1

b SURGERY Generally what is needed is a conducive

atmosphere for the patient.

MODULE 1 SURGERY 1 A formal history must be structured. Do not

It has three units: ask leading questions because the cooperative
pt gives the answer that seems to be wanted;
1. General introduction to surgery and the interview concludes on a note of
2. Soft tissue injuries mutual satisfaction with the wrong answer
3. Chest condtion thus developed.

UNIT 1. Building a history; History is detective.

Avoid preconceived ideas, snap judgments,
Definition. A branch of medicine which treats diseases, and haste conclusions. First determine the
deformities and injuries by manual or operative facts and then search for essential clues. A pt
procedures may conceal the most important symptoms
e.g passage of blood by the rectum hoping
INTRODUCTION that if nothing is inquired about them nothing
is serious. Special emphasis should be put on
The management of surgical problems includes the
the more common surgical conditions. The
following;
symptoms include;
- Application of technical skills
Pain –Analysis of the nature of pain is vital
- Training in the basic sciences to the problems of during hx taking.
diagnosis and treatment and - ascertain how the pain begun, was it
explosive, rapid or gradual in onset?
- Genuine sympathy and love for the patient.
- establish the character of the pain,
The surgeon must be a doctor in the old fashioned sense,
whether so severe that it cannot be relieved
that is,
by medications, is it constant or intermittent?
- An applied scientist
- Are there classic associations like rhythmic
- An engineer pattern of small bowel obstruction
- An artist and
- A minister to his or her fellow human - How does the pt react to the pain?
beings Remember the overeater’s description of pain
is usually inappropriate and is described as
THE HISTORY ‘excruciating’ in a casual or jovial manner.

Introduction- At first contact, the surgeon must gain the Vomiting; -ask what the pt vomited
pt’s confidence and give assurance that help is available
and will be provided. He must demonstrate concern for - How much
the patient as a person who requires help and - How often
not just as a “case’ to be processed through - What the vomitus looked like
the surgical ward. Most pts are eager to like - Was it projectile
and trust their doctors and respond gratefully - Is it necessary for the examiner
to a sympathetic and understanding person. to look at it?

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Change in bowel habits; this is common and usually of no The possibility that an accident might have been caused
significance, however, a person who has always had a by preexisting disease such as epilepsy, diabetes,
regular evacuation notices a distinct change particularly coronary artery disease, or hypoglycemia must be
towards intermittent alterations of constipation and explored.
diarrhea, colon cancer is suspected. Emphasis is placed
upon the size and shape of the stool. Family history

Haematemesis or Haematochezia; Bleeding from any The family history is important in surgical illnesses.
orifice demands the most critical analysis and can never Polyposis of the colon is a classic example, but diabetes,
be dismissed as due to some immediately obvious cause. peutz-jeghers syndrome, chronic pancreatitis,
The most common error is to assume that bleeding from multiglandular syndromes, other endocrine abnormalities,
the rectum is attributable to hemorrhoids. The character and cancers are often understood and better evaluated in
of the blood is of great significance. Does it clot? Is it the light of a careful family history.
bright or dark red? Is it changed in any way, as in the Past History
coffee ground vomitus of slow gastric bleeding or the dark
tarry stool of upper G.I.T bleeding? A detailed past history may illuminate obscure areas of
the present illness. A pt with a long and complicated h/o
Trauma diseases and injuries is likely to be a much poorer risk
Trauma occurs more commonly that it is often difficult to than even a very old pt experiencing a major surgical
establish a relationship between the chief complaint and illness for the first time. It is easier to review the past
an episode of trauma. Children in particular are subject to history by inquiring about each system as you perform the
all kinds of minor trauma, and the family may attribute physical examination on that part of the body. The
the onset of an illness to a specific recent injury. On the nutritional background of the pt should be considered.
other hand, children may be subjected to severe trauma Emotional background
though their parents are unaware of it. The possibility of
trauma having been inflicted by a parent must not be Emotionally and mentally disturbed pts require surgical
overlooked. operations as often as others, and full cooperation
between psychiatrist and surgeon is essential. Before or
When there is a history of trauma, the details must be after an operation, a pt may develop a major psychotic
established as precisely as possible. What was the pt’s disturbance that is beyond the ability of the surgeon to
position when the accident occurred? Was consciousness appraise or manage. There are many situations in which
lost? Retrograde amnesia (inability to remember events the surgeons can and should deal with the emotional
just preceding the accident) always indicates some degree aspect of the pts illness rather than resorting to
of cerebral damage. If the pt is able to remember every psychiatric assistance. T his is particularly important in the
detail of an accident, has not lost consciousness, and has care of pts with malignant dxes or those who must
no evidence of external injury to the head, brain damage undergo mutilating operations such as amputations,
can be excluded. ileostomy, or colostomy.
In the case of gunshot wound and stab wounds, knowing PHYSICAL EXAMINATION
the nature of the weapon, its size and shape, the probable
trajectory and the position of the patient when hit may be A complete examination of the patient includes physical
very helpful in evaluating the nature of the resultant examination, certain special procedures such as
injury. esophagoscopy, laboratory tests, x-ray examinations, and
follow-up examinations. Painful, inconvenient, and costly

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procedures should be avoided unless there is a of tenderness, it may be necessary to use only one in
reasonable chance that the information gained will be order to precisely localize the extent of tenderness. This is
useful in making clinical decisions. of particularly importance in examination of the acute
abdomen.
The elective physical examination
Auscultation is now important in surgery than it is in
It should be done in an orderly and detailed fashion. One medicine. Auscultation of the abdomen and peripheral
should acquire a habit of performing a complete vessels has become absolutely essential. The nature of
examination in exactly the same sequence, so that no ileus and the presence of a variety of lesions are revealed
step is omitted. When the routine must be modified, as in by auscultation. Bizarre abdominal pain in a young
an emergency, the examiner recalls without conscious woman can easily be ascribed to hysteria or anxiety on
effort what must be done to complete the examination the basis of a negative physical examination and x-rays of
later. All pts are sensitive and somewhat embarrassed to the gastro-intestinal tract.
being examined. It is both courteous and clinically useful
to put the pt at ease. The examining to strip for the Examination of body orifices
examination. Most pts will relax if they are allowed to talk
a bit during the examination, which is another reason for Complete examination of the ears, mouth, rectum, and
taking the past history while the examination is being pelvis is accepted as part of a complete examination.
done. Palpation of the mouth and tongue is as essential as
inspection. Inspection of the rectum with a sigmoidoscope
A useful rule is to first observe the pts general physique is now regarded as part of a complete physical
and habitus and then to carefully inspect the hands. Many examination. Every surgeon should acquire familiarity
systemic diseases show themselves in the hands [liver with the use of the ophthalmoscope and sigmoid scope
cirrhosis, hyperthyroidism, Reynaud’s disease, pulmonary and should use them regularly in doing complete physical
insufficiency, heart disease, and nutritional disorders]. examination.

Inspection, palpation and auscultation are the time EMERGENCY PHYSICAL EXAMINATION
honored step in appraising both normal and the
abnormal. Comparison of the two sides of the body often In an emergency, the routine of the physical examination
suggests a specific abnormality. An example is the must be altered to fit the circumstances. The history may
examination of a female breast when the pt raises and be limited to a single sentence, or there may be on history
lowers her arms, will often reveal slide dimpling indicative if the pt is unconscious and there are no other informants.
of an infiltrative carcinoma barely detectable on Although the details of an accident or injury may be very
palpation. useful in the appraisal of the pt, they must be left for
future consideration. The primary considerations are the
Successful palpation requires skill and gentleness. Spasm, following:
tension, and anxiety caused by painful examination
procedures may make an adequate examination almost - Is the pt breathing?
impossible, particularly in children. Another important - Is the airway open?
feature of palpation is the laying of hands that has been - Is there a palpable pulse?
called part of the ministry of medicine. A disappointed - Is the heart beating? and
and critical pt often will say of a doctor, ‘He hardly - Is massive bleeding occurring
touched me’. Careful, precise, and gentle palpation not If the pt is not breathing, airway obstruction must be
only gives th physician the information being sought but ruled out by thrusting the fingers into the mouth and
also inspires confidence and trust. When examining areas pulling the tongue forward. If the pt is unconscious, the
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respiratory tract should be intubated and mouth to - Appraisal of diseases that may
mouth respiration started. If there is no pulse or heart contraindicate elective surgery or require
beat, start cardiac resuscitation. Serious external blood treatment before surgery(eg, diabetes, heart
loss from an extremity can be controlled by elevation failure),
and pressure. Tourniquets are rarely required. - Diagnosis of disorders that require
surgery( eg, hyperthyroidism,
Every victim of major blunt trauma should be suspected pheochromocytoma), and
of having a vertebral injury capable of causing damage - Evaluation of the nature and extent of
to the spinal cord unless rough handling is avoided. metabolic or shock.
Some injuries are so life threatening that action must be
taken before even a limited physical examination is Pts undergoing major surgery, even though they seem
done. Penetrating wounds of the heart, large open to be in excellent health except for their surgical
sucking wounds of the chest, massive crush injuries with disease, should have a complete blood and urine
flail chest, massive external bleeding all require examination. A history of renal, hepatic, or heart
emergency treatment before any further examination disease requires detailed studies. Latent,
can be done. asymptomatic renal insufficiency may be missed,
since many pts with chronic renal disease have
In most emergencies, however, after it has been varying degrees of nitrogen retention without
established that the airway is open, the heart is beating, proteinuria.A fixed urine specific gravity is easily
and there is no massive external hemorrhage- and after overlooked, and preoperative determination of the
anti-shock measures have been instituted, if necessary- blood urea nitrogen and serum creatinine is
a rapid survey examination must be done. Failure to frequently required. Pts who have had hepatitis may
perform such an examination can lead to serious have no jaundice but may have hepatic insufficiency
mistakes in the care of the pt. It takes no more than 2 or that can be precipitated into acute failure by blood
3 minutes to carefully examine the head, thorax, loss or shock.
abdomen, extremities, genitalia (particularly in females),
and back. If cervical cord damage has been ruled out, it Medical consultation is frequently required in the
is essential to turn the injured pt and carefully inspect total preoperative appraisal of the surgical pt, and
the back, buttocks, and perineum. Tension there is no more rewarding experience than the
pneumothorax and cardiac tamponade may easily be thorough evaluation of apt with heart dx or GIT dx by
overlooked if there are multiple injuries. a physician and a surgeon working together. It is
essential, however, that the surgeon does not
Upon completion of the survey examination, control of become totally dependent upon a medical consultant
pain, splinting of fractured limbs, suturing of lacerations, for the preoperative evaluation and management of
and most of emergency treatment can be started. the pt. The total management must be the surgeon’s
LABORATORY & OTHER EXAMINATIONS responsibility and is not to be delegated. Moreover,
the surgeon is the only one with the experience and
Laboratory examination background to interpret the meaning the meaning of
laboratory tests in the light of other features of the
Laboratory examinations in a surgical pts have the
case- particularly the history and physical findings.
following objectives:
Imaging Studies
- Screening for asymptomatic dxes that
may affect the surgical result (e.g, unsuspected Modern pt care calls for a variety of critical radiologic
anemia or diabetes, examinations. The closest cooperation between the
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radiologist and the surgeon is essential if serious Diabetes Mellitus:
mistakes are to be avoided. This means that the
surgeon must not refer the pt to the radiologist, Diabetic pts undergo more surgical procedures than
requesting a particular examination, without non-diabetics and management of the diabetic pt
providing an adequate account of the history and before, during and after surgery is an important
physical findings. Particularly in emergency situations, responsibility of the surgeon. Control of fluids,
review of the films and consultation are needed. electrolytes, glucose and insulin is important in the
operating room .Marked hyperglycemia should be
When the radiologic diagnosis is not definitive, the avoided during surgery; the greater danger is severe
examination must be repeated in the light of the unrecognized hyperglycemia.
history and physical examination. Despite the great
accuracy of x-ray diagnosis, a negative GIT study still Heart diseases and the surgical pt
does not exclude ulcer or a neoplasm; particularly in Anesthesia and surgery present a risk to any pt, but
the right colon, small lesions are easily overlooked. At this risk is increased with pre-existing heart disease,
times the history and findings are so clearly diagnostic whether clinically apparent or undiagnosed.
that operation is justifiable despite negative imaging Complications related to heart diseases are the major
studies. cause of nonsurgical perioperative deaths. Cardiac
Special Examinations diseases may be exacerbated by many of the changes
accompanying surgery, including fluctuations in heart
Examples include cystoscopy, gastroscopy, rate, BP , blood volume, oxygenation, PH, and
esophagoscopy; colonoscopy, angiography, and coagulability. These may lead to myocardial ischemia
bronchoscopy are often required in the diagnostic due to increased myocardial oxygen demand or
appraisal of surgical disorders. The surgeon must be reduced coronary blood flow, impaired myocardial
familiar with the indications and limitations of these contractility. This leads to altered cardiac
procedures and be prepared to consult with performance due to changes in preload or afterload.
colleagues in medicine and the surgical specialties as Increased circulating catecholamines or sympathetic
required. nervous system activity may precipitate arrhythmias
as well as increase heart rate blood pressure.
THE DIFFERENCE BETWEEN SURGICAL AND MEDICAL
CONDITIONS Hypertension

Patients who present with surgical conditions only CLASSIFICATION OF SURGICAL PATIENTS
pose minimal to the surgical team. Their treatment
revolves around the surgical condition with which Patients can be classified into three major groups;
they have presented. Surgical pts who present with a) According to speed of surgical
associated medical diseases pose a great challenge intervention. This will depend on the condition of
and therefore require special attention, because other the patient. The patient could be;
than the surgical condition they have, the i) Emergency case – This is the patient
accompanying medical condition may complicate the whose life is in danger unless immediate surgical
surgical condition or vice versa. Essentially, this is a intervention takes place. Examples include
problem to both the surgeon and the pt ruptured ectopic pregnancy, intestinal
himself/herself. The common medical conditions obstruction, bleeding cut wound and obstructed
encountered include, DM, Hypertension, Cardiac labor.
diseases, Bronchial Asthma, Use of steroids, etc.

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Ii) Elective (planned or cold) case. This is a patient - Counseling to the patient, relatives or
who requires surgical intervention but the condition guardian
of the patient is not putting his life in danger and can - Let everything that is done to the patient
be postponed to another time. Example include be documented
uncomplicated lipoma, hernias which are not - Involve the
complicated and patients with extra digits relatives/guardians/caretakers be involved in the
management of the patient
b) According to whether the patient should - Obtain an informed consent. A person to
stay overnight in the ward before operation or give consent should be above 18 yrs and mentally
come in the morning of the operation. sound at the time of signing the consent. The
1) Admitted (or overnight stay) case. This is consent is valid for between 24-48 hrs from the
usually a major case which requires preparation time of signing.
before operation and therefore patient has to be - Those who are not legible to sign are
admitted into the ward. those less than 18 yrs, mentally unstable and
2) Day case. Patient does not require to be those already premedicated.
admitted. He comes in the morning and is Content of consent
operated. The operation is minor. After operation Type of an operation
the patient is observed and can be allowed home Reason for surgery
provided he is accompanied. Outcome expected
c) According to the general condition of the Validity period
patient. In this group the patient is said to be Signature from a person >18yrs, mentally stable &
either; not yet premedicated
i) Fit – To undergo anaesthesia and surgery. Name of a surgeon
(ii)Unfit – To undergo anaesthesia and surgery.
Premedication;
PRE – OPERATIVE MANAGEMENT OF A PATIENT
Definition – The administration of drugs in the period
It will depend on the type of patient; of 1-2 hrs before induction of anesthesia and surgery.
- Admit the patient to the ward through Objectives – 1) Allay anxiety and fear by
outpatient, SOPC, GOPC or any other special clinic psychotherapy and anxiolytics usually benzodiazepine
from within the hospital.
- Take complete and relevant history 2)Reduction of secretions by giving
- Perform physical examination anticholinergics like atropine 3)
- Do the basic investigations like the vital Reduction of undesired reflexes(vagal reflexes which
signs, grouping and cross matching, full may produce severe bradycardia) like traction of the
haemogram, urinalysis etc. eye muscles may lead to bradycardia and arrhythmias
- Do specific investigations like ultrasound known as oculo-cardiac reflex
according to the condition of the patient
- The patient should go to the ward with 4) Limitation of sympathoadrenal responses during
the results of the investigations to avoid induction and intubation which may lead to
unnecessary delay and time wasting. tarchycardia , hypertension and raised
- Explain to the patient the nature of his catecholamines. The responses are not desired
condition, why he should be admitted and the especially in patients with hypertension, ischaemic
reason for operation heart diseases.

7
 5) Produce amnesia (anterograde and retrograde) observation does not diminish during the journey. The
commonly by benzodiazepines patient must be closely monitored at all times.

6) Post – operative anti emetics Systems affected

7) Reduction of gastric volume and elevation of gastric Central nervous system

PH. In patients with risk of vomiting or regurgitation
e.g. metoclopromide. Consciousness may not return for several minutes after
the end of general anesthesia, and may be impaired for a
In addition to the above different categories will longer period of time. During this period, a patent airway
require their specific pre-medications e.g. diabetics must be maintained. There is a risk of aspiration into the
and hypertensive. lungs of any material, e.g. gastric content or blood, which
is present in the pharynx. Consciousness may be
POSTOPERATIVE CARE depressed also in patients who have received sedation to
In modern practice, the patient is monitored and facilitate endoscopy or regional anesthesia. Excitement
supervised closely and continuously during induction and and confusion may occur during recovery and may result
throughout the operative procedure. However many in injury. Pain may be severe if long acting analgesics have
problems associated with anesthesia and surgery may not been given during surgery.
occur in the immediate postoperative period, and it is Cardiovascular system
essential that supervision by adequately trained
personnel is continued during the recovery period. In Peripheral resistance and cardiac output may be reduced
addition some major and minor complications of because of residual effects of anesthetic drugs in the
anesthesia and surgery may occur at any time in the first absence of surgical stimulation. Hypovolemia may be
few days after the operation. present because of inadequate fluid replacement during
surgery, continued bleeding postoperatively or expansion
The early recovery period of capacitance of the vascular system as a result of
Many hospitals have a recovery ward in close proximity to increased sympathoadrenal activity after restoration of
the operating theatre. A large number of recovery areas consciousness, especially if analgesia is inadequate.
are closed at night and at weekends; at these times, and Respiratory system
in hospitals with no recovery ward, the patient is
supervised usually in corridor close to the operating Hypoventilation occurs commonly, usually as a result of
theatre and often by inadequately trained staff. This residual effects of anaesthetic drugs or incomplete
section describes common problems which occur in the antagonism of neuromuscular blocking drugs.
immediate postoperative period and refers specifically to Hypoxaemia may result from hypoventilation,
their management in a recovery ward; however the same ventilation/perfusion imbalance or increased oxygen
principles are applicable to recovery in other locations. consumption produced by restlessness or shivering.

The recovery period starts as soon as the patient leaves Gastrointestinal tract
the operating table and the direct supervision of the
anesthetist. All the complications listed below may occur Nausea and vomiting are common in the immediate
at anytime, including the period of transfer from postoperative period.
operating theatre to recovery ward; in some operating Staff, equipment and monitoring
theatre suites, the transfer to the recovery ward may last
for several minutes, and it is essential that the standard of

8
The recovery ward should be staffed by trained and High risk patients, or those who have undergone
experienced nurses; one nurse must remain with each major surgery, should stay in the recovery ward for up
patient at all times. The responsibility for the patient’s to 24hrs. If this is not feasible, or if instability persists
welfare remains with the anesthetist. In many hospitals, for longer than 24 hrs, the patient should be
an anesthetist is designated to be available immediately transferred to a high dependency or intensive care.
to treat complications detected by the nursing staff. The
patient is nursed in bed if a prolonged stay is anticipated, WOUND
but more commonly on a trolley. All trolleys and beds Definition: A loss of continuity of skin or mucus
must have facility to be tipped down. Suction apparatus, membrane as a result of injury; soft tissue and bone
including catheters, an oxygen supply with appropriate may or may not be damaged.
facemask, a self inflating resuscitation bag and
anaesthetic mask, and a sphygmomanometer must be Wound healing
available for each patient. In addition, there should be a
The discontinuity in the surface of the body exposes
complete range of resuscitation equipments within the
the deeper tissues to the dangers of bacterial
recovery room; this includes an anesthetic machine, a
infections. This danger persists until such a time an
range of laryngoscopes, tracheal tube , bougies, i.v.
intact surface has been restored by the healing
cannulae, fluids, emergency drugs, ECG monitor and
process. Wound healing can occur in two main ways:
defibrillirator. Facilities for cricothyroid cannulation, e.g.
minitracheotomy set, or for formal tracheostomy should i) Healing by 1st intention
be available. A wide range of drugs should be stored in ii) Healing by 2nd intention
the recovery area for the treatment of common
complications and also emergency events. Healing by 1st intention

All patients should be monitored by measurement of The main objective is to obtain rapid healing of the
heart rate, arterial pressure and respiratory rate and by wound without an infection and with minimum scar
assessment of level of consciousness, peripheral tissue formation. This is achieved by accurately
circulation and adequacy of ventilation; in some joining together the edges of the wound by
circumstances, minute volume may be measured using a stitches/sutures. This can be catgut, nylon, silk or
respirometer. At least one mechanical ventilator should vicryl.
be available. Pulse oximetry is valuable, particularly in
Healing by 2nd intention
children, the elderly, patients with pulmonary disease and
those with cardiovascular instability. Urine output should Occurs under three main circumstances:
be measured routinely in patients who have undergone
major surgery. 1. When the wound edges are not brought
together
Wounds and surgical drains should be inspected regularly 2. When there is skin loss which is not made
for signs of bleeding. The patient should not be up for.
discharged to the ward until; 3. When wound becomes infected and
breaks open or circumstances are such that it has
1) Consciousness has returned fully, and a
been l eft open.
patient airway can be maintained
2) Ventilation is adequate and stable Healing by 2nd intention is the normal way in
3) The cardiovascular system is stable which an abscess heals after it has been drained.
4) Excessive surgical blood loss has stopped An ulcer heals in the same way. Healing by 2nd

9
intention is much slower than healing by 1st 4) Local blood supply: An adequate bld
intention and invariably involves formation of supply is absolutely necessary for formation of
more scar tissue. The longer a wound remains raw granulation tissues to form a satisfactory wound
the greater may be the amount of scar tissue healing. An impaired bld supply may slow healing,
formation and the greater will be the contracture inhibit fibroblast and weaken defense against
and deformity. infection. The bld supply may be interfered by
damage to bld vsls, the initial trauma or presence
FACTORS INFLUENCING WOUND HEALING of scar tissue. The presence of edema,
The nature and efficiency of wound healing congestion, hemorrhage and infection produces a
process are influenced by various factors which swelling and also interferes with the blood supply.
may be local or general. The signs of retarded wound healing as a result of
impaired bld supply are as follows:
A. Local factors a) Delay in formation of granulation tissue
1) Presence of necrotic and devitalized which is composed of collagen and ground
tissues: This produces irritation early and substance.
provides an excellent medium for bacterial b) The tissues are pale and the wound is
growth. The leucocytes, the fluid loss and slow to epithelialise.
absorption of toxins are increased. This reaction c) The line of incision shows little congestion
around dead tissues delay wound healing because and can be easily separated.
the tissues are engaged in defense process trying d) The skin flaps separate easily, die, and
to eliminate the necrotic material and infection. grafts don’t take on such a surface.
2) Infection: Produces varying degrees of 5) Rest: Increased mechanical stress on the
tissue destruction and therefore greater delays wound delays healing. Rest of the part is
healing. This is the commonest cause of delay in important especially to the wound of extremities
healing. near joints. Muscular action and joint movement
3) Presence of foreign bodies: Foreign may disturb the in which cells are growing and results
be introduced from outside or produced in the in extravasations of blood and fluid delay healing.
tissues themselves like the gallstones or urinary Repetitive coughing, vomiting or intestinal
stones. Secretion/excretions escaping from their obstruction frequently cause ruptures of
normal channel into neighboring regions acts as abdominal wounds, commoner in obese people.
foreign bodies e.g. leakage of urine as in VVF, RVF 6) Inaccurate skin apposition: or a large
and feaces acts as an irritant. Abnormal tissue loss effect causes a delay in healing until
accumulation of blood or lymph and a mass of the gap has been bridged.
dead tissue such as sequestrum (dead bone 7) Hemorrhage: Beside general reduction in
tissue) also acts as Fbs. The reaction of tissue due blood volume and production of anemia bleeding
to the presence of Foreign bodies depends on the into the wound adversely affects healing. Ideally
physical and clinical nature of the fbs, the nature blood coagulation should be just be enough to
in which they are placed and the presence or stick the part of the wound together and to
absence of infection. If infection occurs in the eliminate the dead space in the wound. Collection
presence of fbs there is profuse purulent of the blood as a result of injury or inadequate
discharge and unless fb is removed the wound hemostasis during operation keeps the sides of
will not heal. the wound apart and does not allow the parts to
come together. The hematoma increases the

10
tension in the tissues and produces pain, II) Vitamin K: is essential for the control of
ischemia, necrosis and delay healing. Hematomas hemorrhage. Deficiency results in
are also an ideal media for bacterial growth as hypoprothrombinemia which is commonly seen in
they have no circulation the ction cannot be jaundiced pts or those marked hepatic
controlled systemic antibiotics. Large hematomas insufficiency.
which are slow to dissolve and those which III) Vitamin A: It combines with proteins to
haven’t been evacuated surgically sometimes a become an essential part of all specialized
cavity with rigid walls containing capsulated fluid. epithelial tissues. Lack may lower resistance to
8) Irritation: Direct irritation of the wound infections.
acts on living tissue and causes death of tissue IV) Vitamin D: an adequate intake of vit. D is
and therefore there is delay or failure to heal of required for proper absorption of calcium and it’s
the wound. subsequent deposition in bone. Absorption of
9) Type of suture: The nature of the suture vitamin D may be seriously interfered with owing
and method of suturing play a part in wound to impaired liver function due to surgical
healing. Wounds stitched by catgut heal more procedures (after).
slowly than those stitched with silk. They are two 2) Anaemia: There is little evidence that
times stronger than those stitched by catgut. anemia alone interferes with wound healing. And
B) GENERAL FACTORS when delay occurs there is an associated
1) Nutrition: for normal and rapid rate of hypoprothrombinaemia
healing and normal physiological state is 3) Hormones: administration of large doses
essential .If cellular nutrition is not maintained of adrenocortical hormones slows the healing of
the body is unable to mobilize the defense wound because cortisone decreases the
mechanism and this favors the growth of bacteria. formation of collagen. Thyroid deficiency also
a) Protein deficiency: may lead to delayed slows wound healing. Other infections causing
repair due to lack of collagen in the wound and syndrome= hyponatraemia, oedema, leukaemia,
dehiscence (bursting) is common in malnourished jaundice and syphilis. There is no clear cut
patients. The essential amino acids, cysterin and evidence that any specific factor is involved apart
methionine are particularly important in wound from hypoproteinaemia and vitamin C deficiency.
healing. 4) Age: The young heal better than the
b) Vitamin deficiency: the liver is concerned elderly but the specific factors are not clear.
wIth metabolism and storage of the vitamins. The 5) Metabolic disorders: Diseases like liver
surgical procedures and injuries reduce hepatic cirrhosis, DM retard wound healing. In
functions. The vitamins which play a role in uncontrolled DM, the tissues have diminished
wound healing include: resistance to bacterial infection because the
i) Vitamin C: required for the production of excess glucose provides a good medium for
intracellular cement and collagen tissue. bacterial growth. The resultant tissue destruction
Prolonged deficiency is associated with marked in the wound by the organisms delays healing.
interference of healing process. Deficiency of There are certain obliterating changes in the
intracellular substance in the granulation tissue arteries seen in DM affecting local blood supply.
and capillary bed results, in hemorrhage in wound
space. As a result of a prolonged lag period TYPES OF WOUNDS
fibroblast is retarded and the development of 1. INCISED WOUNDS: Are wounds with
tensile scar tissue is delayed. minimal tissue damage. Are sustained as a result
11
 of cuts with sharp objects e.g. knives, broken glass NB: Certain amount of damaged but recoverable
etc tissues should remain in the wound. For this reason it
is unwise to repair deep structures such as tendons
Characteristics- Have even margins bleed very easily and nerves in such a wound. As soon as the skin
and are caused by sharp objects which may also cause wound heals (4-6 wks) a formal secondary repair of
damage to the structures below e.g. nerves and any divided tendons and nerves. Wound excision is
tendons carried out in a pt with a contaminated wound who
arrive late foe treatment e.g. after 24 hrs.

Principles of management Delay in treatment

They should be treated by suturing all structures As a rule treatment should be carried out within 6 hrs
including nerves and tendons within the 1st 6 hours of of injury. But under favorable conditions this time
injury (primary suture). limit can be extended and the use of antibiotics
makes it possible to delay primary suture for as long
2. LACERATED WOUNDS: A laceration or cut as 12 hrs. After 12 hrs treatment is best by delayed
is the result of contact with a sharp object . It is primary suture.
the surgical equivalent of an incised wound. Once
the cutting tool has gone deep to the dermis, 0-6 hrs = ideal
there is less resistance in the subcutaneous 0-12 hrs = 1st (primary) suture
tissues and the cut may penetrate to a
considerable depth. Include wounds that are >12 hrs = delayed sutures
sustained in RTAs, industrial injuries etc. They are
due to relatively blunt objects and are associated 3. CRASHED & DEVITALISED WOUNDS (WAR WOUNDS)
with certain amount of tearing. Sustained in RTA, industrial accidents and in war e.g.
Characteristics; -Edges and surface are ragged (not gunshot wound and explosions.
firm) Characteristics
- Contain moderate amount of 1. Have ill defined margins.
devitalized tissue 2. Foreign bodies usually lodged in the
- Prone to infection wounds

Principles of management The difficulties that exist in this type of wounds.

Are treated by wound excision (debridement), and i. It is hard to differentiate viable from non-
primary suture of the skin within the 6 hrs of injury. viable tissue with curtained.
Wound excision involves thorough cleaning, removal ii. Because of extensive tissue there may be
of all foreign matter and non viable or devitalized great swelling of the tissue and if primary suture
tissues. Each layer is tackled in turn and all devitalized is performed, the tension of the tissue will be so
tissues carefully trimmed away to expose a healthy high resulting in local ischemia (leading to
bleeding surface. Debridement is aimed at converting localwhich of tissues) which was previously viable.
the injury from jagged wound into one which is as iii. The wound may be heavily contaminated
near as an incised wound as possible. by bacteria.

12
PRINCIPLES OF MANAGEMENT; *Crashed and devitalized wound with skin loss =
excision + delayed primary grafting.
Mainly, excision of the wound and delayed secondary
suture. SECONDARY SUTURE

a) Careful excision of dead tissues layer by It is done by freeing the skin at the edge of a
layer. granulating wound then suturing. Now very rarely
b) Any dead muscle should be excised used but can be done under the following conditions:
widely because dead muscles provide an ideal
environment of multiplication of gas gangrene i) When the treatment of the wound has
micro-organisms i.e. Cl. Welchi and Cl. Botulinum. long been delayed for one reason or another.
c) After excision the wound is not sutured ii) When the wound has been infected and
but left open and dressed. has to be left open for aeration. It has to be
d) After 4-6 days the wound is re-examined delayed until the infection has been controlled
and if confirmed that all remaining tissues are and tissues become healthy.
viable and the edema subsided sufficiently to Because of the presence of granulation tissue and
allow the wound to be sutured without tension, young scar tissue the edges of the wound will have
delayed primary suture can be performed. Avoid become bound. In order to free the skin enough to be
tension and it is safer to do skin grafting even sutured it will be necessary to cut the skin edges.
when there is no skin loss. When the wound has
healed and tension of tissues has returned to Disadvantages:
normal the graft can be excised and the skin
i) Results in fresh skin healing.
sutured. If there is any doubt whether it is
ii) Even when the skin flaps are indurated
advisable to suture it should be avoided.
and inelastic due to fibrosis and therefore difficult
WOUNDS WITH SKIN LOSS to suture. Secondary suture is encouraged. It is
safer and easier to carry out secondary skin
In wounds where skin has been lost the pt is in grafting and carry out reconstruction surgery
danger of superadded infection until the wound has later.
been completely healed by epthelialization. Healing 4 PENETRATING WOUNDS
of skin layer is important because of need for its
restoration and also because of the healing of deeper Caused by sharp objects and penetrate deep into the
structures can take place in case of intact skin. Apart body tissues. Wounds are very deceptive in that the
from that, the longer any exposed surface remains sharp object can penetrate many inches with a mere
raw, the greater may be the rate of deformity and slit in the skin as the only immediate obvious sign.
disability. In all wounds with skin loss the skin loss Impaired movement or loss of sensation indicates
should be repaired as soon as practicable. injury to the nerves or tendons and haemorrhage
may be obvious. Penetrating abdominal wound may
The following is the timing of wounds with skin loss: be symptomless until internal haemorrhage or
* Clean incised wound with skin loss = primary peritonitis indicates:
grafting (0-12hrs  Swollen viscera
* Lacerated wound with skin loss = excision + primary  Bowel damage or
grafting  Damage of blood vessels.

13
 NB: Penetrating abdominal wounds must be explored be closed primarily. If they are closed wound healing
without delay to rule out peritoneal involvement.. is unlikely to occur without complications. There may
be wound dehiscence, infection and delayed healing.
Bruises, contusions and hematoma: A closed blunt Gas gangrene and death may even result. The correct
injury may result in a bruise or contusion. There is management is wound excision (excision of
bleeding into the tissues and visible discoloration. devitalized tissue to create a tidy wound). Once an
Where the amount of bleeding is sufficient to create untidy wound has been converted to a tidy wound by
a localized collection in tissues this is described as a excision it can be safely closed or allowed to heal by
hematoma. Initially this will be fluid, but it will clot second intension.
within minutes or hours. Later, after a few days, the
hematoma will again liquefy. There is a danger of WOUND CLOSURE
secondary infection. Bruises require no specific
management, and no treatment is of wproven value. Wound closure can be achieved by a number of
The pt should be advised that the time required for differing techniques. Most tidy wounds that do not
bruising to clear is extremely variable and in some involve loss of tissue can be closed directly. Where
sites, discoloration may persist for months. A there is tissue loss a technique to import appropriate
hematoma may be evacuated by open surgery if large tissue is needed. Reconstructive surgical techniques
or causing pressure effects (such as intracranially), or range from simple skin grafts to complex composite
aspirated by a large bore needle if smaller or on free tissue transfers.
cosmetically sensitive sites. It may be necessary to
await liquefaction and to perform repeated
aspirations, with appropriate antiseptic precautions.
A hematoma will generally reabsorb without scarring,
but on occasions there may be persistent tethering of ANTIBIOTICS ON THE TREATMENT OF WOUNDS
the skin. Blunt injury to the breast may result in an
area of fat necrosis that be mistaken for a breast
lump. T he most important factor in the treatment of
wound is avoidance of infection by careful operative
Wounds can also be classified:
treatment .If only healthy and well vascularised
a) TIDY WOUNDS: They are inflicted by sharp objects tissues remain in the wound edges the defense
and contain no devitalized tissue. Such wounds can be mechanism will be able to deal with all the organisms
closed primarily with the expectation of quiet primary except the most virulent ones. In general antibiotics
healing. Examples include surgical incisions, cuts from
are indicated in extensive wound with much skin
glass and knives. Skin wound are usually single and clean.
damage or if there has been any delay in treatment.
Tendons, arteries and nerves will commonly be injured in
tidy wounds, but repair of these structures is possible. They should be in the form of systemic penicillin for a
Fractures are uncommon in tidy wounds. minimum of five days. Don’t start with broad
spectrum antibiotics. Further antibiotic therapy
b) UNTIDY WOUNDS: They result from crashing, depends on the result of bacterial examination of the
tearing, avulsion, vascular injury or burns. They wound pus swab.
contain devitalized tissue. Skin wounds will often be
multiple and irregular. Tendons, arteries and nerves NB: Antibacterial drugs must be used with discretion
may be exposed, and might be injured in continuity, and only when the sensitivity the organism to various
but will usually not be divided. Fractures are common drugs is known, because indiscriminate use leads to
and may be multifragmented. Such wounds must not
14
resistance to drugs. Always give t.t to all pts with drinks and therefore picnicking people should
open wounds at any part of the body. their drinks.

WOUND INFECTION Bees leave their stings and poison glands protruding
from the wound. Squeezing should be avoided,
Patients complain of itchiness and pain on the instead prick them out. Pressure on the gland
wound. On inspection there is redness and swelling squeezes poison into tissues. The gland and the sting
on the margin of the wound. Later small abscesses should be removed by scraping gently. Bee stings are
appear in relation to the stitches and small beads of acidic and should be neutralized by local application
pus can be seen surrounding the emerging stitches of methylene blue, ammonium, sodium bicarbonate
(stitch abscesses). An infection may spread to the (alkaline solution).
surrounding subcutaneous tissue and this is called
cellulitis. And collection of pus may form in the layers Wasps’ venom is alkaline and should be neutralized
of the wound. At this stage the pt is usually very toxic by local application of an acid such as vinegar.
with fever. If the infection is particularly virulent Antihistamine drugs such as chlorampheniramine
septicemia may occur. mileate (piriton) should be given orally. Local
application of antihistamine creams e.g. piperamine
TREATMENT OF AN INFECTED WOUND mileate (Anthesan cream). If an anaphylactic reaction
Early stage: If treated before pus formation occurs it occurs adrenaline 1:1000 0.5 ml should be given i.m
may be possible to arrest by use of systemic every 10 minutes until pts recovers.
antibiotics. If stitches are tight, remove them to b) Animal bites: Bites from animals should
relieve tension. be treated as any other wounds. Slightest
Stitch abscess formation: Any infected stitches should suspicion that the animal is rabid; the wound
be removed and antibiotic therapy instituted. If there should be freely excised. If possible the
are no deep collections of pus then infection may be responsible animal should be kept under
arrested and the wound may heal. observation for any mental changes for about 7-
15 days. If the is killed the brain should be
When actual pus forms: Stitches should be removed examined for Negri bodies (rabies)
and may result in sufficient separation of the wound c) SNAKE BITE
to allow pus drainage. If drainage is not satisfactory
the pt is taken to theatre, wound opened and drained Not all snakes are poisonous. In Kenya poisonous
and allowed to heal by second intension. Done under snakes are not commonly seen. Cobra, puff adders,
GA. vipers are examples seen in Kenya. Snakes usually
feed at night since they know that is when their prey
SPECIAL TYPES OF WOUNDS is available. They bite when provoked. Poisonous
snakes may bite but not envenominate the victim,
a) Insect bites: Usually inflicted by wasps or
they have to prepare the poison. Snake poisons are
bees. In sensitized people anaphylaxis may occur
different; some toxic to the brain or muscles or
hence anaphylactic shock, circulatory collapse,
blood vessels, while some are combine. Bites by
coma and death may occur within a very short
snakes are not likely to cause any fatal results but
time (20 minutes) ,if the venom is injected
vomiting, giddiness and cardiovascular system
directly into a vein as occurs in stings in the
collapse may occur.
dorsum of the arm. Wasps are fond of alcoholic

15
Snake venom action
mechanism of toxicity
Venomous snakes
-Vasodilators e.g. kalibrein Antivenins
hypotension

-coagulopathies e.g. Russel’s vipers Atractaspididae e.g. rattle black snakes
consumptive coagulopathy * none specific Rx symptomatically

Echis. they activate factors v, x, prothrombin Colubridae e.g. brown tree snake
-Hyalurodinase (all venoms) * brown snake antivenin
spread of venom 
Viperidae e.g. russell’s viper, European adder
- Haemolysins e.g. vipers * viper/European viper antivenom
bleeding from fang sites
Subfamily crotalidae e.g. pit vipers, rattle snakes
- Haemorrhagins e.g. viper inhibits platelet activity * crotalidae polyvalent antivenom
“ “ “ “

Increasing vsl permeability Elapidae e.g. cobras, coral snakes, mambas
* multivalent coral snake antivenom,
-
Samir polyvalent, Thai red cross
Eastern diamond black rattle snake is haemotoxic
Cobra antivenom
and myotoxic e.g. rattle snakes Australian tiger snake, 
vipers Hydrophidae sea snake
sea snake antivenom
cobras, bothrobs, asper,taipans
local tissue necrosis It is difficult to predict which bites will produce
symptoms or clinical outcome.
-
Neurotoxins can* presynaptic, like mamba, puff Ask the patient the time of bite, how long ago, the
adder type of snake

* Post synaptic like krails and cobras

* anticholinesterase
muscular paralysis Rs

-
Failure
Apply tourniquet; if upper limb don’t exceed 30
- minutes, if lower limb don’t exceed 60 minutes.
Cardiotoxins e.g. burrowing asp, some elapids -
coronary vasoconstriction Too tight tourniquet leads to ischaemia and a too
loose one is also dangerous because it will allow
the venom to go into the blood stream
Arteriovenous blockage (tourniquet abuse).
16
 - -
Excision of the wound and application of Of 0.5ml 1:1000 adrenaline (epinephrine) must be
potassium permanganate should not be available when antivenom is given.
encouraged since they cause trauma, bleeding -
and necrosis. Some people use anti snake venom If no reaction, give entire initial dose within 4 hrs
but the efficacy is not proven more so when the of the bite.
type of venom is unknown. -
- In severe envenoming, antivenom given upto 24
Give anti snake venom as you prepare hrs after bite to reverse coagulation deficits.
psychologically for resuscitation incase of
anything.
- There are three types of antivenom reactions;
Be ready for any eventuality a)
- Early anphylactoid
They cause anaphylactic shock and the efficacy is b)
not proven Pyogenic
- c)
Antihistamine can be an antidote to antisnake Late.
venom serum.
If instant anaphylactoid reaction occurs, discontinue
Management antivenom administration and give pt oral
- antihistamines or i.m adrenaline(0.5 ml of 1;1000).
Use large bore i.v cannula on the unaffected limb Infusion of antivenom can be restarted at slower rate.
- Corticosteroids are commonly given to treat serum
Monitor Bp, coagulation, renal function, sickness. If pulses are absent, query compartment
cardiorespiratory status. syndrome and consider surgical assessment.

NB; don’t use Aspirin as analgesics because it may Indications for antivenom administration in snake
aggravate bleeding bites

- -
In severe coagulopathy with thrombocytopaenia Cardiogenic shock
causing DIC, large quantities of fresh frozen -
plasma, cryoprecipitate and platelets are required Neurotoxocity
if response to antivenom is poor ,. -
- Rapidly progressive extensive local swelling
Before antivenom therapy, ask for any history of -
allergy and do intra dermal sensitivity test before Spontaneous systemic bleeding
injecting, 0.02 saline diluted antiserum at site far -
from bite, observe injection site for about 10 min. Haematuria
for development of redness, hives, pruritus, other -
adverse effects. Incoagulable blood
- -
A syringe Other evidence of haemolysis

17
 - In cases where the Fb has been lodged in tissues
Rhabdomyolsis recently, a redish track due to extravasated blood
- indicates the path of the Fb.
Bites on digits by snakes with necrotic venoms.
Te following are Fbs which are likely to lodge in
tissues;

i) Anaphylactic shock due to reaction to the - Hypodermic needles

serum - Domestic needles
ii) Efficiency is not proven - Sewing machine needles
- Fish hooks
Anti-histamines are indicated for: a) Therapeutic - Gravel
effect (b) Antidote for anti-snake venom serum - Glass splinters
sickness. - Metallic sutures used in operations which
d) Scorpion stings: common in desert areas. sometimes break within a few days of insertion
Can cause intensive pain and upsets for long causing pain in the tissue. E.g. patella stout wire.
periods. Patient responds well to emetine 65mg - Pieces of clotting in wounds caused by
for an adult and smaller dose for children. gunshots
e) Human bites: - Swabs and packs may be found in the
- Can be very fatal to life to life or to the abdominal cavity especially during an abdominal
limb itself. The wound becomes contaminated by operation causing irritation leading to tender
so many types of bacteria including Vincent’s palpable swelling within a few weeks. It is
organisms from the mouth. A common injury is an therefore important to count all swabs before and
incised wound over the knuckles resulting from a at the end of a operation before closure of the
clenched fist knocking the front teeth of another wound
person. - Radio opaque threads especially those in
bank notes should be incorporated in all swabs so
Treatment that if the swab count is wrong you can send the
patient for an x-ray.
- Excise
- Antibiotic cover. You may use a broad
spectrum antibiotics (high doses) e.g. tetracycline.
EXAMINATION OF A LUMP:
FOREIGN BODIES INTISSUES
A localized swelling may arise from the local tissues
Whenever an Fb is suspected, an x-ray of the part like ; the skin, subcutaneous tissue, muscle, tendon,
must be taken in at least two planes i.e. Antero- nerve or bone. Some swelling may originate from one
posterior (AP) and Lateral planes. This is done to radio tissue but attach to other surrounding ones. The
opaque foreign bodies. For Fbs which are mportant part of the examination is to determine the
comparatively less radio opaque, personal origin of the swelling.
observation and palpation is of great assistance.
When removal is attempted the following are Method;
necessary, good light, ample time, bloodless field and Inspection
electronic locator.
1. Determine the location of the sweeling

18
 2. Describe the size (measure if possibleor of the swelling is determined by its attachment to
relate to a commonly known object like a pea, the underlyingand or surroundingtissues
tennis ball etc) a. Highly mobile swellings are usually
3. Shape- round or oval situated in the subcutaneous tissue space
4. Borders – regular or irregular b. Swelling that moves with the movement
of skin or can be pinched with skin originate from
Palpation the skin.
1. Tenderness – asses whether mild, c. Swelling that move with every contraction
moderate or very tender. or shifting of muscles in any direction originate
2. Temperature – asses the temperature on from muscles or tendons
the site of swelling and compare with other parts d. Fixed or immobile swellings –can
of the body that are equally exposed. originate from bone or indicate malignancy
3. Surface –asses whether smooth or 6. Transluscency – to determine whether
irregular the swelling is cystic. The procedure of
4. Consistency – soft, firm, hard, fluctuant or transillumination requires a powerful torch and a
pulsating slightly dark room.
a) Pulsating – place the index and middle a. Place the torch on one side of the
fingers over the swelling . if pulsation is present, swelling
the swelling will be felt to move with every beat b. Observe for sparse illumination of the
b) Elicit for fluctuation or transmitted swelling
impulses Note: Always remember to examine the lymph nodes
i. Use the index finger of each hand draining the the area, nerves and distal pulses to the
ii. Place pulp of the tip of the right finger swelling.
halfway between the center and the periphery of
the swelling. ( this is the “ watching finger” and is ACUTE ABSCESS
kept motionless throughout the procedure)
iii. Place the left finger upon a point at an Definition: A localized collection of pus as a result of
equal distance from the center diagonally reaction to pyogenic organisms.
opposite the first. ( This is the displacing finger )
iv. Apply pressure on the swelling using the
displacing finger Aetiology: Usually caused by invasion of microorganisms
v. Feel for outward movement of the like, 1) staph. Aureus (2) Haemolytic streptococci and (3)
watching finger. E. coli in that order
vi. If the “watching finger“ is displaced by
The bacteria may reach any part of the body through
pressure exerted by the “displacing finger” in
three main routes;
both axes of the swelling then fluctuation is
present  By direct infection from out e.g. through
c) Test whether it is possible to empty the penetrating wounds
swelling by compressing it and then noting any  Local extension from adjacent focus
refill after releasing the pressure.  By the blood stream (haematogenous) or
5. Mobility – using your fingers asses lymphatyic
whether it is possible to mve the lump. Mobility

19
In the cause of haematogenous spread, there may be a like the toes and fingers. This is because of greater bld
predisposing factor like a bruised muscle causing supply to the area.
extravasations of blood which forms a suitable media for
multiplication of bacteria. Acute osteomyelitis may occur  Fever
following a minor injury to a limb. Discharging sinuses are  General malaise
very suggestive of osteomyelitis.  Anorexia
 Symptoms of acute abscess
Pathological process  General -raised body temperature -rigors
may occur in severe
Once the bacteriae have gained entry to the tissues they  Local of acute inflammation abscess
multiply and produce toxins and inflammation results.  The five classical signs of inflammation
The area is surrounded by a painful zone of acute are present
inflammation which is infiltrated with leucocytes and  Heat – the inflamed area feels warmer
bacteria. than surrounding tissue
 Redness of the skin over the inflamed
Polymorphs contain a proteolytic enzyme which causes area due to hyperaemia
liquefaction of tissue into pus which is composed of  Tenderness due to the pressure of the
bacteria and dead leucocytes exudates on the surrounding nerves
 Swelling due to hyperaemia and
The tension in the abscess rises owing to the exudation of
inflammatory exudate
plasma and may spread along the paths of least resistance
 Loss of function. The inflamed tissue does
to the surface of the body or to a hollow viscus where the
not perform its physiological function
pus is eventually discharged.
Severity of these signs depends on the extent of the
Occasionally the resistance of the body is sufficient to
inflammation and its proximity to the surface. The
destroy the bacteria before pus has found its way to the
swelling is initially firm and edematous but later becomes
surface. The fluid is absorbed and either fibrosis follows or
soft and fluctuant. In some cases such as acute mastitis
a cavity containing insipissated pus remains (hard dry
increasing edema is characteristic of a deep seated pus. If
pus). Such a condition may occur in the breast when an
not treated an abscess tends to point. The skin or
attempt to cure a breast abscess with antibiotics fails.
membrane covering it gives way and its contents are
When this occurs there is a resultant lump which is called
discharged giving relief.
an antibioma (antibiotic tumor). In some cases such as
staphylococcal abscess of bones remain dormant Treatment
(quiescent) but gives rise to flare ups of inflammation
following local injuries or impaired general health and is When an abscess threatens to form it can sometimes be
called brodie’s abscess and is a variety of chronic aborted by antibiotics of adequate doses and long period.
osteomyelitis. It is a cold abscess. Bed rest
Symptoms of acute abscess Elevation of the affected part to improve venous return
Patient feels ill and this depends on (a) size of abscess (b) Once pus has formed incision and drainage must be done.
virulence of the organism (c) the tension within the The incision should be made at an independent part (the
abscess lowermost part) of the abscess. ? Application of kaolin
Throbbing pain which is characteristic of an abscess which poultice or short wave diathermy promotes hyperemia.
becomes more severe if the affected part is dependent
20
If the abscess is situated in an area where there is danger 1) Redness
of damaging structures (important) such s the neck, groin, 2) Itching or stiffiness community at this site
or the axilla, a modified Hilton method of drainage should inoculators
be used. This method consists of incising the skin and 3) Tenderness
superficial fascia and opening the abscess using a pair of 4) Swelling
sinus forceps or artery forceps. By separating the blades 5) The general features of infection fever,
of the forceps a sufficiently large opening can be made. A malaise, amnesia may also be present.
finger is then inserted and all the locules broken and
converted into a single cavity. A drainage tube is inserted Treatment
and left in situ, so that pus drains freely.  Bed rest
NB  Elevation
 Appropriate antibiotics
Pus from an abscess must be cultured to determine the  If pus is suspected incision should be
severity of the causative organism. made down to the deep fascia
 Diabetic and other condition if present
It is wrong to try to cure an abscess by use of antibiotics should be re..
Care must be taken not to incise an aneurysm mistaken CELLULITICS IN SPECIAL SITUATIONS
for an abscess. In an aneurysm the swelling is
characteristically pulsatile. Cellulitis on the scalp

CELLULITIS Usually results from infection of wound in the scalp. The

infection may involve cranial bones and giving rise to
Def. Inflammation spreading along the subcutaneous or osteomyelitis and even meningitis.
fascial planes, often as a result of infection by
streptococcal pyogens. Formerly used to be called Orbital cellulitis
‘Hospital gangrene’. Gangrene may follow, occasionally
resulting in widespread sloughing of tissues. It follows wounds or spread of infection from one of the
paranasal sinuses in the vicinity. It gives rise to protruding
Aetiology proptosis, impairment of occular movement, oedema of
the eyelid and oedema of the conjectiva.The
The commonest is streptococcal pyogens constitutional symptoms are often severe and there are
In the pelvis E. Coli and strep. Faecalis may be responsible two outstanding dangers of orbital cellulitis.

