Student - Surgery - August 27 PDF

UNITED REPUBLIC OF TANZANIA

Ministry of Health and Social Welfare
CMT 05210
Surgery
NTA Level 5 Semester 1

Student Manual

August 2010

Copyright © Ministry of Health and Social Welfare – Tanzania 2010
CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

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Table of Contents
Background and Acknowledgement ........................................................................ iv

Introduction .............................................................................................................. ix
Abbreviations ........................................................................................................... xi
Module Sessions
Session 1: Introduction to Surgery.............................................................................1
Session 2: Wounds and Soft Tissue Injuries ..............................................................7
Session 3: Animal Bites and Stings .........................................................................13
Session 4: Ulcers .....................................................................................................19
Session 5: Lymphadenitis ........................................................................................27
Session 6: Paronychia, Cellulitis and Pyomyositis ..................................................33
Session 7: Thoracic Empyema and Abscesses ........................................................37
Session 8: Burns .......................................................................................................47
Session 9: Breast Lumps ..........................................................................................55
Session 10: Peritonitis, Appendicitis and Peptic Ulcer Disease ..............................63
Session 11: Intestinal Obstruction ...........................................................................71
Session 12: Urinary Retention .................................................................................75
Session 13: Haemorrhoids, Rectal Prolapse and Rectal Bleeding...........................83
Session 14: Abdominal Swellings ...........................................................................93
Session 15: Scrotal Swellings ................................................................................101
Session 16: Congenital and Surgical Problems in Children ..................................106
Session 17: Dislocations of the Shoulder and Elbow Joints ..................................119
Session 18: Dislocations of the Lower Limb Joints ..............................................127
Session 19: Introduction to Fractures ....................................................................141
Session 20: Fractures of the Upper Limb ..............................................................147
Session 21: Fractures of the Lower Limb ..............................................................159
Session 22: Pyogenic Osteomyelitis and HIV in Surgery .....................................175
Session 24: Arthritis, Frozen Shoulder, Spondylosis, Prolapsed Intervertebral ...193
Session 25: Poisons and Inhaled Foreign Bodies ..................................................201
Session 26: Chest Injuries ......................................................................................207
Session 27: Acute Abdomen and Abdominal Injuries ...........................................213
Session 28: Head and Vertebral Column Injuries..................................................219

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Background and Acknowledgement
In April 2009, a planning meeting was held at Kibaha which was followed up by a Task
Force Committee meeting in June 2009 at Dodoma and developed a proposal which guided
the process of the development of standardised Clinical Assistant (CA) and Clinical Officer
(CO) training materials which were based on CA/CO curricula. The purpose of this process
was to standardize the entire curriculum with up-to-date content which would then be
provided to all Clinical Assistant and Clinical Officer Training Centres (CATCs/COTCs).
The perceived benefit was that, by standardizing the quality of content and integrating
interactive teaching methodologies, students would be able to learn more effectively and that
the assessment of students’ learning would have more uniformity and validity across all
schools.
In September 2009, MOHSW embarked on an innovative approach of developing the

standardised training materials through the Writer’s Workshop (WW) model. The model
included a series of three-week workshops in which pre-service tutors and content experts
developed training materials, guided by facilitators with expertise in instructional design and
curriculum development. The goals of WW were to develop high-quality, standardized
teaching materials and to build the capacity of tutors to develop these materials.
The new training package for CA/CO cadres includes a Facilitator Guide, Student Manual
and Practicum. There are 40 modules with approximately 600 content sessions. This product
is a result of a lengthy collaborative process, with significant input from key stakeholders and
experts of different organizations and institutions, from within and outside the country.
The MOHSW would like to thank all those involved during the process for their valuable
contribution to the development of these materials for CA /CO cadres. We would first like to
thank the U.S. Centers for Disease Control and Prevention’s Global AIDS Program
(CDC/GAP) Tanzania, and the International Training and Education Center for Health (I-
TECH) for their financial and technical support throughout the process. At CDC/GAP, we
would like to thank Ms. Suzzane McQueen and Ms. Angela Makota for their support and
guidance. At I-TECH, we would especially like to acknowledge Ms. Alyson Shumays,
Country Program Manager, Dr. Flavian Magari, Country Director, Mr. Tumaini Charles,
Deputy Country Director, and Ms. Susan Clark, Health Systems Director. The MOHSW
would also like to thank the World Health Organization (WHO) for technical and financial
support in the development process.
Particular thanks are due to those who led this important process: Dr. Bumi L.A.
Mwamasage, the Assistant Director for Allied Health Sciences Training, Dr. Mabula Ndimila
and Mr. Dennis Busuguli, Coordinators of Allied Health Sciences Training, Ministry of
Health and Social Welfare, Dr. Stella Kasindi Mwita, Programme Officer Integrated
Management of Adults and Adolescent Illnesses (IMAI), WHO Tanzania and Stella M.
Mpanda, Pre-service Programme Manager, I-TECH.
Sincere gratitude is expressed to small group facilitators: Dr. Otilia Gowele, Principal, Kilosa
COTC, Dr. Violet Kiango, Tutor, Kibaha COTC, Ms. Stephanie Smith, Ms. Stephanie
Askins, Julie Stein, Ms. Maureen Sarewitz, Mr. Golden Masika, Ms. Kanisia Ignas, Ms.
Yovitha Mrina and Mr. Nicholous Dampu, all of I-TECH, for their tireless efforts in guiding
participants and content experts through the process. A special note of thanks also goes to

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Dr. Julius Charles and Dr. Moses Bateganya, I-TECH’s Clinical Advisors, and other Clinical
Advisors who provided input. We also thank individual content experts from different
departments of the MOHSW and other governmental and non-governmental organizations,
including EngenderHealth, Jhpiego and AIHA, for their technical guidance.
Special thanks goes to a team of I-TECH staff namely Ms. Lauren Dunnington, Ms.
Stephanie Askins, Ms. Stephanie Smith, Ms Aisling Underwood, Golden Masika, Yovitha
Mrina, Kanisia Ignas, Nicholous Dampu, Michael Stockman and Stella M. Mpanda for
finalising the editing, formatting and compilation of the modules.
Finally, we very much appreciate the contributions of the tutors and content experts
representing the CATCs/COTCs, various hospitals, universities, and other health training
institutions. Their participation in meetings and workshops, and their input in the
development of content for each of the modules have been invaluable. It is the commitment
of these busy clinicians and teachers that has made this product possible.
These participants are listed with our gratitude below:
Tutors
Ms. Magdalena M. Bulegeya – Tutor, Kilosa COTC
Mr. Pius J.Mashimba – Tutor, Kibaha Clinical Officers Training Centre (COTC)
Dr. Naushad Rattansi – Tutor, Kibaha COTC
Dr. Salla Salustian – Principal, Songea CATC
Dr. Kelly Msafiri – Principal, Sumbawanga CATC
Dr. Joseph Mapunda - Tutor, Songea CATC
Dr. Beda B. Hamis – Tutor, Mafinga COTC
Col Dr. Josiah Mekere – Principal, Lugalo Military Medical School
Mr. Charles Kahurananga – Tutor, Kigoma CATC
Dr. Ernest S. Kalimenze – Tutor, Sengerema COTC
Dr. Lucheri Efraim – Tutor, Kilosa COTC
Dr. Kevin Nyakimori – Tutor, Sumbawanga CATC
Mr. John Mpiluka – Tutor, Mvumi COTC
Mr. Gerald N. Mngóngó –Tutor, Kilosa COTC
Dr. Tito M. Shengena –Tutor, Mtwara COTC
Dr. Fadhili Lyimo – Tutor, Kilosa COTC
Dr. James William Nasson– Tutor, Kilosa COTC
Dr. Titus Mlingwa – Tutor, Kigoma CATC
Dr. Rex F. Mwakipiti – Principal, Musoma CATC
Dr. Wilson Kitinya - Principal, Masasi ( Clinical Assistants Training Centre (CATC)
Ms. Johari A. Said – Tutor, Masasi CATC
Dr. Godwin H. Katisa – Tutor, Tanga Assistant Medical Officers Training Centre (AMOTC)
Dr. Lautfred Bond Mtani – Principal, Sengerema COTC
Ms Pamela Henry Meena – Tutor, Kibaha COTC
Dr. Fidelis Amon Ruanda – Tutor, Mbeya AMOTC
Dr. Cosmas C. Chacha – Tutor, Mbeya AMOTC
Dr. Ignatus Mosten – Ag. Principal, Tanga AMOTC
Dr. Muhidini Mbata – Tutor, Mafinga COTC
Dr. Simon Haule – Ag. Principal, Kibaha COTC
Ms. Juliana Lufulenge - Tutor, Kilosa COTC
Dr. Peter Kiula – Tutor, Songea CATC

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Mr. Hassan Msemo – Tutor, Kibaha COTC
Dr. Sangare Antony –Tutor, Mbeya AMOTC
Content Experts
Ms. Emily Nyakiha – Principal, Bugando Nursing School, Mwanza
Mr. Gustav Moyo - Registrar, Tanganyika Nursesand Midwives Council, Ministry of Health
and Social Welfare (MOHSW).
Dr. Kohelet H. Winani - Reproductive and Child Health Services, MOHSW
Mr. Hussein M. Lugendo – Principal, Vector Control Training Centre (VCTC), Muheza
Dr. Elias Massau Kwesi - Public Health Specialist, Head of Unit Health Systems Research
and Survey, MOHSW
Dr. William John Muller - Pathologist, Muhimbili National Hospital (MNH)
Mr. Desire Gaspered - Computer Analyst, Institute of Finance Management (IFM), Dar es
Salaam
Mrs. Husna Rajabu - Health Education Officer, MOHSW
Mr. Zakayo Simon - Registered Nurse and Tutor, Public Health Nursing School (PHNS)
Morogoro
Dr. Ewaldo Vitus Komba - Lecturer, Department of Internal Medicine, Muhimbili University
of Health and Allied Sciences School (MUHAS)
Mrs. Asteria L.M. Ndomba - Assistant Lecturer, School of Nursing, MUHAS
Mrs. Zebina Msumi - Training Officer, Extended programme on Immunization (EPI),
MOHSW
Mr. Lister E. Matonya - Health Officer, School of Environmental Health Sciences (SEHS),
Ngudu, Mwanza.
Dr. Joyceline Kaganda - Nutritionist, Tanzania Food and Nutrition Centre (TFNC),
MOHSW.
Dr. Suleiman C. Mtani - Obstetrician and Gynecologist, Director, Mwananyamala Hospital,
Dar es salaam
Mr. Brown D. Karanja - Pharmacist, Lugalo Military Hospital
Mr. Muhsin Idd Nyanyam - Tutor, Primary Health Care Institute (PHCI), Iringa
Dr. Judith Mwende - Ophthalmologist, MNH
Dr. Paul Marealle - Orthopaedic and Traumatic Surgeon, Muhimbili Orthopedic Institute
(MOI),
Dr. Erasmus Mndeme - Psychiatrist, Mirembe Refferal Hospital
Mrs. Bridget Shirima - Nurse Tutor (Midwifery), Kilimanjoro Chrician Medical Centre
(KCMC)
Dr. Angelo Nyamtema - Tutor Tanzania Training Centre for International Health (TTCIH),
Ifakara.
Ms. Vumilia B. E. Mmari - Nurse Tutor (Reproductive Health) MNH-School of Nursing
Dr. David Kihwele - Obs/Gynae Specialist, and Consultant
Dr. Amos Mwakigonja – Pathologist and Lecturer, Department of Morbid Anatomy and
Histopathology, MUHAS
Mr. Claud J. Kumalija - Statistician and Head, Health Management Information System
(HMIS), MOHSW
Ms. Eva Muro, Lecturer and Pharmacist, Head Pharmacy Department, KCMC
Dr. Ibrahim Maduhu - Paediatrician, EPI/MOHSW
Dr. Merida Makia - Lecturer Head, Department of Surgery, MNH
Dr. Gabriel S. Mhidze - ENT Surgeon, Lugalo Military Hospital
Dr. Sira Owibingire - Lecturer, Dental School, MUHAS
Mr. Issai Seng’enge - Lecturer (Health Promotion), University of Dar es Salaam (UDSM)

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Prof. Charles Kihamia - Professor, Parasitology and Entomology, MUHAS
Mr. Benard Konga - Economist, MOSHW
Dr. Martha Kisanga - Field Officer Manager, Engender Health, Dar es Salaam
Dr. Omary Salehe - Consultant Physician, Mbeya Referral Hospital
Ms Yasinta Kisisiwe - Principal Nursing Officer, Health Education Unit (HEU), MOHSW
Dr. Levina Msuya - Paediatrician and Principal, Assistant Medical Officers Training Centre
(AMOTC), Kilimanjaro Christian Medical Centre (KCMC)
Dr. Mohamed Ali - Epidemiologist, MOHSW
Mr. Fikiri Mazige - Tutor, PHCI-Iringa
Mr. Salum Ramadhani - Lecturer, Institute of Finance Management
Ms. Grace Chuwa - Regional RCH Coordinator, Coastal Region
Mr. Shija Ganai - Health Education Officer, Regional Hospital, Kigoma
Dr. Emmanuel Suluba - Assistant Lecturer, Anatomy and Histology Department, MUHAS
Mr. Mdoe Ibrahim - Tutor, KCMC Health Records Technician Training Centre
Mr. Sunny Kiluvia - Health Communication Consultant, Dar es Salaam
Dr. Nkundwe Gallen Mwakyusa - Ophthalmologist, MOHSW
Dr. Nicodemus Ezekiel Mgalula -Dentist, Principal Dental Training School, Tanga
Mrs. Violet Peter Msolwa - Registered Nurse Midwife, Programme Officer, National AIDS
Control Programme (NACP), MOHSW
Dr. Wilbert Bunini Manyilizu - Lecturer, Mzumbe University, Morogoro
Editorial Review Team

Dr. Kasanga G. Mkambu - Obstertric and Gynaecology specialist, Tanga Assistant Medical
Officers Training Centre (AMOTC)
Dr. Ronald Erasto Msangi - Principal, Bumbuli COTC
Mr. Sita M. Lusana - Tutor, Tanga Environmental Health Science Training Centre
Mr. Ignas Mwamsigala - Tutor (Entrepreneurship) RVTC Tanga
Mr. January Karungula - RN, Quality Improvement Advisor, Muhimbili National Hospital
Prof. Pauline Mella - Registered Nurse and Profesor, Hubert Kairuki Memorial University
Dr. Emmanuel A. Mnkeni – Medical Officer and Tutor, Kilosa COTC
Dr. Ronald E. Msangi - Principal, Bumbuli COTC
Mr. Dickson Mtalitinya - Pharmacist, Deputy Principal, St Luke Foundation, Kilimanjaro
School of Pharmacy
Dr. Janeth C. Njau - Paediatrician/Tutor, Kibaha COTC
Mr. Fidelis Mgohamwende - Labaratory Technologist, Programme Officer National Malaria
Control Programme (NMCP), MOHSW
Mr. Gasper P. Ngeleja - Computer Instructor, RVTC Tanga
Dr. Shubis M Kafuruki - Research Scientist, Ifakara Health Institute, Bagamoyo
Dr. Andrew Isack Lwali - Director, Tumbi Hospital
Librarians and Secretaries

Mr. Christom Aron Mwambungu - Librarian MUHAS
Ms. Juliana Rutta - Librarian MOHSW
Mr. Hussein Haruna - Librarian, MOHSW
Ms. Perpetua Yusufu - Secretary, MOHSW
Mrs. Martina G. Mturano -Secretary, MUHAS
Mrs. Mary F. Kawau - Secretary, MOHSW

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IT support
Mr. Isaac Urio - IT Consultant, I-TECH
Mr. Michael Fumbuka - Computer Systems Administrator – Institute of Finance and
Management (IFM), Dar es Salaam

Dr. Gilbert Mliga
Director of Human Resources Development, Ministry of Health and Social Welfare

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Introduction
Module Overview
This module content has been prepared to enhance learning of students of Clinical Assistant
(CA) and Clinical Officer (CO) schools.. The session contents are based on the sub-enabling
outcomes of the curricula of CA and CO. The module sub-enabling outcomes are as follows:
3.4.1. Take proper surgical history and perform physical examination
3.4.2. Manage common surgical injuries/conditions
3.4.3. Manage or refer complicated surgical conditions
3.4.5. Manage surgical emergencies and give pre referral management
Who is the Module For?

This module is intended for use primarily by students of CA and CO schools. The module’s
sessions give guidance on contents and activities of the session and provide information on
how students should follow the tutor when he/she teaches the module. It also provides
guidance and necessary information for students to read the materials on his/her own. The
sessions also include different activities which focus on increasing students’ knowledge,
skills and attitudes.
How is the Module Organized?

The module is divided into 28 Sessions; each session is divided into several sections. The
following are the sections of each session:
• Session Title: The name of the session.
• Learning Objectives – Statements which indicate what the student is expected to have
learned at the end of the session.
• Session Content – All the session contents are divided into subtitles. This section
includes contents and activities with their instructions to be done during learning of the
contents.
• Key Points – Each session has a step which concludes the session contents near the end
of a session. This step summarizes the main points and ideas from the session.
• Evaluation – The last section of the session consists of short questions based on the
learning objectives to check if you understood the contents of the session. The tutor will
ask you as a class to respond to these questions; however if you read the session by
yourself try answering these questions to evaluate yourself if you understood the session.
• Handouts – Additional information which can be used in the classroom while the tutor is
teaching or later for your further learning. Handouts are used to provide extra information
related to the session topic that cannot fit into the session time. Handouts can be used by
the students to study material on their own and to reference after the session. Sometimes,
a handout will have questions or an exercise for students to answer.
How Should the Module be Used?

Students are expected to use the module in the classroom and clinical settings and during self
study. The contents of the modules are the basis for learning Surgery. Students are therefore
advised to learn all the sessions including all relevant handouts and worksheets during class
hours, clinical hours and self study time. Tutors are there to provide guidance and to respond
to all difficulty encountered by students. One module will be assigned to 5 students and it is

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the responsibility of the tutor to do this assignment for easy use and accessibility of the
student manuals to students

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Abbreviations
ABC Airway, Breathing, Circulation
ACS Acute Compartment Syndrome
AFB Acid Fast Bacilli
AMREF African Medical and Research Foundation
APA Anterior Posterior
ART Antiretroviral Therapy
BCG Bacillus Calmette Guerin
BSA Body Surface Area
CMT Clinical Medicine Technician
CPR Cardiopulmonary Resuscitation
DVT Deep Venous Thrombosis
ESR Erythrocyte Sedimentation Rate
GIT Gastro-Intestine Tract
HCL Hydrochloric acid
HIV Human Immunodeficiency Virus
IG Immunoglobulin G
IV Intravenous
NSAIDs Non-Steroidal Anti-Inflammatory Drugs
NTA National Technical Awards
PEP Post-Exposure Prophylaxis
PFAPA Periodic Fever Aphthous stomatitis Pharyngitis cervical Adenitis
POP Plaster of Paris
PPI Proton Pump Inhibitors
PTB Pulmonary tuberculosis
RICE Rest, Ice, Compress, Elevate
SBP Spontaneous Bacterial Peritonitis
SC Subcutaneous
SCC Squamous Cell Carcinoma
SLUD Salivation Lacrimation Urination Diarrhea
TB Tuberculosis
TBSA Total Body Surface Area
TNM Tumor Nodes Metastases
CSF Cerebral Spinal Fluid
GCS Glasgow Coma Score
CT Computerized Tomography
BT Blood Transfusion
IM Intramuscular

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Session 1: Introduction to Surgery
Learning Objectives
By the end of this session, students are expected to be able to:
• Define the term surgery
• Explain components of surgical practice
• Describe the process of history taking in surgery
• Describe the process of performing physical examination in surgery
• Identify relevant and appropriate investigations for making a diagnosis
• Describe the principles of management in surgery
• Describe documentation in surgery
Introduction to Surgery and Components of Surgical Practice

• Surgery: A branch of medicine which deals with treating diseases, injuries, or
deformities by manual or operative procedures.
o In the study of surgery, it is essential to understand the human anatomy and
physiology including pathology of the disease as well as their natural history
o A skilled surgeon can make diagnosis appear very easy, almost intuitive.
• The process of problem analysis and decision making may be faster depending on the
level of experience, but the steps are always the same for every practitioner regardless of
experience. They consists of:
o History
o Physical examination
o Differential diagnosis
o Investigations, if required, to confirm the diagnosis
o Treatment
o Observation of the effects of treatment
o Re-evaluation of the situation, the diagnosis and the treatment
History Taking in Surgery

• There are two types of history in surgical practice:
o The first is the outpatient or emergency room history in which the specific complaint
of the patient is pinpointed.
o The aim is to obtain a diagnosis on which the treatment is ordered.
o The second is the clerking of a patient admitted for elective surgery.
o The aim is to assess that the treatment planned is correctly indicated and to ensure that
the patient is suitable for that operation.
The Process of Taking Surgical History

• Create rapport by greeting and making patient comfortable
• Identify patient’s particulars, including:
o Name
o Age
o Sex
o Religion
o Social status
o Occupation

Session 1: Introduction to Surgery 1
o Geographical residence
• Identify main complaint of the patient and identify the problem
o The presenting complaint: is simply the complaint which made the patient come to
clinic/hospital
Identify the main problem which brought the patient to the clinic
Understand the problem by asking questions relating to the cause or relief and
associating factors
o The history of the complaint: is the key step in surgical diagnosis
It will vary according to the complaint, and will be specific for particular
complaints or systems
• Elaborate the complaint in chronological order as follows:
o Site of problem
o Mode of onset: sudden or gradual
o Duration
o Nature and character
o Progress of the disease: evaluation of the symptoms
o Treatment: past treatment if any
• Identify any previous illness, type of diet, feeding patterns and allergies
• Identify personal and family history
• Review other systems
The Process of Physical Examination

• Physical examination starts when the patient enters the clinic.
• This includes general assessment, local examination and general examination.
o General assessment
Asses the mental status, intelligence, state of nutrition, attitude, gait, colour of the
skin and vital signs
o Local examination
Local examination means examination of the affected region or system
o Describe the affected region or system by:
Inspection
Palpation
Percussion
Auscultation
Movement of the joints
Measurement of the part of the body concerned
Examination of the lymph nodes
o General / systemic examination
o Required mainly for the following purposes:
Diagnosis and differential diagnosis
Selecting type of anaesthesia
Determine the nature of the operation
Determine the prognosis
o Describe individual systems by:
Inspection
Palpation
Percussion
Auscultation

Relevant Routine Investigations for Making Diagnosis
• Determine provisional diagnosis.
o Relate main complaint, history of presenting illness and physical examination to
determine provisional diagnosis and to have a list of differential diagnosis.
• Carry out relevant investigations and interpret the results.
o Outline relevant investigations.
o Interpret the results to confirm final diagnosis and other medical problems found
incidentally during the examination.
• Identify final diagnosis.
o Relate the main complaint to the history of the presenting illness and physical
examination, interpret the results and identify the final diagnosis.
Basic Principles of Management in Surgery

Preparation for Surgery
• The patient must be seen by the surgical and anaesthetic practitioners preoperatively.
• This can range from days or weeks in advance in the case of an elective procedure to
minutes before in an emergency.
• If there is a long time between initial assessment and surgical procedure, it is essential to
ensure that there have been no changes in the patient’s condition in the intervening
period.
• The patient’s stay in hospital before an operation should be as short as possible.
• Complete as much preoperative investigation and treatment as possible on an outpatient
basis.
• Before the operation, correct gross malnutrition, treat serious bacterial infection,
investigate and correct gross anaemia, and control diabetes.
Surgical Ethics
• Ethics and surgical intervention must go hand in hand.
• Patient consent: Before performing a procedure, it is important to receive consent from
the patient.
o Ask permission to make an examination.
o Explain what you intend to do before doing it.
o Ask the patient if he or she has questions and answer them.
o Check that the patient has understood.
o Obtain permission to proceed.
o Be mindful of the comfort and privacy of others.
o With invasive and surgical procedures, it is particularly important to give a full
explanation of what you are proposing, your reasons for wishing to undertake the
procedure and what you hope to find or accomplish.
o Ensure that you use language that can be understood; draw pictures and use an
interpreter, if necessary.
o Allow the patient and family members to ask questions and to think about what you
have said.
o In some situations, it may be necessary to consult with a family member or significant
others who may not be present; allow for this if the patient’s condition permits.

o If a person is too ill to give consent (for example, if they are unconscious) and their
condition will not allow further delay, you should proceed, without formal consent,
acting in the best interest of the patient.
o Record your reasoning and plan.
o Be attentive to legal, religious, cultural, linguistic and family norms and differences.
o The surgeon’s intent is to cure or manage illness and any bodily invasion that occurs;
only do so with the permission of the patient.
• Disclosure
o Any information gained about the patient’s condition belongs to the patient, and must
not be communicated to other persons without patient’s consent.
On The Day of Surgery

• Always see the patient on the day of surgery.
• Make sure that the patient has fasted for about four hours before an elective operation.
• It is the surgical practitioner’s responsibility to ensure that the site to be operated on is
clearly marked just before the operation.
• Recheck this immediately before the patient is anaesthetized.
• The patient’s notes, laboratory reports and X-rays must accompany the patient to the
operating room.
Intraoperative Care
• It is the anaesthetic practitioner’s responsibility to provide safe and effective anaesthesia
for the patient.
• The anaesthetic of choice for any given procedure will depend on his/her training,
experience, the range of available equipment and drugs, and the clinical situation.
• It is important for the surgical and anaesthetic practitioners to communicate any changes
or findings to team during the procedure.
After Surgery Care (Post Operative Care)

• Pain management
o Pain is often the patient’s presenting symptom.
o It can provide useful clinical information and it is your responsibility to use this
information to help the patient and alleviate suffering.
o Manage pain wherever you see patients (emergency, operating room and on the ward)
and anticipate their needs for pain management after surgery and discharge.
o Do not unnecessarily delay the treatment of pain.
o Do not transfer patient without analgesia.
• Prevention of complications
o Encourage early mobilization:
Deep breathing and coughing
Active daily exercise
Joint range of motion
Muscular strengthening
Make walking aids such as canes, crutches and walkers available and provide
instructions for their use
o Ensure adequate nutrition
o Prevent skin breakdown and pressure sores
Turn the patient frequently
Keep bed linen and patients’ clothes dry

Documentation in Surgery
Preoperative Note
• The preoperative note should document:
o The history and physical examination
o Results of laboratory and other investigations
o Diagnosis
o Proposed surgery
o Document informed consent
The Operative Note

• After an operation, an ‘operative note’ must be written in the patient’s clinical notes.
• It should include at least:
o Names of persons in attendance during the procedure
o Pre- and postoperative diagnoses
o Procedure carried out
o Findings and unusual occurrences
o Length of procedure
o Estimated blood loss
o Type of anesthesia
o Anaesthesia record (normally a separate sheet)
o Fluids administered (may also be on anaesthesia record)
o Specimens removed or taken
o Complications, including contamination or potential for infection
o Method of closure or other information that will be important to know before
operating again (for example, the type of incision on the uterus after Caesarean
section)
o Postoperative expectations and management plan
o Presence of any tubes or drains
Postoperative Note and Orders

• The patient should be discharged to the ward with comprehensive orders for the
following:
o Vital signs
o Pain control
o Rate and type of intravenous fluid
o Urine and gastrointestinal fluid output
o Other medications
o Laboratory investigations where necessary
• The patient’s progress should be monitored and should include at least:
o A comment on medical and nursing observations
o A specific comment on the wound or operation site
o Any complications
o Any changes made in treatment
Discharge Note
• On discharging the patient from the ward, record in the notes:
o Diagnosis on admission and discharge
o Summary of course in hospital

o Instructions about further management, including drugs prescribed
• Ensure that a copy of this information is given to the patient, together with details of any
follow-up appointment
Key Points
• History taking and performing of comprehensive physical examination include
identification of patient’s particulars.
• Main complaint, history of presenting illness, physical examination is related to make a
provisional diagnosis.
• Performing relevant investigations and interpret the results to identify the final diagnosis.
• Patient must consent to the operation procedure after receiving information about the
procedure.
• Documentation of all the necessary information is essential pre, intra and post operatively
Evaluation
• What is surgery?
• What are the steps to follow on performing physical examination?
• What are the principles of management in surgery?
References
• Bewes P. (1984). A Manual for Rural Health Workers.Nairobi: African Medical and
Research Foundation.
• Burkitt G. & Quick C. (2002). Essential Surgery, Problems, Diagnosis and Management.
(3rd ed.), Churchill Livingstone.
• Das S. (2008). Concise Textbook of Surgery (5th ed.). India: Dr. Das.
• Russell R.C.G., Norman S.W. & Bulstrode C.J.K. (2004). Bailey and Love’s Short
Practice of Surgery (24th ed.). London: Edward Arnold.
• Swash M. (2008). Hutchison’s Clinical Methods (22nd ed.). Toronto.
• WHO. (2003). Surgical Care at District Hospital. Malta.

Session 2: Wounds and Soft Tissue Injuries
Learning Objectives
• Define the terms wound and soft tissue injury
• Classify different types of wounds
• Describe management of different types of wounds and soft tissue injuries
• Explain complications of different types of wounds and soft tissue injuries
• Describe management of complications of wounds
Definition, Pathophysiology and Classification
• Wound: An injury to living tissue (especially an injury involving a cut or break in the
skin).
Pathophysiology of a Wound Infection

• Most wounds are contaminated except for surgical wounds made under aseptic
conditions.
• Wound infection follows contamination by dirt, damaged tissue, and foreign bodies.
• The bacteria invade tissues and cause more damage while tissues which have not been
damaged resist infection by a process called inflammation.
• When a wound is inflamed, blood vessels dilate to bring more blood to the injured part.
• The capillary walls change so that antibodies and white cells can pass through more
easily.
• The result is the part becomes warmer and redder because there is more blood in it, and
swollen because there are more white cells and fluid.
• Pain is partially due to increased swelling in the part, and partially due to the effects of
the inflammation process.
Signs of Acute Inflammation (Cardinal Signs of Inflammation)

• Heat (Calor )
• Redness (Rubor )
• Pain (Dolor )
• Swelling (Tumor )
• Loss of function (Functio laesa )
Figure 1: An Open Wound and the Balances of Force

Session 2: Wounds and Soft Tissue Injuries 7
Source: Bewes P, 1984, AMREF
Figure 2: The Effect of a Stitch
Source: Bewes P, 1984, AMREF
Classification of Wounds
• There are several classifications of wounds.
• Each classification can direct treatment modality.
• Classification by degree of contamination:
o Clean wounds are mostly those made in the operating rooms in hospitals.
o They have clear sharp edges, not contaminated and have minimal tissue damage.
o Contaminated wounds occur outside the operation rooms, they are potentially
contaminated thus liable to develop infection.
o Tissue damage may be extensive.
o Infected wounds show obvious signs of infection like pus and necrotic tissue.
Management of Wounds
Wound Assessment
• History
o How long ago was the wound sustained?
o How was the wound sustained?
o What is the status of active immunization against tetanus?
• Examination of the wound; look for:
o Active bleeding
o Contamination
o Depth and describe tissues involved
o Edges
o Site
Cleansing the Wound (Social Toilet)

• Clean the wound and surrounding skin with soap and water.
• Do not use hard brush, sponge should suffice.

Figure 3: Social Toilet
Source: Bewes, 1984
Surgical Toilet
• All contaminated wounds need to undergo surgical toilet.
• Clean the wound by debridement (remove dead and damaged tissues using a knife and
apply antiseptic solution).
Figure 5: Trimming the Skin Edge
Source: Bewes, 1984
Classes and Indications for Wound Closures

• Primary wound closure
o Clean post operative wounds
o Surgically clean wounds after surgical toilet
• Delayed primary closure
o Done for contaminated wounds after surgical toilet

o Wound is observed for three to four days observing for onset of infection
o If there is no infection then wound closure is performed
• Secondary closure
o Indicated for obviously infected wounds
o Closure is deferred until infection is under control
Complications of Wounds and their Management

• Cellulitis
o Non suppurative invasive infection of surrounding tissues by organisms such as ß-
haemolytic streptococci, staphylococci and Clostridium perfringens.
o Cellutitis is managed by application of local antiseptic and systemic antibiotics.
• Septicemia
o Multiplication of bacteria in the blood with the production of severe systemic
symptoms such as fever and hypotension.
o It has an extremely high mortality and demands immediate and appropriate attention.
o It is managed by adequate rehydration, systemic antibiotics and antipyretics.
Management of Soft Tissue Injuries

• Soft tissue injuries are those injuries excluding fractures, affecting the joints and
muscles of the limbs.
• Sprains and strains are considered soft tissue injuries.
• Sprains: Ligamentous injuries associated with the overextension of a joint.
o Ligaments connect bone to bone
o Damage to ligaments can range from microscopic to complete disruption
• Strains: Injuries to the musculotendonous unit (tendons connect muscle to bone)
o May range from microscopic to complete disruption.
• The treatment of soft tissue injuries is based on resting the injured part, applying
ice packs to limit swelling and reduce pain by prescribing analgesics or local
analgesic cream or gel.
• RICE: The application of a firm compression bandage as support, and elevation
of the limb.
• The acronym ‘RICE’ can be remembered as follows:
o R= Rest I= Ice C= Compression E= Elevation
• The application of ice and compression causes vasoconstriction and tamponades
the blood vessels and elevation of the limb improves venous drainage.
Complications of Soft Tissue Injuries and Their Management
Compartment Syndrome
• Increased tissue pressure within a muscle compartment compromising the blood
supply and the function of structures within that space.
• Causes
o Tight casts or dressings
o External limb compression
o Burn eschar
o Fractures
o Soft tissue crush injuries
o Excessive exertion

• Clinical presentation
o Pain out of proportion to the injury
o Puffy/tense muscle compartments to palpation
o Parasthesia (decreased sensation)
o Paralysis (weakness of the involved muscle groups)
o Pallor
o Pulselessness (decreased capillary refill, late finding)
• Management
o Split the cast and remove dressings, if present
o Place limb in neutral position; elevation may be harmful
o Support circulation with IV fluids or blood where indicated
o Observe carefully for improvement i.e. colour, pulse and pain
o If signs and symptoms persist, refer for immediate surgical decompression
(fasciotomy)
o Fasciotomy must be performed early, ideally within six hours of the onset of
symptoms
Myositis Ossificans
• Myositis ossificans is an unusual condition that often occurs in athletes who sustain a
blunt injury that causes deep tissue bleeding.
• Severe bleeding into the muscle creates a hematoma, which may trigger a healing
pathway that leads to formation of ectopic bone in the muscle.
• Treatment of myositis ossificans consists of:
o Rest
o Immobilization in a stretched position
o Pain relief with acetaminophen; NSAIDS are avoided in order to limit bleeding
Key Points
• Wounds are common in our daily activities, therefore proper management of wounds
(social toilet, surgical toilet and suturing) are needed to avert complications.
• Soft tissues injuries involve ligaments, muscles, and tendons.
• These can be managed by Rest, Ice, Compression, Elevation (RICE) and
analgesics.
Evaluation
• What are the types of wounds?
• How do you manage the different types of wounds?
• What is the difference between a sprain and a strain?
References
• Bewes P. (1984). A Manual for Rural Health Workers. Nairobi: African Medical and
• Steadman T.L. (1999). Steadman’s Medical Dictionary (27th ed.). USA: Lippincott
Williams & Willkins.

Session 3: Animal Bites and Strings
Learning Objectives
• Define animal bites and stings
• Classify animal bites and stings
• Describe management of animal bites and stings
• Explain complications of animal bites and stings
• Describe how to manage complications of animal bites and stings
Introduction to Animal Bites and Stings

• Animal bites and stings: Wounds or punctures of the skin made by any animal or insect.
• There are different causes of bites and stings caused by the following:
o Animal bites
Human bites
Dog, foxes and cat bites
Snake bites
Crocodile bites
o Stings
Bee
Scorpion
Spider
Centipede
• Snake bites and stings result in injection of venoms.
• Type of venom depends on the causative agent of the bite or sting.
Types of Toxins/Venom
• Cytotoxins cause local tissue damage.
• Haematotoxins cause internal bleeding.
• Neurotoxins affect the nervous system.
• Cardiotoxins act directly on the heart muscles.
• Myotoxins act directly on skeletal muscles.
Bites
• Human bite
o The wound is usually contaminated by mixed organisms.
• Dogs, fox bites and cat bite
o There is danger of transmission of bacterial infection and rabies.
o One should suspect rabies from animal bites.
• Snake bites
o Extremities usually are the sites of the bite.
o Venom is a mixture of enzymes and non-enzyme compounds.
o Most snake bites are not poisonous.
o Many bites from poisonous snakes do not result in poisoning (about 25%).
o Bites by non-venomous snakes can cause infection and allergic reactions.

