° dueston of 89 3 is ° ‘A.52 year man is admitted to the vascular ward for an amputation. The patient complains of unsteadiness. On further examination you detect right facial numbness and right sided nystagmus. There is sensory loss of the left side of the body. What is the most likely lesion? Posterior cerebral artery infarct Pontine infarct, Lacunar infarct Anterior cerebral artery infarct ‘A combination of ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy with contralateral hemisensory loss indicates this diagnosis, [4 [| imorove | Stroke: types * Primary intracerebral haemorrhage (PICH, c. 10%) Total anterior circulation infarcts (TaCI, ¢. 15%) Partial anterior circulation infarcts (PACI, c. 25%) Lacunar infarcts (LACI, c. 25%) Presents with headache, vomiting, loss of, consciousness Involves middle and anterior cerebral arteries Hemiparesis/hemisensory loss Homonymous hemianopia Higher cognitive dysfunction e.g. Dysphasia Involves smaller arteries of anterior circulation €.g. upper or lower division of middle cerebral artery Higher cognitive dysfunction or two of the three TAC! features Involves perforating arteries around the internal capsule, thalamus and basal ganglia Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxiaPosterior circulation infarcts + Vertebrobasilar arteries (POCI, c. 25%) ‘+ Presents with features of brainstem damage + Ataxia, disorders of gaze and vision, cranial nerve lesions Lateral medullary syndrome + Wallenberg's syndrome (posterior inferior cerebellar + Ipsilateral: ataxia, nystagmus, dysphagia, facial artery) numbness, cranial nerve palsy + Contralateral: limb sensory loss Weber's syndrome + Ipsiateral il palsy + Contralateral weakness Anterior cerebral artery * Contralateral hemiparesis and sensory loss, lower extremity > upper * Disconnection syndrome Middle cerebral artery * Contralateral hemiparesis and sensory loss, upper extremity > lower *+ Contralateral hemianopia + Aphasia (Wernicke's) * Gaze abnormalities Posterior cerebral artery * Contralateral hemianopia with macular sparing * Disconnection syndrome Lacunar * Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia Lateral medulla (posterior inferior cerebellar artery) * Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner's * Contralateral: limb sensory loss Pontine + Vinerve: horizontal gaze palsy + Vilnerve * Contralateral hemiparesiseo Question 2 of 89 v Bp oO ‘A.25 year old man is shot in the abdomen and is transferred to the operating theatre following arrival in the emergency department, as he is unstable and a FAST scan is positive. At operation there is an extensive laceration to the right lobe of the liver and involvement of the IVC. There is massive haemorrhage. What is the most appropriate initial approach to blood component therapy? Use Factor VIII concentrates early Avoid use of 'o' negative blood ‘Transfuse packed cells and FFP in a fixed ratio of 4:1 Perform goal directed transfusion based on the Hb, PT and TEG studies ‘There is strong evidence to support the use of haemostatic transfusion in the setting of major haemorrhage due to trauma. This advocates the use of 1:1:1 ratios. [+ | improve Transfusions in major trauma * Uncontrolled haemorrhage accounts for up to 39% of all trauma related death. In the UK approximately 2% of all trauma patients will need massive transfusion. Massive transfusion is defined as the replacement of a patient's total blood volume in less than 24 hours, of as the acute administration of more than half the patient's estimated blood volume per hour. In haemorrhaging patients following trauma there is evidence to support the initial administration of ‘ranexamic acid (CRASH study). During acute bleeding the practice of haemostatic resuscitation has been shown to reduce mortality rates. The principle of haemostatic resuscitation is that blood components are transfused in fixed ratios. For example; packed red cells, FFP and platelets are administered in a ratio of 1:1:1 The typical therapeutic end points include: + Hb: 8-10 g/dl + Platelets > 100 * PT (INR) and APTT < 1.5, * Fibrinogen > 1.0 g/l + cat*> 1 mmol/| + pH: 7.95-7.45 + BE +/-2 + T°c>36°C° Question 3 of 89 ¥ 8 °o ‘An 18 year old male is shot in the left chest. He was unstable but his blood pressure has Improved with 1 litre of crystalloid. His chest x-ray shows a left sided pneumothorax with no lung Visible. What is the best course of action? Insertion of 14Fr chest drain Thoracotomy in ED Thoracotomy in theatre Thoracoscopy The issue in this question is that its a traumatic pneumothorax. As a result, there isa risk of bleeding and indeed, of underlying parenchymal lung injury (these can develop into recurrent pneumothoraces quickly). Blood of even small volumes can quickly block narrow lumen drains and these can then allow a tension pneumothorax to develop. A large bore drain is less likely to develop such a complication and is preferred in the setting of trauma [ [ot | improve Thoracic trauma * Key points related to thoracic trauma * Less than 10% of blunt chest trauma and 15-30% of penetrating chest trauma requires operative intervention. * The physiologic consequences of thoracic trauma are hypoxia, hypercarbla, and acidosis Contusion, hematoma, and alveolar collapse, or changes in intrathoracic pressure relationships (e.g., tension pneumothorax and open pneumothorax) cause hypoxia and lead to metabolic acidosis. Hypercarbia causes respiratory acidosis and most often follows inadequate ventilation caused by changes in intrathoracic pressure relationships and depressed level of consciousness. ‘Types of thoracic trauma Tension ‘+ Often laceration to lung parenchyma with flap pneumothorax + Pressure develops in thorax ‘+ Most common cause is mechanical ventilation in patient with pleural injury ‘+ Symptoms overlap with cardiac tamponade, hyper-resonant Percussion note is more likely in tension pnemothoraxFlail chest Pneumothorax Haemothorax Cardiac tamponade Pulmonary contusion Blunt cardiac jury Diaphragm disruption Mediastinal traversing wounds Chest wall disconnects from thoracic cage Multiple rib fractures (at least two fractures per rib in at least two ribs) Associated with pulmonary contusion Abnormal chest motion ‘Avoid over hydration and fiuid overload Most common cause Is lung laceration with air leakage Most traumatic pneumothoraces should have a chest drain Patients with traumatic pneumothorax should never be ‘mechanically ventilated until a chest drain is inserted Most commonly due to laceration of lung, intercostal vessel or internal mammary artery Haemothoraces large enough to appear on CXR are treated with large bore chest drain Surgical exploration is warranted if >1500mI blood drained immediately Beck's triad: elevated venous pressure, reduced arterial pressure, reduced heart sounds Pulsus paradoxus May occur with as little as 100m! blood Most common potentially lethal chest injury Arterial blood gases and pulse oximetry important Early intubation within an hour if significant hypoxia Usually occurs secondary to chest wall injury ECG may show features of myocardial infarction ‘Sequelae: hypotension, arrhythmias, cardiac wall motion abnormalities Deceleration injuries Contained haematoma Widened mediastinum Most due to motor vehicle accidents and blunt trauma causing large radial tears (laceration injuries result in small tears) More common on left side Insert gastric tube, may pass into intrathoracic stomach Entrance wound In one hemithorax and exit wound/forelgn body in ‘opposite hemithorax Mediastinal haematoma or pleural cap suggests great vessel injury Mortality is 20%°o Question 4 of 89 v n oO ‘A Medical F1 phones you as he is concerned his patient has had a major internal bleed. The Patient is 42 years old and is known to have sickle cell anaemia. His blood results are: Hb 3.7 g/dl Reticulocyte count 0.4% His Hb is normally 7g/dl. What is the diagnosis? Psoas haemorrhage Acute sequestration Splenic haemorrhage Acute haemolysis A sudden anemia and a LOW reticulocyte count indicates parvovirus. Acute sequestration and haemolysis causes a high reticulocyte count. There is no clinical indication to suspect a bleed, therefore you can advise the F1 not to panic and to speak to the haematologists! [| ot | improve Sickle cell anaemi + Autosomal recessive + Single base mutation + Deoxygenated cells become sickle in shape + Causes: short red cell survival, obstruction of microvessels and infarction * Sickling is precipitated by: dehydration, infection, hypoxia + Manifest at 6 months age * Africans, Middle East, Indian + Diagnosis: Hb electrophoresis Sickle crises + Bone pain * Pleuritic chest pain: acute sickle chest syndrome commonest cause of death + CVA, seizures + Papillary necrosis * Splenic infarcts + Priapism + Hepatic painHb does not fall during a crisis, unless there is * Aplasia: parvovirus + Acute sequestration + Haemolysis Long-term complications. * Infections: Streptococcus pnemoniae * Chronic leg ulcers * Gallstones: haemolysis * Aseptic necrosis of bone * Chronic renal disease *+ Retinal detachment, proliferative retinopathy Surgical complications * Bowel ischaemia * Cholecystitis * Avascular necrosis Management + Supportive + Hydroxyurea ‘+ Repeated transfusions pre operatively ‘+ Exchange transfusion in emergencies Sickle cell trait ‘+ Heterozygous state ‘Asymptomatic Symptoms associated with extreme situations ie anaesthesia complications + Protective against Plasmodium falciparum Save my notes Search° aueston of 9 ’ bp © A 28 year old man complains of pain and weakness in the shoulder. He has recently been unwell with glandular fever from which he Is fully recovered. On examination there Is some evidence of muscle wasting and a degree of winging of the scapula. Power during active movements is impaired. What is the most likely cause? Adhesive capsulitis, Rotator cuff tear Osteoarthritis: Calcific tendonitis This Is a peripheral neuropathy that may complicate viral ilinesses and usually resolves spontaneously. | | Improve Shoulder disorders * Shoulder fractures and dislocations Fractures Proximal humerus Background * Third most common fragility fracture in the elderly. * Results from low energy fall in predominantly elderly females, or from high energy trauma in young males, * Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detalled neurological assessment is essential for all upper limb injuries. Anatomy Osteology Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck. The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity. Vascular Supply Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis.Imaging Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation ‘+ Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view. + CT- indicated to better define intra-articular involvement and to aid pre-operative planning. MRI is not useful for fracture imaging. Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion). - Neer Classification: Most commonly used. Describes fracture as 2,3,0r 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments: “greater tuberosity slesser tuberosity - articular surface - shaft Displacement: »1cm or angulation >45 degrees. Treatment ‘The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive ‘mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks, Irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include: oRIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures. Intramedullary Suitable for extra-articular configuration, predominantly surgical neck nal +/-GT fractures Hemlarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality Total shoulder _Unconstructable fractures where high functioning shoulder Is required arthroplasty (hemiarthroplasty will cause glenoid erosion) Reverse shoulder Total shoulder arthroplasty that provides better functional outcome than arthroplasty conventional total shoulder replacement. Seapula BackgroundUncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury. Imaging Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction. Classification Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton Treatment ‘The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenold fractures. Dislocations Types Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here. Glenohumeral dislocation Diagnosis, classification and management are covered here. Background Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that Is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage. Early assessment and management Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and. documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation), This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation. Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view. Types Reduction Direction Features Cause Examination techniquesAnterior Most. Usually traumatic - Loss of shoulder Common — anterior force on arm contour- sulcus sign. Hippocratic. 290% when shoulder is Humeralheadcan be — Mich abducted, externally felt anteriorly Stimson. rotated Kocher not advised due to complication of fracture Posterior 50% 50% traumatic, but Shoulder locked in Gentle lateral missed classically post seizure _ internal rotation. XR__traction to inA&E —_orelectrocution may show lightbulb _adducted appearance. arm. Inferior Rare Associated with As for primary injury Management pectorals and rotator of primary cuff tears, and glenoid Injury fracture Superior Rare Associated with ‘As for primary injury Management acrominon/clavicle of primary fracture Injury Associated injuries ‘+ Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation). ‘+ Hill Sachs defect - chondral impaction on posterlosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation), ‘+ Rotator cuff tear - Increases with age. ‘+ Greater or lesser tuberosity fracture - increases with age. ‘+ Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction Rotator Cuff Disease Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis). ‘Anatomy The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability. ‘Scapular Humeral Muscle attachment attachment ‘Action Innervation‘Supraspinatus Supraspinatus Superior facet of Initiation of Suprascapular fossa greater abductionof nerve ‘tuberosity humerus Infraspinatus _Infraspinatus Posterlorfacet_ External ‘Suprascapular fossa of greater rotation of nerve tuberosity humerus, Teres Minor Lateral border Inferior facet of External Axillary Nerve greater rotation of tuberosity humerus Subscapularis Subscapuler_—_Lesser Internal rotation Upper and lower fossa tuberosity of humerus subscapular nerve + The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid, Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph), * Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles. (infraspinatus, teres minor) Subacromial Impingement * The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis. * Associated with certain types of acromial morphology (Biglian| classification). + Presents as insidious pain which is exacerbated by overhead activities. Rotator Cuff Tear * Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients, ‘+ Majority of tears are to the superior cuff (supraspinatus, Infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement. * Tears present as pain and weakness when using the muscles in question, Rotator Cuff Arthropathy * Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly * Associated with massive chronic cuff tears. Plain radiographs * AP of the shoulder may show superior migration of the humerus with a cuff tear, andfeatures of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture) * Outlet view is useful for defining the acromial morphology uss * Allows dynamic imaging of the cuff, and Is inexpensive. However, itis very user dependent. MRI * Best imaging modality for cuff pathology. * Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity. Treatment Subacromial impingement + Physiotherapy, oral anttinflammatory medication + Subacromial steroid injection can settle inflammation + Arthroscopic subactomial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary. Rotator cuff tear ‘+ When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan. + Mild tears or tears in the elderly can be managed conservatively, as outlined above. + Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence. Calcific tendonitis, Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain. Pathology ‘+ More common in women aged 30-60 years. * Association with diabetes and hypothyroidism There are three stages of calcification ‘+ Formative phase characterized by calcific deposits ‘+ Resting phase deposit is stable, but presents with impingement problems ‘+ Resorptive phase phagocytic resorption. Most painful stage. Presentation + Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature.Imaging + Plain radiographs show calcification of the rotator cuff, usually within 1.5em of its Insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging Is rarely needed Treatment ‘+ Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management. ‘+ Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required Adhesive capsulitis (Frozen Shoulder) + Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion. ‘+ Associated with prolonged immobilization, previous surgery, thyroid disorders (Al) and. diabetes + Classically three stages which can take up to two years to resolve: Imaging + Plain radiographs to exclude other causes of a painful shoulder ‘+ MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical. Treatment ‘+ Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve. + Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy. Glenohumeral Arthritis Background ‘+ May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy, Majority of those with RA will develop symptoms. ‘+ More common in the elderly ‘+ Presents like any other arthritis - pain at night and with movement Imaging + AP and axillary radiographs will show features of arthritis. + CT/MRl is often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacement.Treatment Like all orthopaedics, start with simple measures: + NSAIDS, management of RA, physiotherapy, sterold injection, + Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity. * Arthroscopic debridement is useful if patient has isolated ACY arthritis, but is rarely used for glenohumeral arthritis, + Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival, * Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse Is preferable when the cuff if questionable in integrity. References 1, JAMA, 2015;313(10):1037-1047. dol:10.1001/jama.2015.1629 Bie ‘Save my notes Search ‘Search textbook. ‘Q Google search on "Shoulder disorders” Suggest tink suggest media Dashboard aaron KOOKS(¢) Question 6 of 89 ¥ B © ‘16 year old man sustains a basal skull fracture and is suspected of having CSF thinorrhoea, Which of the following laboratory tests would most accurately identify whether CSF is present or not? Microscopy to identify red blood cells Lab stix testing for glucose Lab stix testing for protein Microscopy, gram stain and culture Beta 2 transferrin is a carbohydrate free form of transferrin that is almost exclusively found in the CSF. Although lab stix testing for glucose is traditional itis associated with false positive results secondary to contamination with other glucose containing bodlly secretions, oo | @ | Improve Head injury management- NICE Guidelines * ‘Summary of guidelines All patients should be assessed within 15 minutes on arrival to A&E + Document all 3 components of the GCS + If GCS <8 or = to 8, consider stabilising the airway * Full spine immobilisation until assessment if: -GOS<15 neck pain/tenderness paraesthesia extremities - focal neurological deficit - suspected ¢-spine injury Ifa c-spine injury is suspected a 3 view c-spine x-ray is indicated. CT c-spine is preferred if - Intubated - GCS <13 Normal x-ray but continued concerns regarding ¢-spine injury - Any focal neurology ‘ACT head scan is being performed = Initial plain films are abnormal Immediate CT head (within 1 hour) if: + GCS<13 on admission* GCS<15 2 hours after admission + Suspected open or depressed skull fracture * Suspected skull base fracture (panda eyes, Battle's sign, CSF from nose/ear, bleeding ear) * Focal neurology + Vomiting > 1 episode * Post traumatic seizure + Coagulopathy (or receiving anticoagulant). Contact neurosurgeon if: + Persistent GCS <8 or = 8 * Unexplained confusion > 4h + Reduced GCS after admission * Progressive neurological signs + Incomplete recovery post seizure + Penetrating injury * Cerebrospinal fluid leak Observations + 1/2 hourly GCS until 15 Reference 1, NICE Guidance C6176 (Published 2019). 