This organism may gain entry into tissues through a minor Thrombosis may extends the ophthalmic plexus of veins
accidental route such as a graze or scratch or as a result of to the cavenous sinus and this may lead to meningitis
an operation. If the general resistance of the patient is The globe of the eye may be infected leading to
reduced by such conditions like D. Mellitus, alcoholism or Panophthalmitis.
renal insufficiency. cellulitis spreads rapidly and
extensively. In this case septicaemia and pynemia may Owing to the risk of meningitis all the wounds of the orbit
develop need careful attention.

Signs and symptoms Cellulitis of the neck.

Depends on type of organism and extent of infection It may occur as a complication of infection in the mouth,
tonsilitis, mastoiditis. The condition (cellulitis of the neck)
21
is described as Ludwig’s angina or submandibular PYOMYOSITIS
cellulitis. The two main dangers are;
BACTEREAMIA AND SEPTICEAMIA
Oedema of the glottis

They are due to the presence of organism in the bld as

Downward spread producing mediastinitis
diagnosed before blood culture. In conclusion the
Pelvis cellulitis organisms are merely present in the bld but they are not
multiplying septicaemia the organism are present in blood
Commonest course in women is bilateral tear of the Cx and actively multiplying. The organisms must be present
during parturision. in large number so that the condition to manifest.

In men it may be the result of rapture of bladder or other

pelvic organs.
Clinical features
Cellulitis of scrotum
Usually features of severe infection i.e.
Occurs as a result of extravasations of urine due to
rapture of the urethra. The infection spreads rapidly to Intermittent temperature
the Sc tissue of the scrotum and later spreads to the
Rigors
abdominal wall. The Pt is usually very toxic.
Icterus due to haemolysis of RBC or liver damage.
BOIL (FURUNCLE): Treatment

Mainly depends on the causative organism (focus).

It is an infection of a pilosabeceous unit with Specifically
perifolliculitis, usually followed by suppuration and
central necrosis. A “blind boil” is one that subsides  Blood for culture and sensitivity
without suppuration. Boils are common on the face, head  Antibiotics depending on the culture and
and neck. Boils are frequently associated with overwork, can be changed if necessary
worry, debility or other undermining influences. They may  Mainly aimed at preventing further
be presenting symptoms of diabetes mellitus. formation of emboli.
 Correction of dehydration by infusion of
CARBUNCLE I.V fluids.
 Administration of intensive antibiotics I.V
This is an infective gangrene of the subcutaneous tissue,
as soon as possible
which often occurs in the nape of the neck. The
 I and D of abscesses where possible.
subcutaneous tissues become painful and indurated, and
 If the condition is caused by thrombosis
the overlying skin is red . Unless the condition is aborted
of the lateral intracranial sinus ligation and
by prompt treatment, extension will occur and, after a
difussion of internal jugular veins may interrupt
few days, areas of softening appear, the skin sloughs and
the stream of the emboli.
discharges pus. Usually there is one central large slough,
 Death usually follows due to abscess
surrounded by a “rosette” of small areas of necrosis.
formation in vital organs e.g. heart and brain.

22
 - Incision and drainage of abscesses where
possible
- If the condition is caused by thrombosis
of the lateral intracranial sinus ligation and
diffusion of internal jugular vein may interrupt the
stream of the emboli.
- Death usually follows due to abscess
PYAEMIA
formation in vital organs.
Def: A grave of septicaemia due to the circulation in the
ULCERS
blood stream of septic emboli composed of masses of
organisms, vegetation or infected clots. Def: Discontinuity of an epithelial surface of skin or
mucous membrane as a result of progressive destruction
The septic emboli lodge and grow in distant organs like
of cell by cell. The destruction of surface tissue is
brain, lungs, heart, kidney to form multiple abscesses. The
microscopic as distinct (different) from death of
organisms responsible are usually streptococci and
macroscopic portion such as occurs in gangrene or
staphlococci.
necrosis.
Predisposing conditions
Ulcers have a tendency not to heal.
- Thrombophlebitis
Classification
- Acute osteomyilitis
- Infective endocarditis (bacterial There are three main classes;
endocarditis).
- Acute suppurative otitis media. 1. Non specific ulcers
- Infection of an intracranial sinus. 2. Specific ulcers
3. Malignant ulcers
Clinical features A. NON SPECIFIC ULCERS:

 Repeated rigors. They are due to, infection of wounds, or physical or

 Intermittent temperature chemical agents. These are predisposing causes as in;
 Rapid pulse
 Toxic pt and has a dry furred tongue  Local irritation e.g. dental ulcer.
 Multiple abscesses may form in any part  Interference with circulation e.g. Varicose
of the body. They are painful and tender but ulcers
discovered as a swelling. Non- specific ulcers include:
 Joints are occasionally affected and may
become quietly disorganized. - Traumatic ulcers
- Venous ulcers (venous diseases e.g.
Treatment: varicose veins).
- Mainly aimed at preventing further - Trophic ulcers
formation of emboli - Ulcers due to arterial dx e.g.
- Administration of intensive antibiotics i.v thromboangitis obliterans (buergers disease).
as soon as possible i) VENOUS ULCERS
- Correction of dehydration by in fusion of
intravenous fluids
23
Occurs either in connection with varicose veins or Raynauds disease occurs in women and mainly the upper
following D.V.T in which canalization of the deep vein has limbs. It is attributed to an abnormal sensitivity of
occurred but the valves are either destroyed or arterioles to cold when exposed to cold the vessels go
incompetent due to the damage. The underlying cause is into spasms.
venous stasis which leads to local tissue anoxia. Nutrition
of the tissue is reduced and it breaks down leading to an Syringomyelia is uncommon progressive dx in the nervous
ulcer. system seen mainly in adults. For an unknown reason
there is cavitation and fibrous tissue reaction in the upper
Signs spiral cord and the brain stem and this interferes with
sensation of pain and temperature especially in the
 Medial aspects of the lower 1/3 of leg. hands. As a result of loss of sensation to pain the pt
 Ulcer is superficial with a pale or neglects any minor injuries in the skin and this later turns
hyperpigmented floor. into ulcers.
 The surrounding tissues and skin are hard
 It worsens in condition which cause In the leg ischemic ulcers occurs around the ankle or
impairment of venous return e.g. pregnant around the dorsum of the foot.

They are very painful and resistant to local treatment.

Treatment: The common causes of trophic ulcers due to anesthesia

are;
Conservative treatment
- Leprosy
- Admission
- Bed rest - D.Mellitus
- Elevation of the leg
- Daily dressing with lotion such as Eusol - Spina bifida
- Exercises - Tabes dorsalis
- Pressure bandaging applied from the toes
to the tibial tubercle - Peripheral nerve injury

Surgical In leprosy and d. mellitus there is neuritis which leads to

loss of sensation and ulceration.
- Skin grafting when a good venous return
has been established Trophic ulcer due to anesthesia are called perforating
- Stripping off of a varicose vein. ulcers.

They start in a cone and penetrate into it. The

suppuration may involve the bones and joint and spread
ii) TROPHICAL ULCER along facial planes upwards and even involve the cuff
They are due to impairment of nutrition which normally muscles.
depends on adequate blood supply. Rx
Caused by ischaemic and anesthesia Treat the underlying cause
Trophic ulcers of the finger tips occurs in chronic iii) ULCERS DUE TO ARTERIAL DISEASE
vasospasms of the (Raynaund’s disease, syringomyelia).
24
Thromboangitis obliterans (buergers dx) A small indurated papule 1st appears. It becomes eroded
and results in a classical ulcer known as hunterrian
Condition characterized by occlusive dx of small arteries chancre. This is an indurate, rounded usually single
e.g. radial, tibial and ulna arteries. painless with a slight raised well defined hyperaemic
Thrombophlebitis of superficial or deep veins margin.

Found in male pts about 20 -30 years of age (under 30). It exudes a serous discharge which is rich in treponema.
Usually heals spontaneously in a few weeks.
It associated with, excessive smoking.
In females the lesion may be situated at the
It does not occur in women or non smokers.
Fourchette
Histologically localized inflammatory changes occur in the
walls of arteries and veins leading to thrombosis. Clitoris
Thrombosis leads to ischaemia and nutrition of the tissue Labia majora
is reduced finally leading to ulceration. Pt complains of
pain on walking (intermittent claudication) Cervix

Pain on the cuff muscles while resting and limb ulcers due In this situation it is not obvious and may pass unnoticed.
to buerger dx commonly progress to gangrene of toe and
fingers. In males

Rx Mucous surface of the prepare

Total abstinence from smoking which arrests the dx but Glans penis
does not reverse the established damage. Shaft of the penis (occassionally)
Administration of peripheral vaso-dilators e.g. presacolin Scrotum
Lumber (or cervico dorsal) symphatectomy surgical Lower abdominal walls
excision of sympathetic nervous system. This is the most
useful surgical procedure because it result in healing of Contact with the early mucous lesion in the mouth may
the ulcers, skin nutrition is improved and relieves pain result in an extra genital chances in the lip and the
tongue or the nipple.
Amputation maybe required.
The primary chancre is usually accompanied by a discrete
mobile shotty (ball like) enlargement of the associate
B. SPECIFIC ULCERS lymph nodes.

Syphilitic ulcers Secondary

Occurs in any of the three stages of the disease Mucous patches may occur anywhere in the mouth or on
the moist surfaces of the genitalia. These are small
Primary stage rounded, often transient superficial erosions. In the
mouth the lesions join together to form the snail track
A sore or chancre appears as the site of entry of the ulcers.
treponema pallidum. Occurs 10 – 90 day after infection.
Tertiary (5-15 YRS)
25
The characteristic lesion is called gumma. This is a mass of Treatment
granulation tissue with central necrosis. Sloughing of
subcutaneous gumma leaves a painless, punched out Bed rest
ulcer whose base has a wash leather appearance. On Good nourishing diet
healing the ulcer leaves a silvery “tissue paper” scar.
Specific anti tuberculous therapy.
Treatment

1. Saline compresses. No local Rx should be applied until

the exudate has been examined for a negative syphilis by
darkground microscopy. 3 successive days specimen
C. MALINGNANT ULCER
should be taken
Squamous cell carcinoma (epithelioma)
2. Anti syphilitic therapy
Basal cell carcinoma (Rodent ulcer)
Procain penicillin 9000 units 1.m (7-14/7). Late syphilis Rx
can be continued to(14-21/7). Squamous cell carcinoma
Benzathene penicillin (“panadur”). A long acting penicillin Predisposing factors
dose 10cc (4.8 m.u) 5cc per buttock. i.m stat. or small
doses weekly x3 doses. Burns

Contractures

TUBERCULOUS ULCERS Ulceration (chronic) due to e.g. tuberculosis and trophical

ulcers
Commonly seen in the axilla, neck, or groin due to the
breaking down of a tuberculous lymph nodes. Tuberclous Sites:
ulcer of the tongue occurs in pt with advanced PTB or
Commonly lower 1/3 of the leg
pharyngeal ulcers. The two cases are this day. It does not
occur in pt under Rx. But may occur on the scalp or anywhere in a burnt area
especially those exposed to the sun
A typical tuberculous ulcer is shallow and painful. The
edges are undermined, irregular and bluish. The floor is Prepuce of the penis
covered with pale granulation. The base is soft and the
discharge is thin and watery. Characteristics of a typical squamous cell carcinoma.

The regional lymph nodes are inflamed and matted Outline-irregular

together.
Edges-Raised and ererted
When a tuberculous ulcer of the skin or mucous
Base-indurated has cauliflower appearance and later
membrane becomes chronic and will show small
becomes attached to the deeper structures
granulation in the subcutaneous tissue often referred to
“apple jelly nodules”. Palpation-Friable (crumbles and bleeds easily).

Long standing tuberculosis ulcers may sometimes Blood stained discharge occurs and decreases in amount
undergo malignancy resulting in a haemangioma, when there is 2nd injection.
squamous Cell Carcinoma (S.C.C)
26
Region lymph nodes are enlarged and fixed. Flies: contaminate minor traumatic wounds thus
formation of tropical ulcer.
Treatment
Summary of the aetiological.
Biopsy for histology for confirmation of Dx
4 fs
After confirmation of Dx wide excision should be done
followed by skin grafting Friction (trauma)

Partial or total amputation of part involved e.g. la penis Food (malnutrition)

Fusiform bacillis

DERMATITIS ARTEFACTA Flies

Self mutation e.g. by application of irritants such as Clinical features

corrosive (hysterical temperament by doing something
intentionally) or litigation (law suit) may be involved. Commonest in males. Exposed to trauma than females

The ulcer is usually square and has straight edges. Age incidence 10 – 20 years.

Heal if protected by an undisturbed dressing. Ulcer in commonest in the lower 1/3 of the leg (ankle
joint).

Spreads rapidly and has a grey foul smelling slough.

TROPICAL ULCER
Usually solitary but occasionally may be more than one
Def: An acute specific localized necrosis of a skin and
subcutaneous tissues. Ulcer is painful

Occurs, as a result of, persistence of an acute stage of a Edges are raised and surrounding tissues edematous
known specific ulcer. Systemic upset general malaise for example.
It is endemic in tropical region (India, Africa, in America) Pathological process

Stage 1:
etiological factors There is a painful lesion which is tense, accompanied by
1. Trauma: commonly initiated by very slight trauma systemic upset e.g. malaise
e.g. thorn brick, scratch, mosquito bites of feet or leg. A blister develops and breaks down with a characteristic
2. Malnutrition: prevalent in people of poor diet, rare in foul smelling discharge.
agricultural commercial and city dwellers, therefore, a Stage 2:
disease of the poor.
Tissue dies giving rise to a black slough
3. Fusiform bacilli and Vincent spirochaete found in the
discharge in the early stages of the ulcer. Slough separates, leaving an ulcer. Ulcer has slight raised
edges. Floor is covered with granulation tissue which
bleeds easily.

27
Ulcer penetrates and muscles, tendons and bones may be Contractures are released by plastic surgery.
exposed on the floor of the ulcer.
Amputaion is done incase of malignancy.
Stage3:
Prevention
Swelling of surrounding tissues subsides.
Encourage footweard (shoes)
Pain subsides
Encourage balance diet
Smell disappears
Destroy fly breeding places
If no healing the ulcer becomes a chronic tropical ulcer.
Antiseptic in dressing new wounds.
Complication

Chronicity
LIFE HX OF AN ULCER
Cancerous osteoma due to ulcer irritating the periosteum
which reacts to the irritation and forms new bone. Consist of three stages

Contracture due to a reduction in skin tissue and Extension stage

excessive scar tissue for formation which leads to Transition stage
Malignancy to squamous cell carcinoma due to instability Repair stage.
of the epithelium and frequent trauma.
Extension stage
Rx
Floor covered with exudates, sloughs while the base is
Acute stage indulated
Systemic penicillin x10/7 Edge of the ulcer is sharply defined
Bed rest Purulent discharge which may be blood stained.
Raise foot on pillow Transition stage
Daily dressing Mainly for preparation for healing.
In stage 2 the edge of the ulcer are excised and the floor Floor become cleaner
of the ulcer curated
Slough separates
Local antibiotics are applied when healthy granulation
tissue appears. Skin grafting can be done. Induration diminishes

Chronic stage Discharge becomes more serous

If there is exostosis (overgrowth of bone tissue) the bones Small areas of granulation tissue appear at the floor and
is chiseled back to its normal contour. this areas join up until surface is covered.

If there is death bone, sequestrectomy is done (surgical

removal).
28
Repair stage Square area or straight edge is suggestive a dermatitis
artefacta.
Granulation tissue is transformed to fibrous which
gradually contracts to form a scar. 4. Edge:

Edge becomes more shelved and epithelium gradually A healing non specific ulcer has shelving edge.
extends from it to cover the floor at a rate of 1mm/day.
Tuberculosis ulcer is undermined
The healing age of the ulcer is composed of three zones:
A rodent ulcer has rolled edge
Outer zone: consist of epithelium and looks white.
Syphilitic ulcer has a vertically punched out or a square
Middle zone: consist of granulation tissue covered by few cut edge
layers of epithelium and is bluish in color
Raised and everted is typical of a malignant ulcer.
Inner zone: Consist of granulation tissue covered by a
single layer of epithelium cell and the zone is reddish in 5. Floor:
color. Is that which is seen by an observer e.g. may be watery or
“apple jelly” granulations are typical in a tuberculous
ulcer.

A granulation ulcer has a slough with a wash leather

CLINICAL EXAMINATION OF AN ULCER appearance.

Should be done in a systematic manner. 6. Base:

Aspects to be considered(S,S,S,E,F,B,D,L,P,D). Is what can be palpated under the floor.

Site: It is indurated in a carcinoma or syphilitic chancre

95% of rodent ulcer on the upper part of the face May affect deep structure.g. a venous ulcer may be
attached to the tibia.
Ca typically affects the lower lip where as a 10 chancre of
syphilis usually affects upper lip 7. Discharge

2. Size: Prevalent shows active infection

Length of Hx should be regarded e.g. ca extends more Bluish greenish discharge suggests infection with
rapidly than a rodent ulcer but extends more slowly than psuedomonous pyocyaneus.
an inflammatory ulcer.
Watery discharge is typically found in TB
3. Shape:
Blood stained discharged is typically found in extension
A rodent ulcer is usually circular shaped. phase of a non specific ulcer.

A gummatous ulcer is usually circular due to the joining NB: Bacteriological examination of the discharge is
together of multiple ulcers. necessary because there may be colonization of micro
organism.

29
Spirochaete are found in 1 chancre. A gummatous ulcer may be associated with other
stigmatic conditions such as chronic glossitis.
8. Local lymph node: are not enlarged in rodent ulcer
13. Pathological examination
In squamous cell Ca they may be enlarged, hard and fixed.
Are of value and must be done on pt with ulcer by:
The inguinal lymph nodes draining a syphilitic chancre of
the penis are found to be firm and shotty Taking a biopsy to r/o cancer

The submandibular lympnodes that drain a chancre of the Blood for kahn test/vDRL or wasserman test to r/o
lip are grossly enlarged. syphilitic.

Mantoux test R/o tb.

9. Pain: Sputum for A.A.F.B R/o TB.

Non specific ulcer in the extension and transition stages Urinalysis to R/o diabetes mellitus
are painful with only one exception of anaesthetic
(trophic) ulcer. Bld for full haemogram

Tuberculosis ulcers vary e.g. a tuberculosis ulcers of the D

tongue are very painful. E.S.R chronic condition

Hb
Syphilitic ulcers are usually painless but anal chancre of Platelet count
the homosexual are painful.
Film

WBC
10. Depth:
Discharge for bacteriology
Should be recorded in MM or CM and anatomatically by
describing the structure it has penetrated. Other- CxR R/o Tb or malignant metastasis.

11.State of local tissue X-ray can confirm or R/o.

Pay attention to local blood supply and nerve supply coz Blood for H.I.V
many ulcers especially those in the limbs are secondary to
LOCAL (TOPICAL) TREATMENT OF NON SPECIFIC ULCERS
vascular or neurological dx
Any underlying cause should be treated e.g. varicose
12. General examination.
veins, diabetes, arterial diseases. Many lotions and non-
Extremely important coz most systemic dxes present with adhesive tapes applications are used to aid separation of
skin lesion and ulcers as the only signs. The examiner sloughs, hasten granulation tissue and stimulate
must look for any evidence of debility, H/failure, anemia, epithelialisation. The basic requirements of an ideal
diabetes mellitus. dressing are;

30
Maintain a high humidity between the wound and the Skin grafting
dressing. Stripping of
varicose veins
Remove excess exudates and toxic compounds
3.Squamous cell Variable Wide excision
Permit gaseous exchange of oxygen, carbon dioxide and carcinoma after a biopsy
water vapor; Skin grafting
Partial or total
Provide thermal insulation to the surface and be amputation
impermeable to microorganisms;
4.karposis Begins Chemotherap
Be free from particles and toxic wound contaminants sarcoma on the y
foot but Radiotherapy
Allow easy removal with no trauma at dressing change can Amputation
spread
Be safe to use and be acceptable to the patient to other
areas
Be cost effective
5.Malignant Lower Surgical
melanoma leg and excision and
Antiseptics and topical antibiotics
sole of skin grafting if
Antiseptics can do more harm than good when used the foot confirmed
(most early
inappropriately. They can interfere with the normal
common
healing process, are toxic to fibroblasts and may permit ) but
more virulent organisms to dominate. The routine use of may
antiseptics and hypocloride solutions should be avoided. affect
If a wound needs cleaning, this can be achieved safely and front and
more economically with normal saline back of
trunk.

6.Venous Variable Dressing

gangrene Skin grafting
Amputation
SUMMARY OF CHRONIC LEG ULCERS
7.madura foot Whole Anti fungal
foot agents: local
& systemic
NAME OF ULCERS SITE TREATMENT Tab
1.Sickle cell Medial Bed rest grisofulsion
anaemia malleolu Dressing Amputation.
s Skin grafting
Antibiotic if 8.Yaw(Framboecia Lower Penicillin as in
septic ) by treponema leg syphilis
pertinue
2.Venus (varicose) Medial Bed rest 9.Leprosy(trophic Sole of Anti
ulcer malleolu Dressing ulcer) feet tuberculous
s Elevation Tip of drugs
Exercises fingers Rest
Pressure P.O.p
banding
31
 Footwear 6. Dense fibrosis prevents contraction and healing
Amputation
Plastic surgery 7. Type of infection, e.g. tuberculosis or actinomycosis

9.Diabetess Toes and Control 8. Presence of malignant disease

mellitus(trophic) feet diabetes
ulcers form of Amputation if 9. Drugs, e.g. steroids, cytotoxics.
gangrene necessary.
10. Malnutrition

Interference e.g. artefacta

SINUSES AND FISTULAS Irradiation as in RVF for the treatment of ca cervix
Sinus: It is a Latin word meaning hollow. This is an Crohn’s disease
abnormal blind track which is usually lined with
granulation tissue. It leads from an epithelial surface into High output fistula
the surrounding tissues. It may be congenital like the
Treatment
periauricular sinus. The acquired forms follow inadequate
drainage of an abscess. For example, a peri anal abscess The remedy depends on the removal or specific treatment
may burst on the surface and lead to a sinus. of the cause.
Fistula: It is Latin word meaning pipe or tube which is an Proper drainage of abscesses
abnormal communication between the lumen of one
organ and the lumen or surface of another, or between Scrapping is sometimes necessary to destroy an epithelial
vessels. Most fistulas connect epithelial lined surfaces. It lining of a sinus or fistula
may be congenital or acquired. Forms which have a
Rest or immobilization of the affected part.
congenital origin include brachia, trachea-esophageal and
arteriovenous fistulas. The acquired type follow
inadequately trained abscess, Example is when a peri anal BIOPSY
abscess opens into the canal and the surface of the
perineum. Definition: Excision of a tissue from a living body for
microscopic examination.
Persistence of a sinus or fistula;
Indications:
1. A foreign body or necrotic tissue is present e.g. a
suture, hairs, a sequestrum, faecolith, or even a worm. Tumors

2. Inefficient or nondependent drainage For distinguishing a benign from malignant tumor. Useful
for growths which initially are benign and have a tendency
3. Unrelieved obstruction of the lumen of a viscus or tube
of becoming malignant e.g. rectal polyp.
distal to the fistula
For confirming the diagnosis before an extensive
4. High pressure, such as occurs in fistula-in-ano due to
mutilating operation.
the normal contraction of the sphincter which force fecal
matter through the fistula For guidance as regards the best line of treatment. The
choice of treatment whether surgery or RT is to be
5. The walls have become lined with epithelium or
employed may depend largely on the microscopic
endothelium
32
differentiation of the tumor. The choice may depend on incised. The piece of tissue should be picked with a needle
radio sensitivity of the tumor. and put in formation 40% (formaldehyde solution).

Enlarged lymph nodes Excisional biopsy:

Generalized lymphadenopathy with splenomegally due to The whole mass is excised and submitted for
various causes can be distinguished by a lymph node histopathology. Done when the growth is small e.g.
biopsy to make a correct diagnosis. For cases with growth in the breast or a lymph gland. On the breast all
generalized lymphadenopathy biopsy from the inguinal growths are malignant until proved otherwise.
l’nodes should be avoided because this l’nodes can be
enlarged due to any other cause and this might mislead Needle biopsy:
the diagnosis. Neck or axillary l’nodes is advised (one or It is done in two ways;
both).
Aspiration of the tumor using a large bore lumina needle
Regional l’node biopsy can be used to diagnose TB of the and submit the aspirate (smear) for histopathology.
joints in the vicinity.
By obtaing a core of tissue from tumors or solid organs by
Scalenic node biopsy: is the biopsy of the paratracheal using certain specialized needles. The most commonly
and inferior deep cervical l’nodes used to confirm used are e.g. silverman needle and meghini needle.
carcinoma of the bronchus. If they are invaded then it
means that it is advanced and a radical surgery is The method is used in obtaining biopsy from the;
contraindicated. It also helps in the diagnosis of
Liver
carcinoma of the post nasal space.
Spleen
Other conditions:
Kidneys
For investigation of endocrine disfunction of the
endometrium by serological examination of the currated Prostate
material.
It is of value in confirming the diagnosis of inoperable ca
Tissue biopsy is being used frequently to study the liver, and pts without superficial condition from which you can
kidney and mucosae of the G.I.T. take an incisional biopsy.
Types of biopsy: Punch biopsy: Carried out in circumstances where tumors
are deeply seated, e.g. vocal cords, esophagus, bronchus,
Incisional (simple) biopsy
urinary bladder and rectum.The tumor is visualized using
Consists removal of a small piece of tissue and take for an endoscope and a piece of tissue is removed by use of a
examination special type of punch forceps.

Usually done under local anesthesia Exfoliative (brush) biopsy: Valuable where pathological
lesions are not readily accessible. For example tumor of
In case of suspected malignant tumor (growth), a tissue the liver, esophagus, respiratory tract and body of the
must be adequate and should be taken from the edge of uterus, cervix. Smears are made from aspirated
the growth and include a bit of normal tissue to be materialand cytological examination carried out e.g. ca
representative to reveal the presence or absence of esophagus- lavage of the esophagus followed by
malignant cells. A wedge shaped piece of tissue should be examination of fluid has led to the discovery of the

33
carcinomaearly when radiology and esophagoscopy have Skin anatomy:
been found negative. Exfoliative dx is rapidly gaining
popularity but the only disadvantage is that it requires  Epidermis;
technical training and even if the smear is positive - is the most superficial layer of the skin
confirmation must be sought for. - It provides the waterproofing layer
- It is constantly replaced from the basal
Drill biopsy: An example is sterna puncture where bone layer
marrow and bone tissue is obtained by use of drill e.g.  Dermis;
leishmaniasis and any bone cancer or blood cancer. - Is the thicker underlyind area that
supplies the strength and integrity of the skin
Biopsy by major operation: Example is laparatomy. I n - Is rich in blood supply from the subdermal
this case a lesion in the abdomen such as a lymphoma is capillary network
removed and sent to laboratory for histopathology. - It contains adnexal structures – hair
Suction biopsy: Especially used for the study of the follicles, sebasceous glands and sweat glands.
endometrium. The classical method is D&C and then Therefore, adnexal structures contain epithelial
followed by suctioning the curettage. If properly done it cells that can proliferate and heal a partial
heals the endometrium oftenly. Its advantage is that it thickness wound by epithelialization.
can be done in the office and can be performed in a
greater number of pts.

Dangers of biopsy:
HEAT INJURY

Scalds –A burn caused by moist heat. Usually caused by

hot water. It is the commonest cause of burns. The
K temperature of boiling water (100 degrees Celsius) or
steam is constant and the major determinant of the
severity of injury is the duration of contact. As with all
burning accidents, those least able to protect themselves
the very young, the very old and the very drunk) are
particularly vulnerable. In most cases it causes partial
BURNS thickness (dermal or superficial) or full thickness (deep)
burns.

Fat burns – Cooking fat or oil has a much higher

temperature (180 degrees c.) than boiling water and hot
A burn is a tissue injury from thermal (heat or cold)
fat cools slowly on the skin surface. Spills therefore cause
application, or from the absorption of physical energy or
deep burns.
chemical contact. Each has its own distinctive features
and management problems. Flame burns – A wound caused by coagulative necrosis.
They usually cause partial and full thickness burns. They
Burn depth depends, in thermal injury, upon:
cause coagulative necrosis. Flame burns have a varied
 The temperature of the burning agent; etiology: house fire, clothing fires, spills of petrol on the
 The mode of transmission of heat; skin, butane gas fires .They often occur in confined spaces
 The duration of the contact. and may be associated with inhalation burns.
34
Electric burns – The passage of electric current through
the tissues causes heating that results in cellular damage,
Heat produced is a function of resistance of the tissues, CLASSIFICATION OF BURNS:
the duration of contact and square of the current. Bone is Can be classified as superficial or deep burns;
a poor conductor of electrical current, whereas blood
vessels, nerves and muscles are good conductors. Low Superficial burns:
voltage such as from a domestic supply causes significant
- They have the ability to heal themselves
contact wounds and may induce cardiac arrest, but no
by epithelialization.
deep tissue damage. High voltage burns cause damage by
 Epidermal burns
two mechanisms: flash and current transmission. The
flash from an arc may cause a cutaneous burn and ignite
clothing, but will not result in deep damage. High voltage
current will result in cutaneous entrance and exit wounds
and deep damage. Electric burns therefore cause, full
- look red,
thickness burns, may cause ventricular fibrillation and
- are paiful,
death. Avoid touching the patient if the current is still on.
- Have no blisters
COLD INJURY Tissue damage cold can occur from - Heal rapidly without sequelae
industrial accidents due to spills of liquid nitrogen or  Superficial dermal burns;
similar substances. The injuries cause acute cellular - Have blisters
damage with the possibility of either a partial thickness or - Are painful
full thickness burn. Severe cooling can freeze tissues and - Heal by epithelialization within 14 days
ice formation is particularly likely to cause cellular without scarring
disruption. Frostbite is due to prolonged exposure to cold - May sometimes leave long term
and there is an element of ischaemic damage. It causes pigmentation changes.
coagulative necrosis.
Deep burns:
FRICTION BURNS: The tissue damage is due to a
- Have lost all adnexal structures and if left
combination of heat and abrasion. Examples include tight
can only heal by second intension with scarring
fitting wear or contact between surfaces like between the
- Deep dermal burns may be blistered and
thighs of an obese subject.
have blotchy (discolored spots) red appearance
PHYSICAL DAMAGE (Ionizing irradiation): irradiation may with no capillary return on pressure and absent
lead to tissue necrosis. Such injuries are extremely rare if sensation to pin prick.
industrial and medical safety precautions are working. - Full thickness burns have a white or
Tissue necrosis may not develop immediately. These charred appearance.
injuries are generally limited in area and surgical excision, - Sensation is absent
and flap reconstruction may be appropriate management. - The charred layer consists of denatured,
Of greater significance is the long term cumulative effect contracted dermis and is called an eschar.
of ionizing radiation in the induction of skin cancers and
ACCORDING TO SEVERITY
other tumors.
First degree
CHEMICAL BURNS This is caused by acids and alkalis. They
cause inflammation, tissue necrosis and allergic skin Extends through the epidermis as far as the moist
responses. superficial dermis
35
Are less than 15% in adults. Evaporation

Characterized by reactive process e.g. erythema, The volume of the fluid loss is directly proportional to the
blistering area of burn.

They may alter pigmentation of the healed scar. Above 15% of surface area the loss of fluid produces
shock
Second degree (deep dermal) burns:
Overwhelming sudden and intense pain.
Involves the dermis but the skin structures are maintained
SEVERITY OF INJURIES DUE TO BURNS
May heal spontaneously
There are four factors which determine the severity of
Usually result in scarring burns; Extent of the body surface involved:
Can be defined as superficial burns of 15-25 degree burns Patients with burns require intravenous fluid resuscitation
or 10-20 in children or <10% in adults. if the injury is >10% in children or > 15% in adults.
Third degree or full thickness burns or major burns Patients with smaller areas may require I.V fluids but not
- They destroy all dermal elements I.V resuscitation

- Skin is white charred and waxy Wallace’s rule of nine (9) is used to estimate burnt area in
adults i.e.
- There is loss of sensation
Head + neck =9
Fourth degree burns: Involves the muscles and tissues of
deeper structures Chest, posterior and anterior = 9 x 2 =18

Fifty degree burns: They involve the bones Trunk, posterior and anterior = 18x2 = 32

Sixty degree burns they involve internal organs. Upper limbs = 9x2 = 18

Burn shock Perineum = 1

The factors contributing to burn shock include; Lower limbs =9x2 = 18

Inflammatory reaction which leads to --------------

Vast increase in vascular permeability = 100

Loss of water, electrolytes, and plasma proteins from the NB: The rule of 9 is inaccurate in children and as a rule of
intravascular to the extravascular spaces (hypovolaemia). the thumb use the following: up to the age of 1yr the
Hypovolaemia occurs through head is 18% and each leg 14%, for each following yr
subtract from the head 1% and to each leg 0.5%
Loss in blister fluid

Loss in exudates

Oedema

36
 Full thickness Burns, both layers (epidermis and dermis)
are destroyed; may penetrate underlying structures. They
----------------- have a white, waxy or charred appearance. The important
NB: The above rule does not apply to infants and the feature is the leathery appearance which is called eschar.
below 14 years because their head and neck are nearly There is no pain sensation. Examples of full thickness
20% of the body surface area. burns are, those from burning clothes, electricity and
mottled metal.
1year child’s head+ neck = 15%
Diagnosis of burn depth
Years child’s head + neck = 13%
Depth color Blister Capillary
Therefore for children and adults use the patient’s own Sensation Healing
palm which is equal to 1%.
Refill
The depth of burn and causative agent:
Epidermal Red No Present
Burns can be partial thickness or full thickness; Present Yes

Superficial Burns Superficial Pale Present Present

painful yes
These will heal spontaneously by epithelialization and can
be divided into: Dermal

Epidermal Burns, these affect only the epidermis and Deep Dermal Blotchy +/- Absent
examples are minor flash injuries and sun burn. Absent No
Hyperemia occurs due to the production of inflammatory
mediators; they are painful and heal within 7 days. Full thickness White No
Absent Absent No
Superficial Dermal Burns (= partial thickness superficial),
these affect the epidermis and the superficial part of the Age of the patient: Individuals of extreme ages the
dermis. The blister is the most important feature. The prognosis is poor. NB Not all burns in children are
exposed dermis is pink to white. T he sensory nerves are accidental (battered child syndrome). So be careful with
exposed and the wound is therefore extremely painful. the mother’s explanation. They satisfactorily defend it.
They heal within 14 days. Associated illness or injury: Concurrent illness increase
Deep Burns mortality. Existence of cardiovascular, renal and
metabolic disorders must be established (r/o). Any
These are more severe and will only heal after a associated fractures increase fluid requirement and the
prolonged period with significant scarring. They are fractures should be treated by conservative method
divided into: (closed) e.g. manipulation under G.A. Open methods
should be avoided to make the skin intact to prevent
Deep Dermal Burns (= partial thickness Deep), there may
infection. Crystalloids e.g. hartman’s solution(Ringer’s
be some blistering but there is the appearance of blotchy
lactate) are suitable because they are close to the plasma.
red discoloration. The important feature is the absence of
capillary refill. The dermal nerve endings are destroyed OTHER METHODS OF ESTIMATION OF BURNS
resulting in loss of sensation to pinprick.
Rule of 5 (for >1 yr) – Head 15%

37
Head 15% respiratory failure in which case mechanical ventilation’s
indicated.
Chest A/P 15%
IMMEDIATE CARE OF BURN PATIENTS
Upper limbs 30%
Pre-hospital care
Abdomen A/P 15
Ensure the safety of the rescuer
Lower limbs 30%
Stop the burning process, stop drop and roll(to extinguish
The rule of 10(< 1yr) a burning person).
Head 20% Check of other injuries ABC followed by rapid secondary
Chest a/p 20% survey to rule out other missed items.

Upper limbs 20% Cool the wound – to provide analgesics and to delay
microvascular drainage.
Abdomen 20%
Give oxygen- anyone involved in a fire in an enclosed
Lower limbs 20% space, any one with altered levels of consciousness.

Fingers and palm Elevate- to reduce swelling and discomfort.

For small burns and it is approximately 1% HOSPITAL CARE

The lund and Browder chart (the most accurate and takes NB: Before hospital admission cover with a clean sheet
into account the age of the patient)
In hospital either expose or dress with one of the
Check from Adobe available topical agents.

Respiratory burns Avoid use of tight dressings in limbs with compromised

circulation
All patients with suspected respiratory burns or smoke
inhalation should receive humidified oxygen with mask Admission criteria
and regular breathing exercises. Administration of
crystalloid fluids (e.g. normal saline).Dextrose should be Age
restricted to amounts that are necessary to maintain life. Neonates always (often deep burns)
Satisfactory hydration and renal function. Patients with Babies (< 1yr) TBSA >5%
oral or nasal burns who develop stridor and respiratory
distress may have laryngeal oedema. Endotracheal Children >8%
intubation should be done before total obstruction
occurs. Tracheostomy should e carried out if intubation is Adults >15%
impossible or prolonged lower RS tract burns cause Site
edema and bronchiospasms. Treatment may include
administration of aminophylline and if no relief then Head and neck
steroids are indicated. Severe cases may develop
Hands and feet

38
Groin and axilla plasma and mainly electrolytes. The fluid should be
replaced by colloid solutions like Dextran. Calculation of
Perineum the rate of administration of fluid formulae are many and
Circumferential burns of the chest and limbs here are some of the examples;

Depth PARKLAND (BAXTER) FORMULAR

Full thickness burns >5% Crystalloids are used in the early phase of fluid
management. Ringer’s (Hartman’s) solution is the one
Special burns internationally accepted. The advantage is that it has
potassium, sodium and calcium. Use 4mls of
Electrical, chemical and inhalational burns
crystalloids/kgbwtx burnt area for the first 24 hrs . For
Others example a 70 kg man with 30% burns.

Social indications. If in doubt admit overnight and 4X70x 30 =8400mls. Half of this amount should be given
reassess next day. during the first 8hrs i.e4200mls.

NB: The first 8hrs start at the time the patient was
burnt. If the patient comes 2hrs after the burn, you must
Immediate general evaluation and treatment still give 4200mls in the next 6hrs. ¼ of the remaining fluid
(2100 mls) is given in the next 8hrs while the remaining
Patient should be assessed in a closed warm room and
4200mls is given in the next 8hrs.
treated as follows;
Ringer’s lactate is preferred because it is balanced and
Emergence sedation
most close to the extracellular fluids. It contains sodium,
Reassure the patient and keep in a quiet place calcium and potassium chlorides which are beneficial in
eliminating lactic acidosis in untreated cases of burn
Remember full thickness burns are painless shock. The total body surface is what matters in the
formular. During the next 24hrs emphasis should be
Partial thickness are relieved by cold water compresses
restoration of plasma volume. Hartman’s soln is still the
and dressing
fluid of choice. By this time the integrity of the capillary
Opiates like morphine may cause vomiting and respiratory wall has been restored. At this point colloids become
depression and should be used with caution and given in useful. The amount of colloids (plasma) to be
small doses i.v. In children the sedative of choice is administered depends on the extent of burns. In general
trimeprazine tartarate (vallergen). burns less than 50% of the body surface area rarely
require more than 700ml of plasma.
Fluid resuscitation
Burns > 50% of the body surface area may require about
Untreated patients can develop hypovolemic shock 1500ml of plasma. Ringer’s is continued to maintain
because of fluid loss from burn wounds or by adequate sodium and adequate urine output.
inflammatory edema.
BROOK (BROOK ARMY HOSPITAL) FORMULA
The volume of fluid loss is proportional to to the surface
area. The larger the area, the more the fluid loss. The rate In the first 24hrs;
of loss is maximal immediately after burns. The rate
Bwt in kg x % burns x 0.5 ml = amount of colloids e.g.
diminishes during the first 36hrs. The fluid lost resembles
dextran, plasma or blood.
39
Bwt in kg x % burns x1.5 ml (crystalloids) e.g. Hartman’s/ 70 x20 x2 = 2800ml= 1400ml crystalloids
Ringer’s lactate
= 1400ml colloids
Normal insensible loss should be taken care of (replaced)
by administration of dextrose in water r(5% dextrose. Hourly assessment of the patient must be met and fluid
Adults= 2000ml, Children up to 1yr =8o ml/kg bwt, 5yr= therapy adjusted accordingly.
60ml/kg body wt and 8yr= 40ml/kg bwt. ADEQUACY OF FLUID REPLACEMENT
First half of the calculated amount of brook formula id Several parameters are important in gauging success in
given in the first 8hrs. The remainder is given in the next treatment of shock. Over hydration may lead to CCF,
16 hrs. i.e. pulmonary edema or both.
½ = first 8hrs Laboratory parameter
½ = next 8hrs Serial hematocrit (PCV) are used to guide in the plasma
½ = next 8hrs volume. Hematocrit of > 45% suggests either low plasma
volume which can be corrected by giving additional
In the next 24hrs the amount required is about ½ of the albumin or plasma. Normally in male is between 45-54,
first 24 hrs. female 36-37 % and children 32-475.

NB: I n this formula calculations are used on 50% body Blood urea, electrolytes and creatinine clearance.
surface as the maximum % to avoid overhydration.
Urine for electrolytes.
Example: 70kg man with 60% burns
Clinical parameters
crystalloids =70 x50 x1.5 = 5250 ml.
Hourly urine output .It is desirable to have a urine output
colloids = 70 x50 x0.5 = 1750 ml. of about 20-30 ml/hr and should not exceed 100ml ml/hr
(i.e. 0.5 – 1ml/kg/hr) at any age.
insensible loss in adult = 2000 ml.
Normal urine output;
Total = 9000 ml
15 yrs old 15-20ml/hr
Summary of Brook army formula – 0.5ml = colloids
5-10yrs 10ml/hr
1.5 ml = crystalloids
Infants up to 5ml/hr
3. EVANS FORMULA
Catheter should be inserted to drain urine. When output
Total amount of fluid needed per day is calculated in kg x exceeds 100ml/hr the rate of fluid administration should
% burn x2 be decreased.
50% = crystalloids Pulse rate
50% = colloids Blood pressure
Insensible loss = 5% dextrose Temperature
Example: 70kg man with 20% burns Jugular and peripheral vein filling.
40
NB The most important is the urine output. The clinician thickness burn. A prophylactic low due of penicillin the
should be aware of the early decrease in GFR. Also check first 5 days especially in extensive burns should be given
urine clinically for glucose since a large urine output may Erythromycin can substitute penicillin. Broad spectrum
be due to diuretic osmosis secondary to glycosuria. You antibiotics should not be given unless there is systemic
must be certain that the patient is not in one of the infection to avoid resistance.
phases of renal failure.
About 4-5 days following burns there is a gradual change
CRITERIA FOR ACUTE ADMISSION. of organism that colonize the wound such as Gram
negative- klebsiella, pseudomonous aerogenosa,
Suspected airway or inhalational burns enterobacter, E. coli, providential stuarti ( all in the 4th-5th
Any burns likely to require fluid resuscitation day).

Burns of any significance to the hands, face, feet, or In the second group pseudomonous is the main offending
perineum. organism ( pseudomonous aerogenosa). The majority of
burn wounds don’t require cleaning, but adherent
Any burns likely to require surgery clothing, dirty of foreign bodies should be removed by
gentle rinsing with warm sterile water. It is not necessary
Any suspicion of non accidental injury
to rupture clean blisters because wound healing is more
Patients of extreme ages rapid in an intact blister than a broken blister. If a full
thickness burn encircles a trunk or limbs (circumferential)
Patients whose psychiatric or social background makes it escharotomy ( eschar – slough forming after burns and is
inadvisable to send them home anesthetic) then the dead skin should be incised along the
axial lines to prevent the trapped edema producing a
Any patient with associated potentially serious sequalae
tourniquet effect and eventually there will be ischemia
including high tension electrical burns and concentrated
leading to ischemic contractures or gangrene.
hydrochloric acid burns.
Escharotomies release tourniquet effects but may cause
INITIAL CARE OF BURN WOUNDS hemorrhage which may necessitate transfusion.

