid irradiation cataracl EI Recurrence afler radialion .. avoid irradiation
Resislance (super-seleclion)

tr

CONTM.INDICATTONS:

tr As BCC + ......
MAR"'OIIN ULCER

FECFJtfl-y, tiloH,S
Rernove lurnor lager bg lager

trflffiW
lill gg%
oE'u$llafi

sEOFgEny
si

reaching surrounding hearthg tissue

Success up to

The frealrnenl

of Choice in cancer of face & sensilive areas

3

otl{ERs UNES oFTREArtJFrttr

Crgosurlerg, Topical cgtoloxics (SFU), photodgnarnic therapg

?lQY

r v-L

TON(,E
/^

(SELftB)
I

\:

r'lt

r*ix
Aulo-immune
disease with

H#Hiil
Eides

gite

Side

of

Undersurface

IiP ot Iohgue

fongue
opposile lo broken tooth
Size Small Oval

of fongue
(ln Prs. Wth
urhoohihd norr6hl

Angwhere But DOEgN'I

&

Tip

Chancrc on Dorsum near

longue ulcer* llgperkeralolic

lesions Rounded

cRosg
MIDLINE

the lip
Heals

Snail track uloer on undersurfaoe & sides of

Post

l/3

Alwags in Midline

longue
small
Oval

small
Oval

Unilaleral

sponlaneouslg

thape
Floot

eruplion of
small veeicles on lhe longue and oheek,

wilhin 6 weeks
Yellowih washLeather elouoh
PUNCHED

Granulalon

lissue

Caseous malerial

lhal
Base
EdEe LNs

leave SOFT UNDERMINED

SOFT

Sofi

small

+ve
PAINFUT Remove

Nol EnlarAed
PAINFUL

Pain

superlicial areas of uloerslion afler eruplion

ouI
+ve
PAltrlFul

Trealmenl

loolh &
Bioosu

Mouth wash, aneslhelic gel

Anfi-fB drugs

aneslhelic
Painl

i{!.Ifl,

Zr'.Iarbtcrrtr
&rd.ruuFfsae

%+Tpdtqrc

fprttalw

fusiurttrlrft

lJPt4-100Nr. fladi c, Turye\

?Ah?

w1

CAtIcERToNGtE
MOST COMMON INTRA-ORAT TUMOR

ETIOLOGY "PREDI SPOSI NG FACTORS" . Chronic irritalion (S) . Benrgn lumors (papilloma)
Pre-cancerouslesions (Leukoplakia) PATHOTOGY . Sile) Lateral side of longue . Macroscopic, Microscopic picture ... As SCC

. Direci, Blood Lgrnphatic CLINICAT PICTURE TYPE OF PAIIENI ) Old male>SO gears
SYMPIOMS . Painful ulcer, 4,1 Salivation, Dgsphagia
SIGNS

SPREAD

onbolh eldeE

. . .

Foeler oris
Ulcer

fender, Elastic lNs(infection) &

Fixed, hard LNs (mal'rgnancg)

Side of Tonoue oooosiie

to broken ioolh

INVESTIGATIONS
Best is excisional Biopsg with lcm safelg matlin

COMPLICATIONg

. .

lnhalalion Pneumonia lnfeclion, secondarg hemorrhage

.
.
INDICATIONS: Small growths,lncomplele regression or recurrenoe, Cancer on lop of pre-cancetous lesions, lf close lo mandible

INDICATIONS:

.
.

INDICAIIONS:

Tr, Tz

(<4cm)

MEIHODS:

- Unresecable lrg growlh - Fixed LNs in lhe neck - Dislant metaslasis

MEIHODS: - Radiolherapg - Pallialive resbclion - Analgesics, NG feeding - Chemolherapg

. -

BMCHYTHEMPY
IETETHERAPY

disseclion on less affecled side

5UR4|-T00N5. l6ehi c, aur

sr{ErrrNqS
. Chondroma . Osleoma . Osleoclasioma
:: 9ee orihopedics ::

F
. Ameloblasloma

bQ\

?tQY

tW

-IAIT,
'EEEIreEEEEIf,EEE

. Sile: Mandible belween Incisors . Clinical Diclure: Slowlg growing

.
painless {irm swelling covered bg inlacl mucous membrane frealmenl: Teelh extraclion , Excision

PATIENT: goung adult, old aEe

of lumor

. CLINICAI PICIURE: . Eadg) dull aching . Lale:

pain.

referred lo lhe teeth

tr Unilaleral nasal

.
iirg6ll lrr$r 9 iiir-oo a i," !Q tolrir ii

. 9iie: Around

a carious loolh

obslruclion
tr EPislaxis tr Swelling of check x Epiphota, proplosis . TREAIMENT

4-Fr

. .

Macroscooic oiclure:

QliDical Diclure: Bleeds on louch TTT: Excision & Removal o{ toolh

.. angle of lhe mandible {lrir girt^rrrgi+r UiLijE blr Ud orl [r-o iitlLo o;J ldgJLu l"r.ltr.oi
;

ii

tor tarl

Ie

i'r,('i! I.J.,

iifir[,,

Mltr.op .
. . .

Hislological examinalion

Egg shell cracliling sensalion Soap bubble appearance iiro5i... 6a6i

ii

ro.

ii51

. EARLY (OPERABLE)) foial radical maxilleclomg . r-ATE (TNOPERABTE)> .

(Honeg comb appearance) {glriJl U, ;ii1f .'l 6 ll brJ 6ii1 I brJtaJLn lgirlrJl pl-5 (Excision & bone gmfting)

qffi,.r*^
SrclAroos .
. .
Young Male Spread bq: BLOOD
BAD PROGNOSIS

Well de{ined sessile swelling covered bg intacl mucous mernbrane causes FliltillEll?IfdililltilEi MicroscoDic Diclure: Gianl Slern cells ITT: Wide excision

Localized excision of maxilla N.B.

. Spread bq: TYMPH SPREAD . TTf: Commando operalion

ONLY bg BIOPSY

ffiuPffi
DEFINIIION: Failure of fusion belween median parl of fronlo-nasal process & one or boih laferal maxillarg processes in a developing face INCIDENCE:

A*{{''TC0rr. flt+lie,

auryry

?l(* t W

2"d MOST COMMON CONGEN|TAI ANOMALy (After hand anornalies)

. . WPES:
Genello prediepocilion Environmenlal faolorc

l)

:
WPES:

,carion is

@IEEE

2) 3) 4)

Clefr uwla CIeft soff palale lnler-maxillarg cleft Bi-parlite, Tri-partite cleft

(Drugs, irradiation, viral. infeolions)

Meohanioal oauses

(e.r

Oligohgdraminos)

Mag be aesocialed bg "Pierre Robin $"

DlAGNOSIS:

l) 2)

ln Upper Lip) Laleral r,ri?ll.-la,Eg! ln lower lip) Median rriailt .-! iiri
Anlenalal dialnosis bg U/S
Flaring

l)
2) 3)

Antenatal diagnosis bg U/8 after 18 weeks Geslalion lmpaired suckling , speech, Dentafion

DIAGNOSIS:

l)

2) 3) 4)

> 18 weeks Oeslation Flatness of Nares, dis{iguremenl Diflicult suckling!, Nasal lone off firio
&

Associated congenital anomalies (35%)

Recurrenl lnfeclions TR,EAIMENT: . PRE-OPEMIIVE: - Atfenlion lo feeding, use spoon or bottle with a large hote in an upr'rght posilion - Prevention & TTI. of Chesl infeclion

ACTIVE TREAIMENT:

. .