Session 3: Animal Bites and Stings 13
o Bites by venomous snakes result in a wide range of effects, from simple puncture
wounds to life-threatening illness and death.
o The findings following a venomous snakebite can be misleading.
o A victim can have no initial significant symptoms, and then suddenly develop
breathing difficulty and shock.
Clinical Presentation of Animal Bites and Stings
Signs and Symptoms of Snake Toxins/Venom

• Local effects
o Pain and tenderness
o Swelling
o Blisters
o Wounds
o Numbness
o Necrotic tissue around the site of the bite
o Bleeding from bite site and internal organs (unchecked bleeding can cause shock or
even death)
• Nervous system effects
o Cobra and black mamba snakes produce neurotoxic venom that can act particularly
quickly by stopping the breathing muscles, resulting in death without treatment.
o Initially, victims may have vision problems, speaking and breathing trouble, and
numbness.
• Muscle death
o Venom from Russell's Vipers, sea snakes, spitting cobras, and some Australian
Elapids contain myotoxins that can directly cause muscle death in multiple areas of
the body.
o The debris from dead muscle cells can clog the kidneys, which try to filter out the
proteins. This can lead to kidney failure.
• Eyes
o Spitting cobras and Ringhals (cobra like snakes from Africa) can actually eject their
venom quite accurately into the eyes of their victims, resulting in direct eye pain and
damage.
• Heamorrhage
o Boomslang snakes produce a heamotoxin that causes poor blood coagulation leading
to bleeding in internal organs, under the skin and at the bite site.
Signs and Symptoms of Stings

• Most of the signs and symptoms are caused by bees, scorpions, spiders and centipedes
which may result in local effects, systemic effects, or both.
• Local effects include:
o Pain and tenderness
o Swelling
o Blister and erythematous rash
o Wounds
o Numbness
o Ischaemic local lesion
o Local necrosis
• Systemic effects include:

o Nervous system effects (transient fever, headache, vomiting, coma)
o Cardiovascular system effects (anaphylactic reaction)
o Respiratory system effects (pulmonary oedema, airway obstruction)
Management of Animal Bites and Stings
Primary Survey Assessment

• Remember ‘A-B-C’:
o Airway: Ensure patent airway and beware of excess secretions
o Breathing: Look out for dyspnea (difficulty breathing)
o Circulation: Look out for bleeding and hypotension
• Reassure patient to reduce anxiety
• Patient should not walk to avoid spread of venom
• No tourniquet or constriction bands
Secondary Assessment
• Look for systemic signs
• Assess affected limb and site of bite
• General treatment
o Reassure patient
o IV line/fluids
o Antibiotics
o Tetanus Toxoid prophylaxis
o Analgesic
Specific Treatment
• Neurotoxicity – may require oxygen and ventilation
o Neostigmine and atropine may prevent the use of ventilation
• Systemic poisoning – antivenom (beware of anaphylaxis)
o Give prophylactic antihistamine and steroids before antivenom
o Adrenaline is helpful for severe cases of anaphylaxis
• Titrate dose according to clinical response
• Extreme swelling – may need fasciotomy
• Monitor vital signs.
• Mammalian, dog and fox bite
o Elevate extremity with sling if edema is present
o Examine the wound for possible nerve or tendon damage, or bone injury
o Clean the wound with water and antiseptics solution and remove any damaged tissue
o Perform surgical debridement and wound should be left open
o Prescribe an antibiotic and Tetanus toxoid
o Give human rabies immunoglobulin
o Give rabies vaccine on days 0, 3, 7, 21, and 28
• Snakebite treatment
o Treat the breathing problems and shock
o Wash the wound with large amounts of soap and water.
o Inspect the wound for foreign bodies (e.g. broken teeth or dirt)
o Even a bite from a non venomous snake requires excellent wound care
o The victim needs a tetanus booster if he or she has not had one within five years

o The victim is monitored for worsening signs at the wound site, or worsening systemic
symptoms in the breathing or cardiovascular systems
o Do not cut and suck.
o Cutting into the bite site can damage underlying organs, increase the risk of infection
and bleeding, and does not result in venom removal
o Do not use ice.
o Ice does not deactivate the venom
o Do not use alcohol.
o Alcohol may deaden the pain, but it also makes the local blood vessels bigger, which
can increase venom absorption
o Do not use tourniquets or constriction bands.
o These have not been proven effective and may cause increased tissue damage
• The specific treatment of snake bite
o Give by very slow intravenous (IV) injection 20 - 30 mls of snake polyvalent antisera
diluted in 3 volumes of normal saline: 100 -150 mls may be given in severe
invenomination with symptoms of neurotoxicity and heamotoxicity.
o This therapy can be life-saving.
o Antivenom can cause allergic reactions, even anaphylactic shock, a life-threatening
type of shock requiring immediate medical treatment with hydrocortisone 200- 500
mg IV, or Adrenaline 1:1000 subcutaneous (S.C.) or IV 1-2 mg stat.
• Stings treatment
o Treatment will depend on the severity of the condition.
o It is important to note that no specific antivenom is available to counteract the poison
injected by the insect.
o Allergic reaction to the sting causes the majority of problems requiring medical
treatment.
o In case of a single sting with no allergic symptoms, remove any stings remaining in
the skin (most likely from bees).
o Application of ice to the sting site may provide some mild pain relief.
o Give an antihistamine such as diphenhydramine (Benadryl) for itching.
o Give non-steroid antinflamatory for pain relief as needed.
o Wash the sting site with soap and water.
o In severe allergic reaction (such as low blood pressure, swelling blocking air getting
into the lungs, and/or other serious breathing problems), treatment may include
intubation, antihistamines, steroids, epinephrine and IV fluids.
Case Study: Snake Bite
Activity: Case Study
Instructions
You will work in small groups.
Refer to Worksheet 3.1: Case Study: Snake Bite.
Read the instruction for the activity on the worksheet. You will have 15 minutes to complete
your work. After 15 minutes you will report your results to the larger group.

Key Points
• Animal bites and stings can produce different types of toxins that affects central nervous
system, cellular, muscular and circulatory systems.
• Management is by administering specific antidotes, wound management and general
systemic resuscitation.
Evaluation
• What are animal bites and stings?
• Name different types of snake toxins.
References

Worksheet 3.1: Case Study: Snake Bite
Instructions:
1. Choose a presenter for your group. The presenter will share your group’s decisions and
answers with the larger group.
2. Choose a recorder for your group. The recorder may write on note paper or flip chart
paper.
3. Discuss the case together and answer the three related questions in the time you are given.
4. Use session notes on this case study.
Case Information
A 35-year-old man comes to your clinic complaining that he was bitten by a snake on his leg
two hours ago. He presents with numbness of his leg and difficulty in breathing. On
examination, his blood pressure is 80/60 mmHg.
Questions
1. What steps would you take to conduct the primary survey?
2. What type of toxicity is the patient been affected?
3. How will you manage?

Session 4: Ulcers
Learning Objectives
• Define the term ulcer
• Describe characteristic shapes of ulcers
• Classify ulcers
• Describe the management of ulcers
Definition and Characteristics of Ulcers

• An ulcer is a non-traumatic disruption of continuity in epithelial surface of the skin or
mucous membrane.
• It may either follow molecular death of the surface epithelium or its traumatic removal.
Characteristics
• Ulcers are characterised by their shapes, margins or edges, floor, and base.
• Edge: This gives clue to the diagnosis of an ulcer and condition of an ulcer.
o There are five common types of ulcer edge:
Undermined edge: Mostly seen in ulcers caused by Mycobacterium (e.g.
mycobacterium tuberculosis causing tuberculous ulcer or mycobacterium ulcerans
causing buruli ulcer).
Punched out edge: Mostly seen in gummatous ulcers (syphilitic) or in deep
trophic ulcer.
Sloping edge Mostly seen in healing traumatic or venous ulcer.
Raised and pearly white beaded edge: A feature of basal cell carcinoma (rodent
ulcer).
Rolled out everted edge: Is a characteristic feature of squamous cell carcinoma or
an ulcerated adenocarcinoma.
Figure 1:Common Types of Ulcer Edge
Undermined edge
Punched out edge

Session 4: Ulcers 19
Sloping edge
Raised and pearly-white beaded edge
Rolled out (everted) edge
Source : Russell et al., 2004

• Floor
o This is the exposed surface of the ulcer.
o Pale and smooth granulation indicates a slowly healing ulcer.
o A trophic ulcer penetrates down even to the bones.
• Base
o It is the site on which the ulcer rests.
o Hardness of the base is an important feature of carcinomatous lessions.
Clinical Classification
• There are two ways of classifying ulcers
o Clinically
o Pathologically
Clinical Classification of Ulcers

• Spreading (acute phase)
o Surrounding skin is inflamed and the floor is covered with profuse offensive slough
without any evidence of granulation tissues.
o The ulcer is inflammed, oedematous and ragged edges; it is a painful ulcer.
o Draining lymphnodes are inflamed, enlarged and tender and may be suppurated with
abscess formation.
• Healing
o The floor is covered with pinkish or red healthy granulation tissue.
o The edges are reddish with granulation, while the margin is bluish with growing
epithelium and the discharge is slight and serous.
• Callous (chronic phase)
o The ulcer shows no tendency towards healing.
o The floor is covered with pale granulation tissue; sometimes shows typical wash-
leather slough in gummatous.
o Discharge is scanty or absent.
• Tropical
o Common feature of this ulcer is callousness and they develop through three stages
Stage One: A pustule, or neglected cut, containing microorganisms (typically
penicillin-sensitive).

Stage Two: Progression of the cut or pustule to form an acutely painful ulcer with
a raised, thickened, and slightly undermined edge.
This ulcer grows rapidly for several weeks.
A bloody discharge covers the grey slough on its floor, the skin around it is dark
and swollen, and muscle, bone, and tendon occasionally lie exposed in its base.
After about a month, the pain, swelling, and discharge improve, and it either heals,
or it goes on to the next stage.
Stage Three: It becomes chronic, and resembles any other long-standing indolent ulcer.
Pathological Classification
• Pathologically an ulcer may be:
o Nonspecific
o Specific (tuberculous or syphilitic)
Non-Specific Ulcers
• Traumatic
o Mechanical: e.g. Dental ulcers of the tongue from jagged tooth, from pressure of a
splint
o Physical: From electrical or X-ray burn
o Chemical: From application of caustics
o These types of ulcers heal quickly and do not become chronic unless supervened by
infection or ischaemia.
• Trophic Ulcers
o Arterial (ischaemic), as in Atherosclerosis (hardening & narrowing of the vessels)
o Venous
Typically situated on the medial aspect of the lower third (1/3) of the lower limb
often associated with varicose veins in upper third (1/3) of the lower limb
Occur as a complication of Deep Venous Thrombosis (DVT)
Presents with eczema and pigmentation around ulcers, slightly painful in the
beginning, but gradually the pain settles down
o Associated with other diseases
Gout
Diabetic Mellitus- may be precipitated by ischeamia due to diabetic
atherosclerosis, infection or diabetic peripheral neuropathy; toes and feet are
commonly affected
Anaemia
Avitaminosis
Rheumatoid arthritis
o Neurogenic trophic
Trophic ulcers are due to impairment of nutrition of the tissues, which depends
upon an adequate blood supply and a properly functioning nerve supply
Ischaemia and loss of sensation do cause these ulcer
In the leg, painful ischaemic ulcers occur around the ankle or on the dorsum of the
foot
These ulcers have punched out edge with slough in the floor thus resembling
gummatous ulcer
Bed sores and perforating ulcers are typical examples of trophic ulcers
Specific Ulcers
• Tuberculous: Caused by mycobacteria tuberculosis

• Buruli ulcer: Caused by mycobacteria ulcerans
• Syphilitic ulcer: There are primary, secondary, tertiary stages in syphilis
o In primary- a hard chancre or hunterian chancre is seen.
o This chancre usually develops at site of entry of tryponema in about three or four
weeks after exposure.
o Sites of the ulcers are the genitalia, lip, tongue, nipple, and perianal region.
o These types of ulcer are single, usually painless and have a characteristic indurated
base which feels like a button.
o In secondary- ulcers may develop in form of mucous patches, snail track ulcers –these
are multiple small, round and superficial erosions which coalesce to form narrow,
curved shallow ulcers.
o They are mostly found in the mouth. Condylomalata are fleshy wart like growths
which are seen in the angles of the mouth anus, vulva.
o In tertiary- gummatous ulcers occur in (late stage) syphilis.
o It is a result of obliterative endarteritis, necrosis and fibrosis, usually seen over the
bones (e.g. tibia, sternum, ulna and skull), in the scrotum in relation to the testis,
upper part of the leg etc.
The most characteristic feature is punched-out indolent edge and yellowish grey
gummatous tissue in the floor.
Pain and tenderness are absent.
Lymphnodes are seldom involved unless secondarily infected.
• Malignant Ulcers
o Squamous cell carcinoma (Marjolin’s ulcer)
A squamous cell carcinoma (SCC) arising from a long standing benign ulcer or
scar.
The most common ulcer to become malignant is a longstanding venous ulcer.
The scar which may show malignant change is an old burn scar.
It’s a slow growing and less malignant SCC.
Edges are not raised and everted as do the typical SCC ulcers.
o Epithelioma (squamous cell carcinoma or basal cell carcinoma)
Arises from layer of the skin, so can arise anywhere in the body.
Commonly seen on the lips, cheek, hands, penis, vulva and old scars.
Mostly seen after 40 yrs as a small nodule, enlarges and gradually the centre
becomes necrotic and sloughs out to develop an ulcer.
In early stages it’s mobile, but later on becomes fixed to the deeper structure.
o Malignant melanoma
A malignancy of pigment producing cells (melanocytes) located predominantly in
the skin, but also found in eyes, ears, GIT, leptomeninges, oral and genital mucous
membranes.
Clinically it presents like a mole which increases in size and changes colour but in
some cases the colour does not change.
Lesions that do not change colour are known as amelanotic melanoma.
Ulceration of the mole can lead to bleeding.
Enlarged regional lymph nodes indicate that there is metastasis.
Malignant melanoma is not painful, although it often itches.
o Basal Cell Carcinoma
Common in the trunk in black population
Presents with raised rolled out edges
Regional lymphadenopathy indicate metastasis (rare)

Principles of Management of Ulcers
• Identification of the exact aetiology of the ulcer is important so as to have a successful
treatment of the ulcer.
o History and clinical physical findings are important.
o Biopsy of the lesion is extremely important to determine the exact nature of the ulcer.
o A clear ulcer with healthy granulation tissue exuding serous discharge should be
dressed once a day, and if there is copious discharge more frequent dressings are
needed.
o Ulcers can be cleaned safely with normal saline solution.
o The ideal dressing should be one that is soft, absorbent, non-adherent, and non-
allergenic.
o Topical antibacterials may be administered, e.g. Povidone Iodine, Metronidazole
cream.
o Systemic antibiotics are prescribed to manage specific bacterial infection.
o Management of melanoma is complicated; it is mainly by surgical excision of the
lesion and later regional lymphnodes excision depending on the site of the melanotic
lesion.
o Management of squamous cell carcinoma ulcers is surgical by wide excision of the
ulcer followed by skin graft which is done at the district hospital.
o Finally the patient should be referred for radiotherapy.
Instructions
Refer to Worksheet 4.1: Case Study.
Read the instructions for the activity on the worksheet and complete the activity within 15
minutes. After completion you will present your responses to the larger group.
Key Points
• An ulcer is a non-traumatic discontinuity in epithelial surface-skin or mucous membrane.
• Ulcers are characterised by their shapes (margin or edge, floor, and base).
• Ulcers are classified into two groups (clinically and pathologically).
• Identification of the exact aetiology of the ulcer, proper history taking and physical
examination of the ulcers are important to successfully treat the ulcer.
• The ideal dressing should be one that is soft, absorbent, non-adherent, and non-allergenic.
• Systemic antibiotics are prescribed to manage specific bacterial infections.
Evaluation
• What are the shape characteristics of ulcers?
• Name common types of ulcers edge.
• Explain the classification of ulcers.
References
• Bickley S. (2003). Guide to Physical Examination and History Taking (8th ed.). USA:
Lippincott Williams and Wilkins.


Worksheet 4.1: Case Study
Instructions:
5. A volunteer will read the case study and questions.
6. As a large group, you will discuss the answers to the questions.
7. Take notes on the worksheet or a blank piece of paper.
8. Choose a recorder. The recorder may write on note paper or flip chart paper.
9. Discuss the questions together and answer the related questions in the time you are given.
Case Information
A patient was involved in a burn accident and sustained injury to the right lower limb about
five years ago. The wound healed well and a big scar remained. One month ago the patient
sustained a bruise on the scar site which developed into a wound. In spite of long term
treatment of this wound, there is still no improvement.
Questions:
1. What is the most likely diagnosis?
2. How will you manage this patient?

Session 5: Lymphadenitis
Learning Objectives
• Define lymphadenitis
• Describe causes of lymphadenitis
• Describe clinical presentation of lymphadenitis
• Identify relevant investigations for lymphadenitis
• Identify differential diagnosis of lymphadenitis
• Describe management and complication of lymphadenitis
• Describe clinical presentation and management of TB lymphadenitis
Introduction and Pathophysiology of Lymphadenitis

Introduction
• Lymphadenitis: The inflammation and/or enlargement of a lymph node.
• Most cases represent a response to benign, local, or generalized infections.
• Lymphadenitis may be generalized or affect a single node (local adenopathy) or a
localized group of nodes (regional adenopathy) and may be unilateral or bilateral.
• The onset and course of lymphadenitis may be acute, subacute, or chronic.
Pathophysiology
• Increased node size may be caused by the following:
o Multiplication of cells within the node, including lymphocytes, plasma cells,
monocytes, or histiocytes.
o Infiltration of cells from outside the node, such as malignant cells or neutrophils.
o Draining of a source of infection by lymph nodes.
• If the cause of adenopathy is not evident, consider congenital or neoplastic causes.
Causes and Clinical Presentations of Lymphadenitis
Causes
• Infections
o Acute, local one-sided, pyogenic adenitis is most common.
o Etiologic agents include group A beta-haemolytic streptococci, staphylococcal
organisms (especially staphylococcus aureus) and viruses
o Mycobacterium tuberculosis
o If inguinal adenopathy- consider sexually transmitted diseases or testicular
malignancy
o Brucellosis
o Yesinia species
o Salmonella
o Infectious mononucleosis
o Cytomegalovirus
o Toxoplasmosis
• Immunologic or connective tissue disorders

Session 5: Lymphadenitis 27
o Rheumatoid
• Primary disease of lymphoid or reticuloendothelial tissue
o Acute leukaemia
o Lymphosarcoma
o Hodgkin disease
o Non-Hodgkin lymphoma
o Non-endemic Burkitt tumour
o Immunodeficiency syndromes
Clinical Presentation
• History
o Upper respiratory symptoms, sore throat, earache, coryza, conjunctivitis, and impetigo
o Fever, irritability, and anorexia.
o Dental and or oral conditions: Submaxillary adenopathy may develop secondary to
stomatitis, dental caries, or a dental abscess.
o Acute or chronic onset
Bilateral acute cervical adenitis is usually caused by either viral pharyngitis or
infectious mononucleosis, but could also been seen in acute HIV seroconversion.
Chronic localized adenopathy can be attributed to a persistent regional infection.
o Skin and scalp conditions: Occipital and postauricular adenopathy may accompany
scalp infections, seborrhic dermatitis, or scalp pediculosis.
Epitrochlear and axillary lymphadenopathy may result from infections on the
arms.
Inguinal and femoral adenopathy may be due to infections on the lower
extremities or sexually transmitted infections in the genital region.
o Periodicity: Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis
(PFAPA) syndrome usually results in adenopathy associated with the other findings
every 3-6 weeks.
• Physical examination
o Location
Most patients with lymphadenitis exhibit small palpable cervical, axillary, and
inguinal nodes.
Some patients have palpable suboccipital or postauricular nodes.
Rubella and parvovirus infection is characterized by enlarged and tender posterior
auricular, posterior cervical and occipital lymph nodes.
Atypical (environmental) mycobacterial may cause submandibular or submental
adenopathy.
Mediastinal or infectious hilar adenopathy may occur in patients with
tuberculosis, chronic sinusitis, histoplasmosis, tularemia, infectious
mononucleosis, candidiasis, coccidioidomycosis, and bronchiectasis.
o Size: Lymph nodes that are noted to increase rapidly in size may indicate potential
malignancy.
o Shape: Confluent lymph nodes may be indicators of malignancy.
o Consistency
Descriptors may include soft, fluctuant, firm, rubbery, or hard.
In early stages, nodes in tuberculosis are well-demarcated, mobile, non tender, and
firm.
If the infection remains untreated, the nodes soften, become fluctuant, and adhere
to the skin, which may be erythematous and eventually ulcerate.
In Hodgkin disease, nodes are initially soft.

They later become firm and rubbery.
o Fixation of lymph nodes to the skin and soft tissue may indicate malignancy.
o Tenderness
Lymph nodes of infectious aetiology are usually tender.
Hodgkin lymphoma may initially present as painless lymph node enlargement,
especially of the cervical and supraclavicular region.
o Overlying skin
The overlying skin may be erythematous in infectious etiologies.
Draining sinuses may develop in patients with tuberculosis adenopathy.
o Systemic signs
Group B streptococcal cellulites and adenitis are characterized by sudden onset of
fever, anorexia, irritability, and submandibular swelling.
Hepatosplenomegaly is common in patients with infectious mononucleosis.
Differential Diagnosis and Investigations of Lymphadenitis
Activity: Small Group Discussion
Instructions
You will work in small groups to answer the following questions:
• What are the differential diagnoses of lymphadenitis?
• List the relevant investigations of lymphadenitis.
Half of the groups will work on the first question. The other half should work separately to
come up with answers to the second question.
Refer to Work Sheet 5.1 Differential Diagnosis and Investigations of

Lymphadenitis.
Differential Diagnosis
• Brucellosis
• Neuroblastoma
• Chronic granulomatous disease
• Non-Hodgkin lymphoma
• Cytomegalovirus infection
• Rhabdomyosarcoma
• Salmonella infection
• Sarcoidosis
• Sickle cell anaemia
• Hodgkin’s disease
• Rheumatoid arthritis
• Tuberculosis
• Mononucleosis and Epstein-Barr virus infection
• Acute HIV or chronic HIV infections
• Syphilis

Investigations
• Laboratory studies
o Gram stain: Staining can be performed on aspirated tissue.
o Culture can be taken of aspirated tissue or specimen can be biopsied.
o Serologies are useful to confirm the diagnosis of infectious mononucleosis.
o Skin testing: Purified protein derivative testing can be helpful in confirming the
diagnosis of tuberculosis lymphadenopathy and may be suggestive of atypical
mycobacterial infection.
o Full blood picture: A high white blood count may indicate an infectious aetiology.
o Erythrocyte sedimentation rate: A high erythrocyte sedimentation rate is a nonspecific
indicator of inflammation.
o Liver function tests: These may indicate hepatic or systemic involvement.
o An elevation may occur in infectious mononucleosis.
o Usually, a blood culture test demonstrates positive results.
• Imaging studies
o Chest radiography: Radiography may be helpful in determining pulmonary
involvement or spread of lymphadenopathy to the chest.
Management and Complications of Lymphadenitis
Management
• In patients with lymphadenopathy, treatment depends on the causative agent and may
include the following:
o Antimicrobial therapy
o Chemotherapy
o Radiotherapy
o Surgical care
Excisional biopsy: Lymphadenitis caused by atypical mycobacterial may have
improved cosmetic outcome with surgical excision.
Aspiration
Incision and drainage
Complications
• Cellulitis
• Suppuration
• Systemic involvement
• Internal jugular vein thrombosis
• Septic embolic phenomena
• Purulent pericarditis
Clinical Presentation and Management of TB Lymphadenitis

• In tuberculosis lymphadenitis tubercle bacilli enter the body through the tonsil of the
corresponding side.
• From there they move to the cervical lymph nodes, so the upper deep cervical nodes are
most often affected.
• There is no generalized infection, so the cervical nodes involvement is not secondary to
tuberculosis anywhere in the body.

• This is commonly found in children and young adults. It may occur at any age.
• This incidence in the young has diminished since the introduction of BCG vaccination.
• The cervical nodes are most frequently involved followed by mediastinal, mesenteric,
axillary, and inguinal nodes according to the order of frequency.
Investigations
• Full blood picture
• Chest X- ray
• Refer for further management (biopsy, AFB and treatment)
Treatment
• Anti-tuberculosis drugs should be prescribed once the diagnosis is confirmed.
• Nutritious food (vitamin supplementation and high protein diet) are the supportive
therapies which every patient with tuberculosis of the lymph nodes should receive.
• If the lymph nodes do not respond to the drug therapy or show initial response but remain
static after that, operative removal is justified.
• If cold abscess has been formed, it is advisable to start the antituberculous therapy and to
aspirate the abscess before it ruptures with sinus formation.
• Aspiration is performed with a thick needle through the healthy skin preferably from
above.
Key Points
• Lymphadenitis is the inflammation and/or enlargement of a lymph node.
• Most cases represent a response to benign, local, or generalized infections.
• Lymphadenitis can be caused by infections, immunologic/connective tissue disorders, and
primary disease of lymphoid or hematopoietic diseases.
• In patients with lymphadenitis, treatment depends on the causative agent and may
include:
o Antimicrobial therapy
o Chemotherapy
o Radiotherapy
o Surgical care such as excisional biopsy, aspiration, incision and drainage
Evaluation
• What are the clinical presentations of lymphadenitis?
• How can you diagnose and treat TB lymphadenitis?
References
• Das S. (2008). Concise Textbook of Surgery (5th ed.). India.
• Fraser L, Moore P & Kubba H. (2008). Atypical Mycobacterial Infection of the Head and
Neck in Children: A 5-Year Retrospective Review. Otolaryngology – Head and Neck
Surgery, 138(3):311-4.
• Friedmann A.M. (2008, February). Evaluation and Management of Lymphadenopathy in
Children. Pediatric Review, 29(2):53-60.

Worksheet 5.1:Differential Diagnosis and Investigations of
Lymphadenitis
Instructions:
paper.
Questions:
1. What are the differential diagnoses of lymphadenitis?
2. List the relevant investigations of lymphadenitis.

Session 6: Lymphadenitis
Learning Objectives
• Define paronychia, cellulitis and pyomyositis
• Describe causes of paronychia, cellulitis and pyomyositis
• Describe clinical presentation of paronychia, cellulitis and pyomyositis
• Identify relevant investigations for paronychia, cellulitis and pyomyositis
• Identify differential diagnosis of paronychia, cellulitis and pyomyositis
• Describe the management of paronychia, cellulitis and pyomyositis
Paronychia
• Paronychia: A soft tissue infection around a fingernail.
Aetiology
• Acute paronychia
o Acute paronychia usually results from a traumatic event, however minor, that breaks
down the physical barrier between the nail bed and the nail; this disruption allows the
infiltration of infectious organisms.
o Acute paronychia can result from seemingly innocuous conditions, such as hangnails,
or from activities, such as nail biting, finger sucking or artificial nail placement.
o Staphylococcus aureus is the most common infecting organism.
o Organisms, such as Streptococcus and Pseudomonas species, gram-negative bacteria,
and anaerobic bacteria are other causative organisms.
• Chronic paronychia
o Chronic paronychia is primarily caused by the yeast fungus Candida albicans.
o Chronic paronychia most often occurs in persons whose hands are repeatedly exposed
to moist environments or in those who have prolonged and repeated contact with
irritants such as mild acids, mild alkalis, or other chemicals.
o People who are most susceptible include housekeepers, dishwashers, bartenders, and
swimmers.
o Other conditions associated with abnormalities of the nail fold that predispose
individuals to chronic paronychia include psoriasis, mucocutaneous candidiasis, and
drug toxicity.
Clinical Features of Acute Paronychia

• The affected area often appears very tender, erythematous and swollen.
• In more advanced cases, pus may collect under the skin of the lateral fold.
• In severe cases, the infection may track proximally under the skin of the finger.
• The fulminant purulence of the nail bed may generate enough pressure to lift the nail off
the nail bed.
Clinical Features of Chronic Paronychia

• Swollen, erythematous, and tender nail folds without fluctuance are characteristic of
chronic paronychia.

• Eventually, the nail plates become thickened and discoloured, with pronounced transverse
ridges.
• The cuticles and nail folds may separate from the nail plate, forming a space for the
invasion of various microorganisms.
Figure 1: Paronychia
Source: Guss,2008
Investigations
• The diagnosis of paronychia is primarily based on the features of the history and on the
physical examination findings.
• Full blood picture: leucocytosis
• Erythrocyte sedimentation rate: raised (this is usually not necessary as the diagnosis is a
clinical one)
Management of Paronychia
• Oral antibiotics with gram-positive coverage against Staphylococcus aureus are usually
administered, such as amoxicillin and clavulanic acid (Augmentin) or cloxacillin.
• Soaking the affected digit in hot (but not burning ) water can also be helpful
• If paronychia does not resolve despite best medical efforts, surgical intervention may be
indicated.
• Also, if an abscess has developed, incision and drainage must be performed.
• The most common surgical technique used is called eponychial marsupialization.
• Give analgesics.
Cellulitis
• Cellulitis: An inflammation of the connective tissue underlying the skin.
Aetiology of Cellulitis
• Cellulitis can be caused by normal flora or by exogenous bacteria and often occur where
the skin has previously been broken, cracks in the skin, insect bite, surgical wound or IV
canulla insertion.
Clinical Features of Cellulitis

• Fever, headache and pain of the affected area.
• Cellulitis is characterized by redness, swelling, warmth and tenderness.
• In advanced cases the cellulitis, red streaks may be seen traversing up the affected area.
Investigations
• Erythrocyte sedimentation rate: raised

• Blood culture
Management
• Combination of IV and oral antibiotics
• Analgesics
• Bed rest and elevation of the limb
Pyomyositis
• Pyomyositis: An acute, subacute, or chronic supurative infection of skeletal muscle.
Aetiology of Pyomyositis
• Pyomyositis is often caused by staphylococcus aureus, but trauma, viral infection, and
malnutrition have been implicated.
• Although most cases of tropical pyomyositis occur in healthy individuals, other
pathogenetic factors include nutritional deficiency, immune deficiency and associated
parasitic infection.
• In the temperate climates, pyomyositis is seen most commonly in patients with diabetes,
HIV infection, and malignancy.
Clinical Features of Pyomyositis

• Fever and malaise are common.
• Muscles are painful, swollen, tender, and indurated.
• Quadriceps muscle is involved most commonly.
• The second most common location is the psoas muscle, followed by the upper
extremities.
• Depending on the site of involvement, it may mimic appendicitis (psoas muscle), or
septic arthritis of the hip (iliacus muscle).
• Findings may be subtle in immunocompromised persons requiring a high index of
suspicion for diagnosis.
Investigations and Management Pyomyositis
Investigations
• Erythrocyte sedimentation rate: raised
• Pus swab for culture and sensitivity
• Blood culture and serology for HIV
Management
• Incision and drainage
• Broad spectrum antibiotics
• Analgesics
• Treat underlying cause
Key Points
• Paronychia is a soft tissue infection around a fingernail.
• Its management includes oral antibiotics, possible surgical intervention and analgesics.
• Cellulitis is an inflammation of the connective tissue underlying the skin.

• Management of cellulitis includes Combination of IV and oral antibiotics, Analgesics and
Bed rest and elevation of the limb
• Pyomyositis is a suppurative infection of skeletal muscle.
• Pyomyositis is often caused by staphylococcus aureus, trauma, HIV, and malnutrition and
its management of pyomyositis include Incision and drainage, Broad spectrum antibiotics,
Analgesics and Treating the underlying cause
Evaluation
• Define paronychia, cellulitis and pyomyositis.
• What are the causes of paronychia, cellulitis and pyomyositis?
References
• Das, S. (2008). Concise Textbook of Surgery (5th ed.). India.
• Fraser L., Moore, P., & Kubba, H. (2008, March). Atypical Mycobacterial Infection of
the Head and Neck in Children: A 5-Year Retrospective Review. Otolaryngology – Head
and Neck Surgery, 138(3):311-4.
• Friedmann A.M. (2008, February). Evaluation and Management of Lymphadenopathy in
Children. Pediatric Review, 29(2):53-60.

Session 7: Thoracic Empyema and Abscesses
Learning Objectives
• Define thoracic empyema and abscess
• Describe causes and pathophysiology of thoracic empyema
• Describe clinical presentation of thoracic empyema
• Identify relevant investigations for thoracic empyema
• Describe management of thoracic empyema and abscesses
Causes and Pathophysiology of Thoracic Empyema

• Thoracic empyema: The presence of pus in the pleural cavity.
Causes
• Pulmonary tuberculosis (PTB) is the most common cause in Tanzania
• Postpneumonic or parapneumonic
• Lung abscess
• Thoracic trauma
• Gastrointestinal tract (from oesophagus or through diaphragm)
• Extension of a non-pleural-based infection (e.g. mediastinitis)
• Instrumentation of the pleural space, such as in thoracentesis, or tube thoracostomy
• Subdiaphragmatic abscess
• Thoracic vertebral osteomyelitis
• Retropharyngeal abscess
Pathophysiology
• An empyema is either acute or chronic
• The formation of an empyema has 3 stages:
o Exudative stage: Protein-rich pleural fluid remains free-flowing.
The number of neutrophils is rapidly increasing.
Glucose and pH levels are normal.
Drainage of the effusion and appropriate antimicrobial therapy are normally
sufficient for treatment.
o Fibrinolytic stage: Viscosity of the pleural fluid is increasing.
Coagulation factors are activated, and fibroblast activity begins coating the pleural
membrane with an adhesive meshwork.
Glucose and pH levels are lower than normal.
o Organizing stage: Loculations are forming.
Fibroblast activity causes adherence to the visceral and parietal pleura.
This activity may progress with the formation of pleural peels in which the pleural
layers are indistinguishable.
Pus, which is a protein-rich fluid with inflammatory cells and debris, is present in
the pleural space.
Surgical intervention is often required at this stage.