Good care of wound is one of the most demanding and Before starting any form of wound treatment it is
challenging problems. The objective is to obtain complete essential wound cultures of the burn area to be carried
healing in the shortest time possible .Initially the burn out. Burn wounds can be treated by: -
wound is sterile due to thermal destruction of the flora of
Closed method
the skin. Within 24 hrs the burn wound is colonized by a
mixture of flora in which gram positive cocci dominate Open method
and the common cultured from the burn wound are;
Excisional method
Staph. Aureus
CLOSED METHOD
Staph epidermidis
Tulles: - this is gauze dipped in paraffin or antibiotics.It
Diphtheroids may be oil based tulle e.g. sofratulle or water based
creams. It may contain agents such as nitrofurantoin,
All in the first to third day.
soframycin or chlorhexidine . The burn is cleaned with a
Group A beta haemolytic streptococci is the most virulent mild antiseptic or normal saline then a layer of tulle is
and can easily convert a partial thickness burn to full
41
applied. This is followed by an absorbent dressing then a Allergies are rare
bandage is applied.
There is significant reduction in the amount
Topical antibacterial agents :- There are various agents
such as; (a) mafenide (sulphamyci), (b) 0.5% silver nitrate, Of evaporation, water loss leading to a decrease
(c) 1% silver sulphadiazine. The use of these agents has In metabolic requirement.
posed a remarkable reduction in the invasive burn wound
infection. It also reduces chances of conversion of partial Technique of application:
thickness to full thickness by infection which has led to a
Initial cleaning and debridement of loose tissue (non
reduction in the amount of skin grafting being carried out.
viable). Gauze dressings which have been saturate with
The use of topical antibacterial agents does not nullify
silver nitrate are applied on the burnt area followed by
daily inspection of the wound, debridement, care,
bandage dressing. Saturate the dressing with warm silver
cleaning as opposed to tulles. These agents have proved
nitrate every 2hrs. The patient is then covered with a dry
to be the most effective to control pseudomonas
sheet or blanket to diminish water loss. The dressings are
aerogenosa.
changed once to thrice daily depending on the degree of
Silver nitrate 0.5%: Is present as acquous solution of 0.5 infection, drainage and the amount of necrotic material
% present in the wound.

Advantages 1% silver Sulphadiazine

Disadvantages
This is the newest topical agent in the control of bacterial
>Effective against pseudomonas > proliferation.
solution is hypotonic which can lead to
Advantages:

No pain when being applied

Marked decrease in serum electrolytes like
Does not precipitate and penetration of eschar is better. It
combines rapidly with DNA and RNA hence more
Na+, k+, cl and decrease in absorption of water
effective.
>Clinical bacterial resistance is unknown
No bacterial resistance.
So monitor serum electrolytes 6-8 hrly
Disadvantages:
>penetrates the eschar poorly because silver Skin rash in some cases
Salts Neutropenia in some cases
are precipitated immediately they come into
Technique of application:

Contact with the minerals of the body Initial debridement and cleaning of the wound

>Doesn’t impair epithelialization Apply to burnt area with sterile gloved hand
>precipitated silver chloride causes marked
The layer of cream should be 3-5 mm in thickness

Followed by a layer of gauze and then bandages.

Staining of the skin, dressing, beddings etc
42
Advantages of closed method: Cuts down the amount of medical attention

Comfort Chances of interference by clinicians and nurses are

reduced and chances of external contamination are
No external contamination of the wound reduced
Decrease in the amount of evaporative water from the Method is economical
wound
Patient is spared the pain experienced when dressings are
Tulles promote drying of the wound changed
Absorbent dressing prevent accumulation of serous or No blood loss as occurs when dressings are being
purulent exudates in the wound. changed.
Splinting is possible Disadvantages:
Disadvantages of closed method Body temperature is not controlled
In addition to the disadvantages of the specific topical Flies access the wound and contamination it to cause
agents, the following are the disadvantages of closed infection
method.
CONTRAINDICATIONS TO OPEN METHOD
Tulles tend to adhere to the wound causing pain during
change of dressing Circumferential burns of the whole trunk

Tulles, topical agents and gauze are expensive Burns of the hand because tissues of the hands are loose
and burns of the hand are often accompanied by massive
OPEN METHOD edema. If the edema is not corrected then the edema
It is ideal when dealing with burns of the face, perineum, fluid organizes into fibrous tissue with contracture of the
unilateral burn to an extremity or trunk, burns in children digital joint capsule and stiffness of fingers.
when dressed are difficulty to apply topical antibacterial Burns of the hands should be treated by:
agents. Aim of the method is the development of a dry
surface that retards bacterial proliferation. This depends Closed method
on the coolness, dryness and exposure to light. This
factors tend to inhibit bacterial proliferation. Elevation

Procedure Active exercises

The burnt area is cleaned and the patient left alone. All those are aimed at reducing edema and formation of
Serum oozes onto the burnt area and dries up to form a contractures and full movement of the joints to prevent
dry cast called eschar. The eschar acts as a physiologic contracture and stiffness.
dressing for the wound and protects the underlying III) EXCISIONAL METHOD
structures from contamination and promotes rapid
healing. If breakages occur in the eschar, it should be It is better accomplished on small full thickness burn
treated by applying topical agents. Areas in which pus is wounds.
noted should be debrided.
Advantage:
Advantages of open method:
43
 Patients with severe burns occasionally develop paralytic
ileus. So for the first 12hrs oral intake should be restricted
Early rehabilitation of the patient. Areas of up to 15% of to 50ml of water per hr. There after the volume may be
body surface can readily be excised so long as good increased with half strength milk followed by a liquid diet.
supportive care is available. Donor sites provide partial An N/G tube should be passed in severely burnt patients
thickness skin grafts (which contain epidermis and to:
capillary dermis) the excision should involve area of 2
degree burns surrounding the obvious full thickness Test for gastric ileus in the early stages. Much secretion
burns. The early danger of this method is secondary aspiration is suggestive of ileus. It should be tested every
infection causing rejection of the grafts. To minimize this hrly.
possibility excisional therapy should be instituted as soon
as possible after resuscitating with fluids. Provides a route for additional calories and protein in the
later stage.
NB: Donor skin must not be used unless it has been
confirmed that the source is HIV negative. Agood example Burns of the face
in which this method is used is the dorsum of the hand. In The majority of facial burns heal spontaneously and
this case early rehabilitation of the hand is essential to should be treated by open method(exposed method).
gain maximum. 2-3 days following burns the burnt areas Daily application of 1% povidine iodine lotion.
of the hand can be excised and then covered with partial
thickness skin graft. The hand is then splinted at a position Burns of the eyes and eyelids
os right angled flexion of the metacarpophalangeal joint
The eye should be examined for corneal damage as soon
and with the finger joint flexion. This kind of splinting
as possible before edema of the eye lids makes it difficult.
serves two purposes:
Burnt eyelids should be done skin grafting before
Provides early motion of burnt hand significant ectropion has developed. Refer the patient to
eye clinic as soon as possible.
Gives excellent cosmetic result.
Cold injury
Excision and skin grafting may be associated with
significant hemorrhage. Carefulbacteriological monitoring Frost bite may be associated with hypothermia. If the
of the wound should be done before skin grafting body temperature falls below 32 degrees the patient
especially a swab for c/s. If staphylococci pyogens are should be kept warm and they are likely to have cardiac
isolated the patient is given cloxacillin or erythromycin.. arrhythmias. Oxygen should be administered together
with 5% dextrose IV. The areas should be compressed
Tetanus prophylaxis: with turbid water of about 40 degrees celcius and then
It should be given to all burn wounds. If within the last treat them as ordinary burns.
3yrs the patient has had TT give only one dose of 0.5 ml. Radiation burns
Nutrition: Acute radiation produces damage to the skin and local
Blood vsls of the GIT undergo vasoconstriction within the tissues. The injuries resemble thermal burns. The
first 24hrs following burns. During this period absorption difference being that acute radiation burn necrosis sets in
from the GIT is poor and therefore nutritional more slowly and more deeply than the initial erythema.
requirements should be given through the IV line for the Surgery is contraindicated until the wound has passed
first 24hrs after which the clinician switches to oral route into subacute stage which is characterized by:

44
Disappearance of erythema Regular breathing exercises are essential to all patients
with significant burns. The patient should be encouraged
Disappearance of edema to use their main muscle groups regularly.
Sub acute and chronic burns should be treated by skin Psychological support
grafting. The timing of skin grafting is dictated by the
appearance of the wound. Burnt patients may become severely depressed and
require constant reassurance and positive encouragement
SUBSEQUENT CARE OF BURNT PATIENT TO ACHIEVE to avoid them from becoming lethargic and anoxic.
HEALING
Follow up and reconstructive surgery
Nutritional support
Patients must be carefully encouraged to return to normal
Patient with burns exceeding 30% require HPD and high life. Deep areas of burns eventually give rise to severe and
caloric diet which should be given through NG tube in permanent scars whether grafted or not. The scars are
additional to a normal diet. Sugar and milk based called hypertrophic scars and partially troublesome in
products should be given by Sutherland method. children. They are hard, dark, raised, irregular and
Adult= proteins (1gmxbwt in kg + gm x % burns) for 24hrs pruritic. The process of maturation of these scars, i.e.
softening, flattening and return to normal skin takes many
Calories (20 kg calories x bwt x % burns) for 24hrs months or years to come to a completion. During this
period scar tissue contract especially those on flexion
Children = proteins and calories should be equal that
areas.
which the child normally receives at his age. Make up for
any deficiency caused by starvation for general Complication of burns
anaesthesia. These additional requirements are reduced
as healing progresses. They are divided into:

Immunology and antibiotic therapy Early (immediate)

Septic complications are the major causes of death in Intermediate

patients with burns because these patients’ immune Late
reserves should be reinforced by the intermittent
administration of fresh frozen plasma to provide Early complications
antibiotics. The pt’s Hb should be monitored and
maintained by fresh blood transfusion. Fluid loss: Mainly plasma and especially electrolytes as
the main components. This is mainly due to oozing of
In general patients with burns should be treated with fluids from the burnt area. The greatest amount loss of
fresh frozen blood accompanied with antibiotics if the fluid occurs in the first 18 hrs. In major burns more than
organisms are present. Antibiotics should be used with 30% of patients develop gastric distention and paralytic
caution because they may cause resistance. Burnt ileus due to loss of electrolytes. For this reason the burnt
patients are also susceptible to viral and fungal infection. patient should be given nothing by mouth because of the
For severely burnt patients isolation and barrier nursing increased chance of vomiting and aspiration. As a routine,
are important. pass an Ng tube for several days until the gastric function
has returned to normal. If the patient is alert, no
Physiotherapy vomiting, and no signs of abdominal distention, other
fluids, calories and proteins can be given orally. If paralytic

45
ileus develops after 5-7 days after burns suspect infection - Paralytic ileus
(sepsis).
-Abdominal distention
Hypothermia: peripheral blood vessels constrict and
blood is deviated to vital organs. This leads to reduction of Initial management of ulcers: It is conservative. The
body temperature. Hypothermia also comes as a result of stomach should be decompressed with NG tube by
skin destruction. aspiration. Check the aspirate for blood. Antacids or milk
should be given. Blood transfusion depending on amount
Acute renal failure: The patients who are likely to develop of loss.
renal failure are; (i) Pts with electric burns (ii) Those with
other forms of trauma e.g. crash injuries (iii) Pts in whom Indication for operation in a patient with curling ulcers;
fluid resuscitation is delayed. These pts have a raise in bld Perforation
urea and creatinine levels, low GFR, and lack of response
to a bolus of fluid (sudden large amount of fluid). Uncontrollable hemorrhage. Other curling ulcers should
be treated conservatively. If surgery is necessary then the
Renal failure is prevented by an early restoration of blood procedure of choice is antrectomy and vagotomy.
volume by fluids and maintenance of fluid balance.
Treatment for renal failure is like for any other type of Curling ulcers can be prevented by prescribing drugs like
renal failure. The clinician must ensure that no overload cimitidine (tagamet) which are H2 receptor antagonists –
of fluid by strict maintenance input and output chart. Ranitidine (zantac).
Acidosis and alkalemia must be detected and treated
appropriately .
A cute toxaemia: This is due to infection in the burnt area
d. Haemoglobinuria: It is caused by coagulation of RBC of
by bacteria. Bacteria produce toxins which are absorbed
the burnt area, haemolysis of RBC by toxins, release
into the blood stream. The patient may go into toxic
of myoglobin from burnt muscles.
shock.
e) Gastroduodenal erosion and ulceration (curling ulcers):
Local edema
The incidence is about 11% of patients but varies with the
% of burns and the presence of sepsis especially in Intermediate complications of burns
patients with burns less than 50%. Curling ulcers are acute
and are thought to be due to stress especially excessive
secretions of steroids. They develop within the first 48hrs. ANEMIA: It frequently follows major burns and
The lesions are primarily gastric in location. They may is due to the following;
develop anywhere in the body and fundus of the stomach
1) Coagulation of circulating blood in the
and they are multiple but occasionally single or multiple
burnt area .
ulcers in the duodenum. The common clinical sign of the
2) Haemolysis of RBCs because of absorption
ulcer is the gastrointestinal hemorrhage with
of tissue breakdown products from the burnt
hematemesis and malaena with dark stools.
area. Up to 10% of the RBCs mass may be lost due
Hematemesis occurs more frequently than malaena ( x3
to haemolysis.
more frequently than malaena). About 1% of the pts will
3) Direct destruction of the RBCs by the
require blood transfusion. 10% of the ulcers go on to
burning agent.
perforate. The first signs of perforation may be;
4) Infection may set in the burnt area and
- Sudden abdominal pains give rise to bone marrow depression.

46
 5) Gastro- duodenal bleeding (curling’s young people. Scar tissues form in phases. Both the
ulcers). intensity and duration are of the active phase of scar
formation and is increased more than the normal. There
Infection: It may come from the following sources; are 3 main stages through which a scar passes.
 Patient himself Stage I: 0-4 wks, the scar is fine, soft, not contracted nor
 Medical staff strong.
 Patient’s environment e.g. bacteria which
are resistant to many antibiotics are common in Stage ii: 4-12 wks, the scar becomes red, hard, thick, and
the wards in which the patients are congested. strong and tends to contract

Conversion of superficial burns to deep burns: may be due Stage iii: 12- 40 wks, the scar gradually softens, becomes
to two major reasons; supple, white and tends to relax. Even in cases where
severe hypertrophy occurs, scars do not become worse
- Infection after 12 wks. The scar is thick, red and often itchy and this
- Improper assessment by the clinician .persists for about 3-6 months. After this it usually
Death of underlying structures: Increased blood vessels regresses.
leads to severe hemorrhage leading to anemia and death Compression treatment of hypertrophic scars:
of underlying structures.
Using elastic appliances to cause flattening and maturing
Osteomyelitis due to exposure of bone. of the scars. It can be in a form of;
Late complications of burns Stockings
During convalescence acute duodenal ulcers may occur Gloves,
in some % of patients and this sometimes becomes
chronic (chronic DU) Armlets

Chronic .renal failure Body pieces

Protein losing enteropathy causing hypoproteinaemia Helmets for head / face/ neck etc.
leading to edema causing delayed wound healing.
Keloids are common in Asians and Africans. The common
Contractures which follow scar tissue formation. sites for keloids include;
Contractures occur in special sites i.e.
Shaving areas of the face
Lower eyelids to ectropion
Earlobes especially the pierced
In the chest wall and will interfere with respiratory
movements Sternum

Over joints. They may be contracted in flexion or Back

extension position. May be so severe, as to cause Difference between keloids and hypertrophic scars:
dislocation.
Hypertrophic scars never get worse after 6 months but
Hypertrophic scar formation: The burnt area heals with keloids continue to get worse even after one yr. Some
excessive scar tissue formation and the area rises above keloids may progress for even 5-10yrs.
the level of the skin. Hypertrophic scars are common in
47
In a keloid the process of maturation and stabilization
takes longer than hypertrophic scar.
PRE-MALIGNANT CONDITIONS OF THE SKIN
Keloids are very difficult to treat because excision and
resuturing is followed by recurrence. Previously LEUKOPLAKIA: A white thickened patch occurring in the
superficial epithelial irradiation was done but the results buccal membrane especially in the tongue can also occur
haven’t been certain on the lip or tongue. Ussually occurs in middle aged
males.
Better results are being obtained by shaving away of the
excessive tissue but care should be taken not to extend Etiological factors
the excision into normal tissue at any point because it is Smoking( esp. pipe)
thought that keloids can spread to normal tissue that was
not affected by burns. After shaving away the tissues the Syphilis(tertially)
area is resurfaced by a thick skin graft over this area.
Sepsis
Some excellent results have been obtained by injection of
steroids into the keloids. Sharp edge of teeth- irritation trauma
Marjolin’s ulcers: It follows burns of lower limbs. This Ingestion of hot spirits
burns typically heal with thin paper like scar formation
when the area undergoes frequent trauma. Squamous cell Idiopathic
carcinoma may result.
Pathological process: It is slow and progressive. If left
Deficient temperature regulation as a consequence of untreated about 20% of all leukoplakia patches undergo
chronic scarring. malignancy.

Hypo pigmentation. The scar remains pale in color. SENILE (SOLAR KERATOSIS): Occasionally occurs as
multiple lesions on the faceand back of the hand in
Tracheal stenosis following respiratory tract burns. persons past middle age. The important predisposing
factor is ultra violet rays . The lesion is 1 cm in diameter
Esophageal stricture following swallowing corrosive
and hard dry scale. Squamous cell carcinoma may develop
agents.
from senile keratosis.
Syndectomy: Joining of two or more fingers occurring due
RADIO DERMATITIS:
to poor dressing of fingers.
In the early stages – Erythema occurs and this progresses
Chondritis of the scarred cartilage.
to pigmentation and disquamtion. If the dose is very high
SUMMARY OF BURNS MAGEMENT ulceration may develop.

First aid In the late stages – Atrophy, irregular hyperpigmentation

and telangiectasis and hair loss. Eventually squamous
Fluid resuscitation carcinoma may develop.
Wound care CHRONIC SCAR
Rehabilitation. For example marjolin scar following burns. A carcinoma
that develops in the scar has the following characteristics;

48
Grows slowly because the scar is relatively avascular * vesicles are present no
vesicles
Painless because the scar has no nerves
*responds to treatment doesn’t
Secondary deposits don’t occur in the regional lymph respond to treatment
nodes because the lymphatic vessels have been
destroyed. Treatment

BOWENS DISEASE Always mastectomy; Skin, breast, underlying pectoral

muscles and all lymph tissue in the axill are removed.
Is an intradermal pre-cancerous condition of the skin in
which a brownish induration with a well defined edge The patient should not be subjected to radio therapy
appears on the skin. Microscopically large clear cells are alone because it is radio resistant. Radio therapy is
seen sooner or .later ca develops. important post operatively.

Treatment – Wide excision MALIGNANT CONDITIONS OF THE SKIN

PAGETS DISEASE OF THE NIPPLE BASAL CELL CARCINOMA (RODENT ULCER)

A persistent emphysema like condition that usually starts Common in whites than blacks
in the nipple of a patient of above 50 years. It does not
respond to treatment. The nipple is eroded and A common tumor of low grade malignancy
eventually disappears. As the disease progresses the Exposure to the sun is a predisposing factor and therefore
areolar becomes involved and the erosion continues to the rodent ulcer is common in the tropics
spread peripherally for about 2 years until the site
becomes manifest. It has been agreed that it a slowly Also occurs in the skin which has been exposed to acids
growing duct carcinoma which infiltrates the epithelial like arsenic
covering of the nipple.
Common in the middle and late age groups
Microscopically: Infected area is characterized by
Site- 99% found on the face usually above a line drawn
presence of large vacuolated cells with small deeply
from the lobe of the ear to the corner of the mouth. The
staining nucleus in the epidermis. In the majority of cases
commonest site is the inner canters of the eye. Although
an exhaustive research reveals malignant changes in the
referred to as a rodent the lesions are non- ulcerated with
duct. Sooner or later a ca of the breast itself develops.
a dark translucent color as if containing water. There is a
DDX network of red blood vessels on the surface of the ulcer.

Eczema – But is an area of erythema, vesicles and oozing TYPES

of fluid after rupture and responds to treatment.
Nodular
Eczema Pagets
Cystic
* bilateral Always
Ulcerative
unilateral
A unusual type called “field fire” basal cell carcinoma in
* occurs during lactation occurs
which the ulcerated type has a typical appearance. A
after menopause
raised rolled edge like a car tyre with a central ulceration.

49
Temporal healing often takes place but is followed by Edges are raised and everted
further lesion with serous discharge with bleeding.
Base is indurated and sooner or later becomes attached
The patient gives a history of a spot which never heals. to the deeper structures
Although they are slow growing when they ulcerate they
involve deeper structures e.g. muscles, cartilage and bone A black stained discharge occurs and increases in amount
and develop severe disfiguration (hence rodent ulcer). when infection sets in.
Rarely the basal cell carcinoma changes to squamous cell The regional lymph nodes may be involved and the
carcinoma. deposits may undergo mucoid degeneration to which
MICROSCOPICALLY infection may be added.

Masses of darkly staining cells with a characteristic Treatment

arrangement in which there is an outer layer of columnar As soon as the diagnosis is confirmed by biopsy wide
cells surrounding a central mass of polyhedral cells. Cystic excision with skin grafting
spaces are seen.
Radio therapy which will depend on; * condition of
NB: Dissemination by lymphatics or blood stream does patient, * size of the tumor, * involvement of underlying
not occur in basal cell carcinoma. structures, * and availability of RT facilities.
TREATMENT If lymph nodes are enlarged and mobile block excision
Surgery or radio therapy is necessary. Excision allows the should be done i.e. dissection of all lymph nodes. Make
whole lesion to be examined. It is essential to excise a sure the enlargement is not secondary infection and they
marginal healthy tissue around the ulcer and do should be fixed. Give antibiotics before excision which
histopathology of the lesion. A skin graft is required to helps to confirm that the enlargement is due to tumor.
cover the lesion. Fixed enlarged lymph nodes are not viable but some
regression may be retained by subjecting the
SQUAMOUS CELL CARCINOMA lymphnodes to RT.

Less common than a rodent ulcer MALIGNANT MELANOMA

More malignant and grows more rapidly. It has been agreed that it is a melanocarcinoma and may
arise in two ways:-
Can occur on its own (independently) “ De Novo” in the
skin of the face of elderly people but more often occurs From preexisting benign melanoma (pigment naevi)
in:-
Can arise De novo.
Pre existing skin conditions or
Etiology
As a result of past irradiation. Can arise from, long
standing venous ulcers, chronic lupus vulgaris ( TB of the Not known
skin), prolonged irritation of the skin by various chemical It is common in light skinned people exposed to hot
e.g. tar, dyes, soot etc. climates (ultra violet rays)
Characteristics of typical squamous cell carcinoma Clinical recognition
Outline is irregular

50
Almost unknown before puberty. It should be suspected metastasis to lungs, liver, brain, bones, skin, breast and
after puberty under the following circumstances:- intestine.

When a previously existing mole (naevi) begins to enlarge, Staging and prognosis
itches, weeps, scabs or becomes deeply pigmented.
Stage I- primary tumor only
When a pigmented lesion appears in an adult and grows
progressively Stage II enlargement of lymph nodes or satellite
deposits or in transit nodes + stage I
When a rapidly growing ulcerated skin tumor appears
which looks as though it may be malignant. Some Stage III widely disseminated disease
malignant melanomas are amelanotic (without melanin) Approximately 70% of patients in stage I survive for 5
and are called amelatic melanomas. years
Site Approximately 25% patients in stage II survive for 5 years
The commonest site is in the lower leg. In males, it occurs Most patients in stage III die within 1 year.
at the foot or back of the trunk.
The outlook is better in females than males. Pregnancy
In black Africans it is common on the sole of the foot. makes pigmentation moles darker and sometimes longer
For reasons not known malignant melanomas don’t but does not change the course.
originate from black parts of the body e.g. eye, meninges, Treatment
or mucocutaneous junctions e.g. the anus.
Stage I surgical excision because malignant melanoma is
DDX non sensitive to treatment. How wide to extend depends
Histiocytoma on the thickness of the tumor. The surgical defect of the
excision is non extensive. If the extent of the excision and
Pigmented basal cell carcinoma laxity of the tissues doesn’t allow suturing then skin
grafting is done.
Basal cell papilloma
NB: Moles should never be cauterized or curreted
Carvenous haemangioma because this destroys vital evidence if the lesion is
Spread malignant the disease may be disseminated.

By local extension Management of lymph nodes;

By lymphatics When the regional lymph nodes are involved clinically

they must be dissected . When clinically not involved
By blood stream decision must be made whether to dissect or watch and
wait until they become enlarged for a thin lesion the rise
Tumor cell may reach lymph nodes by embolism but
of lymph spread is slight. For thicker lesions prophylactic
spread by lymphatic herniation. It can also occur
dissection of lymphnodes is radiant especially for patients
producing local satellite nodules and the in transit
who cannot be regularly be followed up. When regular
deposits (i.e. between primary growth and the regional
follow up is possible dissection of lymph nodes should not
lymph nodes). Secondary lymphedema may occur (distant
be done until they clinically involved.

51
Other methods of management Secondary boils due to infection of neighboring hair
follicles.
Cytotoxic agents are of little value especially when the
lesion is disseminated but they do not help in the control Treatment:
of locally advanced disease in the limbs if administered by
a specialized technique i.e. isolated perfusion where high Improve the general health of the pt because boils are
local concentration without generalized side effects. frequently associated with overwork, worry, debility,
examinations. Incisions are not necessary
Immunotherapy has been tried but not effective. (contraindicated).

Malignant melanoma of colloid A touch of iodine or liquid phenol on a skin pastule

hastens necrosis of the overlying skin so that the pus can
This usually presents with blurring of vision treated by escape.
enucleation of the eye because they eye has no lymphatic
drainage, it spreads by blood to the visceral deposits If softening occurs around the hair follicle especially on
which can be enormous especially in the liver. The eye lash, removal of the hair allows ready escape of pus.
metastasis may not appear clinically for many years after
removal of the eye. Determine the sensitivity of the organism and use
appropriate antibiotics
BOIL (FURUNCLE):
Washing the surrounding skin BD with a suitable
Definition: An acute staphylococcal infection of a hair disinfectant to discourage development of secondary
follicle with perifolliculitis which usually proceeds to boils.
suppuration and central necrosis.
A paste consisting anhydrous magnesium sulphate 24
A painful and indurated swelling appears and this parts + glycerine 2 parts is valuable in the treatment of
gradually extends. After 2-3 days the center of the boil boils because it has osmoticeffects.
softens and a small slough is discharged with a bead of
pus and in the large majority of pts the condition CARBUNCLE
subsides. A boil whch subsides without suppuration is Definition: an infective gangrene of the subcutaneous
called “a blind boil”. tissue due to staphylococcal infection.
Boils are generally common in the back of the neck Uncommon below the age of 40yrs
because of presence of hair follicles. A stye is a special
boil due to an infection of an eye lash also called Males are the usual sufferers
hordelum. Infection of a peri anal hair with suppuration is
DM may be present
likely to result in a sinus. Infection of hair follicle around
the ear meatus causes furunculosis which is very painful Sites
because the skin attaches the underlying cartilage and
also considerable tension. Nape of the neck where the skin is coarse and rough and
ill nourished.
Complications:
Clinical features:
Cellulitis especially in debilitated pts.
Pain and stiffness of the site
Infection of lymph nodes draining the part.
Sc tissue is tender and indurated

52
Overlying skin is red hick pus sloughs General health of the pt

Extension if in treatment and after 3 days areas of Anti-Tb drugs

softening occur, the skin giving way and usually there is
one central large slough surrounded by smaller areas of Excision if healing is slow.
necrosis.

Infection sometimes extends widely and fresh openings

appear on the surface and they then coalesce with those CYSTS
openings that were previously formed. Scarbuncle of the
cheek or upper lip is dangerous because carvenous sinus
thrombosis may form.
Definition: A swelling consisting of a collection of fluid in a
Treatment: sac lined by epithelium.

General treatment and identification of organisms is Broad categories:

similar to that of boils
True cysts
Many carbuncles can be aborted by use of antibiotics
False cysts
LUPUS VULGARIS (Tb of the skin)
True cysts:
Occurs at the age of 10-25 yrs
They are lined by epithelium or endothelium. If infection
Common on the face sets in then the lining may be composed of granulation
tissue and the fluid, usually serous or mucoid, and varies
One or more nodules appear with congestion of the
from being brown stained as a result of altered bloodto
surrounding skin
almost colourless. In epidermoid, dermoid and brachial
Nodule is usually painless cysts the contents are like porridge as a result of secretion
of desquamated cell (also toothpaste like).
When pressed with a glass slide the nodule appears like Cholesterolcysts are often found in them.
apple jelly.
False cysts:
Extension occurs very slowly but suppuration occurs later.
Certain collection of fluids which are not necessary true
Resulting ulcer tends to heal from the area of origin and cysts. They are usually exudation cysts.
migrates. The mucus membrane of the nose and mouth
are attached either primarily or extension from the face. Examples include
Edema occurs if fibrosis caused by lupus obstructs normal
Pseudocyst of the pancreas- An encysted collection of
lymphatic drainage.
fluid in a lesser part of the pancreas.
Infection in the nasal cavity may be followed by necrosis
Tuberculous peritonitis- Fluid may be walled off in a cystic
of the underlying cartilage.
form by adherent coils of intestine.
Epithelioma is prone to occur in lupus scar.
In the center of a tumor due to hemorrhage or due to
Treatment colliquative necrosis can also happen in the brain as a
result of ischaemia ending up with apoplectic cyst.

53
Classification of cysts. Area just below the hyoid bone

Congenital Region of the thyroid cartilage

Acquired Area above the hyoid bone

Parasitic Clinical features:

As a rule a fluctuant swelling in the mid line of the

anterior part of the neck. The only exception is when it
Congenital cysts: occurs at the region of the thyroid cartilage where the
They are due to dermoid cells being buried along the lines thyroglossal tract is pushed to the left.
of closure of embryonic clefts and sinuses by skin fusion, The swelling moves upwards when patient protrudes the
hence the term sequestration dermoids. The cyst is lined tongue or swallows because the thyroglossal duct is
by epidermis and contains paste like desquamated attached to the foramen caecum. It moves down when
material. An example is the brachial cyst. the patient returns the tongue to the mouth. Even the
Brachial cyst: one at the sides behaves the same.

It usually arises from the remnants (rudimentary Treatment

remnants). The 2nd, 3rd and 4th clefts may persist. Brachial Surgical excision, including the entire tract up to the base
cyst is usually lined by squamous epithelium and contains of the tongue. Infection is inevitable because the wall of
clear or paste like fluid. It appears in young adults but the cyst contains nodules of lymphatic tissue which
occasionally in later stages of life. It protrudes from communicates with the lymph nodes of the neck through
beneath the anterior border of the upper 1/3 of the lymphatics.
sternomastoid, and appears as a fluctuant swelling and
may transilluminate but not necessarily a brachial cyst NB: Infected cysts may be mistaken for an abscess and
whether positive or negative. If infection has occurred it is incised. When this happens a thyroglossal fistula arises.
difficult to differentiate a brachial cyst from a tuberculous
abscess. If the aspirated fluid contains cholesterol crystals Cysts of embryonic remnants:
it is a brachial cyst. A rare variety of brachial cyst may be They arise from embryonic tubules and ducts which
found lying near the pharynx and is lined by columnar normally disappear or present as remnants. Example :
epithelium which may contain mucus. Urachus may persist forming a cyst. The urachus connects
Tubulo-dermoid cyst ( Tubulo- embryonic) the umbilicus to the urinary bladder. If there is complete
failure urine escapes through the umbilicus.If lower end
Occurs in a track of an ectodermal tube in development. remains patent then a diverticulum of the bladder forms.
Example is the thyroglossal cyst which arises from the If the middle remains patent then urachial cyst forms
thyroglossal duct during growth. The thyroglossal cyst – leading to suppuration then forming an abscess. The
Due to persistence of the thyroglossal duct which extends treatment is surgical excision. Postnatally it is supposed to
from the foramen caecum to the base of the tongue to become a fibrous cord from the apex of the bladder to the
the thyroid gland. After descending the duct should close umbilicus and is called median umbilical ligament.
but may persist. The thyroglossal cyst may persist in any
part of the tract (duct). ACQUIRED CYSTS:

Sites for thyroglossalcyst Retention cyst -- This is due to accumulation of secretions

of a gland forming obstruction of a duct.Example is a
54
sebasceous cyst (wen) which follows obstruction of the Manifestation:
mouth of a sebasceous duct. Patologically it is classified as
a dermoid cyst. Common sites are the face and the scalp Occurs during early childhood
but can occur anywhere where there are sebasceous Occasionally present at birth when it is so large to cause
glands except the palm and soles. obstructed labor.
Clinical presentation: Swelling occupies lower 1/3 of the neck and enlarges
It appears as a hemispherical swelling, firm or elastic in upwards towards the ear.
consistence with no definite edge. It is also adherent to Often it is the triangle of the neck involved
the skin especially if was previously inflamed or subjected
to pressure. The punctum of the obstructed can Due to intercommunication of this compartment a cystic
occasionally be seen on the cyst and sebasceous material hygroma is softly cystic and partially compressible.
can be expressed from the cyst. An uncomplicated cyst
Increases in size when child cries or coughs
contains yellowish material composed of fats and
epithelial cells. It has a putty like consistence and can The characteristic feature which differentiates it from the
therefore be indented by a finger tip. Rarely there is a others is that it is brilliantly transluscent
minute worm called dermodex folliculorum seen in the
cyst. Other sites include; Neck,axilla.

Treatment: Clinical course of cystic hygroma:

Incision - avulsion under local anesthesia. An incision is It is uncertain in infancy and is not possible to determine
made through the skin and cyst. The contents are what will happen (prognosis). Sometimes the growth is
squeezed out and the cyst wall is torn away (avulsion). rapid and occasionally causes respiratory difficult and this
demands immediate aspiration of the contents of the
Dissection is necessary for cysts which have previously cyst. It may also be necessary to do a tracheostomy . At
been inflamed. A skin incision is made, wall identified and other times there may be infection of the nasopharynx
cyst dissected and removed intact. Unless the wall is and the cyst may swell or regress on its own.
completely removed recurrency is possible
Pathology:
Distension cyst:
The swelling consists of an aggregation of cysts which look
Occurs in the thyroid as a result of dilatation of acini or in like a mass of bubbles of soap. The larger cysts are nearer
ovary from a graafian follicle.An example is the; the surface while the smaller lie deeply and tend to
infiltrate muscle planes.Each cyst is filled with clear lymph
Cystic Hygroma:
and is lined with a single layer of endothelium.
At about the 6th wk of embryonic life there are primitive
Treatment:
lymph sacs develop in the mesoblast (middle layer of
cells) Excision of cysts at an early age
The main pair is situated at the neck between the jugular Often advisable to give injections of sclerosing solutions
and the subclavian vein. They are known as jugular lymph or even boiling water into the cysts at weekly intervals.
sacs. Sequestration of a portion of jugular lymph sacs The purpose is to reduce the swelling in size and the cyst
from the lymph system leads to formation of cystic wall becomes more fibrous and this facilitates easy
hygroma. dissection.
55
Exudation cysts1 Degeneration cysts

Occurs when fluid exudes into an anatomical space which

is already line by endothelial or epithelium. Examples are:

Hydrocele of tunica vaginalis

PARASITIC CYSTS
Bursa- a fibrous sac with synovial membrane filled with
synovial fluid. They are encysted forms of the life cycle of various worms
e.g. Hydatid cyst of;
When a collection of exudates becomes encysted ( they
are false cysts) tinea echinococcus

Cystic tumors Trichiniasis of trichuria spiralis affecting muscles

Examples include dermoid cysts of the ovary or cystic Cystercosis taenia solium of the pig. Rarely affects man
teratomaj but if they occur in man, they calcify and cause effects
depending on where they occur especially in the brain.
Implantation dermoids Eisonophillia is usually present. Only those cysts that are
causing symptoms should be excised. Hydatid cyst is the
They arise from squamous epithelium which has been most important of the three.
driven beneath the skin by a penetrating wound e.g. in
knife grinders, black smith where heavy metal sparks are Effects of a cyst.
likely to fly off and cause injury and a small portion of skin
is eventually driven into the puncture developing a cyst. The effects depend on the size and site of the cyst;
They are therefore traumatic and are commonly seen in May compress ducts and blood vessels e.g. renal cyst or
fingers, palms, legs, cornea. H. cyst may obstruct a common bile duct.
Classically found in fingers of women who sow a lot. The An ovarian cyst may compress the pelvic veins leading to
contents are desquamated cell debris which may undergo varicose veins.
mucoid degeneration
The sheer size of an ovarian cyst may increase intra
Treatment: abdominal tension so much so that the patient may come
The entire cyst should be excised and this gives to hospital with symptoms of hiatus hernia.
permanent cure. Complications of cysts
Traumatic cysts: Infection: The cysts become tense, painful and adheres to
A hematoma may resolve into a cyst. This sometime the surrounding tissue. An abscess may form and
happens to the muscle masses of the loin and the antero- discharge onto the surface and result in an ulcer or sinus.
lateral aspect of the thigh or on the skin. This are located Healing does not occur unless the whole lining has been
between muscle planes or subcutaneous spaces . They excised.
contain brown colored fluid containing Hemorrhage: Sudden hemorrhage as may occur in a
cholesterolcrystals.They beco me lined by thyroid cyst. This causes a painful increase in size. There
endotheliumand calcium crystals may be laid on them. may be difficult in breathing.
Aspiration is only of a temporally value. Only
completeexcision gives complete cure.
56
Torsion: In cysts attached to neighboring structures by cases muscles may also be affected. Sub mucosal
vascular stalk (pedicle). Ovarian cysts sometimes presents strawberry angiomas can cause hemorrhage which can be
this way as acute abdominal emergencies. The cyst turn very alarming in some cases. From the age of 3 months to
purple due to cut of blood supply. 1 yr, the naevus grows in the child then ceases to grow.
Eventually the color fades and then flattening occurs such
Calcification: This follows hemorrhage or infection and as that at the age of 7-8 yrs involution is complete. Final
a result of reaction to a parasite e.g. hydatid cyst. result is better. Better allow them heal on their own.
HAEMANGIOMA Radiotherapy is risk of disturbing of growth.

Definition: A developmental abnormality of the blood Carvenous:

vessels Are relatively uncommon
Not a true tumor Present at birth
It is an example of a hermatoma Consist of multiple channels of varying caliber
Most common in the skin or subcutaneous tissue but can They show no tendency of involution and may become
occur at any tissue of the body. larger and more troublesome later.
A haemangioma can be capillary, venous (carvenous) or Sometimes a whole limb or some parts of adjacent to the
arterial (plexiform) trunk are affected.
Capillary haemangioma Occasionally associated with lipoma and in this case is
There are several varieties; called a naevo-lipoma.

Salmon patch: - it is present at birth often at the forehead In some cases arterio-venous communications are
in the midline and over the occip.. It disappears on its present.
own at the age of 1 yr. The skin overlying the naevus may be atrophic and
Pot wine stain: presents at birth but changes very little besides being a danger of severe hemorrhage from
throughout life. Only the color may change a little and it trauma, the pt may suffer from septicaemia if organisms
may become nodular in some areas. Treatment only for gain entry.
cosmetic reasons. The texture of the skin is normal. If it Antibiotics are urgently indicated
occurs in ladies it can be disguised with application of
cosmetics. In a boy treatment by excision and skin grafting The treatment is generally conservative. Repeated
may be considered. Radiotherapy and any other of injections of hot water and other sclerosing agents may
destructive therapy is of no value. help but generally not employed.

Strawberry angioma: Acommon lesion and has a typical Arterial (flexiform) hemangioma:
history. The baby is normal at birth but after 1-3 wks is
noted to have a red mark which increases rapidly for
some weeks or even up to three months until the typical A type of arterio-venous fistula. Presents as a swelling of
straw berry like swelling is reached. Clinically the sign of arteries and arterialized veins and often referred to as
emptying may be demonstrable. The lesion is composed cirsoid aneurysm, which is rare and difficult to treat.
of immature vaso formative tissue. The subcutaneous Capillary may occur in the skinand beneath this abnormal
tissue as well as the skin are often involved and in severe
57
arteries communicate directly with ascended vein. Most GANGLION:
commonly the superficial temporal artery and its
branches are affected. Cirsoid aneurysm tends to enlarge Definition: A localized tense cystic swelling containing
slowly and hemorrhage occurs if ulceration occurs. clear gelatinous fluid. It is usually painless. It often
communicates with a tendon sheath or capsule of a joint.
Spider neavus:
Aetiology: The exact origin is not known but the following
A type of capillary hemangioma. It may occur in factors are thought to be etiological;
association with cirrhosis of the liver, especially if located
on the skin over the manubrium sterni. May also occur May arise as a mucoid degeneration of connective tissue.
innocently (independently). It shows signs of emptying. It may arise as a consequence of leakage of synovial fluid
Spider naevi usually occur on; through the capsule of a joint.

Face Trauma.

Neck Site: Simple ganglion; dorsum of the foot and dorsum of

hand.
Shoulder
Occasionally minute ganglia can be found on the
Upper arm flexor aspects of the fingers and are extremely painful and
tender.
They physiologically proof to be an overgrowth end artery
with branching arterioles. Treatment:

LYMPHANGIOMA Frequently disappear spontaneously

A congenital localized clusters of dilated lymph sacs in the Removal by surgical excision.
skin and subcutaneous tissue. The lymph sacs are never
connected to the normal lymphatics. The lymph sacs are When exploring a ganglion on the flexor aspect of the
connected together by a connective tissue. They can wrist care must be taken because the radial artery is
occur in association with hemangiomas and are called closely related to the ganglion.
haemolymphangiomas. LIPOMA:
Etiology: Obscure. Likely cluster of lymph sacs that fail to Definition: A cluster of fat cells which have become
form because they are embryological. overactive and so distended with fat that they become
Types: palpable. It is the commonest of non-connective tissue
tumors.
Capillary lymphangiomas: Are composed of capillary lie
lesions in the skins. They are brownish papules or wart Pathology: Consists of adult fat cells with minimum
like. On examination, tense small vesicles which are stromal tissue. It has a capsule from which fibrous
lymphatic naevi can be seen. They occur especially on the strands extend into the growth dividing it into lobes. They
skin but may be found in internal organs. undergo necrosis and calcification but never become
malignant.
Carvenous (cystic) lymphangiomas: Already discussed
(refer) Classification: May be single or multiple. Single lipomas
are similar to multiple lipomas in all aspects.

58
Age incidence: Affects all ages but generally rare in
children.
paget disease of the nipple:emphysema
Sites: The commonest is the subcutaneous plane.
Lipomas are commonest in the subcutaneous plane of the a persistant like condition that usually starts in the nipple
shoulder, Neck, Buttocks but may occur anywhere in the of women over 50yrs. Does not respond to treatment.
body where there is fat. The nipple is eroded slowly and eventually disappears. As
the disease progresses the areolar becomes involved and
Clinically; the erosion continues to spread peripherally for about 2
yrs and at this time a carcinoma on this site becomes
Soft circumscribed, lobulated swelling manifest. (it has been agreed that it is a slowly growing
Swelling may sometimes be penduculated duct carcinoma which infiltrates the epithelial covering of
the nipple).
The swelling is pseudocystic and pseudoflactuant and
freely movable on deep palpation. Microscopically:

Fibrous strands pass from the capsule to the skin. Because The affected area is characterized by presence of large
of this attachment at more than one site and there is vacuolated cells with small deeply staining nucleus in the
dimpling (in drawing) especially when the tumor is moved epidermis. In the majority of the cases, an exhaustive
under the skin. research has revealed malignant changes in the ducts.
Soon or later a cancer of the breast itself develops.
NB: A lipoma can be distinguished from a true cystic
swelling clinically by a feel of the solid edge as the
examiner tries to slip the edge under the fingers. DDX:
DDX eczema. But it is an area of erythema, vesicles, and oozing
Sebasceous cyst but it is attached to the skin at only one of fluid after rupture and it responds to treatment.
point. Eczema
Treatment: pagets

Intracapsular removal by making an incision in the capsule bilateral always

and shelling tumor from the capsule (enucleation). unilateral

PREMALIGNANT CONDITIONS OF THE SKIN occurs during lactation occurs

after menopause
Bowen’s disease:
vesicles are present no vesicles
It is an intradermal pre-cancerous condition of the skin in
which a brownish induration with a well defined edge responds to treatment doesn’t
appearing on the skin. Treatment:
Microscopically: always radical mastectomy- the skin, breast, underlying
Large clear cell are seen sooner or later. pectoral muscles and all lymphatic tissues in the axilla.
The pt should not be subjected to radiotherapy alone
Treatment: wide excision.

59
because it is radioresistant. RT is important post In the late stages, there is atrophy, irregular hyper
operatively. pigmentation and telangiectasis and hair loss. Eventually
squamous cell carcinoma develops.
Leukoplakia:
Chronic scars( like marjolins scars following burns):
A white thickened patch occurring in the buccal
membrane and especially on the tongue. Can also occur A carcinoma that develops in the scar has the following
on the lips or genitalia. Usually occurs in the middle aged characteristics:
males.
Grows slowly because the scar is relatively avascular
Etiological factors:
Painless because scar tissue has no nerves
Pipe smoking
Secondary deposits don’t occur in regional lymph nodes
Syphilis because the lymphatic vessels have been destroyed.

Tertially Sepsis If the ulcer invades normal tissue surrounding the scar it
extends at normal rate and thus lymph nodes are liable to
Sepsis be involved.
Sharp edge of tooth causing irritation trauma

Hot spirit ingestion MALIGNANT CONDITIONS OF THE SKIN

Hot spices Basal cell carcinoma:
Susceptibility(idiopathic) It is also known as a rodent ulcer.
Pathological process: It is common in whites than blacks
A slowly progressing hypernecrosis which if left It is a common tumor of low malignancy
untreated, 20% of all leukoplackic patches undergo
malignancy. Exposure to sun light is a predisposing factor and
therefore the rodent ulcer is common in the tropics
senile (solar) keratosis:
Also occurs in the skin that has been exposed to acids like
it occasionally occurs as multiple lesions on the face and arsenic acid.
back of the hand in persons past middle age. The
important predisposing factor is ultra violet rays. The Age:
lesion is 1cm in diameter and hard dry scale. Squamous
cell carcinoma may develop from senile keratosis. Middle or late age.

Radio dermatitis: Sites:

In the early stage, erythema occurs and this progresses to 99% is found on the face usually above a line drawn from
pigmentation and desquamation. If the dose is very high the lobe of the ear to the corner of the mouth. The
ulceration may occur. commonest site is the inner canthers of the eye. Although
referred to as a rodent ulcer, the lesions are non-
ulcerated with a darkly transluscent color as if containing
water. A network of red blood vessels on the surface.
60
Types: It can also arise from;

Nodular Long standing ulcers

Cystic Chronic Lupus vulgaris

Ulcerative Prolonged irritation of the skin by various chemicals e.g.

tar, dyes, soot.
Unusual type called “ field fire” basal cell carcinoma in
which the ulcerated type has a typical appearance. It has Characteristic of a typical squamous cell carcinoma:
a raised rolled edge like a car tyre with a central
ulceration. Temporally healing often takes place but is Outline is irregular
followed by a further lesion with serous discharge with Edges are raised and everted
bleeding. The pt gives a history of a spot which never
heals. Base is indurated and soon or later becomes attached to
the deeper structures
Although they are slow growing, they ulcerate they
involve deeper tissues e.g. muscles, cartilage, and bone A black stained discharge occurs and increases in amount
develop severe disfiguration(hence a rodent ulcer). when there is secondary infection.
Dissemination by lymphatics or blood doesn’t occur in
Regional lymph nodes may be involved and the deposits
basal cell carcinoma. Rarely the basal cell carcinoma
may undergo mucoid degeneration to which infection
changes to basal cell carcinoma.
may be added.
Microscopically:
Treatment
Masses of darkly staining cells with a characteristic
As soon as the diagnosis is confirmed by a biopsy, wide
arrangement in which there is an outer layer of columnar
excision with skin grafting.
cells surrounding a central mass of polyhedral cells. Cystic
spaces are seen. Radio therapy depending on;
Treatment: Condition of the patient
Surgery or Rt is necessary. Excision allows the whole Size of tumor
lesions to be examined. It is essential to excise a marginal
tissue around and underneath the lesion. Skin graft is Involvement of underlying structures
required to cover the lesion.
Availability of radiotherapy facilities
Squamous cell carcinoma:
If lymph nodes are enlarged and mobile, excision should
It is less common than rodent ulcer. be done i.e. dissection of all lymph nodes. Make sure that
the enlargement is not due to secondary infection and
It is more malignant and grows more rapidly they should not be fixed. Give antibiotics before you
excise and this helps to confirm that the enlargement is
It can occur on its own(independently) “de novo” in the
due to tumor. Fixed enlarged lymph nodes are not
skin of the face of elderly people but more often occurs
removable but some regression may be retained by
in a pre-existing skin condition or
subjecting the lymph nodes radiotherapy.
As a result of past irradiation.
Malignant melanoma:
61
It has been agreed that it is a melanocarcinoma. It may Basal cell papilloma (sebhoreicwart)
arise in two ways;
Carvenous hemangioma.
From a pre-existing benign melanoma(pigmented naevi)
Spread
Can arise de novo
Local extension
Etiology:
Lymphatics
Not known
Blood stream
Common in light skinned exposed to hot climates (ultra
violet rays) of the sun. Tumor cells may reach lymph nodes by embolism but
spread by lymphatic herniation, can slso occur producing
Clinical recognition: local satellite nodules and the in-transit ( i.e. between
primary growth and the regional lymph nodes). Secondary
Almost unknown before puberty lymph edema may occur ( this shows distant metastasis).
Should be suspected after puberty under the following Metastasis is to the lungs, liver brain, bones, skin, breast,
circumstances; small intestine and heart.