At 3-6 months lnfanl should be al leasl we'rghing l0 pounds Hb levellO mg%

At 12-18 monlhs Obiecfives of suroerv: closure of oro-nasal communicalion achieving a compelenl velo-pharengeal sphincler
Speech lherapg

&

POSI-OPEMIIVE:

& Orthodontic ITI

-T00N5. fraeh:u

surbl\

Yt

wb

'

Most cornmon

*it"..@IEIiEEEM

CLINICAL PICTURE:

.H

.
.

.lgiliotl +.flJl
Pgramidal fraclure Al Base oflhe nose ,posterior

. Mandibular pain . Swelling of {loor of moulh.. [liIllT\rltlEGIfFnE . Dislurbance of funclion (abnormal movernent, looseness of
teeth, hgpolhesia)

'
,

fraclure Above ihe level of the leeth

IREATMENI: lnlermaxillarg {ixalion to inferior orbilal marliins bg wires

wall of maxillarg anlrum & across lhe orbil fTf: inlermaxillarg {ixalion lo zggomalic process of fronlal bone bg wires Hgpothesia (il' near exil of infta-orbital N.)

, .
.

U+i4x.l! +ggil ioJl + 6.dl

Craniofacial dgsjunclion Separale facial bone fiom eranial allaohment TTT: as Le Forl 2 +... Correclion of nasal & zgSlomalic fiaclure

INVESTIGATIONS:
Besl invesligation is N.B. (PANOREX )poor visualizalion {or condglar fiaclures)

lf,[tflfi

TREATMENI:

Firsl aid measures

(4-tailed Bandage for supporl,

Analgesics, Anlibiolics, Mouth hggiene Reduclion under anesthesia, Fixalion bg lnlra-dental wiring or arch bars (3-6 weeks) . ORIF bg plate & Screw for more comolicaled fractures

'

. DlAGNosls ." Besl investigalion u

EpiSEitrlEEN

lndicalion for replanlalion of an ampulaled digil: Thumb ampulalion, lf ln children, clean wound Contraindicalion lo replanlalion: . Absolule: sever medical problerns ,mullilevel injurg lo arnpulaled pant, inabilitg lo slop smoking for 3 monihs post replanl & psgchialric illness . Relalive: sever crush, avulsion ,heavilg conlaminaled wound &amputalion belween MCP&PIP joints of a single digit.

associaled wilh Neurovascular changes tr More frequenl tr Oflen associa{ed wilh arlicular damage
X TREATMENT: ALL

FL R TENDOIV INJURIES) Operalive exploralion, therapg or both ln the E.R.") Laceralions wilh bolh ends are visualized for repair Multiple Tendon injuries, or difficull exposure) Attempied ONLY in lhe OR

Mtxlchss,#'#redffi"
. .
Pain in lhe elbow AT REST

& WHILE MOVING

EIIOLOGY: Direcl Traurna

. MOSI COMMON CAUSE OF SHOULDER PAIN . DEFINIIION: lnflammalion of a lendon of

Rolator Cuff Musoles) MOST COMMON lS
gUPMSPINATUS

lo

Common Exlensor orilin, Repealed Alhletic

aclivilg
IREATMENT: Resl, Local

. EIIOIOOY: Repealed lrauma from sports . C/P: Painful aclive Abduclion when thoulder
moves belween 60-120 (PAINFUL ARC

injeclion of Corlicosleroid in Resislant cases

SYNDROME) TREATMENT:

NSAlDs, lmmobilizalion, Gradual aclive exercise afler few dags, Looal lnjeclion Corlicosleroid in resislanl cases

of

rns

fhickening, of Fibrous flexor shealh at MCP joint, leading lo Locking of lhe {inger in Flefon wilh Local fenderness al MCP

lnflarnmalion offendon Shealh of: Abduclor Pollices Longus, Exlensor Pollices brevis while orossing lhe

. C/P:

wrisl

Active and passive movements

joinl

r IREAIMENf:
Flexor sheaih

Division

of

Constricling Fibrous

of lhe thumb exagl2erale the pain & Limil movemenl . TREATMENT: Divieion of Conslricling
Tendon Bhealh

. . .

Progressive lhickening & Contraclion of Palmar aponeutoSle Bilateral in SOTo of Cases ETIOLOGY: ldiopalhio, Familial, 4lncidence wilh Cirrhosler alcoholics, Epileplics under phengloin TTT.
FTEXION DEFORMITY The MCP ioint, Proximal lP Joinl

I
I

. .

Phgsiolherapg (earlg) Surgrcal lrealmenl (tate) ... Subculaneous fasciotomg, Aponeurosis excision

ii

il?t4'-TMrr.fia*te,
and 2570 are induc,ed bg the other agenls .

turyry

?lh7

t Vts

n 2nd degrce burn is furlher subdivided inlo

9uperlioial dermal burn: charaoledzed bg formalion of bullae ,exlend lo lhe ouler dermie and heal within l5 dags DeeD dermal burns: reach deeper bul lhe skin appendages are spared and heal within

3-4 weeks.
of blisters in culaneous burn injurg ) a parlial lhickness burn (second degree) !r Scalds (burne due lo Hot fluids):
More common in children - Tend lo be Parlial lhickness burn tr To determine depth of a burn delermine lhe tgpe of burn, Teel sensibililg of lhe burnl atea. E Rcgarding Rule of 9 )the entire baok accounls for 18 percent. tr The palienls right upper exlremilg becomes cganoiio ahd cool, with delaged oapillarg re{illing, loss of pulse and no llow signal on Doppler ullra sound and lhe nearesl burn cenler is 3 hours awag) the immediale TTT is
tr The presene,

superficial spreading melanoma 757,. BE excised mainlg because of risk of mal'rgnanl lransformalion. x TTI of BCC is mainlg exoision. E The skin grafts harvesled from a donor siie and subsequenllg lransfemed to a recipienl sile on whioh it musl survive, a prooess known as "Take" .. (refers lo vascularizalion of graft) x Regarding skin grafls - Skin graft normallg "lakes" wilhin 3-4 dags of

x Oianl hairv nevus MUSf

grafting
Muscle normallg provides a suilable bed for splil skin grafting. - Slaphglococcus auieus and pseudomonas aeruginosa can resull in traft failure - A split - skin grafl can be slored al low lemperalure for 3 weeks before application tr Earlg excision + graflinEl dramaticallg improve lhe eurvival of burnl patienl while role of prophglactic anlibiolics is conlroversial.