Session 7: Thoracic Empyema and Abscesses 37
Clinical Features, Investigations and Differential Diagnosis of Thoracic
Empyema
Clinical Features
• The patient's history may reveal the following findings:
o Recent diagnosis and treatment for pneumonia
o Recent history of penetrating chest trauma
o Cough productive of bloody sputum that frequently has a fetid odour or offensive
smell
o High-grade fever
o Shortness of breath
o Anorexia and weight loss
o Night sweats
o Pleuritic chest pain during early stages
o Malaise
• Physical examination may reveal the following findings:
o Temperature frequently elevated
o Tachypnea
o Rales/crepitations
o Rhonchi
o Tubular breath sounds
o Decreased breath sounds
o Decreased fremitus
o Stony dullness to percussion
Investigation
• Chest X- ray may reveal:
o Underlying disease (e.g. pneumonia, lung abscess)
o Pleural fluid
• Pleural aspiration; appearance is turbid or purulent fluid
• Sputum gram staining ± culturing and sensitivity testing
• Full blood count
• Pleural effusion
• Pneumonia
• Tuberculosis
• Pulmonary abscess
Management of Thoracic Empyema
Objectives of Treatment
• Control infection
o Parenteral antibiotics are prescribed to control the infection
o Anti TB if indicated
• Drain the purulent fluid
o Insert a chest tube to completely drain the pus.
• Eradicate the sac to prevent chronicity and allow re-expansion of the affected lung to
restore function.
o Decortication (peeling away the lining of the lung) may be indicated if the lung does
not expand properly.
• Note: Remember drainage of the purulent fluid and eradication of the sac (objectives 2
and 3) should be done in a district/regional specialized hospital.
Case Study
Instructions
Refer to Worksheet 7.1: Case Study.
You will work in small groups to complete the activity on the worksheet. After 15 minutes
you report your results to the rest of the group.
Abscesses
• Abscess: A localized collection of pus contained within a cavity that is formed after
tissue destruction; the cavity is surrounded by a pyrogenic membrane.
Types of Abscesses
• Breast abscess
o Breast infections, common during lactation, are most often caused by Staphylococcus
aureus.
o The bacteria gain entrance through a cracked nipple causing mastitis (breast cellulitis)
which may progress to abscess formation.
o The features of a breast abscess are pain, tender swelling and fever, the skin becomes
shiny and tight but, in the early stages, fluctuation is unusual.
o Failure of mastitis to respond to antibiotics suggests abscess formation even in the
absence of fluctuation or an infection caused by bacteria not covered by the
antibiotic(s) being administered (such as Methicillin-Resistant Staphylococcus aureus,
or MRSA).
o When in doubt about the diagnosis, perform a needle aspiration to confirm the
presence of pus.
o The differential diagnosis of mastitis includes the rare but aggressive inflammatory
carcinoma of the breast (inflammatory carcinomatosis).
o Successful drainage of a breast abscess requires adequate anaesthesia.
Refer to:
• Handout 7.1: Incision and Drainage of Breast Abscess and
• Handout 7.2: Abscess Incisions and Drainage of Abscess

• Pelvic abscess
o Pelvic abscesses occur secondary to the same conditions that cause intra-peritoneal
abscesses if the pus and fluid tracks downwards into the pelvis.
o In addition, gynaecological infections can cause pelvic abscesses.
o Pelvic abscesses can cause symptoms of frequent urination, diarrhoea or tenesmus
(a sensation of incomplete bowel emptying).
o If symptoms are mild, pelvic abscesses do not require surgical treatment as they often
respond to systemic antibiotics.
• Sub-phrenic abscess
o This is a collection of pus below the diaphragm (the muscular organ separating the
abdominal cavity from the chest cavity).
o It is often caused by rupture of the gallbladder, generalised peritonitis or post-
abdominal operations that causes fluid to build up under the diaphragm.
o Abscesses in this location are close to the lungs so they can cause basal lung
infections.
o Symptoms may mimic pneumonia.
• Intra-peritoneal abscess
o This is an abscess within the peritoneal cavity due to an infection of free fluid, bile or
blood.
o Often these abscesses are the result of bowel perforation or a complication of bowel
surgery.
o Spillage of feacal material from an inflamed appendix frequently causes this type of
abscess.
• Visceral abscess
o Abscesses are also found on the surface or within gastrointestinal organs.
o Liver abscesses are the most common and account for approximately half of all
visceral abscesses.
o These may cause pain in the right upper part of the abdomen.
o Pancreatic abscesses occur as a late complication of acute pancreatitis.
o Pancreatitis causes severe central abdominal pain that spreads to the back.
o Early recognition and treatment of this disorder will prevent abscesses formation.
o Abscesses of the spleen are rare but can occur if this organ is damaged or if there is an
infection in the blood.
• Psoas abscess
o The psoas muscle is a large muscle running alongside the spine which crosses the
pelvis.
o Clinical signs are back pain or pain during flexion of the hip.
o Abscesses occur in the psoas muscle when infections spread in the blood or from local
organs of the abdomen or pelvis.
o In addition, infections in the bones of the spine (osteomyelitis) can cause psoas
abscesses.
• Anorectal abscess
o The anus and rectum are other common sites of abscess formation worth separate
mention.
o Anorectal abscesses are more common in men and often develop into anorectal
fistulas.
o They usually result from minor trauma in the perineum and anorectal area.
o They present as painful, tender swellings and are easily accessible by surgical
treatment.

Key Points
• Thoracic empyema is the presence of pus in the pleural cavity.
• PTB and pneumonia are common causes of empyema in our settings.
• The formation of an empyema has 3 stages which are Exudative stage, Fibrinolytic stage
and Organizing stage.
• The objectives of treatment are to control infection, drain the purulent fluid and eradicate
the sac.
• An abscess is a localized collection of pus contained within a cavity formed by
destruction of tissue.
• There are different types of abscesses such as breast abscess, pelvic abscess, sub-phrenic
abscess, intra-peritoneal abscess, visceral abscess, psoas abscess and anorectal abscess.
Evaluation
• What is thoracic empyema?
• What are the causes of thoracic empyema?
References
• Bono, M.J. (2004): Recognizing and Managing Thoracic Empyema. Emergency
Medicine, 36(12):37-40. Norfolk: Virginia School of Medicine.
• Das S. (2008). Concise Textbook of Surgery (5th ed.). India.
• Russell R.C.G., Williams, N.S., Bulstrode, C.J.K. (2004). Bailey and Love’s Short
Practice of Surgery (24th ed.). London: Arnold.
• WHO. (2003). Surgical Care at District Hospital. World Health Organization: Malta.

Handout 7.1: Incision and Drainage of the Breast Abscess
Figure 1 Figure 2
Figure 3 Figure 4
Source: WHO, 2003
• Prepare the skin with antiseptic and drape the area

• Make a radial incision over the most prominent part of the abscess or the site of the
needle aspiration (Figure 1).
• Introduce the tip of a pair of artery forceps or a pair of scissors to widen the opening and
allow the pus to escape (Figure 2). Extend the incision if necessary. Obtain cultures for
bacteria, fungus and tuberculosis. Break down all loculi with a finger to result in a single
cavity (Figure 3).
• Irrigate the cavity with saline and then either pack with damp saline gauze or insert a
latex drain through the wound (Figure 4).
• Dress the wound with gauze. Give analgesics as required.

Handout 7.2: Incision and Drainage of Abscess
• Treat abscess cavities with incision and drainage to remove accumulated pus.
• Diagnose by the presence of one or more of the following signs:
o Extreme tenderness, local heat and swelling causing tight, shiny skin.
o Fluctuation is a reliable sign when present, although its absence does not rule out a
deep abscess or an abscess in tissues with extensive fibrous components. These
tissues include the breast, the perianal area and finger tips.
o Be suspicious of deep throbbing pain or of pain which interferes with sleep.
Technique
• If in doubt about the diagnosis of abscess, confirm the presence of pus with needle
aspiration. Prepare the skin with antiseptic, and give adequate anaesthesia. A local
anaesthetic field block infiltrating uninfected tissue surrounding the abscess is very
effective. Perform the preliminary aspiration using an 18 gauge or larger needle to
confirm the presence of pus (Figure1).
• Make an incision over the most prominent part of the abscess or use the needle to guide
your incision. Make an adequate incision to provide complete and free drainage of the
cavity. An incision which is too small will lead to recurrence.
• Introduce the tip of a pair of artery forceps into the abscess cavity and open the jaws
(Figure2).
• Explore the cavity with a finger to break down all septa (Figure3).
• Extend the incision if necessary for complete drainage (Figure4), but do not open healthy
tissue or tissue planes beyond the abscess wall.
• Give antibiotics for cutaneous cellulitis, fever or if the abscess involves the hand, ear or
throat.
• Irrigate the abscess cavity with saline and drain or pack open. The objective is to prevent
the wound edges from closing, allowing healing to occur from the bottom of the cavity
upward. To provide drainage, place a latex drain into the depth of the cavity. Fix the drain
to the edge of the wound with a suture and leave in place until the drainage is minimal.
• Alternatively, pack the cavity open, place several layers of damp saline or petroleum
gauze in the cavity leaving one end outside the wound.
• Control bleeding by tight packing.
Figure 1 Figure 2
Source: WHO, 2003.
Continued on next page.

Figure 3 Figure 4
Source: WHO, 2003.

Instructions:
• Choose a presenter for your group. The presenter will share your group’s decisions and
answers with the class.
• Choose a recorder for your group. The recorder may write on notepaper or flipchart
paper.
• Discuss the case together and answer the 4 questions below in the time you are given.
• Refer to your session notes as needed to help you complete this worksheet.
Case Study
A young man was stabbed on the right side of the chest three weeks ago. Initially he was
treated at a nearby dispensary and the chest wound healed. He is now complaining of chest
pain on the right, cough and difficulty in breathing associated with high grade fever. On
examination, respiratory rate was 28 bpm and temperature was 38.6° C.
•Questions:
1. What are you expecting to find on physical examination?
2. What investigations should be conducted with this patient?
4. How will you manage and treat this patient?

Session 8: Burns
Learning Objectives
• Describe structure of the skin
• Define burns
• Identify different types of burns
• Describe methods of assessing area and depth of burns
• Describe the management of burns and their complications
Overview of Structure of the Skin, Definition and Types of Burns

• The skin has the following layers:
o Epidermis: The uppermost layer consisting of stratified squamous epithelium.
o Dermis: The middle layer just below the epidermis, consists of connective tissue.
o Hypodermis: The innermost layer beneath the dermis, is loose connective tissue that
contains collagens and elastin fibres.
Refer to Handout 8.1: Structure of the Skin
• Burn: A tissue injury caused by thermal, electrical, radioactive, or chemical agents.
Types of Burns
• Dry heat burn causes
o Heated metals
o Flames
o Hot charcoal
These burns are often deep and destructive but may not cover a large surface
• Scalds by hot liquids or steam
o Porridge, tea, soup, milk
Often these burns are superficial but may be life-threatening because they cover a
large surface area.
• Chemicals
o Strong/concentrated alkali or acids
o Liquid or powder
These burns denature the skin and can be aggravated by water.
• Electrical
o Domestic
o Industrial
o Lightening
The surface area of the burn is often small but deep tissue destruction between the
entry and exit site of the electrical charge can be very large.

Session 8: Burns 47
Methods to Assess Area and Depth of Burns, and Criteria of Admission
Assessing Area of Burn (Extension)

• The extent of the burn (percent of total body surface affected) is generally more
significant than the degree (severity of depth) in estimating its effect on the victim.
• There are two main rules used for assessing: the extent of burn in adults and children.
• In adults use a’ rule of nines’(by Wallace)
o The head and neck equals to nine percent, each upper limb equals nine percent, each
lower limb equals to eighteen percent, the anterior and posterior thoracic and
abdomen equals to eighteen percent each and perineum is total of one percent.
• In children,
o The head and neck equals to eighteen percent, each upper limb equals to nine percent,
each lower limb equals to fourteen percent, the anterior thoracic and abdomen
eighteen percent and back eighteen percent, perineum one percent.
• Another additional way of estimating the burn surface area is by using the palm of the
patient’s hand which represents one percent of the body surface area.
Figure 1: Estimation of Total Body Surface Area (BSA) in Adults
The ‘rules of nines’ may be used

to estimate the total body surface
area burnt (%TBSA) of adults.
By adding together the affected
areas the percentage of the total
body surface that is burnt can be
calculated quickly. This rule does
not apply strictly to infants and
children. In a child aged 1 year
the head and neck area is 18
percent and each leg is 14
percent. A useful aide-memoire is
that the patient’s hand (fingers
and palm) is 1 percent body
surface area (after Wallace).
Source: Russell et al, 2004

Session 8: Burns 48
Figure 2: Estimation of Total Body Surface Area in Children
Source: Kobusingye, 2009
Estimating of Depth of the Burn

• 1st degree
o Involvement of epidermis
o It is very painful
o Skin is hyperaemic
o Blistering does not occur
o Two-point discrimination remains intact
• 2nd degree
o Partial injury of dermis
o It is painful
o Skin is pink and with possible blisters
• 3rd degree
o Involves full thickness, including dermal appendages
o Skin is white and leathery and is numb
• 4th degree
o Involvement of fascia, muscle or bone
Criteria for Admission

• 2nd and 3rd degree burns more than 15% BSA in adults or more than 10% of BSA in
children3rd degree burns over 2-5% of BSA in adults
• Burns to hands, face, feet, perineum and inner joint surfaces
• Associated carbon monoxide poisoning
• Severe underlying medical illness (diabetes, emphysema, coronary artery disease, etc)
• Minor chemical burns
• Suspected battered child (intentionally inflicted injuries)
Transfer to Burn Centre

• 2nd and 3rd degree burns more than 25% of BSA in adults or more than 20% of BSA in
children

Session 8: Burns 49
• 3rd degree burns more than 10% of BSA
• 3rd degree burns to hands, feet, face and perineum
• Major chemical or electrical burns
• Respiratory tract injury
• Associated major trauma
• Circumferential burns
Case Study 1
Activity: Case Study 1
Instructions
Refer to Worksheet 8.1: Case Study 1: Estimation of Surface Area of Burns.
Work in small groups to complete the activity on the worksheet. After 10 minutes you will
share your results with the rest of the class.
Management of Burns and Their Complications
Initial Treatment
• Stop the burning process and relieve pain
o Remove victim`s clothes, rings and other jewellery.
o Immerse or cover the affected area in cool water.
o Provide pain relief such as pethidine IM or slow IV and titrate to response.
• Fluid resuscitation principles
o Insert intravenous cannula (16G or 14G) through unburned skin.
o Popular formulas: Modified Brooke (2ml) and Parkland (4ml)/kg/%BSA).
o In the first 24 hours post burn, use Parkland formula.
Give Ringer’s Lactate 4ml x % of BSA x body weight (kg). (if Ringer's Lactate is
not available, you can use normal saline)
Half of the amounts should be administered in first 8 hours post burn and the rest
in the next 16 hours.
Monitor vital signs and urine output hourly.
Replacement should be reassessed on an hourly basis.
Insert a Foley’s catheter to assess urine output.
Urine output should be no less than 0.7ml/kg/hr.
If urine output is inadequate, increase infusion by 200ml next hour.
o In the 2nd 24 hours

Add 5% dextrose
Electrolyte and fluid replacement will be guided by urine output
• Cardiac rhythm should be continually monitored for arrhythmia
Tetanus Prophylaxis
• Previous immunization <5 years: Nil
• Previous immunization > 5 years: booster
• No immunization or >10 years, 250-500 units of human anti tetanus globulin then full
course TT when patient is stable

Session 8: Burns 50
Assess for Concomitant Injuries and Complications
• Burns 20% or greater carry a high incidence of paralytic ileus and Curling’s ulcer.
• A nasogastric tube should be inserted and Pantoprazole 40 mg administered IV slowly in
10 minutes stat, then 20 mg in 500 mls dextrose saline 8 hourly for at least 72 hours (3
days).
• Elevate limbs to decrease oedema.
• Flame burns to the neck and chest may contribute to respiratory difficulties.
• The inelastic eschar of the anterior and post chest inhibits respiratory efforts.
• Do not administer antibiotics for prophylaxis since they predispose to resistant organisms.
Case Study 2
Activity: Case Study 2
Instructions
Refer to Worksheet 8.2: Case Study 2: Burns Surface Estimation and

Management.
Work in groups to complete the activity on the worksheet. After completing the activity you
will share your results with the rest of the class.
Key Points
• The structure of the skin consists of epidermis, dermis, and hypodermis.
• Types of burns include thermal, scald, chemical, electrical and by the depth.
• Methods of assessment of burns include ‘rule of nine’ for adults.
• In fluid resuscitation for burn treatment, fluid is calculated by either modified Brookes
Formula or Parklands Formula.
Evaluation
• Define burn.
• What are the criteria for admission of a burn patient?
• Explain the fluid management of burns injury.
References
• Keith L.M. & Anne M.R.A. (2007): Essential Clinical Anatomy (3rd ed.). USA:
• Lett & Kobusingye. (2009). Trauma Team Training Course, Student’s Manual. CNIS
ICCU.

Session 8: Burns 51
Handout 8.1: Structure of the Skin
Source: Keith et al, 2007

Session 8: Burns 52
Worksheet 8.1: Case Study 1: Burns Surface Estimation
Instructions:
paper.
15. Discuss the case together and answer the related questions in the time you are given.
Case 1 Information
Scenario A:
A 25-year-old man comes in with burn injuries on the both upper limbs and anterior chest.
Scenario B:
A 5yrs old child is brought with burn injuries on both lower limbs and perineum estimate the
total surface area of that particular burn injury.
Question Scenario A:
Estimate the total surface area of that particular burn injury.
Question Scenario B:
Estimate the total surface area of that particular injury.

Session 8: Burns 53
Worksheet 8.2: Case Study 2: Burns Surface Estimation and
Management
Instructions:
paper.
Case 2 Information
A 50-year-old man, with a 60 kg body weight, sustained burn injuries while preparing
charcoal in the forest. On arriving to the health centre his entire lower left limb has blisters
and oedematous. His upper right limb from the shoulder joint towards the palm had
superficial burns.
Questions:
1. Estimate the percentage of burns of this patient.
2. How would you manage the patient? Discuss the formula applied for burns estimation
and fluids to be given.

Session 8: Burns 54
Session 9: Breast Lumps
Learning Objectives
• Describe the clinical anatomy and physiology of the breast
• Describe the different types and clinical features of breast lumps
• Describe the history and clinical examination of the breast
• Identify relevant investigations used to diagnose breast lumps
• Explain the management of the different types of breast lumps
Clinical Anatomy and Physiology of the Breast

• The female breast lies against the anterior thoracic wall, extending from the clavicle and
the 2nd rib down to the 6th rib, and from the sternum across to the mid axillary line.
Figure 1: Cross Section of the Breast
Source: Russell R.C.G et al, 2004
• The breast is divided into four quadrants by drawing imaginary longitudinal and
transversal lines which cross at the nipple (see Figure 2 below).
o This divides the breast into the following quadrants:
- Upper outer
- Upper inner
- Lower outer
- Lower inner
• The region around the nipple is known as the periareola.

Session 9: Breast Lumps 55
Figure 2: Breast Quadrants
• The lymphatics from most of the breast drain toward the axilla lymphnodes.
• The breast lymph also drains into other less palpable lymphnodes, namely:
o Pectoral nodes: Anterior, located along the lower border of the pectoralis major inside
the anterior axillaries fold.
o These nodes drain anterior chest wall and much of breast.
o Subscapular nodes: Posterior, located along the lateral border of the scapula; palpated
deep in the posterior axillary fold.
o They drain the posterior chest wall and a portion of the arm.
o Lateral nodes: Located along the upper humerus.
o They drain most of the arm.
Figure 3: Direction of Lymph Flow

Blood Supply, Venous Drainage and Nerve Supply
• Arterial supply is by the thoracic branches of the axillary arteries and from the internal
mammary and intercostals arteries.
• Venous drain is through the axillary and mammary veins.
• Nerve supply is by the branches from 4th, 5th, and 6th thoracic nerves which contain
sympathetic fibres.
• The nipples contain numerous somatic nerve endings sensitive to touch.
• When stimulated during suckling they send impulses to the hypothalamus which
stimulate the release of oxytocin, promoting ejection of milk.
Types and Clinical Features of Breast Lumps
Non Malignant Breast Disease (Benign)

• Fibroadenoma
o Firm, painless swelling that gradually increase in size
o It is not fixed to the skin
o Characteristically very mobile if small in size
o Mostly found in females less than 40 years
• Breast cysts
o Soft cystic swelling that may gradually increase in size
o Most of them have a fluid collection
• Papilloma
o May present as single (solitary) or multiple (diffuse papillomatosis)
o May present as a lump or nipple discharge, or as a nodule on ultrasound
o Standard recommendation is to excise papillomas by core needle biopsy, as they can
harbour areas of atypia or ductal carcinoma in situ
o After excision, no additional treatment necessary as risk of subsequent breast cancer
is small
• Mastitis (inflammation of the breast)
o TB mastitis, lactational mastitis, bacterial mastitis
• Galactocele
o Collection of milk in a duct after a ductile has been blocked
o Commonly in a lactating mother
Malignant Breast Disease

• Ductile or Lobular Adenocarcinoma: Presents with a breast lump with or without
ulceration
o Presents with skin changes, such as ‘peau de orange’
o Breast lump fixed to the skin
o Bloody nipple discharge
o Common from the age of 40 and above
o May be accompanied by enlarged lymph nodes of the same site of the affected breast
o In advanced disease, supraclavicular nodes may be involved
o Metastasis may spread in the lungs, resulting in pleural effusion, and in the liver

Figure 4: Advanced Lobular Adenocarcinoma
• Paget’s disease: Resembles eczematous nipple with destruction of the nipple. Mostly
unilateral (single breast) and mostly seen in menopause.
Figure 5: Paget’s Disease of the Nipple
Site of the
lesion
• Inflammatory carcinoma
o Occurs in elderly, non-lactating women
o It is the most aggressive of breast malignancy
o It presents as acute mastitis
• Phyllodes tumours
o Unusual fibroepithelial tumours characterized by rapid growth
o If suspected, core needle biopsy required to distinguish from fibroadenoma
o Require extensive surgical resection
Clinical Staging of Malignant Disease

• Breast cancer disease is clinically staged in four groups according to the TNM
classification (Tumour size, Nodes- Presence of palpable enlarged lymph nodes,
Metastases to different organs)
o Stage I: Lump in the breast not fixed to the underlying tissues, size less than 2cm

o Stage II: Size of lump more than 2cm but less than 5cm
o Stage III: Size of lump 5cm and above
o Stage IV: Size of lump 5cm and above and fixed to skin and underlying tissue
History and Clinical Examination of the Breast

• Age
o Fibroadenoma usually occurs in females below 35 years of age
o Carcinoma of the breast usually occurs in women above 40 years of age, though it
may occur in younger women
• Lump
o Ask for the onset, duration, and rate of growth
• Pain
o Breast carcinoma mainly presents with a painless lump
Except in inflammatory disease where the pain is throbbing in nature with pus
discharge
Also unlike inflammatory carcinomatosis which presents as mastitis with all
classical signs and symptoms of acute inflammation
o In fibroadenoma, pain is not a prominent feature unless it is large in size, thus causing
pressure
• Discharge from nipple
o Blood may be discharged from the nipple in the case of papilloma or carcinoma
o Pus may be discharged in the case of mammary abscess
o Milk may be discharged during lactation or galactocele or from mammary fistula due
to chronic subareolar abscess
o Serous or greenish discharge is seen in cases of fibroadenosis (mammary dysplasia)
and mammary duct ectasia
• Retraction of nipples
o Recent retraction is of importance and is usually due to underlying carcinoma of the
breast
Activity: Demonstration
Instructions
Refer to Handout 9. 1: Clinical Examination of the Breast
The tutor will demonstrate the clinical examination of the breast as shown on Handout 9.1
using a manikin or model of the female breast.
Clinical Investigations and Management of Breast Lumps
Clinical Investigations
• Investigations are mainly used to differentiate cancer of the breast from other benign
lesions of the breast, and to help determine presence and extent of metastasis.
• Initial clinical investigations, such as full blood picture and chest x-ray can be done.
• Other investigations can be done at a referral hospital, such as:
o Ultrasound of the breast
o Mammogram

o Aspiration (fine needle aspiration) for cytology
o Biopsy for histology
• Search for distant metastasis
o Bone scan
o Ultrasound of abdomen (liver)
Management
• Management in non-malignant breast disease:
o For fibroadenoma, galactocele, breast cysts, and papilloma, refer to district hospital
for surgical excision of the lesion and a biopsy for histological examination.
o For inflammatory breast diseases (except for inflammatory carcinoma) such as TB
mastitis, lactating mastitis: when confirmed, antibiotics are prescribed and, if it is TB
mastitis, refer to district TB clinic for anti-TB regimen.
• Management in malignant breast disease depends on the stage of the disease and occurs at
the referral hospital and national cancer institute.
o Treatment options include surgery, chemotherapy and radiation or a combination of
the options.
Key Points
• Clinical anatomy of the breast includes lymphatic system, blood circulation, innervations,
and muscles of the breast.
• There are two types of breast lumps: malignant and non-malignant.
• History and clinical examination includes age, lump, pain, discharge from the nipple, and
retraction of the nipple.
• Clinical investigations include full blood picture, chest x-ray, and special investigations
occur at referral hospitals.
• Management of malignant lumps depends on the stage of the disease and is managed at
referral hospitals; management of non-malignant lumps are also treated at referral
hospitals.
Evaluation
• What are the types of breast lumps?
• What are characteristics of each type of breast lump?
• Explain how to examine breast lumps.
References
• Das S. (2004). A Manual of Clinical Surgery (6th ed.). India.
• Lynn. S. Bickley. (2003). Guide to Physical Examination and History Taking (8th ed.).
USA: Lippincott Williams and Wilkins.

Handout 9.1: Clinical Examination of the Breast
• Wedge: Palpating from the nipple outwardly.

• Vertical strip: Moving vertically zig zag across the breast.
• Circular: Moving in a circular motion from the nipple and spiraling outwardly.

Session 10: Peritonitis, Appendicitis and Peptic
Ulcer Disease
Learning Objectives
• Define peritonitis, appendicitis and peptic ulcer disease
• Describe the causes and clinical features of peritonitis, appendicitis and peptic ulcer
disease
• Identify the relevant investigations for peritonitis, appendicitis and peptic ulcer disease
• Mention the differential diagnoses of peritonitis
• List the complications of peritonitis, appendicitis and peptic ulcer disease
• Describe the management of peritonitis, appendicitis and peptic ulcer disease
Peritonitis
• Peritonitis: Inflammation of the peritoneum (the serous membrane which lines part of the
abdominal cavity and some of the viscera it contains).
Causes
• Infected peritonitis
o Perforation of a hollow viscus is the most common cause of peritonitis.
Examples include perforation of the stomach (peptic ulcer, gastric carcinoma, of
the duodenum (peptic ulcer), intestine (e.g. appendicitis, diverticulitis and
anastomotic leakage).
o In most cases of perforation of a hollow viscus, mixed bacteria are isolated; the most
common agents include gram-negative bacilli.
o Disruption of the peritoneum, even in the absence of perforation of a hollow viscus,
may also cause infection simply by letting micro-organisms into the peritoneal cavity.
Examples include trauma, and surgical wounds
o Spontaneous bacterial peritonitis (SBP) is a peculiar form of peritonitis occurring in
the absence of an obvious source of contamination.
It occurs either in children, or in patients with ascites.
o Systemic infections (such as tuberculosis) may have a peritoneal localisation.
• Non-infected peritonitis
o It can be caused by leakage of sterile body fluids into the peritoneum, such as blood
(e.g. endometriosis, blunt abdominal trauma), bile (e.g. liver biopsy), and urine
(pelvic trauma).
o It is important to note that, while these body fluids are sterile at first, they frequently
become infected once they leak out of their organ, leading to infectious peritonitis
within 24-48 hours.
• Sterile abdominal surgery
o This normally causes localized or minimal generalised peritonitis.
Clinical Features of Peritonitis

• Peritonitis may be localized or generalized, generally has an acute onset.
• General features: Patient presents with acute abdomen with peculiar facial expression
(anxious look, bright eyes, pinched face and cold sweat).
• In peritonitis the patient remains quiet because movements will increase the pain unlike in
intestinal obstruction the patient will have colicky abdominal pain.

Session 10: Peritonitis, Appendicitis and Peptic Ulcer Disease 63
• Specific features
o Abdominal pain, tenderness and guarding (diffuse abdominal rigidity or ‘washboard
abdomen’) is often present, especially in generalised peritonitis
o Fever
o Tachycardia
o Vomiting
o At a later stage patient may develop anaemia, cyanosis and jaundice
o Paralytic ileus
Investigations
• A diagnosis of peritonitis is based primarily on clinical grounds
o Routine investigations such as full blood picture
o Plain abdominal X-rays may reveal dilated intestines, pneumoperitoneum (in cases of
perforation of bowel)
Differential Diagnoses of Peritonitis

• Intestinal obstruction
• Pancreatitis
• Renal colicky
• Appendicitis
• Ruptured ectopic pregnancy
• Pelvic inflammatory disease
• Septic abortion
• Cystitis
Complications of Peritonitis
• Septicaemia
• Hypovolaemic shock with electrolytes imbalance
• Anaemia
Management of Peritonitis
• Peritonitis generally represents a surgical emergency which needs urgent medical and
surgical attention.
• General supportive measures are required such as vigorous intravenous rehydration and
correction of electrolyte imbalance.
• IV fluids such as Ringer’s Lactate and normal saline are recommended.
• Amount of intravenous fluid administration should be given with caution to patients with
cardiac insufficiency.
• Blood Transfusion may be indicated to some patients depending on the status of anaemia.
• Antibiotics are usually administered intravenously.
• The empiric choice of broad-spectrum antibiotics often consists of multiple drugs.
• Surgery (laparotomy) is needed to perform a full exploration and lavage of the
peritoneum, as well as to correct any gross anatomical damage which may have caused
peritonitis.
o This procedure is done at a referral hospital.
o The exception is spontaneous bacterial peritonitis, which does not benefit from
surgery.

Appendicitis
• Appendicitis: A condition characterized by inflammation of the vermiform appendix.
Figure 1: Surgical Anatomy of the Appendix
Source: George et al, 2002
Causes
• (Primarily obstruction of the appendix lumen)
• Among the causative agents are:
o Foreign bodies
o Intestinal worms
o Feacolith
o Lymphadenitis
• Abdominal pain specifically located in the right iliac fossae radiating to the umbilicus.
• The abdominal wall becomes very sensitive to gentle pressure (palpation).
• There is rebound tenderness, in case of a retrocecal appendix; however, even deep
pressure in the right lower quadrant may fail to elicit tenderness (silent appendix).
• If the appendix lies entirely within the pelvis, there is usually complete absence of the
abdominal rigidity.
• In such cases, a digital rectal examination elicits tenderness in the retrovesical pouch.
• Coughing causes point tenderness in this area (McBurney's Point) and this is the least
painful way to localize the inflamed appendix.
• Special signs

o Rovsing's sign
Deep palpation of the left iliac fossa may cause pain in the right iliac fossa.
This is a sign used in the diagnosis of acute appendicitis.
Pressure over the descending colon causes pain in the right lower quadrant of the
abdomen.
o Psoas sign
Occasionally, an inflamed appendix lies on the psoas muscle and the patient will
lie with the right hip flexed for pain relief.
o Obturator sign
If an inflamed appendix is in contact with the muscle internal orbtutator, spasm of
the muscle can be demonstrated by flexing and internally rotating the hip.
This maneuver will cause pain in the hypogastrium.
Investigations
• Diagnosis is based on patient history (symptoms) and physical examination.
• Elevation of neutrophilic white blood cells is present.
• Ultrasonography provides useful means to detect appendicitis, especially in children.
• Despite these limitations, sonographic imaging performed by experienced hands can often
distinguish between appendicitis and other diseases with very similar symptoms such as
inflammation of lymph nodes near the appendix or pain originating from other pelvic
organs such as the ovaries or fallopian tubes.
Treatment
(General measures)
• An intravenous drip is used to hydrate the patient.
• Use Ringer lactate or normal saline.
• Keep patient fasted in preparation for surgery.
• Refer the patient.
o Antibiotics given intravenously such as cefuroxime and metronidazole may be
administered early to help kill bacteria and thus reduce the spread of infection in the
abdomen and postoperative complications in the abdomen or wound.
o The surgical procedure for the removal of the appendix is called an appendicectomy
(also known as an appendectomy).
• In children
o Gastroenteritis, intussusceptions, lobar pneumonia, mesenteric adenitis
• In adults
o Regional enteritis, ureteric colic, perforated peptic ulcer, pancreatitis, cholecystitis,
pelvic inflammatory disease, ectopic pregnancy, torsion/rupture of ovarian cyst, renal
colic
Peptic Ulcers
• Peptic Ulcer: An ulcer of the alimentary mucosa, exposed to acid gastric secretion.

Figure 2: Surgical Anatomy of Stomach and Duodenum Showing Common Sites of Peptic
Ulceration
Classification
• May be acute/chronic ulcer
• Common sites: stomach and duodenum
• Common sites of duodenal ulcers are:
o 1st. part or bulb
o Post bulbar: 2nd part
o Pyloric channel
• Common sites of gastric ulcer:

o Lesser curvature
o Prepyloric region
Pathophysiology
• Gastric Secretion
o The gastric glands produce 2-3 liters of gastric juice per day mainly composed of

water, hydrochloric acid and pepsin (pH low as 0.8).
Predisposing Causes
• H.pylori infection
• Acid-pepsin production (exaggerated gastrin response to intake of certain types of food)
• Reduced mucosal resistance
• Other mucosal irritants (alcohol, non steroidal anti-inflammatory drugs are all known to
induce acute mucosal inflammation directly)
• Smoking increases vagus activity
• Symptoms
o Epigastric pain with dyspepsia
o Periodicity
o Nocturnal pain
o Pain provoked by certain types of food (e.g. citrus fruits, highly spiced food)
• Associated complications
o Haemorrhage (Haemetemesis, Melaena)
o Perforation leading to peritonitis
o Pyloric Stenosis leading to stomach outlet obstruction
• Signs
o Tenderness in the epigastric area
Investigations
• Endoscopy – Oesophagoduodenoscope
• Barium meal x-rays
• Full blood picture & stool for occult blood
Differential Diagnosis of Peptic Ulcer Diseases

• Chronic gastric ulcer
o Majority of patients are above 40 years.
o It presents with epigastric discomfort or pain which may vary from vague and mild
discomfort, dull aching or burning to very severe pain which compels the patient to lie
down.
o The pain appears immediately after taking food.
o The pain radiates to the back when the ulcer penetrates into the pancreas.
• Chronic duodenal ulcer
o Majority of the patients are under 40 years.
o It presents with pain which appears 2-4 hours after meals when the stomach becomes
empty (hunger pain).
o The pain appears early in the morning or late afternoon.
• Pyloric stenosis
o This is due to scarring of duodenal or juxta-pyloric ulcer.
o It presents with vomiting which is foul and frothy containing undigested food
materials.
o On examination, visible peristalsis passing from left to right is path gnomonic.
• Carcinoma of the stomach
o This is a disease of elderly, but if suspected in the young, it should not be dismissed
based on age only.

o This is more common in men.
o Malignancy should be suspected when there is loss of periodicity of the attacks,
remission being shorter or nil.
o The sharp burning pain is replaced by dull ache.
o Nausea is common but vomiting gives no relief as previously (vomiting may be blood
stained or look like coffee grounds).
o Loss of appetite, weight loss is rapid.
o Specific dislike of meat is also a feature noted.
• Chronic cholecystisis and cholelithiasis
o The feeling of distension is the first symptom and the patient may feel that one has
eaten too much before completing the meal.
o Gradually the patient complains of pains over the upper right rectus muscle often
radiating to the inferior angle of right scapula.
o Pain is severe after taking fatty foods.
o Nausea is very common but vomiting is rare.
o Attacks of abdominal pain are irregular.
• Chronic pancreatitis
o Abdominal pain is the main presenting symptom which starts in the epigastrium and
tends to pass through to the back.
o Patients may have a history of massive alcohol consumption prior to attack.
o The pain is often quite intolerable which becomes slightly relieved when the patient
sits up.
o Jaundice is present in less than 20% cases but diabetes is common.
• Chronic appendicitis
o Young girls are main victim of this condition
o Pain is at the right iliac fossa.
o Vomiting may be present but does not offer any relief to pain.
o Constipation and pain during micturation may mimic ureteric colic.
o Cardinal sign is a distinct tenderness over the appendix.
Management of Peptic Ulcer

• Aim
o Relief of symptoms
o Heal ulcer
o Prevent recurrence
• General
o Regular meals, balanced diet, high fibre (there is no specific ulcer diet, only avoid
foods which provoke symptoms)
o Rest and avoid stress
• Medical
o H2 – receptor blockers- Cimetidine
o Proton pump inhibitor- Omeprazole
o Avoid (predisposing factors) irritants
NSAIDS
Corticosteroids
Alcohol
Smoking
o Treat helicobacter pylori-triple therapy
Bismuth salt
Metranidazole

Amoxicillin
• Surgical
o Indications: intractable pain, recurrent pain, with frequent loss of work, failure to
respond to medical treatment
o Complications
Pyloric stenosis
Hour glass deformity
Perforation
Bleeding
Penetration
≥5yrs old ulcers
Key Points
• Peritonitis is defined as inflammation of the peritoneum.
• Differential diagnoses of peritonitis include intestinal obstruction, pancreatitis, renal
colicky, appendicitis, ruptured ectopic pregnancy, pelvic inflammatory disease, and
cystitis.
• Appendicitis is a condition characterized by inflammation of the vermiform appendix.
While mild cases may resolve without treatment, most require removal of the inflamed
appendix.
• Peptic ulcer disease is an ulcer of the alimentary mucosa, usually in the stomach or
duodenum, exposed to acid gastric secretion.
• Clinical presentation of peptic ulcers includes epigastric pain with dyspepsia, periodicity
in relation to food intake, haemetemesis or melena.
• Perforation is a serious complication of peptic ulcer.
Evaluation
• What is peritonitis?
• What are the causes of peritonitis?
• What are the complications of peritonitis?
• List causes and symptoms of peptic ulcer.
References
• Das S. (2004). A Manual of Clinical Surgery (6th ed.). India: Dr. Das.
• George B. & Clive Quick. (2002). Essential Surgery, Problems, Diagnosis and
Management (3rd ed.). Churchill Livingstone.
• Lynn S. Bickley. (2003). Guide to Physical Examination and History Taking (8th ed.).