When a previously existing benign mole (naevi) begins to Secondary deposits are typically black but sometimes they
enlarge, itches, weeps, scabs, or bleeds or becomes contain little or no melanin even when the growth is
deeply pigmented deeply pigmented.

When a pigmented lesion appears in an adult and grows Staging and prognosis:
progressively Stage I – Primary tumor only
When a rapidly growing fleshy ulcerated skin tumor Stage II – enlargement of lymph nodes or satellite
appears as though it may be malignant. Some malignant deposits or in-transit nodes + stage I.
melanomas are aemlanolitic (without melanin) and are
called amelanotic melanomas Stage III – widely disseminated disease

Site: Approximately 70% of pts in stage I survive for 5yrs 25

yrs for stage II . Most pts in stage III die within the 1st. The
Commonest site in women is the lower leg outlook is better in females than in males. Pregnancy
In males the foot or back of the trunk makes pigmented moles darker and sometimes larger but
does not affect their course.
In black Africans, sole of the foot
Treatment:
For reasons not known, malignant melanomas don’t
originate from black parts of the body e.g. eyes, Stage I- Surgical excision because malignant melanoma is
meninges, or mucocutaneous junction like the anus. non sensitive to radiotherapy. How wide to excise
depends on the thickness of the tumor. The surgical
DDX: defect is closed by a primary suture if the excision is non
extensive. If the extent of excision and laxity of tissues
Histiocytoma
don’t allow primary suture then skin grafting is done.
Pigmented basal cell carcinoma
62
NB: moles should never be cauterized or curratted
because this destroys vital evidence and if the lesion is
malignant the disease may be disseminated .

Management of lymph nodes:

When the regional lymph nodes are involved clinically

they must be dissected. When clinically not involved,
decision must be made whether to dissect then watch
and wait until they become enlarged. For a primary lesion CIRCUMCISION
(thin), the risk of lymph spread is so slight. For thicker
Definition: Excision of a circular portion of the prepuce.
lesions prophylactic dissection of lymph nodes is indicated
and especially for pts who cannot be regularly followed It is usually preferred on young boys to allow the prepuce
up. When regular follow up is possible, dissection of to be drawn back over the glans penis to facilitate
lymph nodes should not be done until they are clinically urination and cleaning the penis.
involved.
Indications:
Other methods of management:
In infants and young boys
Cytotoxic agents are of little value especially when the
lesion is disseminated, but they do help in the control of
locally advanced disease in the limbs if administered by
Request by parents (religious and personal)
specialized technique i.e. isolated perfusion. When high
local concentrations without generalized side effects. Recurrent balanitis with inability to retract the prepuce

Immunotherapy has been tried but not effective. Very long prepuce (rarely)

Malignant melanoma of cholloid: Except for the ritual operation, most circumcisions are
unnecessary. It is normal for the prepuce to be long,
This usually presents with blurring of vision. It is treated
adherent to the glans within, for these parts become
by enucleation of the eye. Because the eye has no
satisfactorily separated and the prepuce mobile in the
lymphatic drainage, it spreads by blood to the visceral
first few yrs of life.
deposits which can be enormous especially in the liver.
The metastasis may not appear clinically for many yrs Recurrent balanophosthitis and phimosis often follow
after removal of the eye. attempts by the parents forcibly to retract the prepuce.

In adults:

Inability to retract for intercourse

A tight frenum

Ballanits

Prior to radiotherapy for carcinoma

63
A posterior slit may suffice especially if an emergency approximated accurately with fine interrupted catgut
arises e.g. paraphimosis stitches.

Technique in an adult: The cut edge at the immediate vicinity of the frenum can
be drawn together neatly by a mattress suture, the four in
Applying a clamp or bone forceps across the redundant one frenal stitch.
prepuce distal to the glans with blind division of the
foreskin can no longer be condoned (forgiven). This can
lead to partial or total amputation of the glans. It is better
to perform a proper circumcision under direct vision as in
an adult .
GANGRENE
A new device ( plastibell ( holster)) is used. The ring Gangrene is death with putrefaction of macroscopic
separates spontaneously between 5 and 8 days post portion of tissue. It is commonly seen affecting the distal
operatively. The device causes excessive oedema i.e too part of a limb, the appendix, a loop of small intestine and
tight, it can be removed easily by fracturing the ring. sometimes organs like the gall bladder, the pancreas,
testes and the appendix.
The foreskin is freed and retracted
VARIETIE OF GANGRENE ACCORDING TO CAUSE
After the plastibell device has been slipped in place over
the glans penis, the foreskin is ligated over the groove of Secondary to arterial obstruction from disease, for
the plastibell, and redundant foreskin is cut away. example;

 Thrombosis of an atherosclerotic artery

 Embolus from the heart in arterial
In adults and adolescents: fibrillation or after coronary thrombosis,
 Arteritis with neuropathy in diabetes
Preferred method:
 Beurger’s disease
The prepuce is retracted until it’s tense orifice is apparent  Arterial shutdown in Raynaud’s disease or
or until the tip of the glans penis comes to view. ergotism
 Effect of intra arterial injection of
On the edge of the prepuce are placed three haemostats , thiopenthone or cytotoxic substances.
one in the midline ventrally and two either side of the
midline dorsally. Infective gangrene

The prepuce is then slit up in the midline dorsally to Boils and carbuncles, gas gangrene, gangrene of the
within 1.25 cm of the corona. The under surface of the scrotum (fournier’s gangrene)
prepuce having been completely separated from the glans
Traumatic
penis and corona, the layers of each flap are excised ,
keeping 1.25 cm distal to the corona. Direct, such as crashes, pressure sores and the
constriction groove of strangulated bowel, or indirect, due
The superficial layer is retracted and bleeding points are
to injury of vessels at some distance from the site of
secured and ligated.
gangrene, e.g. pressure on the popliteal artery by the
The inner layer of the prepuce having been trimmed to lower end of a fractured femur.
3mm from the corona, the two cut edges are
Physical gangrene:

64
As in burns, scalds, frost bite, chemicals, irradiation and granulation tissue which forms between the dead and the
electricity. living parts. These granulations extend into the dead
tissue until those which have penetrated farthest are
Clinical features of gangrene: unable to derive adequate nourishment. Ulceration
The parts lack; follows and thus a final line of demarcation (separation)
forms which separates the gangrenous mass from healthy
 Arterial pulsation, tissue.
 Venous return
 Capillary response to pressure (color In dry gangrene – If the blood supply of the proximal
return) tissue is adequate, the final line of demarcation appears
 Sensation in a matter of days and separation begins to take place
 Warmth and function. neatly and with the minimum of infection (separation by
 The color of the part changes through a aseptic ulceration). Where bone is involved, complete
variety of shades according to circumstances separation takes longer than when soft tissues are
( pallor, dusky grey, mottled, purple) until finally affected, and the stump tends to be conical as the bone
taking on the characteristic dark brown, greenish has a better blood supply than its coverings.
black or black appearance, which is due to the In moist gangrene – There is more infection and
disintegration of haemoglobin and the formation suppuration extends into the neighboring living tissues,
of iron sulphide. thereby causing the final line of demarcation to be more
Clinical types of gangrene: proximal than in dry gangrene (separation by septic
ulceration). This is why dry gangrene must be kept as dry
Dry gangrene: - occurs when the tissues are dessicated by and aseptic as possible, and why every effort should be
gradual slowing of the bloodstream. It is typically the made to convert moist gangrene into the dry type.
result of atherosclerosis. The affected part becomes dry
and wrinkled, discolored from disintegration and greasy Vague demarcation spread of gangrene, skipping and die
to the touch. back

Moist gangrene: - occurs when both venous and arterial In many cases of gangrene from atherosclerosis and
obstruction are present, when the artery is suddenly embolism, the final demarcation is very slow to form or
occluded, as by a ligature or embolus, and in diabetes. does not develop. Unless the arterial supply to the living
Infection and putrefaction are always present, the tissue can be improved, the gangrene will spread to
affected part becomes swollen and discolored, and the adjacent tissues or toes, or will suddenly appear as ‘skip’
epidermis may be raise in blebs. Crepitus may be areas further upwards beyond the line of demarcation
palpable, owing to infection by gas forming organisms. along the lymphatic vessels or cellular tissue into the
Moist gangrene is manifest also in such conditions as healthy parts, extensive inflammation then results. Except
acute appendicitis and strangulated bowels. in diabetic gangrene without concomitant atherosclerotic
obstruction these forms of spread do not usually respond
SEPARATION OF GANGRENE to efforts to save the limb and an above knee amputation
becomes necessary. To attempt local amputation in the
Separation by demarcation:
phase of vague demarcation is to court failure as
A zone of demarcation between the truly viable and the gangrene reappears in the skin flaps (die back)
dead or dying tissue appears first. It is indicated on the
Treatment
surface by a band of hyperaemia and hyperaesthesia.
Separation is achieved by the development of a layer of
65
General principles Excess of sugar in the tissues which lowers their
resistance to infection including fungal infection. The
A limb saving attitude is needed in most cases of neuropathic factor impairs sensation and thus favors the
asymptomatic gangrene affecting hands and feet. The neglect of minor injuries and infection so that
surgeon is concerned with how much can be preserved or inflammation and damage to tissues are
salvaged. With arterial disease all depends upon there ignored .Muscular involvement is frequently accompanied
being a good blood supply to the limb above the by loss of reflexes and deformities. In some cases, the feet
gangrene, or whether a poor blood supply can be are deformed (neuropathic joints). Thick callosities
improved by such a measures as percutaneous develop on the sole and are the means whereby infection
transluminal angioplasty or direct arterial surgery. A good gains entry.
or an improved blood supply indicates that a conservative
excision is likely to be successful and a major amputation Clinical examination and investigations
is required for a bad crushed limb, rapidly spreading
symptomatic gangrene and gas gangrene  Urine and blood for diabetes
 Palpfate dorsalis pedis and posterior tibial
General treatment includes that of cardiac failure, arterial pulses
fibrillation and anaemia, to improve the tissue  Absence of rest pain and intermittent
oxygenation. A nutritious diet, is essential in all forms of claudication imply that there is no assocated
gangrene. Control diabetes if present. There is pain, major arterial disease
especially at night. Pain may be difficult to relieve. Non  Bacteriological examination is made of
addictive drugs should be used whenever possible. any pus
 A radiograph may help to reveal to reveal
Local treatment: the extent of any osteomyelitis
The affected part should be kept dry Treatment:
Exposure and the use of a fan may assist in the Control diabetes by diet and appropriate drugs
dessication and may relieve pain.
Infection requires incision and drainage with removal of
The limb must not be heated any obviously dead tissue
Protection of local pressure areas, e.g. the skin of the heel Treat as explained above.
or the malleoli, is required otherwise fresh patches of
gangrene are likely to occur in these places DIRECT TRAUMATIC GANGRENE

Bed cradle, padded rings. This is due to local injury and may arise as a result of
crushes, pressure ( as in the case of splints or plasters) or
VARIETIES OF GANGRENE bedsore. Gangrene following severe injury like when a
DIABETIC GANGRENE vehicle passed over a limb, is of the moist variety and
excision without delay is indicated. Amputation may be
Diabetic gangrene is due to three factors, thus; performed as close to the damaged part as will leave the
most useful limb.
Trophic changes resulting from peripheral neuritis
Bed sores: ( decubitus ulcer) are predisposed by five
Atheroma of the arteries resulting in ischaemia
factors

Pressure
66
Injury The likelihood of gangrene depends upon the sufficiency
of the collateral circulation.
Anaemia
Treatment:
Malnutrition and
It is directed towards the cause for example; close or
Moisture open reduction of a fracture together with direct arterial
They can appear and extend at an alarming rapidity in surgery for the damaged vessel will prevent onset of
patients with disease or injury of the spinal cord and pts gangrene. The limb must be kept cool to reduce
with debilitating illness metabolism to the full.

Prophylactic measures should be taken to prevent bed Ergot: I s a cause of gangrene among the dwellers on the
sores and they include; shores of the Mediterranean sea and the Russian steppes
who eat rye bread infected with claviceps purpurae. It
Avoid pressure over the bony eminencies also occurs in migraine sufferers who, for prophylactic
reasons, unwittingly take preparations over a long period.
Regular turning of pts
The fingers, nose, and ears may be affected.
Nursing on specially designed beds
Physical and chemical causes of gangrene
A bed sore is expected if erythema appears which does
Frost bite:
not change color on pressure. The part must be kept dry.
Actual bed sores may be treated by lotions or by exposure -This is due to exposure to cold, especially if accompanied
to keep them as dry as possible. Once pressure sores by wind or high altitude ( like mountain climbers)
develop, they are difficult to heal. They should be kept
clean and debrided. The HB of the pt should be
maintained at a normal level by transfusion of packed Also encountered in elderly, or the vagrant during cold
cells if need be. If the pt is young and healthy, excision of spells.
the dead tissue and flap pedicle skin grafting is often
successful.
Treatment
INDIRECT TRAUMATIC GANGRENE
Frost bitten parts must be warmed very gradually. Any
This is due to interference with blood vessels; temperature higher than that of the body is detrimental.
From pressure by a fractured bone in a limb or by Clothing should be provided
strangulation (strangulated hernia)
Powerful analgesics
Thrombosis of a large artery following injury
Warm drinks
Ligation of the main artery of a limb, as after division by
injury Paravertebral injection of the sympathetic chain may be
helpful in relieving associated vasospasms
Poor technique for local digital anaesthesia. The
combination of a tourniquet and an adrenaline containing Hyperbaric oxygen may help (at greater than normal )
local anesthetic solution can lead to permanent occlusion
of all arteries.

67
Trench foot:
CHEST NJURY
Is due to cold, damp and muscular activity.-
They are common after trauma and are frequently severe.
It is predisposed by tight clothing like;
Almost half of all accident deaths include some element
Garters (elastic bands) of chest injury, and approximately a quarter of these
deaths can be directly attributed to thoracic injuries. Blunt
Ill fitting shoes injuries to the chest, such as from R.T.A are more
common than those from penetrating trauma, except in
Numbness is followed by excruciating pain when boots
some urban areas where penetrating injuries
are removed. The skin is mottled like marble and, in
predominate. Among penetrating injuries, stab wounds
severe cases, blisters containing blood stained serum
are in general more common than gunshot wounds. Most
develop. Moist gangrene follows. The pathology is similar
chest injuries can be treated with relatively simple
to that of frost bite and the treatment is essentially the
methods, such as tube thoracostomy, appropriate
same.
analgesics and good pulmonary care. However, delay in
Inadvertent intra-arterial injection thiopenthone: diagnosis and treatment of severe chest injuries (e.g.
tension pneumothorax, aortic transaction, rib fractures
The appreciation by palpation of pulsation of the vessels with pulmonary contusion) is a common cause of
and of the withdrawal of bright red blood prior to preventable death after trauma.
injection should prevent this calamity. Injection causes
immediate and severe burning pain, with blanching Anatomic consideration:
(becoming pale) of the hand.
The thorax can be divided into anatomic zones:
Drug abuse:
The chest wall
In drug addicts, usually, the femoral artery in the groin is
The pleural space
involved and is usually due to inadvertent intra-arterial
injection of drugs. The pulmonary parenchyma

Chemical gangrene: Mediastinal structures

Carbolic acid (phenol) is the most dangerous, as Injuries to the chest wall include injuries to the bony
anaesthesia masks the pain which occurs before the onset thorax and shoulder girdle, as well as the soft tissue
of gangrene. The gangrene is due to local spasms. There is injuries.
also danger of severe systemic effects from absorption of
phenol. Local bicarbonate soaks should be applied. Later, The pleural space injuries include the pneumothorax and
excision of the slough and skin grafting are necessary. hemothorax, in which the potential space between the
visceral and parietal pleura is occupied by either blood or
Ainhum: air.

A disease of unknown aetiology, usually affects black Pulmonary parenchymal injuries include contusion,
males and some females who have run barefoot in hematoma and pneumatocele.
childhood. A fissure appears at the level of
interphalangeal joint of a toe, usually the fifth. This fissure Mediastinal injuries involve major vascular structures and
becomes a fibrous band, which encircle the digit and the aerodigestive tract. Mediastinal vascular injuries
causes necrosis. include injuries to the heart, aorta, and great blood

68
vessels. Aerodigestive injuries include tracheal and begins with complete exposure of the chest and
bronchial disruption, traumatic asphyxia, and esophageal inspection for for signs of contusion, lacerations, or
injuries. penetrating wounds. These visible signs may give clues to
the mechanism of injury. The breathing pattern,
Diagnosis: effectiveness in ventilation, and any abnormal motion of
Initial evaluation- Initial evaluation and treatment of a the chest wall should be observed. Chest wall splinting
patient with chest injuries is the same as for any trauma and shallow respiration may be noted in pts with rib
victim; fractures. Asymmetrical chest wall expansion with
hyperinflation of one hemithorax is suggestive of tension
An effective airway is secured pneumothrax. Paradoxical motion of a segment of chest
wall is diagnostic of flail chest. Pressure of penetrating
Adequacy of breathing is ensured and circulation is
wounds should be noted, both anteriorly and
assessed and supported with control of external
posteriorly. The wounds should not be probed because it
hemorrhage.
can turn a minor laceration injury into a pneumothorax,
Establishment of a large bore peripheral venous access. requiring a chest tube and longer hospitalization.
Penetrating injuries below the nipple line must be
Therapy for potentially life threatening problems should presumed to involve the abdominal cavity as well.
be initiated immediately.
On auscultation, the breath sounds should be compared
A careful relevant history should be taken, including bilaterally for quality and symmetry. Absence of breath
details of the mechanism of injury. The speed and sounds on the side is highly suggestive of hemothorax or
direction of impact and the degree of frontal deceleration pneumothorax.
are important factors in motor vehicle crashes. Aorta
transaction is associated with severe deceleration injury. On palpation of the chest wall may demonstrate areas of
Patient not using restraint systems are likely to contact tenderness that may be associated with fractures of the
the steering wheel or the dash board of the car, placing ribs, sternum, or clavicle. Areas of referred pain should be
them at an increased risk for chest injuries, such as rib noted, such as sternal compression causing lateral rib pain
fractures, flail chest, and pulmonary contusion, as well as in the case of lateral rib fractures. Shoulder pain may be
tracheal or laryngeal injuries. associated with diaphragmatic irritation of splenic injury
(kehr’s sign).Crepitus over the chest wall may be due to
In patients with penetrating trauma, the characteristics of fractures or by air in the subcutaneous tissues from a
the offending instrument are important. External wounds pneumothorax. On percussion hyperesonance should
can be misleading. Pts with complaints of hoarse voice, raise suspicion of pneumothorax. Dullness to percussion is
dyspnoea, throat pain and dysphagia should be carefully suggestive of hemothorax.
evaluated for injuries to the larynx and the cervical
portion of the esophagus. Complaints of dyspnoea or Other investigations
pressure in the chest with or without chest wall pain may
CXR
be indicative of pneumothorax or hemothorax.
It may show fractures of ribs, clavicle, or sternum.
The pt’s past medical history is also important. A history
of pulmonary disease, heart disease, or prior thoracic Widening of the mediastinum (superior)
surgery can alter interpretation of diagnostic studies and
affect therapeutic decisions. A history of medications, Presence of air in the mediastinum indicating injury to the
allergies, smoking, and the recent ingestion of drugs and esophagus or tracheobronchial tree.
alcohol should be obtained. The physical examination
69
Haziness over one hemithorax can indicate a hemothorax cause, the principle of management should remain
(supine). focused on the mechanical systems involved;

Treatment The pump

Most chest injuries can be successfully managed without The hydraulics

surgical intervention. The routine use of chest tube for
the treatment of hemothorax and pneumothorax is a And the bellows (the suction- blow system that draws
cornerstone of therapy. atmospheric air into the alveoli and expels it). The heart
must be working, and the vessels must have the integrity
Thoracotomy is often needed for the control of massive and suitable contents to transport the gases to and from
bleeding or bleeding that persists despite chest tube. the tissues.

TYPES OF CHEST INJURIES Conditions requiring urgent correction:

They are usually classified according to the type of insult Airway obstruction:
that caused the damage. The injury is often influenced by
the setting in which it occurred; military or civilian, urban Most pts with major disruption of the airway leading to
or rural. obstruction will not the initial accident. The leading cause
of death at the accident site is airway obstruction. During
Most military injuries are often high velocity penetrating the early stages of resuscitation and transportation,
wounds. Low velocity gunshot wounds are replacing knife correctable airway obstruction may occur. The
wounds as the most common in urban civilian population. oropharynx should be cleared of any mechanical debris
Blunt injuries from motor vehicle or occupational (e.g. and the chin and neck positioned to facilitate opening the
logging) accidents make up the majority of non-urban posterior pharynx (chin thrust). Tracheal intubation may
injuries. Penetrating wounds are becoming more frequent be required. If the upper airway injury prevents safe
in sub-urban and rural areas as violent crimes increase, access to the vocal cords from above, cricothyroidectomy
and blunt trauma also occurs commonly in urban areas. should be performed.
Complications and death are often associated with;
Tension pneumothorax:
Pulmonary contusion
It occurs when there is injury to the lung parechyma
Post traumatic pulmonary insufficiency, and allowing air to enter the pleural cavity (space) with each
respiratory effort. It occurs when there is a flab- valve
Trauma to the heart and great blood vessels, are effect of the injury preventing the air re-entering the
significant. bronchial tree for regress through the trachea during
Penetrating wounds of the lower thoracic region are expiration. Tension develops within the pleural space until
treacherous. The diaphragm usually rises to the level of equilibrium with the negative pressure the pt is able to
the nipples during expiration and penetrating trauma to generate is reached. At that time effective ventilation and
this area can injure the subdiaphramatic viscera. Some venous blood can no longer enter the chest. Pain may be
surgeons belief that a stab wound of the left lower part of the only complaint, with no evidence of respiratory
the chest mandates early abdominal exploration, because distress. However, if the lung wound is behaving like a
the knife may have injured the spleen, stomach or colon. check valve, some air escapes into the pleural cavity with
The abdominal findings in these pts may be each inspiration or with each cough. Gradually
overshadowed by initial peritoneal lavage. Whatever the intrapleural pressure builds up, the lung collapses, and
tension pneumothorax can develop. A shift of the

70
mediastinum and compression of the large veins result in Hypercapnia occur.
a decreased cardiac output that may lead to sudden
death. The diagnosis should be made instantly by A pt who is conscious may splint the segment sufficiently
observation of a pt with dilated neck veins making to make it inapparent to cursory examination, but the
respiratory effort but not respiratory motions and unable continuing extra effort In the attempt to move air soon
to move air. It is immediately confirmed by the leads to tiring and may result in sudden respiratory
hyperesonant percussion note over the injured decompensation. The progressing failure may be
hemithorax and absent or distant breath sounds. The aggravated by the developing pulmonary contusion that
immediate release of the tension by placement of a large accompanies blunt trauma sufficient to break multiple
bore needle followed immediately by insertion of a ribs. In the unconscious pt, the lesion may be less
thoracostomy tube is life saving. dangerous because it is more readily recognized and more
apt to be treated early.
OPEN PNEUMOTHORAX
In massive flail chest, the diagnosis may be difficult unless
It has a sucking chest wound in which a full segment of the chest wall is visualized during the respiratory effort. If
the chest wall has been destroyed and the negative unconscious, the pt ordinarily is making vigorous
intrapleural pressure sucks air directly through the chest respiratory motions but moving little air. The paradoxical
wall. Occurs most commonly after shot gun blasts, segment should be obvious. The pt who is awake may
explosions with flying debris or piercing ( implement) exhibit a very rapid shallow breathing pattern at or above
injuries.It may or not be associated with underlying 40 breaths per minute. Other aspects of management
parenchymal damage wound. include endotracheal intubation and positive pressure
ventilations are mandatory.
Patient may present with normal or collapsed neck veins.
Patient makes respiratory motions but no air movement.

On inspection (immediate) there is a chest wound. THE SKULL

The patient is stabilized by any mechanical covering over MICROCEPHALLY:

the wound. As soon as possible a water tight dressing
should be placed in place and an intercostals catheter An abnormally small head.
inserted into the pleural cavity. Early debridement and May be associated with agenesis of the brain and
formal closure of the wound should then be performed. imbecility
MASSIVE FLAIL CHEST May result later from premature synostosis in normal
When severe blunt injury results in two point fractures of child
four or more ribs, a segment of the chest wall becomes OXYCEPHALLY
flail. On inspiration, the negative pressure in the chest
pulls the unstable segment of the wall inwards in a The skull is egg shaped following premature fusion of the
paradoxical motion. The pt may be unable to develop sutures
sufficient intra tracheal negative pressure to maintain
Most patients develop increased intracranial pressure.
adequate ventilation, and
Treatment: cranioplasty allows normal skull expansion
Atelectasis
and cerebral development.
Hypoxia and
MENINGOCELE:
71
Is protrusion of portion of pouch of dura matter through TUMORS OF THE SKULL
congenital bone defect forming a cyst filled with C.S.F.
Benign tumors:
Signs and symptoms:
They are rare
Protrusion of a part of dura matter through a defect in the
skull at the root of the nose or over the occipital bone. Occasionally an “ivory” osteoma (compact osteoma)
arises in the region of an air sinus.
Transphenoidal projections protrude through the base of
the skull into the nasopharynx mimicking the nasal polyps. The lesion constitutes of a small knot of extremely hard
Attempted removal of such a projections has resulted In and dense but otherwise normal often arising in the inner
development of meningitis. or outer table of the skull

Meningocele presents at birth and forms a tense rounded Malignant tumors:

swelling which is translucent. It yields an impulse when They are the same as those of the other bones.
the child coughs or cries. Growth of the skull may occlude
the neck of small sac and a cyst remains which does not Pericranial sarcoma:
pulsate and is not affected by coughing.
Its consistence depends on its vascularity and rate of
ENCEPHALOCELE: growth. It may be pulsatile or of an almost bone hardness.
It is not common. The commonest is secondary from the
It is similar to meningpocele but some part of rain is also breast, prostate, and thyroid glands.
involved. If this cerebral extension contains part of a
ventricle the encephalocele is called hydroencephalocele. Hypernephroma (Grawitz tumor):
In encephalocele and hydroencephalocele vascular
It is a malignant tumor of the kidneys. It grows to produce
pulsations are present. The child may be still born or may
more rapidly growing vascular tumors which pulsate
have an associated degree of idiocy or both.
when the outer table is eroded. Cellular deposits from
Treatment for meningocele and encephalocele: hypernephroma produces a single clear area with
irregular margin on X-ray of the skull. Deposits from ca
Skin surface should be protected by tulle grass to prevent breast are usually multiple.
ulceration and infection.
INTRACRANIAL ABSCESS:
If at the age of 1/12 the child shows normal development
operation is done under L.A as the child sucks a feeding There are three types;
bottle. A curve incision is made in one margin of the sac
Extradural abscess: it is produced by osteomyelitis of the
so that when the wound is sutured the incision will not
skullwhich may in turn occur as a result of infection from
overly the bone. The neck of the sac is identified, ligated
the following sites;
and the sac is removed together with the excess skin.
Muscle fascia are brought together over the bone defect. Direct infection such as a compound fracture of the skull.
Many cases of meningocele have a small encephalocele at Local extension of infection from the frontal sinus or
the base and if this is so it is removed with the sac mastoid anthrum or cellulitis of the skull
without any harmful effect as the tissue will already be
functionless. Blood borne infection by circulating organisms practically
unknown but rarely follows boozing of bone in young

72
children. Extradural abscess is usually secondary to spread hemispheres. Successful treatment depends on; early
of infection from middle ear or frontal sinus. recognition and early intervention.

Clinical features: Clinical features:

They are those of osteomyelitis; It follows a heavy cold or influenza

Acute localized head ache The pt runs a high temperature becoming dehydrated
with wrinkled skin.
Tenderness on local percussion
Blockage of the superior compartment of the superior
Localized pitting edema of the skull over the affected area sinus of the frontal sinus into which Csf is absorbed and
“pott’s puffy tumor” produces a raised intracranial pressure with head ache
Constitutional signs and symptoms i.e. nausea, general and later on papilloedema (edema of the optic disc).
malaise, rigors and fever Blockage of the lower compartment receiving the
Rarely if the abscess is large there is evidence of pressure superior cerebral veins may cause epilepsy and paralysis
of neurological signs such as convulsions, paralysis, and of sudden onset and associated features.
paresis. All these appear in a matter of days (sudden).
Treatment: Treatment:
Drain the abscess and the process depends on the cause Bilateral frontal burr holes are made just between the
of the abscess. Many cases are dealt with by removal of hairlines above temporal crest.
the posterior wall of the frontal sinus incase the abscess is
secondary to frontal sinusitis. On opening dura thin pus is found in the subdural space
and is allowed to escape.
Burr hole at the site of edema, the dura is pressed slightly
inwards to allow the pus to escape spontaneously. The A fine catheter is then introduced to instill an appropriate
pus can be removed by suction. Penicillin powder is then antibiotic into the space about 2-3 ml
insufflated (blown) into the wound and then wound
drained for 24hrs. Systemic antibiotics in adequate doses Intravenous systemic antibiotics in full dose.a
should be given. Intracerebral abscess:
Subdural abscess: Are produced by
It used to be fatal but now can be treated with 30% - Implantation of infection
mortality. It is produced by thrombophlebitis of superior
longitudinal sinus (one of the channels containing venous - Blood metastasis
blood). It usually spreads from infections of the frontal
- Local extension of an adjacent infection (more than 50%
sinus or accessory air cells in the mastoid process.
result from extension from the middle ear)
Infection extends from the superior sinus to the superior
cerebral veins and thus infects the subdural space. The NB: in diagnosis general features are more important
abscess extends in the subdural space over the cerebral than focal features which are few in number and come
hemispheres often bilaterally and must be treated before late.
the spread to the inner or under aspects of the cerebral
Clinical features:
73
Acute stage Pallor

Persistent pyrexia and headache should lead to suspicion Catchexia

of an abscess in association with an ear or sinus infection.
C.s.f may return to normal but the abscess continues to
Raised pulse rate at the start of the acute stage but as the enlarge
abscess enlarges and the intracranial pressure is raised
there is slowing of the pulse. Skull adopts the enlargement of the abscess and can
accommodate the abscess but when no more space is
Irritability available the pt develops features of increased
intracranial pressure
Drowsiness
NB: There may be no physical sign in the chronic stage. In
Vomiting all cases of suspected cerebral abscess it is important to
Leucocytosis but may not be significant especially if some examine all sources of infection or foci. For example, o.m,
other condition is present. sinusitis, wound on scalp and tonsillitis. In many cases
probable cause is usually clear but discharge from an ear
Focal signs are often absent in the acute stage may cease by the time intracranial abscess develops.

Lumbar puncture will show increased cells and proteins at Treatment:

about 80mg%. as a result of administration of antibiotics
in the treatment of the primary focus of infection. Many Formerly, drainage of the abscess was the method of
cases are arrested and many abscesses are aborted in the treatment.
acute stage without frank pus Aspiration and occasional excision have now replaced
Sub acute stage: drainage. Drainage is only indicated if the abscess is
superficial as in the abscess following penetrating wound.
Low temperature to subnormal
In the early stage of cerebral inflammation antibiotics are
Low pulse rate indicated.

If the abscess is located on the frontal lobe there is a Ventriculography may be required to determine whether
contralateral facial weakness ( opposite side of the face) there is an abscess. When the abscess has localized or
when signs show danger a diagnostic burr hole is made
If the abscess is on the temporal lobe there will be
and instillation of antibiotic. The burr holes are made
contralateral hemiparesis with absent abdominal reflexes
depending on where the abscess is situated.
and an extensor plantar response (Babinski +ve)
For the frontal abscess the burr hole is made immediately
If on the cerebellum there will be nystigmus, hypotonus
within the hairline
and incorodination on same side of the lesion
F or cerebellar abscess the burr hole is made over the
Lp shows reduced number of cells but an increase in
occipital plate.
protein s to 120 mg %
CEREBRAL TUMORS
Chronic stage:
They arise in connection from with the meninges, nerve
Intermittent headache
sheaths or from the cerebral substance itself. Tumors of
General ill health the pituitary gland, gummas, tuberculomas, vascular
74
malformations, blood clots, chronic abscesses can also Clinical features
contribute to cerebral tumors. Secondary Ca is by far
more common than primary intracranial tumors. Initial period of silent growth- All cerebral tumors have a
Secondary deposits commonly originate from the lung but silent growth period. The tumors vary depending on the
may originate from any organ of the body and the naso- site and rate of growth. If the tumor is not near any area
pharynx. When secondary deposits have been excluded which will produce signs and symptoms it will occupy
the following primary tumors should be suspected; space in the sub arachnoid cisterns (space) and they serve
as reservoirs foe the CSF. The tumor will then flatten and
meningioma 18% displace the ventricle and the brain until it cannot gain
any more width. Once there is no more space the tumor
Neurinoma 8% will producesymptoms of increased intracranial pressure
glioma 42% like, effortless vomiting, papilloedema, morning headache
etc. in the case of haemangioma the period may take
pituitary adenoma 12% several yrs. I f the tumor is situated in a vital area it may
as a result of its local effects produce symptoms of
hemiopharyngioma 5%
epilepsy or progressive neurological syndromes before
blood vessel tumors 2% any evidence of increased intracranial pressure is
produced. The mere absence of headache, vomiting and
glanulomas and unclassified rare tumors 6% papilloedema does not exclude the tumor.

Meningioma: Focal syndromes and epilepsy –

- they vary in structure and vascularity Epilepsy arising for the first time in adult life should
- are globular always be suspected to be due to a tumor until proved
- tumor arises from the arachnoid and gets otherwise. Idiopathic epilepsy does not occur before the
secondary attachment to the dura age 6yrs. 99% of cases of idiopathic epilepsy have their
- the arteries and veins of the dura provide first seizure before the age of 30yrs. After 30yrs epilepsy
nourishment to the tumor is usually symptomatic. In patients of between 30-50 yrs
cerebral tumor is usually a common cause of epilepsy.

Progressive focal syndromes should also be regarded as

indicating cerebral tumors until proved otherwise. Only
cerebral tumor produces a steadily progressive syndrome

Neurinoma: Raised intracranial pressure : May develop in association

with focal symptoms or may be the sole evidence of the
presence of a tumor. Signs of raised intracranial pressure
occur. Late in the tumors of the frontal lobes, signs of
- Found from the sheath of the 8th cranial
raised intracranial pressure occur. Early in the tumors of
nerve (auditory nerve)
temporal and parietal lobes which obstruct the outflow of
- May be multiple in association with
the CSF from the adjacent ventricle. They occur earliest in
multiple neurofibromatosis of the skin
tumors located in the midline and posterior fossa which
- May occur in association with
obstruct the flow of CSF from both ventricles and produce
cerebrospinal meningiomas
an internal hydrocephalous.
Rarely occurs on its own.

75
Signs and symptoms: Lack of insight

Headache in the early morning aggravated by coughing Neglect of normal hobbies, occupation and duties
and straining.
Alteration in emotional reaction particularly noticeable to
Vomiting occurs without warning and not preceded by relatives e.g euphoria, irritability
nausea not related to food
Epilepsy is generalized in type and localizing signs are
Bradycardia limited to contralateral facial weakness.

Retarded mental activity

Blindness from papilloedema Parietal lobe tumors

They produce;

Stage of cone formation Jacksonian epilepsy

When the intracranial pressure becomes high, the inner Progressive hemiparesis
border of one hemisphere may be forced under the falx
cerebri. Eventually the hemisphere blocks the pathway for Examination reveals loss of touch resulting in inability to
the absorption of the CSF. The temporal lobe may be recognize the size and shape of objects
forced down from above into the tentorial opening. A part Deeply situated tumors may show defects of a special
of the cerebellum may also be pushed into the tentorial relationship and loss of power of calculation.
opening. These are the ominous signs of a threatened
cone formation; Occipital lobe tumors:

violent paroxysmal norcturnal headaches Present with generalized epilepsy which;

Drowsiness Is preceded by an aura or flashing lights in the

contralateral visual field
Slow pulse
Homonymous hemianopia ( loss of vision on the same
Slow cerebration side)
Neck stiffness Temporal lobe tumors
Unilateral pupillary dilatation ( an urgent sign) Those on the left side produce;
NB: lumbar puncture must be avoided at the stage of Progressive apasia
cone formation
Visual and auditory hallucination

Generalized convulsions
Frontal lobe tumors
Hallucinations of smell and taste
If situated deeply they present with the following;
Dreamy states of unreality
Progressive change in personality
Localizing signs e.g. hemiparesis

76
Investigations of a cerebral tumor By pressure changes which include (a) a beaten silver
appearance of the vault as a result of the pressure of a
History: may sometimes locate the site of the tumor and tight involusions (b) separation of sutures especially in
also give a hint of it’s pathological type. If the complaints young patients (c) erosions of the crinoids process is a
are of long standing it shows it is a slow growing tumor. A valuable sign because it indicates a long standing pressure
short history may be due to final breakdown of and therefore a possibly recoverable tumor
adaptation in a slowly growing tumor or may indicate a
rapid malignant growth. History may suggest a primary By lateral displacement of calcified pineal shadow
disease to which a cerebral condition is only secondary. indicating the site of the tumor. The pineal body is a small
Since metastasis cancer is far more common than primary redish grey conical structure situated in dorsal surface of
cerebral tumors. Attention must be paid to know about; the midbrain. Its function is not known but thought to
secrete a hormone related to growth.
Wt loss
By characteristic calcification produced by tumors such as
Recent cough or astrocytoma (slow growing tumor of the glial tissue of the
Hemoptysis brain), angioma, meningioma, tuberculoma and 50% of
craniopharyngiomas don’t show calcification
Secondary brain abscess is suggested by a history of lung
abscess and bronchiectasis. Symptoms like catchexia and By alteration in skull vascular markings especially in
ear discharge suggest otitis brain abscess. Wt lossis always meningiomas
suspicious as there is no wasting with primary cerebral By changes in the skullbones including local expansion at
tumor. the site of a cyst and evidence of bone destruction
Clinical examination: it must be include general E.E.G: Certain characteristic wave forms indicates the site
examination in search of primary diseases. or presence of deep seated tumor and also distinguish
Neurological examination of cranial nerves and nerve between epileptic seizure produced by focal lesions and
tracts. This may help to localize where the tumor is but seizure produced by idiopathic causes
does not indicate what kind of tumor it is. Lumbar puncture in early cases where it is necessary to
Others (accessory) investigations. This are essential and exclude non-tumerous conditions like meningitis and
must be done; tuberculosis. The pressure and content of CSF are
recorded and increase in pressure and protein suggests a
Skull x-ray tumor. Lumbar puncture should be avoided in the
presence of increased intracranial pressure is absolutely
Cxr
contraindicated at the stage of cone formation
Blood for ESR
Surgical investigation by arteriography. Involves ingestion
CXR may reveal an unsuspected bronchial ca of dye into common carotid artery and films taken at 1
second intervals. This helps to localize a silent tumor
30% of bronchial ca present with signs of cerebral producing pressure but no physical signs or may indicate
symptomsbefore any chest symptoms extent of a known tumor and also provide evidence of its
type
A skull X-ray may show presence of a tumor in the
following ways;
THE NECK
77
 continues or certain lymph nodes become large
formentation is done. Abscess should be drained if
The brachial apparatus and its abnormalities: formed.
Brachial cyst ( already discussed) Chronic cervical lymphadenitis: in an early stage it is
Cystic hygroma (already discussed) extremely difficulty to differentiate tuberculous adenitis
but clinical experience shows that chronically inflamed
Brachial fistula cervical lymphnodes within 3-4 weeks is nearly always Tb
adenitis.
Cervical lymphadenitis
Tuberculous adenitis: Majority of the patients affected are
Brachial fistula:
children but can occur for the first time at any age.
It may be unilateral or bilateral. It presents a persistent Usually one group of nodes is affected first most
second brachial cleft that did not disappear whose frequently are those of the upper jugular chain. More
occluding membrane has been interrupted. The external rarely you have all groups affected and there is matting or
orifice of the fistula is nearly always situated on the lower periadenitis becoming evident. When there is widespread
1/3 of the neck near the anterior border of infection.
sternomastoid. The anterior orifice is situated on the
Cervical source of infection: majority Tb bacilli gain
anterior aspect. The inner orifice is located on the
entrance through the tonsil on the corresponding side.
anterior aspect of the posterior pillar of the faucies just
The nodes of the posterior triangle are infected in 22% of
behind the tonsils. But more often the tract ends blinds at
cases. That probably stems from adenoidal infection.
the lateral pharyngeal wall and becomes a brachial sinus
Contrary to what is believed it is the human but not the
other than a fistula. The pillars of the faucies lie lateral to
bovine strain that is responsible for Tb adenitis in about
the tonsils. The track closed with muscles and lined by
90% of the cases. In black Africans it accounts for 100%
ciliated columnar epithelium remains until the lining has
cases (human strains). In 80% of the cases the tuberculous
been destroyed by repeated infection. The discharge is
process is virtually limited to the clinically affected lymph
purulent. The fistula can be secondary to an incision of an
nodes. Nevertheless a primary focus in the lungs should
infected brachial cyst.
be suspected. Tb adenitis can coexist with renal Tb and
Treatment: therefore urine should be examined for Tb bacilli. If the
patient develops resistance, or as a result of inappropriate
It should be excised when causing troublesome symptoms treatment, it becomes chronic. In other circumstances
like producing mucous. caseating material liquefies, breaks through the capsules
of nodes and a cold abscess results. The pus is at first
CERVICAL LYMPHADENITIS
confined to the deep cervical fascia. In a few week’s time
There are approximately 800 lymphnodes in the body. these dense sheath becomes eroded at one point and pus
About 300 lie in the neck. Inflammation of lymph nodes in flows through the small opening into the much larger
the neck is common. Infection occurs in the oral and nasal space beneath the superficial fascia. The process is now
cavities,ear, scalp, and the face. said to have reached a stage of collar stud abscess. The
superficial abscess enlarges and unless suitable treatment
Acute cervical lymphadenitis: the affected lymph nodes is adopted the skin soon becomes red over the centre of a
are enlarged, tender and a varying degree of pyrexia. fluctuating swelling and before long a distinguishing sinus
Treatment is directed to the general condition and focus forms.
of infection. The neck should be protected by a bandage
or cotton wool. If inspite of antibiotic therapy pain DDX: Depends on the nature of swelling;
78
When the swelling is solid > chronic non tuberculous localized for yrs but regional metastasis occur in the about
lymphadenitis 20-30% of the cases while distant metastasis occur less
frequently.
>Hodgkins lymphoma
Clinical features:
>nonHodgkins lymphoma
Unilateral
>secondary malignant
disease. Middle age but may come earlier

- cystic swelling * brachial cyst Diagnosis is suggested by a long history of a lump at the
bifurcation of the carotid artery which moves from side to
* extension of an abscess side, left to right but not vertically.
connected with a tuberculous cervical vertebrae.
Usually a pulsating vessel overlies the outer surface of the
- sinus -actinomycosis tumor.
- acquired brachial fistula Investigations.
Treatment Arteriography is valuable and shows the carotid fork to be
General measures and appropriate chemotherapy broader and bluish or a red colouration outlining the
tumor. The special danger of excising the tumor is due to
Aspirate abscess if present and culture the Tb bacilli and its vascularity and this can cause;
sensitivity to anti Tb drugs.
Torrential hemorrhage occurring if biopsy is attempted in
NB: Repeated aspiration of the collar stud abscess is not the wrong belief that the lump is an infected neoplastic
recommended because it can lead to sinus formation or lymph node.
secondary infection.
Puncture of one of the carotid arteries and to control of
Operation for collar stud abscess. An incision is made in bleeding by artery forceps results in occlusion of carotid
line with the skin creases and the pusiIn the superficial artery with hemiplegia or death occurring in at least 33%
compartment is mopped away. The whole space in the big of the cases.
fascia is opened so that caseating lymph node is scrapped
with a curate and the cavity packed with iodoform gauze. If extirpation is to be attempted it is essential to have a
The gauze is removed after 24hrs but the sutures length of silicon bypass tubing in case carotid occlusion
removed after 10 days. becomes necessary.

Excision of lymph nodes when there is no local response In some cases it is possible to dissect the tumor away
to chemotherapyand when a sinus forms. If there is from the carotid York. But when the tumor is inseparable
coexistent PTB it is illogical to remove the lymph nodes. resection is necessary and a bypass is necessary while a
veinautografty is being inserted to restore arterial
PRIMARY MALIGNANT TUMORS OF THE NECK continuity. Recurrence is unusual. The tumor is not
sensitive to radiotherapy.
CAROTID BODY TUMOR: (PITATO TUMOR):
THE THYROID GLAND AND THE THYROGLOSSAL TRACT
The carotid body is situated at the bifurcation of the
carotid artery. It is the most important part of the Embryology: thyroid gland develops from the median duct
chemoreceptor system. Carotid body tumors remain of the pharynx.
79
Surgical anatomy: - Classification:

it weighs gms Failure of thyroid development;

lies deep to infrahyoid muscle and the sternomastoid Complete

medially related to thyroid cartilage and upper portion of Partial

tracheal and the recurrent laryngeal nerves which lies in
the groove between trachea and the esophagus Endemic cretinism (often goitorous)

posteriorly lies the pharynx, esophagus, parotid glands Iatrogenic hypothyroidism

which may be imbedded into the thyroid or lies close to it, After thyroidectomy
and the common carotid artery.
After radio-iodine therapy
The gland consists of left and right lobe joined by an
isthmus. The pyramidal lobe is situated on the isthmus After pituitary removal
and it marks the junction of the thyroglossal tract. The
Drug induced by anti-thyroid drugs, para-aminosalicylic
pretracheal fascia surrounds the gland and is attached to
acid (P.A.S) and iodides in excess.
the thyroid cartilage and the hyoid bone. This explains
why the gland moves down with swallowing. The Autoimmune thyroiditis which can be;
functioning unit of the thyroid is a lobule supplied by a
single arteriole consisting of 20-40 follicles lined by Non-goitorous (primary myxoedema)
cuboidal epithelium. The resting follicles contain cholloid
Goitorou (Hashimotos disease or goiter)
in which fibroglobulin is stored.
Goitorogens;
Blood supply:
Vegetables
Arterial supply is very rich, 2 superior and 2 inferior
thyroid arteries and branches from tracheal and Peanuts
esophageal arteries. Occasionally there is an additional
supply from the thyroid long artery, a branch of inominate Cabbage
artery.
Tunip
Venous drainage:
Sprout
Superior and middle thyroid veins which drain into the
Drugs
internal jugular veins while inferior thyroid veins drain to
the inferior thyroid vein. Propylthiurocil

Lymphatic drainage: Carbimazolepotassium percherates

Some lymph channels pass directly to deep cervical lymph Potassium thiocyanate
nodes but the subcapsular plexus drains mainly to the
pretracheal and paratracheal nodes and the nodes of Iodides
superior and inferior thyroid veins and then finally these
Dyshormogenesis
drains to the deep and mediasternal lymph nodes.
Vascular damage to the anterior pituitary.
HYPOTHYROIDISM
80
CRETINISM (INFANTILE OR FETAL HYPOTHYROIDISM) Coarse voice

Sporadic cretinism is due to complete or partial failure of Slow movement and slow action of the ankle jerk.
thyroid development. The parents and the other children
may be normal. Partial failure causes juvenile Investigations;
myxoedema. In endemic areas goitorous cretinism is Serum T4 is below 55 nmol/l
common due to maternal and fetal iodine deficiency.
Immediate diagnosis and treatment with thyroxine within Radio-iodine studies show reduced thyroid uptake and
a few days of birth are vital if physical and psychological increased renal excretion. Iodine uptake of less than
development is to occur or further deterioration is to be 12%/24hrs is diagnostic.
prevented. Women under treatment with anti-
Serum T.S.H are raised
thyroidbdrugs may give birth to hypothyroidic infants.
T.R.H test is helpful in doubtful cases.
ADULT HYPOTHYROIDISM
Treatment:
Myxoedema is a very advanced form of adult
hypothyroidism. Myxoedema should never be applied to The hormone, Levo-thyroxine is curative. A full
the mild degree of hypothyroidism commonly seen more replacement dose of 0.15- 0.2 mg/day can be given as a
frequently after thyroidectomy and with auto-immune single dose. In the elderly or those with myocardial
thyroiditis. insufficiency the initial dose must be as low as
0.05mg/day and increased carefully.
Symptoms;
If a rapid short lived response is required tri-
Significant early symptoms include
iodothyronine is used.
Tiredness
MYXOEDEMA
Mental lethargy
The s/s of hypothyroidism are exaggerated. There is a
Cold intolerance typical appearance;

Increase in wt Pt has a bloated look ( face looks swollen)

Menstrual disturbance Lips are pushed out

Carpal tunnel syndrome due to increase in tissue fluid A dull expression

which causes pressure to the median nerve characterized
Supra-clavicular puffiness
by numbness, tingling, and constipation.
Malar flush (flushing of the cheeks and a yellow tinge of
Signs;
the skin)
Slow pulse rate
Myxoedema comma occurs in neglected cases. In
Dry skin and hair myxoedema comma carries a high risk of mortality.
Temperature is low and the pt must be warmed slowly. 1
Cold extremities gm of hydrocortisone i.v should be given and i.v tri-
Peri-orbital puffiness iodothyronine slowly increasing doses.