ESCHAROTOMY

ln exlensive burns, lhe fluid replaoemenl during the lirsl 24 hours: - Ringer laclale (according to parkland formula) - Conlrolled bg urine oulpuVhour - Should be supplemented bg blood lransfusion lo mainlain lhe hemalocril around 35% - ls calculaled according to the bodg weighl and surfaoe area 11 fhe mosl ueeful measure in prevenling renal shul-down in post burn palienl is mainlaining an hourlg urine oulDul belween 30 and 5O ml. x Biological dreesings for burn wounds : Vpain, Vprolein loss, Prevenls conlaminalion )1 Partial lhiokness bums - More painful, sensitive lo air (Terminal N.
El

X CLEFI LIP:

Cleft upper lip is due lo non-fusion of maxillarg

prooees wilh median nasal process. Fusions and formaiion of lhe oral cavilg lake place in the 8th week intraulerine Mosl common tgpe of ole0l lip is unilateral ( left sided ) The aim of lrcalmenl of an infanl with a cleft lip is lo improve appearance. Cleft lip should be repaired al lhe age 3 monlhs Cleft lip and clefl palale is familial in 12% ol
casee.

endings still intact)

- lf kept clean il will heal wilhin 3 weeks,

lhickness requires excision + grafting.
tr ESCHARS

Full

lnelaslio dead lissue "nol fibrous" resulls from full lhickness burn. lnsensilive lissue... (d'rvided ae bedside
procedure wilhoul aneslhesia) Circumferenlial Eschars arc dangercus Acule limb isohemia "comparlmenial 0", Respiralorg impairmenl.

trCLEFT PAIAIE:

- 5O% of lhe children with Clefl palale

heve

some degree of deafness. - Cleft palate repair is ideal at 6-18 monlhs.

REGARDING CARCINOMA OF LIP : - lncidence: Mosl frequenllg squamous cell carcinoma, in the lower lip. - ll is usuallg low grade and well differentiated. - lf occurs al angle of moulh)More Malignant in behavior > lhal of upper or lower lip. - ll rnelaslasizes via lgmphafics. - Mag be confused wilh a keraloacahlhoma. - ls curable bg surgerg. REGARDING

x Regarding basal cell carcinoma: - Arise from lhe basal area of appendages

Common form of skin cancer occurring in elderlg

male.

- 9O7o ol lesions found in lhe face. - Nodular tgpe is the commonesl histo-palhological
varianl of BCC.

!1

Currenl guidelines advice lhal lhis lesion is resecled with a 5 mm margin.

IHE CARCINOMA OF IHE

IONOUE: - ls more common in males.

- lt mag cause earache. - Melaslasize via lhe lgmphalics al an earlg - ln mang inslances
mandible.

C/O: 9gmplomless (Earlg), ll mag be simplg presenl wilh a lump in lhe neck, Alleralion of lhe voice is an earlg feature of carcinoma of the back oflhe longue. Mosl common Presenlalion) indolent ulcer.

Regarding squamous cell carcinoma: A malignanl lumor arising from epidermis. - Frequenllg occurs in pre- exisling skin lesion - The lrealmenl of choice is surgerg, radiolherapg - Marjolin's ulcer is skin squamous oell carcinoma on lop of chronic benign ulcer or chronic scar. E Regardihg malignanl melanoma: - Melanocgles develops from neural cresl &

migraled

lo epidermis

The incidence is increasing, lOTo afise in a pre-

slage of lhe disease. the lgmphatics draining lhe anlerior UO oi lhe longue and lhe floor of lhe moulh lraverse lhe periosleum of lhe
Causes

of dealh in lerminal slage:

Hemorrhage, Bronchopneumonia,

Malnulrilion

exisling naevus Sites olher lhan the skin can be affecied Superficial spreading melanoma is lhe mosl common histo-palhologi cal lgpe (75%) Breslow's lhickness is a beller prognoslic indicalor lhan clark's levels. Spread of malignant melanoma is Local, lgmphalic and vascular.

IIgSUE EXPANDERS - DEFINIIION: fhg are inflalable silicone

implanls SITE: Theg are placed subculaneouslg in collapsed slale

SYNDACTYLY - AUIOSOMAL DOMINANT, M=F . MOg COMMONLY IN 3'd WEB SPACE

5O7o Bilate,al

C/P:

.SIMPLE: d'rgils connecled bg sofl lissue .COMPLEX: Complicaled wilh shared bones, Nerves, vessels, Nails INVESTIGAIIONS: X-rag, Felal Sonogram
TREATMENT: ....gURGlCAt....

.Anglime from Neonalal period lo 4-5 gears .gtaged operalion

POLYDACTYTY

AUTOSOMAL DOMINANT,

M=F

C/P: Rudimenlarg {inger or fullg developed Exlra-digils - INVESII0ATIONS: X-rag, Felal Sonogram - TREATMENT: ......9URG1CA1...... .Angfime from Neonalal period lo 4-5 gears

'glaged operalion

ilPq41\rr.

fl*ohe,

1uryry

?AhY

t t10

\/R
MELANOMA
RFICIAT
aged palienl presenls with pigmented nodule raised above lhe surface wilh irregular edge. The palienl gives past hislorg of prolonged exposure to sunrags or benign melanoma.

KE

NODULAR
Palienl presenls wilh grag or black colored
lesion raised above lhe surface wilh smoolh surface mainlg in lrunk or head and neck.

ACRAL

AMELANOTIC MELANOMA Palient presenls wilh

p'rgmented lesion in ang

TENIIGIOUS
Dark skinned old age palienl presenls wilh black or grag colored lesion in palm, sole or under nail.

area of muco-culaneous

junclion ( ege, anal canal&

meninges). DOPA reaclion

lesl is positive.

The palienl

gives pasl hislorg lo benign melanoma.

Male palienl >4O gears farmer, sailors (or ang occupalion wilh prolonged exposure lo UV rags) presenls with slowlg growing, progressive ulcer wilh necrolic floor, rolled in beaded edge & induraled base in the face above line joining tragus with angle of moulh. The palienl give past Hx of nodule, uloer resislanl for lrealmenl. With NO LN enlargemenl.

SQUAMOUS CETI CARCINOMA

Male above 4O gears ,farmer or sailor ,faired colored presents wilh painless nodule lhen ulcer for lrealmenl. fhe ulcer is rapidlg growing wilh everled edge and necrotic {loor, LN is enlarged

Neonale presenls wilh impairmenl of suckling congenital anomalies. The mother gives hislorg

& recurrenl chesl infeclion & multiple io radialion exPosure during preghancg

MALIGNANT ULCER OF THE TONGUE

Male >50 gears old, heavg smoker, presenls wilh dgsphagia & painful ulcer in lhe iongue wilh raised and everled edge. Pain is referred lo lhe ear with Asalivalion and lhe palient spils as he {ind it painful lo swallow his saliva. O/E tongue deviaied lo the side of lhe lesion with palpable submandibular L.N

Female patient 2O-4O gears old presenls wilh painless progressive swelling lhe mandible which qives eqA-shell cracklin! sensation on examinalion

of

Female patienl presenls with painful ulcer in the oral cavitg esPeciallg near lhe tip of lhe lonlue rounded with red marqin wilh no LN enlarlement

fe44W6.16sItc,

ruryry

?W t

l.