Session 11: Instestinal Obstruction
Learning Objectives
• Define intestinal obstruction
• List the types of intestinal obstruction
• Describe the causes and clinical features of intestinal obstruction
• Identify the relevant investigations for intestinal obstruction
• Mention differential diagnoses of intestinal obstruction
• Describe the management of intestinal obstruction
• List the complications of intestinal obstruction
Overview of Intestinal Obstruction

• Intestinal obstruction: Partial or complete blockage of the bowel that results in the
failure of the intestinal contents to pass through.
Paralytic Ileus/Adynamic Intestinal Obstruction

• Obstruction of the bowel may be caused by ileus, in which the bowel doesn't function
correctly but there is no ‘mechanical’ (anatomic) problem.
• Paralytic ileus, also called pseudo-obstruction or adynamic, is one of the major causes of
obstruction in infants and children.
• Causes of paralytic ileus:
o Medications, especially narcotics
o Intraperitoneal infection, such as peritonitis secondary to perforated appendix, TB
peritonitis
o Ruptured ovarian follicle
o Mesenteric ischemia (decreased blood supply to the support structures in the
abdomen)
o Injury to the abdominal blood supply
o Complications of intra-abdominal surgery
o Spinal cord injuries with mesenteric denervation
o Metabolic disturbances (such as decreased potassium levels, uraemia, spinal injuries)
Mechanical Obstruction
• Mechanical obstruction occurs when movement of material through the intestines is
physically blocked.
• The mechanical causes of obstruction are numerous and may include:
o Hernias
o Volvulus (twisted intestine)
o Postoperative adhesions or scar tissue
o Impacted faeces (stool)
o Gallstones
o Tumours blocking the intestines
o Granulomatous processes (abnormal tissue growth)
o Intussusceptions
o Foreign bodies (ingested materials that obstruct the intestines)
o Helminths infestation particularly ascaris lumbricoides in children

Session 11: Intestinal Obstruction 71
Figure 1: Causes of Intestinal Obstruction
Obstruction due to mesenteric Obstruction due to volvulus

Obstruction due to hernia
occlusion
Obstruction due to Obstruction due to tumour Obstruction due to adhesions

intussusceptions
Clinical Features of Intestinal Obstruction

• Abdominal pain
o In mechanical obstruction pain is the first symptom, it occurs suddenly and is usually
severe.
o It is colicky in nature and is usually centred around umbilicus (small bowel) and
lower abdomen (large bowel).
o In paralytic ileus pain is due to the cause (e.g. peritonitis) or due to gross abdominal
distension.
o The development of severe pain is indicative of the presence of strangulation in
mechanical obstruction or possibly due to ischemia of the intestines.
• Vomiting
o Projectile vomiting (usually only in children, most adults do not have projectile
vomiting) is found in mechanical obstruction.
The more distal the obstruction, the longer the interval between the onset of
symptoms and the appearance of vomiting.
As the obstruction progresses, the character of vomitus alters from digested food
to faeculent material due to presence of enteric bacteria overgrowth.
• Absolute constipation
o It may be classified as absolute (neither faeces nor flatus is passed) or relative (where
flatus is only passed).
o Absolute constipation is the cardinal feature of total obstruction.
• Abdominal distension
o In the small bowel, the degree of distension is dependent on the site of obstruction and
is greater the more distal the lesion.

• Dehydration
o Seen more in small bowel obstruction due to repeated vomiting and fluid loss
• Pyrexia in obstruction may indicate
o The onset of ischemia
o Intestinal perforation
o Inflammation associated with the obstructing disease
Investigations and Differential Diagnosis of Intestinal Obstruction

Investigations
• Radiological investigation
o A clinical diagnosis is aided by taking a plain, erect and supine abdominal X-ray.
o The normal bowel doesn’t contain air fluid levels (except in the stomach) but in an
obstructed bowel air fluid levels will be present and bowels will be distended.
• Blood investigations at hospital level
o Full blood picture
o Blood for grouping and cross-match
o Serum electrolytes
o Serum creatinine
Differential Diagnoses of Intestinal Obstruction

• Peritonitis secondary to perforated appendix, TB, perforated duodenal ulcer
• Paralytic ileus secondary to spinal injury, electrolyte imbalance, uraemia
• Pancreatitis
Management and Complications of Intestinal Obstruction
Management
• Nasogastric decompression by inserting a nasogastric tube
• Amount of IV fluids depends on the condition of the patient
• Broad spectrum antibiotics, IV route (if infection suspected)
• Urethral catheterization for recording urine output
• Blood for grouping and cross match
• Refer for surgical management
Complications of Intestinal Obstruction

• Water, electrolytes imbalance and shock
• Bowel gangrene
• Perforation leading to peritonitis
Key Points
• Intestinal obstruction involves a partial or complete blockage of the bowel that results in
the failure of the intestinal contents to pass through.
• Obstruction of the bowel may be mechanical or non mechanical
• Features of bowel obstruction include Abdominal pain, Projectile vomiting, Absolute
constipation, Abdominal distension, Dehydration and Pyrexia

• A clinical diagnosis of intestinal obstruction is aided by taking a plain, erect, and supine
abdominal X-ray.
• Management includes: Inserting an nasogastric tube, giving IV fluids , antibiotics,
catheterization, blood grouping and cross match and Refer the patient
Evaluation
• What are the clinical features of intestinal obstruction?
• Mention differential diagnoses of intestinal obstruction.
• Explain the management of intestinal obstruction.
References
• Bickley, L.S. (2003). Bates’ Guide to Physical Examination and History Taking (8th ed.).
• Das, S. (2004). A Manual of Clinical Surgery (6th ed.). India Bickley S. (2003): Guide to
Physical Examination and History Taking (8th ed.). USA: Lippincott Williams and
Wilkins.
• Paul D. T. (2008). Abdominal X-Ray of a Bowel Obstruction. Boise: Healthwise.
• Ronald L. (1990). Gastrointestinal Radiology (2nd ed.). Philadelphia: Lippincott.
• WHO. (2003). Surgical Care at District Hospital. Malta: World Health Organization.

Session 12: Urinary Retention
Learning Objectives
• Define urinary retention
• Explain the common causes of urinary retention
• List classifications and clinical features of urinary retention
• Describe management of urinary retention
Definition and Types of Urinary Retention

• Urinary retention: Is a condition whereby a patient fails to pass urine voluntarily.
Types of Urinary Retention

• There are two types of urine retention: acute and chronic
o Acute retention
It is an abrupt and painful retention.
Acute urine retention in a normal bladder is rare; it may occur after anaesthesia,
an injury to the urethra or after a surgical operation.
o Chronic urinary retention
Elderly individuals are mainly affected by this disease.
Chronic retention is a painless condition and the patient is often unaware of
his/her distended bladder unless infection supervenes.
Figure 1: Distended Bladder Due to Urine Retention

Distended urinary
bladder due to
urine retention
Causes and Clinical Presentation of Urinary Retention

• Causes of urine retention can be:
o Mechanical
o Neurogenic
Causes of Urine Retention by Mechanical

• Urinary bladder: stone, tumour, blood clot and contracture of the bladder neck

Session 12: Urinary Retention 75
• Prostate: prostatic abscess, benign and malignant enlargements
• Urethra: urethral stricture, rupture, congenital valves, foreign body, acute urethritis, stone,
growth, pin-hole meatus, meatal ulcer
• Prepuce: paraphimosis, phimosis
• Other causes: pregnancy (retroverted gravid uterus), fibroid, ovarian cyst, carcinoma of
the cervix, uteri and rectum and any pelvic growth and paraphimosis
Common Cause of Urine Retention Secondary to Mechanical Obstruction

• Benign prostate hypertrophy
o This is a disease of old age in males.
o Hyperplasia and hypertrophy affect the inner glandular and fibrous tissue which
compresses the outer portion known as ‘surgical capsule’.
o It is also called adenomatous enlargement of the prostate.
o Clinical presentations
Increased frequency of micturation particular at night is the earliest symptom.
Urgency of micturation.
Difficulty in micturation (straining) is quite common.
Poor stream on straning
Terminal haematuria
Paraphimosis (Mechanical)
• It is the retracted painful swelling of the fore skin.
• Occurs most commonly in children.
• The glans penis is visible, and is surrounded by an oedematous ring with a proximal
constricting ring.
Figure 2: Paraphimosis
Source: WHO, 2003
Phimosis
(Mechanical)
• This is inability to retract the distal prepuce over the glans penis.
• Once the foreskin can be retracted so that the glans penis partially appears, a phimosis is
no longer present.

Figure 3: Phimosis
Source: WHO, 2003
Urethral Stricture
(Mechanical)
• This is due to formation of fibrous tissue following damage to the urethral mucosa.
• This is most commonly caused by gonococal urethritis transmitted through sexual
intercourse.
• It can also be caused by trauma to the urethra (e.g. during urethral catheterization), or by
ruptured urethra following pelvic fracture.
• Clinical symptoms
o Difficulty in micturation (dysuria)
o Flow of urine increases on straining
o Acute urine retention
o Main complication arising from urethral stricture caused by gonococci urethritis is
periurethral abscess which may burst causing a urethral fistula or extravasations of
urine
Neurogenic Causes of Urine Retention

• Spinal cord disease: disseminated sclerosis, tabes dorsalis, transverse myelitis
• Injuries and disease of the spine example fracture: dislocation, Pott’s disease
• Miscellaneous: postoperative retention, hysteria, tetanus, drugs such as anti-cholinergics,
smooth muscles relaxants, and tranquillizers
Complications of Urine Retention

• Infection (cystitis, pyelonephritis), formation of bladder stones and renal failure
Management of Urinary Retention
Catheterization
• Urethral catheterization
o Urine retention is managed by urethral catheterization
Refer to Handout 12.1: Urethral Catheterization in the Male Patient
• Supra pubic catheterization

o If urethral catheterization is not possible due to trauma to the urethra or urethral
stricture, then supra pubic catheterization is indicated.

o In some cases supra pubic puncture is done for temporary relieve of acute urine
retention.
Refer to Handout 12. 2: Supra Pubic Puncture
Management of Paraphimosis and Phimosis

• Should be referred to the health centre or district hospital where circumcision can be
done.
Case Study
Instructions
Refer to Worksheet 12.1: Case Study
you will report your results to the larger group.
Key Points
• Urine retention is a condition whereby a patient fails to pass urine voluntarily.
• There are two types of urine retention: acute and chronic.
• Acute retention is abrupt and painful whereas chronic retention is longstanding and
painless unless infection supervenes.
• Chronic urinary retention occurs in elderly individuals.
• Urine retention can be caused by mechanical agents or neurogenic agents.
• Acute urine retention is managed by urethral catheterization or suprapubic
catheterization.
• Stop medication that might be causing the retention.
Evaluation
• What is urinary retention?
• Explain common causes of urinary retention.
• What are differential diagnoses of urinary retention?
References
Research Foundation (AMREF).
• Das, S. (2004). A Manual of Clinical Surgery (6th ed.). India.
• Lett, R.R. & Kobusingye, O. (2009). Trauma Team Training Course, Student’s Manual.
Canadian Network for International Surgery (CNIS) ICCU.

Handout 12.1 Urethral Catheterization in Male Patient
Technique
• Explain to the patient that the procedure may be uncomfortable but should not be very
painful (if it is very painful, then it could be an obstruction or poor positioning for
placement).
• Wash the area with soap and water, retracting the prepuce to clean the furrow between it
and the glans. Put on sterile gloves and, with sterile swabs, apply a bland antiseptic to the
skin of the genitalia.
• Lubricate the catheter with generous amounts of water or soluble gel but note that, the
catheter should remain sterile at all times, so only use water or gel if they are sterile.
• If you are right-handed, stand to the patient’s right, hold the penis vertically and slightly
stretched with the left hand, and introduce the Foley catheter gently with the other hand
(Figure 1).
• If you are using a Foley catheter, inflate the balloon with 10 –15 ml of sterile water or
clean urine, after insertion (Figure 2).
• Partially withdraw the catheter until its balloon abuts on the bladder neck. If the catheter
has no balloon, knot a ligature around the catheter just beyond the external meatus and
carry the ends along the body of the penis, securing them with a spiral of strapping
brought forward over the glans and the knot (Figure 3, 4 and 5).
• If the catheterization was traumatic, administer an antibiotic with a gram negative
spectrum.
• Always decompress a chronically distended bladder slowly (as removing too much urine
too quickly could cause decompensation). Connect the catheter through a closed system
to a sterile container (Figure 6).
• Secure the catheter to the patient's thigh with a wide tape; this will avoid a bend in the
catheter at the penoscrotal angle and help to prevent compression ulceration.
• Change the catheter if it becomes blocked or infected, or as otherwise indicated. Ensure a
generous fluid intake to prevent calculus formation in recumbent patients, who frequently
have urinary infections.
Figure 1 Figure 2

Figure 3 Figure 4 Figure 5
Figure 6
Source: WHO, 2003

Handout 12. 2: Supra Pubic Puncture
If urethral catheterization fails, bladder puncture may become necessary. It is essential that
the bladder is palpable if a suprapubic puncture is to be performed. If ultrasound is available
this can be helpful in identifying the bladder.
Technique
• Assess the extent of bladder distension by inspection and palpation.
• Make a simple puncture 2 cm above the symphysis pubis in the midline with a wide-bore
needle connected to a 50 ml syringe. This will afford the patient immediate relief, but the
puncture must be made again after some hours if the patient does not pass urine.
• Perform a suprapubic puncture with a wide bore cannula.
• Make a simple puncture 2 cm above the symphysis pubis in the midline with a wide bore
needle.
• After meeting some resistance, they will pass easily into the cavity of the bladder, as
confirmed by the flow of urine when the needle is withdrawn from the cannula.
• Introduce the cannula well into the bladder.
• Fix the cannula to the skin with the stitch or plaster to secure the cannula and connect it to
a bag or bottle.
Potential Complications
• Urinary tract infection
• Bleeding
• Haematuria
• Catheter blockage
• Skin infection
• Bladder lithiasis (stone formation into the bladder)

Worksheet 12. 1:Case Study
Instructions:
paper.
Case Information
An elderly male of 67 years is complaining of lower abdominal pain and has increased
frequency of micturation. His symptoms are occasionally associated with haematuria and a
burning sensation.
He has been having these problems for at least one year, but recently he noticed that he was
not getting any better. Despite being treated in the village dispensary with antibiotics, he got
no relief. Now he presents with dribbling of urine, and with a distended lower abdomen.
Questions
1. What is the most possible diagnosis?
2. What could be the differential diagnosis?
3. How will you investigate and manage this patient?

Session 13: Haemorrhoids, Rectal Prolapse and
Rectal Bleeding
Learning Objectives
• Define haemorrhoids and rectal prolapse
• Describe the aetiology of haemorrhoids and rectal prolapse
• Mention types and grades of haemorrhoids
• Describe the clinical features of haemorrhoids and rectal prolapse
• Describe complications and management of haemorrhoids and rectal prolapse
• Identify differential diagnoses of rectal bleeding
Definition and Aetiology of Haemorrhoids

• Haemorrhoids: Dilated veins occurring in relation to anus.
Figure 1: Haemorrhoids
Source: webMD, 2009
Aetiology
• Familial tendency: the condition is frequently seen in members of the same family
• Increased straining during bowel movements by constipation or diarrhoea
• Straining during micturition in obstructive uropathy
• Portal hypertension can also cause haemorrhoids because of the connections between the
portal vein and the vena cava in the rectal wall (also known as portocaval anastomoses)
• Obesity can be a factor by increasing rectal vein pressure
• Poor muscle tone or poor posture can result in too much pressure on the rectal veins
• Pregnancy causes increased intra abdominal pressure

Session 13: Haemorrhoids, Rectal Prolapse and Rectal Bleeding 83
Types and Grading of Haemorrhoids
• Haemorrhoids may be external or internal to the anal orifice.
• The external variety is covered by skin while the internal variety lies beneath the anal
mucous membrane.
External Haemorrhoids
• These occur below the dentate line, outside of the anal verge (the distal end of the anal
canal).
• They are sometimes painful, and can be accompanied by swelling and irritation.
• Itching is a symptom and is more commonly due to skin irritation.
• External haemorrhoids are prone to thrombosis.
• When a blood clot develops, the haemorrhoid becomes a thrombosed haemorrhoid.
Internal Haemorrhoids
• These occur above the dentate line, inside the rectum.
• Internal haemorrhoids are usually not painful and most people are not aware that they
have them, they may bleed when irritated.
Grading of Internal Haemorrhoids

• First degree: The haemorrhoids do not prolapse.
• Second degree: The haemorrhoids prolapse upon defecation but spontaneously reduce.
• Third degree: The haemorrhoids prolapse upon defecation, but must be manually
reduced.
• Fourth degree: The haemorrhoids are prolapsed and cannot be manually reduced and are
at risk of strangulation.
Figure 2: Grading of Haemorrhoids.
First Degree
The haemorrhoids do not

prolapse.

Second and Third Degree
Dotted lines shows second degree
Continuous lines shows third

degree
Fourth Degree
The haemorrhoids are prolapsed

and cannot be manually reduced.
Source: George. B. 2002
Clinical Features and Diagnosis of Haemorrhoids

Clinical Features
• Bright red painless bleeding is the principal and earliest symptom and occurs during
defecation.
• Prolapse is a much later symptom.
• Initially the protrusion is only slight and occurs during defecation and reduces
spontaneously; later, the prolapse may need to be reduced manually after defecation.
• Further progression may lead to prolapse even without defecation that cannot be manually
reduced.
• Mucoid discharge is normally associated with prolapsed haemorrhoids.
• Pain is absent unless complication develops such as thrombosis or strangulation.
Diagnosis
• Physical examination of the perianal and anal area.
• The common sites where the swellings are located are: 3, 7 and 11 o’clock position.
• This is done when the patient is in lithotomy position.
• For external or prolapsed haemorrhoids you should conduct a digital examination.
• In addition to probing for haemorrhoidal bulges, look for indications of rectal tumour or
polyp, abscesses and enlarged prostate in males.

• Internal haemorrhoids cannot be felt unless they are thrombosed.
• Proctoscopy is used to make diagnosis of internal haemorrhoids in a specialized hospital.
Management and Complications of Haemorrhoids
Management
• Adding fibre to the diet may help patients with bleeding from haemorrhoids
• Supportive treatment
o Warm sitz baths
o Keep the area clean and dry, with some lubrication provided by haemorrhoid creams,
lubricants and anal suppositories
o Anti-pruritic creams (e.g. hydrocortisone) – but should not be used for longer than
one week
o Analgesics
• Surgical treatments
o Rubber band dilation
o Injection sclerotherapy
o Surgical Haemorrhoidectomy
Complications
• Untreated internal haemorrhoids can lead to prolapsed and strangulated haemorrhoids,
which can lead to gangrene, a life-threatening condition.
• Immediate haemorrhoidectomy is indicated in the case of strangulation.
Definition and Aetiology of Rectal Prolapse

• Rectal prolapse: A condition in which the rectum becomes stretched out and protrudes
out of the anus.
Figure 3: Rectal Prolapse
Source: Poritz, 2009
Aetiology
• Weakness of the anal sphincter muscle is often associated with rectal prolapse.
• While the condition occurs in both sexes, it is much more common in women than men.

• The aetiology of rectal prolapse is unknown, but it is often associated with long-standing
constipation, prolonged diarrhoea in children, cystic fibrosis, malnutrition/malabsorption,
pinworms, and chronic cough.
• Other predisposing condition includes infestation by Trichuris trichiura, pregnancy,
previous surgery or trauma to the anus or pelvic region, and neurologic disease.
Clinical Features and Management of Rectal Prolapse

Clinical Features
• Patients with rectal prolapse report a mass protruding through the anus.
• Initially, the mass protrudes from the anus only during defecation and usually retracts
when the patient stands up.
• As the disease process progresses, the mass protrudes more often, especially with
straining and valsalva manoeuvres such as sneezing or coughing.
• Finally, the rectum prolapses with daily activities such as walking and may progress to
continual prolapsed.
• Symptoms can include rectal pain and faecal incontinence.
Management
• In rectal prolapse caused by helminthic infection (i.e., Trichuris trichiura or enterobiasis)
give Albendazole.
• Surgical treatment is recommended for irreducible rectal prolapse.
• However, always first treat internal prolapse medically with bulking agents, stool
softeners, and suppositories or enemas.
• It is recommended that patient is referred for surgical management in a referral hospital.
Differential Diagnosis of Rectal Bleeding
Figure 4: Anal Fissure
Fissure in ano: This is a longitudinal
ulcer in the anal canal, posteriorly
situated in the majority of cases.
Source: Lund, 2008

Figure 5: Anal Warts
Perianal warts (condylomata
acuminata): These are warts caused
by a virus which is a variant of
papilloma virus.
Other Differential Diagnoses for Rectal Bleeding

• Anorectal carcinoma: malignant disease
• Proctitis and colitis
• Rectal polyps
Refer to Handout 13.1: Anal and Perianal Disorders
Case Study
Instructions
Read the instructions and complete the activity on the worksheet. After 15 minutes you will
present your responses to the larger group.
Key Points
• Haemorrhoids are dilated veins occurring in relation to the anus.
• They may be external or internal to the anal orifice.
• Haemorrhoids can be classified into first, second, third and fourth degree.
• Management of haemorrhoids includes supportive or surgical treatments
(haemorrhoidectomy).
• Rectal prolapse is a condition in which the rectum becomes stretched out and protrudes
out of the anus.
• In rectal prolapse caused by helminthic infection (e.g. trichuris tricuria), give
Albendazole.
• Surgical treatment is recommended for rectal prolapse (in referral hospital).

• Rectal bleeding can be due to anal fissures, perianal warts, anorectal carcinoma and
proctitis.
Evaluation
• What is a haemorrhoid?
• What are the clinical features of haemorrhoids?
• What are the differential diagnoses of rectal bleeding?
References
• Jonathan Lund. (2008). Anal Fissure. Retrieved March 23, 2010 at http:
//commons.wikimedia.org/wiki/File:Anal_fissure.JPG
• Lisa S. Poritz (2009). Rectal Prolapse. Retrieved March 23, 2010 at
http://www.emedicine.medscape.com/article/196411-overview

Handout 13.1:Anal and Perianal Disorders
Source: George. B. & Clive. Q., 2002

Instructions:
17. You will be allowed time to discuss the answers to the questions.
18. Take notes on the worksheet.
19. Choose a recorder. The recorder may write on note paper or flip chart paper.
Case Information
A patient comes in with long history of constipation and painful defecation with bright red
blood stained stool. She also notices a mass protruding during defecation and usually retracts
when she stands up.
Questions:
2. What are the differential diagnoses?

Session 14: Abdominal Swellings
Learning Objectives
• Describe nine anatomical regions of abdomen
• Explain the causes of abdominal swellings in different regions of the abdomen
• List differential diagnoses of abdominal swellings in different regions of the abdomen
Anatomical Regions of the Abdomen and Swelling in the Hypochondrium

• Abdominal swellings can be classified according to the location of the swelling within the
nine anatomical regions of the abdomen.
Figure 1: Anatomical Regions of the Abdomen
Source: Michael S. & Michael Glynn, 2007
Abdoinal Regions Label Number

Right Hypochondrium 1
Epigastrium 2
Left Hypochondrium 3
Right Lumbar 4
Umbilicus 5
Left Lumbar 6
Right Iliac 7
Hypogastrium 8
Left Iliac 9
Right Hypochondrium Region

• Parietal swellings
o They occur in connection with:

Session 14: Abdominal Swellings 93
Swellings involving the skin and subcutaneous tissue include sebaceous cyst,
lipoma and fibroma.
A hepatic, subphrenic or epigastric abscess may burrow through the anterior
abdominal wall to form a parietal abscess.
• Intra-abdominal swellings
o Liver
o Amoebic hepatitis and abscess, hydatid cyst, carcinoma of the liver or gallbladder
o Subphrenic abscess
o Pylorus of the stomach and duodenum
o Hepatic flexure of the colon
o Right kidney; features of a kidney swelling are:
It moves very slightly with respiration as it comes down a little at the height of
inspiration
It is ballottable
A hand can be easily insinuated between the upper pole of swelling and the costal
margin
Percussion will reveal resonant note in front of a kidney swelling as coils of the
intestine and colon will always be in front of the kidney
o Right suprarenal gland
o The kidneys are usually retroperitoneal and are actually somewhat difficult to palpate
by most people
They are not superficial
Left Hypochondrium Region

o These are swellings involving the skin and subcutaneous tissue including sebaceous
cyst, lipoma, and fibroma.
o A hepatic, subphrenic or epigastric abscess may burrow through the anterior
o Spleen: an enlarged spleen is differentiated from a renal swelling by the following
points:
Spleen enlarges towards the umbilicus whereas the kidney enlarges towards the
iliac fossa, i.e. downwards, forwards and directly downwards towards the iliac
fosse.
Splenic swelling is smooth and uniform.
It has one notch and it moves with respiration more freely than with renal
swelling.
Spleen is easily palpated in the anterior aspect and the kidney in the posterior
aspect.
On percussion the splenic swelling has dull percussion note while the kidney has
tympanic note due to overlying bowels.
o Causes of enlargement of the spleen include:

Malaria (is common)
Haemolytic anaemia
Portal hypertension
Leukaemia
o Splenic flexure of the colon
o Pancreatic tail

o Left kidney
o Left suprarenal gland
Causes and the Swellings in the Epigastrium and Umbilical Regions
The Epigastrium Region

o These are swellings involving the skin and subcutaneous tissue, including sebaceous
cyst, lipoma, and fibroma.
o A hepatic, subphrenic or epigastric abscess may burrow through the anterior
• Intra-abdominal swellings occur in connection with the:
o Liver and subphrenic space
o Stomach and duodenum: congenital hypertrophic pyloric stenosis
o Transverse colon: intersusseption or malignancy
o Head of pancreas
The Umbilical Region

o Those occurring in connection with umbilical and rectus sheath are important.
Umbilicus: umbilical hernia, incisional hernia
Rectus sheath: haematoma resulting to trauma on the anterior abdominal wall
Desmoids tumour: this is a type of fibroma which is not encapsulated and is hard;
it arises from the deeper part of rectus abdominis
• Intra-abdominal swellings may develop in connection with the:
o Stomach and duodenum
o Transverse colon
o Omentum
o Small intestine and mesentery
o Lymph nodes
o Pancrease
o Aorta (usually a pulsatile mass)
o Small intestine and mesentery
In this group tuberculosis of the intestine presents with matted coils of intestine
with tubercolous mesenteric lymphadenitis.
Tumours of the small intestine are rare compared to the large intestine
The common tumours of the small intestine are lipoma, leiomyoma and
lymphoma
Causes and the Swellings of Lumbar, Iliac and Hypogastrium Regions
Lumbar Regions
o These are lumbar abscesses due to tuberculosis gives rises to a swelling which
requires to be differentiated from a lumbar hernia.
o Both these conditions produce impulse on coughing.
• Intra-abdominal swellings develop in connection with the:
o Ascending and descending colon
o Right or left kidney

Right Iliac Region
o There is no special parietal swelling in this region.
o An iliac abscess or appendicular abscess may burrow through the anterior abdominal
wall and become parietal.
o They may develop in connection with the structures which are normally in this region
Appendix
Caecum
Terminal part of the ileum: impaction of round worms
Lymph nodes
o Swelling can also arise from other regions which may be abnormally located in the
right iliac fossa
Renal swelling
Gall bladder swelling
Uterine swelling
Undescended testes
Urinary bladder swelling
Ovarian swellings
The Left Iliac Region

o There is no special parietal swelling in this region.
o An iliac abscess may burrow through the anterior abdominal wall and become
parietal.
Sigmoid colon: there are two pathologies of the sigmoid colon which may give
rise of a mass in the left iliac fossa region, diverticulitis (diverticular abscess) and
carcinoma
Descending colon
Spleen
Lymph nodes
The Hypogastrium Region

o Incisional hernia
Urinary bladder
Small intestine
Uterus and its appendages: fibroids, ovarian tumour and cyst
Pelvis: pelvic abscess
Generalised Abdominal Swellings

• Ascites resulting from liver cirrhosis, right heart failure, renal failure, intra abdominal
malignancies, TB peritonitis

Figure 2: Ascites Due to Liver Cirrhosis
Figure 2 shows the end stage liver

cirrhosis. The patient in the image
has end-stage liver disease
demonstrating muscle wasting
and gross abdominal distension
due to ascites.
Source: Russell R.C.G., 2004
Small Group Discussion
Instructions
Refer to Worksheet 14.1: Abdominal Regions and Abdominal Swellings
you will report your results back to the larger group.
Key Points
• There are nine abdominal regions, which are:
o Right and left hypochondrium
o Epigastrium
o Right and left lumbar
o Umbilicus
o Right and left iliac
o Hypogastrium
• Abdominal swellings can be classified according to the location of the swelling within the
nine anatomical regions of the abdomen.
• An enlarged spleen is differentiated from renal swelling by the following points:
o Spleen enlarges towards the umbilicus whereas the kidney enlarges towards the iliac
region, i.e. downwards, forwards and directly downwards towards the iliac fosse.
o Splenic swelling is smooth and uniform, and grows towards the umbilicus. It has one
notch and it moves with respiration more freely than with renal swelling.

Evaluation
• List nine anatomical abdominal regions which cause abdominal swellings.
• What are the swellings that occur in the right and left iliac regions?
References
• Lett, R.R. & Kobusingye, O. (2009). Trauma Team Training Course, Student’s Manual.
Canadian Network for International Surgery (CNIS) ICCU.

Worksheet 14.1: Abdominal Regions and Abdominal Swellings
Instructions:
paper.
3. Discuss the task together and answer the related questions in the time you are given.
Identify four (4) diseases for each of the (9) abdominal regions that can cause abdominal
swelling.
Note: Your instructor may assign your group to work on one abdominal region.
1. Right hypochondrium
2. Epigastrium
3. Umbilicus
4. Left hypochondrium
5. Right lumbar region
6. Left lumbar region
7. Right iliac region
8. Hypogastrium region
9. Left iliac region

Session 15: Scrotal Swellings
Learning Objectives
• Describe scrotal swellings
• List the scrotal swellings
• Describe the causes of different scrotal swellings
• Describe the management of different types of scrotal swellings
Scrotal Swellings
• For swelling arising from either the scrotum or its contents, the most important thing to
determine on examination is if it is possible to get above the swelling.
• If you can’t get above the swelling, this suggests the pathology has originated from the
groin.
Instructions
Refer to Worksheet 15.1: Scrotal and Inguinal Swellings
You will work in groups to read the instruction for activity on the worksheet and work
together to complete the exercise. After 10 minutes you will report your results back to the
larger group.
Common Causes of Scrotal Swellings

• Hydrocele
• Epididymal cyst
• Varicocele
• Epididymo-orchitis
• Testicular tumour
Common Causes of Swelling in the Groin / Scrotum

• Inguinal Hernia
• Femoral Hernia
• Enlarged Inguinal Lymph Node
• Lipoma
Hydroceles
• Hydrocele: An abnormal collection of serous fluid in some part of the processus
vaginalis, usually the tunica vaginalis.
Pathogenesis of Hydrocele
• The fluid collects because of an imbalance between production and absorption.
• The tunica vaginalis normally produces around 0.5ml of fluid per day.

Session 15: Scrotal Swellings 101
• Hydrocele fluid is straw-coloured and sterile, and contains albumin and fibrinogen.
Aetiology
• A hydrocele can be produced in four ways:
o Excessive production of fluid within the sac, e.g. secondary hydrocele
o Defective absorption of fluid
o Interference with lymphatic drainage of scrotal structures
o Connection with the peritoneal cavity in the congenital hearnia
• Most causes can are due to:
o Congenital
o Idiopathic
o Trauma
o Tumour
o Infections, such as bacterial epididymoorchitis, filariasis (Wunchereria bancrofti)
• History
o A painless swelling in the scrotum
o Onset may be gradual or sudden
• Examination
o A scrotal swelling (soft or tense and fluctuant) which you can get above
o The testis cannot be palpated separate to the swelling
o Shining a flashlight through the fluid helps to identify a hydrocole versus a solid mass
Investigation
• Diagnosis of hydrocele is most cases a clinical diagnosis.
• Other investigations includes: scrotal ultrasound in a hospital to rule out this as an
underlying pathology, blood slides for filaria.
Management
• Management should be conservative if the hydrocele is small in order to cause no
discomfort to the patient
• Aspiration is not recommended due to the following complications:
o Recurrence is about 100%
o Infection
o Haemorrhage
o Puncture of the testis
• Surgery (hydrocelectomy)
Complications of Hydrocele
• Rupture by trauma
• Haematocoele (spontaneous, trauma, aspiration)
• Infection (pyocoele)
• Calcification of the sac
• Atrophy of the testis (in long standing cases)
Epididymal Cyst, Varicocele and Epididymo Orchitis
Epididymal Cyst
• Definition: a cystic swelling arising from the epididymis (mostly congenital)

• History
o Painless scrotal swelling
o Onset usually gradual
• Examination
o Scrotal swelling which you can get above
o Testis palpable separate from the lesion
o The clusters of tense thin-walled cysts feel like a tiny bunch of grapes on palpation
• Management
o Simple surgical excision of the cyst
o Aspirating will not work because the cyst is multiloculated
o For epididymal cysts, conservative management if the patient is asymptomatic
Varicocele
• Definition: a varicocele is a dilatation of the veins of the pampiniform plexus, i.e.
dilatation of the veins draining the testis
• Aetiology
o Obstruction of the left testicular vein by a renal tumour or after nephrectomy is an
occasional cause of varicocele in mid-life and later after
o Therefore all patients with a varicocele should undergo kidney imaging (usually
ultrasound)
o Scrotal swelling far more common on left than on right, dragging / aching sensation in
the groin / scrotum is the most common symptom
o Scrotal swelling which you can get above feels like a ‘bag of worms’
• Management
o Refer the patient
Figure 1: Varicocele
Source: varicoceles.com
Source: riversideonline.com
Epididymo-Orchitis
• Definition: an inflammation of the tissues of the epididymis and testis
• Cause: most common cause is trauma
• Clinical features

o Painful scrotal swelling
o A scrotal swelling which can occur in the upper area of the scrotum, and which is hot,
tender, and erythematous
• Treatment: appropriate broad-spectrum antibiotic and analgesics
• Need to differential from a torsion of the testes which is an emergent medical and
possibly surgical management problem
Hernia
• Hernia: A protrusion of a viscous or part of viscous through an abnormal opening in the
wall of its containing cavity.
• Most frequent varieties are the inguinal (75%), umbilical (15%), and femoral (8.5%). The
rarer forms comprise 1.5%, excluding incisional hernias.
Figure 2: Common Anatomical Sites for Hernia
Source: Russell R.C.G et al., 2004
Aetiology
• Any condition which raises intra-abdominal pressure, such as a powerful muscular effort,
may produce a hernia.
• Whooping cough is a predisposing cause in childhood, and in adults a chronic cough,
straining on micturition or straining on defecation may precipitate a hernia.
Surgical Anatomy of the Inguinal Region

• The area extends between the anterior superior iliac spine and the pubic tubercle.
• Anatomically, it is a region where structures exit and enter the abdominal cavity and is,
therefore, clinically important because these are potential sites of herniation.
• Superficial (external) ring:
o Triangular aperture in the external oblique aponeurosis (1.25cm above the pubic
tubercle)
• Deep (internal) ring:
o U shaped in the transversalis fascia (1.25 mid inguinal ligament)
• Inguinal canal
o 3.75cm long
• Contents passing through the inguinal canal are:
o Spermatic cord (in males)
o Round ligament of the uterus in females

o Ilioinguinal nerve
o Genital nerve
o Blood and lymphatic vessels
Types of Inguinal Hernia

• Indirect inguinal hernia
o Passes via both inguinal rings
o Most common type of hernia, common in young, and common in right side in adult
males
• Direct inguinal hernia
o Passes via external ring only
Figure 3: Inguinal Hernia
Source: David et al., 2009
Treatment Options for Hernias

• Non-surgical
o Use abdominal binder and avoidance of strenuous activity.
o Non-surgical option is often ineffective and is reserved for patients who are too ill or
old for surgery.
• Surgical
o Refer the patient for herniorrhaphy or herniotomy.
Testicular Torsion
• Torsion of the testes is common in children and adolescents.
• The predisposing factors are congenital scrotal abnormalities, which are:
o Long spermatic cord
o Ectopic testes
• Clinical Features
o Sudden onset of lower abdominal pain
o Pain in the affected testes
o Vomiting
o Testes is swollen and drawn upwards
• Differential Diagnoses
o Epididymorchitis: the patient often has urinary symptoms, including urethral
discharge

o Testicular tumour: the onset is not sudden
• Treatment
o Refer the patient immediately
Scrotal Elephantiasis
• This is a condition in which the skin and subcutaneous tissues of the scrotum are
enormously swollen because of obstruction of lymphatics.
• Causes
o Obstruction due to microfilaria (filariasis)
• Investigations
o Blood slide and examine for microfilaria parasites (Wuchereria bancrofti).
o Take blood at midnight when parasites can be found in the bloodstream.
• Treatment
o If the blood slide is positive for filaria, medical treatment is initiated
o Elephantiasis can be treated surgically so the patient should be referred to a hospital
• Differential diagnosis
o Hydroceles
o Cysts of the epididymis
o Testicular tumours
Key Points
• Common causes of scrotal swellings include Hydrocele, Epididymal Cyst, Varicocoele,
Epididymo-orchitis, and Testicular Tumour.
• Common causes of a swelling in the groin / scrotum which you cannot get above include
inguinal hernia, femoral hernia and Enlarged inguinal lymph node.
Evaluation
• List types of scrotal swellings.
• Identify differential diagnosis of hydrocele.
References
• David C.D. et al. (2009). Inguinal Hernia. University of Washington School of Medicine.
• Moore, K.L., Agur, A.M.R. (2007): Essential Clinical Anatomy (3rd ed.). USA: Lippincott
Williams and Wilkins.
• Varicocele. (2009). In MayoClinic.com Health Library (Men’s Health). Retrieved March,
2010 from http://www.riversideonline.com/DS00618.cfm
• Varicocele. (date unknown) In Varicoceles.com, by Vascular and Interventional
Radiologists (Chicago, Illinois). Retrieved March 2010 from
http://www.varicoceles.com/what-is-a-varicocele.htm

Worksheet 15.1: Scrotal and Inguinal Swellings
Instructions:
paper.
Questions
1. Identify causes of scrotal swellings for which you can go above the swelling during
examination.
2. Identify causes of scrotal swellings for which you cannot go above the swelling during
examination.