2, Hodgkinson S et al. Early management of head injury: summary of NICE guidance. BMJ 2014 (348):34-37. [ save my notes Search Search textbook. a Q Google search on “Head injury management: NICE Guidelines Suggest nk ‘+ Suggest media° Question 7 of 89 x 5 So 68 year old male is admitted to the surgical ward for assessment of severe epigastric pain. His abdomen is soft and non tender. However the Nurse forces you to look at the ECG. It looks abnormal. Which of the following features is an indication for urgent coronary thrombolysis or percutaneous intervention? Right bundle branch block ‘ST elevation of 1mm in leads V1 to V6 [verse tachycardia Q waves in leads V1 to V6 ECG changes for thrombolysis or percutaneous intervention: ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (Ii, Il, avF, avL) OR New Left bundle branch block ST elevation of 1mm in leads Il, ll and aVF reflects significant cardiac ischaemia due to the right coronary artery occlusion. The medical registrar should be contacted to urgently assess the patient. Note right coronary artery occlusions puts the patient at risk of cardiac arrhythmias (due to blood supply to the sino atrial node). | @ | Improve Thrombolysis or percutaneous intervention in myocardial infarction * Thrombolytic drugs activate plasminogen to form plasmin. This in tum degrades fibrin and help breaks up thrombi. They in primarily used in patients who present with a ST elevation myocardial Infarction. Other indications include acute ischaemic stroke and pulmonary embolism, although strict inclusion criteria apply. Examples + alteplase + tenecteplase + streptokinaseContraindications to thrombolysis * active internal bleeding * recent haemorrhage, trauma or surgery (including dental extraction) + coagulation and bleeding disorders * intracranial neoplasm + stroke <3 months * aortic dissection recent head injury * pregnancy * severe hypertension Side-effects + haemorthage + hypotension - more common with streptokinase * allergic reactions may occur with streptokinase Bie [Sevens] Search Search textbook GB ‘Q Google search on "Thrombolysis or percutaneous intervention in myocardial infarction” + Suggest lnk ‘Suggest media Dashboard Moaarena ELEBs awestinore9 © ‘27 year old man is involved in a road traffic accident. He is seen in the emergency department with chest pain. Clinical examination is essentially unremarkable and he is discharged. He subsequently is found dead at home. What Is the most likely underlying injury? Tracheobronchial tree injury Cardiac laceration Diaphragmatic rupture Rupture of the oesophagus Aortic injuries that do not die at the scene may have a contained haematoma, Clinical signs are subtle and the diagnosis may not be apparent on clinical examination. Without prompt treatment the haematoma usually bursts and the patient dies. wo | @ | Improve Thoracic aorta rupture * ‘+ Mechanism of injury: Decelerating force Le. RTA, fall from a great height * Most people die at scene ‘+ Survivors may have an incomplete laceration at the ligamentum arteriosum of the aorta Clinical features * Contained haematoma: persistent hypotension * Detected mainly by history, CXR changes CXR changes * Widened mediastinum + Trachea/Oesophagus to right * Depression of left main stem bronchus + Widened paratracheal stripe/paraspinal interfaces * Space between aorta and pulmonary artery obliterated * Rib fracture/left haemothorax Diagnosis Angiography, usually CT aortogram. Treatment Repair or replacement. Ideally they should undergo endovascular repair.° Question 9 of 89 v B So ‘4.68 year old man Is involved in a road traffic accident that is relatively minor and sustains a minor head injury with small associated scalp laceration. Apart from atrial fibrillation for which he is treated with bisoprolol and dabigatran. He is well. On examination, he Is well and GCS Is 15 with no localizing neurological signs. What is the most appropriate course of action? Arrange a skull x-ray Arrange an MRI scan of the brain Admit for observation with GCS measurements every 30 minutes Admit for observation with GCS measurements every 60 minutes Head injury with anticoagulants= CT head | | imorove | Head injury management- NICE Guidelines * ‘Summary of guidelines * All patients should be assessed within 15 minutes on arrival to A&E + Document all 3 components of the GCS + If GCS <8 or = to 8, consider stabilising the airway * Full spine immobilisation until assessment if -GCS<15 neck pain/tenderness paraesthesia extremities - focal neurological deficit suspected c-spine injury Ifa c-spine injury is suspected a 3 view c-spine x-ray Is indicated. CT c-spine is preferred if: - Intubated Ges <13 - Normal x-ray but continued concerns regarding c-spine injury Any focal neurology - ACT head scan Is being performed = Initial plain films are abnormalImmediate CT head (within 1 hour) if: + GCS<13 on admission + GCS<152 hours after admission + Suspected open or depressed skull fracture + Suspected skull base fracture (panda eyes, Battle's sign, CSF from nose/ear, bleeding ear) + Focal neurology + Vomiting > 1 episode + Post traumatic seizure + Coagulopathy (or receiving anticoagulant), Contact neurosurgeon if: + Persistent GCS <8 or = 8 + Unexplained confusion > 4h + Reduced GCS after admission + Progressive neurological signs * Incomplete recovery post seizure + Penetrating injury + Cerebrospinal fluid leak Observations + 1/2 hourly GCs until 15 Reference 1. NICE Guldance C6176 (Published 2019). 2. Hodgkinson $ et al. Early management of head injury: summary of NICE guidance. BMJ 2014 (348):34-37, Save my notes Search Search textbook Bg Q Google search on “Head injury management: NICE Guidelines* Suggest nk “Suggest mediaVy ‘Question 10 of 89 = ba) 77 ‘A 62 year old male attends the hemnia clinic. He suddenly develops speech problems, left facial weakness and left sided arm and leg weakness lasting longer than 5 minutes. A CT head shows no intracerebral bleed. What is the next line of management? Aspirin 300mg Aspirin 75 mg z Clopidogrel 300mg Carotid endarterectomy This patient is within 3h of symptom onset of a stroke. Therefore he should be urgently referred to the medical team for thrombolysis, before Aspirin Is given. There are concerns that high dose aspirin would increase the risk of intracerebral haemorrhage if thrombolysis is undertaken. This Is an example of the type of medical problem you should be aware of as a surgeon, as ultimately you can make a difference by referring QUICKLY to the correct specialty for ‘management. Improve Stroke: types * Primary intracerebral * Presents with headache, vomiting, loss of haemorrhage (PICH, c. 10%) consciousness Total anterior circulation infarcts * Involves middle and anterior cerebral arteries (TACI, ¢. 15%) + Hemiparesis/hemisensory loss * Homonymous hemianopia * Higher cognitive dysfunction e.g. Dysphasia Partial anterior circulation * Involves smaller arteries of anterior circulation infarcts (PACI, c. 25%) .g. upper or lower division of middle cerebral artery * Higher cognitive dysfunction or two of the three TACI features Lacunar infarets (LACI, c. 25%) * Involves perforating arteries around the internal capsule, thalamus and basal ganglia * Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxiaPosterior circulation infarcts * Vertebrobasilar arteries (POCI, c. 25%) * Presents with features of brainstem damage * Ataxia, disorders of gaze and vision, cranial nerve lesions Lateral medullary syndrome * Wallenberg's syndrome (posterior inferior cerebellar * Ipsilateral: ataxia, nystagmus, dysphagia, facial artery) numbness, cranial nerve palsy + Contralateral: limb sensory loss Weber's syndrome + Ipsilateral il palsy + Contralateral weakness Anterior cerebral artery + Contralateral hemiparesis and sensory loss, lower extremity > upper ‘+ Disconnection syndrome Middle cerebral artery + Contralateral hemiparesis and sensory loss, upper extremity > lower + Contralateral hemianopia + Aphasia (Wemnicke's) + Gaze abnormalities Posterior cerebral artery + Contralateral hemianopia with macular sparing + Disconnection syndrome Lacunar ‘+ Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia Lateral medulla (posterior inferior cerebellar artery) * Ipsilateral: ataxla, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g, Horner's + Contralateral: limb sensory loss Pontine + Vinerve: horizontal gaze palsy + Vilnerve + Contralateral hemiparesis°o Question 11 of 89 & B >) A 20 year old man is hit over the head with a mallet. On arrival in the accident and emergency department he opens his eyes to pain and groans or grunts. On application of a painful stimulus to his hands, he extends his arm at the elbow. What is his Glasgow coma score 10 eo 2:00 3 7 ¥ @ E=2, V= 2, M=2. oo | | Improve Glasgow coma scale * Modality options Eye opening ‘+ Spontaneous + To speech + To pain + None Verbal response + Orientated = Confused © Words + Sounds + None Motor response + Obeys commands + Localises to pain + Withdraws from pain ‘+ Abnormal flexion to pain (decorticate posture) + Extending to pain + None<) Question 12 of 89 v ) ©} A year old boy falls off a wall the distance is 7 feet. He lands on his left side and there is left flank bruising, There is no haematuria. He is otherwise stable and haemoglobin is within normal limits. What Is the most appropriate initial course of action? Undertake a CT scan of the abdomen Undertake diagnostic peritoneal lavage Undertake a splenectomy Arrange an angiogram and possibly proceed to embolisation This will demonstrate any overt splenic injury. A CT scan carries a significant dose of radiation. In the absence of haemodynamic instability or other major associated injuries the use of USS to ‘exclude intraabdominal free fluid (blood) would seem safe when coupled with active observation. ANUSS will also show splenic haematomas. «+ Improve Splenic trauma * The spleen is one of the more commonly injured intra abdominal organs + In most cases the spleen can be conserved. The management is dictated by the associated injuries, haemodynamic status and extent of direct splenic injury. Management of splenic trauma Conservative ‘Small subcapsular haematoma Minimal intra abdominal blood No hilar disruption Laparotomy with conservation Increased amounts of intraabdominal blood Moderate haemodynamic compromise Tears or lacerations affecting <50% Resection Hilar injuries Major haemorthage Major associated injuries Splenectomy TechniqueTrauma + GA + Long midline incision * If time permits insert a self retaining retractor (e.g. Balfour/ omnitract) * Large amount of free blood