---

gears old male

a closed room

femate patienl , resulling burn.

weighini--- kg, suslained aflame burn (kasr

in

Diagnosis of burn depth and exianl

2OO8 - Ain shams: 2OO5 )

Firsf aid ( kasr : 2OOB - Azhar m: 2OO7 ) and hospital manalemenl ( kasr : 2OOB ,3in shams: 2OOS - Azhar m: 2OO7 Earlg and lale complicalions and possible causes of death
Local

Azhar

f: 2OO7

ttt of burn

( kasr : 2OOB )
( Ain shams: 2OlO )

Faclors affeciing prognosis

( Azhar

f: 2oll

2. --- kg , ---

room wilh a burn lhat affecled lhe anlerior aspecl of the right leg and anlerior aspeci of lhe abdomen & chesl . OlE , her vital signs were stable aparl from a lachgcardia of llO , and locallg the burnl area was erglhemalous wilh blislers and was sensilive to pinpricking . which fluid she will require in lhe firsl and second 24hrs.
gears old female

/ male presenled to the emergencg

3. D.D of Leg ulcer

4. 5.
( kasr: 2008 - 3in shams:2OlO - Azhar rn:2O1L2OOS Tgpes , complicalions and lreatrnenl plan for clefr palale
Cancer longue : diagnosis

( kasr 2OO8 )

Azhar f:2OOl )

( kasr 20ll )
,ltt
and prognosis

( Ain shams 2OO4 )

6. Managernenl of rnelanoma
( Ain shams: 2OOg )

7. D.D of ulcers of the lip

( Ain shams: 2OO9 ) 8.
Basal cel! carcinoma

( Azhar m: 2OOl

- Azhar l:2OO7.2O04 )

5)?q-a)Ar, flazlic, ,urdt\

?AQe

W-

ilP4-10Tr5. Urdro-Ittoriuc,

ourgery

?I,QY

tW

. Cardiac arrest & CPR . Fracture ribs . Pneurno-thorax . Herno-lhorax . Ernpu ema

' Posl-operalive
PulrnonarU cornplications

cloor x-rqyshovued l bmkcn dbr but re ft:ted itwi{t PlrotoohoP.t

ffirrc
M Mgcocardial anoxia ...e.g. infarclion ElMelabolic : l) Hgperkalemia ... hgpokalemia ...

ilP4--Tw.lr. Urdio-flprtcie,

ourgzry

?l@

tW

DEFINITION: Sudden failure of hearl

lo mainlain circulalion

Mgocardial depression lnadequale venous relurn

M MECHANICAL:
Massive Pulmonarg ernbolism Pleural ef{usion M Acute Hemorrhage M Genera!. spina! anesihesia

2)

Hgponatremia ...acidosis

M Severe lrauma M Vagal stimulation

T/FES:

I.

VENTRICULAR FIBRIILATION..

2. Asgslole 3. Eleclrornechanical dissocialion

STEIHOSCOPE HAg NO RULE IN DIAGNOSIS OF CARDIAC ARREST, ONCE THE CONDITION IS SUSPECTED.. CAR,OTID VESSEIS ARE PALPAIED TO CONFIRM THE DIAONOSIS & SIARI CPR

M SUDDEN LOSS OF coNscrousNEsg M ABSENI CAROIID PUTSE M CESSATION OF RESPIRAIION EI BIIAIERAI DITATED FIXED PUPIL

il84-jf0Cr\5 Ur d,i o-fl16,rhci e, ourg,.nl

?th7

vtt"

MATTFEST
VAntF/

DlAgilo$s
M M M M
SUDDEN LOSS OF

coNscrougNEss
ABSENI CAROIID
PULSE

FIRSI

AID)

ABCD

Resiore NOR.MAL COP

keep >9O
,,rlfrtlg CaCl2, Elucose, insulin
NaHCOS it'fl't ir,,1
t.' :,rr.i-:,lil
',,":l,itr:1it'{l
rr'd .fl:.r

CESSAIION OF RESPIRAIION BII.AIERAT DII.AIED

FIXED PUPIT

M Airuag Head iilt, chin lift M Breathing Look, listen, feel)

Mouth lo mouth breathing

M De{ibrillation M Correclion of
reversible causes

EI Endotracheal tube M Wide bore cannula

M Circulation
Cardiac massage
(15 compressions :

IV drugs

i_-'.

1t -;

Proohulaclio Lionooaine Anii-convulsanls

2 Brealhs)

M Drugs

l)

lV fluids, Mannitol

4(ToDrrr.'ITFEE)

2) Dobutamine 3) Dopamine 4) NaHCO3 5) Atropine

M Maintain CPR M lntra-cardiac injeclion of Adrenaline

DEHBRIT.TNON

M M M M M

2o0joules lf Failed) Repealed again lf Failed) 36O joules lf Failed) lmg IV epinephrine lf Failed) I minute CPR lf Failed) 3 shocks of S6ojoutee

ilE{*-{00r\5. C.rtrdio-lhorkuc,

cur6ary

V{+ t

V1

!'TITTI:III

Fraclure of

al I sile

EE

tllltua!iluitt
Each al

Multiple ribs

I poinl

EXE@

(>3

ribs)

Fraclure of mulliple ribs al mulliple points, lntermediale segmenl of fraclured rib is sucked inside & Fixed

Al lhe mosl convex Darl of ribs

a

Syrnptornc

A-P comoression Hislorg of lrauma Pain, swelling, Dislurbance of funclion (Dgspnea)

Direcl lrauma Hislorg of lrauma

Pain, swelling, Dislurbance of funclion (Acule chesl oain, duspnea, couEh) Signs of Respiralorg dislress) .... Shock. Enoorped neck veins (l{ complicated) Ecchgmosis, bruises, 9Movemenls On affecled side

GeneralSigns lilspection

Signs of Respiralorg dislress

Working Ala nasi, Cganosis

Ecchgmosis, bruises, VMovemenls

Ecchgmosis, bruises & lnlermediale segmenl of fraclured rib is sucked inside & Fixed

Palpation Aurcultotion Others

CsmpliEotia{rs

fenderness, Creoilus, VWF

V WF& shifl of lrachea lo oDDosile side VAir enlrlt

Associaled ch, rst iniuries, abdominal iniuries Pneumolhorax , Hemolhorax, Ruplure mediaslinum, Kidneg, Spleen, Liver
I I

lnvestigations Treatment

Plain x-rag: gites

EiTIEIItrilIqIIE
(MORPHTNE COUTD BE GIVEN IF VENTII.ATION BE suPPoRrED)

CXR, CI scan, ABGs, KFTs of fiaclures can be seen ! Us ) ruoture soleen ABGs.... VO2 Saluralion, 'l CO2 saluralion in blood ABCD (if Polu-lraumalized palienl), Resusoilalion & Moniloring after lrg surveu , Becondarg surveg V lf small segmenl)glrapping chest over firm pad . lmmobilizalion :

courD

lnlernal bg Conlrolled Venlilalion Exlernal bg Adhesive irapping

g
g

lf

lf

severe paradoxical Respiralion) Positive Pressure Respiralion bg Venlilalor lhere's an indicalion of fhoracolomu )ORIF

. .

Adhesive Slrapping Reduciion bg

lraclion OR|F...

T00Nt Urdio-lnorkcie, eur6ery

?hfcY

t18

1'
Definilion

\
Valvular lear" allowing air lo enler bul nol lo come oul fiom lhe
Dleural sDace

Lillle amounl of air is enlrapped inlo pleural cavilg

Pleural space communicales wilh

exlerior

Etiologg

Sponlaneous

Traumalic (Accidental or lalrogenic)

. IreIEEEIEpIiEEDEi@
on affecled side :

.
.

Alnlra-pleural
Pressure Mediaslinal shifl lo opposite side leading lo collapse

) ) .