Session 16: Congenital and Surgical Problems in
Children
Learning Objectives
• Describe the congenital and surgical problems in children
• Describe clinical presentation of surgical problems in children
• Describe the management of the surgical problems in children
Introduction to Congenital Surgical Problems in Neonates

Surgical Problems in Neonates
• While there are many types of congenital anomalies, only a few of them are common.
• Some require urgent surgical attention while others should be left alone until the child is
older.
• However, resuscitation cannot await referral and you may need to perform essential life-
saving interventions prior to referral of the child for definitive surgery.
Congenital Surgical Problems in Children

• Intestinal Obstruction
• Hypertrophic Pyloric Stenosis
• Oesophageal Atresia
• Abdominal Wall Defects
• Anorectal Anomalies
• Meningomyelocele (Spina Bifida)
• Congenital Hip Dysplasia
• Septic Arthritis
• Congenital Talipes Equinus Varus (Club Foot)
Intestinal Obstruction, Hypertrophic Pyloric Stenosis and Oesophageal

Atresia
Intestinal Obstruction
• Any newborn with abdominal distension, vomiting or no stool output, has a bowel
obstruction until proven otherwise.
• This can be due to duodenal atresia, hirchsprungs disease, or imperforate anus.
• Bile stained (green) vomiting can be a sign of a life threatening condition.
• A peristaltic wave across the abdomen can sometimes be seen just before the child vomits
• Management
o Place a nasogastric tube
o Start intravenous fluids
o Keep the child warm
o When the child is stable, refer for definitive management
Hypertrophic Pyloric Stenosis

• There is muscular hypertrophy of the gastric pylorus which can be seen as a bump just
beneath the skin of the abdomen.

Session 16: Congenital and Surgical Problems in Children 109
• This condition is caused by enlargement of the muscle that controls stomach emptying
(pylorus).
• In a relaxed infant, a mass can be observed in the upper abdomen at the midline or
slightly to the right of the midline.
Figure 1: Hypertrophic Pyloric Stenosis
The University of California, San Francisco, 2009
Palpable mass
Source: www.pathology.pitt.edu/lectures/gi/stom-a/01.htm
• The condition most commonly occurs in male infants 2–5 weeks of age.
• The main symptom is vomiting of undigested milk (non bilious) soon after feeding.
o Vomiting usually begins at four weeks of age but can happen as early as two weeks
after birth.
o Once vomiting begins it becomes more frequent, and severe, and is often described
as ‘forceful’ or ‘projectile’.
• Infants with pyloric stenosis commonly present with dehydration and electrolyte
imbalances.
• It is treated with pyloromyotomy.
• This is a process of cutting through the muscle fibres of enlarged pyloric muscle in order
to widen the opening into the intestine.
• Intravenous fluid resuscitation is required urgently:
o Use ringer lactate or normal saline (20 ml/kg bolus) and insert a nasogastric tube.
o Repeat the fluid boluses until the infant is urinating and vital signs have corrected to
normal (2 or 3 boluses may be required).

o Once the fluid and electrolyte abnormalities have been corrected provide for
maintenance for ongoing losses and refer the patient.
Oesophageal Atresia
• This is failure of oesophageal development.
• It is often associated with a fistula from the oesophagus to the trachea.
• The newborn presents with drooling or regurgitation of the first and subsequent feeds.
• Choking or coughing on feeding is frequent.
• The diagnosis can be made by trying to pass a catheter down the infant’s oesophagus; in
oesophageal atresia, the cather cannot be advanced further than 10-15cm.
• A plain film CXR will show the catheter coiled up in a pouch in the upper oesophagus.
• Management:
o Keep the infant warm and nurse in the 30° head up position.
o Insert drain in the oesophageal pouch.
o Administer intravenous fluids calculated according to weight.
o IV antibiotics help to prevent aspiration pneumonias.
o Refer the stable infant to a paediatric surgeon.
Abdominal Wall Defects and Anorectal Anomalies

Abdominal Wall Defects
• Defects of the abdominal wall occur at or beside the umbilicus:
• In omphalocoele, there is a transparent covering over the extruding bowel.
Anorectal Anomalies
• Imperforate anus can occur in a variety of forms.
• There may be no opening at all.
• In other instances, a tiny opening discharging a little meconium may be seen at the base
of the penis or just inside the vagina.
• Delay in diagnosis may cause severe abdominal distension, leading to bowel perforation.
• The diagnosis should be made at birth.
• Management:
o Place a nasogastric tube.
o Start intravenous fluids.
o Refer the child to a surgeon.
Meningomyelocele (Spina Bifida) and Cleft Lip and Palate
Meningomyelocele (Spina Bifida)

• It is a small sac that protrudes through a bony defect in the skull or vertebrae.
• The most common site is the lumbar region.
• It may be associated with neurological problems (bowel, bladder and motor deficits in the
lower extremities) and hydrocephalus.
• These patients should always be referred.
o Meningitis occurs if the spinal defect is open.
o The defect should be covered with sterile dressings and treated with strict aseptic
technique until closure.

Figure 2: Meningomyelocele (Spina Bifida)
Source: Geneva Foundation for Medical Education and Research
Cleft Lip and Palate

• Cleft lip and palate may occur together or separately.
• A baby with a cleft palate may have difficulty sucking, leading to malnutrition.
• An infant with cleft lip or palate who is not growing normally should be fed with a spoon.
• The optimal timing of operations for a cleft lip or cleft palate has not been established
definitively, and may vary from patient to patient depending on the type of operation(s)
required.
• Urgent referral is not required.
Figure 3: Cleft Lip and Palate
Source: Russell R.C.G. et al., 2004
Hip Disorders

Congenital Hip Dysplasia
• Congenital hip dysplasia is an abnormal formation of the hip joint in which the ball at the
top of the thighbone (femoral head) is not stable in the socket (acetabulum).
• Also, the ligaments of the hip joint may be loose and stretched.
• The degree of instability or looseness varies.
• Symptoms include:

o The condition is not painful and there are no definite signs.
o The child may have problems with hip development.
o The following are associated with the condition:
One leg appears shorter than the other.
An extra deep crease is present on the inside of the thigh.
One hip joint moves differently from the other and the knee may appear to face
outwards.
The child crawls with one leg dragging.
o After walking age it may be noted that the child walks with a limp in an attempt to
accommodate the difference in leg length.
Figure 4: Congenital Hip Dysplasia
Source: www.neogaf.com/forum/showthread.php?t=370017
Septic Arthritis
• Septic arthritis destroys the articular and growth cartilage through bacterial enzyme
release into the infected joint.
• Impairment of the blood supply to the hip causes necrosis of the bone with collapse of the
round contour of the femoral head.
• This impairs motion and leads to later degenerative arthritis.
• Lateral + superior displacement of the femoral head may be seen, with relatively normal
acetabular anatomy.
• This may also impair motion and lead to degenerative arthritis.
Figure 5: Septic Arthritis
Source: WHO, 2003

• Clinical presentation of septic arthritis:
o Age is a useful indicator of the diagnosis.
o All of these disorders are associated with decreased motion, but loss of internal
rotation is seen earliest.
o In the older child, knee pain and limp are common presentations.
o Infection is associated with the systemic signs of fever and malaise.
• Investigation:
o X-rays are helpful but not essential initially.
o If available, they help to determine the long term prognosis during the follow-up
period.
o Full blood picture should be taken.
o Erythrocytes segmentation rate is increased.
o Diagnostic joint aspiration for culture and sensitivity in a hospital should be taken.
• Management: refer the patient immediately.
Congenital Talipes Equinus Varus (Club Foot)

• This condition is present at birth and is distinguished by rigid inversion of the heel and
forefoot and a plantar flexed ankle.
• The entire affected foot and calf are smaller than their normal counterparts.
• The foot is inverted and supinated and the forefoot is adducted.
• The heel is small, rotated inwards and elevated.
• The calcaneus is inverted beneath the talus.
Figure 6: Congenital Talipes Equinus Varus (Club Foot)
Source: www.nursingcrib.com
• Aetiology:
o Although the majority of cases are idiopathic, the condition can regularly be related
to factors such as posture in utero, heredity and associated conditions like
neuromuscular disease.
o The risk of club foot is increased 20-fold if a first-degree relative has the condition.
o The most difficult club feet tend to be in association with neuromuscular,
syndromic or dysplastic conditions.
• Management:
o These children should be referred for assessment and management.
• Treatment varies between splintage and surgery.

Figure 7: Correction of Club Foot
Source: WHO, 2003
Source: Geneva Foundation for Medical Education and Research
Case Study
Instructions
you will reports your results to the larger groups.
Key Points
• By recognizing common congenital conditions you can identify when urgent referral is
required.
• There are many types of congenital anomalies, but only a few of them are common.
• Some require urgent surgical attention while others should be left alone until the child is
older.
• For cases such as intestinal obstruction, hypertrophic pyloric stenosis, oesophageal atresia
and anorectal anomalies, remember to place a nasogastric tube, start intravenous fluids,
and refer for definitive management when the child is stable.
• Diagnoses in orthopaedic conditions are made by clinical examination. X-rays are useful
for follow-up care, but are not essential.

Evaluation
• Describe the congenital and surgical problems in children.
• Describe clinical presentation of child with hypertrophic pyloric stenosis.
• What are the principles of management of child with intestinal obstruction?
References
• Geneva Foundation or Medical Education and Research: Developmental and Genetic
Disease: Meningomyolecele. Retrieved March 15, 2010 from
htpp://www/gfmer.ch/genetic_disease_v2/gendis_detail_list. php? cat3=197
• Hypertrophic Pyloric Stenosis. Retrieved March, 2010 from
http://www.pathology.pitt.edu/lectures/gi/stom-a/01.htm
• Congenital Talipes Equinus Varus. Retrieved March, 2010 from
http://www.nursingcrib.com/nursing-care-plan/nursing-care-plan-clubfoot-or-talipes-
equinovarus/
• University of California San Francisco. (2009). Hypertrophic Pyloric Stenosis. Retrieved
March 23, 2010 from www.pedsurg.ucsf.edu/.../pyloric-stenosis.aspx

Instructions:
paper.
Case Information
A baby, who was apparently normal at birth, develops persistent regurgitation and vomiting
in the second and third weeks of life. No fever is present and haematological studies and
blood chemistries are normal.
Questions:

Session 17: Dislocations of the Shoulder and Elbow
Joints
Learning Objectives
• Define dislocation
• Describe dislocation of the shoulder and elbow joints
• Classify dislocations of shoulder and elbow joints
• Describe clinical presentation of shoulder and elbow dislocations
• Identify relevant investigations for shoulder and elbow dislocations
• Describe basic principles of management of shoulder and elbow dislocations
Review of Anatomy of Shoulder and Elbow
Anatomy of Shoulder
• The shoulder joint is a ball-and-socket joint that is comprised of three main bones:
o Clavicle (the collarbone)
o Scapula (the shoulder blade)
o Humerus (upper arm bone)
• The upper end of the humerus where it rotates is a smooth, rounded head (ball) that fits
into the glenoid cavity (socket) of the shoulder blade.
• The joint is highly mobile therefore it has decreased stability.
• Dislocations and sublaxations following trauma are common.
Figure 1: Shoulder Anatomy
Source: Exactech Inc.
Elbow Joint
• This joint is formed by the articulation of three bones, namely:
o The distal end of the humerus
o The proximal end of the radius
o The proximal end of ulna

Session 17: Dislocations of the Shoulder and Elbow Joints 119
• Ligaments connected to the bones keep all of these bones in proper alignment.
• Due to the involvement of three bones, the elbow consists of three joints:
o Between humerus and ulna (ulno-humeral)
o Between humerus and radius (radio-humeral)
o Between ulna and radius (radio-ulnar joint)
Part of the ulna that articulates with the humerus includes the olecranon process
and the coronoid process.
The corresponding part of humerus that articulates with these processes is called
trochlea.
The head of the radius articulates with the capitulum of the humerus.
Figure 2: Anatomy of the Elbow Joint
Source: http://www.joint-pain-expert.net/elbow-anatomy.html
• The different movements possible at this joint include:

o Flexion (touching the shoulder with the finger tips of the same side)
o Extension (straightening your upper limb)
o Supination (palm facing upwards)
o Pronation (palm facing downwards)
Flexion and extension occur mainly at the ulno-humeral joint.
Supination and pronation occurs at the radio-ulnar joint.
• Main muscles acting across the elbow include:
o Biceps brachii (responsible for supination and flexion)
o Brachialis (causes flexion)
o Triceps (causes extension)
o Pronator teres (causes pronation)
Shoulder and Elbow Dislocations
Introduction
• Dislocation can be defined as a displacement of a bone from a joint (The articular
surfaces are no longer in full or correct contact).

• Signs include loss of motion, temporary loss of function of the involved joint, pain and
swelling.
• Some dislocations, especially of the hip, are congenital, usually resulting from a faulty
development of the joint.
• Dislocations can be complete or partial.
o In a complete dislocation, the joint surfaces are completely separated.
o In a partial dislocation, the joint surfaces are only partly separated.
• A subluxation is a partial dislocation.
• Some of the articular surface is in partial contact, but the congruence of the two joints has
been lost.
• For description of either a dislocation or subluxation, the joint needs to be named, and the
direction of the disruption should be described (e.g. an inferior glenohumeral dislocation).
• Dislocation of the shoulder occurs when hand is outstretched; the arm is abducted and
externally rotated.
• Dislocations of the elbow occur with a fall on the outstretched arm.
Classification
• Shoulder dislocation can be classified as:
o Anterior dislocations
More common (~95%)
Usually traumatic
Occurs when the abducted arm is externally rotated
o Posterior dislocations
Less common (~5%)
Caused by force applied along the axis of the arm
Shoulder is adducted, internally rotated and flexed
• Elbow dislocation can be classified as:
o Posterior or posterior lateral direction (~90%)
o Anterior (~10%)
Clinical Presentation of Shoulder and Elbow Dislocations

Shoulder Dislocations
• Arm is held at the side, usually slightly away from the body with the forearm turned
outward.
• The contour of the shoulder is changed from the usual curved appearance to one that is
much more angular.
• Any shoulder movement is painful.

Figure 3: Contour of the Dislocated Shoulder.
Source: WHO, 2003
Elbow Dislocations
• Tenderness, swelling, deformity can be present.
• Check for pulses at the wrist.
• It is also important to check the nerve supply to the hand.
• If nerves have been injured during the dislocation, some or all of the hand may be numb
and not able to move.
• Clinically examine the triangular relationship of the ulna and the two epicondyles to
ascertain if it is disturbed.
• The olecranon is felt protruding in a posterior direction and any elbow motion is painful.
Relevant Investigations for Shoulder and Elbow Dislocations

• An X-ray is necessary to determine if there is a bone injury. X-rays can also help show
the direction of the dislocation.
• X-rays are the best way to confirm that the shoulder or elbow is dislocated.
• Two views are necessary: anterio-posterior view and lateral view.
• In addition to the anterio-posterior and lateral view one would obtain a Y-view or an
axillary view as this helps determine the type of dislocation – anterior or posterior.
Figure 4:X-ray of Elbow Dislocation
Source: WHO, 2003

Managing Shoulder and Elbow Dislocation
• Normally, closed reduction is used.
• In this method, the bone and joint are manipulated from outside the body without surgical
exposure.
• In cases where closed reduction is not successful, surgical open reduction may be needed.
• In closed reduction, there are several methods to reduce the shoulder dislocation into its
normal position.
• If the patient is in the emergency room, the patient will receive anesthesia for the
procedure.
• Intravenous (IV) sedation
o Most commonly, patients with a shoulder or elbow dislocation are given IV sedation
and pain killers before reduction.
o During that time, the physician can manipulate the dislocated shoulder or elbow back
into anatomical position.
• Local injection
o This is used only for shoulder dislocation.
o Injection of novocaine into the joint can provide ample anesthesia to perform a
reduction of a shoulder dislocation.
o There are two manoeuvres (Hippocrates and Kochers methods) that can be used to
reposition a shoulder dislocation.
o In general, the goal is to manipulate the bones to allow them to slide back into
position without causing further damage to the shoulder joint.
Reduction of Shoulder Joint

• Reduce acute dislocations with the patient in the supine position.
• Hippocrates method:
o If you have an assistant, he/she should place a sheet or other material under the axilla
for counter traction.
o Pull slowly and steadily on the flexed elbow.
o When the patient relaxes the shoulder muscles, you will feel the humeral head move
into the joint socket.
o If you are alone, place your foot in the axilla for counter traction and gently pull on
the arm.
• Once the shoulder dislocation is back in place, repeat X-rays are performed to ensure it is
indeed in the correct position, and to evaluate for other injuries such as fractures.
• After reduction, place the arm in a sling to prevent abduction and external rotation.
• Begin strengthening exercises at 6 weeks, with an emphasis on internal rotation strength.
• After reduction one should test sensation over the lateral deltoid as that is the distribution
of the axillary nerve which can be damaged during a dislocation and / or reduction.

Figure 6: Reduction of Shoulder Joint
Source: WHO, 2003
Reduction of Elbow Joint

• The method is also performed through closed reduction, including traction and then
flexion.
• Perform anterior elbow dislocation reductions by having an assistant grasp the humerus
with 2 hands to apply counter traction, while the operator manipulates the forearm to
reposition the joint once the elbow dislocation is back in place.
• After the procedure, repeat X-rays are performed to ensure it is indeed in the correct
position, and to evaluate for other injuries such as fractures.
• Patients are placed in a POP for 4 weeks.
• If reduction fails refer for open reduction (surgery).
Figure 7: Reduction of Elbow Joint
Source: WHO, 2003
Key Points
• Injury to the shoulder and/or elbow can occur with a fall on the outstretched arm.
• Make the diagnosis based on the history and a physical examination.
• Treat with immediate closed reduction.
• When comfortable, begin range of motion and active muscle strengthening of the joint.
• Treat with closed manipulation.
• X-rays help to evaluate the reduction and the presence of fractures.
Evaluation
• What is dislocation?
• Describe clinical presentation of shoulder and elbow dislocations.
• Describe basic principles of management of shoulder and elbow dislocations.
References
• Anatomy of Elbow Joint.(2010). Retrieved March 15, 2010 from http://www.joint-pain-
expert.net/elbow-anatomy.html

• Bewes P. (1984). A Manual for Rural Health Workers.Nairobi: African Medical and
• Exactech Inc. Shoulder Anatomy. Retrieved March 15, 2010 from
http://www.exac.com/patients-caregivers/shoulder-replacement/shoulder-anatomy

Session 18: Dislocations of the Lower Limb Joints
Learning Objectives
• Describe the anatomy of the hip, knee and ankle joints
• Classify dislocations of the hip, knee and ankle joints
• Describe the clinical presentations of dislocations of the hip, knee and ankle joints
• Identify relevant investigations of dislocations of the hip, knee and ankle joints
• Describe basic principles of management of dislocations of the hip, knee and ankle joints
Review of Anatomy of Hip, Knee and Ankle Joints
The Hip Joint

• The hip is a ball and socket joint formed by the head of femur and the acetabulum.
• The femoral head is situated deep within the acetabular socket, which is further enhanced
by a cartilaginous labrum.
• It has a considerable range of movements including flexion, extension, abduction,
adduction, medial and lateral rotation, and circumduction.
• The joint is supported by iliofemoral ligaments, pubofemoral ligaments, ischiofemoral
ligaments, ligamentum teres and transverse acetabular ligaments and many strong
muscles of the upper thigh and gluteal region.
• Because of this anatomic configuration, the hip is stable, as in the image below.
Subsequently, a large force is required to dislocate the joint.
Figure 1: Anatomy of the Hip Joint
Source: Thomas, 2008

Session 18: Dislocations of the Lower Limb Joints 127
Figure 2: Ligaments of the Hip Joint
Anterior View
Posterior View
Source: Keith L.M & Anne M.R.A., 2007
Figure 3: A Normal Anteroposterior (AP) Pelvis Radiograph
Source: Tham, 2009

The Knee
• The knee joint is formed by the articulation of femoral condyles and tibial plateau.
• The joint is bicondylar, with a third joint formed by patella articulating on the front of the
femur.
• The knee is a complex hinge joint which allows some rotation and indeed some glide
between the joints surfaces.
• The major ligaments supporting the knee joint are the patellar ligament, anterior and
posterior cruciate ligaments as well as medial and lateral collateral ligaments.
Figure 4: Anatomy of the Knee Joint
Source: Thomas N.J. (2008)
Figure 5: Cruciate Ligaments of the Knee Joint
Source: Keith L.M. & Anne M.R.A., 2007
The Ankle
• The ankle joint is synovial in type and involves the tallus of the foot, the tibial and fibula
of the leg.

• The ankle joint mainly allows hinge, like dorsi flexion and plantaflexion of the foot on the
leg.
• The ligaments supporting the ankle joints are medial, calcaneofibular, anteriorfibular,
long and short plantar, and supported by tibial fibula syndesmosis.
Figure 6: Anatomy of the Ankle Joint
Source: www.graysanatomyonline.com
Classification of the Hip, Knee and Ankle Joint Dislocations
Dislocations of the Hip

• In general, hip dislocations can be classified into congenital and traumatic.
• Congenital hip dislocations are commonly the result of femoral head or acetabular
dysplasia.
• High-energy blunt force trauma is the most common cause.
• The relationship of the femoral head to the acetabulum is used to classify hip dislocations.
• The 3 main patterns are posterior, anterior, and central.
• Posterior hip dislocation:
o Posterior dislocations compromise approximately 80-90% of hip dislocations.
o Posterior dislocations occur when the knee and hip are flexed and a posterior force is
applied at the knee
o The femoral head is situated posterior to the acetabulum.
• A posterior dislocation is shown in the image below in Figure 7.

Figure 7: Right Posterior Hip Dislocation
Source: Tham, 2009
• Anterior hip dislocation:

o The femoral head is situated anterior to the acetabulum.
o An anterior dislocation is most commonly caused by a hyperextension force against
an abducted leg that levers the femoral head out of the acetabulum.
o Less commonly, an anterior force against the posterior femoral neck or head can
produce this dislocation pattern.
• Central hip dislocation:
o A central dislocation is a fracture-dislocation, shown in the image below in Figure 8,
where the femoral head lies medial to a fractured acetabulum.
o Direct impact to the lateral aspect of the hip forces the hip centrally through the
acetabulum into the pelvis.
Figure 8: Central Hip Dislocation
Source: Tham, 2009

.
Dislocations of the Knee

• Knee dislocations are uncommon.
• A knee dislocation is defined as complete displacement of the tibia with respect to the
femur, with disruption of 3 or more of the stabilizing ligaments.

• Most knee dislocations are the result of high-energy injuries, such as motor vehicle.
• Multiple ligament injuries are required for knee dislocation.
• Based on the direction of tibial displacement, knee dislocations are classified into 5 main
patterns:
o Anterior
o Posterior
o Medial
o Lateral
o Rotational
• An anterior knee dislocation usually results from a hyperextension injury to the knee that
initially tears the posterior structures and drives the distal femur posterior to the proximal
tibia.
• A posterior knee dislocation usually results from a direct blow to the proximal tibia that
displaces the tibia posterior to the distal femur.
• Medial dislocations are caused by valgus forces. (A knee which is in a valgus position is
knock-kneed, i.e. tending to touch the opposite knee.)
• Lateral dislocations are caused by varus forces. (A knee which is in a varus position is
bow-legged, with a space between the two knees.)
• Rotational or rotatory dislocations are the result of indirect rotational forces, usually
caused by the body rotating in the opposite direction of a planted foot.
o Rotatory dislocations can be of 4 different types, named for the direction of the
displaced tibial plateau.
For example, posterolateral rotatory dislocation describes a posterior position of
the lateral tibial plateau and is the most common rotatory dislocation reported.
• Knee dislocations can also be classified as open or closed and as reducible or irreducible.
Figure 9: Knee Dislocation
John G. et al., 2008
Dislocations of the Ankle

• Ankle dislocations occur when significant force applied to the joint results in loss of
opposition of the articular surfaces.
• Because of the large amount of force required and the inherent stability of the joint,
dislocation of the ankle joint is rarely seen without an associated fracture.

• Common classification is based on fracture of distal fibula to the relation of syndesmosis,
classified by Webber.
o Webber A: fracture of distal fibula below the syndesmosis.
o Webber B: fracture of fibula within the syndesmosis.
o Webber C: fracture of fibula above the syndesmosis.
• Dislocations of the ankle are, by definition, unstable due to accompanying disruption of
the lateral or medial ligaments or the tibiofibular syndesmosis.
• Ligamentous disruption varies according to the type of dislocation.
• Associated fractures are the rule rather than the exception with ankle dislocations.
Mechanism of Fracture Dislocation of Ankle Joint

• Isolated fractures of the distal fibula are caused by an eversion/external rotation force
through the ankle.
• With only one component of the articular ring disrupted, these are stable injuries (Image 1
below).
• A similar injury combined with a fracture of the medial malleolus or tear of the deltoid
ligament (Image 2 below) is not stable and causes subluxation of the ankle joint.
• Inversion injuries result in medial subluxation of the joint and fractures of both malleoli
(Image 3 below).
• A vertical load causes the distal tibial articular surface to fracture (Image 4 below),
resulting in a compression injury to the calcaneous bone and significant disruption of the
articular cartilage of the ankle.
Figure 10: Fracture Dislocation of Ankle Joint.
Image 1 Image 2 Image 3 Image 4

Source: WHO, 2003
Clinical Presentation of the Hip, Knee and Ankle Dislocations
Hip Dislocation: History

• A high index of suspicion for hip dislocation must be present whenever evaluating a
patient involved in a major trauma.
• Patients with a hip dislocation will be in severe pain.
• They may complain of pain to the lower extremities, back, or pelvic areas.
• Patients will have difficulty moving the lower extremity on the affected side and may
complain of numbness or paresthesias.
• Frequently, patients will be a victim of multiple traumas and may not pinpoint pain to the
hip as a result of altered mental status or distracting injuries.

Hip Dislocation: Physical
• As with any major trauma victim, assessment of the airway, breathing, and circulation are
of primary importance.
• During the secondary survey, an examination of the pelvic girdle and hip are mandatory.
• Examination should consist of inspection, palpation, active/passive range of motion, and a
neurovascular examination.
• Inspection
o Isolated anterior and posterior dislocations have classic appearances.
o In practice, these appearances may be altered by the presence of fracture-dislocations
or other bony abnormalities along the leg.
o Posterior: The hip is flexed, internally rotated, and adducted.
o Anterior: The hip is minimally flexed, externally rotated and markedly abducted.
o Central: The leg is shortened, abducted or adducted, and internally or externally
rotated, depending on the type and extent of penetration into the pelvis.
• Palpation
o Palpate the pelvis and lower extremity for any gross bony deformities or step-offs.
o In an anterior hip dislocation, the femoral head can occasionally be palpated.
o Large hematomas may signify vascular injury.
• Range of motion
o Patients with a hip dislocation have severely limited range of motion.
o Evaluate what the patient can do comfortably.
o Do not forcefully perform range of motion on a patient who cannot tolerate
manipulation.
o Normal, painless range of motion virtually excludes hip dislocation.
• Neurovascular examination
o Signs of sciatic nerve injury include the following:
Loss of sensation in posterior leg and foot
Loss of dorsiflexion (peroneal branch) or plantar flexion (tibial branch)
Loss of deep tendon reflexes at the ankle
o Signs of femoral nerve injury include the following:
Loss of sensation over the thigh
Weakness of the quadriceps
Loss of v. dorsiflexion (peroneal branch) or plantar flexion (tibial branch)
Loss of deep tendon reflexes at knee
o Signs of vascular injury include the following:
Hematoma
Loss of pulses
Pallor
Clinical Presentation of Knee Dislocation

• There is history of trauma.
• There is tenderness, swelling, deformity.
• Check for pulses at the pedis dorsalis and tibialis posterior.
• Physical examination should include knee stability test:
o Anterior drawers test for the anterior cruciate ligaments
o Posterior drawers test for posterior cruciate ligaments
o Valgus stress test for the medial collateral ligaments
o Varus stress test for the lateral collateral ligaments

Refer to Handout 18.1: Drawers Tests
Clinical Presentations of Ankle Dislocation

• Ankle dislocations are almost always associated with sprains and fractures.
• There is always history of injury/trauma
• There is excruciating pain.
• There is loss of ankle function (the patient cannot use the foot).
• There is numbness or paralysis in the foot (because of compression of the nerves).
• On examination, the ankle is deformed.
• Pulses distally (dorsalis pedis) may be faint or absent depending on the degree of
compression.
Investigations and Managing Hip, Knee and Ankle Dislocations
Investigation
• The clinical examination is sufficient to make the diagnosis, but X-rays (anterior,
posterior and lateral views) are necessary to identify associated fractures.
Management
• The hip
o Reduce the dislocation as soon as possible
o Skeletal traction is applied after reduction on unstable hip for four weeks.
o Refer the patient for further management if reduction fails.
Refer to Handout 18.2: Reduction of Hip Dislocation
• The knee
o After evaluation, closed reduction should be performed.
o Under anaesthesia, reduction is performed by stabilizing the distal femur and applying
longitudinal traction on the tibia and reversing the direction of the dislocation.
o The knee should reduce easily with a satisfactory clunk.
o Do not apply any pressure over the popliteal fossa during the reduction, to lessen the
risk of additional injury to the popliteal artery.
o After reduction, the knee should be immobilized in 15-20° of flexion.
o Refer for further management if the knee is unstable.
o Post reduction assessment
After reduction, vascular and neurological status should be recorded again.
Repeat anteroposterior and lateral radiographs are obtained to confirm reduction.
If the limb is dysvascular, then emergent vascular surgery consultation should be
undertaken.
Anteroposterior and lateral radiographs should be repeated in the first week to
confirm reduction.
• The ankle
o In patients with obvious or complete neurovascular compromise, perform reduction
prior to radiographic studies.
o Prompt reduction is important in reducing the risk of complications related to
neurovascular compromise.
o Unstable fractures

Reduce unstable fractures with gentle longitudinal traction followed by
manipulation in the opposite direction to the deformity:
Position eversion/external rotation fractures with the heel in inversion, the foot
internally rotated and the ankle at 90 degrees of flexion; maintain this position by
holding the big toe to support the weight of the leg, while an assistant applies the
splint.
Position inversion-type fractures with the heel everted slightly, the foot in neutral
and the ankle at 90 degrees of flexion.
Refer for further management if the ankle is unstable.
Activity: Case Study (20 minutes)
Instructions
Refer to Worksheet 18.1: Knee Joint Injury
Work in groups to complete the activity on the worksheet. After 10 minutes you will share
your results with the larger groups.
Key Points
• Make the diagnosis from the history and from clinical findings; use X-rays to confirm
associated fractures.
• To avoid the complications of vascular necrosis and loss of hip joint motion, reduce the
dislocation as soon as possible.
• Closed reduction is usually successful if carried out promptly.
• Timely diagnosis and management may minimize the significant morbidity that may
result.
Evaluation
• Explain the classification of the hip joint dislocation.
• Describe clinical presentations of lower limb dislocations.
References
• Edward T. T. & Christopher I. D. (2009). Dislocation, Hip. Yale University School of
Medicine. Department of Surgery, Section of Emergency Medicine. Retrieved March 16,
2010 from http://www.emedicine.medscape.com/article/823471-overview
• Hutchison C. (2000). Review Notes and Lecture Series: Orthopaedics. MCCQE.
• John G. et al. (2008). Knee Dislocation. University of Washington Medical Centre
.Department of Orthopaedics and Sports Medicine. Retrieved March 16, 2010 from http:
//www.emedicine.medscape.com/article/823471-overview
• Thomas N.J. (2008). Hip Joint. Retrieved March 17, 2010 from
http://www.nlm.nih.gov/medlineplus/ency/presentations/100006_1.htm

Handout 18.1: Drawers Tests
Source: Keith L.M & Anne M.R.A., 2007

Handout 18.2: Reduction of Hip Joint Dislocation
• With the patient supine, apply traction to the flexed hip while an assistant holds the pelvis
down for counter traction, muscle relaxation is usually necessary.
• If you have no assistant, use an alternative method with the patient prone. Apply traction
downward with the leg flexed over the edge of the table.
• Gently rotate the hip while applying pressure on the femoral head in the gluteal region.
• Place the patient in post-reduction skin traction for a few days and then begin non-weight
bearing ambulation with crutches. Allow weight bearing after 12 weeks.
• If there is a large posterior rim fracture, treat the patient in traction for 8–12 weeks while
the fracture unites.
Source: WHO, 2003

Instructions:
paper.
Case Information
A 24-year-old male presents at the facility complaining of severe right knee pain with
difficulty in walking and pivoting, though he remains able to ambulate. He has a history of
sport injury prior. Physical examination revealed a positive valgus stress test. A plain film of
this knee is normal.
Questions:

Session 19: Introduction to Fractures
Learning Objectives
• Define a fracture
• Describe causes of a fracture
• Classify fractures
• Describe the clinical presentation of a fracture
• Identify relevant investigations for a fracture
• Describe basic principles of management of a fracture
• Explain the complications of a fracture
Definition and Causes of Fractures

• Fracture: The interruption of a bone’s cortex continuity, (i.e., a break or disruption in
bone or cartilage).
Causes
• Trauma, such as motor vehicle accidents and falls are the leading cause of fracture.
• Pathology, such as a tumour, metabolic bone disease, infection and ageing, osteoporosis.
• Stress, such as bone fatigue (repetitive mechanical loading).
Classifications of Fractures
Classification by Quality of Bone in Relation to Load
• Traumatic fracture
o Occurs when an excessive force is applied to normal bone.
• Pathological fracture
o This is produced when the strength of the bone is reduced by disease or age.
o In this case, a force which is within normal limits leads to a fracture.
• Stress fracture
o This occurs when a bone is subjected to a very large amount of force, none of which
alone would be enough to break the bone, then the mechanical structure of the bone
can gradually fatigue and the bone will then break.
o This is particularly a problem for people who repetitively apply force on small bones,
e.g. soldiers from long matches and drills, joggers on pavements in cities.
• Greenstick fracture
o Bones in young people are very flexible.
o They bend and then may buckle or partially break, instead of breaking cleanly when
overloaded (as bones in adults do).
o One characteristic of a greenstick fracture is that there may be a discontinuity in one
cortex of the bone, but not in the other.
Classification by Anatomical Site

• Long bones are divided into three parts: proximal, mid and distal part.
• Fractures can be described in relation to which part of the long bone is affected.
• For example:

Session 19: Introduction to Fractures 141
o Fracture to the distal third
o Fracture to the mid third
o Fracture to the proximal third
Classification by Bone Exposure

• There are two classifications by bone exposure: open and closed.
• An open fracture can be defined as a broken bone that is in contact with the environment,
through the skin.
o The amount of contact can vary from a small puncture wound or laceration in the skin
to a large avulsion of soft tissue that leaves the bone exposed.
o Open fractures are surgical emergencies because of their complications (soft tissue
damage, infection, haemorrhage).
• Closed fracture occurs when there is no contact between fracture fragments and the
environment.
Clinical Presentations and Investigations of Fractures

Clinical Presentation of a Fracture
• Pain and tenderness
• Loss of function
• Deformity
• Abnormal mobility
Investigations for a Fracture

• Radiographic haemoglobin level
• Haemoglobin level (for major fractures like pelvic and femoral)
• Other investigations are determined by the possible cause
Principles of Management of a Fracture
Early Treatment (Neurovascular Problems)

• Principle management of fractures is to deal with life-and limb-saving problems first
o A–Airway
o B– Breathing
o C– Circulation
• Evaluate neurovascular status of the limb.
Reduction of Fractures
• Some fractures may not need reduction, especially if there is minimal displacement or an
impacted stable fracture, which is only slightly displaced.
• Displaced fractures need reduction.
• Closed fracture of the femur needs traction or internal fixation.
• Open fractures need surgical debridement, antibiotics, tetanus toxoid, analgesics and
immobilization (P.O.P cast, external fixator or traction).
Immobilization of Fractures
• Once a fracture has been reduced it needs to be held until it has united by P.O.P cast,
internal fixation, external fixation or traction.