is usually present. Pack all 4 quadrants of the abdomen. Allow the anaesthetist to ‘catch up’ + Remove the packs and assess the viability of the spleen. Hilar injuries and extensive parenchymal lacerations will usually require splenectomy. * Divide the short gastric vessels and ligate them, * Clamp the splenic artery and vein. Two clamps on the patient side are better and allow for double ligation and serve as a safety net if your assistant does not release the clamp smoothly. * Be careful not to damage the tail of the pancreas, if you do then this will need to be formally removed and the pancreatic duct closed. * Wash out the abdomen and place a tube drain to the splenic bed * Some surgeons implant a portion of spleen into the omentum, whether you decide to do this is a matter of personal choice. + Post operatively the patient will require prophylactic penicillin V and pneumococcal vaccine. Elective Elective splenectomy is a very different operation from that performed in the emergency setting, The spleen Is often large (sometimes massive). Most cases can be performed laparoscopically. The spleen will often be macerated inside a specimen bag to facilitate extraction. Complications + Haemorthage (may be early and either from short gastries or splenic hilar vessels * Pancreatic fistula (from iatrogenic damage to pancreatic tall) * Thrombocytosis: prophylactic aspirin * Encapsulated bacteria infection e.g. Strep. pneumoniae, Haemophilus influenzae and Nelsseria meningitidis = ir & we Save my notes Search Search textbook Q Google search on “Splenic trauma’ Suggest ink[<) Question 13 of 89 x 5 (>) 82 year old male type 2 diabetic is admitted to the vascular ward for a femoral popliteal bypass. He suddenly develops expressive dysphasia and marked right sided weakness. The Senior house officer arranges a CT head scan which shows a 60% left middle cerebral artery territory infarct. There are no beds on the stroke unit. Overnight the patient becomes unresponsive and a CT head confirms no bleed. What Is the next best management option? IV heparin [Berson Burr hole surgery Aspirin The likely cause for the reduced consciousness Is raised intracranial pressure due to increasing cerebral oedema related to the infarct. In this situation, urgent neurosurgical review is needed for possible decompressive hemicranleotomy to relieve the pressure. Ideally no further antiplatelet or anticoagulation therapy should be given until a plan for surgery is confirmed. Indications for hemicranieotomy include: * Age under 60 years Clinical deficit in middle cerebral artery territory Decreased consciousness >50% territory infarct | @ | Improve Stroke: types * Primary intracerebral + Presents with headache, vomiting, loss of haemorrhage (PICH, c. 10%) consciousness Total anterior circulation infarcts * Involves middle and anterior cerebral arteries (TACI, c. 15%) + Hemiparesis/hemisensory loss + Homonymous hemianopia ‘+ Higher cognitive dysfunction e.g. DysphasiaPartial anterior circulation infarcts (PACI, c. 25%) Lacunar infarcts (LACI, c. 25%) Posterior circulation infarcts (POCI, c. 25%) Lateral medullary syndrome (posterior inferior cerebellar artery) Weber's syndrome Anterior cerebral artery Involves smaller arteries of anterior circulation €.g. upper or lower division of middle cerebral artery Higher cognitive dysfunction or two of the three TAC! features Involves perforating arteries around the internal capsule, thalamus and basal ganglia Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia Vertebrobasilar arteries Presents with features of brainstem damage Ataxia, disorders of gaze and vision, cranial nerve lesions Wallenberg's syndrome Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy Contralateral: limb sensory loss Ipsilateral Ill palsy Contralateral weakness ‘+ Contralateral hemiparesis and sensory loss, lower extremity > upper ‘+ Disconnection syndrome Middle cerebral artery ‘+ Contralateral hemiparesis and sensory loss, upper extremity > lower Contralateral hemianopia ‘Aphasia (Wernicke's) ‘+ Gaze abnormalities Posterior cerebral artery = Contralateral hemianopia with macular sparing ‘+ Disconnection syndrome Lacunar + Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxiaLateral medulla (posterior inferior cerebellar artery) * Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner's. * Contralateral: limb sensory loss Pontine * Vinerve: horizontal gaze palsy + Vilnerve * Contralateral hemiparesis Tr &- @ @ + Suggest lnk “+ suggest media ‘SeomasihConscaner3° Question 14 of 89 v n oS ‘63 year old male is admitted to the surgical ward for an elective femoral popliteal bypass. He suddenly starts complaining of central, crushing chest pain which Is radiating to the left arm. An ECG shows some ischaemic changes. The Nursing staff start high flow oxygen and give a spray of glyceryl trinitrate spray. Unfortunately there is no relief of symptoms, What is the next agent to, be administered? Aspirin 75mg Clopidogrel 75mg Clopidogrel 300mg Direct admission to angiography suite Aspirin 300mg should be given as soon as possible. If the patient has a moderate to high risk of ‘myocardial infarction, then Clopidogrel should be given with a low molecular weight heparin Thromboloysis or urgent percutaneous intervention should be given if there are significant ECG changes. Management of acute coronary syndrome * NICE produced guidelines in 2010 on the management of unstable angina and non-ST elevation ‘myocardial infarction (NSTEMI). They advocate managing patlents based on the early risk ‘assessment using a recognised scoring system such as GRACE (Global Registry of Acute Cardiac Events) to calculate a predicted 6 month mortality All patients should receive - aspirin 300mg - nitrates or morphine to relieve chest pain if required Whilst its common that non-hypoxic patients receive oxygen therapy there Is ttle evidence to support this approach. The 2008 British Thoracic Society oxygen therapy guidelines advise not giving oxygen unless the patient is hypoxic. Antithrombin treatment. Low molecular weight heparin should be offered to patients who are not at a high risk of bleeding and who are not having angiography within the next 24 hours. if angiography is likely within 24 hours or a patients creatinine is > 265 umol/l unfractionated heparin should be given. Clopidogrel 300mg should be given to patients with a predicted 6 month mortality of more than1.5% or patients who may undergo percutaneous coronary intervention within 24 hours of admission to hospital. Clopidogrel should be continued for 12 months. Intravenous glycoprotein Ilb/llla receptor antagonists (eptifibatide or tirofiban) should be given to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission, Coronary angiography should be considered within 96 hours of first admission to hospital to patients who have a predicted 6-month mortality above 3.0%. It should also be performed as soon as possible in patients who are clinically unstable. Reaitteatt Save my notes Search Search textbook GB Q Google search on "Management of acute coronary syndrome” + Suggest nk “suggest media Dashboard tv 20 av av 5 ov ov 7% ev ov 10 v uv wye Question 15 of 89 v n ©} Which of the following is not a change found on an ECG in acute pulmonary embolism? No changes P pulmonale Right ventricular strain ‘Twave inversion in the inferior leads $1, Q3, 3 J waves are pathognomonic of hypothermia, [ [ot | improve Pulmonary Embolism: ECG changes * + No changes + $1,03,T3 + Tall R waves: V1 + P pulmonale (peaked P waves): inferior leads * Right axis deviation, Right bundle branch block + Atrial arrhythmias + Twave inversion: V1, V2, V3 * Right ventricular strain: if identified is associated with adverse short-term outcome and adds prognostic value to echocardiographic evidence of right ventricular dysfunction in patients with acute pulmonary embolism and normal blood pressure. References Vanni $ et al. Prognostic value of ECG among patients with acute pulmonary embolism and normal blood pressure, Am J Med. 2009 Mar;122(3):257-64, [save mynces |BG weston teofa9 © A 28 year old Indian woman, who Is 18 weeks pregnant, presents with increasing shortness of breath, chest pain and coughing clear sputum. She is apyrexial, blood pressure Is 140/80 mmHg, heart rate 130 bpm and saturations 94% on 15L oxygen. On examination, there is a mid diastolic murmur, there are bibasal crepitations and mild pedal oedema. She suddenly deteriorates and has a respiratory arrest. Her chest xray shows a whiteout of both of her lungs. What is the most likely explanation? ‘Acute exacerbation asthma Pulmonary embolus Mitral regurgitation Aottic dissection Mitral stenosis is the commonest cause of cardiac abnormality occurring in pregnant women. Mitral stenosis is becoming less common in the UK population, however should be considered in women from countries where there Is a higher incidence of rheumatic heart disease. Mitral stenosis causes mid diastolic murmur which may be difficult to auscultate unless the patient is placed into the left lateral position. These patients ate at risk of atrial fibrillation (up to 40%), which can also contribute to rapid decompensation such as pulmonary oedema (hence exr ‘whiteout ‘of lungs). Physiological changes in pregnancy may cause an otherwise asymptomatic patient to suddenly deteriorate. Balloon valvuloplasty Is the treatment of choice. [4 [9 | improve Chest pain in pregnancy * Aortic dissection + Predisposing factors in pregnancy are hypertension, congenital heart disease and Marfan's syndrome + Mainly Stanford type A dissections + Sudden tearing chest pain, transient syncope + Patient may be cold and clammy, hypertensive and have an aortic regurgitation murmur + Involvement of the right coronary artery may cause inferior myocardial infarction Surgical management Gestational Management timeframe < 28/40 Aortic repair with the fetus kept in utero28-32/40 Dependent on fetal condition > 32/40 Primary Cesarean section followed by aortic repair at the same operation Mitral stenosis + Most cases associated with rheumatic heart disease + Becoming less common in British women; suspect In Immigrant women * Commonest cardiac condition in pregnancy + Commonly associated with mortality * Valve surgery; balloon valvuloplasty preferable Pulmonary embolism * Leading cause of mortality in pregnancy + Half dose scintigraphy; CT chest if underlying lung disease, should aid diagnosis * Treatment with low molecular weight heparin throughout pregnancy and 4-6 weeks after childbirth * Warfarin is contra indicated in pregnancy (though may be continued in women with mechanical heart valves due to the significant risk of thromboembolism) References 1. Bates S.M. and Ginsberg J.S. How we manage venous thromboembolism during pregnancy. Blood 2002 (100): 3470-3478. 