Expands wilh expiralion Collapses with

lnspiralion

F Oscillalion of air
belween 2 lungs D Normal lung is alwags {illed with air de{icienl in Orloaded with CO,

of olher
lung

. Mediaslinal Flufter . Loss of Negalive lnlralhoracic Pressure

CLINICAL PICTURE

Lose of -VE lntralhoracic Pressure-- VVR

Kink of Aorfa= VCOP

Sgmploms
General

MILD CONDITION

examinalion

Historg of trauma , Chesl pain, Dgspnea ,cough, cuanosis . Signs of shock: 4Pulse,VBP, Subnormal Temp. . Resp. dislress: working ala nasi, cganosis, lracheal shifl
Local examinalion Ecchgmosis , Bruises

lnspeclion
Palpation Percussion

V0hest movemenl
on affected sile

, V0hest movemenl

. V TVF on affecled

sile Shift of trachea lo opposile side

HYPER-RESONANCE

NO mediastinal shift HYPER-RESONANCE

WMPANIC
REgONANCE

Auscullalion lnvesligalions

9Air enlrg ... (in Open pneumolhorax ) Whistling sound)

,
. .

oh lhe affecled side NO Broncho-vascular markings Edge collapsed lung is visible

on lhe affecled side Tolal lung collapse on affecled side Parlial collapse on

Noi needed
Done if Diagnosis is suspicious

of

First Aid Definilive f realmen{ NO Dgspnea :

Conservalive
TTT

. Monilorlnl & eeoondaru

Moniloring t ABGs Dgspnea : lnlercoslal lube under waler seal unlil complele expansion o{ collapsed lung

opposile side . Mediaslinal shift to opposile side . Dianhraomalio flaflenino ABCD al site of accidenl , Resusciialion & Primarg surveg
eun eu
a

/ /

Sulure wound Inlercoslal

lnlercoslal lube under waler seal in 2"d Space MCt

Recenllu : ln Srh space and direcled lowards
anex of lund

lube under
waler seal in

2nd Space MCt

?WtYn

DEFINITION: Colleclion
LOCAT CAUSES:

of blood in lhe Pleural space

GENEML CAUSES:

fraumalic injurg of infercoslal

vessels, internal mammaru vessels or lung tissue Posl-operative Pathological (tumors, Aorlic aneurgsm)

. .

. . .

Blood disease Hgpertension

Dr"ugs

PArltot

&ch

|Gl/

I.

IHE COIIECTED FLUID:

Remains fluid

in the pleural space in mosl of the cases

respiralorg & Cardiac movemenl defibrinates blood '. Verg irrifanl as il oontains an effusion rich in Proteins Excellenl cullure for infeclion (COMMON) 2- Mag be associaled with Pneumolhorax
CLINICAL PICIURE: As pneumolhorax except

lN\lEsnqlkno}.ls . cxR
.

/ /

Obliteralion o{ costo-phrenic Angle, opacilg rising to axilla Fraclures

Aspiralion ) Blood For cornplications ) ABGs, invesl'rgations For associaled injuries

ffi
FotlrTRA,NIAT'ZED PANENT
M ABCD M Resuscilalion & Monitoring

FED/b\ALoF BLooD
MSevere bleeding>2OOml/hour M Persislenl bleeding despite of conserualive Tff hemolhorax

Repeated aspiralion

lnlercoslal lube under waler sea! in lhe 5s lnlercoslal

sPace

EI Looulated

M Associaled wilh olher

injuriee

For.eign bodg

X)P{4-{ 0}rr. UrN o-lnorAci c, curgery

DEFINIIION: Colleclion of Pus in lhe Pleural space

ETIOLOGY

.ORGANSIM: , Staph, Putrid Empgema, Slrepl.

.ROUIE: Local, Direcl, Blood

.lpf
M

Children following Lobar

. .

Pneumonia

CLINICAL PICTURE Sgmpioms

S'rgns

GENERAL

FAHM

. .

Fever,

. .

lnadequale drainage lnadequale poslop. care Underlging disease Poor general

. .

Encgsled
Empgema

Recurrenl
Empgema

rocAt

Tachgcardia Cganosis, workino Ala nasi .IN9PECTION:

condilion

General) Chronic
loxemia, acule
exacerbalions (Fever, chills) Local Chronic sinus in chesl wall Per{oration

VMovemenl

of

PALPATION :

inlercoslal space

vwF,
.
.

shift of

mediaslinum
PERCUSSION: Dullness AUSCULTATION:

SC abscess Expansile impulse

As acule emPgema

+ .....

PUTMONAR,Y FIBROSIS

VAir entrg

COMPI.ICATIONS

General: foxemia, Bacteremia,

. . . . . . . . ,

Cullure & Sensilivitg for spulurn or pus

CBC) Anemia, ,l\ EgR,4

TLC

CXR)

Septicemia, Pgemia

overcrowded ribs, shift of lrachea, elevation of diaphragm

CT CHEST

+ BIOPSY..."mosl accurale"

o o o

CBC: ,ITLC, OESR CXR: obliieration of coslophrenic angle with opacitg rising lowards axilla

General) correclion of anemia, conlrol DM Aniibio{ics, Mulli-vitamins Local Re-drainage bg rib reseclion*
Phgsiotherapg

Decorlicalion

lung expansion
areas

Thoraco-ceniesis:

Pus)

C&S

lf failed) Thoracoplaslg for localized

Z
O O

IREATMENT:

GENEML: Resi, analgesics,

anlibiolics, anli-pgretics
LOCAI-:

l)

Aspiration drainage

2) lf Failed) Closed

(Bg inserlion of inlercoslal lube under waler seal in lhe Sth - 7h space al mid axillarg line)

3) lf Failed) Open Surgical

drainate
(Bg rib reseclion & surgical evacualion of pus onlg when full localizalion has occurred)

Weol|Ptl
ll. )
lnhalalion of gashic conlenl (Mendelson's sgndromo)
Excessive secrelions:

a- Bronchilis, Bronchopneumonia b- Lung abscess c- Aleleciasis d- Empgema

embolism

lll. Pulmonarg

lV. Adull respiralorg distress sgndrome (ARDS)

. lt

occurs in lhe postaneslhelic period when

ETIOTOGY in a Palienl with full slomach or has inleslinal obslruction. - ln oomalose palienfs, e.g. after head injurg or drug poisoning. CTINICAL PICIURE - Wheezes, cganosis, lachgcardia, lachgpnea & hgpolension. COMPLICAIIOITIS - Severe pneumonilis, which mag be falal.

the viial

- During induclion of anesihesia

swallowing coughing are absenf. The resull is pneumonia, which is usuallg mild & lrealed as aleleolasis.

&

reflexes

as

INVESI!GAIIONS

- CXR) widespread lung irrlillralion (Rt.>Lt. , ,l.in tower - ABGs ) severe hgpoxia.
TREAIMENI

lobes)

- PROPHYLAXIS ) -

all h'rgh-risk patients should have a nasogaslric tube inserted before lhe operalion for suclion

of

lhe gaslric conlenls. Endolracheal inlubalion & suclion of lhe aspiraled malerial)cleaning with saline irrigalions. Anlibiolics, corlicosleroids.

.ETIOLOGY: De novo or as an exacerbation of

exisling bronchilis.

.ETIOLOGY: Bronchifis) Patohg consolidations .ORGANISMS: H. in{luenza. pneurnococci.

.WPES: Sirnple cough wilh muco-purulenl spulum,

severe suppuralive bronchilis. .O/E: Rhonchi & crepitations all over lhe lungs. .CXR: notmal.

Slaph aureus.

.O/E: FEVER 39"C, Bronchial breathing is

heard, Palient looks ill. CXR: patchg mottling.

lJRl4-4 00Nr. Ur di o*1\orfuu c, eur6ery

morning. ETIOIOGY:

?[hY

t+L

I a

Bronchilis) ooclusion of a bronchus bg visoid seorelions of mucus or pus) Aleleclasis

of the affecled lobe.

PREDTSPOSINO FACTORS:

I b

o . o .