PRIMARY OR ATROPHIC MYXOEDEMA

81
It is considered to be an auto-immune condition which is Other rare goiters:
similar to Hashimotos disease but without goiter
formation from T.S.H stimulation. It is more severe than Acute bacterial thyroiditis
goitorous myxoedema. Chronic bacterial thyroiditis (Tb or syphilis)
DYSHORMOGENEISI AND GOITOROGENS Amyloid goiter
Genetically determined deficiencies in enzyme SIMPLE GOITER:
thatcontrolthe synthesis of hormone thyroxine and it
leads to formation of goiter. If the enzyme deficiency is of It is due to stimulation of the thyroid gland by anterior
moderate degree, a simple uethyroidgoiter occurs. pituitary, i.e. increased level of T.S.H. T.SH secretion is
Similarly goitorogens may produce goiter with or without increased by low levels of circulating thyroid hormones.
hypothyroidism. Any factor that maintains a persistently low level of
circulating thyroid hormone can be responsible for simple
goiter. The most important is iodine deficiency but
GOITER defects in hormone synthesis may also be responsible.

Definition: An enlarged thyroid gland. Aetiological factor:

Classification of goiter: Iodine deficiency:- The daily requirement is about 100-

105 ug. In nearly all cases where simple goiter is endemic
Simple goiter (may be endemic or sporadic) + euthyroid there is a very low iodine content in water and food. In
which is divided into diffuse hyperplastic and nodular Kenya, Eburu nearGilgil, lowland where soil lacks iodine or
goiter. There is no hypothyroidism. the water supply comes from far away in the highlands.
Calicium is also goitorogenic and goiter is common in low
iodine areas of chalk or limestone. Although iodides in
Toxic goiter: It is divided into; food and water may be adequate there may be failure of
intestinal absorption.
Diffuse toxic goiter (Grave’s disease) where the whole
gland is enlarged Defects in the synthesis of thyroid hormones

Toxic nodular goiter Enzyme deficiency within the gland which are responsible
for many sporadic goiters in non-endemic areas. And
Toxic nodule (solitary) there is often family history in this cases suggesting
genetic defect. If the iodine intake defect is very high and
enzyme deficiency may be overcome. Iceland has never
Neoplastic goiter: which can be benign or malignant. reported any goiter case because they encourage people
to a lot of iodine. Enzyme deficiency is often associated
with a low iodine intake e.g. a dislike for seafood.

Thyroiditis which can be granulomatous thyroid Well known goitrogens are in the vegetables of the
(DeGuervan’s disease), auto-immune thyroiditis or brassica family e.g kale, cabbage and tunips. They contain
Riedel’s thyroiditis. thiocyanate. Others are drugs such as P.A.S and anti-
thyroid drugswhich interfere with iodine trapping.
Carbimazole and Flouracil compound interfere with
oxidation of iodine to thyrocin to form triiodothyrosines.
82
Iodides in large amounts are goitrogenic because they Titers of thyroid antibodies estimation to differentiate
inhibit the organic binding of iodine and give rise to an nodular goiter from Hashimoto’s disease.
iodide goiter which is usually seen in asthmatics who have
taken preparations containing iodides for a long period Plain X-ray of the neck may show calcification and
e.g. Felsol. tracheal deviation or compression.

Clinical types of simple goiter:

Simple hyperplastic simple goiter—It corresponds to the Complications:

first stages of the natural history of a simple goiter due to Tracheal obstruction due to gross lateral replacement or
persistent T.S.H stimulation causing hyperplasia. The decompression of the trachea in lateral or antero-lateral.
goiter appears in childhood in endemic areas but in
sporadic cases it appears in puberty when metabolic Acute respiratory obstruction
demands are very high. If T.SH stimulation ceases the
Secondary thyroid toxicosis
goiter may regress but tends to recur later at times of
stress such as pregnancy. The gland is; soft, diffuse, may Carcinoma usually of follicular thyroid ca. it is uncommon
be large enough to cause discomfort. A choroid goiter is a but an increased incidence has been reported from
late stage of a diffused hyperplasia when T.S.H stimulation endemic areas.
has fallen off.
Prevention and treatment of simple goiter:
Nodular goiter:- Persistent fluctuating T.S.H stimulation
results inevitably in progressive nodular formation. All cooking and table salt should be iodized by adding
Nodules are usually multiple forming a multinodular potassium iodide 1:1000. In endemic areas this
goiter. Occasionally only one macroscopic nodule is found prophylactic measures have reduced simple goiter.
but microscopic changes will be present throughout the
In the early stage hyperplastic goiter is reversible when or
gland. This is one form of clinically solitary nodule.
if levothyroxine is given in maximum doses 0.2 mg/day for
Nodules appear early in endemic goiter and appear later
several months and then very slowly tail off to 0.1 mg/day
in sporadic goiter 20-30 yrs. Although the pt herself will
which should then continue for several yrs.
not be aware of the goiter until late 40s or 40s. all types
of simple goiter are far more common in females than If regression does not occur thyroidectomy may be done
males. Recently oestrogen receptors have been identified for cosmetic measures or pressure symptoms.
in normal thyroid tissue.
Nodular stage of simple goiter multinodular goiter is often
Diagnosis: uncomfortable and unsightly and view of the possible
complications subtotal thyroidectomy is advisable unless
Usually straight forward. Nodules are palpable and often
the expectation of life is short. Resection aims at
visible, smooth, firm and not hard. It is not painful and
removing the nodules and having up to 8gms of relatively
moves freely with swallowing. Hardness or irregularity
normal tissue in each remnant.
due to calcification may mask carcinoma. A painful nodule
with sudden appearance or rapid enlargement raises Occasionally the multinodular change is asymmetrical
suspicion of ca but is usually due to hemorrhage to a with one lobe. One lobe significantly involved with only a
single nodule. minimal amount and even micro-nodules. Under this
circumstances unilateral total lobectomy of the affected
Investigations:
side is the appropriate management. In many cases the
Test for thyroid function to exclude hyperthyroidism causative factors persist and recurrence is likely
83
particularly in the younger patient unless further T.S.H It is treated by excision or radio-iodine.
stimulation is prevented. 0.1 mg of levothyroxine/day
should be given post operatively to all pts until after It is a functioning adenoma or a simple nodule with some
menopause. If one thyroid lobe appears normal in size active thyroid tissue in it. Very rarely a very differentiated
and inconsistent it is not justified to resect that lobe but ca may take up isotope. Because a functional adenoma
post operative levothyroxine is essential. may develop an overactive adenoma it should be excised.

Clinically solitary nodule Euthyroid cold nodule: it is suspect because a carcinoma

so rarely takes up isotope, if normal thyroid tissue is
Def. A goiter which on clinical examination appears to be present. It should be excised. Resection entails taking a
a simple nodule in otherwise normal gland. There are two wide marginal healthy thyroid tissue. In order to achieve
categories; this total lobectomy should be done on the side of the
lesion including the thyroid isthmus. Subtotal lobectomy
Nodules in which there is a certainty or suspicion of is rarely appropriated and should only be performed
malignancy. In these nodules exploration is essential. when the; nodule is small, anteriorly situated, and has
2nd far larger category in which there is a smooth, firm, been shown on cytology to be benign. Incisional biopsy is
mobile nodule which is probably benign and small but totally contraindicated as it could result in seedling of
carries a significant risk of being a carcinoma. In this malignant cells.
category about 50% proof to be simple multilobular Other investigations of solitary nodule include;
goiter. The thyroid status of this pt must be established by
clinical examination and by laboratory tests. Isotope Needle biopsy—It is an available technique which can aid
scanning is essential to find if there is hyperthyroidism. diagnosis and influence its subsequent management. Two
Isotope scanning is only essential if there is distinct types of needle biopsy are
hyperthyroidism but of limited value if there is
malignancy. This test should divide the pt into three (i). Trucut large needle biopsy. It produces a core tissue
categories; for cytology. It has a high diagnostic accuracy but has poor
pt compliance. They are also associated with
Those who are hyperthyroid with a “hot” (hyperactive) complications like pain, bleeding, tracheal damage and
nodules i.e. one which takes up isotope while the recurrent laryngeal nerve damage.
surrounding thyroid is inactive because the nodule is
producing such a high levels of the hormone that T.S.H (ii). Thin needle aspiration biopsy (ABC) –It produces a
secretion is suppressed. thin smear for cytology. It has an excellent pt compliance.
It is simple and quick to perform even in OPD. It can be
Those who are euthyroid with a “warm” (inactive) nodule. performed repeatedly and if well performed it has a high
A warm nodule takes up isotope and so does the normal diagnostic accuracy many aspirations have been done
tissue around it. without complications. Tumor implantation with seeding
does not occur. Thyroid condition which tend to be
Those who are euthyroid with a “cold” (inactive) nodule. diagnosed with thin needle ABC are (i) colloid nodules (ii)
A cold nodule does not take up isotope. thyroiditis (iii) papillary ca (iv) anaplastic ca(v) lymphoma
Solitary toxic nodule: Thyroid cysts can also be aspirated and the aspirate
It is never malignant. examined cytologically. However there is need for caution
as many cysts occur in malignancies. After aspirating a
It is a toxic adenoma. cyst a check must be made for any residual mass. Ideally a
frther sample should be taken from a cyst wall and take it
84
for cytology. Any cyst which reaccumulates after initial A retrosternal ,goiter may be symptomless or produce
aspiration must be subjected to surgery. severe symptoms such as; dyspnoea especially at night
and cough or stridor. The pt may attend a chest clinic with
Ultra sound- this is of limited value in the diagnosis of a diagnosis of Asthma before the discovery of the true
malignancy but should help to differentiate between solid diagnosis.
and cystic nodules and other nodules present but can’t be
palpable nodule. Dysphagia

Computerized axial tomography (CAT SCAN) and magnetic Engorgement of neck veins and superficial veins on the
resonance imaging (MRI) are sophisticated. They have chest wall. In severe cases there may be obstruction of
only small role to play in the day to –day management of superior vena cava
thyroid disorders
Recurrent laryngeal nerve paralysis resulting in dysphonia
Fluorescent scanning- It permits an in vivo demonstration (hoarseness) rare.
of thyroid gland iodine content. In an old solitary nodule
the ratio of iodine content in the nodule to that of the Malignant or toxic.
corresponding of the contralateral lobe may be used to Investigations:
distinguish between benign from malignant lesions.
X-rays show a soft tissue shadow in the superior
NB: Clinically solitary nodule presents a diagnostic mediastinum and sometimes with calcification often
problem when the nodule is smooth, firm, and mobile in a causing deviation and compression of the trachea.
euthyroid pt. scanning, needle bx and ultra sound may
increase or decrease the suspicion of malignancy but Iodine 1, 2, 3 scan may help to distinguish a retrosternal
excisional biopsy is the only certain diagnostic procedure. goiter from a retrosternal tumor.

Retrosternal goiter: a very small number of retrosternal If there are obstructive symptoms it not wise to treat with
goiters arise from ectopic thyroid tissue but most arise anti-thyroid drugs or radio-iodine as they enlarge the
from the lower pole of a nodular goiter. If the neck is goiter further. Resection can almost always be carried out
short and the tracheal muscles are strong as in men the from the neck and a midline sternoctomy is often
negative intra- thoracic pressure tends to draw these unnecessary. Hemorrhage is rarely a peoblem because
nodules to the superior mediastinum. The degree of the goiter takes its blood supply from the neck.
descent varies and this accounts for 3 types of
The recurrent laryngeal nerve should be identified before
retrosternal goiter.
delivery of the retrosternal goiter by traction and finger
Substernal type – this is when the nodule is palpable mobilization. This is because the recurrent laryngeal nerve
clinically is vulnerable to damage by traction and finger
mobilization. If a large multinodular retrosternal goiter
Plunging type—occurs when intra thoracic goiter is cant be delivered intact it can be broken by finger and
occasionally forced into the neck due to increased intra- removed peacemeal but this should never be done if the
thoracic pressure. lesion is solitary.
Intra-thoracic goiter. TOXIC GOITER (thyroitoxicosis/ hyperthyroidism)
Clinical features of retrosternal goiter
The term thyroitoxicosis is retained as much as possible
h/o a previously cervical goiter which has disappeared is because hyperthyroidism is not responsible for the
common. manifestation of the disease.
85
Clinical types of thyroitoxicosis; Sex incidence: thyroitoxicosis is 8 times common in females
than males, i.e. F:M =8:1
Diffuse toxic goiter (Grave’s disease)
WAYNE’S CLINICAL DIAGNOSTIC INDEX- It gives all the
Toxic nodular goiter important symptoms and signs of thyroitoxicosis and indicates
by their score the relative importance of each symptom and
Toxic nodule
sign.
Hyperthyroidism due to rarer causes
Most important significant symptoms,

Wt loss inspite of good appetite

Diffuse toxic goiter:
A recent preference for cold or heat intolerance
This is a diffuse vascular goiter appearing at the same time as
Palpitations.
the hyperthyroidism usually in the younger women and
frequently associated with eye signs. The syndrome is that od Important significant signs,
primary thyroitoxucosis. The whole of the functioning thyroid
tissue is involved and the hypertrophy and hyperplasia are due Excitability of the pt – pt appears agitated and is unable to sit
to abnormal stimulatingantibodies. still

Toxic nodular goiter The presence of goiter

A simple nodular goiter is present for a long time before the Exophthalmos
hyperthyroidism usually in the middle aged or elderly and very
Tarchycardia or cardiac arrhythmias the resting or sleeping
infrequently associated with severe eye signs. The syndrome is
pulse is elevated above 80 beats per a minute and this is
that of secondary hyperthyroitoxicosis. In many cases the
diagnostic. Water hammer pulse is felt. There is an initial high
nodules are inactive and it is the internodular tissues that are
upthrust and then quickly falls away. There may be a rise in
super active. Basically toxic nodular goiter is graves’ disease in a
systolic pressureand extra systole may occur.
background nodular goiter. In some cases we may haveone or
all nodules being hyperactive. In this case hyperthyroidism is Wayne’s clinical diagnostic index
due to autonomous thyroid tissue.
Symptoms of recent present
Toxic nodule signs

It is a solitary overactive nodule. It is autonomous and its Onset and /or increased
hypertrophy and hyperplasia are not due to T.S.Ab. because
T.S.Ab secretion is suppressed by the increased level of the Severity score score
circulating thyroid hormones the normal thyroid tissue present absent
surrounding that nodule is itself suppressed and is inactive.
Dyspnea on exertion +1 - 1.
Histology: the normal thyroid gland institute of acini lined by palpable gland +3 -3
flattened cuboidal epithelium and looks uniform all through. In
hyperthyroidism there is hyperplasia of the acini which are lined Palpitations +2 - 2. Bruit
by high columnar epithelium. Many of the acini are empty and of gland +2 -2
others contain vacuolated colloid.
Tiredness +2 - 3.
Symptomatology of thyroitoxicosis:
Exophthalmos +2
Age incidence: it may occur at any age
Preference for heat - -5 4. Lid
retraction +2
86
Regarless of duration Athrill of bruit may be present usually at the upper pole of
the gland over the superior thyroid arteries.
Preference for cold +5 - 5.
Hyperkinetic movement+4 -2 The oriset is aborpt but remission and exacerbation are
common
Indifferent to temp. 0 - 6. Lid lag
+1 Hyperthyroidism is severe than 2 degrees thyroitoxicesis
but in 1 degree thyroidoxicosis cardiac failure is rare.
Excessive sweating +3 - 7. Fine
finger tremors +1 OTHER MANIFESTATIONS NOT DUE TO
HYPERTHYROIDMS PER SE
Nervousness +2 8. Hands
hot +2 -2 Orbital proptosis

Increased appetite +3 9. Opllithslmophgica

Hands moist +1 -1
Pre-tibial myxoedema inslightly skin over the chins and
Decreased appetite -3 10. feet
Casual pulse rate
In 2 degree thyrotoxicosis the goiter:

Atrial fibrillation +4 Nodular

Increased wt. -3 11. Onset is insidious

Regular rates Pt may present with cardiac failure or it is characteristic
80/min. -3 that hyperthyroidism is not seen severe arterial fibrillation

80-90/min. 0 Eye signs apart from lid lag and lid spasms are very rare.

90/min. +3

Decreased wt -3. CARDIAC RHYTHM

key A fast heart rate, which persist during sleep is

characteristic of thyroitoxicosis. As the disease progresses
key: symptoms score + sign score =diagnostic index cardiac arrhythmias are super imposed to the
tarchycardia and this arrhythmias are common in older
if the diagnostic index is under 11 then it is non toxic patients’ with thyroitoxicosis because of preference of
goiter incidental heart disease.
11-19 it is suspicious There are 4 stages of development of thyroitoxicosis
Over 19 it is toxic arrhythmias:

Goiter in 1 degree thyroitoxicoxis is diffused and First multiple extrasystole

vasculem may be large or small. Paroxysmal arterial tarchycardia
Firm or soft Paroxysmal arterial fibrillation.

87
Persistence arterial fibrillation not responding to digoxin This is the thickening of the skin over the shin and feet by
amucin like deposit nearly always associated with true
MYOPATHY exophthalmos. Past or present hyperthyroidism and high
Weaknesses of proximal limb muscles are commonly levels of T.S.Abs, is usually symmetrical and minor
found to be weak if looked for. Occasionally severe degrees are common but they are easily missed. The
weaken resembling myasthenia gravis a disorder earliest stage is a shiny red dark skin with coarse have.
characterized by muscle weakness. When this occurs in The skin may be cyanotic when exposed to cold. In severe
the thyroitoxicosis it is called thyroitoxicostic myopathy. cases the skin of the whole leg below the knee involved
The patient recovers from myopathy when together with the skin of the foot and ankle and there
hyperthyroidism is controlled. may be clubbing of fingers and toes.

Diagnosis of thyroitoxicosis:

EXOPHTHALMOS Most cases are diagnosed clinically and the wayne

diagnostic index is necessary. Difficulty is likely to arise in
Some degree of exophthalmos is common. It may be the differentiation of mild thyroitoxicosis from anxiety
unilateral. True exophthalmos is a proptosis of the eye when a goiter is present. In this cases where
caused by infiltration of the retrobulbar tissues filled with differentiation must be done, diagnostic tests must be
fat and round cells which a varying degree of retraction done. If there is still doubt after aroutine thyroid profile
spasms of the upper eye lid. These result in widening of and an iodine 1, 2, 3 thyroid test then a T.R.H test should
the eye palpetral fissure so that the sclera can be seen be done. Thyroitoxicosis diagnosis is established by
clearly above the main of the eye lids and cornea.Spasm estimating the T3 levels. It should be suspected if the
are retraction of the eye lid usually diapers when the clinical picture is suggestive but routine test for thyroid
hyperthyroidism is controlled but that may be improved function are within the normal range and this is called T3
by beta adrenergic blocking agents like cuanethidine eye thyroitoxicosis. A thyroid scan is essential for the
drops.Weakness of the extra occular muscles particular diagnosis of an autonomous toxic nodule. There are four
the elevators results in diplopia. In severe cases of general clinical features thyroitoxicosis;
exophthalmos, papilloedeme and ulceration of the cornea
occurs. When severe and progressive it is known as In children with a growth spurt, behavior problem and
malignant exophthalmos and the eye may be destroyed. myopathy
Exophthalmos is usually self limiting and may even regress Tarchycardia or arrhythmias in the elderly
a littleSleeping in a propped up position and lateral
tarsorrhaphy (suturing eyelid together) help protect the Unexplained diarrhea
eye ball but will not prevent development of
exophthalmos. Hypothyroidism increase the Loss of wt.
exophthalmos by a few millimeters and this should be Principles of treatment of thyroitoxicosis:
avoided. Improvement has been reported with massive
doses of predinson. Intraorbital injection of steroids is Non specific measures
dangerous because of the venous congestion. When the
Bed rest
eyes are in danger orbital decompression may be
required. Sedation
Pre-tibial myxoedema: In established thyroitoxicosis this measures should be
used in conjunction with specific measures.

88
Specific measures: drugs. This is probably due to T.S.Abs stimulation during
the prolonged course of Rx but is not a direct effect into
Anti-thyroid drugs the blood. Very rarely there is a dangerous a drug reaction
which is characterized by; agrnulocytoss, urticaria, anaemia
Surgery
In agranulocytosis, if the pt develops sore throat, discontinue
Radio-iodine
treatment until the level of wbc count decreases. Initially start
Antithyroid drugs with 10mg of carbimazole tds and there is a latent interval of 7-
14 days before any clinical improvement is apparent. It is most
Those in common use are important to maintain high concentration of the drug through
out the 24hrs by spacing the doses by 6-8 hourly administration.
Carbimazole (neomarcazole) and When the pt becomes euthyroid use a maintainance dose of
5mg bd or tid for another 12- 28 months. Carbimazol acts by
Propylthiouracil imparing the binding of iodine. It laso has hormone suppressive
action on T.S.Abs. it is effective in almost all pts though it takes
Others include;
as long as 4-6 wks to give the effects that have been mentioned.
Beta adrenergic blockers e.g propranolol Give T3 20ug bd- tid or thyroxine 0.1mg od in conjunction with
ant-thyroid drugs, there is less danger of producing iatrogenic
Iodides were once thought to reduce vascularity of the
thyroid insufficiency or an increase in size of the body.
thyroid gland. They should only be used as immediate Potassium perchlorate 200-400mg qds is sometimes used. It has
pre-operative treatment in some days before surgery. ability to block iodine transport. It’s action is slower than
carbimazole. It also produces side effects. Propranolol has
Anti thyroid drugs are to restore the pt to euthyroid state
recently been used when ordinary anti-thyroid therapy has
and these are used for a long period in hope that a failed and also in cases of thyroid crisis.
permanent solution may occur. It should be noted that
anti-thyroid drugs cannot cure a toxic nodule. The SURGERY
overactive thyroid tissue is autonomous and even if you
In diffuse toxic goiter and toxic nodular goiter with overactive
bring the pt to euthyroid state recurrence occur when you interlobular tissue surgery cures by reducing the mass of the
discontinue the drug. overactive tissue. A cure is probable if the thyroid tissue is
reduced a critical mass. This may result in reductionof T.S.Abs
Advantages of anti-thyroid drugs
or the circulating T.S.Abs however high it’s level it can only
produce limited hypertrophy and hyperplasia.
No surgery
In the autonomous toxic nodule surgery cures by removing the
No use of radio-active material
tissue.
Disadvantages
Advantages of surgery:
Rx is prolonged and failure rate after a course of 11/2 - Goiter is removed
2yrs is 50%. Long term Rx is unacceptable to many pts.
Recently there has been a trend towards the use of short Long term drug maintenance is not necessary.
term drugs of about 6/52.
Cure is rapid. Euthyroid atste is achieved quickly.
It is impossible to predict which pt is likely to go into Cure rate is high if surgery has been accurate.
remission
Disadvantages:
Some goiters enlarge and become very vascular during
treatment even when thyroxine is given together with A recurrence of thyroitoxicosis in less than 5% of the cases.
89
Every operation carries morbidity but with suitable preparation family commitment and any other co-existing surgical or
with an experienced surgeon, the morbidity is negligible. medical condition.

Although postoperative thyroid insufficiency occurs in some 20- How to choose therapeutic treatment in diffuse toxic goiter:
30%, this is rarely due to operation itself.
Over 45yrs radio iodine
Parathyroid insufficiency occurs in < 0.5% cases.
Under 45yrs (i) for large goiter ,surgery (ii) for small goiter, anti-
thyroid drugs. Large goiters are uncomfortable and remission
with anti- thyroid drugs is less likely as small goiter.
RADIO-IODINE:
Toxic nodular goiter
It was first used in treatment in 1922. Iodine destroys the
thyroid cells. As in thyroitectomy it reduces the thyroid mass to Surgery is the treatment of choice. Toxic nodular goiter does
below the critical level. It inhibits iodine binding. It is of not respond as rapidly as a diffuse toxic goiter does to radio-
considerable value since it is a faster mode of treatment. The iodine or anti-thyroid drugs. The goiter itself is often large and
main indication is repeated toxicity after previous surgery. It is uncomfortable and enlarges further if anti-thyroids are given.
more effective in diffuse goiter than nodular goiter.

Advantages:

No surgery is necessary

No prolonged drug therapy

Disadvantages
GASTROINTESTINAL
Isotope facilities must be available TRACT (G.I.T)
There is a high and progressive incidence of thyroid THE ESOPHAGUS
insufficiency which may reach 75-80% after 10yrs. Incidence
increases with live. 75-80% develops hypothyroidism after 10yrs Surgical anatomy:
due to sublethal damage to those cells not actually destroyed
by the initial treatment and this eventually causes failure of This is a fibromuscular tube measuring 25cm long. It occupies
cellular production. the posterior mediastinum and extends from the
cricopharyngeal sphincter to the cardia of the stomach. 2cm of
An indefinite follow up is essential because of the real and this tube lies below the diaphragm. The musculature of the
potential risks such as production of carcinomatous changes upper one third is mainly striated, giving way to smooth muscle
most clinicians don’t give radioiodine in pt less than 45yrs of below. It is lined by squamous epithelium and replaced by
age. The dose of radio iodine varies in the size of goiter a specialized epithelium at the level of the hiatus similar to
suggested dose 160 micro-curies/gm of thyroid tissue. gastric mucosa but without oxyntic and peptic cells. The
Response is slow but a substantial improvement can be specialized mucosa lines the lower 3cm. Nerve supply
expected after about 8-12 wks. Accurate dosage is difficulty and
(parasympathetic) is mediated by the vagus through an extrinsic
if after 2 wks there is no clinical improvement further dose is
and intrinsic plexus. The intrinsic plexus has no meissner’s
necessary. Two or more doses is necessary in about 20-30%.
which is elsewhere throughout the alimentary canal. There are
The choice of therapeutic agent: thre physiological constrictions in the tube with distinct lesions
at each level as shown below.
Each case must be considered individually. They must be
modified according to facilities availableand personality, Diagram:
intelligency and wishes of the individual pt, her business or

90
 Dysphagia: difficulty (not pain) in swallowing. There are
two types, i.e. oropharyngeal and esophageal. The type of
dysphagia is vital. It may be dysphagia for solids or liquids,
intermittent or progressive, precise or vague in its
appreciation. Pain may be present. Painful dysphagia is
usually due to esophagitis.

Regurgitation:

It is important to report the volume, contents, presence

of blood or bile and the reaction to litmus. Loss of wt,
cachexia and change of voice are also important
symptoms.

Investigations of the esophagus:

Radiography- it is the most valuable investigation. A plain

film will show an opaque foreign body and the site of its
arrest. A barium swallow is vital and will show motility,
size, distortion, or presence of S.O.L.

Physiology: Eso[phagoscopy- it is required to view the inside of the

esophagus and the esophagogastric junction, to obtain
The main function is to form part of coordinated
biopsy, for removal of foreign bodies and to dilate
mechanism transferring food from the mouth to the
strictures. There are two instruments available;
stomach. The initial mov ement of food through the
oropharynx is induced voluntarily and involves sequential A rigid esophagoscope
contraction of the respiratory passages and opening of
the upper esophageal or cricopharyngeal sphincter. The Flexible fibreoptic esophagoscope
body of the esophagus then sweeps the food bolus by an
Esophagoscopy with a rigid esophagoscope should never
involuntary peristaltic wave through a relaxed gastro-
be carried out without a preliminary barium swallow. If
esophageal sphincter into the stomach. The
this rule is broken then sooner or later the esophagus will
cricopharyngeal sphincter is normally closed at rest and
be perforated during the examination.
serves as a protective mechanism against regurgitation of
stomach contents into the respiratory passage. Failure of PH measurement- these are carried out to measure the
it to relax on swallowing may predispose to development presence or absence of reflux with change in posture and
of a pharyngeal pouch (pulsion divericulum). At the lower also decide whether the pain of which the pt complains is
of the esophagus there is a physiological sphincter, which indeed due to acid reflux into the esophagus.
together with other anatomical mechanisms, prevent
gastric contents refluxing. The esophagus is a peristaltic Therapeutic procedures:
organ, and the sphincter relaxes in advance of the
Removal of foreign bodies- some objects are removed
peristaltic wave. Abnormal conditions e.g achalasia or
fairly easily and these cases it is usually necessary to
scleroderma show changes in both esophageal peristalsis
withdraw the esophagoscope at the same as the
and sphincter tonus and function.
retrieving forceps which are holding the foreign body. If
the foreign body is sharp or jagged and is likely to damage

91
the esophagus during its removal, it is preferableto open It should be suspected in all cases of
the esophagus above the fb through a high thoracotomy. polyhydramnious(50% of cases of atresia – hydramnious
was present)
Dilatation of stricture- benign and malignant strictures
may require dilatation with bougies which must be well Clinical confirmation:
introduced and without too much force.
Size 10 rubber catheter is introduced into the esophagus
DDX OF DYSPHAGIA: through the mouth. If an obstruction is encountered at
about 10cm from the lips, the diagnosis is practically
Esophagitis atresia.
Pulsion diverticulum Radiological confirmation:

Never give barium emulsions in this cases.

CONGENITALESOPHAGEAL ANOMALIES Injection of not more than 1ml of dianosil down the
Atresia with or without trachea-esophageal fistula catheter will demonstrate the catheter. During the
examination the supine position is advised, because in the
Stenosis- rare rare cases of categoriesthe medium is likely to enter the
trachea. In all cases the dianosil should be aspirated after
Short esophagus with hiatus hernia- rare. Most cases of
the radiograph has been taken.
short esophagus are a result of a hiatus hernia.
Gas in the stomach will confirm that the lower end of the
Dysphagia lusoria(compression by an aberrant subclavian
esophagus reaches the trachea and that an anastomosis
artery) i.e. esophageal compression by an abnormal
can be carried out.
artery usually the subclavian artery.
Treatment:

Urgent surgery
Congenital atresia of the esophagus:
Preoperatively N.P.O., rehydration, antibiotics.
It is usually associated with a trachea-esophageal fistula.
It is seen that 85% of cases it is the lower segment that Aspiration pneumonia is nearly always present and
communicates with the trachea. antibiotics should be given.

Diagram

Clinical features:

The new born baby regurgitates all its first and Operation- urgent right sided thoracotomy at the 5th
subsequent feeds. intercostals space.

Saliva pours from the mouth almost continuously. This is a Complications –pneumonia, leakage from the
sign of esophageal atresia because it does not occur in anastomosis.
any other condition.

Attacks of cough and cyanosis on feeding

FOREIGN BODIES IN THE ESOPHAGUS:

92
 Presence of Ng tube

All sorts of swallowed fbs have become arrested in Presence of hiatus hernia
the esophagus. They range from coins, pins, and dentures
head the list. All cases should have an urgent- Inadequate or slowed clearance of refluxed material
rayexamination including dilute barium or water soluble Delayed gastric emptying and increased gastric volume,
contrast medium(gastrographine)swallow. contributing to the volume of refluxed material.
Rigid esophagoscopy is necessary in almost all cases. Reduction in the reparative capacity of the esophageal
Position so that it may be grasped by suitable forceps mucosa by protracted exposure to gastric juice.
introduced through the esophagoscope. The
esophagoscope together with the forceps still grasping The acid- peptic action of gastric juice is critical to the
the Fb is then gently withdrawn. development of esophageal mucosa injury. Anatomic
changes depend on the causative agent and on the
duration and severity of the exposure. Simple hyperemia
ESOPHAGITIS: (redness) may be the only alteration.in uncomplicated
reflux esophagitis three histologic features are
It may be acute or chronic. characteristic;

Acute – may follow burns or scalds. Infection(spreading Presence of inflammatory cells including eosinophils,
from the pharynx), or peptic, sometimes from trauma of neutrophils, and excessive numbersof lymphocytes in the
an indwelling stomach tube. Due to a sliding epithelial layer.

Hiatus hernia. Reflux is common in pregnancy but Basal zone hyperplasia exceeding 20% of the epithelial
usually resolve after delivery. thickness

Elongation of lamina propria papillae with congestion,

extending into the top 3rd of the epithelial layer
Reflux esophagitis:
Clinical features:
Reflux of esophageal contents the lower esophagus is the
1st and foremost cause of esophagitis. Other causes Although largely limited to adults > 40yrs, reflux
include; esophagitis is occasionally seen infants and children.
Clinical features include;
Decreased efficacy of esophageal anti-reflux mechanism
particularly; Dysphagia

Central nervous depressants Heartburn

Hypothyroidism Sometimes regurgitation of sour brush

Pregnancy Hematemesis or

Systemic sclerosing disorders Malaena

Alcohol The potential consequences of severe reflux esophagitis

are bleeding, development of stricture, development of
Tobacco Barret’s esophagus.
93
BARRETT ESOPHAGUS: Ingestion of mucosal irritants e.g. alcohol, corrosive acids
or alkalis(in suicide attempts) and excessively hot fluids
This is a complication of longstanding with reflux and not (e.g. hot tea in Iran) as well as heavy smoking
in others.ing gastroesophageal reflux. It occurs over time
in up to 10% of pts with symptomatic reflux disease. The Cytotoxic anticancer therapy, with or without
distal squamous mucosa is replaced by metaplastic superimposed infecton.
columnar epithelium as a result of prolonged injury. The
pts tend to have a history of heartburn and other reflux Infection after bacteriamia or viraemia. Herpes simplex
symptoms. They appear to have more massive reflux with virus and cytomegalovirus are the more common
more and longer reflux episodes than most reflux pts. It is offenders in the immunosuppressed.
not known why the columnar epithelium develops in Fungal infection in the immunosuppressed or debilitated
some pts with reflux and not in others. pts or during broad spectrum antimicrobial therapy.
The lesion on endoscopy, is seen as a red, velvety mucosa Candidiasis is by far the most common.
located between the smooth, pale esophageal squamous Uremia in renal failure
mucosa and the more lush light brown- pink gastric
mucosa. It may exist as tongues or patches (islands) It may also occur after radiotherapy.
extending up from the gastroesophageal junction or as a
Morphology:
broad circumferential band displacing the
squamocolumnar junctionsegment. A small zone of Infectious and chemical causesof esophagitis exhibit their
metaplastic mucosa may be present only at the own characteristic features but finally there is severe
esophageal junction ( short segment Barrett mucosa) acute inflammation, superficial necrosis and ulceration
with the formation of granulation tissue and eventual
Microscopically the esophageal squamous epithelium is
fibrosis.
replaced by metaplastic columnar epithelium complete
with mucosal glands. The metaplastic mucosa may Candidiasis: Patches or all of esophagus become covered
contain only gastric surface and glandular mucus secreting by adeherent, gray white pseudomembranes teeming
cells, making clinical distinction from hiatal hernia with densely matted fungal hyphae.
difficult. Diagnosis is more readily made when the
columnar mucosa contains intestinal goblet cells. Herpes and cytomegalovirus:

Clinical features Cause punched out ulcers of the esopheal mucosa.

Symptoms of reflux esophagitis Pathogenic bacteria: account for 10-15% of cases of

infective esophagitis. They invade lamina propriawith
Local bleeding due to ulceration necrosis of the squamous epithelium.
Stricture formation Chemically induced injury: (lye, acids, detergents). May
produce only mild erythema and edema, sloughing of the
Development of adenocarcinoma
mucosa, or outright necrosis of the esophageal ulceration
INFECTIOUS AND CHEMICAL ESOPHAGITIS: may result from pharmaceutical tablets or capsules
sticking in the esophagus
Other thangstroesophageal reflux (which is, a chemical
injury ), esophageal inflammation may have many origins After irradiation: submucosal and mural blood vessels
as follows; exhibit marked intimal proliferation with luminal

94
narrowing. The submucosa becomes severely fibrotic and Dietary carcinogens/ ? geographical e.g. molibdinum in mt
the mucosa atrophies. Kenya region, Zimbambwe, nitrites (nitrosomines by
fungi).
ESOPHAGEAL VARICES: regardless of cause, portal
hypertension, when sufficiently prolonged or severe , Plummer- vinson syndrome (Peterson Kelly)
induces the formation of collateral bypass channels
wherever the portal and caval systems communicate. The Hot beverages
collaterals develop in the region of lower esophagus when Poor dental and oral hygiene
portal blood is diverted through the coronary veins, then
into the azygous veins, and eventually into the systemic Pathology:
circulation. The increased pressure in the esophageal
The lesion is usually squamous cell carcinoma
plexus produce dilated tortuous vessels called varices.
Varices develop in 90% of cirrhotic pts and are most often True adenocarcinoma occurs in only 3-5% and arises from
associated with alcoholic cirrhosis. Worldwide, hepatic the columnar cell lined lower esophagus
schistosomiasis is the second most common cause of
variceal bleeding. Other carcinomas are usually of gastric origin spreading
upwards
Morphology: varices appear as tortuous dilated veins
lying primarily within the submucos of the distal Macroscopically:

Three types are recognized;

A annular stenosing lesion usually at the cardia

An epitheliomatous ulcer with raised and everted edge

CARCINOMA OF THE ESOPHAGUS A fungating cauli flower like friable mass

Accounts for 5% of all carcinomas. Incidence:

Mostly occurs over the age of 45 yrs Upper 1/3 = 17%

More common in males than females Mid 1/3 = 5%

Predisposing factors(suggested) Lower i/3 = 33%

Barrett esophagus Spread:

The lower esophagus is lined with columnar epithelium Direct: this is the main method of spread and most
important to the surgeon. It occurs both transversely and
It is secondary to esophago-gastric reflux (as in hiatus longitudinall and erodes the muscular walls to invade the
hernia) and ectopic gastric mucosa. most important structures of the neck and posterior
mediastinum. Also affects the the left main bronchus and
Tobacco – smoking/ chewing.
trachea. It may perforate and cause mediastinitis and
Heavy alcohol intake rarely causes massive bleeding from the aorta. May also
affect the ruccurent laryngeal nerve causing hoarseness of
Achalasia voice.

95
Lymphatic: submucosal lymphatic permeation may lead to M0 – no distant metastasis
satellite nodules away from the main tumor. Also embolic
spread to surrounding lymphnodes occurs. From the M1 – distant metastasis
cervical esophagus the spread is to the lymphnodes of the
supraclavicular triangle. From the thoracic esophagus
spread is to the paraesophageal and tracheobronchal Stage I = T1, N0, M0
lymphnodes up to the subdiaphragmatic lymphnodes.
II = T1, N1, N2, M0
From the abdominal esophagus spread is to the
lymphnodes of the lesser curvature of the stomach. = T2, N0-2, M0
Blood stream: metastasis is to the liver which is fairly III = T3,any N, M0
common.
= any T, N3, M0
TNM STAGING:
IV = any T, any N, M1
T1
Clinical features:
tumor < 5cm length
Usually(not always) occurs over the age of 45yrs
No obstruction
More common in men than females
No circumfrential involvement
Dysphagia – often the only symptom. The difficulty is
No extra esophageal spread steadily progressive. 40% of the pts report within 3/12.
Otherwise the pt often delays and seeks advise when he
T2
can only swallow liquids by which time considerable,
Tumor > 5cm
Wt loss has occurred
No extra esophageal spread or
Regurgitation(pseudo-vomiting) the regurgitated material
Tenis size + obstruction is alkaline mixed with saliva and maybe with streaks of
blood.
Tenis size + circumfrential involvement but
Anorexia I those tumors involvingthe lower esophagus
No extra esophageal spread
Pain is a late manifestation.
T3
Investigations:
Any tumor + extra esophageal spread.
Cxr and cervical x- ray after barium swallow
N0 – regionalnodes not involved
Barium swallow
N1 – unilateral regional l’nodes involved
Esophagoscopy
N2 – bilateral regional l’nodes involved
Bronchoscopy
N3 –extensive multiple regional nodes involved
Ultra sound

96
Exfoliative cytology Pt fitness- weight, pulmonary reserves, to withstand a
major operation.
C.t. scanning
B .CT evaluation: to rule out evidence of spread of the
Asseses; growth to the supraclavicular gland, trachea-bronchial
Tumor length and width tree or liver.

Lung fields Palliative:

Liver Intubation

Celiac glands Bypass

Mediastinal glands Radiotherapy

Ct scan of the chest and abdomen evaluates local l’nodes Laser treatment
spread and distant spread. Intravenous feeding
Routine investigations Curative treatment by surgery in 25%
Full blood count Preparation
LFTs Correct anaemia
Total proteins Fluid and electrolyte imbalance
Electrolytes Nutrition
Renal function test Resection – provides hope for cure especially indicated in
Many of these pts have a longstanding nutritional ca. of the lower 1/3(adenocarcinoma).
deficiency and therefore hemoglobin, plasma proteins Postcricoid carcinoma:
and blood chemistry must all be checked and corrected if
necessary, especially before surgical treatment. It should be treated by R.T. The alternative surgical Rx of
pharyngolaryngectomy with gastric transposition (Oug),
Treatment: colon transposition( Besley), or plastic tube
A gastrostomy should never be carried out in pts with ca. insertion(Stuart) is a very major undertaking associated
esophagus. Unfortunately about 25% of pts who present with a high complication rate.
late are so ill that no treatment is possible other than Carcinoma of the upper 1/3 of the esophagus:
short term measures to reduce suffering. The operative
problem is to remove the tumor and restore continuity by Early diagnosis is very rare and when dysphagia occurs
interposition of stomach jejunum, or colon. Curative there are often malignant glands in the neck or a
treatment should be attempted provided the assessment recurrent laryngeal nerve paralysis, indicating
allows. inoperability. The only treatment is then possible is R.T.

Asses operability Carcinoma of the middle 1/3:

Clinical;
97
A growth of the area may become adherent to the aorta, Palliative short circuit operation. Done when the tumor is
venous azygous or left main bronchus. Surgical treatment unresectable. Esophagogastrostomy or esophago-
usually has bad results (complication rate is very high). jujenostomy is done.

Carcinoma of the lower 1/3: Palliative radiotherapy. Patients are too ill to undergo
radical radiotherapy for 4-6 wks but may gain some relief
It may be resected by a partial esophago-gastrectomy from a shorter course.
through a thoraco-abdominal incision through the 8th rib.
Laser treatment. The intra luminal bulk of the tumor can
Indication for radiotherapy: be destroyed by laser therapy to enable pts to swallow
Squamous cell carcinoma- radiosensitive liquids and avoid choking on their saliva .

When the diagnosis is made late with spread Terminal complications:

When surgical results are bad Unresected, the growth causes death in one of the
following ways;
When surgical complication rate is high
Progressive catchexia and dehydration
Palliative treatment:
Pneumonia from perforation into some part of the
The tumor may be inoperable due to; bronchial tree.

General condition of the pt. Erosion of the aorta

Presence of metastasis.

Tumor may be unresectable at thoracotomy or

laparatomy.
PEPTIC ULCER DISEASE:
Palliative procedure should be carried out to enable the The term “peptic ulcer” embraces five types of conditions;
pt to swallow.
1. Gastric
This may be either by; 2. Duodenal
3. Stomal following gastro-jejunostomy
Surgical bypass 4. Lower end esophagus following reflux
esophagitis
Intubation
5. Ectopic gastric mucosa (meckel’s
Radiotherapy diverticulum).
These occur in the presence of acid and pepsin.
Laser therapy. Acute peptic ulcers:
Internal tube through tumor. To allow swallowing saliva Aetiology;
and soft food. The three types of tubes used include;
They are thought to be due to disruption of the gastric
Soultar tube ( coiled Germany wire) mucosal barrier. They occur as multiple erosions and at
least half of the pts give a history of ingestion of drugs like
Celestine tube (armoured rubber tubewith a long tail)
A.S.A or tone of the other nonsteroidal anti-inflammatory
Nottingham (Atkinson tube)- funnel shaped proximally. groups. They classically present with hemorrhage and this

98
is common in older pts with arthritis receiving the above  Correct dietetic irregularities to prevent
mentioned drugs recurrence or chronicity.

 Drugs Complications:
 A.S.A
 Steroids  Recurrence
 NSAID  Chronicity
 Stress  Anemia
 Shock  Perforation
 Curling’s ulcers Chronic gastric ulcers:
 Cushing ulcers.

Pathology:
CHRONIC GASTRIC ULCERS
 Acute peptic ulcers are usually multiple
(in 75% of the cases > 3 of those lesions are Etiology:
present.
 They can occur in any part of the
stomach. It is associated with the normal acidity or hyposecretion
 In the duodenum they are almost
confined to the first part Atrophic gastritis
 The ulcers are oval/circular in shape and
Usually occurs in a later age group
vary in size from 1-2 mm or more in diameter.
 They are; Constantly associated with smoking especially of
 Shallow cigarettes.
 Punched out
 They don’t invade the muscular Incidence:
coat.when healing occurs peptic ulcers are
Affects 1-2% of the population
unlikely to leave scars.
 Clinical features: Affects both sexes equally.
 They occur frequently
 Short lived attacks of dyspepsia which are Pathology:
not diagnosed and ulcer heals
Usually larger than aduodenal ulcer
 They are recognized when they cause
hematemesis Varies in size but in well established cases it will admit the
 If on the anterior wall of duodenum tip of a finger
perforation occurs.
 Treatment: The floor of the ulcer is situated in the muscular coat of
 If possible remove the cause. the stomach.
 Acute peptic ulcers tend to heal rapidly As it advances the ulcer occupying the posterior wall
with medical treatment (antacids) becomes adherent to and later erodes the pancreas
 Blood transfusion may be required for (chronic perforation).
hematemesis

99
The ulcers situated at the antero-posterior aspect of the  Endocrine: Emotional effects as well as
stomach can penetrate the liver while a saddle shaped physical stress are hormonally transmitted to the
ulcer situated on the lesser curve can, and often does, stomach via the pituitary adrenocorticoid axis.
penetrate both the liver and the pancreas. Specific endocrine disorders which may be
associated with severe or intractable ulceration
As with duodenal ulcer, gastric ulcers tend to occur in the include;
non acid secreting mucosa at the boundary with the body  Zollinger Ellison syndrome- this is where a
of the stomach. This area is much smaller than the area of non –beta cell tumor secreting “gastrin” occurs in
chronic gastritis which is the precursor of chronic gastric the pancreas.
ulcer.  Multiple adenoma syndrome- This is
Microscopic examination: where adenomas occur in the pituitary, adrenal,
pancreatic and parathyroid glands.
The microscopic examination of chronic gastric ulcer is  Hyperparathyroidism.
similar to that of chronic duodenal ulcer.  Infection: Helicobacter pylori, a
spirochaete bacteria which exists in the
NB:
duodenum deep to the mucosal layer. It has the
Chronic duodenal ulcers never become carcinomatous ability to split urea with the formation of
ammonia consequently this leads to rise to PH
Chronic gastric ulcers may become malignant. which causes epithelial cellular damage and
ulceration. If the organism is removed by
CHRONIC DUODENAL ULCERS:
antibiotics, metronidazole, the recurrent ulcer
Etiology: rate is reduced.
 INCIDENCE:
 Most pts have gastric hypersecretion of  D.U is rare before the age of 16 yrs
acid.  Becomes frequent as middle age
 Duodenal ulcer pts tend to have a larger approaches
than normal parietal cell mass.  Male to female ratio is 2:1 due to
 Genetic and blood group:- occupation
 There is evidence that chronic ulcers  D.U is found four times more common
occur in families than gastric ulcer in patient under the age of
 Persons of group O are 3 times more 35yrs but after 45 yrs of age it is only one or two
likely to develop P.U than those with other blood times more common.
groups. It therefore seems that the ABO genes  pathology:
may modify the size of the parietal cell mass.  Ulcers, when gastric or duodenal, tend to
 Neurogenic theory: stimulation of the occur in alkaline mucosa.
vagus results in gastric hypersecretion and  A chronic D.U invades the muscular coats
hypermotility. Stress and anxiety and may be a which it tends to penetrate. When a G.U or D.U
cause of duodenal ulcer and if so, may exert their heals, the site heals and is covered by mucosal
via the vagus. scar. Fibrosis, the result of recurrent ulceration,
 Accessory causes: inadequade causes deformities, including pyloric stenosis and
mastication, alcohol, irregular meals, excessive hourglass contracture of the stomach. The
smoking and vitamin deficiency have been duodenal ulcer is nearly always situated in the
blamed. Smoking delays healing and promotes first part and sometimes two “kissing” ulcers are
recurrence of a previously healed ulcer.
100
 present. One on the anterior surface and one on Occurs any time during adult life, but commonly between
the posterior surface of the 1st 3cm of the 25-50yrs. It common in men who otherwise appear
duodenum. An anterior ulcer may perforate, healthy.
while a posterior one carries the risk of
hemorrhage by erosion of a large vessel. Periodicity: Attacks are precipitated by work or worry or
weather. The attacks usually last from 2-6 wks with
MICROSCOPIC EXAMINATION: decreasing intervals of freedom from 1-6 months.