2. Scarsbrook A Fand Gleeson V. Investigating suspected pulmonary embolism in pregnancy. BM, 2007 (326) : 1135 doi: 10.1136/bm,7399.1138. 3. Morley C. A. and Lim B. A. Lesson of the Week: The risks of delay in diagnosis of breathlessness In pregnancy. BMJ 1995 (311) : 1083, Search ‘Search textbook. ‘Q Google search on “Chest pain in pregnancy" “Suggest nk°e Question 17 of 89 ’ a So What is the least likely examination finding in patients with Le Fort Il fractures? Excessive mobility of the palate | Peseaessnneresonsptesy nee ent Malocclusion of the teeth Enopthalmos Parasthesia in the region supplied by the infraorbital nerve Le Fort Il fractures have a pyramidal shape. The fracture line involves the orbit and extends to involve the bridge of the nose and the ethmolds. In continues to involve the infraorbital rim and usually through the infraorbital foramen. As a result infraorbital parasthesia, palatal mobility and ‘malocclusion are common findings. Severe fractures may result in enopthalmos. However, the fracture does not, by definition, involve the inferior alveolar nerve. 9 | improve ] Craniomaxillofacial injuries * Craniomaxillofacial injuries in the UK are due to ‘+ Interpersonal violence (52%) Motor vehicle accidents (16%) Sporting injuries (19%) Falls (11%) Le Fort Fractures Grade Feature le The fracture extends from the nasal septum to the lateral pyriform rims, travels Fort horizontally above the teeth apices, crosses below the zygomaticomaxillary junction, and traverses the pterygomaxillary junction to interrupt the pterygoid plates. le These fractures have a pyramidal shape and extend from the nasal bridge at or Fort2 below the nasofrontal suture through the frontal process of the maxilla, Inferolaterally through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus; it then travels under the zygoma, across the pterygomaxiliary fissure, and through the pterygoid plates.Le These fractures start at the nasofrontal and frontomaxillary sutures and extend Fort3 posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmold bones. The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic canal. Instead, the fracture continues along the floor of the orbit along the inferior orbital fissure and continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch, Intranasally, a branch of the fracture extends through the base of the perpendicular plate of the ethmoid, through the vomer, and through the interface of the pterygoid plates to the base of the sphenold. This type of fracture predisposes the patient to CSF rhinorrhea more commonly than the other types. Ocular injuries ‘Superior orbital fissure syndrome Severe force to the lateral wall of the orbit resulting in compression of neurovascular structures. Results in: + Complete opthaimoplegia and ptosis (Cranial nerves 3, 4, 6 and nerve to levator palpebrae superioris) + Relative afferent pupillary defect, + Dilatation of the pupil and loss of accommodation and corneal reflexes + Altered sensation from forehead to vertex (frontal branch of trigeminal nerve) Orbital blow out fracture Typically occurs when an object of slightly larger diameter than the orbital rim strikes the incompressible eyeball. The bone fragment is displaced downwards into the antral cavity, remaining attached to the orbital periosteum. Periorbital fat may be herniated through the defect, interfering with the inferior rectus and inferior oblique muscles which are contained within the same fascial sheath. This prevents upward movement and outward rotation of the eye and the patient experiences diplopia on upward gaze. The initial bruising and swelling may make assessment difficult and patients should usually be reviewed 5 days later. Residual defects may require orbital floor reconstruction. Nasal Fractures + Common injury + Ensure new and not old deformity + Control epistaxis + CSF thinorthoea implies that the cribriform plate has been breached and antibiotics will be required. ‘+ Usually best to allow bruising and swelling to settle and then review patient clinically. Major persistent deformity requires fracture manipulation, best performed within 10 days of injury. Retrobulbar haemorrhage Rare but important ocular emergency. Presents with: + Pain (usually sharp and within the globe) + Proptosis + Pupil reactions are lost + Paralysis (eye movements lost) + Visual acuity is lost (colour vision is lost first) May be the result of Le Fort type facial fractures,Management: + Mannitol 1g/Kg as 20% infusion, Osmotic diuretic, Contra-indicated in congestive heart fallure and pulmonary oedema + Acetazolamide 500mg IV, (Monitor FBC/U+E) Reduces aqueous pressure by inhibition of carbonic anhydrase (used in glaucoma) + Dexamethasone 8mg orally or intravenously + Ina traumatic setting an urgent cantholysis may be needed prior to definitive surgery. Consider Papaverine 40mg smooth muscle relaxant Dextran 40 500mis IV improves perfusion Bie w&- Tr By @ © Search Search textbook B Q Google search on *Craniomaxillofacial injuries * Suggest tink suggest media Dashboard 2246 6WH 44464 aS© Question 18 of 89 v PB °o ‘A.60 year old female presents to the emergency room after tripping on a step. She complains of shoulder pain. On examination there is pain on initiating shoulder abduction. What is the most likely diagnosis? Glenohumeral dislocation Fracture of the anatomical neck of the humerus Stemoclavicular dislocation Infraspinatus tear A supraspinatus tear is the most common of rotator cuff tears. It occurs as a result of degeneration and is rare in younger adults. | 99 | improve Shoulder disorders * ‘Shoulder fractures and dislocations Fractures Proximal humerus Background + Third most common fragility fracture in the elderly. ‘+ Results from low energy fall in predominantly elderly females, or from high energy trauma in young males. + Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries. Anatomy Osteology Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis) Between the tuberosities and the metaphysis is the surgical neck. The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity, Vascular Supply Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis.Imaging Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation, ‘+ Radiographs - True anteroposterior (AP), axillary lateral and/or scapula ¥ view. ‘+ CT indicated to better define intra-articular involvement and to aid pre-operative planning. MRIs not useful for fracture imaging. Classification Description of the fracture is often more useful than classification. Particular attention should be ald to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion). - Neer Classification: Most commonly used. Describes fracture as 2,3,0r 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments: “greater tuberosity lesser tuberosity - articular surface ~shaft Displacement: >1cm or angulation >45 degrees. Treatment The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks. irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include: RIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures. Intramedullary Suitable for extra-articular configuration, predominantly surgical neck all +/-GT fractures, Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality. Total shoulder _Unconstructable fractures where high functioning shoulder is required arthroplasty (hemiarthroplasty will cause glenoid erosion) Reverse shoulder Total shoulder arthroplasty that provides better functional outcome than arthroplasty conventional total shoulder replacement. Scapula BackgroundUncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury. Imaging Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula ¥ view. CT scanning Is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction, Classification Based on the location of the fracture (coracold, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton. Treatment The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and. displaced/angulated glenoid fractures. Dislocations Types Dislocations around the shoulder joint include glenohumeral dislocation, acromioctavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here. Glenohumeral dislocation Diagnosis, classification and management are covered here. Background ‘Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage. Early assessment and management Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation. Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation. Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view. Types Reduction Direction Features Cause Examination techniquesAnterior Most —_—Usually traumatic - Loss of shoulder Common anterior force on arm contour sulcus sign. Hippocratic. 290% when shoulder is Humeral head canbe — Milch abducted, externally felt anteriorly. stimson rotated Kocher not advised due to complication of fracture Posterior 50% 50% traumatic, but Shoulder locked in Gentle lateral missed classically post seizure internal rotation. XR__ traction to inA&E —_orelectrocution may show lightbulb adducted appearance. arm. Inferior Rare Associated with As for primary Injury Management pectorals and rotator of primary cuff tears, and glenoid injury fracture Superior Rare Associated with As for primary injury Management acrominon/clavicle of primary fracture injury Associated injuries ‘+ Bankart lesion - avulsion of the anterior glenold labrum with an anterior shoulder distocation (reverse Bankart if poster labrum in posterior dislocation). ‘+ Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation), ‘+ Rotator cuff tear increases with age. + Greater or lesser tuberosity fracture - increases with age, ‘+ Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction. Rotator Cuff Disease Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis). ‘Anatomy The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability. ‘Scapular Humeral Muscle attachment attachment Action InnervationSupraspinatus Supraspinatus Superior facet of _ initiation of ‘Suprascapular fossa greater abductionof nerve tuberosity humerus, Infraspinatus Infraspinatus Posterior facet External ‘Suprascapular fossa of greater rotation of nerve tuberosity humerus Teres Minor Lateral border Inferior facet of External Axillary Nerve greater rotation of tuberosity humerus Subscapularis Subscapular_ Lesser Internal rotation Upper and lower fossa tuberosity of humerus subscapular nerve ‘+ The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid. Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph). + Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles. (infraspinatus, teres minor) ‘Subacromial impingement ‘+ The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis. ‘+ Associated with certain types of acromial morphology (Bigliani classification) ‘+ Presents as insidious pain which is exacerbated by overhead activities, Rotator Cuff Tear ‘+ Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients, ‘+ Majority of tears are to the superior cuff (supraspinatus, Infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement. ‘+ Tears present as pain and weakness when using the muscles in question, Rotator Cuff Arthropathy + Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly ‘+ Associated with massive chronic cuff tears. Imaging Plain radiographs ‘+ AP of the shoulder may show superior migration of the humerus with a cuff tear, andfeatures of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture) *+ Outlet view is useful for defining the acromial morphology uss * Allows dynamic imaging of the cuff, and is inexpensive. However, itis very user dependent, MRI * Best imaging modality for cuff pathology. * Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity. Treatment ‘Subacromial impingement + Physiotherapy, oral antiinflammatory medication + Subacromial steroid injection can settle inflammation * Arthroscopic subacromial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary. Rotator cuff tear + When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan. + Mild tears or tears in the elderly can be managed conservatively, as outlined above. + Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence. Calcific tendonitis Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, itis associated with subacromial impingement and pain Pathology ‘+ More common in women aged 30-60 years, + Association with diabetes and hypothyroidism There are three stages of calcification + Formative phase characterized by calcific deposits + Resting phase deposit is stable, but presents with impingement problems + Resorptive phase phagocytic resorption. Most painful stage. Presentation + Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature.Imaging * Plain radiographs show calcification of the rotator cuff, usually within 1.5cm of its insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging \s rarely needed, Treatment + Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management. * Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required. ‘Adhesive capsulltis (Frozen Shoulder) + Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture, Patients present with a painful and decreased arc of motion. + Associated with prolonged immobilization, previous surgery, thyroid disorders (Al) and diabetes * Classically three stages which can take up to two years to resolve ‘Stage one the freezing and painful stage ‘Stage two the frozen and stiff stage ‘Stage three the thawing stage, where shoulder movement slowly improves Imaging * Plain radiographs to exclude other causes of a painful shoulder * MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical. Treatment + Non-operative NSAIDS, steroid injection and physiotherapy. Patience Is required as condition can take up to 2 years to improve. * Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy. Glenohumeral Arthritis Background + May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with RA will develop symptoms. + More common in the elderly + Presents like any other arthritis - pain at night and with movement Imaging + AP and axillary radiographs will show features of arthritis. + CT/MRlis often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacementTreatment Like all orthopaedics, start with simple measures: + NSAIDS, management of RA, physiotherapy, steroid injection, + Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity. + Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis. * Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival. * Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity References 1. JAMA. 2015;313(10):1037-1047. doi:10.1001/jama.2015.1629 Nex mis @- Save my notes Search Search textbook. a Q Google search on “Shoulder disorders Suggest ink Suggest media Dashboard aun ena C446 EKQo Question 19 of 89 v p oO A.19 year old motorcyclist Is involved in a road traffic accident. His chest movements are ltegular. He is found to have multiple rib fractures, with 2 fractures in the 3rd rib and 3 fractures in the 4th rib, What is the underlying diagnosis? Simple rib fractures oe Cardiac tamponade @ Pneumothorax Qe Aortic rupture @ Multiple rib fractures with > or = 2 rib fractures in more than 2 ribs is diagnosed as a flail chest. This is associated with pulmonary contusion. ry Improve Thoracic trauma * Key points related to thoracic trauma + Less than 10% of blunt chest trauma and 15-30% of penetrating chest trauma requires operative intervention. * The physiologic consequences of thoracic trauma are hypoxia, hypercarbia, and acidosis, Contusion, hematoma, and alveolar collapse, or changes in intrathoracic pressure relationships (e.g,, tension pneumothorax and open pneumothorax) cause hypoxia and lead to metabolic acidosis. Hypercarbia causes respiratory acidosis and most often follows inadequate ventilation caused by changes in intrathoracic pressure relationships and depressed level of consciousness Types of thoracic trauma Tension * Often laceration to lung parenchyma with flap pheumothorax * Pressure develops in thorax * Most common cause is mechanical ventilation in patient with pleural injury + Symptoms overlap with cardiac tamponade, hyper-resonant percussion note is more likely in tension pnemothorax Flail chest * Chest wall disconnects from thoracic cage * Multiple rib fractures (at least two fractures per rib in at least two 4 sibs).Pneumothorax Haemothorax Cardiac tamponade Pulmonary contusion Blunt cardiac njury Aorta disruption Diaphragm disruption Mediastinal traversing wounds Associated with pulmonary contusion ‘Abnormal chest motion Avoid over hydration and fluid overload ‘Most common cause Is lung laceration with air leakage Most traumatic pneumothoraces should have a chest drain Patients with traumatic pneumothorax should never be mechanically ventilated until a chest drain is inserted Most commonly due to laceration of lung, intercostal vessel or Internal mammary artery Haemothoraces large enough to appear on CXR are treated with large bore chest drain Surgical exploration is warranted if >1500mI blood drained immediately Beck's triad: elevated venous pressure, reduced arterial pressure, reduced heart sounds Pulsus paradoxus May occur with as little as 100m! blood Most common potentially lethal chest injury Arterial blood gases and pulse oximetry important Early intubation within an hour if significant hypoxia Usually occurs secondary to chest wall injury ECG may show features of myocardial infarction ‘Sequelae: hypotension, arrhythmias, cardiac wall motion abnormalities Deceleration injuries Contained haematoma Widened mediastinum Most due to motor vehicle accidents and blunt trauma causing large radial tears (laceration injuries result in small tears) More common on left side Insert gastric tube, may pass into intrathoracic stomach Entrance wound in one hemithorax and exit wound/foreign body in opposite hemithorax Mediastinal haematoma or pleural cap suggests great vessel injury Mortality is 20%@ Question 20 of 89 ¥ Bp >) ‘A25 year old male pedestrian is hit by a van on a busy road. He is brought to the Emergency Department by ambulance. On examination he is dyspneoic, and hypoxic despite administration of high flow 100% oxygen. His blood pressure is 110/70 and pulse rate is 115 bpm. The right side of his chest is hyper-resonant on percussion and has decreased breath sounds. The trachea Is. deviated to the left. What is the most likely underlying diagnosis? Fat embolism oe Rupture of the right main bronchus eo Rupture of the diaphragm oe oe Pulmonary contusion Blunt or penetrating chest trauma that creates a flap type defect on the surface of the lung can result in a tension pneumothorax. Typical features include dyspnoea, progressive hypoxia, hyperresonance and tracheal deviation. Treatment is with needle decompression and chest tube insertion. @ | | Improve Thoracic trauma * Key points related to thoracic trauma * Less than 10% of blunt chest trauma and 15-30% of penetrating chest trauma requires operative intervention. ‘+ The physiologic consequences of thoracic trauma are hypoxia, hypercarbia, and acidosis. Contusion, hematoma, and alveolar collapse, or changes in intrathoracic pressure relationships (e.g,, tension pneumothorax and open pneumothorax) cause hypoxia and lead to metabolic acidosis. Hypercarbia causes respiratory acidosis and most often follows inadequate ventilation caused by changes in intrathoracic pressure relationships and depressed level of consciousness. Types of thoracic trauma Tension + Often laceration to lung parenchyma with flap pneumothorax + Pressure develops in thorax + Most common cause is mechanical ventilation in patient with pleural injury + Symptoms overlap with cardiac tamponade, hyper-resonant percussion note is more likely in tension pnemothoraxPneumothorax Haemothorax Cardiac tamponade Pulmonary contusion Blunt cardiac injury Aorta disruption Diaphragm disruption Mediastinal traversing wounds. Chest wall disconnects from thoracic cage Multiple rib fractures (at least two fractures per rib in at least two ribs) ‘Associated with pulmonary contusion Abnormal chest motion Avoid over hydration and fluid overload Most common cause is lung laceration with air leakage Most traumatic pneumothoraces should have a chest drain Patients with traumatic pneumothorax should never be mechanically ventilated until a chest drain is inserted Most commonly due to laceration of lung, intercostal vessel or Internal mammary artery Haemothoraces large enough to appear on CXR are treated with large bore chest