Depression ofcough reflex, bg pain or sedation & poor venlilalion. Produclion of lenacious muous due lo: Pre-operalive Respiralorg lracl infeclions, inhalalion of FBs, vomilus or seplic malerial, Premedicalion wilh alropine. Prolonged Elher anesthesia.

Posl-operativedehgdralion.

PATHOTOGY

. .

Obstruclion of a bronohus bg a plug of mucous) absorplion of air dislal to lhe obslruolion and deflalion oflhe affecled area.
THE CONOEOUENT COLLAPSE MAY BE:

l. 2.
- fhe palient

Lobular: collapse of scaftered areas lhroughoul the lung. Lobar: oollapse of one lobe usuallg ihe lower.

does nol feel well, is brealhless

& there mag be fever & lachgcandia.

breath sounds.

- Reslricled movemenl of the affecled side of lhe chesl - PERCUS$ION & AUSCUTTATION: lmpaired percuesioh note & diminished - Slighf cough and spulum is difficull lo expel and scanlg.
!NVESIIOATIONS CXR:

- fhe

collapsed lobe appears as

Major aleleciasis causes approximation of the ribs, elevalion of lhe diaphragm and devialion of lhe mediaslinum loward lhe affected side.

,.\v/

rVr

Jr

:liisan
.
sudden expecloralion a larlle amounl of PUs. CXR.: cavitg with {luid level.

of ang of lhe above.

PROPI{YIACIIC

. . . . . . .

PoslPone operalions in palienls wilh bronchilis unlil trealed properlg. Theg should be taught brealhing & coughing exercises. Bmoking, should be slopped for several dags before operalion. Denlal sepsis should be lrealed. Al lhe end of lhe operalion, lhe lracheo-bronchial lree should be aspiraled rhotoughlg. Earlu relurn of consoiousness & cough reflex should be aimed fo. BrealhinE, & coughing exetcises slarted verg soon

'
.
.

ESTABTISHED CASES Phusiolherapg, sleam inhalalions and encourage expecloralion. expecloranls lf nol enough calheler suclion is performed. bronchoscoPic suclion If nol effeclive of bronchial lree under local anesfhesia. tf aleleclasis recurs, bronchoscopg is repealed or lracheoslomg is done (beftet) especiallg when lhe secrelions are profuse. tl diminishes lhe dead spaoe, & provides eaeg access for repealed

) )

after recoverg. . Psin is conlrolled bg small doses of pethidine

. Epulum

aspiralions. is examined microscopicallg & proper anlibiolic is given. cullured

il

does nol depress respiralion.

3) ADOLT
Definilion . Lung condilion lhal leads lo low 02 level in blood. . l{ is also called: non-cardiogenic pulmonarg edema. Etiologg Severe sepsis. Patienls in septic shock are particularlg al risk of developing ARDS. 2. Severc shock (ang tgpe) especiallg if requiring large volumes of lV fluids.

l.

3. Major lrauma.

4. Extensive burns. 5. lalrogenic {aclors:

- lUon-{iltered blood lransfusion. - Overlransfusion of {luids. - Use of oxullen concenlralions over 5O7o. - Massive doses of sleroids.

6. Lun! injurg due lo lrauma, inhalation of fumes or aspiralion of gaslric conlenls. Pathophgsiolo4g . ARD8 is associaled with severe and diffuse iniurg lo lhe alveolar-capillarg membrane (lhe air sacs and small blood vessels) of the lungs. Some alveoli dislend wilh fluids, while some olher alveoli collapse. . This alveolar damage impedes lhe exchange of oxggen and carbon dioxide, which leads lo a reduced concentralion of oxggen in the blood. . Defect in lhe 3 aspecls of lhe respiraiorg process (venlilalion / perfusion / diffusion). . Hgpoxia causes damage lo other vilal organs of lhe bodg such as lhe kidnegs. Palhologg Macroscopic piclure) Greal increase in lung weighl, Petichial hemorrhages on epilhelial surfaces. Microsoopic picture Inlerslitial edema and hemorrhage, Alveolar edema, Peri-alveolar hemorrhage. lnconslanllg, inlravascular fal globules and librin plugs. Clinical Diagnosis Medical hisloru of condilions lhal can lead to ARDS e.g. severe pneumonia.

. .

l. 2.

lnilial slale:

) ) ) ) ) )

Shook

Laclic acidosis Hgperveniilation (low PaCOr, bul PaO2 mag be normal or slightlg low).
The palient mag apPear well recovering

3.

Chesl X-rag is normal PaO, is invariablg low Confusion and occasional pelechial rash. Chesl x-tag reveals bilateral pulmonarg infiltralions. Risin! PaCO, and falling PaO, occul despile oxulleh suPPlemenl.

4.

) ) )

Complicalions of ARDS

l- lnfeclion. 2- Pneumolhorax. 3- Deep vein thrombosis (DW) & pulmonarg embolism. 4- Lun{ scarrinQ: - ARDS causes lhe lungs lo become stiff (scarred) ) cannoi expand. - Being on a venlilalor for a long lime also can cause lung scarring.

ilPq-Twlr.
lnvesl'4alions
. Laboralorq:

Urd,io-llprfucie, eurp-,,ery

?W t

l++

ABG: reveals hgpoxemia (reduced levels of oxggen in the blood). CBC: 6WBCs in sepsis. . RadioloAical: a- CXR: mag show lhe presence of fluid in lhe lungls. b- Cf scan chesl: mag be required onlg in some silualions (rouline chesl x-rag is suflicienl in mosl oases). Echocardio{ram: exclude hearl problems lhal cause fluid build-up in lhe lung.

ab-

.lnslrumenlal:

c-

abfrealmenl

Moniloring wilh pulmonarg ar.lerg calheler mag be needed lo exclude a cardiac cause for the difficultg in brealhing. Bronchoscopu mag be considered lo evaluale the possibilitg of lung infection.

'@ l.

Admission

lo

an inlensive care unit (lCU).

2.
3.

4.
5.

Supplemenlal oxggen. Mechanical venlilalor (in the stage of respiralorg failure indicaled bg a PaOo < 6O mmHg). Trealmenl of lhe cause e.g. correciion of shock and eradicalion of sepsis. lV fluids are $ven lo provide nulrilion and prevenl dehgdralion, and are carefullg monilored to prevenl fluid from accumulalin! in lhe lungs (pulmonarg edema). The following drugs mag be adminislered: - Antibiotics lo lreal infeclion because il is oflen lhe cause of ARDS.

- Anli-in{lammatorg drugs, such as oorlicosleroids, lo reduce inflammalion in lhe lungs

in

the lale phase or somelimes if lhe person is in seplic shock. - Diurelics lo eliminale fluid from lhe lunls. - Drues lo counleracl low blood Dressurc lhal mag be caused bg shook. - Anti-anxielu drugs lo relieve anxielg. - lnhaled dru(s adminislered bg respiratorg lherapisls lo decrease in{lammalion and provide respiralorg comfort.

rcSr-offiHytror(lA
Manifesls clinicallg bg o Resllessness. anielu or confusion. o fachgpnea, Tachgcafoia, arrhglhmias or hgpotension. o Cenlra! cuahosis is lale.
Common causes

o . . .

Pulmonaru embolism. Pulmonarg edema. lnvesl.igefions Pulse oximelrg. ABG:'1.PCO2 (ventilalion failure) and 9PO2 (Oxgllenation failure) 3. Chest x-rag

. .