Rehabilitation
• Once the fracture is stabilized, the patient may need help with rehabilitation so that they
can regain their mobility and function.
Complications of Fractures
• Local complications
o Early complications can include: neurovascular injury, infection, and compartment
syndrome (see further explanation of this condition below).
o Late complications can include: malunion, non union, osteonecrosis, osteomyelitis,
post traumatic arthritis and dystrophy.
• Systemic complications
o These include sepsis, deep venous thrombosis, pulmonary embolism, fat embolus,
adult respiratory distress syndrome and hemorrhagic shock.
Compartment Syndrome
• This is defined as increased tissue pressure within a muscle compartment compromising
the blood supply, nerves and the function of structures within that space.
• Acute compartment syndrome (ACS) is serious condition and should be treated as an
emergency.
• The most common areas involved are the anterior and deep posterior compartment of the
leg and the volar forearm compartment.
• Other areas include the thigh, the dorsal forearm, the foot, and the dorsum of the hand.
• Causes
o Tight casts or dressings
o External limb compression
o Burn eschar
o Fractures
o Soft tissue crush injuries
o Arterial injury
• Clinical Presentation
o Pain out of proportion to the injury
o Puffy-tense muscle compartments to palpation
o Parasthesia-decreased sensation
o Paralysis-weakness of the involved muscle groups
o Pallor
o Pulselessness-decreased capillary refill (late finding)
• Management
o Split the cast and dressings, if present
o Elevate the limb
o Observe carefully for improvement
o If signs and symptoms persist, refer for immediate surgical decompression
Instructions
You will work in groups to complete the activity on the worksheet.

Key Points
• A fracture is the interruption of a bone’s wholeness.
• A fracture can be caused by trauma, pathology, stress-bone fatigue or ageing.
• Fractures can be classified according to quality of bone in relation to load, direction of
force, anatomical site, bone exposure, position and management.
• Clinical presentation of a fracture include Pain and tenderness, Loss of function,
Deformity, Abnormal mobility and Altered neurovascular status
• Principles of management of a fracture include: early treatment to prevent neurovascular
problems, reduction of fractures, immobilization of fractures and rehabilitation.
Evaluation
• Define a fracture.
• What is the clinical presentation of a fracture?
• List the complications of a fracture.
References

Instructions:
paper.
3. Discuss the questions together and answer the related questions in the time you are given
Case Information
A 24-year-old female was admitted to the hospital after a motor vehicle accident. She
sustained a right humerus fracture, multiple rib fractures and a contusion over her right lower
leg.
The next morning, she was complaining of severe pain in her right lower leg. Her
temperature was 37.2°C, heart rate was 96/min, respiratory rate was 18/min, and blood
pressure was 140/82 mmHg. Physical examination reveals a tense swelling around the right
calf region. The pain is worsened on palpation and passive movements of the foot.
Neurological examination reveals motor weakness and hypoesthesia of the distal right leg.
Questions:

Session 20: Fractures of the Upper Limb
Learning Objectives
• Describe the fractures of the clavicle, humerus, ulna, radius and carpal bones
• Describe the clinical presentation of fractures of the clavicle, humerus, ulna, radius and
carpal bones
• Identify relevant investigations for fractures of clavicle, humerus, ulna, radius and carpal
bones
• Describe the basic principles of management of fractures of the clavicle, humerus, ulna,
radius and carpal bones
• Explain the complications of fractures of clavicle, humerus, ulna, radius and carpal bones
Fractures of the Clavicle
Introduction
• The clavicle connects the upper limb to the trunk.
• Its sternal end articulates with the manubrium of the sternum at the sternoclavicular joint.
• Its acromial end articulates with the acromion of the scapula at the acromioclavicular
joint.
• The medial two thirds of the shaft of the clavicle are convex anteriorly whereas the lateral
third is flattened and concave anteriorly.
• Fractures of the clavicle are common, accounting for 5-10% of all fractures.
• Males are more commonly affected than females.
• The fracture is usually due to sporting injuries or road traffic accidents.
• The fracture may be caused by direct trauma or indirectly.
• Displaced clavicle fractures can injure subclavian vessels, nerves and lung appex due to
their proximity to the clavicle bone.
• Location of clavicle fractures: approximately 80% of clavicle fractures occur in the
middle third, 15% involve the distal or lateral third, and 5% involve the proximal or
medial third.
Figure 1: Anterior View, Fracture of Clavicle

Session 20: Fractures of the Upper Limb 147
• The patient typically reports a fall onto an outstretched upper extremity, such as a fall
onto a shoulder, or direct clavicular trauma.
• Patient presents with pain and tenderness, especially with upper extremity movement.
• Swelling/oedema can be present.
• Deformity
• Echymosis, especially when displacement is severe, causes tenting of skin.
• Bleeding from open fracture is rare but possible.
• If there are decreased breath sounds on auscultation, this indicates possible
pneumothorax.
• There can be decreased pulses or evidence of decreased perfusion on vascular
examination, suggesting vascular compromise.
• There is possible diminished sensation or weakness on distal neurovascular examination,
suggesting neurologic compromise.
• There can be non- or limited use of the arm on the affected side.
Investigations
• Routine clavicle radiography
o A fracture is usually demonstrated on an anteroposterior (AP) view.
o Other tests may be required when clinically indicated to assess the possibility of life-
threatening associated injuries.
Chest radiography is recommended if pneumothorax is suspected.
Management of a Fracture of Clavicle

• The vast majority of clavicle fractures are treated conservatively with the limb rested in a
broad arm sling (as shown below).
• Mobilisation can be commenced as comfort allows, with a return to full activities within
3-6 weeks.
• Malunion is common but is not usually a functional problem.
• Non-union may occur in up to five percent of fractures and is more common after high-
energy mechanisms such as road traffic accidents.
• Refer the patient if there are open fractures associated, neurovascular injuries, or fractures
of the lateral end of the clavicle with significant displacement of the fragments or non-
union.
Figure 2:Splints of Upper Limb: Triangular Armsling
• Using a triangular bandage,

flex the elbow joint of the
injured limb at an angle of
approximately 90º.
• Place the triangular arm
sling supporting the upper
limb and tie the bandage
around the neck.
Source: WHO, 2003

Complications of a Fracture of Clavicle
• Brachial plexus compression can occur resulting from hypertrophic callus formation (may
cause peripheral neuropathy).
• Delayed union or non-union can occur (especially with distal third fractures).
• Poor cosmetic appearance can occur.
• Posttraumatic arthritis can occur.
• Intrathoracic injury:
o As with first rib fractures, great force is necessary to cause proximal third clavicle
fractures; it is important to exclude underlying injuries.
o Pneumothorax can occur.
o Subclavian artery and vein injury can occur.
o Internal jugular vein injury can occur.
o Axillary artery injury can also occur.
Fractures of the Humerus
Proximal Humerus Fractures

• Fractures of the proximal humerus result from direct or indirect trauma and are classified
by the anatomical region injured, which are the greater tuberosity, surgical neck and
anatomic neck.
Figure 3: Fracture of Greater Tuberosity Figure 4: Surgical Neck Fracture
Source: WHO, 2003
o Suspect the diagnosis from the history of trauma.
o Physical findings include pain, swelling and loss of motion of the shoulder joint.
• Investigations
o X-rays (AP and lateral views) to confirm the type of fracture.
• Management
o Immobilize non-displaced fractures in a sling and swath.
o Begin mobilization of the shoulder joint within a few days.
o Treat displaced fractures and fracture dislocations by closed manipulation under
anaesthesia.
o If the reduction is not acceptable, refer for surgical treatment.
o Begin motion as soon as the patient can tolerate hanging arm exercises.
o Begin active motion against gravity or with weights when the fracture has healed.
Note: This is usually at 6–8 weeks.

Humeral Shaft Fractures
• Fractures of the shaft of the humerus are the result of direct trauma or rotational injuries.
• The radial nerve wraps around the posterior midshaft of the bone and is injured in about
15 percent of humeral shaft fractures.
Figure 5: Humeral Shaft Fracture and Pattern of Radial Nerve
Source: WHO, 2003
o Suspect the diagnosis from the history of trauma.
o Physical findings include tenderness, deformity and instability of the bone.
• Investigations
o X-rays (AP and lateral views) to confirm diagnosis, but are most useful in judging the
position and healing of the fracture during treatment.
o Always check the radial nerve function before and after fracture reduction.
• Management
o Treat with closed reduction and apply a POP splint.
o It is not necessary for the alignment to be anatomical; a few degrees of angulation or
rotation will not impair function.
o Radial nerve palsy (presents with a wrist drop) is not associated with an open fracture.
This will resolve in most cases.
o Splint the wrist in extension, and begin passive extension exercise until motor
function returns
o See Figure 6 below for image of splinting.
Figure 6: Splinting of the Fractured Humeral Shaft
Source: WHO, 2003

Supracondylar Fractures of the Humerus
• Fracture patterns include:
o Supracondylar
o Intercondylar
o Fractures of the medial and lateral epicondyles
o Isolated fractures of the capitulum and trochlea
o History of trauma
o Physical findings: swelling, tenderness about the elbow and pain with attempted
motion, deformity is often masked by swelling
o Evaluate the neurological and vascular status of the arm; arterial injuries lead to
compartment syndrome in the forearm and are associated with:
Extreme pain
Decreased sensation
Pain with passive extension of the digits
Decreased pulse at the wrist
Pallor of the hand
• Investigations
o X-rays (AP and lateral views) to confirm diagnosis.
• Management
o Perform a closed reduction, using longitudinal traction on the extended arm, followed
by flexion at the elbow with anterior pressure on the olecranon.
o Monitor the pulse during the reduction.
o If it decreases, extend the elbow until it returns, and apply a posterior splint in this
position.
o Check the reduction by X-ray.
o If a satisfactory reduction cannot be obtained, refer the patient for internal fixation.
Forearm Fractures
• Forearm fractures are caused by direct trauma or by a fall on the outstretched arm with an
accompanying rotatory or twisting force.
• One can have a fracture of the radius or ulna alone, or both.
• Fractures of both the ulna and the radius are the result of severe injury.
• A direct injury usually produces transverse fractures at the same level, often in the middle
third of the bones.
• Because the shafts of these bones are firmly bound together by the interosseous
membrane, a fracture of one bone is likely to be associated with dislocation of the nearest
joint.
Olecranon Fractures
• Olecranon fractures result from a fall on the tip of the elbow.
• The triceps muscle pulls the fracture fragments apart

Figure 7: Olecranon Fracture
Source: WHO, 2003
o Usually there is a history of trauma.
o Physical examination can show swelling about the olecranon and a palpable gap at the
fracture site.
o Examine the ulna nerve function.
• Investigation
o X-rays (AP and lateral views) to diagnose the fracture and associated injuries.
• Management
o Treat non-displaced fractures in a splint with the elbow at 90 degrees.
o Refer displaced fractures for surgical management.
Fractures of the Radial Head and Neck

• The radial head is important for pronation and supination of the forearm as well as for
flexion and extension motions at the elbow.
• Fractures are classified by the articular involvement.
Figure 8: Fractures of the Radial Head and Neck
Source: WHO, 2003
o There is usually a history of trauma.
o Patients have pain and swelling over the lateral aspect of the elbow.
o Some motion remains in minimally displaced fractures.
• Investigation
• Management
o Treat fractures with minimal displacement in an arm sling and begin motion when
comfortable.
o To reduce displaced fractures of the radial neck:
Place your thumb over the radial head and apply longitudinal traction with a varus
stress to the arm.

Gently rotate the forearm while applying medial pressure with your thumb to the
radial head.
Place the arm in a long arm splint.
Begin motion out of the splint at 3 weeks.
Treat comminuted or displaced intra-articular fractures with early motion.
If available, alternatives are surgical stabilization or radial head excision.
Monteggia Fractures
• Involve the proximal ulna with dislocation of the radial head, usually in the anterior
direction.
Figure 9: Monteggia Fractures
Source: WHO, 2003
Galeazzi Fractures
• A fracture of the distal radius and a dislocation of the radial-ulnar joint at the wrist.
• The radius fracture is usually oblique, causing the bone to shorten
Figure 10: Galeazzi Fractures
Source: WHO, 2003
o There is often a history of direct trauma or a fall on the outstretched arm.
o The forearm is swollen and tender, with limited motion.
o Evaluate vascular function by checking pulse, capillary refill and skin temperature of
the hand.
o Check sensory and motor function of the radial, median and ulnar nerves.
• Investigations
• Management
o Midshaft fractures may involve one or both bones; treat single bone fractures with
minimal displacement in a long arm cast, with the elbow at 90 degrees and the
forearm in neutral rotation.

o Treat displaced fractures by closed reduction and application of a long arm splint;
perform the reduction by applying traction to the fingers and manipulating the
forearm with the elbow bent to 90 degrees.
o Apply counter-traction above the bent elbow.
o Reduce Monteggia fractures as described for displaced fractures.
o Apply a long arm cast in supination.
o It is possible to obtain a satisfactory reduction in children, but adults often require
surgical management.
• Treat Galeazzi fractures as described for midshaft fractures.
• They are unstable and often need surgical stabilization.
• Rehabilitation
o Begin motion out of the cast at 6-8 weeks.
Distal Radius Fractures

• This includes Colle`s, Smith and Burton fractures.
• Fractures of the distal radius occur with a fall on the outstretched hand.
• Colles fracture occurs at distal end of radius 2cm from the wrist joint.
• There is a dorsal angulation of the distal fragment, impaction, rotation, dislocation of the
radial- ulna joint and radial deviation.
• The direction of the deformity depends on the position of the wrist at the time of impact.
Figure 11: Colles Fracture (Dinner Fork Deformity)
o There is often a history of a fall on the outstretched hand.
o Physical examination shows swelling and tenderness about the wrist and the presence
of deformity.
o Evaluate tendon function, vascular supply and sensation in the hand.
• Investigation
o X-rays distinguish radius fractures from carpal injuries and determine if the fracture is
adequately reduced.
• Management: the goal of fracture treatment is to restore the normal anatomy.
o Anaesthetize for closed reduction.
o Reduce the fracture by placing longitudinal traction across the wrist and apply
pressure to the distal radial fragment to correct the angular deformity.

o For fractures that are dorsally angulated (Colle’s fractures), this is accomplished by
wrist flexion and slight ulna deviation.
o Apply Colle’s POP to maintain the fracture position.
o Three point moulding involves application of pressure above and below the fracture
and counter pressure on the opposite side of the bone near the fracture apex.
o Conduct a control X- ray to check the fracture position after 1 week.
o Healing takes about 6 weeks.
o If a satisfactory position of the fracture fragments cannot be obtained or maintained,
refer the patient for open reduction and internal fixation.
Figure 12: Reduction of Colles Fracture
Source: WHO, 2003
Carpal Fractures and Fracture Dislocations

• Injuries to the carpal bones fall into three major categories:
o Scaphoid fractures
o Trans-scaphoid perilunate fracture/dislocations
o Perilunate dislocations
The scaphoid bone bridges the proximal and distal rows of carpal bones, making it
especially vulnerable to injury.
Most commonly, fractures occur at the waist but may also involve the proximal or
distal pole.
Perilunate dislocations occur with or without an accompanying scaphoid fracture.
The lunate stays in a volar position while the remaining carpal bones dislocate
posteriorly

Figure 13: Scaphoid Fracture
o There is often a history of trauma.
o Physical findings include that the wrist appears swollen and painful to move.
o Scaphoid fractures are tender in the anatomic snuff box and over the scaphoid
tubercle on the volar aspect of the wrist. (Pain occurs primarily on the lateral side of
the wrist, especially during dorsiflexion and abduction of the hand).
o If a perilunate dislocation has occurred, these findings are diffuse about the wrist.
• Investigations
o X-rays are necessary to make a definitive diagnosis.
o Initial radiographs of the wrist may not reveal a fracture, but radiographs taken 14
days later reveal a fracture because bone resorption has occurred.
o Union of the fractured parts may take several months due to the poor blood supply to
the proximal part of the scaphoid.
o In perilunate dislocations, the lateral X-ray shows an anteriorly displaced lunate bone,
with its concavity facing forward.
o The carpus is shortened and the proximal margin of the capitate does not articulate
with the concavity of the lunate.
• Management
o Treat scaphoid fractures with minimal displacement in a thumb spica splint or cast.
o Healing time is between 6 and 20 weeks.
o Perilunate dislocations require reduction followed by placement in a long arm thumb
spica splint.
o The reduction is usually unstable over time and most patients will need surgical
stabilization.
Key Points
• Most of the clavicular fractures are treated conservatively.
• The most significant complications of humeral shaft fractures are radial nerve injury and
non-union.
• Supracondylar fractures of the humerus are complex, unstable fractures.
• For supracondylar fractures, refer displaced intra-articular fractures for surgical treatment.
• Forearm fractures are complex fractures (midshaft, Monteggia, Galeazzi).
• The distal radius is one of the most common upper extremity fractures.

• Treatment of distal radius is usually by closed reduction and application of a U-shaped
splint POP.
• Carpal injuries result from a fall on the outstretched hand in hyperextension.
• Diagnosis of carpal injuries is difficult and is often overlooked; adequate X-rays are
necessary for accurate diagnosis.
• Closed reduction is the initial treatment for carpal injuries, but surgical stabilization may
be necessary.
Evaluation
• What are the complications of clavicular fracture?
• Define Colles, Monteggia, and Galeazzi fractures.
References
• Hutchison C. (2000). Review Notes and Lecture Series. MCCQE.

Session 21: Fractures of the Lower Limb
Learning Objectives
• Describe fractures of the pelvis, femur, tibia, patellar and foot
• Describe clinical presentation of the fracture of pelvis, femur, tibia, patellar and foot
• Identify relevant investigations for fractures of the pelvis, femur, tibia, patellar and foot
• Describe management of fractures of the pelvis, femur, tibia, patellar and foot
Pelvic and Acetabular Fractures
Introduction and Classification of Pelvic Fractures

• Pelvic fractures occur as a result of high-energy trauma and are frequently accompanied
by injuries to the genitourinary system and abdominal organs.
• Most common fracture involves the pubic rami, followed by ilial, ischial, acetabular,
coccygeal and sacral bones.
• Internal blood loss caused by fracture of the pelvis and soft organ damage causes
hypovolaemic shock.
• Pelvic fractures can be classified into:
o Type A
Stable
Minimally displaced
Includes avulsion fractures and fractures not involving pelvic ring, e.g. rami
fracture
o Type B
Partially unstable
Rotationally unstable, but vertically stable, e.g. “open book” fracture from
external force to pelvis
o Type C
Unstable
Rotationally and vertically unstable
Associated with rupture of ipsilateral ligaments e.g. vertical shear fracture
Figure 1: Classification of Pelvic Fractures
Source: Hutchison, 2000

Session 21: Fractures of the Lower Limb 159
Clinical Presentation of Pelvic Fractures
• Physical findings:
o Flank ecchymosis
o Labial or scrotal swelling
o Abnormal position of the lower extremities
o Pain with pelvic rim compression
• Remember to focus on a systemic examination of the whole patient.
• If the fracture is unstable, you will feel differential motion of the pelvic components when
gently manipulating them.
• Place your hands on the iliac wings and gently rock the pelvis.
Investigation of Pelvic Fractures

• Confirm the diagnosis with an anterior-posterior view X-ray of the pelvis.
Management of Pelvic Fractures

• Primary survey
o Airway, Breathing and Circulation
o Focus the initial management on general resuscitation efforts.
o Manage stable pelvic fractures with bed rest and analgesics.
o Stable fractures are rarely associated with significant blood loss.
• Unstable fractures
o Unstable fractures are associated with visceral damage and there is often significant
bleeding.
o Manage as an emergency procedure:
Place compression on the iliac wings, using a sheet or sling to close the pelvic
space and tamponade active bleeding (Figure 2).
Treat with a pelvic sling and/or traction on the leg to reduce the vertical shear
component of the fracture.
Maintain the traction until the fracture has consolidated.
This usually takes 8-12 weeks.
Note: Most pelvic fractures are refered to the district hospital
Figure 2: Compression on the Iliac Wings Using a Sheet
Source: WHO, 2003
Acetabular Fractures
• The fracture disrupts the congruence of the femoral head with the acetabulum and causes
damage to the articular surface.
• A small number of fractures will be combined acetabular and pelvic ring injuries.
Clinical Presentations of Acetabular Fractures

• History and physical findings are similar to those in pelvic ring fractures.
• Evaluate and treat hypovolaemic shock and visceral organ damage as an emergency.
• Evaluate sciatic nerve function and look for an associated femoral shaft fracture.

Investigations of Acetabular Fractures
• Anterior-posterior pelvic X-ray.
Management of Acetabular Fractures

• Minimally displaced fractures
o Treat minimally displaced fractures with bed rest and gradual mobilization.
o When comfortable, begin partial weight bearing until fracture healing has occurred.
This usually takes about 12 weeks.
• Displaced and unstable fractures
o Treat displaced and unstable fractures with traction to maintain the alignment of the
femoral head with the weight-bearing portion of the acetabulum.
o If a satisfactory position cannot be maintained, or if there are bone chips within the
hip joint, refer for surgical stabilization.
Fractures of the Femur

Fractures of the Proximal Femur (Hip Fractures)
• Hip fractures in elderly people with osteoporotic (weak) bones frequently occur following
simple falls (muscles stronger than bone).
• Hip fractures occur more frequently in females than in males.
• In younger people, a moderately severe trauma is required to produce a fracture in this
region.
Classification
• Subcaptal (intra-capsular fractures)
• Intertrochanteric (extra-capsular fractures)
• Subtrochanteric (extra-capsular fractures)
o In intra-capsular fractures, the blood supply to the femoral head is disrupted.
o This may lead to the secondary complication of avascular necrosis of the femoral
head.
Figure 3: Blood Supply to Femoral Head and Fracture Classification
Source: Hutchison C., 2000

Clinical Examination
• History of trauma, pain about the hip and inability to bear weight on the extremity.
• The physical examination reveals a leg that is shortened and externally rotated.
• The pain is made worse by attempted motion of the hip, especially with rotation.
Investigation
• Confirm diagnosis by X-ray ( AP view)
• Full blood picture
Management
• Intra-capsular fractures
o Treat non-displaced or impacted fractures with light skin traction and a gentle range
of motion until the fracture has healed; this will be in about 8-12 weeks.
o Displaced fractures should initially be placed in light traction for a few weeks to
control pain, and then the patient can begin sitting and walking with crutches.
o Refer for surgery
• Extra-capsular fractures
o Treat with Perkin’s traction or refer for surgical fixation.
o Perkin’s traction will maintain the fracture position while permitting the patient to sit
up to move the knee and hip joint, preventing pressure sores and pneumonia.
Femoral Shaft Fractures

• Fractures of the shaft of the femur can occur in any age group.
• In the adult a shaft fracture of femur is usually associated with a high-energy injury such
as a motorcycle crash.
• In the elderly this fracture is again associated with pathological fractures secondary to an
osteolytic lesion.
• It is unusual for this fracture to be associated with neurovascular damage, but in a high-
velocity accident in a young adult this must always be considered.
Causes of Fractures of the Shaft of the Femur

• In adolescents, usually high-velocity injury
• In the elderly, may be pathological
• History of major trauma and the physical findings of swelling, pain, angular or rotational
deformity or abnormal motion at the fracture site.
• Examine the skin and soft tissue on all sides of the limb to check for possible open
fractures.
• Evaluate the neurological and vascular status for injury to the sciatic nerve and the
femoral artery.
Investigations
• Confirm the diagnosis with X-rays of the entire femur, including the proximal and distal
joints.

Management
• In infants, use gallows traction.
• In children and adolescents, use skin traction.
• In adults and the elderly, use skeletal traction or internal fixation.
Refer to Handout 21.1: Tractions
• Fractures of the shaft of the femur heal very quickly in children and the fracture can be
stabilised with non operative means.
• In children under the age of 2 years, vertical skin traction (gallows traction) can be used
to hang the legs off the bed.
• In the young child the femur is capable of considerable remodelling, so a perfect
reduction is not necessary.
• A fractured femur in an adolescent can be managed on traction or on static traction using
a splint.
• If traction is applied through a tibial pin, care must be taken not to apply the traction for
too long as there is a risk of causing stretching of the ligaments around the knee.
• This produces a permanently lax and unstable knee (a frame knee).
• Great care must be taken to watch that the femur does not fall into varus at this stage.
• Traction for fractured mid-shaft femur can also be used in the adult but requires that the
patient stay in bed for 12-16 weeks.
• Refer for internal fixation.
Distal Femoral Fractures

• Supracondylar fractures occur just above the knee joint.
• The distal fragment angulates posteriorly because of the pull of the gastrocnemius muscle
at its attachment on the posterior aspect of the distal femur (Figure 4A).
• Intra-articular fractures occur as either a single femoral condyle fracture (Figure 4B) or as
a supracondylar fracture with extension distally into the joint (Figure 4C).
• There are many different patterns of fracture, but commonly a fracture line enters the
knee joint through the intercondylar notch creating an unstable Y shaped fracture.
• In the elderly, neurovascular compromise is unusual, but in the young, high-velocity
accident may easily damage the popliteal vessels and nerves that lie close to the fracture.
Figure 4: Distal Femoral Fractures

A B C
Source: WHO, 2003
Clinical Presentations
• There is a history of a high-energy injury.

• Physical findings include swelling and deformity just above the knee.
• Check sensation, motor power and the vascular status of the leg and foot.
Investigations
• X-rays are necessary to confirm the diagnosis and to evaluate articular surface injury.
Management
• Non-displaced fracture:
o Treat non-displaced fractures in a long leg cast without weight bearing.
• Displaced fractures:
o Treat displaced fractures in skeletal traction using a tibial pin.
o Flexing the knee will help to reduce the angular deformity of the distal femur.
o This is done with pillows under the knee, balanced suspension.
o When the fracture is united (at 4-6 weeks), transfer the patient to a long leg cast or
cast brace with knee hinges.
o Begin weight bearing at 3 months when the fracture is solidly healed.
o Popliteal artery injuries require immediate surgical correction if the limb is to be
saved.
Patella Fractures
• The fracture of the patella will displace if the quadriceps tendon is torn and the
quadriceps muscle pulls the fragments apart.
• Lateral patella dislocations follow a direct force to the medial side of the bone or from a
twisting injury in a developmentally unstable patella.
• To reduce the dislocation, place the knee in extension and push the patella medially.
• There is a history of trauma directly over the anterior knee.
• Physical findings include swelling and pain.
• If the fracture is displaced, the patient is unable to extend the leg and a gap is often
palpable between the displaced fragments.
• A rupture of the quadriceps tendon proximal to the patella, or to the patella tendon distal
to it has similar physical findings.
Investigation
• X-rays (Anterio- posterior and lateral views).
Management
• Undisplaced fracture patella can be managed conservatively by a cylinder cast for 3-6
weeks.
• Refer displaced fracture patellar for internal fixation.
Fractures of the Tibia

• Tibial plateau fractures result from a vertical or lateral force driving the femoral condyles
into the tibial articular surface of the knee.
• The most unstable fractures involve both plateau and cross the tibial shaft.
• The knee is swollen, painful and shows deformity at the location of the injury.

• Perform a careful examination of the neurological and vascular functions at the foot and
ankle.
• Injury to the popliteal artery requires immediate repair if the leg is to be saved.
Investigation
• X-rays determine the location of the fracture and indicate the treatment.
Management
• Non-displaced fractures
o Treat non-displaced fractures, and fractures with less than 5 mm of articular surface
depression, in a POP.
Refer to Handout 21.2: POP Application and Removal
o Keeps the patient non-weight bearing for 6 weeks and partial weight bearing with
crutches or a stick for an additional 6 weeks.
• Displaced fractures
o Treat displaced or unstable fractures by closed reduction followed by a cast, calcaneal
traction or refer for surgical reduction and internal fixation.
Tibial Shaft Fractures

• Fractures in this region are often open because of the proximity of the anterior tibia to the
skin surface.
• Fracture patterns include: (Figure 5)
o Spiral fractures, from low energy injuries (A)
o Short oblique fractures (B)
o Transverse fractures (C).
Figure 5: Patterns of Tibial Shaft Fractures
• The amount of soft tissue (skin,

muscle, nerve, and artery) damage
influences the rate of healing and
the chance of subsequent infection.
Source: WHO, 2003
• Inspect the skin closely for any wounds.
• Full thickness breaks in the skin indicate an open fracture and you should prepare for
debridement and lavage of the fracture.
• During the initial examination, check the neurological and vascular function to the foot.
Signs of a developing compartment syndrome include:
o Increasing pain
o Coolness and pallor of the foot and toes

o Pain with passive extension or flexion of the toes or ankle
o Increasing tight feeling in the compartments in the calf
• Treat with surgical release as soon as possible.
Note: If acute compartment syndrome develops treat immediately.
Management
• Immediately debride open fractures.
• Reduce tibial fractures by hanging the leg over the end of the examination table and apply
longitudinal traction.
• Place the limb in a long back slab with the knee in 10-20 degrees of flexion.
• In 2-3 weeks, remove the slab and apply a long leg cast.
• Recheck the patient about every three weeks.
• X-rays are useful to check the position of the fracture and the extent of healing.
• The healing time for uncomplicated tibial fractures is about six months.
• Refer open fractures that require skin grafts and unstable comminuted fractures for
external fixation after initial debridement.
Tarsal Bones Injuries
Talus Fractures
• Talar neck fractures result from an axial load which forces the foot into dorsiflexion.
• The neck of the talus is pushed against the anterior tibia, fracturing the neck (Figure 6).
• Continuation of this force produces a dislocation of the subtalar joint as the body of the
talus extrudes posterior medially from the ankle joint.
Figure 6: Talus Fracture
Source: WHO, 2003
• There is a history of a dorsiflexion injury.
• Physical findings include swelling and pain about the ankle and hind foot.
Investigation
• Obtain ankle and foot X-rays to confirm the location and extent of the fracture.

Management
• Treat minimally displaced fractures in a splint followed by a short leg nonweight bearing
cast for 6-8 weeks.
• Reduce displaced fractures with gentle longitudinal traction, pulling the heel forward and
dorsiflexing the foot.
• Next, evert the foot and bring it into plantar flexion to align the major fragments.
• Apply a short leg cast.
• If the talus is dislocated, apply direct pressure over the extruded fragment during the
reduction manoeuvre.
• Refer the patient with gross displaced fracture for surgical management.
Calcaneus Fractures
• Calcaneous fractures result from a vertical load force driving the talus downward into the
subtalar joint and the body of the calcaneus (Figure 7A).
• Avulsion fractures of the calcaneal tuberosity are produced by the contracting Achilles
tendon (Figure 7B).
• These fractures usually do not enter the subtalar joint and have a better prognosis.
Figure 7: Calcaneus Fractures
A B
Source: WHO, 2003
• The physical examination reveals swelling and tenderness about the hind foot.
Investigation
• X-rays will confirm diagnosis.
Management
• Treat calcaneal fractures with a compression dressing, short leg splint and elevation.
• Keep the patient from bearing weight on the affected limb.
• Encourage toe and knee motion while the limb is elevated.
• Begin partial weight bearing 6–8 weeks after the injury and full weight bearing, as
tolerated, by 3 months.
Fracture Dislocation of the Tarsal-Metatarsal Joint

• The injury causes dislocation of the tarsal-metatarsal joints and fractures of the
metatarsals and tarsal bones.

Figure 8: Fracture Dislocation of the Tarsal-Metatarsal Joint
Source: WHO, 2003
• Deformity is often not evident because of the large amount of swelling present.
Investigation
• On the X-ray, the medial borders of the second and fourth metatarsals should be aligned
with the medial borders of the second cuneiform and the cuboid respectively.
Management
• Perform a closed reduction to return the mid-foot to the anatomic position.
• Apply a short leg splint and ask the patient to keep the limb elevated.
• If reduction cannot be attained or maintained refer for surgical stabilization with pins or
screws.
Fractures of the Metatarsals and Toes

• Clinical findings are tenderness and swelling.
• Deformity is not always evident.
• X-rays confirm diagnosis.
• Overuse fractures (stress fractures) occur in the metatarsal bones.
• The patient has pain and tenderness but no history of acute trauma.
Management
• Treat dislocations and angulated fractures with closed reduction.
• Immobilize metatarsal fractures in a firm bottom shoe or a short leg cast.
• Treat toe fractures and dislocations by taping the toe to a normal adjacent toe (Figure 9).
• Treat stress fractures by limiting the amount of time the patient spends on his/her feet.
• If necessary, use a firm shoe or cast until pain-free.
Figure 9: Stabilization of the Fractured Toe
Source: WHO, 2003
Key Points
• Pelvic ring fractures result from high-energy trauma and are classified as stable or
unstable.
• Unstable fractures are associated with significant blood loss and multiple-system injury.

• Femoral shaft fractures result from high-energy trauma and are often associated with
other significant injuries in children the fracture heals faster, ambulate early to avoid joint
stiffness and open fractures are common and require immediate debridement.
• Fractures of the metatarsals and toes are common injuries resulting from minor trauma.
Evaluation
• What are the complications of pelvic and femur fractures?
References
• Bewes P. (1984). A Manual for Rural Health Workers Nairobi: African Medical and

Handout 21. 1: Tractions
Skin Traction
• Skin traction requires pressure on the skin to maintain the pulling force across the bone.
• A maximum of 5 kg of weight may be applied using this method.
• More than 5 kg of weight will result in the skin becoming excoriated with blister
formation and pressure sores caused by slipping of the tightly wrapped strapping.
• Wrapping the straps more tightly to prevent slipping increases the risk of creating a
compartment syndrome in the injured extremity.
• If more than 5 kg of weight is needed to control the fracture, use skeletal traction instead.
• Do not apply traction to skin with abrasions, lacerations, surgical wounds, ulcers, loss of
sensation or peripheral vascular disease.
Technique
• Clean the limb with soap and water and dry it.
• Measure the appropriate length of adhesive strapping and place it on a level surface with
the adhesive side up. Ask the patient about adhesive tape allergy before applying.
• Place a square wooden spreader of about 7.5 cm (with a central hole) in the middle of the
adhesive strapping (Figure 1 below).
• Gently elevate the limb off the bed while applying longitudinal traction.
• Apply the strapping to the medial and lateral sides of the limb, allowing the spreader to
project 15 cm below the sole of the foot (Figure 2 below). Pad bony areas with felt or
cotton-wool.
• Wrap crepe or ordinary gauze bandage firmly over the strapping (Figure 3 below).
• Elevate the end of the bed, and attach a traction cord through the spreader with the
required weight (Figure 4 below).The weight should not exceed 5 kg.
Complications
• Allergic reactions from the adhesive material
• Blister formation and pressure sores from slipping straps
• Compartment syndrome from over-tight wrap
• Peroneal nerve palsy from wraps about the knee
Figure 1

Figure 2
Figure 3
Figure 4
Source: WHO, 2003
Skeletal Traction
• Apply skeletal traction by placing a metal pin through the metaphyseal portion of the
bone and apply weight to the pin.
• It is important to place the pin correctly to avoid injury to vessels, nerves, joints and
growth plates.
• The amount of weight to be used depends on the fracture but, generally, between 1/10 and
1/7 of body weight is safe and adequate for most fractures.
Technique
• Wash the skin with antiseptic solution and cover the surrounding area with sterile drapes.
• Infiltrate the skin and soft tissues down to the bone with 1% lidocaine on both the
entrance and exit sides.
• Make a small stab incision in the skin and introduce the pin through the incision
horizontally and at right angles to the long axis of the limb.
• Proceed until the point of the pin strikes the underlying bone (Figure 5 below).
• Ideally, the pin should pass through the skin and subcutaneous tissue, but not through
muscles.
• Insert the pins with a T-handle or hand drill (Figure 6 below).
• Advance the pin until it stretches the skin of the opposite side and make a small release
incision over its point (Figure 7 below).
• Dress the skin wounds separately with sterile gauze.
• Attach a stirrup to the pin, cover the pin ends with guards and apply traction (Figure 8).
• Apply counter-traction by elevating the appropriate end of the bed or by placing a splint
against the root of the limb.