drain Surgical exploration is warranted if >1500m! blood drained immediately Beck's triad: elevated venous pressure, reduced arterial pressure, reduced heart sounds Pulsus paradoxus May occur with as little as 100m! blood Most common potentially lethal chest injury Arterial blood gases and pulse oximetry important Early intubation within an hour if significant hypoxia Usually occurs secondary to chest wall injury ECG may show features of myocardial infarction Sequelae: hypotension, arrhythmias, cardiac wall motion abnormalities Deceleration injuries Contained haematoma Widened mediastinum Most due to motor vehicle accidents and blunt trauma causing large radial tears (laceration injuries result in small tears) More common on left side Insert gastric tube, may pass into intrathoracic stomach Entrance wound in one hemithorax and exit wound/foreign body In opposite hemithorax Mediastinal haematoma or pleural cap suggests great vessel injury Mortality is 20%(<) Question 21 of 89 ¥ B 3° A583 year old teacher is admitted to the vascular ward for a carotid endarterectomy. Your FY1 does a preoperative assessment and notes that there is a right homonymous hemianopia. There sno other neurology. What is the most likely cause? Lateral medullary syndrome eo Middle cerebral artery infarct @ Anterior cerebral artery infarct Cerebellar infarct oe ee - This patient has had a left occipital infarct, as there is only a homonymous hemianopia. If this Patient had a temporal or parietal lobe infarct, there would be associated hemiparesis and higher cortical dysfunction. This is important to differentiate, as the carotid endarterectomy is inappropriate in this patient as the lesion is in the posterior cerebral artery. | improve Stroke: types * Primary intracerebral * Presents with headache, vomiting, loss of haemorrhage (PICH, c. 10%) consciousness Total anterior circulation infarcts * Involves middle and anterior cerebral arteries (TACI, c. 15%) + Hemiparesis/hemisensory loss * Homonymous hemianopia * Higher cognitive dysfunction e.g. Dysphasia Partial anterior circulation * Involves smaller arteries of anterior circulation infarcts (PACI, c. 25%) e.g. upper or lower division of middle cerebral artery * Higher cognitive dysfunction or two of the three TACI features Lacunar infarcts (LACI, ¢. 25%) * Involves perforating arteries around the internal capsule, thalamus and basal ganglia * Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxiaPosterior circulation infarcts + Vertebrobasilar arteries (PoCI, c. 25%) ‘+ Presents with features of brainstem damage + Ataxia, disorders of gaze and vision, cranial nerve lesions Lateral medullary syndrome + Wallenberg’s syndrome (posterior inferior cerebellar + Ipsilateral: ataxia, nystagmus, dysphagia, facial artery) numbness, cranial nerve palsy + Contralateral: limb sensory loss Weber's syndrome + Ipsilateral ill palsy + Contralateral weakness Anterior cerebral artery + Contralateral hemiparesis and sensory loss, lower extremity > upper + Disconnection syndrome idle cerebral artery + Contralateral hemiparesis and sensory loss, upper extremity > lower + Contralateral hemianopia ‘+ Aphasia (Wernicke's) + Gaze abnormalities Posterior cerebral artery ‘+ Contralateral hemianopia with macular sparing + Disconnection syndrome Lacunar ‘* Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia Lateral medulla (posterior inferior cerebellar artery) * Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g Horner's = Contralateral: limb sensory loss Pontine + Vinerve: horizontal gaze palsy = Vilnerve + Contralateral hemiparesis° Question 22 of 89 v Re °° ‘A 44 year old man is involved in a road traffic accident. He suffers significant injuries to his thorax, he has bilateral haemopneumothoraces and a suspected haemopericardium. He is to undergo surgery, what Is the best method of accessing these injuries? Bilateral thoracoscopy and mediastinoscopy Midline sternotomy E Bilateral posterolateral thoracotomy None of the above Patients with significant mediastinal and lung injuries are best operated on using a Clam shell thoracotomy. All modes of access involve a degree of compromise. A sternotomy would give good access to the heart. However, it takes longer to perform and does not provide good access to the lungs. Trauma should not be managed using laparoscopy. w@ | P| Improve Trauma management * ‘The comerstone of trauma management is embodied in the principles of ATLS. Following trauma there is a trimodal death distribution: ‘+ Immediately following injury. Typically as result of brain or high spinal injuries, cardiac or great vessel damage. Salvage rate is low + In early hours following injury. In this group deaths are due to phenomena such as splenic rupture, sub dural haematomas and haemopneumothoraces ‘+ In the days following injury. Usually due to sepsis or multi organ failure. Aspects of trauma management ‘+ ABCDE approach, + Tension pneumothoraces will deteriorate with vigorous ventilation attempts. + External haemorrhage is managed as part of the primary survey. As a rule tourniquets should not be used. Blind application of clamps will tend to damage surrounding structures and packing Is the preferred method of haemorrhage control, + Urinary catheters and naso gastric tubes may need inserting. Be wary of basal skull fractures and urethral injuries. + Patients with head and neck trauma should be assumed to have a cervical spine injury until proven otherwise.‘+ Simple pneumothorax ‘+ Mediastinal traversing wounds ‘+ Tracheobronchial tree injury ‘+ Haemothorax + Blunt cardiac injury + Diaphragmatic injury + Aortic disruption ‘+ Pulmonary contusion Management of thoracic trauma ‘+ Simple pneumothorax insert chest drain. Aspiration is risky in trauma as pneumothorax may be from lung laceration and convert to tension pneumothorax. ‘+ Mediastinal traversing wounds These result from situations like stabbings. Exit and entry wounds in separate hemithoraces, The presence of a mediastinal haematoma indicates the likelihood of a great vessel injury. All patients should undergo CT angiogram and ‘oesophageal contrast swallow. Indications for thoracotomy are largely related to blood loss and will be addressed below. ‘+ Tracheobronchial tree injury Unusual injuries. In blunt trauma most injuries occur within 4cm of the carina. Features suggesting this injury include haemoptysis and surgical emphysema. These injuries have a very large air leak and may have tension pneumothorax. ‘+ Haemothorax Usually caused by laceration of lung vessel or internal mammary artery by rib fracture, Patients should all have a wide bore 36F chest drain. Indications for thoracotomy include loss of more than 1.5L blood initially or ongoing losses of >200m! per hour for 2 hours. + Cardiac contusions Usually cardiac arrhythmias, often overiying sternal fracture. Perform echocardiography to exclude pericardial effusions and tamponade. Risk of arrhythmias falls after 24 hours ‘+ Diaphragmatic injury Usually left sided. Direct surgical repair is performed. ‘+ Traumatic aortic disruption Commonest cause of death after RTA or falls. Usually incomplete laceration near ligamentum arteriosum. All survivors will have contained haematoma. Only 1-2% of patients with this injury will have a normal chest x-ray. ‘+ Pulmonary contusion Common and lethal. Insidious onset. Early intubation and ventilation. ‘Abdominal trauma ‘+ Deceleration injuries are common. ‘+ In blunt trauma requiring laparotomy the spleen is most commonly injured (40%) ‘+ Stab wounds traverse structures most commonly liver (40%) ‘+ Gunshot wounds have variable effects depending upon bullet type. Small bowel is most commonly injured (50%) ‘+ Patients with stab wounds and no peritoneal signs up to 25% will not enter the peritoneal cavity + Blood at urethral meatus suggests a urethral tear ‘+ High riding prostate on PR = urethral disruption ‘+ Mechanical testing for pelvic stability should only be performed once Investigations in abdominal traumaAbdominal CT scan uss Diagnosti Peritoneal Lavage Indication Document bleeding Document organ injury if Document fluid if If hypotensive normotensive hypotensive ‘Advantages Earlydiagnosis and Most specific for Early diagnosis, non sensitive; 98% localising injury; 920 98% invasive and accurate accurate repeatable; 86 to 95% accurate Invasive and may Location of scanner away Operator dependent miss retroperitoneal from facilities, time taken and may miss and diaphragmatic for reporting, need for retroperitoneal injury injury contrast + Amylase may be normal following pancreatic trauma + Urethrography if suspected urethral injury Search ‘Search textbook. Q Google search on “Trauma management” Suggest ink “+ uggest media Dashboard Ree° Question 23 of 89 ¥ B © ‘45 year old man complains of sharp chest pain. He Is due to have elective surgery to replace his left hip. He has been bed bound for 3 months. He suddenly collapses; his blood pressue is 70/40mmlg, heart rate 120 bpm and his saturations are 74% on air. He is deteriorating in front of you. What Is the next best management plan? Aspirin eo Unfractionated heparin Thrombolysis with streptokinase Clopidogrel oe This man is peri arrest with the diagnosis of pulmonary embolism (chest pain,bedbound, collapse, low saturations). He needs urgent thrombolysis with alteplase (he may not survive if you wait for the medical Spr/ITU to arrive!) | @ | Improve Pulmonary embolism: management * Asummary of the British Thoracic Society guidelines + Heparin should be given if intermediate or high clinical probability before imaging. + Unfractionated heparin (UFH) should be considered (a) as a first dose bolus, (b) in massive PE, or (c) where rapid reversal of effect may be needed, * Otherwise, low molecular weight heparin (LMWH) should be considered as preferable to UFH, having equal efficacy and safety and being easier to use. * Oral anticoagulation should only be commenced once VTE has been reliably confirmed, + The target INR should be 2.0-3.0; when this is achieved, heparin can be discontinued. * The standard duration of oral anticoagulation is: 4 to 6 weeks for temporary risk factors, 3 months for first idiopathic, and at least 6 months for other; the risk of bleeding should be balanced with that of further VTE. Massive PE + CTPA or echocardiography will reliably diagnose clinically massive PE. + Thrombolysis is 1st line for massive PE (je circulatory failure) and may be instituted on clinical grounds alone if cardiac arrest is imminent; a 50 mg bolus of alteplase is, recommended, * Invasive approaches (thrombus fragmentation and IVC filter insertion) should be considered where facilities and expertise are readily available.