There is nearly always greater destruction of the muscular Pain: It is severe and may curl up the patient. Usually
coat than of the mucosa. The base of the ulcer is covered occurs 1-2 and ½ hrs after food. It is often relieved by
by a thin layer of granulation tissue. The neighboring food and pain is usually known as “hunger” pain and
arteries show evidence of endarteritis obliterans. There classically patient always carries food which he eats at
are no nerves in the floor of the ulcer but always many in frequent intervals. It is also relieved by alkalis, often
the edge. awakens the pt at around 2 a.m but usually absent at
normal waking hours.
Clinical features of chronic gastric ulcer.
Vomiting: rare unless self induced or stenosis has
NB: It is important to record the pt’s history under seven occurred. Regurgitation of burning fluid or sudden
headings: salivation (water brash) + pain deep to the sternum (heart
Patient is usually beyond middle age. Thin because of burn) due to reflux esophagitis are common (1:10).
restriction of diet. They usually appear anemic. Haematemesis and malaena: ratio is 40:60, but
Periodicity: Attacks lasts for several weeks followed by sometimes together are rather more frequent than in
interval of freedom from 2-6 months. G.U.

Pain: epigastric, may occur immediately or any time up to Appetite: good but tries to avoid solid foods during
2hrs after food. attacks

Vomiting: Is present in 50% of cases. It reliefs pain and Diet: usually don’t discriminate until they are advised to
may be self induced avoid fried foods.

Hematemesis and malaena: at some time 30% of the pts Weight: no loss in wt (become plump).
bleed. Ratio of hematemesis to malena is 60: 40 On examination, pain is localized deep tenderness in the
Appetite: good but patient is afraid to eat right hypochondrium.

Diet: pt learns to avoid fried foods, stews, and curries. SPECIAL INVESTIGATIONS:
Milk, eggs and fried fish are the stapple food. Barium meal: I t is usually conclusive. In the lesser
Weight: They usually lose wt. curvature, gastric ulcer will show a niche ( a small hollow
place) projecting from the usually smooth outline. In D.U
On examination: There is frequent deep tenderness in the it will demonstratean ulcer crater filled with barium, a
midline of the epigastrium, a few inches above the positive evidence of an active ulcer. Appearance of pyloric
umbilicus. stenosis and hourglass appearance.

Clinical features of chronic D.U: Blood studies: HB may show evidence of chronic blood
loss.

101
Gastric function studies: Active duodenal ulcer disease is associated with increased
gastric acid secretion and the pain of D.U arises from the
Peak acid output ( pentagastrin): increased levels are contact of acid with the lesion.
associated with increased acid secretion.
Therefore the control of acid secretion is the logical
Insulin test (Hollander): insulin given to patient who has treatment. Spontaneous healing of D.U within 6wks is
had vagotomy done should show no increase in acid common and the aim of treatment is the abolition of pain
production. Test is valuable postoperatively. during the healing phase.
Chew and spit: To stimulate the vagus nerve. An N/G tube Antacids are helpful in the immediate relief of symptoms.
is passed and pt given food to chew but does not swallow Magnesium hydroxide mixture (120 ml per day) will
but spits it into a receiver. The stomach is aspirated and neutralize gastric acid but are not acceptable because of
contents analysed for the concentration of acid. the incidence of diarrhea.
Gastroduodenoscopy: H2 receptor antagonists: At the parietal level acid
TREATMENT OF UNCOMPLICATED GU AND DU secretion is mediated partly by histamine acting on H2
histamine receptors. Such drugs include cimitidine 800mg
Conservative management: nocte and ranitidine 300mg nocte.

If there is no life threatening complication the initial Surgical treatment:

treatment should be conservative (medical). This
therefore .means that there be collaboration between the Indications for surgical treatment;
surgeon and physician. The aim of conservative Intractable pain or recurrence of pain with frequent loss
management is to relief symptoms. Since gastric acid is of work, failure to respond to adequate medical
the main provocative factor, the control of acid secretion treatment.
is the essential therapy. The introduction of drugs which
selectively and specifically block acid secretion has Complications- E.g. pyloric stenosis, hourglass deformity,
increased the effectiveness of conservative therapy. The perforation or bleeding.
drugs don’t alter the natural history of the chronic
disorder. Ulcers which have lasted more than 5yrs are unlikely to
heal.
Chronic gastric ulcer:
In gastric ulcers
Once the lesion has been confirmed as benign,
symptomatic treatment is instituted. Although secretion Billroth (partial gastrectomy), vagotomy
of acid may be subnormal, H2 receptor blockade with In duodenal ulcers:-
cimitidine or ranitidine will secure healing in more than
half the patients in a period of 6 wks. Provocative agents Vagotomy (vagus nerve section) with gastric drainage.
should be avoided including chemical irritants such as Vagotomy reduces hypermotility and hypersecretion of
aspirin, corticosteroids, NSAIDS, and alcohol. Cigarette the stomach.
smoking should be stopped.
Vagotomy causes;
Chronic duodenal ulcer:
Reduced gastric secretion

Reduced gastric motility

102
Gastric stasis During the early stages of peritoneal irritation the pt is;

Episodic diarrhoea Pale, anxious and loaths more

Complications of p.u; Temperature may be subnormal

Acute complications- Pulse may be raised

Perforation Abdomen is held still, moving little or not at all with

respiration.
Hematemesis and or malaena (hemorrhage)
Slow perforation:
Intermediate: - Residual abscess
Pain may less severe and
Chronic
Generalized with definite tenderness
Stenosis, (pyloricstenosis, tea pot deformity and hourglass
contracture) Guarding and rigidity are equivocal

Penetration into neighboring viscera, notably the Bowel sounds persist

pancreas
Right iliac fossa pain due to some small amount of fluid
Carcinoma (gastric ulcer) tracking down the paralytic gutter and may simulate
appendicitis. It is important to establish the site of the
PERFORATED PEPTIC ULCER: pain.
Sex ratio is m:f 8:1 Diagnosis:
Age. Highest incidence is between 45 and 55 yrs Plain abdominal x-ray with the patient erect will show a
Perforation is common in the anterior surface of the translucent area beneath the right cupora (round part or
duodenum. Perforation is less frequent on the anterior dome) of the diaphragm in 70% of the cases.
surface of the duodenum usually near the lesser Aspiration of the abdominal cavity will reveal bile stained
curvature or the pyloric antrum. There is long history of fluid which is alkaline to the litmus.
peptic ulceration (80%). But there is no such history in 20
% of the cases, it is a “silent chronc ulcer” that perforates, Treatment:
especially those pts on cortisone treatment. In this case
the perforation is sudden in occurrence. The gastric or NB: don’t give morphine to the pt because it causes
duodenal contents escape through the perforation into spasms of the sphincter of Oddi.
the peritoneal cavity and this leads into peritoneal This is a surgical emergency
irritation (peritonism). This is when the pt cries out in
agony. The peritoneum reacts to the chemical irritation by Admit the pt
secreting peritoneal fluid copiously and this gives relief of
Resuscitate the pt by
pain for a short time. This reaction lasts 3-6 hrs and is
followed by diffuse bacterial peritonitis. Giving i.v fluids
Clinical features of perforation;
N.G. tube suctioning
Massive perforation
103
Antibiotics Haematemesis due to chronic P.U

Prepare for surgery as soon as the general condition of Bleeding is slight due to trauma from solid food
the pt permits by;
Occurs frequently from all chronic P.Us
Getting an informed consent
Bleeding is demonstrated by finding traces of blood
Blood for grouping and cross matching during gastric analysis and occult blood in stool There is
increased risk with advancing age due to arteriosclerosis
Premedications and erosion of an artery in the base of the ulcer
Laparatomy in theatre and the perforation is closed with The vessels involved occasionally are splenic or
interrupted sutures gastroduodenal artery.
In case of G.U biopsy is taken for histopathology Hematemesis due to acute P.U.
Perotneal toilet (lavage) May be due to solitary or multiple erosions all over the
Continue with NG tube suctioning stomach

Drainage is left in situ. Diagnosis is gastroscopy

Antibiotics Should be treated conservatively

Breathing excercises All drugs should be withdrawn

CAUSES OF HEMATEMESIS AND MALAENA: I.V cimitidine 300mg bd or QDS if the renal function is
normal may control the bleeding and is very useful in
Differentials: stress ulcers.

Chronic peptic ulcers-65% of cases MALLORY-WEISS SYNDROME:

Acute peptic ulcers and The patient is usually a male of over 50yrs and has a
prolonged vomiting bout often after inhibiting (stopping)
multiple erosions- 30
alcohol. After vomiting gastric contents, he suddenly
Esophageal varices starts vomiting blood profusely and persistently and
becomes exhausted. As a result of straining and retching a
Ca stomach longitudinal tear of the mucosa just below the cardiac
occurs and gives rise to the sudden onset of
Mallory Weiss syndrome
hematemesis.the violent vomiting is sometimes due to
Peptic ulcer in Meckel’s diverticulum migraine or vertigo (dizziness, fear).

Purpura Diagnosis:

Hemophilia From history

Pernicious and other anemias Confirmed by gastroscopy

Eller’s Danlo’s syndrome-5% In over 90 of the cases they respond to;

104
To secretion and hence poor peripheral perfusion. Maintain a well
charted ; pulse chart,
;lood transfusion
Urinary output and Bp.
Pitressin
Note that Hb estimation after severe hemorrhage will
10% may require laparatomy and repair of the incision. remain unchanged and may not be helpful at this time.
General clinical features of haematemesis and malaena: After 3 hrs the Hb then may change and its estimation
may be helpful.
Initially;
Signs of severe haemorrhage:
Faintness
Cold nose
Sweating
Increasing pallor
Pallor
Ncreasing
Occasionally pt collapses
Pulse ratei
Afterwards
Beads of sweat on the fore head
Effortless haematemesis
Clammy palms of the hands
Vomiting coffee ground material or bright red blood
Blindness is rare and a serious complicationo
Later
Factors to be considered on whether to treat the pt
Black tarry stools (malaena) or red clotted blood may be conservatively (medical) or surgical:
passed per rectum.
There should be consultation between the surgeon and
Treatment of haematemesis and malaena: the physician.

On admission; Response to treatment. If the is under adequate

conservative treatment and is not responding then
Collapsed pt is laid flat with a pillow under the head and
surgery is indicated.
foot of bed raised.
Chronicity of the ulcer-the shorter the history the better
Cover him to keep him warm depending on the climate of
the pt’s response to conservative management.
the day
Age- 70% of cases that bleed are >45yrs and surgery is
If evidently restless i.v. morphine 15mgand repeated 4hrly
increasingly necessary after this age.
PRN
Ingestion of drugs- if the pt has been taking drugs which
Plasma expanders are started e.g. haemacel to correct
predispose to gastric ulceration like A.S.A, NSAID, or
hypovolaemia.
cortisone, then their withdrawal will improve the pt’s
NB: sometimes the pt can be given uncross matched condition conservative
blood if the condition is desperate to save life. The main
Condition of the arterial tree- presence of arteriosclerosis
objective is to prevent irreversible shock due to
suggests evidence of recurrent bleeding.
hypovolaemia which may lead to reduced cardiac output
105
 Malignant change- only occurs in gastric ulcers and is rare
in the lesser curvature.

Tea[pot stomach- shortening of the lesser curvature due

to cicatrisation around a long standing gastric ulcer

CARCINOMA OF THE STOMACH:

Conservative management:  “This is the captain of death in men”
Bed rest  It is more common in men than females
 No age is excempt from early adult life to
Blood transfusion senility.
 The highest incidence is between 40-60
i.v morphine to allay anxiety
yrs of age.
H2 receptor antagonists i.v  Occurs three times as many males as
females (3:1)
Chest physiotherapy to prevent pulmonary complications

Prophylactic antibiotics to prevent pulmonary

complications Etiology:

Light diet The premalignant conditions and risk factors include;

Routine treatment for peptic ulcers  Gastric polyp

 Pernicious anemia
NB: Gynaecomastia has been reported in association with  Postgastrectomy
high doses of cimitidine.  Posttruncal vagotomy
 Longstanding dyspepsia
Surgical management:
 Gastric ulcer
If the gastric ulcer is the source of bleeding then  Genetic (possible)
gastrostomy and underrunning of the offending vessel is  Ingested carcinogens
all that is required. Reason is to limit the scale of  Substances which cause irritative gastritis
operation in an already very sick pt. e.g. spirit
 Cigarette smoking
Rarely gastrectomy may be required
Site:
Vagotomy and wide pyloroplasty may be carried out.
The most common site for neoplasms is in the pre-pyloric
Chronic complications of P.U: region but when carcinoma follows pernicious anemia it is
more likely to be fundal and polypoid.
Pyloric stenosis- due to cicastration from D.U/juxtapyloric
ulcer. Pathology:

Also in ca situated at/ near the pylorus Macroscopically;

Hourglass stomach occurs exclusively in women - There are five macroscopic types that are
recognized
Penetration of pancreas

106
 - Cauliflower like growth with sharp  Gastric distension- inability to take
defined edge whose surface is indurated and later normal meals, vomiting
ulcerated.  Anorexia leading to wt loss
- An ulcer with an irregular indurated  Anemia, tiredness, weakness and pallor.
edge.  Persistent pain – no response to
- Colloid carcinoma treatment and noperiodicity.
- Scirrhous localized or diffuse (leather
bottle) with thick wall. Clinical types:
- Carcinoma secondary to a chronic ulcer.  New dyspepsia:
- Early gastric cancer is classified into;
- Type I – protruded tumor which After 40yrs with vague persistent indigestion
protrudes above gastric mucosa
 Obstructive type: ca of the cardia which
- Type II – Superficial inconspicuous
presents with, fullness, belching, and vomiting
unevenness to the surface
(gastric output obstruction)
- Type III – excavated tumor which is
 Insidious onset: especially in men. He
centrally ulcerated and its base may reach the
feels tired and weak with, Anorexia, Anaemia,
muscularis propria.
Asthenia (3As).
Microscopically;  Lump: incidental discovery of a lump in
the epigastrium with no any other symptom
Early gastric ca is restricted to the sub mucosa  Silent: ca of the body of the stomach may
irrespective of lymph node metastasis be silent but give rise to features in other organs
The prognosis is excellent and the 5yr survival rate is 90% such as ;

The growth is usually columnar celled but cubical and Obstructive jaundice due to secondary deposits to the
even squamous cells neoplasms arise near the esophageal liver
orifice. Ascites from carcinomatosis of the peritoneum
Spread: Krunkenberg tumors- tumor of the ovaries due to
 Direct spread to the neighboring metastasis
structures Phlebothrombosis of superficial veins e.g. legs –
 Lymphatic spread by both emboli and Trosseou’s sign, left supraclavicular fossa- Troisier’s sign.
permeation.
 By blood stream Investigations:
 Trans peritoneal implantation- ca cells
sometimes pass from the stomach into the
peritoneal cavity. Hb- 45% of the cases have anemia
Clinical features: Stool for occult blood- present in 80% of the cases
This disease is difficult to diagnose early because; Radiology- cxr, barium meal
 It’s diverse presentation Gastric secretory studies
 Symptoms appear late
Gastroscopy
107
Exfoliative cytology  Meckel’s diverticulum
 The basement (i.e. the pelvis)
Treatment:  Salpingitis
Depends on the stage at which it has been discovered;  Ectopic gestation
 Ruptured ovarian follicle
 If early gastrectomy  Twisted ovarian cyst
 If late palliative  Diverticulum of the caecum
 The backyard (the retroperitoneal
structures)
Prognosis: -poor.
 Ureteric colic
 Acute pyelonephritis
ACUTE ABDOMEN DDX:  Electrical installation( central nervous
system)
 There are many conditions which can  Pre-herpetic of the 10th and 11th dorsal
present as acute abdomen. It is with this reason nerves
that it is considered wise to carefully consider  Tabetic crisis
possible diseases of the throat, chest, abdomen,  Other spinal conditions
pelvis, the GUT, the CNS and spine.  Oil tank (blood)
 It is for this reason that we should  Abdominal crisis of porphyria
visualize the body as a house and compare the  Diabetic abdomen
seven parts of the house to the appropriate
anatomical regions. Acute appendicitis:
 Attic (the nasopharynx and throat)
This is one of the commonest requiring surgery. It is
 Tonsillitis- Abdominal colic may follow
common in the second and third decade of life. It is rare
swallowed exudates (tonsil tummy)
in young children. Common in males than females.
 Pneumonia and pleurisy- especially at the
right sided abdominal pain. Etiology:
 They are associated with an increased
respiratory rate and the pain prevents deep Luminal obstruction in 80% of the cases. The obstruction
inspiration. is usually due to ;
 The upper storey- (i.e diaphragm to the  Faecolith
level of the umbilicus)  Strictures and
 Perforate peptic ulcer  Exceptionally a foreign body or
 Acute cholecystitis  Round worm or thread worms
 Cyclical vomiting
 The ground floor (i.e umbilicus to the Less common:
level of the pelvis)
 Appendicitis  Stricture or adhesions or kinking
 Enterocolitis secondary to previous inflammation
 Non specific mesenteric lymphadeinitis  Caecal or appendicular tumors
 Intestinal obstruction  Abuse of purgatives particularly castor oil
 Regional ileitis by pts with “stomach aches” leading to violent
 Ca of the caecum peristaltic action which results, favors and often
determines, perforation of an inflamed appendix.
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Pathology: About two of every three cases of acute appendicitis
belong to this group. The obstruction can be:
The severity of appendicitis lies in the frequency with
which the peritoneal cavity is infected from this focus by; In the lume- faecolith, foreign body, parasite

Perforation In the wall – usually inflammatory but may be due to a Ca

of the caecum
Transmigration of bacteria through the appendicular wall.
Outside the wall- adhesions or kinking
The omentum attempts to wall off the spread of
peritoneal invasion, while violent peristalsis from ingested Of these the most common is the faecolith. Fibrosis of the
purgatives tends to spread it. If the inflamed appendix lies wall from previous attacks of appendicitis can cause
freely dangling, the risk of peritonitis is increased and appendicitis by causing narrowing the lumen and
should early perforation occur diffuse peritonitis is promoting faecolith impaction. Obstructive appendicitis
inevitable. There are two types of acute appendicitis. proceeds more rapidly and more certainly to gangrene or
perforation. Usually within 12-18 hrs the appendix distal
non obstructive acute appendicitis: to the obstruction becomes gangrenous. Perforation
An inflammation usually commences in the mucous occurs most often at the site of an impacted faecolith
membrane, les often in the lymph follicles and can before protective adhesions have had time to follow.
terminate in one of the following ways: Subphrenic and pelvic abscesses are common later
complication if the pt survives the initial peritonitis.
Resolution
Clinical features:
Ulceration
Age incidence:
Suppuration
Rare before the age of 2yrs
fibrosis
Becomes increasingly common during childhood and
gangrene adolescence

Once the infection reaches the loose submucous tissues it Maximum incidence is 20-30 yrs but no age is excempt.
progresses rapidly. The organ becomes rigid, dusky red,
and hemorrhage occurs into the mucous membrane. The General features:
blood supply to the distal part of the appendix is often During the first 6hrs there is no change in temperature or
affected because at this point the artery is liable to pulse rate.
occlusion by inflammation or thrombosis. This may lead to
gangrene of the tip. Non obstructive appendicitis may After that there is slight pyrexia of 37.2-37.7degrees
progress slowly to form localized peritonitis. In many centigrade with increased pulse rate of <.> 80-90/min.
cases the infection never progresses beyond the mucous
lining (i.e catarrhal inflammation). Complete healing never In90% of the cases the WBC is greater than 10,000 cells
occurs. Fibrosis of the tip and shrinking occurs and is per mm3 (10x10power9)liter.
usually a classical finding in recurrent appendicitis. Specific features:
Obstructive acute appendicitis Abdominal pain: it shifts. Usually at the umbilicus,
epigastrium or may be generalized. This is visceral pain
and vague, and is due to distension of the appendix. Pain
109
is constant in non obstructive appendicitis but colicky in Retrocaecal- Rigidity is absent (silent appendicitis)
obstructive. because the caecum is filled with gas and prevents
pressure from examining hand to reach the inflamed
Upset of gastric function: appendix.
Anorexia Acute appendicitis in the aged: Gangrene and perforation
Nausea occur much more frequently because they have a lax
abdominal wall. They also like self medication with
Infrequent of short duration and stops as soon as the laxatives.
stomach is empty
Obese pts may harbor a gangrenous appendix with little
Complication in majority of cases but occasional diarrhea evidence of its existence. Obesity diminishes or obscures
occurs all local signs of appendicitis

Local tenderness at the site of the appendix. The clinical picture may mimic sub acute intestinal
obstruction and an enema if given will spread peritonitis
As soon as the pain has shifted, there is localized
more widely.
tenderness at the Mcburney’s point or elsewhere as is
determined by the site of the appendix. This tenderness Acute appendicitis in pregnancy: the appendix shifts to
may be confined to the pelvis and therefore rectal the upper abdomen favoring peritonitis. The nearer to
examination must be done in every case of lower term thereafter the danger even without perforation.
abdominal pain. After 6 months there is a maternal mortality of 20% (ten
times greater than in the first three months). As
Rigidity in the right iliac fosa
pregnancy advances the pain becomes higher and more
As time passes, accurate localization becomes more lateral. Acute perforated appendicitis causes abortion or
difficult as muscular rigidity becomes evident in addition initiates premature labor in 50% of the cases. While in
to the tenderness. A positive release sign is an indication acute non perforated appendicitis reduces the figure to
of an acutely inflamed appendix adjacent to the parietal 30%.
peritoneum.
Treatment of acute appendicitis:
Obstructive acute appendicitis:
Appendicectomy- By use of Grid iron incision. An incision
Clinical features and their frequency occur much more made at right angles to a line joining the anterior iliac
quickly and early diagnosis and treatment are accordingly spine to the umbilicus, its centre being at the Mcburney’s
much more urgent. Onset is abrupt and there may be point.
severe generalized abdominal colic from the start. The
Antibiotics
temperature can be normal. Vomiting is common, so that
the clinical picture mimics acute intestinal obstruction. Analgesics
The diagnosis becomes clear when abdominal x-ray shows
that the typical signs of obstruction are absent. If diarrhea Complications of acute appendicitis:
is present, gastroenteritis may be suspected , but a pelvic
appendix must be remembered. Ultra sound will help in
making a diagnosis. chronicity

Specific features according to position. Perforation

110
Peritonitis peritoneum, supported by a small amount of areola
tissue, lies a network of lymphatic vessels and rich
Appendicular abscess plexuses of capillary blood vsls from which all absorption
Complications after appendicectomy: and exudation must occur. Normally only sufficient
peritoneal fluid, which is pale yellow fluid containing
Early: lymphocytes and polymorphs is secreted to ensure that
more mobile viscera glides easily.
Ileus
Nearly all types of peritonitis are due to bacterial invasion.
Residual abscess( local, pelvic, paracolic or subphrenic)
To an extent that when the term “peritonitis” is used
Intestinal obstruction from adhesions without qualification, bacterial peritonitis is implied.

Wound sepsis Bacteriology:

Faecal fistula Bacteria from the alimentary canal usually caused by two
or more strains. The commonest are, E. coli, anaerobic
Pyelephlebitis and aerobic spores, the bacteroides.

Postoperative thrombosis and embolism Less frequently, cl. Welchi, staphylococci, klebsiella
pneumonia
Actinomycosis
Many of the strains of E. coli, bacterpoides, and Cl. Welchi
Pulmonary complications like pulmonary collapse or
produce toxins which cause severe illness or death when
pneumonitis
they invade a large absorptive area (endotoxic shock).
Late complications:
Bacteroides:
Intestinal obstruction from adhesions
Are gram-ve non sporing
Incisional hernia
Predominant in the lower intestine
Sterility In females from frozen pelvis
Are slow to grow on culture media unless there is
Acute peritonitis adequate Co2 tension in the anaerobic apparatus.

Introduction: They are resistant to penicillin and streptomycin

The peritoneum is divided into two parts; the visceral They are sensitive to metronidazole, clindamycin and
(surrounding the viscera) and parietal (lining the rest of lincomycin.
the cavity). The parietal is richly supply with nerves and
Bacteria not from the alimentary canal:
when irritated, causes severe pain acutely localized to the
affected area. The visceral is poorly supplied with nerves Examples include;
and pain arising from there is vague and badly localized.
The peritoneal cavity is the largest cavity in the body Gonococcus
nearly equal to that of the skin .This serous membrane is Beta hemolytic streptococci
composed of flattened polyhedral cells, one layer thick
resting upon a thin layer of fibroblastic tissue, the two Pneumococci
layers constituting the peritoneum. Beneath the
111
Mycobacterium tuberculosis Immune deficiency – may be due to drugs (e.g. steroids),
disease (e.g. AIDS) or infancy or old age.
In young girls and women, pelvic infection via the
fallopian tubes is responsible for high level of non Clinical features of peritonitis:
alimentary infections e.g. gonococcus and streptococcus,
but bacteroides is also found normally in the female Localized features;
genital tract. If localized the initial feature s are those of the causative
Routes of infection: lesion

Direct infection Fever

Via perforation of the gastrointestinal canal Increased pulse rate

Through penetrating wounds of the abdominal wall Abdominal pain and associated vomiting

Operative e.g. drains, dialysis tubes, foreign material Guarding and rigidity of the abdominal wall over the area
of the abdomen which is involved, with a positive release
Blood stream- part of general septicaemia sign.

Even an initial sterile peritonitis (e.g. intraperitoneal If inflammation arises under the diaphragm, shoulder tip
rupture of the bladder or hemoperitoneum) soon (phrenic) pain may be felt.
becomes infected by transmigration of organisms from
the bowel. DIFFUSE (GENERALIZED ) PERITONITIS

Natural factors which tend to cause diffusion of Initial phase:

peritonitis: Severe pain made worse by moving or breathing
Perforation of an inflamed appendix or other hollow Vomiting may occur
viscus early before protective mechanisms have
mobilized, there is a free gush of intestinal contents into Pt lies still
the peritoneal cavity which spreads over a large area
Tenderness and rigidity on palpation if anterior abdominal
almost instantly.
wall
Ingestion of food or water which stimulates peristalsis
Tenderness and rigidity are diminished or absent if the
which hinders localization. Violent peristalsis occasioned
anterior abdominal wall is not affected, e.g. pelvic
by administration of purgatives or an enema promotes a
peritonitis
widespread distribution of an infection that would
otherwise have remained localized. In pelvic peritonitis the pt may complain of urinary
symptoms like tenderness on rectal or vaginal
When the virulence of the offending organism is so great
examination
as to render the localization of the infection difficult or
imposible. Pulse rises progressively
In children the omentum is short Infrequent bowel sounds which cease with the onset of
paralytic ileus
Rough handling of localized collection e.g. appendix mass
or pericolic abscess. Intermediate phase
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May dissolve so that; Blood indicates intraperitoneal bleeding

Pain and tenderness diminishes leaving a silent and soft If aspiration fails, a small amount of physiological saline is
abdomen introduced, followed with few minutes, by a repeat
aspiration which may produce fluid of diagnostic value.
The pulse slows Abdominal X-ray may show free air or dilated gas filled
The condition may localize producing one or more loops of bowel with multiple fluid levels.
abscesses with overlying swelling and tenderness. Treatment:
Terminal phase: General care of the pt;
If there is no resolution or localization the abdomen I.v fluids- pts are usually hypovolaemic and with
remains silent and increasingly distends electrolyte imbalance. Plasma proteins are also depleted
Circulatory failure ensues through the inflamed peritoneum.

cold and clammy extremities Ng tube to aspirate the stomach contents until the
paralytic ileus is restored and abdomen is soft and not
Sunken eyes tender and bowel sounds have returned.

Dry tongue Antibiotics- to prevent multiplication of bacteria and the

release of endotoxins. Combine parenteral Ampicillin,
Thread and irregular pulse
gentamycin and metronidazole.
Withdrawn and anxious
A fluid balance chart must be started and maintained
The pt finally lapses into unconsciousness
Analgesics – Nurse pt on a sitting position ( morphine in
Diagnosis: small doses)

The most important is careful history and physical Physiotherapy to prevent D.V.T and pulmonary embolism.
examination i.e.
Neutralization of local cause:
Tenderness,
If the cause is treatable by surgery, operation must be
Guarding and rigidity, carried out as soon as the pt is fit for anaesthesia. This
should be within a few hrs. this applies to conditions like
A distending and silent abdomen perforated appendicitis, diverticulitis, salpingitis, or in
cases of primary peritonitis of streptococcal or
Other investigations may give doubtful diagnosis and even
pneumococcal origin, conservative treatment is the
confuse it .
procedure of choice(you should be certain with the
Full hemogram may show leucocytosis diagnosis.

Peritoneal diagnostic aspiration from each quadrant of Peritoneal lavage:

the abdomen
After dealing with the cause by surgery, the peritoneal
Bile stained fluid indicates perforated P.U cavity should be explored by a sucker and mopped dry
until the purulent exudates is removed. Large volumes of
Presence of pus indicates bacterial infection (peritonitis) saline are effective in this respect.
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Prognosis:  Calcium bilirubinate
 Calcium phosphate
The advent of modern therapy has reduced mortality due  Calcium carbonate
to diffuse peritonitis to 10%. Lethal factors include;  Calcium palmitate and proteins
Bacterial toxaemia - Usually they are multiple and faceted
c) Pigment stones;
Paralytic ileus - Common in the far east
- Composed almost entirely of calcium
Bronchopneumonia
bilirubinate
Electrolyte imbalance - Usually small, black and multiple
- Some are hard and coral like while others
Renal failure are soft.

Undrained collections Incidence of gall stones:

Bone marrow suppression - A Fat, Fertile, Flatulent,Female, of Fifty is

a classical sufferer of symptomatic gallstones.
Multisystem breakdown.
- However;
Complications:  It occurs in both sexes
 It is often in much early age and even in
All complications of severebacterial infection are possible, childhood.
but the special complications of peritonitis are as follows;  Is more common old age.
- Stones are rarer in Africa and South India.
Acute intestinal obstruction due to adhesions

Paralytic ileus
Causal factors:
Residual abscesses, subphrenic, appendicular, pelvic.
Metabolic – Cholesterol is insoluble in water but bile salts
GALLSTONES (CHOLELITHIASIS):
render it into solution. When cholesterol is in excess in
They are the commonest billiary pathology. relation to bile acids and phospholipids it allows
cholesterol crystals to form. Such cholesterol is termed as
Classification: “supersaturated”or lithogenic. Cholesterol (bile) increases
with age and raised in women particularly those on oral
They are classified according to their chemical
contraceptives and the obese.
composition.
Infection: - The role of infection is unclear because bile
a) Cholesterol stones;
from pts with gallstones is sterile. However organisms
- They comprise of 6% of all gallstones
have been cultured from the center of gallstones.
- Consist almost entirely of cholesterol
- Are often solitary Bile stasis: - The contraction of the gall bladder is reduced
b) Mixed stones; by the following factors which in turn cause stasis of the
- Account for 90% of all gall stones in the bile; estrogen, pregnancy and truncal vagotomy.
western world
- Cholesterol is the major component Pigment stones are seen in pts with haemolysis in which
- Other components include, bilirubin production is increased e.g. hereditary

114
spherocytosis, SCD, thalasaemia, malaria mechanical The cystic duct: is about 2.5 cm long and contains the
destruction of RBCs by prosthetic heart valves. spiral valve of Heister

Gallstones in relation to other disorders: The common hepatic duct is usually less than 2.5 cm long
and is made of a combination of left and right hepatic
Gallstones, diverticulitis, hiatus hernia frequently coexist ducts.
(SAINT’S TRIAD). It is therefore important to find out
which lesion is the cause of the pt’s dyspeptic symptom. The common bile duct is about 7.5 cm long and is made of
the cystic and common hepatic ducts.
Complications of gallstones:
Surgical physiology:
1. In the gall bladder
- Silent stones As bile leaves the liver it is composed of;
- Chronic cholecystitis
- Acute cholecystitis – gangrene, - 97% water
perforation, empyema - 1-2% bile salts
- Mucocele - 1% pigments, cholesterol and fatty acids.
- Carcinoma The liver secretes bile at a rate of 40ml per hr.
2. In the bile duct
Functions of the gall bladder:
Obstructive jaunduice
1. Reservoir for bile
Cholangitis
During fasting, resistance to flow through the
Acute pancreatitis sphincter is high and bile excreted by the liver is
In the intestine: diverted to the gall bladder.

Acute intestinal obstruction (gallstone ileus) After ,feeding, the resistance to flow through the
sphincter of Oddiis reduced, the gall bladder contracts
CHOLECYSTITIS and bile enters the duodenum. These motor
responses of the billiary tract are in part affected by
The gall bladder and the bile duct: the hormone cholecystokinin produced by the upper
Surgical anatomy: intestinal mucosa in response to foodparticulary fats.

The gall bladder is pear shaped 2. Concentration of bile:

Measures 7.5-12.5 cm long By active absorption of water, sodium, chloride and

bicarbonate by the mucus membrane of the gall
Normal capacity is about 50ml, but is capable of bladder. The hepatic bile which enters thgall bladder
considerable distension in certain pathological conditions becomes concentrated 5-10 times with a
corresponding increase in the proportion of the bile
Its wall is made of muscle fibers arranged in criss-cross
salts, bile pigments, cholesterol, and calcium it
manner especially in the neck. Its mucous membrane
contains.
contains indentations of the mucosa (crypts of Lushka)
that stick into the muscle coat. 3. Secretion of mucin about 20 ml per a
day.

115
CHOLECYSTITIS ACUTE CALCULOUS: DIFFERENTIAL DIAGNOSIS:

The gall bladder already affected by chronic cholecystitis Appendicitis

is now acutely inflamed. In 90% of all the cases a stone is
found impacted in the Hartman’s pouch or obstructing Perforated p.u
the cystic duct. In most cases bacteria can be cultured Acute pancreatitis
from the bile or bladder wall. The common organisms
include; Right acute pyelonephritis

E. coli Myocardial infarction

Klebsiella Right lower lobar pneumonia.

Streptococcus feacalis Treatment:

Strict anerobes e.g. bacteroides are rare. Conservative followed by cholecystectomy. 90% of the
cases subside with conservative measures. non operation
Gas forming organisms e.g. clostridia are rare is based on four principles;
Salmonella are also rare. Ng tube aspiration and i.v fluids
Outcome: Analgesics
Mucocele- the bladder is distended and mucous Broad spectrum antibiotics
membrane is lifted away from the sides of the stone. The
stone then slips back into the body of the gall bladder Subsequent management.
leaving mucoid or mucopurulent cyst at the duct.
By the 3rd day when signs and symptoms have subsided
Empyema- alsi known as a pyocele and less common the Ng tube is removed, fluids given orally and a fat free
diet started. Then cholecystectomy performed after the
Perforation which may itself lead to local abscess or acute episode has resolved.
generalized peritonitis.
NB: conservative treatment is not advised when there is
Clinical features: uncertainty about diagnosis. Conservative treatment must
Sudden onset be abandoned if the pain and tenderness spread across
the abdomen and pulse.
Pain at the hypochondrium
Routine early operation- Occasionally early surgery is
Severe nausea and vomiting advocated by some surgeons in acute cholecystitis.
Usually done within 48hrs.
A mass may be palpated if the pt is able to relax
Other causes of acalculous cholecystitis:
Pyrexia of up to 38 degrees celcius
Cholesterosis (straw berry gall bladder)- the interior looks
Tenderness and rigidity at the right hypochondrium like a straw berry, it has yellow specks due to
BOAS’S SIGN – An area of hyperparaesthesia between the accumulation of cholesterol.
9th and 11th ribs posteriorly on the right side. Polyposis

116
Ademyomatosis 6/12. Not all the stones will disappear and may
reccur on cessation of treatment
Cholecystitis glandularis proliferans
PANCREASE:
Typhoid fever.
Surgical anatomy:
CHRONIC CALCULOUS CHOLECYSTITIS:
Pancreas is a Greek word meaning (pan- all,kreas –flesh)
The bladder wall is fibrotic and thickened. Bacteria is
cultured from the bile in less than 30% of the cases. Initially thought to act as a cushion for the stomach.
Chronic acalculous cholecystitis can be;
It weighs 80gm
a) Asymptomatic: - An only incidentally
discovered on laparatomy or autopsy It is retroperitoneal
b) Symptomatic: - The symptoms are due to It is comprised of a head and neck (comprises of 46% of
either , inflammation of the gall bladderwall or the whole organ) moves up and down with respiration
obstruction of the outlet of the gall bladder.
Moves forward and backward with the aortic pulse
Symptoms:
Head lies within the curve of the duodenum
- Rt hypochondrial pain which is episodic
with varying severity. It may be a mere It has the superior mesenteric vsls as a posterior relation
discomfort.
The pancreatic acinar tissue is organized into lobules
- Flatulent dyspepsia. This is a feeling of
fullness after food associated with belching and The main duct ramifies into interlobular and intralobular
heart burn. ducts, ductules and finally acini
Diagnosis: The acinar cells are clamped around a central lumen to
form an acinus which communicates with the duct
1. Usually ultrasonography is the only
system.
investigation
2. Abdominal x-ray following oral Acinar cells form 84% of the pancreas
cystography may reveal the stones. You may give
opiates though they cause Oddi spasms but Duct cells and bld vsls 4%.
counter themwith hyosine butylbromide.
Endocrine cells (Islets of Langerhans)
Treatment:
The rest is connective tissue and fat.
1. Analgesica for biliary pain
PANCREATITIS:
2. Gall bladder should be removed provided
the pt is fit. cholecystectomy is rarely indicated. It is classified on two ways:
3. Dissolution of gallstones- the bile acids,
chenodeoxycholic and ursodeoxycholic acid taken According to clinical presentation
orally will dissolve the stones as long as; they are
According to etiology.
radioluscent and the gall bladder is not non
functioning. This treatment however causes Classification according to presentation;
diarrhea in half of the pts and has to continue for

117
Acute pancreatitis- returns to normal when primary cause others- after biliary or gastric surgery 25%
is removed
after trama e.g. blow to the pancreas
Relapsing acute pancreatitis- returns to normal when the
primary cause is removed. when there is distortion of Ampula of Vater due to P.U or
carcinoma
Chronic pancreatitis- functional or structure damage still
remains even if the cause is removed. as a result of generalized disorders e.g. hypocalcaemia

Classification according to etiology; hyperlipidaemia, D.M and pophyria

Etiology is very vital in relating the natural history of the Rxn to some drugs e.g corticosteroids
disease to prognosis, long term treatment and prognosis. Viral infections like mumps
Billiary tract disease Some autoimmune conditions like polyarthritis Nodosa
Alcoholism Impaired blood flow e.g. after cardiopulmonary bypass.
Post operative The main cause of damage is autodigestion of the gland
Traumatic by its own enzymes. If due to calculi, the stone is passed
through the ampulla of Vater distending or splinting the
Rare causes (mumps, hyperthyroidism, vascular disease) sphincter. The duodenal pressure rises with spasms or
contractions and duodenal contents reflux into the
Idiopathic. pancreas triggering the proteolytic enzymes and the
However the most agreed is the division of pancreatitis inflammation. High level of alcohol consumption alters
into acute and chronic. metabolism in the acinar cells and alters the composition
of pancreatic juice forming protein plugs within
ACUTE PANCREATITIS: pancreatic ducts causing alcoholic pancreatitis.

Incidence: Clinical feature:

About 5 in every 10000 per yr in the UK d) Epigastric pain- frequently severe and
radiates to LT and RT, through the back.
e) Anorexia
-same as in men and women f) Nausea and vomiting
g) Abdominal guarding
In men the peak age is 30-40yrs h) Bowel sounds may be reduced or absent
i) Fever in 60% of the pts
In women the peak age is 50yrs
j) Tarchyopnoea in 50% of the patients
There is a varying degree of edema, hemorrhage and k) Jaundice in 10% of pts
necrosis of the pancreas and surrounding fat. l) Retroperitoneal hemorrhage may be
occurring in 5% of the pts producing a bluish
Causes: ecchymotic discoloration of the flanks (Grey
Turners syndrome) and periiumbilical area
Billiary calculi 50%
(cullens syndrome)
alcoholism 25%
Investigations:
118
 Blood serum for amylase is elevated to above 100 Complications:
somogyl units
Shock due to;
Plain abdominal x-ray may show;
G.i.t fluid loss
An air containing, slightly dilated loop of small bowel
over the upper quadrant called sentinel loop. Retroperitoneal hemorrhage

Mild distension of the transverse colon with collapse Electrolyte imbalance

of descending colon Pulmonary insufficiency(hypoxia) due to;
Pancreatic ultra sound confirms pancreatic edema Retroperitoneal edema
and may demonstrate calculi in the gall bladder or
bile duct. Elevation of the diaphragm

Treatment: Reduced ventilation due to pain

Criteria to identify high risk pts; Rt to left arterial shunting of blood in the lungs

Old over 50 yrs Intravascular coagulation of platelets in the lungs

activating phospholipase A with loss of surfactant and
Wbc> 16000/cm increased affinity of oxyhemoglobin for oxygen.
Fasting blood sugar>200mg/100ml Secondary for edematous pancreatitis
Increased LFT (SGOT)

Haematocrit fall>10% Hypocalcaemia in 3-30% of the cases. Mechanism not

Serum calcium drop< 8mg/100ml fully understood.

Pao2<60mmhg Colonic stricture due to scarring of transverse colon

Main stay of treatment; bed rest, i.v fluids, ng tube Pseudocyst.

decompression. Pain control by opiates preferably Prognosis:
pethidine with an antispasmodic
- Varies with severity- 3-10% for edematous pancreatitis
Attempt to reduce pancreatic secretions with
anticholinergics (glucagon, calcitonin, somatostatin, - 40-50% for necrotizing pancreatitis.
vasopressin, acetazolamide and isoprenoline have been
- 100% for completely necrotized pancreas.
shown to be of no value).
Patients who have recovered from pancreatitis due to
Peritoneal lavage but has got little value
gallstones should undergo
Sphincterotomy if due to calculi
Cholecystectomy and removal of bile duct stones. This
In pts whose condition doesn’t improve after 7-14 days, should be done within a month of the attack before
ultrasound and Ct canning should be done and surgery if another attack develops.
there is evidence of local complication
CHRONIC PANCREATITIS:

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It is characterized by persistence of pancreatic damage c) Ultrasound may be useful in the pancreas
even if the primary cause of pancreatitis has been with cysts and dilated ducts
removed. It occurs more frequently in males than females d) CT scan
(M:F 4:1). Mean age of onset is 40yrs. However
preference in women seems to be increasing. Treatment:

Pathology: 1. Low fat diet

2. No alcohol
The pancreas enlarges and becomes hard due to sclerosis 3. Pancreatic enzyme supplements even in
while the ducts become distorted and dilated with areas absence of steatorrhoea
of ectasis. Calcified stones weighing a few mg to as much 4. Strong analgfor pain
as 200mg may form within the ducts. The changes affect a 5. Control DM if present
large part of or all of the pancreas and the pancreas may 6. Medical management is often able to
be surrounded by sclerosis which can narrow the arteries, sustain life but surgery is occasionally indicated
lymphatics, portal and splenic veins, bile ducts and when the disease is not controlled
transverse colon. The most frequent cause of chronic
pancreatitis is high alcohol consumption accompanied
with a diet rich in proteins and fat. Occasionally, stenosis INTESTINAL OBSTRUCION:
of the ampulla of vater can result to chronic pancreatitis.
This is a common and serious surgical emergency. It
Clinical features: requires early diagnosis and quick relief. It may be
1. Epigastric pain in 95% of all cases classified into two classes;

Reffered to the left in 29% of the cases and through to Dynamic (mechanical) intestinal obstruction;
the back This is where peristalsis is working against a mechanical
Reffered to the right in 44% of the cases and through obstruction. The obstructing lesion may be;
to the back Intraluminal - like impacted feces, foreign bodies
Reffered to the back in56% gallstones.

 The pain is worsened by taking alcohol Intramural (in the wall) – like malignancy or inflammatory
2. Wt loss due to loss of appetite brought by strictures
pain and malabsorption. Extramural (from outside the wal) like intraperitoneal
3. Gross malabsorption bands and adhesions, hernias, volvulus or
4. D.m intussusceptions.
5. Jaundice in 3% of cases
6. A tender epigastric mass may be Adynamic intestinal obstruction. It may occur in two
palpable- may be due to cyst formation or cancer forms;

Investigations: Peristalsis may be absent (e.g. paralytic ileus) or

a) Serum amylase May be present in a non propulsive form (e.g. mesenteric

b) A plain abdominal x-ray- may show vascular occlusion or pseudo- obstruction). In both types a
calcification in 65% of the cases mechanical element is absent.

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DYNAMIC (MECHANICAL) INTESTINAL OBSTRUCTION: Distension involves the central abdomen

The diagnosis is based on the quartet of pain, distension, X-ray shows multiple central fluid levels
vomiting and absolute constipation. Itmay be classified as;
Large bowel obstruction- is characterized by early
- (i) Simple: when there is obstruction to the passage of abdominal distension, mild pain. Vomiting and
contents but blood supply is intact. dehydration are late.

(ii) When there is obstruction to the passage of contents Can be classified according to the speed of onset.
plus obstruction of blood supply of the involved segment.
Acute- usually involves small gut with sudden severe
Can also be classified according to etiology, thus; onset of colicky central abdominal pains, early vomiting,
central abdominal distension and constipation.
Causes in the lumen- gallstones, food bolus fecal
impaction. Chronic obstruction –seen in large bowel obstruction with
lower abdominal colicky at first and absolute constipation.
Causes in the wall- congenital atresia, neoplasm, Distension comes later and involves the periphery.
inflammatory or malignant strictures
Acute on chronic i.o. –it spreads from the large bowel to
Causes outside the wall- strangulated hernias, adhesions, involve the small intestine giving rise to pain and
bands volvulus, intussusceptions. constipation on a variable time scale, later followed by
Can also be classified according to the site i.e. general distension and vomiting.