Pulmonargaspiralion. Failure lo brealhe deeplg and cough during recoverg from anesthesia. Airwau block bg secrelions. Hgpovenlilalion due to pain of upper abdominal or lhoraco-abdominal incisions, opiales overdose or prolonged recumbencu.

l. 2. . '

frealmenl
Treal lhe specific cause. The patient mag need mechanical venlilation.

5)K4-10A.1r. Ur dt o-lnoY6u c, lurde\

?tQV

t45

l.

Polg-traurnalized palient presenls with acule chesl pain, dgspnea and cganosis. Auscullalion shows dirninished air enlrg. lung percussion gives lgmpanic resonance on affecled side. Chest x-rag shows jet black opacilg.

Ptewttotltorax 2. Palienl presenls with dull aching or slitching pain,

cough and dgspnea. CXR shows Homogenous opacitg with obliteration of coslo-phrenic angle rising Io axilla.

Phlral affisnn 3. Polg-traurnalized palienl presenls with acule chesl

pain, dgspnea and cganosis. Auscullalion shows diminished air enlng. Lung percussion gives dullness on affected side. Chesl x-rag shows oblileralion of costo-phrenic angle.

llemo-thorax.

4.

Polg-traurnalized patienl presenls wilh acute chesl pain, dgspnea, cough, cganosis, engorged neck veins & respiralorg disfress\E part of chest rnoves paradoxicallg wilh respiralion.

flarl cltest.
5. lmrnuno-compromized
irnpulse wilh cough.

patient with past historg lo TB or recurrenl pneumonia presenls wilh subculaneous swelling in lhe inlercoslal space gives expansile

EnVyetta llecmsitats. 6.
OId age palienl heavg smoker presenls with change of characler of smoker cough and exaggeralion of COPD rnanifeslalion.
B rortchogettb cdrc r/ort/d

5/..)R4-:lC0f5. Urd,io-fltordcic,

our6ery

?llrY

twb

a)

ilRq-4Mrr.

?qd{atric,

surye\

?tQY

t We

. CO]IGETrIAL AIIOIIIATIES OF TESTIS

. ECTOPICTHTROD . ESOPHAGEATATRESN . JEJUTIAL, ILEAL, BILNff ATRESIA , CIOLEDOCIIAL CTST, HEPATOBI.ISTOTiA . IIYDROCEPIIALItrS . HETIAilGIOTiA
(liluolJllllc
us. 1o1l Nuoll,Illlc)

'SWELLII{GS OUE$IRATIOII, T}IYROGIOSSAI, BRAIICHIAI)

l'R$-Iwrr.

?edi6tric,

5uwry

?Wt W

OFffi
ollt^rBIllBIT.AIERAL

tr DEFINITION: Testis pass tr EIIOLOGY: tr srTEs: -Moslcommon)@

-Olhers:

an eclopic sile

ln response to :
-Cold exposure -Scratching medial side

of lhigh

tr

CLINICAL PICIURE:

a) b)

c)

Above rool of Penis Transverse scrola! Femoral triangle

d) Perineal CLINICAL PICIURE:

-SYMPTOMS: Molher ClO lhal one or both sides are emptg -SIGN8: a) Well-developed Scrolum

-Well-developed Scrolum -Normal Teslis -DIAGNOSIS) Make child squal lo help descent of

leslis
IREATMENT: Re-assurance

deal'lr or abrrormal lenifalia Fetus: DOWN $

Mofher:

. .

b) Normalfesfis c) Outside tnguinal canal tr

,

<2O, >35 gears Exposure lo pesficides loxic chemicals Poor heallh

COMPLICAIIONS: Psgchological, liabililg lo lrauma, lorsion TREATMENT: Orchipexg

t t60

UNILATEML
ETIOLOGY

INCIDENCE

tr Dgsglenesis (small lestis) E l-arte testis tr Shorl leslicular arlerg tr Short spermalic cord E Associated hernia sac E Narrow inouinal rinQ, canal E 30 % in PRETERM E 50% on Righl side ,2O7o bilaleral E Urinarg lract anomalies in 13.5 % tr tr

tr tr

BILATERAL

U Maternal

HCG

Fetal pituitarg Gonadolropins

cuNtcAt
PICTURE

Mosl cornmon sile of arrest is INOUINAL CANAL SYMPIOMS: Mother C/O lhal one or bolh sides are emplg SIGNS: Poorlg developed scrolum, Poorlg developed Teslis , usuallg in lhe
inguinal canal

COMPLICA-

IIONS

E tr tr tr E tr tr
tr tr tr

Associaled anomalies
Psgchological
Liable Liable

to lrauma

to Malignancg

SEMINOMA (x3O limes)

lndirecl inguinal hernia

Epididgmo-Orchitis

Sterilitq: (Bilateral causes) Cruptorchidism, Hupogonadism)

Best bg Laparoscopg US, CT scan
IN BILATERAL CASES) Hormonal assau, Karuotupino

INVEgTIGATIONS TREATMENT

tr tr

Orchiopexg for affected side

Al 6-24 monlhs (Preserve

hormonal funclion)

tr tr

Methods : l) De-Nelo 2) Bi-Van 3) lf cord is short : // Disseclion lo elonglale il z/ Fowler-sfeven Technique

trrM

500 lUl lwice

For

weeklg

4-6

weeks

#HCO>6weeks # Tesloslerone
lf failed)
Orchiopexg

DEFINITlON Presence of lhgroid lissue in a sile olher lhan the normal siie

COMPLICATIONS

.
. .

Pre-cancerous (papillarg carcl;roma).

SIIEg

INVESTIGAIlONS

. MOST COMMON IS LINGUAL THYROID . Relroslernal is lhe 2nd mosl common. . Linqual)
tongue swelling

CT!NICAt PICTURE dgsphagia.

delecl exacl sile and exlension. delecl olher co-existing functioning lhgroid.
CT scan: TCrn scan:

dgspnea,

'Retros.terna!

pressure manifeslafions.

IREAIMENT . Surgical removal if normal ihgroid coexisls. . lf nol ) remove and rein lhe arm

tta

!l
Etiologg

5ll

a-q

Mrl i IllrrI ll l

,vr

lll

I:

l a :I I I H r t Lr+lJrt r tt'4s{

Palienl
CLINICAL PICTURE

9equestralion of piece of epithelium al a line of [usion Child .... (occurs durino l'elal lil-e I
Slowlg growing , Painless, SC swelling

Un-oblileraled porlion of fhgroglossal ducl E Persislenl Cervical sinus )Cgsl E 2"d arch doesn'l {use wilh Sth ) Fisiula child 6-8 uearc appears ar ate oi trllEEE
Slowlg growing painless swelling in lhe midline of Neck Slowlg growing painless al Laleral side of neck upper parl o{ Neck)Anlerior frian$e Passes bel ECA,ICA

clo
Site

r.5rJl,Jr

rihoJl,

Jr

2o

rsldl,Jr

Moslcommonsf;@N[UEU

. .

M External angular .... lniernal angular M Posl-auticular .... Pre-auricular M Suora-muelohuoid .... lnfra-Muelohuoid
Size Shabe

Exlend lo side of nasophargnx "Fossa of Rosenmuller" !Imell Rounded Normal skin or {islula Rounded, oval

Globular Well delined Lax, Cuslic

Surface
Edoe

smoolh
Well defined
Tense

Consislencu Relalions
Special
I I

Moves Exlernal angular) lie on Bone defecl Pedicle connecls deep aspecl of cusl lo dura matter

lo

side to side

Moves up wiih deglulilion

& prolrusion of

I a

Characlers

fongue

fflffim

ffi

Complicalions

lnvesligalions Trealmenl

As ang cgsl (infeclion,ruplure,Hge,pressure) Cerebral compression, !C complicalion RecuHence for bone defecls

. .

t...