°o Question 24 of 89 v p ° ‘4.20 year old man falls over and bangs his head whilst intoxicated. On arrival in the emergency department he opens his eyes in response to speech, and Is able to speak, although he is disorlentated. He obeys motor commands. What is his Glasgow coma score? 10 eo @ 15 eo @ eo | | Improve Glasgow coma scale * Modality Options. Eye opening * Spontaneous * To speech * Topain + None Verbal response = Orlentated = Confused + Words + Sounds = None Motor response + Obeys commands + Lovalises to pain ‘+ Withdraws from pain ‘+ Abnormal flexion to pain (decorticate posture) + Extending to pain + None° Question 25 of 89 v p ° A 10 year old child is admitted to the emergency department after a fall. On examination, the blood pressure is 100/5SmmHg, pulse rate 90, abdomen soft but tender on the left. Abdominal imaging demonstrates a grade Ill splenic laceration. What Is the most appropriate course of action? Undertake an immediate laparotomy and splenectomy Undertake a laparoscopy and laparoscopic splenectomy oe |sovmennemiettonmin Arrange splenic artery embolisation Qo eo Undertake a laparotomy and splenic repair Splenic trauma is nearly always managed conservatively. Hilar injuries (grade IV) are less amenable to this and will tend to come to surgery. [ae | | improve Trauma management * The cornerstone of trauma management is embodied in the principles of ATLS. Following trauma there is a trimodal death distribution: + Immediately following injury. Typically as result of brain or high spinal injuries, cardiac or great vessel damage. Salvage rate is low. * In early hours following injury. n this group deaths are due to phenomena such as splenic rupture, sub dural haematomas and haemopneumothoraces * In the days following injury. Usually due to sepsis or mult! organ failure. Aspects of trauma management * ABCDE approach, * Tension pneumothoraces will deteriorate with vigorous ventilation attempts + External haemorrhage is managed as part of the primary survey. As a rule tourniquets should not be used. Blind application of clamps will tend to damage surrounding structures and packing is the preferred method of haemorthage control, * Urinary catheters and naso gastric tubes may need inserting. Be wary of basal skull fractures and urethral injuries. * Patients with head and neck trauma should be assumed to have a cervical spine injury until proven otherwise.Thoracic injuries + Simple pneumothorax + Mediastinal traversing wounds + Tracheobronchial tree injury + Haemothorax * Blunt cardiac injury * Diaphragmatic injury + Aortic disruption + Pulmonary contusion Management of thoracic trauma imple pneumothorax insert chest drain. Aspiration is risky in trauma as pneumothorax may be from lung laceration and convert to tension pneumothorax. ‘+ Mediastinal traversing wounds These result from situations like stabbings. Exit and entry wounds in separate hemithoraces, The presence of a mediastinal haematoma indicates the likelihood of a great vessel injury. All patients should undergo CT angiogram and oesophageal contrast swallow. Indications for thoracotomy ate largely related to blood loss and will be addressed below. + Tracheobronchial tree injury Unusual injuries. In blunt trauma most injuries occur within 4cm of the carina, Features suggesting this injury include haemoptysis and surgical emphysema. These injuries have a very large air leak and may have tension pneumothorax. ‘+ Haemothorax Usually caused by laceration of lung vessel or internal mammary artery by rib fracture, Patients should all have a wide bore 36F chest drain. Indications for thoracotomy Include loss of more than 1.5L blood initially or ongoing losses of »200ml per hour for =2 hours. + Cardiac contusions Usually cardiac arrhythmias, often overlying stemal fracture. Perform echocardiography to exclude pericardial effusions and tamponade, Risk of arrhythmias falls after 24 hours. ‘+ Diaphragmatic injury Usually left sided, Direct surgical repair is performed. + Traumatic aortic disruption Commonest cause of death after RTA or falls. Usually incomplete laceration near ligamentum arteriosum. All survivors will have contained haematoma. Only 1-2% of patients with this injury will have a normal chest xray. Pulmonary contusion Common and lethal. Insidious onset. Early intubation and ventilation. ‘Abdominal trauma ‘+ Deceleration injuries are common, + Inblunt trauma requiring laparotomy the spleen is most commonly injured (40%) ‘+ Stab wounds traverse structures most commonly liver (40%) ‘+ Gunshot wounds have variable effects depending upon bullet type. Small bowel is most commonly injured (50%) ‘+ Patients with stab wounds and no peritoneal signs up to 25% will not enter the peritoneal cavity + Blood at urethral meatus suggests a urethral tear ‘+ High riding prostate on PR = urethral disruption ‘+ Mechanical testing for pelvic stability should only be performed once Investigations in abdomiInvestigations in abdominal trauma Diagnostic ‘Abdominal CT scan Peritoneal Lavage Indication Document bleeding Document organ injury if if hypotensive normotensive Advantages Early diagnosis and Most specific for sensitive; 98% localising injury; 92 to 98% accurate accurate Disadvantages Invasive andmay _Locattion of scanner away miss retroperitoneal from facilites, time taken and diaphragmatic for reporting, need for Injury contrast + Amylase may be normal following pancreatic trauma + Urethrography if suspected urethral injury [savers] Search ‘Search textbook Q Google search on "Trauma management” Suggest lnk ‘+ Suggest media Dashboard uss Document fluid if hypotensive Early diagnosis, non Invasive and repeatable; 86 to 95% accurate Operator dependent and may miss retroperitoneal injury3° Question 26 of 89 ¥ p ° ‘A23 year old man who plays rugby for a hobby presents with recurrent anterior dislocation of the shoulder. Which of the following abnormalities is most likely to be present to account for this? Rotator cuff tear Biceps tendon rupture Axillary nerve injury Infraspinatus tendinitis ‘A Bankart lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into It. Anterior dislocations are the most common. When recurrent, a Bankart lesion is the most ‘common underlying abnormality. This is usually visualised by CT and MRI scanning and often repaired arthroscopically. 1 | Improve Shoulder disorders * Shoulder fractures and dislocations Fractures Proximal humerus Background + Third most common fragility fracture in the elderly. ‘+ Results from low energy fall in predominantly elderly females, or from high energy trauma in young males. + Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries. ‘Anatomy Osteology Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck. ‘The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity.Vascular Supply Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis. Imaging Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation, ‘+ Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view. ‘+ CT- indicated to better define intra-articular involvement and to aid pre-operative planning, MRIs not useful for fracture imaging, Classification Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion). - Neer Classification: Most commonly used. Describes fracture as 2:3,0r 4 part depending upon the number main fragments. Also comments on the degree of displacement, Fragments: -reater tuberosity -lesser tuberosity - articular surface shaft Displacement: >1cm or angulation >45 degrees. Treatment ‘The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive ‘mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks, Ireducible fracture dislocation Is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include: ORIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures. Intramedullary Suitable for extra nail +/- GT fractures. ‘cular configuration, predominantly surgical neck Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality. Total shoulder Unconstructable fractures where high functioning shoulder is required arthroplasty (hemiarthroplasty will cause glenoid erosion) Reverse shoulder Total shoulder arthroplasty that provides better functional outcome than arthroplasty conventional total shoulder replacement.Scapula Background Uncommon fractures usually associated with high energy trauma, Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury. Imaging Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction. Clas: Based on the location of the fracture (coracold, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton ication Treatment ‘The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures. Dislocations Types Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here. Glenohumeral dislocation Diagnosis, classification and management are covered here, Background Shoulder dislocation is commonly seen in A&E. Ithas a high recurrence rate that is as high as {80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage. Early assessment and management Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation. Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation, Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view.TYROS Reduction Direction Features Cause Examination techniques Anterior — Most Usually traumatic - Loss of shoulder Common anterior force on arm contour sulcus sign. Hippocratic. >90% when shoulder is Humeral head can be — Milch abducted, externally felt anteriorly Stimson rotated Kocher not advised due to complication of fracture Posterior 50% 50% traumatic, but Shoulder locked in Gentle lateral missed classically post seizure internal rotation. XR_traction to InA&E —_or electrocution may show lightbulb __adducted appearance. arm Inferior Rare Associated with ‘As for primary injury Management pectorals and rotator of primary cuff tears, and glenoid injury fracture Superior Rare Associated with AAs for primary injury Management acrominon/clavicle of primary fracture injury Associated injuries + Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation). ‘+ Hill Sachs defect -chondral impaction on posteriosuperior humeral head from contact with

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