Sites of Pin Placement
• Proximal tibia
o Insert the pin 2 cm distal to the tibial tubercle and 2 cm behind the anterior border of
the tibia (Figure 5 below).
o Begin on the lateral side to avoid the common peroneal nerve.
• Calcaneus
o Insert the pin 4.5 cm inferior and 4 cm posterior to the tip of the medial malleolus
(Figure 6).
o Begin on the medial side to avoid damage to the posterior tibial artery and nerve and
to avoid entering the subtalar joint.
Figure 5 Figure 6
Figure 7 Figure 8
Source: WHO, 2003

Handout 21.2: POP Application and Removal
Cast Application
• Clean the skin and apply dressings to any wounds.
• Next, apply a uniform thickness of cotton padding over the skin and put extra padding
over any bony prominence such as the patella, the elbow or the ankle
• Soak the plaster roll in a pail containing water at room temperature. Do not use warm
water as the heat given off by the plaster as it sets may burn the patient. Leave the plaster
in the water until it is completely soaked and the air bubbles cease to rise.
• Gently pick up the ends of the bandage with both hands and lightly squeeze it, pushing
the ends together without twisting or wringing.
• While applying the plaster, hold the relevant part of the body steady in the correct
position. Movement will cause ridges to form on the inside of the plaster. Work rapidly
and without interruption, rubbing each layer firmly with the palm so that the plaster forms
homogenous mass rather than discrete layers.
• Apply the plaster by unrolling the bandage as it rests on the limb. Do not lift it up from
the patient or apply tension to the roll. Overlap the previous layer of plaster by about half
the width of the roll.
• Mould the plaster evenly around the bony prominences and contours.
• Leave 3 cm of padding at the upper and lower margins of the cast to protect the skin from
irritation by the edge of the cast. This can be folded back over the edge and incorporated
in the last layer of plaster to provide a smooth edge.
• Mould the cast until the plaster sets and becomes firm. Complete drying takes 24 hours so
advise the patient to take care not to dent the cast or apply weight to it during this time.
Removing a Cast
• Remove the cast with an oscillating electric cast saw, if available, or with plaster shears.
• Make two cuts along opposing surfaces of the cast, avoiding areas where the bone is
prominent.
• Begin cutting at an edge, then loosen the cast with a plaster spreader.
• Complete the division of the plaster and the padding with plaster scissors, being careful
not to injure the underlying skin.
• Under difficult conditions, or if the patient is a child, soften the plaster by soaking it in
water, or water with vinegar added, for 10-15 minutes and then remove it like a bandage.
Source: WHO, 2003

Session 22: Pyogenic Osteomyelitis and HIV in
Surgery
Learning Objectives
• Define pyogenic osteomyelitis
• Describe causes and pathophysiology of pyogenic osteomyelitis
• Classify pyogenic osteomyelitis
• Describe clinical presentation of pyogenic osteomyelitis
• Identify relevant investigations for pyogenic osteomyelitis
• Identify differential diagnosis of pyogenic osteomyelitis
• Describe management and complication of pyogenic osteomyelitis
• Explain how HIV can be transmitted during surgery
• Identify strategies to prevent the transmission of HIV during surgery
Definition, Causes and Classification of Osteomyelitis

• Ostemyelitis: Infection of bone and bone marrow.
Causes
• Many bacteria can be implicated; In Tanzania most commonly due to Staphylococcus
aureus, streptococci, Salmonella species and Mycobacterium tuberculosis.
• Coagulase negative staphylococci and other bacteria can be involved in post-operative
and hardware –associated infections.
Route of Transmission
• Direct inoculation from an overlying wound or via an open fracture or operation
• Haematogenous spread from another infected site
Classification
• Acute
• Chronic
• Another classification scheme: proposed by Chierny and Mader
o Stage 1 – marrow involvement
o Stage 2 – superficial (osteitis)
o Stage 3 – through the cortex but with bone integrity maintained
o Stage 4 – through both corticies and bone integrity lost
Figure 1: Osteomyelitis
Source: www.bsac.org.uk

Session 22: Pyogenic Osteomyelitis and HIV in Surgery 175
Pathophysiology of Osteomyelitis
• The most common organism is staphylococcus aureus and the most common sites of
infection are the femur and tibia.
• Haematogenous infections begin with the lodging of bacteria in the post capillary
sinusoids on the metaphyseal side of the epiphyseal plate.
o Haematogenous osteomyelitis in children and young adults usually involves the long
bones before the epiphyseal plates have completely ossified.
o In adults haematogenous osteomyelitis commonly involves the vertebral bodies and
can be associated with spinal epidural abscesses
• The organisms proliferate in this area of sluggish circulation, forming an intramedullary
infection.
• This is the acute phase.
• If the infection is not treated, it forms an abscess cavity within the bone.
• Pressure within the abscess causes purulent material to penetrate the cortical bone.
• The periosteum is elevated and a subperiosteal abscess forms.
• This marks the physiological beginning of the chronic form of the disease.
• There is usually clinical evidence of soft tissue involvement at this point, with swelling,
redness and tenderness.
• If left untreated, the infection will either drain through the skin to decompress the abscess
and/or dissect under the periosteum, encompassing much of the diaphysis.
o In the case of vertebral body osteomyelitis the infection may track to the epidural
space causing an epidural abscess and cord compression and rapidly lead to paralysis.
• In non-axial (non-spine) infection, the original diaphysis becomes engulfed in the
abscess, is devoid of a blood supply and becomes a sequestrum.
• The most important aspect of this process now occurs: the elevated periosteal sleeve
begins to form new bone which becomes the involucrum
• The integrity of the involucrum determines the final form and function of the limb.
• Injury to the periosteum, either from overwhelming infection or from premature surgical
debridement, results in incomplete involucrum formation and impaired limb morphology.
• The epiphyseal plate might also be injured if the infection is severe.
Acute Osteomyelitis
Clinical Presentation of Acute Osteomyelitis

• Pain
• Fever
• Malaise
• Local swelling
• Limited use of the limb
• There may be a history of sore throat or other intercurrent infection
• Tenderness is greatest in the metaphyseal region of the involved bone
• Movement of neighbouring joints is limited
• With vertebral infection patients will present with back pain and may rapidly progress to
spinal ache (radicular pain) and then symptoms related to cord compression and cord
infarction.

• Acute septic arthritis
• Acute rheumatic arthritis
• Acute poliomyelitis
• Bone tumours
Investigation
• X-ray of the infected bone, (note that this is seldom positive first 2-4 weeks)
• Cultures of blood
• Full blood picture and erythrocytes sedimentation rate
• Administer intravenous antibiotics during initial phase (first 72 hrs).
• Switch to oral antibiotics can occur at any time provided antibiotics with good
bioavailability are an option.
• Duration of treatment is variable and depends on the organism and extent of infection but
is typically at 4-6 weeks if there is not extensive bony destruction.
• Provide anti-pain medication.
• Rest the limb.
• If an abscess forms, the infection is beyond the acute phase and surgical drainage is
necessary.
• Vertebral osteomyelitis can be managed non-operatively provided the spine is not
unstable, there are no neurological symptoms or evidence for cord compression and there
are no large para-vertebral abscesses.
o In cases with progressive neurological symptoms or with imaging demonstrating cord
compression emergent surgical decompression is warranted to prevent spinal cord
infarction and paralysis.
o Tuberculosis spine infection is more indolent than pyogenic bacteria and does not
always require surgical intervention although surgery often leads to more rapid
improvement, more rapid control of the infection, less deformity and may allow
shorter courses of antibiotics.
Complications
• Systemic: septicaemia and pyemia
• Local: chronic osteomyelitis, acute pyogenic arthritis, pathological growth plate
disturbance, pathological fracture.
• With vertebral osteomyeltitis – epidural abscess, spinal cord compression and infarction
and para-vertebral abscesses.
Chronic Osteomyelitis
• May be without signs or symptoms other than minimal persistent swelling of the limb.
• When the infection reactivates, the limb becomes swollen and painful.
• Draining sinus may occur.
• Scar tissue formation may be present.
• There may be deformities.
• Tuberculosis spine osteomyelitis often presents with chronic back pain, a gibbous
deformity and frequently with neurological symptoms.

• Pyogenic vertebral osteomyelitis usually presents as an acute infection although some
bacteria (e.g. Brucella) can present with a more indolent course like tuberculosis.
Investigation
• X-rays findings:
o Cortical thickening
o Brodies abscess
o Sequestrum formation
o Involucrum
o Pathological fracture
Activity: Demonstration
Instructions
The tutor will show you an X ray film of chronic osteomyelitis. After the demonstration you
will briefly discuss and point out the features of chronic osteomyelitis.
Management
• Sequestrectomy and saucerisation
o Delay removal of the sequestrum until the involucrum has matured, which is a process
that takes between 6 and 12 months.
o When the involucrum has formed adequately, the sequestrum can be removed to
control the residual infection.
o After surgery, protect the limb with a cast application.
o Antibiotic use at this stage should be limited to treatment of active soft tissue
infection, systemic illness, locally aggressive infection, or before and after surgical
sequestrectomy.
Complications
• Acute exacerbation
• Growth abnormalities:
o Shortening
o Lengthening
o Deformity
• Pathological fracture
• Joint stiffness
• Sinus tract malignancy
• Vertebral osteomyelitis: neurological deficits
Introduction to HIV in Surgery

• The purpose of infection precautions and aseptic technique is to prevent the transmission
of infection.
• The best protection against HIV and other transmissible infection is attention to every
detail of asepsis, with special care to avoid injury during operation or patient care.
• In some places, prophylactic medications (PEP) are offered after needle stick injury or
other potentially infectious contact.
• Each hospital should have clear guidelines for the management of injury or exposure to
infectious materials.

• Patients infected with the Human Immunodeficiency Virus (HIV) may require surgery to
treat infections and diseases associated with the condition.
• HIV infects white blood cells called CD4 cells.
• Since white blood cells are the main component of the immune system, HIV patients have
an increased risk of developing infections.
• With the introduction of antiretroviral therapy (ART), a combination of anti-HIV drugs,
HIV patients are able to live longer lives.
• As a result, it is possible for HIV patients to require surgical interventions for long-term
conditions.
• Common complications of surgery include bleeding, infections, and nerve damage.
• It has been suggested that HIV patients may have an increased risk of surgical
complications (especially infections) because they have weakened immune systems.
• However, there is currently no scientific data on the prevalence of surgical complications
among HIV patients compared to non-infected patients.
Transmission of HIV in Surgery

Transmission of HIV in the Clinical Setting
HIV can be transmitted by:
• Injury with needles or sharp instruments contaminated with blood or body fluids
• Contact between open wounds, broken skin (for example, caused by dermatitis) or
mucous membranes and contaminated blood or body fluids
• Transfusion of infected blood or blood products
• ‘Vertical’ transmission between mother and child during pregnancy, delivery and breast
feeding
• The use of equipment that has not been properly disinfected, cleaned and sterilized
o Most of the small number of reported infections of health workers with HIV has
resulted from injuries caused by needles (for example, during recapping) and other
sharp instruments.
o After use, always put disposable needles and scalpel blades (‘sharps’) into a puncture-
and tamper-proof container that has been labelled clearly.
o The risk of transmission in the case of any given exposure is related to the prevalence
of the disease in the area, the portal of entry (cutaneous, percutaneous or transfusion)
and the inoculum dose from the exposure.
o Take care of your patients, your co-workers and yourself.
Do not recap needles.
Set up sharps containers in the places where you use sharps; the further you have
to move to dispose of a sharp the greater the chance of an accident.
Do not use the same injection set on more than one patient.
Dispose of your own sharps.
Pass needles, scalpels and scissors with care and consideration.
Prevention Strategies
Infection-Control Precautions
Three methods for preventing perioperative HIV transmission are:
• Implement stringent precaution during surgery
o Reduction of the incidence of intraoperative exposure to blood requires caution and
attention to detail.

o Avoidance of hand-to-hand passage of sharp instruments and increased use of staple
devices instead of suturing are methods that reduce injury.
o Sharp instruments may be placed on a sterile mayo stand positioned between the
scrub nurse and the surgeon, although this practice requires continual diversion of the
surgeon's attention from the operative field.
o Therefore, this method is good for short, low-risk procedures but may be impractical
for longer procedures with the potential for significant blood loss.
o Surgeons often use their fingers to protect underlying viscera, particularly when
closing the abdomen.
o This practice is now outmoded and is potentially dangerous.
o Blunted needles are slowly gaining acceptance for fascial closure.
o The widespread use of laparoscopy has introduced the possibility of release of HIV-
infected blood and peritoneal fluid into the operating room environment during
pneumoperitoneal evacuation.
o Awareness of this potential problem can reduce the risk of HIV transmission.
• Nonoperative treatment of HIV-infected patients.
o Surgeons planning treatment must weigh the risks to the patient against the potential
benefits of surgery.
o If the surgeon weighs the risks and benefits to the patient and believes the procedure
will have a positive effect on the patient's life, he or she should offer surgical
treatment.
• Blood should be treated as an infectious substance
o Contact of patients' blood with the skin and mucous membranes of health care
workers is unacceptable.
o Protective eyewear, masks, and water-impermeable gowns, sleeves, and boots are
standard equipment.
o Wearing two pairs of latex gloves reduces the risk of exposure due to glove defects
from approximately 17% to 5%.
o During procedures involving open fractures, a pair of cloth gloves worn with latex
gloves significantly reduces the risk of exposure.
Key Points
• Bone infections come from haematogenous spread from a distant site, from penetrating
wounds and after surgery.
• Acute infections are treated with antibiotics; once an abscess forms, surgical drainage is
necessary.
• Chronic osteomyelitis is the most common type; a draining sinus and sequestrum are
usually present.
• Removing the sequestrum is necessary to control the infection.
• During surgery, the best protection against HIV and other transmissible infection is
attention to every detail of asepsis, with special care to avoid injury during operation.
Evaluation
• What are the radiological findings of chronic osteomyelitis
• What are the differential diagnoses of an acute osteomyelitis?
• Mention the possible ways of HIV prevention in clinical settings.

References
• Bottles K. et al. (1988). Fine-Needle Aspiration Biopsy of Patients with Acquired
Immunodeficiency Syndrome (AIDS): Experience in an Outpatient Clinic. Ann Intern
Med, 108(1):42-5.
• Shenoy R et al. (2002). A Fine Needle Aspiration Diagnosis in HIV-Related
Lymphadenopathy in Mangalore, India. Acta Cytol, 46 (1):35-9.
• WHO (2003). Surgical Care at District Hospital. Malta: World Health Organization.

Session 23: Shock
Learning Objectives
• Define shock
• Identify different types of shock
• Explain how to conduct a quick assessment of different types of shock
• Describe how to perform life saving management
• Explain how to manage a patient in shock
Definition and Types of Shock

• Shock: A clinical syndrome which follows critical reduction of blood flow within the
microcirculation with inadequate tissue perfusion and oxygen delivery to meet nutritional
requirements of cells and removal of waste products of metabolism.
o If compensation remains inadequate, anaerobic metabolism occurs with lactic
acidosis, irreversible cellular damage, cellular oedema, capillary endothelial damage
and multiorgan dysfunction.
o Five types of shock include hemorrhagic shock, cardiogenic shock, neurogenic shock,
septic shock, and anaphylactic shock.
Hemorrhagic Shock (Also called hypovolaemic shock)

• Loss of blood to the exterior or internal tissues (15-25%). e.g. trauma, haemorrhage,
peritonitis, burns.
• Shock can be due to internal (concealed) or external (revealed) haemorrhage.
• Internal haemorrhage may be concealed as in ruptured spleen or liver, fractured femur,
and ruptured ectopic gestation or cerebral haemorrhage.
• External haemorrhage is a concealed haemorrhage which becomes revealed, for example
hematemesis or melena from bleeding peptic ulcer or hematuria from ruptured kidney.
• Types of Haemorrhage
o Primary haemorrhage is that which occurs at the time of injury or operation.
o Reactionary haemorrhage: may follow primary haemorrhage, within 24 hours (usually
4-6 hours) and is mainly due to rolling (slipping) of a ligature or dislodgement of a
clot. Precipitating circumstances include:
Rise of blood pressure
Restlessness, coughing, and vomiting which raises the venous pressure
o Secondary haemorrhage: occurs after 7-14 days and is due to infection and sloughing
of part of the wall of an artery. Predisposing factors include:
Pressure of the drainage tube
Fragment of the bone
Ligature in an infected area or cancer
Arterial surgery
Amputation
• Note: Hypovolemia may also follow severe body fluid loss found in severe diarhhoea and
vomiting.
Cardiogenic Shock
• This is defined as the inability to pump enough blood to supply all body parts.

Session 23: Shock 183
• Patients may be normovolemic or hypovolaemic.
• Pump failure:
o Inadequate function of the heart
o The heart muscle can no longer generate enough pressure to circulate blood to all
organs
o Causes a backup of blood into the lungs
o Results in pulmonary edema
Neurogenic Shock
• This is defined as shock resulting from inadequate peripheral resistance due to
widespread vasodilation.
• Common causes include:
o Spinal cord injury
o Central nervous system injuries
Septic Shock
• This is caused by severe bacterial infections, toxins, or infected tissues.
• Toxins damage vessel walls, causing them to leak and become unable to contract well.
• This leads to dilation of vessels which results into poor perfusion.
Anaphylactic Shock
• This is defined as a widespread hypersensitivity reaction to a specific antigen resulting in
vasodilation, peripheral pooling, relative hypovolaemia leading to decreased perfusion
and impaired cellular metabolism.
Quick Assessment and Investigation of Shock

• Priorities: (ABC)
o Airway
Maintain a clear airway.
Position the patient in a semi-lateral position.
Extend neck, support jaw and suction.
Administer oxygen by nasal catheter depending on severity.
o Breathing
Ensure normal breathing.
o Circulation
Stop external bleeding.
Do not leave tourniquet on extremities more than 30 minutes.
Insert an intravenous line and take blood for grouping and cross-match.
• Investigations
o Full blood picture- haemoglobin, haematocrit
o Chest x-ray
o Abdominal ultrasound
o Vital signs (blood pressure, pulse, temperature,urine output)
• Diagnosis
It is a clinical diagnosis indicated by the following findings:
o Anxious with air hunger
o Cold crammy sweat
o Cold extrimities
o Prolonged capillary refilling

o Fast, feeble pulse
o Low blood pressure
o May be unconcious
Performing Life Saving Management in Shock

• General management of shock: Airway, Breathing and Circulation
o Ventilate
o Oxygen
o Maintain neck immobilization
• Management of hypovolaemic shock
o Stop the blood loss by pressure and packing.
o Manage various types of non-traumatic haemorrhage, for example epistaxis,
haemoptysis, haematemesis, and obstetrical haemorrhage.
o Volume replacement:
Use large bore IV lines using normal saline or Ringer’s lactate.
In an adult, give 1-2 litres as quickly as possible, followed by maintenance fluid
according to the hydration status of the patient.
In a child, give 20 ml/kg.
Catheterize the patient.
Record fluid input and urine output.
If superficial intravenous line fails perform intraosseous insertion or cut-down.
Refer to Handout 23.1: Venous Cut Down and Intraosseous Puncture
Arrange blood group and cross match early.

A blood transfusion is indicated when bleeding has been controlled or when
haemoglobin is less than 7gm/dl.
Conduct serial measurement of vital signs.
Refer the patient.
• Management of septic shock
o The principles of treatment include support of respiratory function (supplemental
oxygen and circulatory function), social and surgical debridement, and a combination
of parenteral antibiotics covering aerobes and anaerobes, and treatment of
complications, which includes tetanus.
• Management of anaphylactic shock
o Recognize the allergen and stop administration of the allergen (e.g., blood transfusion
or drug).
o Airway: administer oxygen.
o Drugs: adrenaline (1: 1000) 0.5-1.0mg. IM.
o Hydrocortisone 100-500 mg I.
• Management of neurogenic shock
o Atropine and IV fluids.
• Management of cardiogenic shock
o Correct underlying cause
o Cardiac massage if cardiac arrest occurs
Refer to Handout 23.2: Cardiopulmonary Resuscitation
o Oxygen

o Strong analgesics
Managing a Patient in Shock
Instructions
Refer to Worksheet 23.1: Case Study: Managing Patient in Shock
Read the instruction for, and complete the activity, on the worksheet. After 15 minutes you
will share your responses with the larger group.
Key Points
• Shock is inadequate circulatory failure with vasoconstriction and organ failure.
• Shock is classified as haemorrhagic (hypovolaemic), cardiac, septic, neurogenic and
anaphylactic.
• Quick assessment of shock includes Airway, Breathing and Circulation.
• Management differs depending on types of shock.
• Quickly refer patients who have complications.
Evaluation
• What is shock?
• Describe different types of shock.
• Explain life saving management of shock.
References
• Bewes P. (1984). A Manual for Rural Health Workers. Nairobi: AMREF.
• Image of ambu bag setting. Retrieved March, 2010 from
http://www.fotosearch.com/illustration/oxygen-mask.html.
• Image of ambu bag. Retrieved March, 2010 from http://www.megahowto.com/how-to-
use-ambu-bags.

Handout 23.1: Venous Cut Down and Intraosseous Puncture
Venous Cut Down

• Venous cut down is a useful means of obtaining access to a peripheral vein when
percutaneous techniques are insufficient or central lines are not available.
• The saphenous vein is the most common site of cutdown and can be used in both adults
and children.
• All that is required is:
o Small scalpel
o Artery forceps
o Scissors
o Wide bore sterile catheter (a sterile infant feeding tube is one alternative).
• Make a transverse incision two finger breadths superior and two fingers anterior to the
medial malleolus.
• Use the patient’s finger breadths to define the incision: this is particularly important in the
infant or child.
• Use the sutures that close the incision to tie the catheter in place. Do not suture the
incision closed after catheter removal as the catheter is a foreign body.
• Allow any gap to heal by secondary intention.
Figure 1: Venous Cut Down
Source: WHO, 2003

Intraosseous Puncture
• Intraosseous puncture can provide the quickest access to the circulation in a shocked child
in whom venous cannulation is impossible.
• Fluids, blood and many drugs may be administered by this route.
• The intraosseous needle is normally sited in the anterior tibial plateau, 2-3 cm below the
tibial tuberosity, thereby avoiding the epiphyseal growth plate.
• Once the needle has been located in the marrow cavity, fluids may need to be
administered under pressure or via a syringe when rapid replacement is required.
• If purpose-designed intraosseous needles are unavailable, spinal, epidural or bone marrow
biopsy needles offer an alternative.
• The intraosseous route has been used in all age groups, but is generally most successful in
children below about six years of age.
Figure 2: Intraosseous Puncture
Source: WHO, 2003

Handout 23. 2: Cardiopulmonary Resuscitation
• Cardiopulmonary resuscitation (CPR) is a lifesaving procedure to support and maintain

breathing and circulation for a person who has stopped breathing (respiratory arrest)
and/or whose heart has stopped (cardiac arrest).
Performing CPR
• Before starting CPR, check:
o Is the person conscious or unconscious?
o Remember the ABCs- Airway, Breathing and Circulation.
o Move quickly through airway and breathing to begin chest compressions.
Rescue Breathing
• Check to see if the person is breathing normally.
o Do this by first opening the person's airway.
o Tilt the victim's head back by lifting the chin gently with one hand, while pushing
down on the forehead with the other hand.
o Next, place your ear next to the victim's mouth and nose and look, listen, and feel:
Look to see if the chest is rising.
Listen for any sounds of breathing.
Feel for any air movement on your cheek.
Taking no more than 5-10 seconds. If you do not see, hear, or feel any signs of
normal breathing, you must breathe the victim by using ambu bag (Figure 1
below).
Make sure that the patient’s airways are clear of mucus before you use the ambu
bag.
Make sure that the face mask is connected to the adapter on the bag.
Put the mask tightly over the mouth and nose of the patient with your hand and
hold the mask towards his face.
Use your thumb to squeeze the bag in a brisk manner in order to put pressure onto
it. Make sure that the bag is squeezed hard enough so as to produce an elevation
in the patient’s chest just like when s/he is breathing normally.
Give 2 slow breaths, making sure that the person's chest rises with each breath.
Chest Compressions
• After giving 2 breaths immediately begin chest compressions.
• Place the heel of one hand on the center of the chest, right between the nipples. Place the
heel of your other hand on top of the first hand.
• Lock your elbows and position your shoulders directly above your hands. Press down on
the chest with enough force to move the breastbone down about 2 inches. Compress the
chest 30 times, at a rate of about 100 times per minute.
• After 30 compressions, stop, open the airway again, and provide the next 2 slow breaths.
• Then, position your hands in the same spot as before and perform another 30 chest
compressions. Continue the cycles of 30 compressions and 2 breaths until s/he is
breathing normally.

Figure 1: Ambu Bag
Source: megahowto.com
Figure 2: Ambu Bag Setting
Source: fotosearch.com
Figure 3: Chest Compressions
Source: WHO, 2003

Worksheet 23.1: Case Study: Managing Patient in Shock
Instructions:
2. You will be allowed time to discuss the answers to the questions.
3. You are encouraged to take notes on the worksheet.
4. A recorder will be selected. The recorder may write on note paper or flip chart paper.
5. Discuss the questions together and answer the related questions in the time you are
given.
Case Information
A 40-year-old man was involved in a motor car accident has an open fracture of the upper
arm and a cut wound on the head. He is brought to the hospital semi-unconscious and looks
pale with fluctuating pulse (fast low volume). Blood pressure diastolic is about 50 mmHg.
Questions
1. What type of shock is this?
2. How will you confirm clinical investigation?
3. Outline the management of this patient.

Session 24: Atrthritis, Frozen Shoulder,
Spondylosis, Prolapsed Intervertebral Disc and TB
of the Spine
Learning Objectives
• Define arthritis, frozen shoulder, spondylosis, prolapsed intervertebral disc and Pott’s
disease
• Describe the pathophysiology of arthritis, frozen shoulder, spondylosis, prolapsed
intervertebral disc and Pott’s disease
• Describe causes of arthritis, frozen shoulder, spondylosis, prolapsed intervertebral disc
and Pott’s disease
• Describe clinical presentation of arthritis, frozen shoulder, spondylosis, prolapsed
intervertebral disc and Potts disease
• Identify relevant investigations for arthritis, frozen shoulder, spondylosis, prolapsed
intervertebral disc and Pott’s disease
• Describe management of arthritis, frozen shoulder, spondylosis, prolapsed intervertebral
disc and Pott’s disease
Arthritis
• Arthritis: A process of irritation or inflammation of the joints.
Pathophysiology
• Degenerative arthritis occurs from wear and tear of the cartilage.
• This is associated with ageing, joint injury or following a joint infection.
• Inflammatory or rheumatoid arthritis is secondary to an immune reaction that destroys the
articular cartilage.
• It usually involves multiple joints and leads to progressive joint deformities.
• The articular cartilage is primarily affected, at first becoming rough and irregular and
eventually being destroyed completely.
Clinical Features
• Pain, swelling
• Loss of motion
Degenerative Arthritis
• History
o Slow onset of pain on using the joint
o Decreased range of motion and stiffness
o Mild swelling
• Examination
o Tenderness about the joint
o Palpable spurs at the joint margins
o Loss of motion
o Crepitus (a rough or crunchy sensation) may be palpated during motion of an
involved joint

Session 24: Arthritis, Frozen Shoulder, Spondylosis, Prolapsed Intervertebral Disc and TB of the Spine 193
• X-ray
o Asymmetric joint-space narrowing
o Sclerosis of bone about the weight bearing surfaces
o Spur formation at the joint margins (the most characteristic findings.)
o Subchondral cysts
Rheumatoid Arthritis
• History
o Joints painful and swollen with morning stiffness
o Multiple joints frequently affected (3 or more)
o Possible family history of similar problems
• Examination
o Joints swollen and tender with decreased range of motion
o Hands and feet frequently involved
o Deformity common
• X-ray
o Narrowed joint space
o Osteopenia
o Calcifications
o Bony erosions at the joint margins are common
o Deformities
o Bone spurs are rare
• Management
o Rest: for both types of arthritis, try to preserve joint motion and extremity muscle
strength.
o Decrease activities that are likely to strain your joints
o During acute episodes of rheumatoid arthritis, splint the joint with a removable plaster
dressing.
o Begin a range of motion exercises as soon as pain allows.
o Medication
o Administer non-steroidal anti-inflammatory medication.
o Patients with rheumatoid arthritis may benefit from oral corticosteroid medication or
other special drugs.
o Intra-articular injections; in patients with rheumatoid arthritis, cortisone helps to
control the inflammation and periodic injections may be helpful.
Septic Arthritis
• Definition: direct invasion of joint space by any infectious agent including bacteria,
viruses, mycobacteria, and fungi; bacterial pathogens are the most significant because of
their rapidly destructive nature.
• Causes
o Direct inoculation (open wound or puncture)
o Contiguous spread from infected periarticular tissue (i.e. from adjacent osteomyelitis
or cellulitis)
o Through the bloodstream from an infection elsewhere (the most common route).
o Pyogenic infections result most frequently from staphylococcus species
(staphylococcus aureus). Other organisms responsible for joint infections include
Streptococcal species, Neisseria gonorrhoeae , mycobacterium tuberculosis,
brucellosis, salmonella and various types of fungus.

o Enzymes released by organisms within the joint destroy the articular cartilage, leading
to loss of motion, degenerative arthritis and spread of the infection to surrounding
tissues.
o Prompt drainage of the purulent fluid and administration of antibiotics is necessary to
preserve joint function.
• Clinical presentation of septic arthritis
o History of a wound near the joint, or of an infection elsewhere in the body
o Erythema, swelling (90% of cases), warmth, and tenderness of the joint
• Marked limitation of both active and passive ranges of motion Investigation
o Blood cultures to rule out a bacteraemic origin of the septic joint.
o Erythrocyte sedimentation rate and C-reactive protein - Helpful in monitoring
treatment course
o Complete blood count with differential - Often reveals leukocytosis with a left shift
o Confirm the diagnosis by needle aspiration of the joint.
o Infected joint fluid is cloudy or overtly purulent typically yellow-green. Send it for
culture, gram stain, cell count, crystal analysis and sensitivity testing, but do not wait
for the results before beginning treatment.
• Management
o Treat septic joints with prompt drainage and systemic antibiotics.
o Refer patient for drainage of the joint by open lavage.
o Apply a splint to rest the joint during the initial treatment phase.
o Do not allow the patient to bear weight on the affected joint.
o Administer parenteral antibiotics, then oral doses when joint swelling subsides and
motion is no longer painful.
Frozen Shoulder (Adhesive Capsulitis)

• Frozen shoulder: Is the common term for adhesive capsulitis, an inflammatory condition
that restricts motion in the shoulder.
• Aetiology
o Diabetes
o Shoulder trauma (including surgery)
o Hyperthyroidism
o History of cervical disc disease
o Pain
o Stiffness
• Investigation
o X-ray of shoulder for differential purpose
o Investigate underlying causes
• Management
o The diagnosis is made primarily by physical exam and the patient's medical history.
There is usually a history of shoulder pain followed by severe stiffness, which may
not be very painful.
o If the patient has any history of the risk factors associated with frozen shoulder, these
may require treatment as well.
o These include:
Non-steroidal anti-inflammatory medications (NSAIDs) and steroid injections
Physical therapy (it can take as long as 12-18 months to see improvement)
Treat underlying causes

Refer if no improvement
• Complications
o Persistent stiffness and pain despite therapy
o Loss of functional use of the upper extremity
If forceful manipulation, the joints can dislocate or there can be neurovascular injury
Spondylosis
• Spondylosis: Degenerative arthritis of the joints between the centres of the spinal
vertebrae.
o Radiculopathy (sensory and motor system disturbances, such as severe pain in the
neck, shoulder, arm, back, and/or leg)
o Muscle weakness
o Gait dysfunction, loss of balance
o Loss of bowel and/or bladder control
o The patient may experience a phenomenon of paresthesia in hands and legs because
of nerve compression and lack of blood flow.
• Investigations
o X-rays
o MRI
o Myelography
• Management
o Treatment is usually conservative in nature; the most commonly used treatments are
non steroidal anti-inflammatory drugs (NSAIDs),
o Physiotherapy
o If symptoms persist refer the patient
Prolapse of Intervertebral Disc

• Prolapse of intervertebral disc: Intervertebral discs are interposed between the vertebral
bodies.
o These discs act as shock absorber for the spinal column and provide mobility between
the bodies of the vertebrae.
o Each intervertebral disc consists of a central semi fluid spongy material known as
‘nucleus pulposus’ which is surrounded by a tough fibrous ring, known as ‘annulus
fibrosus’.
o The intervertebral disc is enclosed between the fibrocartilaginous plates above and
below which are attached to the vertebral bodies.
• Etiology
o Traumatic
o Increased tension
o Degeneration
• When a fragment of nucleus herniates, it irritates and/or compresses the adjacent nerve
root.
• This can cause the pain syndrome known as sciatica and, in severe cases, dysfunction of
the nerve.
• Sites
o Protrusion of the disc is most common in the mist mobile positions of the spine, as
these portions are subjected to greater stress and strain.

o Lumbosacral region – above and below the L5 vertebrae i.e. L4/5 and L5/S1. 80% of
disc prolapse occurs in this region.
o Lower cervical region – above and below the C6 vertebra i.e. C5/6 and C6/7. 19% of
disc prolapse occurs in this region.
o Dorsal region – which constitutes 1% of all disc prolapse.
• Clinical presentation of lumbar disc disease
o Intermittent or continuous back pain (this may be made worse by movement,

coughing, sneezing, or standing for long periods of time)
o Spasm of the back muscles
o Sciatica: pain that starts near the back or buttock and radiates down the leg (calf) or
into the foot.
o Muscle weakness in the legs
o Numbness in the leg or foot
o Decreased reflexes at the knee or ankle
o Changes in bladder or bowel function
• Investigations: X-ray- shows loss of spine curvatures due to spasms; MRI and
myelography (in the higher level facilities)
• Management
• Conservative therapy is the first line of treatment to manage lumbar disc disease.
• This may include a combination of the following:
o limit activity (strict bed rest not recommended)
o Patient education on proper body mechanics
o Physical therapy
o Weight control
o Use of a lumbosacral back support
o Medications (to control pain and/or to relax muscles)
• When these conservative measures fail, refer the patient
Tuberculosis (TB) of the Spine (Pott’s Disease)

• Tuberculosis (TB) of the spine is also known as Pott’s disease.
• The spine is the most common site of bone infection in TB; hips and knees are also often
affected.
• The lower thoracic and upper lumbar vertebrae are the areas of the spine most often
affected.
• Pott's disease is a presentation of extrapulmonary tuberculosis that affects the spine.
Pathogenesis of Pott’s Disease

• Pott’s disease results from haematogenous spread of tuberculosis from other sites, often
pulmonary.
• The infection then spreads from two adjacent vertebrae into the adjoining disc space.
• If only one vertebra is affected, the discs are normal, but if two are involved the
intervertebral disc, which is avascular, cannot receive nutrients and collapses.
• The disc tissue dies and is broken down by caseation, leading to vertebral narrowing and
eventually to vertebral collapse and spinal damage.