Mosl common is INFECIION

T

$@fts
)

'.
. .

CUst

Fislula

US

Fislulooram

. Adenocarcinoma . U/g) Diagnosis of casl & Exclude D.D. . Fisluloqram) Fislula

I I

a
I

Uncomplicaled

Excision

lf infected)

INCISION

&

DMINAGE EXCtStON

'CUsl, lrack

ElEuillllgllilliliug{

Cgst) Complele excision lf {islula) Excision

after in{lammalion subsides lf hourglass) wail for closure of skull

Cenlral part of Hgoid bone Pgramidal lobe

Definition

Failure of recanalizalion of foregut

+ failure of ils separation from the lrachea (fistula).

lncidmce . l/4000 live birth, more common in males.

Types
EA + dislal IEF (listula of lower pouch), commonesi. It. Pure EA (wilhoul TEF), 2"d mosl common. lll. EA with proximal TEF ({isrula of upper pouch).

l.

lV.

EA

with double TEF (fistulas with both pouches).

Symptoms

. .

AnU newborn presenting with frothg saliva should be considered having EA unlil proved olherwise.
General: Bad chest (aspiration pneumonia).

Signs

Bad general condition (dehgdration Associaied anomalies.

& FIT).

Local:

lf distal fislula ) abdominal dislension with respirafion. lf no distal fistula ) scaphoid abdomen.
Calheler test

arresled lOcm from noslrils.

Causesaf degdr
L Associaled anomalies.

2, Pneumonia tnwtigotfur

(alwags presenl).

'

FsrdEqnosis:.

l.Plainx-rag:
ABDOMEN

2.Gastrographin ) diagnoses EA and proximal fistula (visualizalion of bronchial . For eeneral condilion: ABGs, CBC, KFT, LFT. . For associaied anomalies: U/S & Echo. fiuanotfi(EffifiG8ilEil ' l. Preoperalive preparalion ) Excision of fislula + Primarg end-lo-end anastomosis.
2.Trealmenl of associaled anomalies. N.B. if long gap or bad general condilion feeding

lree).

) esophagoslomg for draining upper pouch * gaslroslomg for lhen, laler on life, delinitive repair bg slomach pull-up, colon or small bowel lransposilion

Definition

Congenilal slriclure of bile ducls due inflammatorg process of unknown etiologg.

TWes

A. B.

lnlra-hepalic. Exlra-hepalic

) ) )

Tgpe Tgpe ll Tgpe lll

I ) involves CBD > + CHD > + Rt. & Ll. hepalic ducls
&
clag slool, Prurilis

CllnicalPlcture
Neonaie wilh obslruclive iaundice:....... Olive green jaundice, Dark urine

lnvcatQatlons

l. 2. 3.

Lab: LFTs choleslalic patlern Bil. & alk. P) HIDA scan non visualizalion of duodenum. Liver biopsq: lf inlra-hepalic no bile ducts. lf extra-hepatic dilated inlra-hepalic ducls.

) )

(t

. .

) )

lf no palenl proximal segmenl

of bile ducl (9O%)
Kasai $era+ion

lf paten{ segment

(IO%)

+
Hepalico-jejunostomg wilh Rorrx-cn-Y

[!7
Clinical Piclure: Earlg vomiling in lhe
l8T

24 hrs.

Clinical piclure
Abdominal dislension in the l"r 24 hours

lnvesligalions
X-rag

vomifinE.

TRIPLE BUBBLE SIGN

Dilaled bowel

lnvesl'rgalions

frealmenl

Reseclion

end-lo-end anaslomosis.

X-raV) Dilated bowel +mulliple fluid Treatmenl

levels.

Reseclion

end-lo-end anaslomosis.

I 1r):r t1
Tgpes Incidence
MOST

L .'r 7r

. .

COMMON) DIFFUSE DIITTATION OF

CBD

CAROLI'S DISEASE (Mulliple inlra-hepalic cgsls)

MOST COMMON MALIGNANT TIVER TUMOR IN CHILDREN

Clinical hclure Stasis (Cholangilis), Swelling at Rt. Hgpochondrium, biliarg peritonilis. Ruplure Complicalions: Cholangiocarcinoma. lnvesfigalions U/S, CI scan or MRl, ERCP, Operalive cholangiographg

Spread

freslment

excision of lhe cgsl Diffuse dilalalion choledocho-jej unoslom g. liver lransplanlalion. Caroli's disease

MrU be melaslasis io the lungs. Clinical Piclure Abdominal mass in children <3 gears. lnvesl'rgalions U/S, CT scan or MRl. Elevaled serum o-feloprolein. Treatmenl Chernotherapu + reseclion

l" 2. .

ilP4-1w.1,

?adi

atr[ c,

rur6e\

?AhY

I t5+

'
Tgpes

Dislurbance of formalion, flow or absorplion of CSF

) | volume of lhe venlricular sgslem.

I. 2.

Communicatin(: mosllg due lo defeclive CSF absorplion. Non-communicatinq: mostlg due lo obslruclion of the venlricular sgslem. Con(enilal causes: slenosis of Aqueduci of Sglvius - Arnold Chiari rnalformalion. Acquired causes: mass lesions, venlricular hemorrhale or infeclion (post-meningitis).
Poor feeding, vomiling & delaged menlal aolivitg. Head enlargemenl (> 98'n percenlile). Widelg-opened skull sulures. Tense bulging fonlanelles. Dilaled scalp veins. McEwen's sign (resonance on percussion). Sunsel sign.
CT scan

Etiologg

l. 2. . . . . . . .

Clinical Piclure

Y, l.r

lnvestigalions

. ,

&

Skull x-rag

MRI are invesligalions of ohoice. silver-bealen appearance.

Trealmenl

l. 2.

Medical: Acelazolamide to J CSF production. Surqical: rnosl preferred is shunl (most commonlg used venlriculo-periloneal shunls) obstruclion and infeclion.

liable

lo

True neoplasm o{ endolhelial cells bul undergo

These are hemangiomas presenl a{ birth and persisl

inlo adullhood
Allover bul common in both head and neck Appears afler birlh during the l"t 2-3 surface bul common in face Present al bidh persists inlo adullhood Start as l'ght red laler on lheg deepen in color

Grows rapidlg for 4-6 monlhs lnvolulion DroBresses slowlu bu 5-7 a- superficial b- deep c- combined (superficial & deep)
Ulceralion 8%, infection, bleeding, airwag obslruclion, visual fi eld de{ecls, Kasbuch-Merrifl

a- porl wine

b- cavernous
c- a-v fislula lhe mosl comrnon & venous

. .
frsriffiEni

Nol usuallg indicaled

lndicalions:

a. b. c.

appearance following sponlaneous regression

surgical excision wilh lrg closure super seleclive embolizalion lo prevenl misdireciion avoiding skin necrosis. Small
Large

) )

large hemanglioma of braw or egelid hemangioma of mucosal surface of lips

Trealmenl of complications.

N.B. Recentlg, the besl melhod for porl wine slain is photo - lhermolgsis