High small bowel obstruction. The features include; Pathology:

Early, profuse and frequent vomiting leading to The proximal bowel dilates and alters motility.Increased
peristalsis continues for about 48hrs to several days. The
Rapid dehydration due to increased fluid loss more distal the point of obstruction the longer it remains
vigorous. If obstruction is not relieved, a time reaches
Oliguria
when increasing distension causes peristalsis to become
Dehydration and early collapse feebler and finally ceases and the obstructed intestine
becomes flaccid and paralyzed. The intestine below the
Sunken facial features point of obstruction show normal peristalsis and
absorption from it continues for 2-3 hrs following the
Distension +/- in early stages and later limited to
obstruction, until the residue of its contents has been
Epigastric region passed onwards. Then the distal empty intestine become
immobile, contracted and pale, and so remains, until the
Feces or flatus may be passed obstruction has been overcome or death ensues.

Shows no fluid levels Distension:

Low small bowel obstruction: Occurs proximal to the obstrusion and begins immediately
after the obstruction occurs.
The onset is gradual
Two factors account for the distension;
Severe and colicky pains
Gas –
Vomiting comes later and less frequent

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Swallowed atmospheric air (68%) APPROXIMATE ELECTROLYTE CONTENTS OF THE
GUT:
Diffusion from the blood into the lumen (22%)
Fluid Na+ K+
The product of digestion and bacterial activity (10%) Cl-(mmol)
When oxygen and Co2 has been absorbed into the Gastric juice 60 10
bloodstream the resultant mixture is made up of nitrogen 100
(90%) and Hydrogen sulphate.
Bile juice 145 5
Fluid 100
It is made of whatever fluid the pt swallows as well as the Pancreatic juice 140 5
various digestive juices. It is about 8000 ml per 24 hrs . 75
Above the pylorus- 4000 ml =saliva Small bowel 140 5
1500ml 100
= gastric juice Intestinal toxins:
2500ml
Death may occur even if the obstruction is relieved
Below the pylorus- 4000ml = bile + pancreatic juice especially in strangulated obstruction. In unrelieved
1000ml strangulation, toxic substances appear in the peritoneal
= Succus entericus fluid only when the viability of the bowel wall is affected.
3000ml However when the obstruction is relieved, this toxins may
pass on the bowel where the absorption can occur . Most
In i.o, absorption from the gut is retarded but excretion of peobably the toxins are endotoxins from gram negative
water and electrolytes into the lumen bacilli.

Persists and may even be increased. Therefore the causes Strangulation of the bowel:
of dehydration and electrolyte imbalance are;
It occurs when the bowel is trapped by a hernia or a band
Vomiting or involved in a volvulus or intussusceptions cause
progressive interference to blood supply. This is very
Defective intestinal absorption
dangerous and requires urgent treatment before
Sequestration in the bowel lumen gangrene sets in. mesenteric vascular occlusion alone
gives rise to gangrene without mechanical obstruction.
Reduced oral intake
Onset of gangrene:
Severity and speed of clinical manifestation depends on
the level of obstruction. The strangulation compresses the veins causing
strangulation on the bowel, involving the mesentery
It is most severe in high intestinal obstruction which becomes b lue and congested. Severity depends on
the tightness of the constricting agent. When the venous
Later in ileal obstruction
return is completely occluded the color of the intestine
Slow to appear in colonic obstruction. turns from purple to black. At this time due to increased
edema at the point of obstruction, the arterial supply is

122
jeopardized. The peritoneal coat loses it’s glistering The interval depends on the level of obstruction
appearance, the mucous membrane ulcerates and
gangrene is imminent. Loss of blood into the congested As acute obstruction progresses, the character of the
segment is proportional to the length of the segment. vomitus alters. Initially it contains partly yellow or green
from regurgitation of bile.
Distension:
Finally it is faeculent.
For a considerable time the strangulated segment alone
distends, the greatest distension occurring when the Distension :
venous return is completely obstructed while the arterial In early cases of obstruction of the small intestine
supply remains uninterrupted. abdominal distension is often slight, or even absent.
CLOSED LOOP OBSTRUCTION: Centrally placed distension is present in fully established
It occurs when the bowel is obstructed at both distal and cases of obstruction to the ileum.
proximal points. Visible peristalsis may be present
Diagram Borborygmi are sometimes loud enough to be heard by an
It presents with late distension. When it starts turning unaided ear.
gangrenous distension occurs in both ends of the External hernia may be present although the pt is entirely
obstructed segments. If not relieved it results in necrosis unaware of it.
and perforation.
It is important to examine the hernia sites in case of
Clinical features of acute intestinal obstruction: intestinal obstruction. An irreducible external hernia may
Abdominal pain: be present though

It is the first symptom Distension depends on site of obstruction. It is greater if

theobstruction is low down.
Commences suddenly without warning
Constipation:
Becomes increasingly severe, then passes off gradually
only to return at intervals of a few minutes. It is classified as absolute (neither faeces nor flatus is
passed) or relative (when only flatus is passed). Absolute
The attacks of intestinal colicky lasts about 3-5 minutes constipation is a cardinal sign of complete intestinal
spreading all over the abdomen, but mainly localized at obstruction. Some pts may pass faeces or flatus after the
the umbilicus. onset of obstruction owing to evacuation of the distal
bowel contents. The rule that constipation is present in i.o
The pain is associated with increased peristaltic activity does not apply in Ritcher’s hernia, gallstones, mesenteric
When distension occurs the pain becomes diffuse and vascular obstruction and i.o associated with pelvic
constant. abscess, partial obstruction (faecal impaction, colonic ca)
where diarrhea may often occur.
Distension associated with severe pain indicates
strangulation. Other features

Vomiting: Dehydration

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On due to vomiting and loss of absorptive power by the In case of chronic obstruction, this should be preceded by
distended gut an enema.

Dry skin Methods of taking an x-ray:

Dry tongue Plain abdominal- erect ( standing) or lying

Sunken eyes Barium studies – barium meal and follow through or

barium enema
Reduced urine output, concentrated and contains little
Gas shows:
Increased blood urea
The diameter of the viscus is no criteria as to whether it is
Increased haematocrit ( which may cause a misleading small or large intestine.
raised hemoglobin figure)
Obstructed small intestine is revealed by relatively
Hypokalaemia may occur but is rare straight segments that generally lie more or less
Pyrexia indicates septic shock transversely

Abdominal tenderness is localized in ischemic areas. May Obstructed large intestine is disclosed by its haustration
also be due to peritonism or peritonitis if there is (folds that don’t completely traverse the width of the
infarction or perforation. gut). The folds are spaced irregularly and the indentations
are not placed opposite one another. A distended caecum
Clinical features of strangulation: is shown by a rounded gas shadow usually in the right
inguinal fossa. In total i.o no gas shows in the rectum.
All features mentioned above+
Fluid levels:
There may be presence of shock indicating ischemia
Infants < 2yrs a few fluid levels in the small intestine are a
Symptoms are usually sudden and reccur regularly.
normal occurrence.
Strangulation of external hernia presents with tense,
In adults, two inconstant fluid levels must be regarded
tender, irreducible lump which is non expansile on cough
physiological. One is at the duodenal cap, while the other
impulse.
is within the terminal ileum. In i.o it takes a little time for
Obstruction where pain persists even in the absence of gas to separate from the fluid and therefore fluid levels
these symptoms indicates strangulation appear later than gas shadow. When paralysis sets in fluid
levels become more conspicuous and more numerous.
General tenderness and presence of rigidity requires The number of fluid levels is proportional to the degree of
urgent laparatomy. obstruction and to its site in the small intestine. The
nearer the obstruction is to the ileocaecal valve, the larger
Investigations:
the number of fluid levels. Obstruction low in the colon
X-Ray diagnosis: does not commonly give rise to fluid levels in the small
gut but in case of obstruction high in the large intestine
This is by far the most important of all investigations. the phenomenon is not unusual because the ileocaecal
valve is incompetent in many individuals. In obstruction of
5% of the pts may have normal x-ray findings
the large gut, a plain X-ray always shows a large amount
Should be taken with the patient standing and lying down of gas in the caecum.
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Summary of x-ray: Chest physiotherapy

Supine abdominal film Daily cleaning and dressing of the wound

Obstructed small gut is characterized by straight Social toilet

segments
Input output chart
The jejunum is characterized by its vulvae convente which
pass across the width of bowel and are regularly spaced Follow up at the S.O.P.C after discharge.
giving a ladder picture. ACUTE INTUSSUSCEPTION:
Caecum is distended and shows a round gas shadow. It occurs when one portion of the gut becomes
Large bowel shows haustral folds which are irregularly invaginated into another immediately adjacent. It is
spaced. almost always the proximal one invaginating into the
distal.
TREATMENT OF ACUTE INTESTINAL OBSTRUCTION:
Etiology:
Gastrointestinal drainage:- in every case of i.o the first
step is to empty the stomach by a nasogastric tube by Obvious causes in a few cases include;
withdrawing the contents by continuous suctioning. A polyp
Replacement of the fluids and electrolytes – this should A papilliferous carcinoma
be the second step in the management of i.o.
A submucous lipoma
Relief of the obstruction by operation should be done as
soon as dehydration and electrolyte imbalance have been A meckel’s diverticulum
corrected. The main indications for early operation are;
In infants it is generally agreed that;
Obstructed or strangulated external hernia
Idiopathic intussusception occurs usually between the 6th
Internal intestinal strangulation and 9th month of life.

Acute on acute on chronic i.o Change in diet (weaning period)

Supportive: Idiopathic intussusceptions usually commences in some

part of the last 50cm of the small intestine
Continuous Ng tube decompression
The maximum aggregation of the peyer’s patches is the
i.v.f usually plasma expanders, the volume depending on lower ileum
the biochemical disturbance
NB:-
broad spectrum antibiotics should be started early. It is a
must in a healthy pt undergoing large bowel surgery. Mainly found in children 3-9 months

Parenteral analgesics 70-95% is idiopathic in nature

Treatment of pressure points It is associated with the following conditions; URTI e.g
adenovirus or rotavirus, Diarrhoea, UTI.
Vital signs monitoring
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Pathology: DDX:

It is composed of three parts: 1. Acute enterocolitis- has abdominal pain,

vomiting, occ.blood and mucus in stool. Diarrhea
The entering (inner) tube= the proximal segment is the leading symptom.
The returnin (middle) tube=intussuscipiens 2. Rectal prolapsed – the projecting mucosa
is in continuity with perianal skin while in
The sheath ( outer ) tube.=intussusceptum intussusceptions the examining finger may pass
into the sulcus
Intussusceptions is an example of strangulation
3. Henoch’s Schonlein purpura – has a
obstruction as the blood supply of the inner layer is
characteristic rash and abdominal pain.
usually impaired. Ischemia follows depending on the
tightness of the invagination. Treatment:

Clinical features: 1. Barium enema may reduce it.

2. Surgery and manual reduction.
Usually the pt is a fine child of between 6-9 months.

Onset is sudden.
VOLVULUS:
The child has bouts of abdominal pain, drawing up her
legs and screams. Def. It is a twisting or axial rotation of a portion of a
bowel about its messentry. When complete it forms a
He may vomit after onset of the attack but this is not
closed loop of obstruction resulting in ischaemia due
a constant occurrence but after 24hrs it becomes
to vascular occlusion.
obvious.
Types:
The attack occurs after every 15 minutes
accompanied by facial pallor. 1. Volvulus neonatorum
2. Volvulus of the small intestine. It is
Bld plus mucus are passed at late stages (red-currant
usually in the lower ileum and is favoured by the
jelly stools)
presence of adhesions.
Abdomen is not distended
In Africans volvulus involves many feet of small
Lt sausagelike lump may be felt at the lt side of the intestine without causative adhesions occurs
umbilicus commonly. Consumption of a large maize meal and
vegetables seems to to predispose the condition.
Per rectal blood plus mucus on an examining finger
Treatment:
Diagnosis:
1. Untwist the loop if possible.
1) Plain abdominal x-ray usually reveals 2. The causative band must be divided.
increased gas in the small intestine and
sometimes an absence of caecal gas shadow VOLVULUS OF THE CAECUM:
2) Barium enema may show a claw sign if
Occurs when the Rt half of the colon is lax and mobile.
ileocolic intussusceptions. NB- barium may be
therapeutic. It is nearly always in clockwise direction.

126
 It occurs between the of 14 to 88yrs. There is early progressive distension

It is about twice common in females than males. Retching

The first twist obstructs the ascending colon and if the Hiccups
second twist occurs, it obstructs the ileum also.
Late vomiting
It usually presents as acute abdominal pain in 90% of
the pts. Absolute constipation

There is nausea and vomiting in 70% of the cases. X-RAY:

There is constipation in 60% of the pts. Massive colonic distension

There is apalpable tympanic swelling in 25% of the Dilated loop running diagonally across the abdomen,
cases in the Rt iliac fossa but not as a rule. Rt to Lt

A plain x-ray shows loops of gas filled ileum and Fluid levels within the loops
sometimes an especially large gas shadow which can Treatment:
be recognized as the caecum.
Do sigmoidoscopy or
Barium enema shows bird neck deformity and there
will be no barium in the caecum. Pass flatus tube to deflate the gut, if it succeeds
arrange for laparatomy with untwisting. If it fails then
Treatment: urgent laparatomy and untwisting is done. The bowel
Operation- In early stages untwist the bowel may be fixed to the posterior abdominal wall to avoid
reccuring.
Before untwisting the ballooned caecum is deflated
by insertion of needle ACUTE OBSTRUCTION IN A NEWBORN:

Untwisting should be followed by caecostomy to relief It occurs in 1:2000 births

distension Causes:
The caecum should be fixed to the wall to prevent 1. Congenital atresia/ stenosis
reccurence.
Incidence
If the caecum is gangrenous Rt hemicolectomy is
performed. Duodenum 35%

Jejunum 15%

SIGMOID VOLVULUS: Ileum 25 %

It is rare but common in Africans and is predisposed by Ascending colon 10%

high residue diet and chronic constipation
Multiple sites 15%
Clinical features:
a) Duodenal atresia or stenosis
Presents with signs of large bowel obstruction
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Both stenosis and atresia occur in the same Radioactive opaque fluid enema(gastrographin) for
proportion confirmation or reliefing.

This is due to an intrauterine accident occurring If it fails, surgery is done to resect the dilated
during pregnancy such as volvulus intussusceptions or segment( with end to end anastomosis.
strangulation at the umbilical region.
MEGACOLON:
The ischaemic portion is absorbed and disappears
because the fetus is germ free. If the obstruction is A relatively uncommon condition which occurs in two
complete the fetus presents with persistent peristalsis varieties;
with no distension at the Lt upper quadrant. i) Primary or true mega colon
Treatment: Surgery after resuscitation. ( Hirchsprung’s disease or congenital aganglionic
mega colon)
b) Atresia or stenosis of the jejunum or ii) Secondary or acquired mega colon
ileum.
HIRCHSPRUNG’S DISEASE:
Child is born with abdominal distension and presents
within 24hrs of birth (ileal) It is also known as primary or true megacolon or
congenital aganglionic mega colon
c) In jejuna atresia vomiting occurs early
Pathology: - it is characterized by dilatation and
The vomitus contains bile and some meconeum hypertrophy of the pelvic colon which sometimes
extends to the descending colon. It rarely involves the
X-RAY shows air or fluid in late stages more proximal portions of the large intestine. The
MECONEUM ILEUS: pelvic mesocolon is elongated and thickened and its
blood vsls are large and prominent. All coats of the
This is a neonatal manifestation of cystic fibrosis. dilated intestine show gross pathological changes. The
mucosa is chronically inflamed and ulcerated. There
The condition is due to an autosomal recessive
is a terminal constricted, non hypertrophied segment
genetic defect.
of bowel usually involving the anal canal, rectum, and
Meconeum is usually kept fluid by action of a variable part of large intestine. In 9 out 10 cases the
pancreatic enzymes. upper limit of the contracted segment is at or below
the pelvirectal junction. Occasionally the deficiency
The terminal and viscid mucus, results in progressive extends to a higher level. It is in this contracted
insipissation in utero and meconeum obstruction. segment that physiological obstruction lies, and the
dilatation, hypertrophy of the normal colon above is
This may be palpated as a rubbery swelling.
due to absence of peristalsis in the spastic segment.
40% of the cases are associated with complications Surprisingly the anal sphincters retain their normal
like volvulus, atresia, and meconeum peritonitis. physiological function.

There is absence of trypsin in stool or bile. Clinical features:

Concentration of sodium in sweat. Affects 1:4500 births

TREATMENT: Shows familial tendency

128
Common in males than females ACQUIRED OR SECONDARY MEGACOLON :

Symptoms appear within 3 days in 90% of the cases The obstruction is due to suppressed defaecation and
faecal impaction. Dilatation and hypertrophy of an
More frequent in babies with Down’s syndrome otherwise normal large bowel extends to the anal
i) Constipation: canal.
 Infants fail to pass meconeum during the Characteristically there is;
first 2-3 days and occurs only after insertion of
small finger or tube into the rectum Anal fissure
 Subsequently the motions are tooth paste
like and inadequade in amount A spastic sphincter and
 Straining is obvious during passage of Much peri anal soiling
motions
 Diarrhea also occurs and baby may die. As a rule faulty bowel care and training are the
ii) Distention with borborygmy and visible sources of the trouble, and usually, they can be traced
peristalsis are evident. to infancy. The onset however is never from birth.
iii) On per rectal examination, the anus is Sometimes this condition is encountered in the insane
free from fissures with no peri anal soiling. The and the old.
rectum is empty and grips the examining finger
Investigations:
iv) Complete intestinal obstruction occurs
quite frequently within a few days of birth and 1. Per rectal examination- is usually painful
may be fatal. As a rule attacks reccur. Relief is by a and there is a mass felt just inside the anus which
small enema, passing a greased examining finger is contrary to the findings in hirchsprung’s disease
or by spontaneous passage of large stools 2. Sigmoidoscopy- chronic insertion of
sometimes followed by diarrhea. aperients for many yrs to relief constipation may
v) Chest infection may be present due to lead to a dark discoloration of the mucus of the
massive abdominal distension. colon and rectum (melanosis coli)
vi) If the child survives, malnutrition and 3. X-ray – in all cases of megacolon the
stunted growth are obvious dilatation is shown by a barium enema ends at
the anal canal
Investigations:
Treatment:
X-ray following barium enema shows a typical picture;
Conservative should an anal fissure in ano or stricture be
Dilated , normal proximal bowel
present appproperiate treatment must be done. The
A narrower segment the transitional zone and essential thing is anal training so that a regular habit is
developed. It is wise to start with regular enemas and
Undilated distal bowel which is aganglionic portion laxatives.
Treatment: ADYNAMIC INTESTINAL OBSTRUCTION: (Is commonly
Excision of the entire aganglionic segment. No known as paralytic ileus)
reparative operation should be done till the child is Definition: A state where the intestine fails to transmit
18kg I wt and thriving. peristaltic waves due to failure in the neuromuscular

129
mechanism i.e the myenteric plexus (Auerbach) and the This form may occur following fractures of the spine
submucus plexus (meissner). This leads to; or ribs, retroperitoneal hemorrhage,or even the
application of a plaster jacket.
Collection of fluid and gas in the intestine
4. Uremia
Diste
This type is characterized by distension, vomiting and
nsion hiccups. It is seen in renal failure. It may follow
Vomiting prostatectomy.

Absent bowel sounds 5. Hypocalaemia. Low serum potassium

may cause ileus
Absolute constipation (failure to pass flatus and stool)
Clinical features of ileus
Varieties of paralytic ileus;
Suspect ileus if after laparatomy;
1. Postoperative
 May be local or general following 1. There has been no passage of flatus
abdominal operation 2. There is no return of normal bowel
 Not serious if not accompanied by sounds on auscultation
infection Abdominal distension becomes more marked and
 Motility and absorption usually return in drumlike (tympanic) if operation has not been done
about 16hrs ahead of gastric and colonic activity
 Paralysis may be prolonged if there is; Effortless vomiting of large dirty fluids
- hyponatraemia
- Latent renal failure There is no colic nor pain at all

Gastrointestinal suction is continued beyond the point Respiratorydistress from the abdominal distension
at which effective bowel sounds have returned. Pulse rate may increase
2. Infective Prolonged distension may lead toburst
Peritonitis gives rise to prolonged ileus but several abdomen(dehiscence)
factors may be involved. At first peristalsis stops as a X-ray shows gas filled loops of intestine with multiple
normal response to spread but afterwards, bacterial fluid levels
toxins prevent the normal activity of the nerve
plexuses. When the bowel begins to recover the early NB: it is important to note the three types of bowel
weak ( feeble) peristaltic waves may not be able to sounds;
overcome the obstructive effects of the newly formed
1. The normal borborygmy each lasting
adhesions between loops. In this kind of ileus, there
about one second and occurring every 20 -30
are therefore mechanical as well as neurogenic
seconds or so
factors to be considered. Typhoid is associated with
2. The prolonged, rapidly reccuring and
ileus in its acute form.
noisy borborygmy of dynamic obstruction
3. Reflex 3. The high tinkling note “ like bells at
evening pealing” which occur after every 10-30
seconds and is distinctive of paralytic ileus. It is
130
 not due to peristalsis but due to overflow of fluid - The usual type seen in surgical practice
from one distended loop to another. - After initial shock has passed off, there
are signs which point to intraabdominal bleeding
Management: - General signs of internal haemorrhage are
 To prevent paralytic ileus routine NG tube variable;
suction and withholding fluid by mouth after  Increasing pallor
laparatomy until return of normal bowel sounds  A rising pulse
or passage of flatus  Sighing respiration
 Electrolyte balance should be achieved Local signs;
before and maintained during operation
 Remove primary cause  abdominal guarding in 50% (more in the
 Decompress the GIT distension by NG Lt quadrant)
tube(non sphigoted) to allow swallowed air to be  local bruising and tenderness in the Lt
evacuated. abdominal quadrant
 Small doses of morphine or pethidine are  abdominal distension in about 3hrs after
valuable in this cases the accident
 Antibiotic prophylaxis is essential  restlessness Kehr – pain reffered to the Lt
 Gentle handling of bowels shoulder
intraoperatively  shifting dullness in the flunks is often
 Sound technique that reduces possibilitry present
of leakage  rectal examination frequently reveals
tenderness and sometimes a soft swelling,due to
NB: never stimulate peristalsis. The objective is to rest bld or clot in the retrovesical pouch.
the bowel not to stimulate. 3. The delayed type of case:
RUPTURED SPLEEN: After the initial signs have passed off, the symptoms
It should be suspected after any trauma particularly if of serious intraabdominal catastrophe are postponed
there had been direct injury to the upper quadrant of for a variable period even upto 15/7. This time the pt
the abdomen from any angle. Occasionally a fall appears to have recovered from the blow, for
without direct trauma to the trunk can rupture the example a rugby player, may continue to play after a
spleen especially if it is diseased or enlarged as in short rest, only to collapse later from internal
malaria or infectious mononucleosis. haemorrhage. The cause for delayed haemorrhage is
local vasoconstriction with or without formation of
Spleen rupture may be divided into three groups; bld clots which seal the tear. The cause of the
haemorrhage are those of reactionary or secondary
1. Pt succumbs rapidly, never recovers from
haemorrhage.
the initial shock:
- This type is rare Investigation:
- There is tearing of the splenic vsls and
complete avulsion of the spleen from its pedicle 1. Ultrasound examination is the
giving rise to rapid bld loss which can be fatal investigation of choice.
within minutes. 2. Abdominal X-ray may show;
2. Initial shock; recovery from shock; signs of - Obliterated splenic outline
ruptured spleen: - Obliterated psoas shadow

131
 - Indentation of the Lt side of the gastric air - Pernicious anaemia
bubble - Polycytaemia vera
- Fracture of one or more lower ribs on the - Hereditary spherocytosis
Lt side in 27% of the cases) - Autoimmune haemolytic anaemia
- Free fluid between gas filled intestinal - Idiopathic thrombocytopaenic purpura
coil. - Thalasaemia (meditteranean anaemia)
- Elevation of the left side of the - SCD
diaphragm. 3. Metabolic
- Rickets
Treatment: - Amyloid disease
- Immediate laparatomy and splenectomy - Porphyria
is the only step. - Gaucher’s disease
- Bld is evacuated 4. Circulatory
- Abdomen is closed after exclusion of - Infarct- infective endocarditis, mitral
injury to other viscera. stenosis

DDX OF SPLENOMEGALLY: - Occlusion of the portal vein- portal Ht,

thrombophlebitis, neoplastic like ca head of pa-
1. Infective ncreas.
a) Bacterial
- Typhoid and paratyphoid 5. Collagen diseases- still’s disease, Fetty’s disease
- Typhus 6. Non-parasitic cysts- congenital or acquired
- Anthrax
- Tuberculosis 7. neoplastic – angioma, primary fibrosarcoma,
- Septicaemia Hodgkin’s disease and other lymphomas.
- Abscess of the spleen
b) Spirochaetal
- Weils’ disease
- Syphilis HERNIA:
c) Viral
- Infectious mononucleosis Def. A protrusion of a viscus, or part of a viscus,
- Psittacosis through an abnormal opening in the wall of its
d) Protozoal and parasitic containing cavity.
- Malaria
- Trypanosomiasis External abdominal hernia is the commonest form
- Schistosomiasis (spontaneous) hernia. Of these hernias, the inguinal
- Kalar azar hernia is the commonsest (73%)
- Hydatid cyst
- Femoral (17%)
- Tropical splenomegally
- Umbilical (8.5%)
2. Blood diseases
- 15% is left for the rarer form of
- Myelofibrosis
spontaneous hernias.
- Acute leukaemia
- Chronic leukaemia (lymphocytic or Etiology:
granulocytic)
132
Any condition which raises intra abdominal pressure - A portion of the circumference of the
e.g; intestine(Ritcher’s hernia)
- A portion of the bladder or diverticulum
- A powerful muscular effort or of the bladder
- Strain occasioned by lifting heavy wt. - A meckel’s diverticulum( Littre’s hernia)
- Whooping cougfh( in children)
- Chronic cough Classification of hernia irrespective of site;
- Straining on micturition or defaecation
- Intra abdominal malignancy 1. Reducible
- Stretching of abdominal musculature 2. Irreducible (a complication of reducible
because of an increase in contents as in obesity, hernia)
pregnancy. 3. Obstructed (a complication of irreducible
- Fat which separates muscle bundles and hernia)
layers weakens aponeurosis, and favours 4. Inflamed ( a complication of irreducible
appearance of hernia)
- Para- imbilical, direct inguinal and hiatus Reducible hernia;
hernia.
The hernia reduces itself when the patient lies down
Composition of a hernia; or can be reduced by the patient or by another
As a rule, a hernia consists of three parts; the sac, the person. The intestine gurgles on reduction and the
covering of the sac, and the contents of the sac. last portion is more difficulty to reurn than the first.it
impacts an expansile impulse on cough.
i) The sac: it is a diverticulum of peritoneum
consisting of mouth, neck, body and fundus. The Irreducible hernia
neck is usually defined but not so in some direct The contents cannot be returned to the abdomen and
inguinal and many incisional hernias. There is no there is no evidenceof other complications. This is due
actual neck. The diameter of the neck is to adhesions between the sac and its contents or
important, because strangulation is common from overcrowding within the sac. Irreducible without
where the neck is narrow as in femoral and other symptoms is almost diagnostic of an
umbilical hernia omentocele especially in femoral and umbilicalhernia.
ii) The body of the sac: in cases occurring in
infancy and childhood, the wall is thin. In long Obstructed hernia:
standing cases, especially after yrs of pressure the
There is an irreducible hernia containing intestine
wall is thick. The size varies and is not necessarily
which is obstructed from without but there is no
occupied.
interference to the bld supply to the bowel. The
iii) The covering: these are from the layers of
symptoms are less severe and the onset more gradual
the abdominal wall through which the sac passes.
than is the case in strangulation.
iv) Contents: this can be any abdominal
viscus,except the liver, but most commonly are; Strangulated hernia:
- Fluid (peritoneal exudates),
- Omentum (omentocele) The bld supply to the contents is seriouslyimpaired,
- Intestine (enterocele usually small rendering gangrene imminent. Gangrene may occur
intestine but occasionally large intestine or the as early as 5-6 hrs after the onset of the first symptom
appendix) of strangulation. Although inguinal hernia is four
133
times common than femoral hernia, a femoral hernia How to examine for inguinal hernia:
is more likely to strangulate because of
thenarrowness of the neck of the sac and its rigid - The clinician is seated infront of a
walls. standing pt with legs apart.
- The pt is instructed to look up at the
Indirect (oblique) inguinal hernia: ceiling and asked to cough.
- The hernia usually comes down
- This is the commonest of all the hernias. - The examiner looks for the impulse and
- Most common in the young whereas should be able to come out with the following;
direct is common in middle life or after.  Whether the hernia is right or left or
- In early life it is more common on the bilateral
right side in the male because of the deffered  Whether it is inguinal or femoral
descent of the right testis  Whether it is direct or indirect inguinal
- After the second decade the left inguinal hernia
hernia are as common as the right.  Whether reducible or irreducible
- The hernia is bilateral in nearly 30% of  Whether complete or incomplete
cases. There are three types of inguinal oblique  The contents.
hernia i.e.
i) Bubonocele – the hernia is limited to the DDX:
inguinal canal
ii) Funicular – the peocessus vaginalis is In males;
closed just above the epidymis. The contents of - A vaginal hydrocele
the sac can be felt separately from the testis - Encysted hydrocele of the cord
which lies below the hernia. - Femoral hernia
iii) Complete – also known as scrotal. It is - An incompletely descended testis
rarely present at birth but commonly - Lipoma
encountered in infancy. It also occurs in - Spermatocele
adolescence and adulthood. The testes appear to - Abscess
lie within the lower part of the hernia.
In females;
Clinical features of hernia:
- Hydrocele of the canal of Nuck
- It occurs at any age - Femoral hernia.
- males are 20 times affected than females
- pt complains of pain in the groin or Treatment of indirect inguinal hernia:
reffered to the testicles when performing heavy
Surgery is the treatment of choice
work or strenuous exercise.
- Transient swelling may occur (seen and  Herniotomy- the hernia sac is dissected
felt) when pt coughs (in the inguinalregion). out and opening the sac, the contents are
- Positive expansile impulse on coughing reduced and the neck transfixed and the
- When the sac is still in the inguinal canal remainder removed.
the bulge may be seen (better) by observing the  Herniotomy and repair (herniorrhaphy)
region from the side or even looking down the - Hernial sac is excised
abdominal wall while standing slightly behind the - Repair of thestretched internal inguinal
the respective shoulder of the pt. ring and the transversalis fascia.
134
 - Reinforcement of the posterior wall of the - Prevalence rises between 20 and 40 yrs
inguinal canal and continues to old age.
- The right side is affected twice as much
NB the first two steps should be done without as the left
tension. - It is bilateral in 20% of the cases
Femoral hernia: - The symptoms of a femoral hernia are
more pronounced than those of inguinal hernia
- It is the third commonest hernia - Adherence of the greater omentum
( incisional is the second). sometimes causes a dragging pain
- Accounts for about 20% of hernia in - A large sac is rarely present
women
- Accounts for about 5% of hernia in males DDX:
- It can never be controlled by truss like any 1. Inguinal hernia
other hernia 2. A saphenous varix (varicosity)
- It is the most liable to become 3. An enlarged femoral lymphnodes
strangulated because of the narrowness of the 4. Lipoma
neck of the sac and rigitidy of the femoral ring. 5. Femoral aneurysm
Sex incidence: 6. Psoas abscess
7. A distended psoas bursa
- The female to male ratio is 2:1 8. Ruptured adductor longus with
- Female pts are frequently elderly while haematoma
the
- Male pts ar ebetween 30-45 yrs Umbilical hernia:
- It is more prevalent in women who have Exomphalos (omphalocele)
deliverd than in nulliparous
- The broader female pelvis also - Occurs once in every 6000 births
predisposes to the condition.
-It is due to failure of all or part of the mid gut to
Pathology: return to the coelom during early life

The hernia passes down the femoral canal descending Sometimes a large sac ruptures during birth.
verticall as far as the saphenous opening. It is
confined to the inelastic walls of the femoral canal When it remains unruptured it is semi transluscent.
and is narrow but once it escapes through the Although very thin it consists of three layers;
saphenous opening into the loose areolar tissue of - Outer layer of amniotic membrane
the groin, it expands sometimes considerably. A fully - Middle layer of wharlou’s jelly
distended femoral hernia assumes the shape of a - Inner layer of peritoneum
retort (closed bottle with a long narrow bent spout),
and its bulbous extremity may be above the inguinal Types of exomphalos;
ligament.
i) Exomphalos minor:
Clinical features: - the sac is relatively small and the
umbilicus is attached to its summit.
- Rare before puberty

135
 - A loop of small intestine or meckel’s - A big percentage of hernias disappear
diverticulum can be included in the ligature spontaneously during the 1st few months
applied to the base of an umbilical cord - Cure may be hastened by putting the skin
containing this protrution and abdominal musculature together by adhesive
strapping placed across the abdomen.
Treatment:
Paraumbilical hernia (supra or infra umbilical
The cord is only twisted to reduce the contents of the hernia):
sac through the narrow opening into the peritoneal
cavity and to retain them by firm strapping. Despite a - In adults the hernia does not occur
seropurulent discharge on no account must the through the umbilical scar.
strapping be removed for fourteen days. - This is a protrusion through the linea alba
just above or sometimes just below the umbilicus.
ii) Exomphalos major: - As it enlarges it becomes rounded or oval
The umbilical cord is attached to the inferior aspect of in shape with a tendency to sag downwards
the swelling which contains small and large intestine - It can become very large
and nearly always a portion of the liver. Half the cases - The neck of the sac is often narrow as
belong to this group. compared to the size of the sac.
- The sac contains greater omentum often
Treatment: accompanied by small intestine
- May contain portion of the transverse
Operation within the first few hrs of life is the only
colon.
hope, otherwise the sac will burst. In order to prevent
- In long standing cases the sac sometimes
further distension of the contents of the sac, the
becomes localized due to adherence of omentum
infant sould not be fed. A few newborns with a
to its fundus.
ruptured sac have survived following immediate
operation and antibiotic therapy Epigastric hernia:

Umbilical hernia of infants and children: Occurs through the linea alba anywhere between the
xiphoid process and the umbilicus, usually midway
- This is a hernia through a weak umbilical
between these structures. Usually commences as a
scar usually as aresult of neonatal sepsis.
protrution of extraperitoneal fat through the linea
- The ratio of males to females is 2: 1
alba. Sometimes more than one hernias are present.
- Often symptomless but increases with
A swelling the size of apea consists of a protrusion of
crying and this causes pain which makes the
extraperitoneal fat only (fatty hernia of the linea
infant to cry more.
alba), if the protrusion enlarges, it drags a pouch of
- Small hernias are spherical
peritoneum after, and so becomes a tru epigastric
- Big hernias are conical
hernia. The mouth of the hernia is rarely large enough
- Obstruction or strangulation below the
to permit a portion of hollow viscus to enter it.
age of three yrs is extremely uncommon.
Consequently the sac is either empty or it contains a
Treatment: small portion of greater omentum. The cause may be
the direct result of a sudden strain tearing the
- Conservative treatment is successful in interlacing fibres of the linea alba. The pts are often
93% of cases manual workers between 30- 45 yrs.
- If symptomless, reassure the parents
136
Clinical features: Treatment:

1. Symptomless- may present as a small 1. Palliative- an abdominal belt is sometimes

fatty hernia of the linea felt than can be seen. It satisfactory especially in cases where a hernia
may be symptomless only to discovered on through an upper abdominal incision.
routine abdominal examination (palpation). 2. Operation.
2. Painful – there may be attacks of local
pain which is worse on physical exertion. May be
tender to touch and tight clothing.
FAECAL FISTULA:
3. Referred pain - the pt may complain of An external fistula communicatin with the caecum
pain suggestive of a peptic ulcer. The pt may have sometimes follows;
not noticed the hernia.
- An operation for gangrenous appendicitis
Treatment: or
- The opening of an appendicular abscess.
If it gives rise to symptoms surgery is the only remedy.
A faecal fistula can occur from;
INCISIONAL HERNIA:
- Necrosis of a gangrenous patch of
Incisional hernia (ventral, postoperative hernia):
intestine after the relief of a strangulated hernia
Etiology: or
- A leak after an intestinal anastomosis
- Most often in obese pts - The opening of an abscess connected
- Persistent postoperative cough with chronic diverticulitis or
- Postoperative abdominal distension - Carcinoma of the colon
- There is a high incidence of incisional - Other causes include;
hernia folloiwngoperations for peritonotis,  Tb peritonitis
because, as a rule, the wound becomes infected.  Ileocaecal actinomycosi
Clinical features:  Amoebiasis
 Regional ileitis (always follows operation)
- The degree varies
- The hernia may occur through a small External faecal fistulae are divided into three;
portion of the scar usually at the lower end 1. A track lined by mucus membrane
- There may be a diffuse bulging of the protruding above skin level
whole length of the incision 2. A direct track lined by granulation tissue
- Post operative hernia especially one communicating with the exterior
through a lower abdominal scar usually increase 3. A long ortous track lined by fibrous tissue
steadily in size the contents becoming irreducible and partly epithelialized
- Sometimes the skin overlying it is so thin - The discharge from a fistula connected
and atrophic so that normal peristalisi can be with the duodenum or jejunum is bile stained and
seen causes severe excoriation of the skin.
- Attacks of subacute intestinal obstruction - When the ileum or caecum are involved
are common and strangulation liable to occur at the discharge is fluid faecal matter
the neck of the sac.

137
 - When the distal colon is involved it is solid 1. Incorrectly performed
or semi-solid faecal matter haemorrhoidectomy where too much skin is
- When the leak from the small intestine or removed leading to anal \
caecum is small it may be difficulty to distinguish 2. Leading to tearing when hard stool
a faecal discharge from a faeculent pus. passes.
- Methylene blue is given orally and if a
faecal leak is present the blue colour will be Acute anal fissure:
distinguished easily in the discharge a few hrs There is a deep tear through the skin of the anal
later. margin extending into the anal canal. There is little
Treatment: inflammatory induration or oedema of its edges.
There is accompanying spasm of the anal sphincter
- Those fistulas which connect to the small muscle.
intestine tend to heal spontaneously provided
there is no obstruction beyond the fistulous Chronic anal fissure:
opening. There are inflamed indurated margins,and a base
- The abdominal wall must be protected consisting either scar tissue or the lower border of the
form erosion by the use of a disposable ileostomy internal sphincter muscle. The ulcer is shaped like a
bag canoe and has a skin tag, which is usually
- Give nil orall or minimal residual diet and oedematous, at the inferior extremely. The tag is
Supplement by intravenous feeding, this will known as a sentinel pile because it guards the fissure.
facilitate closure by resting the bowel while There may be spasm of internal sphincter. Chronic
maintaining the condition of the pt. fissure in ano have a specific cause, often a
ANAL FISSURE (FISSURE IN ANO) granulomatous infection e.g. crohn’s disease or
syphilis. biopsy is adviced.
Def. An elongated ulcer in the long axis of the lower
anal canal. Clinical features:

Site: - Common in women especially in the child

bearing age
Midline posteriorly (90%) - Uncommon in the aged because of
muscular atony
Next mot common is the midline anteriorly) - Not rare in children. May occur in infancy
Aetiology: and may cause megacolon
1. Pain – sharp agonizing pain starting
Not completely understood. during defaecation the during defaecatio, often overwhelming in
pressure of a hard faecal mass is mainly on the intensity and lasting an hour or more. As a rule it
posterior anal tissues, in which event the overlying stops suddenly and comes over in the next bowel
epithelium is greatly stretched and being relatively action. Pts tend to become constipatedrather
unsupported by muscle, is vulnerable by hard stool. than enduringthe agony of defaecation.
2. Bleeding: usuallyslight and consists of
Other causes:
bright streaks of blood on the stool or tissue
paper.

138
 3. Discharge: fully established caseshave a Operative measures:
slight discharge.
A wide, forcible dilatation of the sphincter under G.A
On examination: the index and middlefinger of eachhand are inserted
spontaneouslyinto the anus and pulled apart to
- A sentinel tag can usually be seen maximal dilation. Pt may go home after the procedure
- Together with a typical history of a tightly but should be warned of possible faecal incontinence
closed, puckered anus,is pathognomonic of the for between 7-10 days.
condition.
If the above procedure is not successful or if the
By gently parting the margins of the anus, the lower fissure is chronic with fibrosis, a skin tag. Or a mucus
end of the fissure can be seen. polyp then surgery is advised.
Digital examination should not be done because of HAEMORRHOIDS (PILES):
pain unless;
They are veins occurring in relation to the anus.
1. The fissure cannot be seen
2. You want to exclude a major intrarectal Classification:
pathology.
A. It is customary classified by degree;
It is therefore importantto apply a local anaesthetic  First degree – only bleeding announces
such as 5% xylocaine before examination their presence
 Second degree – spontaneously reducing
DDX: prolapsed at defaecation
i) Ca anus in its early stage  Third degree – prolapsed requiring
ii) Multiple fissures manual replacement
iii) Anal chancre  Fourth degree – permanent prolapsed.
iv) Tuberculosis ulcer B. They may be external or internal in
v) Proctalgia fugax- A disease not related to relation to the anal orifice.
organic disease characterized by attacks of severe The external ones are covered by skin while the
pain arising in the rectum, reccuring at irregular internal ones lie beneath the anal mucus membrane.
intervals When the two varieties are associated, they are
Treatment: known as interoexternal heamorrhoids.

The aim of treatment is complete relaxation of the The veins forming internal haemorrhoids become
internal sphincter. The pain is intense and needs to be engorged as the anal lining descends and is gripped by
addresed. the anal sphincters.

Conservative management:if the fissure is acute and Haemorrhoids may be symptomatic of some other
superficialand the inflammation is minimal, conditions and this important fact must be remembered.
conservative management is advised. Xylocaine 5% in They appear in;
a water soluble lubricant is applied. After 5 minutes a - Carcinoma of the rectum
well lubricated finger is introduced into the anal - During pregnancy
canal. Alternatively a small dilator is introduced and - Straining at micturition due to stricture or
even a bigger one if the anaesthesia allows. prostate
139
 - From chronic constipation ii) The internal haemorrhids – commences
just below the anorectal ring. It is bright red or
A great majority of haemorrhoids are not purple and covered by mucous membrane
symptomatic. iii) An external associated haemorrhoid - it
INTERNAL HAEMORRHOIDS: lie between dentate line and the anal margin. It is
covered by skin, through which blue veins can be
- They are exceedingly common. seen, unless fibrosis has occurred.
- They include interoexternal haemorrhoids
- Essentially it s a dilatation of the internal Clinical features:
veinous plexus within an enlarged displaced anal 1. Bleeding: - at first the bleeding is slight, it
cushion. is bright red and occurs during defaecation.
1. Heredity Haemorrhoids that bleed but do not prolapsed
2. Morphological – veins in both internal are called first degree haemoorrhoids.
and external haemorrhoidal vein (plexuses) don’t 2. Prolapsed: - a much later symptom.
have valves. This produces a high pressure in the Initially slight occurring on at stool with
lower rectum. Haemorrhoids are rare in animals spontaneous reduction. Later they don’t reduce
except a few fat old dogs. unless returned by the patient. Those that
3. Anatomical. prolapsed on defaecation and return or need to
a) The collecting adicles of the superior be replaced manually and then stay reduced are
haemorrhoidal veins lie unsupported in the very called second degree haemorrhoids.
loose submucous connective tissue of the
anorectum Haemorrhoids that are permanently prolapsedare
b) The veins pass through muscular tissue called 3rd degree haemorrhoids
and are liable to be constricted by its contraction
during defaecation 3. Discharge: - a mucoid discharge is a
c) The superior rectal veins, being frequent feature. Pruiritis will almost always
tributaries of the portal veins have no valves follow this discharge.
4. Pain: - pain is absent unless complications
Pathology: set in. any pt complaining of painful piles must be
suspected of having another condition (possibly
Internal haemorrhoids are arranged in three groups, serious) and examined accordingly.
at 3, 7, and 11 o’clock with the pt in lithotomy 5. Anaemia: - due to persistent profuse
position. The distribution is attributed to the internal bleeding.
supply of the anus whereby there are two
subdivisions of the right branch of the superior rectal On examination:
artery, but the Lt branch remains single. There may be
smaller secondary haemorrhoids in between the There may be no evidence of internal haemorrhoids.
three primary haemorrhoids. A principal haemrhoid Redundant folds or tags of skin can be seen in the
can be divided into three parts; position of one or more of the three primary
haemorrhoids. On straining the internal haemorrhoid
i) Pedicle – is situated at the anorectal ring. may come into view transiently, or if they are of the
On proctoscopy it is seen to be covered with a 3rd degree they are and remain prolapsed.
pale pink mucosa. Occasionally a pulsating artery
may be felt.  Digital examination:

140
Internal haemorrhoids cannot be felt unless they are from a collapsible tube filled with a nozzle at night
thrombosed and before defaecation suppositories are also useful.

 Proctoscopy: - a proctoscope is passed to b. Incase of inflamed and permanently

the fullest extent and the obturatoris removed. prolapsed haemorrhoids:
The proctoscope is then slowly withdrawn just
below the anorectal ring. Internal haemorrhoids if Oedema should be reduced by repeated dressings of
present will bulge into the lumen of the glycerine and then surgery gives permanent cure.
proctoscope. However severe MAD is frequently successful in
 Sigmoidoscopy: - Should be done as a relieving symptoms even in advanced cases of the
precaution in every case to rule out other piles.
conditions like ca. c. Active treatment:
Differential diagnosis; - Injection treatment – indications include;
(i) ideal for 1st degree internal haemorrhoids
1. Anal tags – they are cutaneous which bleed. (ii) early 2nd degree haemorrhoids
protruberances at the junction of the anderm and are often cured by the method but some relapse.
perianal skin whose origin is unknown. 3-5 ml of 5% phenol in almond oil is injected.
2. Fibroepithelial polyp d. Banding:
3. Sentinel pile
4. Fissure For 2nd degree haemorrhoids which are too large for
5. Dermatitis successful handling by injection. A tight elastic band is
6. Perianal haematoma slipped to the base of the pedicle of thee
7. Rectal prolapsed haemorrhoid with a special instrument. The band
8. Rectal tumour causes ischaemic necrosis of the piles which slough
off within a few days. The procedure should be
Complications: painless if done properly. Not more than two piles
should be banded at one sitting.
1. Profuse haemorrhage
2. Strangulation - Cryosurgery – application of liquid
3. Thrombosis nitrogen ( extremely cold at -195 degrees celciuc)
4. Ulceration causes coagullative necrosis of the piles which
5. Gangrenous subsequently separate and fall off. It causes
6. Fibrosis troublesome mucus discharge which has limited
7. Suppuration its use.
8. Pyelephlebitis - Photocoagulation – this is application of
infrared coagulation by a specially designed
Treatment: instrument. It is effective and painless.
a. Non operative: - Operation -- indicationfor peration
include;( the following cases are unsuitable for
Recommended when a haemorrhoid is a symptom of injection or banding)
other conditions or disease except when a carcinoma  3rd degree haemorrhoids
is present. The bowels are regulated by hydrophilic  Failure of non operaton treatment for 2nd
colloids (isogel etc) and a small dose of senokot nocte degree haemorrhoids
prn. Various creams can be inserted into the rectum  Fibrosed haemorrhoids

141
  Interoexternal haemorrhoids- when the - More common than secondary
external haemorrhoid is well defined haemorrhage
- The haemorrhage may be mainly or
Therefore the above are theindications for entirely concealed but becomes eveident on
heamorrhoidectomy. rectal examination.
Haemorrhoidectomy: - Treatment is a suitable dose of morphine
and if there is no response the patient is taken to
Preoperative management; theatre to identify and secure the bleeder.
4. Late/secondary haemorrhage:
- An aperients on the evening prior to
- Uncommon
operation
- Occurs at the 7th/8th day
- A soap and water enema is administered
- Controlled by morphine and is not a
- The anal region is shaved
suture is applied to the bleeder
- On the morning of the operation the
5. Anal stricture
rectum is evacuated
6. Fissure
MAD (which greatly reduces post operative pain) is 7. Submucous abscess
done before the ligation and excision of the
External haemorrhoids:
haemorrhoid. Petroleum jelly gauze are tacked into
the anus so as to cover the area denuded of skin. A They comprise a group of distinct clinical entities i.e.
pad of gauze and wool are applied and a T bandage
applied. 1. A thrombosed external haemorrhoid: --
commonly known as a perianal haematoma. A
Postoperative managmeet: small clot occurring in the perianal subcutaneous
connective tissue and usually superficial to the
- Saline sitz baths twice daily
corrugators’ cutis ani muscle. It is due to back
- The dressing can be removed after the
pressure on an anal venule as a result of straining
first day
at stool; coughing or lifting of a heavy wt. the
- Enema is not necessary because bowel
condition appears suddenly and is very painful.
usually move at day 4-5.
- Baths and dry dressing are best O/e
- Antibiotics.
- Analgesics. – A tense, tender swelling is seen.
– The haematoma is usually situated in a
Postoperative complications: lateral region of the anal margin.