• The disease progresses slowly, signs and symptoms include:
o Back pain
o Fever
o Night sweats
o Anorexia
o Weight loss
o Paravertebral swelling may be seen (gibbus)
o Neurological signs may occur, leading to paraplegia
• Late complications of the disease are:
o Severe kyphosis
o Sinus formations
o Paraplegia (so called Pott's paraplegia)
Investigations
• Spine X-ray may not show early disease, because in order for changes to be visible on X-
ray, 50% of bone mass must be lost.
• However, plain radiographs can show vertebral destruction and narrowed disc space.
• Chest X-ray
• Tuberculin skin test (TST)
• Full blood picture and ESR
• In district or regional hospital the following can also be done:
o Needle biopsy of bone or synovial tissue
o Acid-fast stain for mycobacterium tuberculosis
Management of Pott’s Disease

• Non-operative: antituberculous drugs
• Immobilization of the spine region
• Refer for operation in specialized hospital care
Key Points
• Joint infections arise from infections elsewhere in the body or from a direct wound into
the joint.
• Suspect infection when there is swelling, pain and loss of joint motion.
• Spondylosis is degenerative arthritis of the joints between the centres of the spinal
vertebrae.
• Tuberculosis of the spine is the most common site of bone infection in TB.
• Pott’s disease results from haematogenous spread of tuberculosis from other sites, often
pulmonary.
• Manage Pott’s disease by ant-TB and immobilization of the spine region.
Evaluation
• What is arthritis?
• List the etiology of frozen shoulder.
• Describe clinical presentation of TB spine.

References
• WHO (2003). Surgical Care at District Hospital. Malta. Geneva: World Health
Organization.

Session 25: Poisons and Inhaled Foreign Bodies
Learning Objectives
• Define poison
• List common types poisons
• Describe clinical features and management of common types of poisoning
• Identify types of inhaled foreign bodies
• Describe clinical features of inhaled foreign bodies
• Explain complications and management of inhaled foreign bodies
Definition and Common Types of Poisons

• Poison: Any substance taken into the body by ingestion, inhalation, injection or skin
absorption that interferes with normal physiological function.
Common Types of Poisons

• Kerosene (hydrocarbon)
• Pesticides / organophosphorus
• Mushrooms
• Corrosives
• Medications (specific poisoning of medication will be dealt in pharmacology sessions)
Clinical Features and Management of Individual Types of Poisoning

Kerosene (Hydrocarbon) Poisoning
• Symptoms of kerosene poisoning
o Burning of mouth and throat
o Cough with subsequent nausea and vomiting
o Rare symptoms
Coma
Seizures
Acute hepatic or renal failure
Low doses of kerosene can cause central nervous system excitation
o The most serious poisoning from kerosene occurs when it is inhaled or aspirated into
the respiratory canal causing chemical pneumonitis.
• Management
o The treatment is mainly supportive: administration of oxygen, provision of respiratory
support
o Never induce vomiting if the victim has swallowed kerosene or other volatile liquids.
Vomiting can cause aspiration and pneumonitis.
Pesticides Poisoning/ Organophosphorus Poisoning

o Abdominal pain
o Restlessness
o May present with impaired level consciousness

Session 25: Poisons and Inhaled Foreign Bodies 201
Presence of frothing from the mouth
o
Constriction of the pupils (pinpoint pupils)
o
Hyperglycaemia
o
Typical signs of organophosphorus poisoning: ‘SLUD’ response
o
S= Salivation
L= Lacrimation
U= Urination
D= Diarrhoea
Pulmonary oedema
Weakness and muscle paralysis
Death is caused by pulmonary oedema and paralysis of respiratory muscles

• Management
o I.V. fluids dextrose saline and Ringers lactate
o I.V. Atropine, 2 mgs every ten minutes (maximum 4 doses) until the secretions in the
lungs dry up
o I.V. Pralidoxime 1 to 2 gram to restore muscle strength
o Anti-acids
Mushroom Poisoning
o Serious symptoms do not always occur immediately after eating; often not until the
toxin attacks the kidney, from minutes to hours later.
o Symptoms typically include:
Lethargy
Headache
Dizziness
Cold sweats
Vomiting
Sharp abdominal pains
Jaundice
Severe diarrhoea
Blurred vision
• Management
o There is no specific antidote for mushroom poisoning
Early replacement of body fluids has major factor in improving the survival rates
The therapy is aimed at decreasing amount of toxin in the body
Do gastric lavage to remove mushrooms in upper G.I.T. (from the stomach and
oesophagus)
Figure 1: Position of Patient for Gastric Lavage and Aspiration
Source: Boucher et al., 1995

Corrosive Poisons (Acid and Alkaline)
o Nausea
o Vomiting
o Diarrhoea
o Burning sensation in the buccal cavity
o Oliguria follows renal failure
• Management
o The best first aid is to dilute the poison as quickly as possible
o For acids or alkalis give the patient water or preferably milk
Give one cup for victims under five years.
Give one to two glasses for patients over five years.
Milk is better than water because it dilutes and helps neutralize the poison. Water
only dilutes the poison.
o It is very important that the victim gets to a hospital without delay.
Types and Clinical Features of Inhaled Foreign Bodies

• In our environment the most swallowed foreign bodies are:
o Coins
o Seeds
o Pieces of bones
o Others include teeth, piece of meat
• Clinical features of foreign bodies
o Foreign bodies in the respiratory tract most commonly are lodged in the right main
stem and lower bronchus.
Choking or coughing is present in 95% of patients presenting with foreign body
aspiration.
Stridor is commonly present with upper airway or upper tracheal foreign bodies.
Stridor in children or adults indicates a partial upper airway.
Patients may present with respiratory distress, pneumonia, pulmonary oedema, or
wheezing.
Case Study
Instructions
You will work in some groups to complete the activity on the worksheet. After 15 minutes
you will present your responses to the larger group.
Complication and Management of Foreign Bodies in the Respiratory Tract
Complication
• Asphyxia

o This is a condition of severely deficient supply of oxygen to the body that arises from
being unable to breathe normally.
o Asphyxia causes generalized hypoxia, which primarily affects the tissues and organs.
Management
• Foreign bodies should be removed manually, immediately if possible.
• Heimlich manoeuvre: Stand behind the patient, give a sharp upward thrust into the
epigastrium (round the front) with both fists to raise intrathoracic pressure and expel the
blocking agent.
Refer to Handout 25. 1: Illustration of the Heimlich Manoeuvre
Key Points
• Poison is any substance taken into the body by ingestion, inhalation, injection or
absorption that interferes with normal physiological function.
• Management of a patient with poison includes Dilute the poison as quickly as possible,
Administer of oxygen, provision of respiratory support, Never induce vomiting if the
victim has swallowed kerosene or other volatile liquids, For acids or alkalis give the
patient water or preferably milk and It is very important that the victim gets to hospital
without delay.
• Clinical features of foreign bodies in the respiratory tract includes Choking or coughing,
Stridor and Patients may present with respiratory distress, pneumonia, pulmonary
oedema, or wheezing
Evaluation
• What is poison?
• List the most common types of poisons.
• Identify symptoms of organophosphates poisoning.
References
• Das Das S. (2004). A Manual of Clinical Surgery (6th ed.). India.
• Ian Boucher, Christopher H. & Edwin C. (1995). Principles and Practice of Medicine.
ELBS with Churchill Livingstone.
• Jonas. (2005). Mosby's Dictionary of Complementary and Alternative Medicine. Elsevier.

Handout 25.1: Illustration of the Heimlich Manoeuvre
Definition
• The Heimlich maneuver is an emergency procedure for removing a foreign object lodged
in the airway.
Precautions
• Incorrect application of the Heimlich maneuver can damage the victim`s chest, ribs, and
internal organs.
• People may also vomit after being treated with the Heimlich manoeuvre.
• The Heimlich manoeuvre can be performed on all people. Modifications are necessary if
the choking victim is very obese, pregnant, a child, or an infant.
Performing the Heimlich Manoeuvre on Adults

• To perform the Heimlich maneuver on a conscious adult:
o Stand behind the victim. The victim may either be sitting or standing.
o Make a fist with one hand, and place it below the victim’s rib cage and above the
waist. Then encircles the victim’s waist, placing your other hand on top of the fist.
o In a series of 6-10 sharp and distinct thrusts upward and inward forces the foreign
object back up the trachea. If the maneuver fails, it is repeated.
o As the victim is deprived of oxygen, the muscles of the trachea relax slightly. Because
of this loosening, it is possible that the foreign object may be expelled on a second or
third attempt.
• If the victim is unconscious, you should lay him or her on the floor, bend the chin
forward, make sure the tongue is not blocking the airway, and feel in the mouth for
foreign objects, being careful not to push any farther into the airway.
o After the abdominal thrusts, repeat the process of lifting the chin, moving the tongue,
feeling for and possibly removing the foreign material. If the airway is not clear,
repeat the abdominal thrusts as often as necessary.
o If the foreign object has been removed, but the victim is not breathing, start CPR
Figure 1: Heimlich Manoeuvre
Source: Jonas, 2005

Instructions:
paper.
4. Use session notes on poisoning to help with this case study.
Case Information
A farmer, 40-year-old man, was thirsty. He drank water from a beer bottle, without realising
that it contained some other mixed fluid used to kill cattle ticks. After a few minutes he
started vomiting and lost consciousness. Then he started producing white froth from his
mouth. His wife took notice and immediately rushed him to the hospital.
Questions
1. What do you think happened to this patient?
2. What did he ingest?
3. Which are the main symptoms in such a case of poisoning?
4. How would you manage this patient?
5. Which complications can occur to this patient?

Session 26: Chest Injuries
Learning Objectives
• Describe injuries to the chest
• Classify causes of chest injuries
• List types and clinical features of chest injuries
• Describe method of investigations for chest injuries
• Describe complications and management of chest injuries
Chest Injuries and Causes

• Chest injury among trauma victims is common and these injuries can be life threatening.
• However the majority of these (about 90% of blunt trauma and about 80% of penetrating
trauma) can be effectively managed without open surgery.
• Timely and careful assessment of these patients and competency at a number of basic
procedures can save lives.
• As for any trauma, managing chest injury must be seen in the whole context of the ABC’s
of trauma management.
Causes
• It ranges from blunt chest injuries to penetrating chest injuries:
o Motor traffic accidents
o Bullet injuries
o Assaults/violence
Types and Clinical Features of Chest Injuries
Types
• Simple bruises and laceration
• Rib fracture
• Flail and stove-in chest
• Traumatic pneumothorax
• Haemothorax
• Traumatic arrest
Simple Bruises and Laceration

• These are simple non penetrating cut wounds or bruises on the chest wall which may be
associated with lung contusion.
• Clinically, pain is a feature associated with bleeding from site of injury or haemoptysis in
cases where there is lung contusion.
Rib Fracture
• Rib fracture may be single or multiple.
• Multiple rib fractures will often be associated with an underlying pulmonary contusion.
• Injuries to upper ribs are less commonly associated with injuries to adjacent great vessels
• Fracture of the first rib can be associated with thrombosis and other significant injuries:

Session 26: Chest Injuries 207
o First rib fractures are rarest of all rib fractures, and were once thought to be a
harbinger of severe trauma, since the first rib is very well protected by the shoulder,
lower neck musculature, and clavicle.
o It was thought to require a much higher impact force to fracture than other ribs
o These data are now in question, but until further studies are done, fractures of the first
rib should raise suspicion of significant chest trauma.
o Mortality rates as high as 36% have been previously reported with fractures of the
first rib, which are associated with injury to the lung, ascending aorta, subclavian
artery, and brachial plexus.
o Other complications associated with first rib fractures include delayed subclavian
vessel thrombosis, aortic aneurysm, tracheobronchial fistula, thoracic outlet
syndrome, and Horner's syndrome.
• Clinical features include:
o Inspiratory chest pain
o Discomfort over the fractured rib or ribs
• Physical findings include:
o Local tenderness and crepitus over the site of the fracture may be present.
o If a pneumothorax is present, breath sounds may be decreased and resonance to
percussion may be increased.
o It should be noted that in some incidences, fractures of the lower ribs may be
associated with diaphragmatic tears and spleen or liver injuries and pulmonary
contusion.
Flail Chest
• A flail chest occurs when a segment of the thoracic cage is separated from the rest of the
chest wall. This is usually defined as at least two fractures per rib (producing a free
segment), in at least two ribs.
• A segment of the chest wall that is flail is unable to contribute to lung expansion.
• Clinically presents with:
o Pain at the fracture sites
o Pain upon inspiration
o Frequently dyspnoea
• On physical examination:
o There is paradoxical motion of the flail segment. The chest wall moves inward with
inspiration and outward with expiration.
Figure 1: X-ray Showing Rip Fractures
Source: Lett & Kobusingye, 2009

Traumatic Pneumothorax
• This is defined as air in the pleural space due to trauma.
• In the majority of trauma cases, blood is associated with air in pleural, this is called
haemopneumothorax.
• There are three types of traumatic pneumothorax:
o Closed pneumothorax
When air comes out in the pleural cavity through a small vent in the lung, which
later closes.
o Open pneumothorax
Air may enter the pleural cavity through a wound in the chest wall.
o Tension pneumothorax
When lacerated lung communicates with a branch of the bronchial tree, this
permits air to enter the pleural cavity from the lung during inspiration, but does
not permit it to escape during expiration as the leak in the lung becomes closed, so
vent becomes valvular.
o Inspiratory pain
o Pain at the sites of the rib fractures
o Dyspnoea
• On physical examination
o Decreased breath sounds
o Hyper-resonance to percussion over the affected hemithorax
o Shift of trachea and apex beat towards the opposite side
Haemothorax
• This can be defined as the accumulation of blood within the pleural space due to trauma
causing bleeding from the chest wall (e.g. lacerations of the intercostals or internal
mammary vessels attributable to fractures of chest wall elements) or to hemorrhage from
the lung parenchyma or major thoracic vessels.
o These usually follow chest injury either blunt or penetrating.
o The patient will present with chest pain especially during breathing.
• On physical examination
o There is reduced chest movement on affected side.
o Trachea may be pushed away from the affected side.
o There is a stony dull on percussion.
o On auscultation, there is no or reduced air entry.
Investigation and Complications of Chest Injuries

• Chest X-ray the antero-posterior chest radiograph, and sometimes x-ray the lateral view.
• Check haemoglobin level.
Complications
• Shock (hypovolaemic)
• Surgical emphysema
• Traumatic pneumothorax
• Haemothorax
• Flail chest
• Pulmonary contusion and laceration

• Injury to the heart and pericardium
• Traumatic asphyxia
• Injury to the diaphragm and diaphragmatic hernia
• Injury to the subdiaphragmatic organs (liver, spleen, kidneys, colon and stomach.)
Management of Chest Injuries

• The management of rib fractures is usually bed rest in cardiac (prop-up) position,
analgesics and prophylaxis antibiotics.
o However this depends on severity and number of rib fractures.
o A simple rib fracture does not require bed rest or antibiotics.
• For tension pneumothorax, urgent treatment in needed by chest tube insertion under
waterseal or, if no tube available, by large bore needle.
• Oxygen therapy is needed if patient has flail chest.
• If haemorrhagic shock is in progress, do urgent blood grouping and cross matching.
• This depends on the facilities for blood transfusion availability, otherwise refer the
patient.
• For haemothorax, insert chest tube under water seal drainage.
Case Study
Instructions
you will present your reponses to the larger group.
Key Points
• Chest injury among trauma victims is common and these injuries can be life threatening.
• Immediate life-threatening thoracic injuries
o Airway obstruction and injury
o Lung and chest wall injuries
o Open pneumothorax
o Tension pneumothorax
o Haemopneumothorax
o Flail chest
• Potential life-threatening thoracic injuries
o Pulmonary contusion
o Ruptured tracheobronchial tree
o Ruptured diaphragm
o Esophageal perforation
o Myocardial contusion
o Injury to major blood vessels
• Flail segments are defined as 2 or more ribs fractured in 2 or more places.

Evaluation
• List causes and types of chest injuries.
• Describe the clinical features of chest injuries.
• Identify complications of chest injuries.
References
• Lett & Kobusingye. (2009). Trauma Team Training Course, Student’s Manual. CNIS
ICCU.

Instructions:
paper.
Case Information
A young man of 25 years was involved in a fight. He was stabbed with a sharp object on the
right chest posterior. On observation he was dyspnoeic, sweating and cyanotic. BP 100/60
mm Hg, pulse 90 / minute fast, irregular, low volume. Respiratory rate 30/minute,
tachypnoeic.
Local examination: on the posterior right chest between the 5th and 6th ribs open cut wound
about 5 cm width and 4cm length and 4cm depth extending towards the latismus muscles.
The chest is tender on palpation and dullness on auscultation.
Questions:
1. What is the possible diagnosis and why?
2. Which emergency investigation will you do?
3. Explain the first line management that will be given to this patient as a life support.
4. In this case you need expert management. Which expert management is carried out to this
patient?

Session 27: Acute Abdomen and Abdominal
Injuries
Learning Objectives
• Define acute abdomen
• List types and causes of acute abdomen
• Describe clinical features of acute abdomen
• Discuss differential diagnosis of acute abdomen
• Explain management of acute abdomen
• Describe causes and management of abdominal injuries
Definition and Types of Acute Abdomen

• Acute abdomen: Abdominal pain that may occur suddenly or gradually over a period of
several hours or days and presents complex symptoms which suggests a possible life-
threatening disease and demands an immediate or urgent diagnosis for early management.
o Cardinal symptom of acute abdomen is pain
Types and Causes of Acute Abdomen

• Visceral pain
o Caused by stimulation of visceral afferent nerves
o Commonly caused by distension, contraction, ischaemia, chemical irritation
o Usually colicky and relieved by pressure
o Diffuse, poorly localized, and difficult to describe
o May be referred to a distant region
• Parietal pain
o Irritation of parietal peritoneum by blood, inflammatory exudates, content of hollow
viscus (e.g. bile, acid, pancreatic juice)
o Constant, sharp and localized to site of irritation
o Aggravated by pressure and movement
o Associated with reflex rigidity, reduced bowel activity
• Referred Pain
o Pain of visceral disease refers to a superficial area of body derived from the same
segment of the spinal cord as the viscus. The areas are as follows:
Stomach: duodenum and gall bladder referred to the upper abdomen
Small intestine: appendix, right colon is referred to the mid abdomen
Mid transverse: descending, sigmoid colon and rectum occurs in lower abdomen
Kidney and pancreas may present with back pain
Ureteric pain radiates to the testicle or labia
Diaphragmatic irritation presents as shoulder tip pain
• Generalized pain
o Generalised soiling of the peritoneum by pus, blood or acid/bile/pancreatic juice
Note: Pathology does not always follow the rules and the clinician needs to maintain a wide
differential for abdominal pain (e.g. the types and causes of acute abdomen may not always
follow these guidelines perfectly).

Session 27: Acute Abdomen and Abdominal Injuries 213
Causes and Differential Diagnosis of Acute Abdomen
Activity: Small Group Activity
Instructions
You will work in small groups to answer the questions the tutor has provided. After 20
minutes each group will present their results.
Refer to Worksheet 27.1: Causes and Differential Diagnosis of an Acute

Abdomen
Causes of Acute Abdomen

• Inflammatory causes
o Peritoneum
Primary: gram positive bacteria (pneumococcal, streptococcus)
Secondary: spread from other viscera
o Hollow organs: peptic ulcer, cholecystitis, and appendicitis
o Gastroenteritis: HIV, diverticulitis
o Solid organs: pancreatitis, hepatic abscess
o Mesentery: mesenteric adenitis
o Pelvic organs: pelvic inflammatory diseases, tubo-ovarian abscess
• Mechanical causes
o Obstruction, perforation and distension
Hollow organs: intestinal obstruction, biliary colic
Perforated ulcer, e.g. peptic, typhoid
Solid organs: acute hepatomegaly, spleenomegaly
Pelvic organs: torsion, ovarian tumour
• Vascular cause
o Bleeding/ ischemia
Hollow organs: mesenteric thrombosis or embolus
Solid organs: rupture liver, spleen, splenic infarction
Pelvic organs: rupture ectopic pregnant, bladder
Vascular aortic aneurysm: dissecting rupture aortic aneurysm.
Differential Diagnosis of Acute Abdomen

• Acute appendicitis
• Acute cholecystitis
• Acute pancreatitis
• Diverticulitis
• Acute salpingitis
• Ulcerative colitis
• Peptic ulcer perforations
• Intestinal obstruction
• Intussusceptions
• Renal colicky
• Abdominal injuries

Clinical Presentation of Acute Abdomen
History
• Anorexia, nausea, vomiting
• Diarrhoea, constipation, stool colour and consistency of melaena, presence of fresh blood
in stool
• Menstrual history
• Previous medical/ surgical history
• Inquire about any allergies, current medications, alcohol intake, and last meal
Physical
• Pain
o Duration and site
o Localized or diffuse
o Onset
Abrupt/sudden: colic, perforation, rupture, torsion
Gradual/ insidious: inflammatory
o Progress
Shift or spread
Increase or decrease
o Type
Sharp
Burning
Dull
o Character
Constant
On and off
Colicky
o Severity
Slight
Moderate
Severe
Worst ever
o Radiation
Biliary radiates to scapula
Pancreatitis radiates to back
Ureteric radiates to groin/testes
o Exacerbating/ relieving factors
Movement
Cough
Food
Position
o Associated Features
Respiratory
GIT
Genitor-urinary
o Some features that may assist in identification of cause of pain
Explosive pain may be due to myocardial infarction, rupture viscus,
biliary/ureteric colic

Rapid, severe, constant, may be due to acute pancreatitis, strangulated bowel,
mesenteric thrombosis
Gradual steady pain may be due to acute cholecystitis, appendicitis, diverticulitis
Intermittent colicky pain may be due to mechanical small bowel obstruction
Causes and Management of Abdominal Injuries
Causes
• The main causes of abdominal injuries are
o Road traffic accidents
o Assaults
o Fall from height
o Weapon injuries (i.e. handgun)
• Abdominal injuries may be grouped as
o Penetrating: caused by sharp objects
o Blunt injuries: caused by blunt objects
Figure 1: Penetrating Abdominal Wound with Evisceration
Source: Russell et al., 2004
• Pelvic injury
o Trauma to the pelvic organs is an expected feature
o Patients present with blood in the urethra, or passing blood stained urine may indicate
urethral injury in this case do not catheterise instead place a suprapubic catheter
o Urethral bleeding may be a feature after pelvic injury
Management
• Any patient with abdominal trauma, pulse rate and blood pressure should be examined
carefully as may present with shock if there is concealed haemorrhage and managed
accordingly.
• The abdomen is examined routinely for signs of developing peritonitis.
• Resuscitation by IV fluids ringer lactate and normal saline.
• Blood for grouping and cross match.
• Administer intravenous antibiotics.
• Administer analgesics.
• Control bleeding and do the following under local or general anaesthesia:
o Wound irrigation (mechanical cleaning to remove dirty material) with boiled or
sterilized tap water.
o Wound debridement: remove dead/devitalised tissue suture soft tissue if possible.

• In penetrating abdominal injury, laparatomy should be done. Therefore resuscitate and
refer the patient.
• In blunt abdominal trauma: the patient is admitted for observation for 24 hours. During
this time the patient is has frequent (hourly), regular checks of their haemodynamic
status. If not stable refer.
Key Points
• Serious abdominal injuries need to be referred for expert assessment and treatment.
• At dispensary level, do pre-referral management.
• An acute abdomen can be due to inflammatory problems, mechanical and vascular
problems.
• Patient may present with an acute onset of abdominal pain, anorexia, nausea, and
vomiting.
• Pain of visceral disease refers to a superficial area of body derived from the same
segment of the spinal cord as the viscus.
• Abdominal injuries may be grouped as penetrating or blunt injuries
• Management:
o Give analgesics.
o Control bleeding and do wound irrigation and wound debridement, resuscitate and
refer the patient.
Evaluation
• What are the clinical features of acute abdomen?
• List the differential diagnosis of acute abdomen.
References

Worksheet 27.1: Causes and Differential Diagnosis of An Acute
Abdomen
Instructions:
paper.
3. Discuss the questions together and answer the related questions in the time you are give.
Questions:
1. What are the causes of acute abdomen?
2. What are the differential diagnoses of an acute abdomen?

Session 28: Head and Vertebral Column Injuries
Learning Objectives
• Describe the aetiology and mechanisms of head and vertebral column injuries
• Describe clinical presentation of head and spine injuries
• Identify relevant investigations for head and vertebral column injuries
• Describe management of head and vertebral column injuries
• Explain the complications of head and vertebral column injuries
Introduction, Aetiology and Mechanism of Head Injury

Introduction to Head Injury
• Head injury occurs following an impact to the head.
• It can result in alteration in mental or physical functioning relating to a blow to the head.
• There might be a history of loss consciousness.
• The duration of loss of consciousness varies according to the severity of the injury.
• Delay in the early assessment of head-injured patients can have devastating consequence
in terms of survival and patient outcome.
• Hypoxia and hypotension double the mortality of head-injured patients.
Aetiology
• Road traffic accidents
• Interpersonal violence
• Falls from height
• Industrial accidents
• Sports
Mechanism
• Head injury implies trauma to:
o Scalp
o Skull
o Meninges
o Blood vessels
o Brain tissue itself
• Acceleration/deceleration of the brain leads to:
o Tearing of nerve fibres
o Tear of small blood vessels
o Burst temporal or frontal poles of the brain
Sequel
• Increased intracranial pressure due to:
o Brain swelling
o Contusion
• Intracranial haematomas, for example:
o Acute epidural haematoma

Session 28: Head and Vertebral Column Injuries 219
o Acute subdural haematoma
o Intracerebral haematoma
o Subarachnoid haemorrhage
Epidural Haematoma
• Located epidurally
• Occurs in young people and has a good prognosis because it is easily accessible to
drainage
• Loss of consciousness following a lucid interval, with rapid deterioration
• Middle meningeal artery bleeding with rapid raising of intracranial pressure
• Development of hemiparesis on the opposite side of the impact area with a dilating pupil
on the same side, with rapid deterioration
Subdural Haematoma
• Presents in young people, but chronic subdurals may present in elderly patients who have
had tearing of the bridging veins
• Acute subdural haematoma (clotted blood in the subdural space accompanied by severe
contusion of the underlying brain)
• Occurs from the tearing of bridging veins between the cortex and the dura matter
• Located between the dura and arachnoid matter
Intracerebral Haematoma
• Intracerebral haematoma may result from acute injury or progressive damage secondary
to contusion
• Intracerebral haematoma increases intracranial pressure that impairs neurological function
by direct pressure and by compromising cerebral circulation
• Headache
• Loss of consciousness
Subarachnoid Haemorrhage
• Headache
• Loss of consciousness
Clinical Presentation and Monitoring Parameters
• Scalp bruises/ laceration/ cut wounds
• Scalp haematoma
• Headache
• Altered level of consciousness
• Nausea and vomiting
• Bleeding from the ear, nose or mouth
• Racoon eyes/Battle’s sign
• Skull fracture
• Subconjunctival haematomas
• Anosmia
• CSF rhinorrhoea

Monitoring Parameters
• Level of consciousness
• Pupil size and response
• Pulse and blood pressure
• Temperature
Level of Consciousness
• Need for a simple, objective, reproducible scoring system
• Glasgow coma scale meets these criteria
o Motor response
o Verbal response
o Eye opening
Figure 1: The Glasgow Coma Score (GCS)

Score Best Eye Best Verbal Best Motor Response
Opening Response
6 - - Obeys
5 - Oriented Localizes pain
4 Spontaneous Confused Withdraws to pain
3 To speech Inappropriate Flexor
2 To pain Incomprehensible Extensor
1 None None None
• Mild: (GCS 13-15)

• Moderate: (GCS 9-12)
• Severe: (GCS less than 8)
Pupils
• Pupils are very important to monitor in a head injury
o Chart size of pupil in approx mm
o Response to light:
Present or absent
If present is it brisk or sluggish
o A dilated pupil is indicative of a mass lesion on the same side as the dilated pupil
Investigations and Management
Investigations
• Skull X-ray
• CT scan (in consultant hospital)
• Haemoglobin level

Management
• Stabilize the Airway, Breathing and Circulation and immobilize the cervical spine
• Vital signs of important indicators in the patient’s condition
• Neurological status must be monitored and recorded frequently
• Undertake a Glasgow Coma Scale (GCS) evaluation
• Elevate head end of bed cir. 30º
• Osmotic diuretic, e.g. mannitol 1 gm/kg body weight give IV rapidly (in district or
regional)
• Sedation should be avoided as it not only interferes with the state of consciousness, but
will promote hypercarbia (slow breathing with retention of CO2)
• Caution: never transport a patient with a suspected vertebral column injury in the sitting
or prone position; always make sure the patient is stabilized before transferring
• Scalp Injuries
o Abrasions
Apply iodine paint
o Lacerations
If big they are associated with massive bleeding, do surgical debridement and
maintain the hemodynamics (IV fluids/blood transfusion).
Wound closure
Prophylaxis: antibiotic and tetanus toxoid
o Contusions/haematoma
Reassure the patient
Do not puncture the scalp haematoma
• Skull fractures
o Open fractures
Do surgical debridements, maintain the hemodynamics (IV fluids/ Blood
transfusion)
Wound closure
o Closed fractures
If not depressed, and not associated with epidural haematoma, reassure the patient.
If significantly depressed, refer the patient for skull elevation.
If epidural haematoma resuscitate and refer for craniotomy.
o Penetrating objects
Remove the foreign body as possible.
Do surgical debridements; maintain the hemodynamics (IV fluids/ BT).
Wound closure
Intracranial Haematomas
• ABCs
• Elevate head end of bed
• Refer patient on emergency base
Complications of Head Injury

• Post traumatic syndrome
o Headaches, memory lapses, dizziness
• Seizures
o Immediate post trauma

o Early
o Late are likely to become chronic
• Infections, e.g. in case of cerebral spinal fluid leaks
Instructions
You will work in small groups to compete the activity on the worksheet. After 15 minutes
you will present your responses to the larger group.
Vertebral Column Injury

• Vertebral column injury consists of injury to the cervical, thoracic, lumbar and sacral.
• The incidence of nerve injury in multiple traumas is high.
• Injuries to the cervical spine and the thoraco-lumbar junction T12–L1 are common.
• Other common injuries include brachial plexus and nerve damage to legs and fingers.
Mechanisms
• Axial compression
o Indirect injuries, stable, burst fracture
o With high incidence neurological damage
• Hyperextension
o Common in cervical spine
o Usually stable
• Flexion-crush injury
o Stable
o Most common
• Flexion and compression combined with posterior distraction
o Unstable if facets and pedicles are crushed
• Flexion combined with rotation and shear
o Most serious
o Forward shift with or without bone damage
• Horizontal translation
o Vertebral body ‘sliced through’
o Unstable
Thoracic Fractures (T1 – T9)

• The spine is splinted by the ribs (therefore it is stable region).
• The commonest fractures are wedge fractures, in the elderly often associated with
osteoporosis.
• Other patterns of fracture are often caused by high-energy injuries, and multiple injuries
are common in these patients.
• Thoracic fractures and sternal fractures are often associated with aortic rupture, and a
high index of suspicion is recommended in the patients.
Thoracolumbar Fractures (T10 – L5)

• These fractures are more common than thoracic fractures because this part of the spine is
not splinted by the ribs.
• The most common fractures are T12 and L1 because these are at the junction between the
stiff thoracic spine and the mobile lumbar spine.
Clinical Presentation and Examination of Vertebral Column Injury
• Neck and back pain
• Numbness or loss of sensation
• Bruises or swelling
Physical Examination
• Palpate the spine for areas of tenderness and check for gaps or changes in the alignment
of the spinous processes.
• Perform a careful and complete neurological examination and record your findings.
Neurological Examination in Patient with Vertebral Column Injury

• Sensation
o Test sensation to pinprick in the extremities and trunk
o Test perianal sensation to evaluate the sacral roots
• Motor function
o Evaluate motion and strength of the major muscle groups
o Determine if rectal sphincter tone is normal
• Reflexes
o Spinal cord injury above C3 causes paralysis of the respiratory muscles and patients
usually die before reaching a medical care facility.
o At or below this level, treat similarly to patients without neurological deficit.
o However, begin care of the skin, bowel and bladder immediately.
• Bulbocavernosus reflex
o Squeeze the glans penis; the bulbocavernosus muscle contracts in a positive test
• Anal wink
o Scratch the skin next to the anus; the anus contracts in a positive test
• Babinsky reflex
o Stroke the bottom of the foot; the toes flex normally and extend with an upper motor
nerve injury
Investigations and Management of Vertebral Column Injury
Investigations
• X-ray the entire vertebral column.
• X-ray the cervical spine in all patients involved in high-energy multiple trauma.
o All seven cervical vertebrae must be seen on both views.
Management
The first priority is to undertake the primary survey with evaluation of:
• A-Airway maintenance with care and control of a possible injury to the cervical spine
• B -Breathing control or support
• C -Circulation control and blood pressure monitoring

• D -Disability: the observation of neurological damage and state of consciousness
• E -Exposure of the patient to assess skin injuries and peripheral limb damage
• Management of acute lesion especially of thoraco-lumbar spine is based on the
classification of whether the injury is stable or unstable to normal movements.
• Principals of management
o First aid
o Early management
o Refer the patient for definitive treatment:
To preserve neurological function
To relieve any reversible nerve or cord compression
To stabilize the spine
To rehabilitate the patient
o Patient with no neurological deficit
If injury is stable: support vertebral column avoiding further strain-firm neck
collar/lumbar brace
Bed rest
If injury is unstable: should be held secure until tissues heal and vertebral column
is stable
o Patients with incomplete neurological loss
If injury is stable: conservative management–bed rest until pain subsides then
local support.
If injury unstable: refer for early operative reduction or decompression.
Key Points
• Head injury occurs following an impact to the head.
• Alteration of consciousness is the hallmark of brain injury.
• Among the consequences of head injury is increased intracranial pressure due to:
o Brain swelling
o Contusion
o Intracranial haematomas
Acute epidural haematoma
Acute subdural haematoma
Intracerebral haematoma
Subarachnoid haemorrhage
• Determine level of consciousness by using Glasgow coma scale which has three
parameters:
o Motor response
o Verbal response
o Eye opening
• Evaluate the spine based on a history of injury, physical examination, a complete
neurological examination and X-rays.
• Spinal column injuries are stable or unstable, based on bone and ligament damage.
• Base your treatment on the extent of injury.
Evaluation
• What are the clinical presentations of head injuries
• Mention the complications of head injury.
• What are the clinical features of spine injury?

References

Instructions:
paper.
Case Information
A 30-year-old male is brought to the health centre with the history of loss of consciousness,
bleeding from nose, and a large bleeding cut wound on the scalp. He was involved in a motor
bicycle accident few hours ago. His pulse rate is 140bpm and his blood pressure is
95/60mmHg systolic.
Questions:
2. List down the possible investigations

The development of these training materials was supported through funding from the President’s Emergency Plan for AIDS Relief
(PEPFAR) through the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA)
Cooperative Agreement No. 6 U91 HA 06801, in collaboration with the U.S. Centers for Disease Control and Prevention’s Global AIDS
Programme (CDC/GAP) Tanzania. Its contents are solely the responsibility of the authors and do not necessarily represent the official
views of HRSA or CDC.

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UNITED REPUBLIC OF TANZANIA

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

Background and Acknowledgement ........................................................................ iv

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

In September 2009, MOHSW embarked on an innovative approach of developing the

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

These participants are listed with our gratitude below:

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

Editorial Review Team

Librarians and Secretaries

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

Who is the Module For?

How is the Module Organized?

How Should the Module be Used?

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

Introduction to Surgery and Components of Surgical Practice

History Taking in Surgery

The Process of Taking Surgical History

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

The Process of Physical Examination

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

Basic Principles of Management in Surgery

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

On The Day of Surgery

After Surgery Care (Post Operative Care)

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

The Operative Note

Postoperative Note and Orders

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

Definition, Pathophysiology and Classification

Pathophysiology of a Wound Infection

Signs of Acute Inflammation (Cardinal Signs of Inflammation)

Figure 1: An Open Wound and the Balances of Force

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

Figure 2: The Effect of a Stitch

Source: Bewes P, 1984, AMREF

Cleansing the Wound (Social Toilet)

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

Source: Bewes, 1984

Figure 5: Trimming the Skin Edge

Source: Bewes, 1984

Classes and Indications for Wound Closures

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

Complications of Wounds and their Management

Management of Soft Tissue Injuries

Complications of Soft Tissue Injuries and Their Management

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

Introduction to Animal Bites and Stings

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

Clinical Presentation of Animal Bites and Stings

Signs and Symptoms of Snake Toxins/Venom

Signs and Symptoms of Stings

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

Management of Animal Bites and Stings

Primary Survey Assessment

CMT 05210 Surgery NTA Level 5 Semester 2 Student Manual

Case Study: Snake Bite