1. Pain If untreated it may;

– May necessitate pethidine PR.
– Xylocaine jelly into the rectum by a nozzle  Resolve
may help.  Suppurate
2. Urine retension  Fibrose leading to a cutaneous tag
- Especially in males due to a rectal tube or  Burst and extrude the clot or continue
pack or both bleeding.
- Reassure pt an give an analgesic before In the majority of the cases resolution or fibrosis
resorting to catheterization. occurs. It is reffered to as a 5 day , self curing lesion. If
3. Reactionary haemorrhage
142
seen within the first 36 hrs of onset it should be - Persistent seopurulent discharge which
treated as an emergency and the haemorrhoid should irritates the skin in the neighbourhood and causes
be bisected and the two halves excised together. discomfort.
- The history usually dates back for many
2. Associated with internal haemorrhoids i.e years
interoexternal haemorrhoids - Pain is not present so long as the opening
3. Dilatation of the veins of the anal verge. It is large enough to allow pus to escape.
becomes eveident only if the pt strains, when a - If the orifice is occluded pain increases
bluish cushionlikering appears. until discharge erupts
4. A sentinel pile is associated with an anal - Usually there is a solitary external
fissure opening within 3-7 cm of the anus which presents
FISTULA IN ANO: as a small elevation with granulation tissue
protruding from the mouth of the opening.
Def. A track lined by granulation tissue which Sometimes superficial healing occurs, pus
connects deeply in the anal canal or rectum and accumulates and an abscess reforms and
superficially on the skin around the anus. discharges through the same opening, or anew
opening. Therefore there may be two or more
Usually results from an anorectal abscess which
external openings usually grouped together on
bursts spontaneously or was opened inadequadely. It
the right or left of the midline.
continues to discharge and because of constant
reinfection from the anal canal or rectum, it never NB: fistulas with an external opening in relation to
closes permanentlywithout surgical intervention. An the anterior half of the anus tend to be of the direct
anorectal abscess may produce a track to the orifice type. Those with an external opening or openings in
of which has the appearance of a fistula, but it does relation to the posterior half of the anus (are more
not communicate with the anal canal or the rectum. common), usually have curving tracks).
This is not a fistula but a sinus.
 On digital examination:
Types of anal fistulae:
Usually an internal opening can be felt as a nodule on
They are divided into the wall of the anal canal. Irrespective of the number
of external openings, there is almost always only one
a) Low level- they open into the canal below
internal opening.
the anorectal ring.
b) High level – they open into the anal canal  Proctoscopy: sometimes reveals the
at or above the anorectal ring. internal opening of the fistula.
 Probing: used to be done in the wards or
A low level fistula can be laid open without fear of
outpatient but are of no value and painful and
permanent incontinence, while a high level fistula can
liable to spread infection.
be treated only by staged operations often with a
 CXR should be done to rule out PTB.
protective colostomy to prevent septic complications
and to shorten healing time between the stages. Treatment:

Clinical features of low level fistulas: The fistulous track must be laid open from the
terminal end to the source.

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 NB: fistulas of high level are difficulty to treat. If the - Benign tumours
track is laid open as for low level fistulas incontinence - Malignant tumours
will follow. e) Urethral causes
- Injury
THE URINARY SYSTEM: -
-
Stones
Tumours
Urinary symptoms: f) Blood dyscrasias
- Purpura
The three most common symptoms of the tract are; - Sickle cell disease
- Anticoagulants
1. Haematuria
2. Pain
This is the presence of in urine and should not be
Different forms of pain arise from the urinary tract;
ignored. Haematuria is described as;
a) Renal pain
- Initial haematuria
- It arises from the kidney
- Blood throughout the urtinary stream
- May be associated with inflammation or
- Terminal haematuria
obstruction at the level of the pelvi-ureteric
- Bleeding with clots and perhaps pices of
junction and is well localized
tissues.
- If due to obstruction it will be described
These variations may be used to indicate the site of as an ache
bleeding, thus; - If infection is present, there may be
irritation of the psoas muscle. There may be
a) Renal causes tenderness at the costovertebral angleand the
- Infarcts right hypochondriac region
- Injury b) Ureteric pain
- Stone
- Tb This is pain passing from the loin to the groin. It is
- Hypernephroma associated with the passing of a stone.
- Papillary tumours
- It is usually sudden in onset and severe
- Carcinoma
- Pt is unable to get comfortable and
- Wilm’s tumour
prefers to pace about
b) Ureteral causes
- It is different from the painof peritonsm
- Stone
which is excercabation of the pain.
- Neoplasm
- The pain is restricted to the loin when the
- Focal and glomerularonephritis
stone is just coming out of the kidney. As the
c) Bladder causes
stone moves down to the upper ureter the pain
- Cystitis
moves into the upper abdomen and gradually
- Tumours
down towards the groin.
- Tb
- When the stone is in the lower ureter the
- Stones
pain radiates into the perineum or to the vulva in
- Bilharzias
women and sometimes to the base of the penis in
- Tauma
men. It may also go down the inner thigh.
d) Prostate cauases
c) Vesical pain
144
 - It is usually sited at the suprapubic region a) Macroscopically for;
- It is made worse by the filling of the - Presence of RBCs
bladder or emptying and sometimes by - “ “ WBCs
defaecation. - Bacteria
- Crystals and
- Casts
b) Biochemically for;
d) Prostatic and seminal vesicle pain - Electrolytes
- It is usually deeply seated in the rectum - Glucose
or the perineum - Bilirubin and its products
- Usually described as an ache which may c) PH
also occur both in the suprapubic region and in d) Bacteriologically – by simple culture
one or both iliac fossa. which may reveal infection
e) Urethral pain Mid stream specimen is better because
- Typically scalding in nature and
associated with active cystitis - It avoids contamination and
- May also be felt in the base of the penis, - There is no risk of catheterization
particularly with the presence of vesical calculus
(at the neck of the bladder) Early morning specimen should be cultured on a
3. Frequency Lowenstein Jensen medium when looking for Tb.

It may be due to; e) Malignanc

- Incomplete emptying as in prostatism The papanicolaou stain used to demonstrate the

- Irritability of bladder by inflammation or presence of ca in situ in the cervix has been adopted
stones for cells exfoliating from the urinary tract. This has a
- A contracted bladder. place in the detection of urothelial malignancy
- A dieresis 2. Renal function tests
- Sphincter weakness
Structural damage to the may occur before the

URINARY TRACT functional damage becomes apparent. Kidney

function impairement can occur in three principal

INVESTIGATIONS: ways:

i. Pre-renal – reduced renal plasma flows

A complete history and physical examination is vital ii. Renal - damage to the glomeruli
before investigation of any condition. Remember that iii. Postrenal – impaired tubules
haematuria may not arise from primary disease of the
urinary tract but because of some other systemic Range of specific gravity (concentration)
illness e.g. bleeding secondary to thrombocytopaenia
- The ability of the kidney to concentrate or
(reduced platelets) caused by leukaemia.
dilute urine is a good test of their functional
1. The urine: integrity.
- Fluid is withheld for 12hrs overnight.
The urine may be examined;
145
 - The specific gravity of the first two 2ml/kg in an equal amount of isotonic saline over
specimens should reach 1.020 a period of 10 minutes.
- A specific gravity of 1.025 in a urine free - Retrograde uretropyelography
of protein indicates good renal function
- A liter of water is given orally. Within 4hrs A systoscope is initially passed and subsequent
the specific gravity should be as low as 1.002. passage of ureteric catheter into the ureteric orifice.
- A fixed gravity of 1.010 under these It normally requires GA. A contrast media is injected
varying circumstances is an evidence of impaired into the ureter if there is doubt about the presence of
function of the distal renal tubules. intraluminal lesion.

Blood urea – is normally between 2.5-6.5 mmol/l (15- - Renal arteriography

40mg/100ml) - Cystography
- Urethrography
Creatinine – It is 42-130mmol/l (0.2-1.5mg/100ml). A - Venography
more sensitive test of renal function 4. Ultrasonography
- It can demonstrate the size of kidneys and
Creatinine clearance – it measures the glomeruli the thickness of the cortex. Individual calyces can
filtration rate. One sample of bld and an accurately be demonstrated and the width of the collecting
timed collection of urine for a period of aout 24 hrs system (hydronephrosis can be diagnosed within
are all that is required. The normal clearance is seconds). Fluid can be differentiated from solid
between 90 and 130 ml/min. it decreases in old age. 5. Computed tomography
3. Radiology: 6. Endoscopy.
- Plain abdominal x-ray can reveal a lot of
information like;
 Gastric air bubble on the left ANURIA
 Liver on the right
 Presence of previous pelvic fractures It is also called suppression of urine
 Kidney shadow Definition: absence of secretion of urine for 12hr
 Calculi
- Intravenous urogram Oliguria: excretion of urine less than 300ml in 24hrs
 It relies on the glomeruli filtration of
Classification of anuria;
sodium diatrizoate ( this substance is allergenic)
 A laxative is given prior to the 1. Pre-renal anuria
investigation and pt starved for 6-8hrs
 The contrast (urographin or niopam 370) The Bp in the glomeruli is normally about 90mmhg.
is given i.v on the forearm. Observe for any rxn. When the systolic Bp falls bellow 70mmhg, filtration
An x-ray is then taken to demonstrate the urinary from the glomeruli stops.if the glomeruli are diseased,
system. At the end of the study the pt is asked to a higher pressure of up to100mmhg may be
to micturateand a final film taken to demonstrate inadequate to maintain filtration.
the bladder.
Causes of pre renal anuria are;
- Infusion urography (rarely used this days)
 In pts with a bld urea of 16.6-33.2 mmol/l - Traumatic shock
(100-200mg/100ml), an infusionof 50% hypaque - Severe haemorrhage
- Spinal anaesthesia
146
 - Extensive burns b) Sulfonamide crystalluria
- Dehydration from vomiting, diarrhea or c) Uric acid crystalluria
excessive sweating d) Accidental ligation of the ureters
- Cardiac failure e) Involovement of both ureters in a
neoplastic process e.g ca cx, ca prostate
Treatment: f) Involvement of the urters in
- Bld transfusion if due to haemorrhage retroperitoneal fibrosis
- i.v fluids ( plasma expanders) if due to KIDNEYS AND URETERS
dehydration. If hypotension is prolonged damage
to the renal epithelium results leading to tubular Congenital abnormalities of the kidneys:
necrosis.
2. Acute renal anuria ( acute tubular 1. Absence of one kidney:
necrosis) Pyelography reveals only one functioning kidney and
- It occurs due to damage to or ischaemia at cysytoscopy only one ureteric orifice is present.
of the renal tubular epithelium Sometimes a ureter and a pelvis are present on the
The principal causes (surgical) are; non functioning side, but the parenchyma is almost or
entirely absent. In either case the functioning kidney
a) Severe shock (hypotension) lasting 2hrs or is hypertrophied. An absent or congenitally atrophic
more. kidney is present in about 1:1400 individuals.
b) Incompatible BT
c) Bilateral pyelonephritis 2. Renal ectiopia:
d) Crush syndrome Occurs once in 1000 cases. The kidney is arrested in
e) Concealed accidental haemorrhage and some part of its normal ascent, usually at the brim of
abortion the pelvis. As a rule the kidney the kidney of the
f) Certain poisons e.g. media used for opposite side is present and in its normal position.
arteriography, toxins of eclampsia, chemicals like The left kidney is far more often affected than the
mercury salts and carbon tetrachloride. right kidney. The reason is not known. Ectopia may
g) Acute pancreatitis present a diagnostic problem when acute disease
h) Operation on jaundiced pts develops in the ectopic kidney.
i) Drugs like aminoglycosides,
cephalosporins esp. in pts on lasix. 3. Horse shoe kidney:
3. Post renal anuria (obstructive anuria)
During embryonic life, the most medial subdivision of
Causes; the primary mesophrenic bud of each side fuse and
the kidney fail to ascend completely. The adrenal
a) Calculi anuria – it arises in one of the glands develop separately and are in their normal
following ways; positions. It occurs one in every 1000 of renal
- Impaction of calculi in the ureter of the cases.the bridge joining the lower poles lies infront of
only functional kidney, the other kidney being the 4th lumbar vertebra. Fusion occurs very early,
congenitally absent, previously removed or when the embryo is about 30-40 days old, at which
destroyed by disease. time the two masses of mesoblast destined to form
- Both ureters become obstructed by the kidneys lie very close together. Exceptionally, it is
stones or crystals the upper poles that are fused.

147
Clinical features: - Haematuria ue to to rupture of one of the
cysts due to overdistension. It may be profuse.
The kidneys are prone to become diseased mainly - Infection. The most common complication
because the ureters are angulated as they pass over being pyelonephritis.
the fused isthmus. This causes urine stasis and - Hypertension usually those aove the age
consequently simple infection, tuberculosis, and of 20yr. Nobody understands why some pts
calculus formation are common complications. escape this complications
Investigations: - Uraemia – Pts complain of anorexia, head
ache and vague gastric symptoms. Later
1. Urography – the most characteristic drowsiness and vomiting occurs.
finding, the lowest calyx on each side is reversed
in position (directed towards the vertebral Investigations:
column). Rarely most or all of the ureterscurve - Excretory urography is the best way of
like a flower vase. Urinary complications are more confirming the diagnosis
frequent in pregnancy but horse shoe kidney is - The kidney shadows are enlarged in all
not a contraindication to pregnancy.Surgery is directions
only indicated when trying to correct - Renal pelvis is enlarged and may be
anabdominal aortic aneurysm. elongated
4. Congenital cystic kidney ( polycystic - The calyces are stretched over the cysts
kidney and are oten narrow (like the legs of a spider) or
In 18% of the cases there is a congenital cystic liver. bell like.
Occasionally the pancreas and lung are similary Treatment:
affected. The disease is hereditaryand can be
transmitted by either parent. The disease is not easily 1. Conservative;
demonstrable in a urograph before the late teen (13 – - Drink large quantities of water routinely
19yr). It rarely gives clinical manifestations until the - Have low protein diet
4th decade of life. - Iron supplements to prevent anaemia
- Infections, when present, should be
Pathology: treated with appropriate drugs
The kidney becomes enormously enlarged. The 2. Operative;
surface appears as many bubbles. On section the To remove pressure on the remaining renal
renal parenchyma is occupied with cysts of varying parenchyma. Many surgeons advocate this operation
sizes, some containing clear fluid, others thick brown now.
material while others contain coagulated blood.
3. Renal failure should be treated by dialysis
Clinical features: possibly bilateral nephrectomy and kidney
- the condition is slightly common in transplantation.
women than men. Other congenital abnormalities of the kidney:
- Renal enlargement
- pain due to the wt of the organ dragging a) Infantile polycystic disease
upon its pedicle or totension within the cyst. b) Unilateral multicystic disease
c) Solitary renal cyst

148
 d) Aberrant renal vsls - It may be discovered at childhood but is
more often discovered during adulthood
Congenital abnormalities of the renal pelvis and - Women are affcted more than men
ureter: - It is bilateral in 10% of the cases.
I. Duplication of the renal pelvis Treatment:
- Is the commonest congenital anomally of
the renal tract - Many cases are symptomless and require
- Is found in about 4% of the pts no treatment
- Usually unilateral - It may complicate to;
- Common in the left side than the right  Hydronephrosis
ii. Duplication of a ureter  Stone formation
- Double ureters are present in addition to  Reccurent ifections
double renal pelvis in about 3% of the cases
- The ureters usually join in the lower 1/3 This complications may necessitate treatment, by
of theeir course and have a common opening into cauterizing a hole through the wall of the cyst with a
the bladder diathermy.
- Less frequently the ureters open into the CONGENITAL ABNORMALITIES OF THE URINARY
bladder independently. BLADDER:
iii. Ectopic ureteric orifice
- This is a rare anomally 1. Diverticula:
- In both sexes the existence of double
A vesical diverticulum consists of a pouch like
ureter is determined by excretory urography.
eversion or evagination of the bladder wall. It may
iv. Congenital mega ureter
arise as a congenital defect but are more commonly
- May be unilateral or bilateral
acquired lesions from persistant urethral obstruction.
- In later stages it is accompanied by other
The congenital type may be due to a focal failure of
congenital abnormalities
development of the normal musculature or to some
- Common in males
urinary tract obstruction during fetal development.
- Usually symptomless until infection sets
Acquired diverticula are more often seen with
in.
prostatic enlargement (hyperplasia or neoplasia),
v. Post caval ureter
producing obstruction to the urine outflow and
The right ureter passes behind the inferior vena cava marked muscle thickening of the bladder wall. The
instead of lying to the right of it. It may cause increased intravesical pressure causes outpouching of
obstructive symptoms. If the symptoms occur it may the bladder wall and the formation of diverticula.
require surgery to divide the ureter at the dilated Diverticuli are important because they constitute sites
portion and reanastomosed infront of the vena cava. of urinary stasis and predispose to infection and the
formation of bladder calculi. They may also
vi. Ureterocele predispose to vesicoureteral reflux. Rarely,
- This is due to congenital atresia of a carcinomas may arise in bladder diverticula.
ureteric orifice which causes a cystic swelling of
the intramural portion of the urete. 2. Extrophy:
- It may sometimes involve the muscle This is the presence of a developmental failure in
coat the anterior wall of the abdomen and the bladder.
The bladder either communicates directly
149
through a large defect with the surface of the 4. Penoscrotal: the urethra opens at the
body or lies as an open sac. The exposed bladder junction of the penis with the scrotum.
mucosa may undergo colonic glandular 5. Perineal: The scrotum is split and the
metaplasia and subject to the development of urethra opens between its two halves. Is
infection this infection often spreads to upper sometimes associated with bilateral
levels of urinary system. When chronic infections maldescended testes, in which even the sex of the
persists the mucosa becomes converted into an child is difficult to determine.
ulcerated surface of granulation tissue and the
marginal epithelium becomes transformed into a Glandular hypospadias is the most frequent
stratified squamous type which may later develop variety and due to failure of canalization of the
into carcinoma (adenocarcinoma). May surgically glans.
be corrected with long term survival. In all except the glandular variety the penis is
curved in a downward direction. The furtheraway
Congenital abnormalities of the penis: the opening is from the normal position, the more
They range from congenital absence and pronounced is the bowing. In all the cases the
hypoplasia to hyperplasia, duplication etc. most of inferior aspect of the prepuce is poorly developed
these are extremely rare and apparent on (hooded prepuce).
inspectioncertain other abnormalities are more
frequent and have greater clinical significancy. Treatment:

No treatment is required in the glandular type unless

Hypospadias:
the opening is too small in which case meatotomy is
It occurs once in every 350 cases of congenital
performed. In either varietie, plastic operation
anomalies of the renal system.
(reconstruction) is carried out.on this account,
This is when the external meatus is situated at
circumcision during infancy should not be carried out
some point on the undersurface of the penis or in
in this cases because the skin is required for this
the perineum.it is the commonest congenital
reconstruction.
abnormality of the urethra.
Classification: Epispadiasis:
1. Glandular hypospadias:
- It is very rare.
There is an ectopic opening on the undersurface - Occurs 1/30000 males and 1/400000
of the glans penis which is separated from a blind females
depression at the normalsite of the external - The defect may be glandular, penile,or
urinary meatus. Sometimes achannel connec ts total, the later usually associated with ectopia
the ectopic too the normal meatus. vesicae. In
- the first two varieties the urethral orifice
2. Coronal hypospadias:
is situated at the dorsum, and in the penile
The meatus is situated at the junction of the variety, the penis curves upwards.
undersurface of the glans with the body of the - The female variety is associated with
penis. many other abnormalities.

3. Penile: Meatus opens at some point of Phimosis:

the undersurface of the penis.
This is the narrowing of the preputal orifice

150
Causes; Incompletely descended testis:

1. Acquired as a result of chronic or acute Incidence;

inflammation of the lining of the prepuce.
2. Congenital narrowing of the preputal a) In neonatal period – Incomplete descent
orifice which is associated with an unduly long in one or both sides is 4% in full term infants and
foreskin. 30% in premature infants. The testis or testes
reach the scrotum in 50% of children in their 1st
Clinical features: month of life. Incomplete descent of testis is not
usually detected during infancy.
In extreme cases; b) In late childhood and puberty: - The
incidence is 2%. Still remains unrecognized unless
- When the pt micturates the prepuce a routine medical examination is done. In a few
balloons out first, and a thin weak stream of urine cases, presence of hernia pain or acute torsion in
follows. that order is what makes the abnormality to be
- Difficulty of micturition, with residual detected.
urine, hydroureters, hydronephrosis are rarely c) In adult life: - it is believed that a good
due to phimosis but due to atresia of the meatus number of cases have this problem but don’t seek
which may be hidden by the phimosis. advice unless symptoms develop.
Treatment: The incidence is 0.8% and in 10% of unilateral cases
Circumcision. there is a familial history.

Paraphimosis: Pathology:

This is when a tight prepuce has been retracted but Up to the age of 6yrs there are no microscopical
cannot be returned and is constricting the glans penis differences between an incompletely descended and
which is engorged and oedematous. a normal testis. After 6yr, due to the higher
temperature to which it is subjected, the
Treatment: development of the undescended testis is
progressively retarded. By the time puberty is
1. Injection of 1ml of isotonic saline
reached, the incompletely descended testis is flabby
containing 150 turbidity units of hyalurodinase
and hardly more than half the size of its intr ascrotal
into each lateral aspect of the swollen ring of
counterpart. Histologically, the epithelial elements
prepuce. 15 minutes later the swelling is much
are grossly immature and at the age of 16yrs
reduced and in early cases reduction is done with
irreversible destruction has occurred in the germinal
easy.
epithelium. The internal excretory mechanism of an
2. Circumcision when the above fails.
incompletely descended testis functions but feebly
Undescended testes: and, often after a few months or yrs, stops and
therefore the power of spermatogenesis may be
This could be in a form of; negligible. The internal excretory activity of an
incompletely descended testis is reduced.in bilateral
1. Incomplete descent – The testis is
cryptoorchidism about half the normal amount of
arrested in some part of its route to the scrotum
androgen is produced. If an incompletely descended
2. Ectopic testis: The testis is abnormally
placed outside this route
151
testis is brought down satisfactorily before puberty, it - Operation is performed between 4-8 yrs
develops and functions satisfactorily. - Percentage of success after puberty falls
considerably
Clinical features: - Orchydopexy which involves ,
- Rt testis 50% of the cases mobilization of the spermatic cord and testicular
- Lt testis 30% of the cases vsls, retaining the mobilized testes in the
- Bilaterally 20% of the cases descended position
- Other abnormalities of the urinary tract - In cryptorchidism one side should be
may be present operated at a time with an interval of 6 months
- The testes may be; between the operations.
 Retained within the abdomen Haematocele:
 In the inguinal canal
 In the superficial sub-inguinal pouch Can be recent or old clotted bld.
- When both testes are in the abdomen or
inguinal canal and are impalpable, the condition is Recent: - It is usually as a result of injury of small bld
known as cryptorchidism (hidden testes) vsls during tapping or aspiration of a hydrocele.
- When the testes can be placed in anormal Refilling of the sac with considerable pain and
position temporarily it is not truly imperfectly tenderness and poor or absent transillumination ( this
descended testes. It is known as a retractile testis. confirms the diagnosis).the treatment should be
They require no endocrine nor operative urgent surgery with evacuation of bld and excision or
treatment. Retractile testes should be suspected eversion of the sac. Exploration also confirms whether
if the scrotum is normal. the testes are ruptured. Neoplasms may also present
this way.
Hazards of an incompletely descended testis:
Old clotted haematocele:
1. Sterility in bilateral cases
2. Pain: - A inguinal testis is liable to Slow haemorrhage into the tunica vaginalis can occur
repeated trauma spontaneously apparently painless. There is no history
3. An associated indirect inguinal or of trauma to the testis nor pain to the organ. An old
interstitial hernia in 70% of the cases. It is the clotted haematocele mimmicks a neoplasm of the
hernia that causes symptoms in the adolescents testis soo closely that pre-operative differential
and adults. diagnosis is sometimes impossible.
4. Torsion Treatment:
5. Epididymorchitis. The right one is not
possible to differentiate from acute appendicitis. Unless exposure of the organ leaves no doubt as to
6. Atrophy the innocent nature of the swelling, unquestionably
7. Increased liability to malignancy. 1 in 20 orchidectomy should be done. As a rule it is
abdominal becomes malignant. 1 in 80 inguinal impossible to be certain of the diagnosis until the
becomes malignant. mass has been bisected. The testes are usually
compressed as to be virtually functionless.
Treatment:
Ddx of scrotal swelling:
- Operation is never performed in the 1st
2yrs - Seminoma
- Teratoma
152
 - Lymphoma Clinical features:
- Interstitial tumour
- Varicocele It is a big mistake to belief that the disease is confined
- Elephantiasis to the elderly because 40% of the cases are under the
- Sebaceous cyst of the scrotum age of 40yrs.
- Carcinoma of the scrotum - The progress of the disease is slow
CARCINOMA OF THE PENIS: - The first symptoms are a mild irritation
and purulent discharge from the prepuse
Aetiology: - These symptoms are usually neglected
and sometimes more than
NB: circumcision correctly performedsoon fter irth - A yr after symptoms have appeared, there
gives almost total immunity against ca penis ( reason is blood stained discharge which has a foul smell
not understood). Circumcision ater ear infancy does - Pain is absent
not provide the same degree of protection (reason - Inguinal lymphnodes are enlarged in 60%
not known). The best example are the muslims who of the pts, half of these enlargement is due to
circumcise their boys at the age of between 4 and 9 secondary deposits and the remainder is due to
yrs. Ca penis therefore occurs in men whohave not sepsis.
been circumcised in early infancyand is favoured by - The prepuse cannot be retracted and
chronic balanitis. must be slit to view the lesion.
The following are also precarcinomatous; - In all cases biopsy must be taken.

1. Leukoplakia of glans Treatment:

2. Longstanding genital warts due to human 1. Radiotherapy gives good results with
papilloma virus small, well differentiated tumours. The five yr
3. Pagets disease of the penis survival rate is 60-70%.
Pathology: 2. Surgery

The condition presents squamous carcinoma of two Indications for surgery;

types; - Large anaplastic growths, if there is
i) The flat or infiltrating – This t is associated infiltration of the shaft of the penis
with leukoplakia - When RT has failed
ii) The papilliferous type – commences in - Elderly men who don’t mind the
papilloma of longstanding period mutilation as much as the pain to be expected
from the extensive reaction to RT.
The growth strictly remains local for many months.
The earliest spread is to the inguinal and then to the PARTIAL AMPUTATION: is used for distal growths
iliac lymphnodes. Direct spread to the body of the provided there is at least 2cm of the dependent shaft
penis is prevented for many months by the fascial which is not involved.
sheath of the corona. Once this barrier is broken the Total amputation: done when there is an advanced ,
growth extends more rapidly and the illiac infiltrating, or anaplastic lesion (must).
lymphnodes become onvolved. Distant metastatic
deposits are not frequent. SURGICAL EMERGENCIES:

153
RUPTURED URETHRA:
the rupture of the urethra is categorized into two
distinguished classes, thus, bulbous and Treatment:
membranosus (intrapelvic ) urethra. Each is again a) Catheterization under aseptic precautions
subdivided into complete and incomplete, which should be attempted (folley’s catheter). The roof
relates to the circumference of the urethral wall. of the urethra is likely to be intactand the peak of
When it is said to be total or partial it relates to the the catheter should be directed towards it.
thickness of the wall. b) If catheterization is successful it should be
Rupture of the bulbous urethra: left in situ for 48hrs. A perineal haematoma
should be drained and the midline wound packed.
This is a more common accident. There is usually a c) If the catheter fails to pass, the site of
history of a fall astride on a projecting object. The obstruction should be explored with the pt in
common cases involve; lithotomy position, through a midline incision. If
not possible a suprapubiccystostomy should be
- Cycling performed and a fully curved sound passed down
- Loose manhole from the internal meatus. The urethra is then
- Gymnasium accident. Falling astride on repaired and a suprapubic catheter left in situ. If
the beam. the bladder has been repaired without
Clinical features; cystostomy, a cathetercan be passed into the
bladderfrom the urethrostomy. The perineal
The triad sign of a ruptured b urethra is wound is packed but not stitched.
- A course of antibiotics is continued until
 Haemorrhage
healing is complete
 A perineal haematoma
- Urine must be recultured after a wk
 Retension of urine
- Perineal wound irrigated daily with a
Preliminary treatment and investigation: weak eusol solution
- Remove catheter after 8-10 days
If suspected and to diminish the possibility of - Perineal leak may persist for a few days
extravasatio, the pt should be advised against trying - P.O.S must be passed 2wks after healing
to pass urine. and a urethrogram performed after 2wks to reval
the result
- No attempt should be made to
catheterize him until fit to be taken to theatre Complications:
where asepsis can be assured and operation done
in necessary cases. 1. Subcutaneous extravasation of urine. In
- Start on pain killers and sedative like case of total rupture if the pt tries to pass urine.
morphine 2. Stricture – usually due to infection.
- Start on antibiotics
Rupture of membranous urethra (extraperitoneal
- If circumstances don’t allow and the
rupture of the bdladder)
bladder is full it should be treated by suprapubic
puncture until the pt is fit to be taken to theatre. Intrapelvic rupture of the urethra occurs in the
- If the pt has passed urine when first seen membranous portion near the apex of the prostate.
and there is no extravasation, then the rupture is
partial and catheterization should be avoided.
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As in extra peritoneal rupture of the bladder it may be - For the extraperitoneal rupture there is
due to; some suprapubic tenderness and perhaps a little
dullness to percussion.
- Penetrating wounds - There will be blood in urine and often
- Fracture of the pelvis clots
The prostate is firmly attached to the pubis by the - A plain X-R may show pelvic or any other
pubo-prostatic ligaments. A displaced fracture of one bony structure.
ischiopubicramus infront of the corpus carvenosum Treatment:
usually ruptures the urethra. A “butterfly” fracture of
both pubic rami on each side usually springs back into - Treat for blood loss and shock
place and the urethra remains intact.
Mitchel’s theory:
- Complete rupture with floating prostate
-1-2% - Injury to the urethra is incomplete in
- Incomplete intrapelvic rupture of urethra majority of pts.
- 4-6% - Catheterization through the urethra
- Extraperitoneal rupture of the bladder might lead to further damage and cause the
– 4-6% rupture tto be complete
- Combined urethra and bladder damage - Suprapubic cystostomy and the bladder
– 1-2% drained which allowsthe pt recover.
- Primary recovery of the urethra should be
NB: clinical features. discouraged
- Endoscopy is then attempted after 3/52
The most common cause of pelvic rupture are; R.T.A, after the injury which may allow a cystoscopy to
severe crash injuries and falls from heights. The be passed past an area of bld clot and granulation
clinician should therefore bear in mind that there tissue into the urethra.
could be accompanying injuries like, head, thoracic,
abdominal or fracture of long bones. The pts are Brandy’s theory:
usually in a state of shock from either bld loss and
may be unconcous. A careful assessment of the whole It recommends a single attempt to pass a small soft
pt must be made including radiographs of the head ( if urethral catheter.
there is hx of head injury or loss of consciousness), cxr
to rule out pneumothorax, abdomen, pelvis and
appropriate long bones. - This should be done by an experienced
using aseptic technique.
- The classic sign of urethral injury is bld at - If this fails, a suprapubic cystostomy
the external urinary meatus should be performed and the bladder drained for
- It may be associated with gradual a day or two until the pt is fit for management of
distension of the bladder (assuming it is not the urethra.
injured). - The pt should be given a broad spectrum
- Signs of peritonitis will developif there is antibiotic.Complications:
an intraperitoneal rupture of the bladder 1. Urethral stricture
- If the rupture is extraperitoneal the 2. Urinary incontinence – damage of
diagnosis is often difficult. external sphincter.

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 3. Impotence – erectile impotence. day and 3rd wk after injury. This is due to a clot
becoming dislodged.
- Meteorism (abdominal distension) due to
Causes are usually through; retroperitoneal haematoma
- Perinephric haematoma – should be
- Blows suspected if there is even a slight flattening of the
- Fall upon the loin normal contour of the loin (provided there is no
- Road traffic accident scoliosis).

Haematuria following Management:

Minor injuris should suggest the possibility of pre - Conservative management is usually
existing renal abnormality like stone, hydronephrosis successful
or tuberculosis. - Bear in mind that other organs may me
injured
Types of renal injuries;
- Pt rests flat in bed until macroscopic
a) Small subcapsular haemorrhage haematuria has been absent for 1/52
b) Large subcapsular haemorrhage - Morphine for pain and sedation
c) Cortical laceration with perinephric - Hourly pulse and blood pressure
haematoma - Prophylaxis (antibiotics)
d) Medullary laceration with bleeding into - Save a sample of each specimen of urine
the renal pelvis passed
e) Complete rupture - GXM
- The degree of injury varies. - Urgent i.v.u if no change with the above
- The kidney may be partially or wholly management then explorative laparatomy should
avulsed from its pedicle. be performed.
- Tears of the renal parenchyma follow the
Exploration should be done if;
lines of the uriniferous tubules.
- The whole of one pole may be detatched - There are signs of progressive blood loss
- The injury is usually peritoneal - An expanding mass develops in the loin
- Occasionally in children the peritoneum - Signs of perirenal infection develops
may be torn (due to little adipose tissue) involving
the renal capsule and this may allow urine to RENAL CALCULI:
escape into the peritoneum. ETIOLOGY;
Clinical features; 1. Dietetic
- Superficial bruising (rarely) Deficiency of vitamin A which causes a desquamation
- Local pain and tenderness of epithelium forming a nidus around which the stone
- Haematuria; is deposited.
 A cardinal sign but may appear hrs after
injury. If haemorrhage is profuse, it may be 2. Altered urinary solutes and cholloids;
followed by clot colic.
 Severe delayed haematuria – sudden In hot climates, the concentration of solutes will rise.
profuse haematuria can occur between the 3rd Also reduction of urinary cholloid which absorb
156
solutes, or excess microproteins which may seize kidney to bleed and altered blood is precipitated
calcium, predisposes to the formation of insoluble on the surface of the stone. An oxalate calculus
complex. Common in which is usually single casts a good shadow
radiologically. A calcium monohydrate stone is
3. Decreased urinary output of citrate. very hard.
The presence of urine (300- 900ml/24hrs) as citric 2. Phosphate calculus
acid, tend to maintain in solution otherwise relatively - Usually magnesium phosphate but
insoluble calcium phosphate and carbonate. - Sometimes combined with ammonium
magnesium phosphate and rarely composed of
4. Renal infection phosphate and is smooth and dirty white
- In alkaline urine it enlarges rapidly and
Infection favours the formation of urinary calculi.
often filling the renal calyces, taking their shape
Usually common in Streptococcal, staphylococcal or
( staghorn calculi). Because it is smooth, a
proteous infection. The predominant bacteria found
phosphatic calculus gives rise to few symptoms,
in the nuclei of urinary calculi are staphylococci and E.
until it has attained a large size. Because of itssize
coli.
but not density it is demonstrated readily by x-
5. Inadequate urinary drainage. rays
3. Uric acid and urate calculi
Stones are prone to occur in pts with obstruction to - Are hard and smooth
the free passage of urine - Because they are usually multiple, they
are usually faceted
6. Prolonged immobilization
- Their colour varies from yellow to reddish
From any cause in paraplegia. This may lead to poor brown.
renal drainage favouring the deposition of calcium - Pure uric acid calculi are not opaque to x-
phosphate calculi. In uninfected cases spontaneous rays
dissolution sometimes occurs. - But absolutely pure uric acid calculi are
not common. The majority contain enough
7. Hyperthyroidism calcium oxalate crystals making them radio –
opaque
Rare but occurs in 5% of the cases hyperthyroidism
- Calculi of ammonium and sodium urate
results in a great increase in the elimination of
are sometimes found in children. Such stones are
calcium in the urine.
yellow, soft and friable and unless they contain
8. Randal’s plaque impurities they do not cast an x-ray shadow.
4. Cystine calculi
When there is erosion at the apex of one of the renal - Usually appear in the urinary tract of pts
papillae. On this erosion are deposited urinary salts with cystinuria
(Randal’s plaque) minute concretions (microliths) - Sometimes encountered in young girls
occur normally in the renal parenchyma. - Cystinuria occurs because of reduce d or
absent reabsorption of cystine from the renal
Varieties of renal calculi
tubules
1. Oxalate calculus (calcium oxalate) – - Cystine crystals are hexagonal, white,
Populary known as the mubery stone. It is transluscent, and appear only in acid urine
covered with sharp projections. These causes the

157
 - They assume a cast of the renal pelvis and - The pulse quickens and as the attack
calyces progresses the temperature becomes subnormal.
- Are hard and pink or yellow when first - An attack of colic rarely lasts more than
removed 8hrs
- On exposure the colour changes to a - The condition is often due to stone
greenish colour entering the ureter but also occurs when a stone
- They are opaque due to the sulphur they in the renal pelvis temporarily blocks the pelvi-
contain ureteric junction. Colick may be caused by
5. Xanthine calculi passage of a shower of oxalate crystals e.g after
- They are extremely rare eating an excess of strawberries.
- They are smooth and round 3. Haematuria:
- Brick red in colour - Rarely haematuria, is a leading , or the
- They show a lamellar structure only symptom.
- As a rule haematuria occurs in small
Clinical features of renal stones amount (enough to render the urine smoky)
 50% of pts with renal stones are between during or after an attack of pain.
30 and 50yrs 4. Pyuria:
 The male – female ratio is 4:3 - Infection of the kidney is liable to
 Symptoms are not stereotype and supervene and pus will be found in the urine in
sometimes the diagnosis remain obsequire until varying amounts.
radiological examination has been done - Stones lead to an increase in the number
1. Quiescent calculus: - Especially those of white cells in the urine even in the absence of
mainly composed of phosphate lie dormant for a infection
long time during which there is progressive Investigations:
destruction of the renal parenchyma, uraemia
may be the first indication. Secondary infection 1. Radiographs of K.U.B
usually supervenes.
2. Pain: - I s the leading symptom in 75% of DDX of renal calculi on a radiograph;
the cases - Calcified lumbar/mesenteric lymphnode
a) Fixed renal pain – is located in the renal - Gallstone or concretion in the appendix
angle posteriorly often worse on movement, - Drugs like fesolate or FB in the
particulary on walking upstairs G.I.Tphleboliths
b) Ureteric pain: - - Ossified tip of the 12th rib
- An agonizing pain passing from the loin - A chip fracture of the transverse process
to the groin coming on suddenly. of the lumbar vertebrae
- Causes the pt to draw up his kneesand - Calcified tuberculous lesion of the kidney
roll about - A calcified suprarenal gland
- Often accompanied by vomiting and 2. Urine analysis and culture
profuse sweating 3. Blood urea nitrites
- Strangury may occur if the stone is in the 4. Cystoscopy
intramural ureter ( strangury is the passage of few
drops of urine, often blood stained, after painful Treatment:
straining.
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 1. Surgical removal - Occasionally torsion develops during
2. Extracorporal shock wave lithotripsy sleep.
(stone banger). A shock wave is generated within
an ellipse and if the kidney stone is placed where Clinical features:
the the waves focus will be broken up. - Highest incidence is between 10 and 25
TORSION OF THE TESTES: yrs of age
- The second most common age period is
It is also known as torsion of the spermatic cord. during infancy
- Symptoms vary with the degree of torsion
Predisposing factors (causes): - The most common is the sudden
- Torsion of the testis is not common agonizing pain in the groin and lower abdomen
- It does not occur in a normal, fully and
descended testis. - Vomiting
- It’s anchorage prevents rotation. NB: it is difficult to distinguish torsion of an
Therefore one of the testicular anomalies must be imperfectly descended testis from a strangulated
present; inguinal hernia until the parts have been exposed on
operation.
1. Inversion of the testis – This is the
commonest predisposing cause - The side of the scrotum is emptyand
2. High investiment of the tunica vaginalis – I oedematous
t causes the testis to hang within the tunica like a - A tender lump at the external abdominal
clapper in the bell. Occasionally, torsion is ring
extravaginal. - Torsion of a completely descended testis
3. In cases where the body of the testis is is less difficult problem to diagnosis
separated from the epididymis. – Torsion of the - In other times it can be confused exactly
body can occur without involving the cord. The by a small, tense, strangulated inguinal hernia
twisting is confined to the messentry that joins compressing the cord and causing congestion.
the testis to the epididymis - Torsion of the fully descended testis can
also simulate closely acute epididymo-orchitis.
Exciting causes:
After 6hrs or so have elapsed the skin of the scrotum
Normally the cremaster contracts concurrently with becomes reddened and slight elevation of
violent contraction of abdominal musculature. temperature (up to 37.2 oc).
Contraction of the spirally attached cremaster favours
rotation around the vertical axis in the relevant cases. - Scrotal elevation relieves pain of
epididymitis but increases the pain of torsion of
- Straining at stool the spermatic cord.
- Lifting heavy wts and - It is therefore important to rule out
- Coitus , mumps, in a boy, and urethritis in an adult. If
these two are ruled out then the diagnosis should
Are all exciting causes but usually hx does not reveal
be insisted upon.
any of them.
Treatment:

159
In the first hr or so, attempt to untwist the testis may d) By connection with the peritoneal cavity
immediately relief the pain. Try gentle twisting in one as in the congenital type.
direction.relief is obtained if towards the right
direction. Pain increases if it is towards the wrong Hydrocele fluid:
direction.urgency is removed if untwisting is achieved - Amber coloured
but operation and fixation should be performed as - Specific gravity is 1.022-1.024
quick as possible. - Contains water, inorganic salts, 6%
- Urgent exploration of the srotum is albumin and some fibrinogen.
indicated if untwisting is not successful. If after - If the fluid is run through a cannula into a
exploration the testis is viable, then it mustbe receptacle, it does not clot but,
fixed to avoid reccurence. The opposite testis - If a few drops of bld come into contact
should also be fixed at the same time. the hydrocele fluid clots firmly.
- A totally infracted testis shoud be - In old standing cases the fluid may
removed contain so much cholesterol
- If the testis is seen days or wks later the
pain is subsided and little is to be gained.
- The testis will slowly become woody and Diagnostic rules for hydrocele:
shrink to a fibrous nodule.
- 99% out of every 100 hydroceles are
- The opposite testis must be fixed at an
transluscent
early date.
- On examination it is possible to get above
HYDROCELE: the swelling.

Definition – it the collection of serous fluid in some

part of the processus vaginalis, usually the tunica.
1. Primary vaginal hydrocele:
Anatomical varieties of congenital hydrocele:

1. Vaginal hydrocele
- most common in middle aged or elderly
2. Infantile hydrocele (unusual)
men but may
3. Congenital hydrocele
- occur ( not common) in children
4. Hydrocele of cord
- common in tropical countries
Aetiology: - the only comlaint is the swelling and pt
only seeks aid when the swelling is massive
a) Excessive production of fluid within the - in acute hydrocele in a young man, there
sac e.g. secondary hydrocele may be an underlying testicular neoplasm which
b) Defective absorption of hydrocele fluid by can be confirmed by an ultra sound
the tunica vaginalis. This appears to be the - About 5% of inguinal hernias are
common variety of primary hydrocele. The cause associated with a vaginal hydrocele of the same
is not clearbut damage to the endothelial wall by side.
low grade infectionis thought to be the cause. - Usually alarge hydrocele obsecuresa small
c) Interference with the drainage of fluid by inguinal hernia.
the lymphatic vls of the cord. -
2. Congenital hydrocel:
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 HYDROCELE en BISAC:
- The processus vaginalis communicates
with the peritoneal cavity but; - Rare
- The communicating orifice is too small to - Has two intercommunicating sacs, one
develop a hernia above, one below the neck of the scrotum
- The fluid disappears into the abdomen - The upper sac lies supervicial to or partly
when the pt lies horizontal but reappears when within the inguinal canal and it may move itself
an erect position is resumed. into muscle layer.
- Ascites or ascetic TB peritonitis should be Complications of a hydrocele:
suspected in bilateral cases.
1. Rupture
- Usually traumatic but may be
3. Infantile hydrocele: - Sometimes spontaneous
- On rare occasions cure results after
absorption of the fluid
2. Hernia of the hydrocele in longstanding
- Does not necessarily appear in infants cases. This is caused by tension of fluid within the
- The tunica and processus vaginalis are tunica.
distended up to the internal abdominal ring but 3. Transformation into a haematocele. May
there is no connection with the general peritoneal be spontaneous or as a result of trauma
cavity. 4. Calcification of the sac wallsometimes
occurs in the longstanding cases

4. Encysted hydrocele of the cord Management:

1. Surgery –Hydroelectomy
2. Tapping. After transillumination, the
- Forms a smooth, oval swelling associated swelling is made tense by manual compression. A
with the spermatic cord. canula is inserted into an unquestionably
- May be mistaken for irreducible inguinal transluscent area and the fluid evacuated.the sac
hernia usuallyrefills. Repeated tapping is liable to be
- On traction upon the testis it moves followed by oozing of blood into the sac. Deposits
downwards and becomes less mobile (and this of blood on the walls of the sac increases its
confirms the diagnosis). thickness and so diminishes its transluscence

HYDROCELE OF THE CANAL OF NUCK: SECONDARY HYDROCELE:

- This is a condition comparable to the - An effusion into the tunica vaginalis which
encysted hydrocele of the cord accompanies certain conditions affecting the
- It occurs in females testes.
- The cyst lies in relation to the round - It is usually associated with acute and
ligament chronic epididymoorchitis.
- Unlike hydrocele of the cord, a hydrocele - Is nearly always present in syphilitic testis.
of the canal of Nuck is always wholly, or partially, - Occasionally complicates malignant
in the inguinal canal. conditions of the testes
161
 - Secondary hydrocele rarely attains a large - Competent sphincter control.
size.
- Usually lax and does not interfere with A careful history and physical examinationwill usually
the palpation of the testes and its epididymis. be sufficient to disclose the cause. Investigations of
the urinary system as a whole, is nearly always
POST HERNIORRHAPHY HYDROCELE: indicated. The urine should be cultured for evidence
of infectionand biochemical estimation of the bld to
Appears after an operation for inguinal hernia in 0.2% assess renal function.it may be approperiate to have
0f the cases where there wasn’t an evidence of a anatomical visualization of the urinary tract with
hydrocele pre-operatively. This could be due to intravenous urography, although ultrasound
damage of the lymphatic vsls of the tunica vaginalis. examination will often provide adequate details.
HYDROCELE OF A HERNIAL SAC: Causes of incontinence:
The neck of a hernia sac becomes plugged with Common causes may be classified into male, female
omentum or occluded by adhesions and a hydrocele or mixed sex groups;
develops.
Male;
FILARIAL HYDROCELE AND CHYLOCELE:
- Chronic urine retension with overflow
- Filarial hydrocele usually follows repeated - Secondary to BPH which may be
attacks of filarial epididymitis. coexistent with ca prostate
- It develops rapidly or gradually. - Hypetrophy of the bladder neck usually in
- Can be large or small. a yuoinger age group.
- It is frequently bilateral. - Rarely urethral stricture
- In early cases, the hydrocele fluid is - The key to the diagnosis is history of
similar to that found I the idiopathic variety. prolonged hesitancy and a poor urinary stream
- In longstanding cases, if the fluid is placed with both daytime and nocturnal “drippling
in a tall glass, after afew hrs a film of liquid fat incontinence”.
(chyle) will be floating on the surface.
- This is rich in cholesterol, and is derived Examination may reveal;
from rupture of a lymph varix into the tunica.
- The presence of chyle is proof (positive) - A visible distended bladder
of the filarial origin of a hydrocele. - A lost transverse suprapubic crease
- A painless distension of bladder may be
INCONTINENCE OF URINE: palpable or percused.
- Post-operative (post prostatectomy) –
Passage of urine depends on a fine balance between may result from injury to the external sphincter
the bladder having a storage capacity. The brain being mechanism.
aware of fullness, and the subsequent coordination of
the detrussor and the urethral sphincters to perform Females;
the act of voiding. The basic prerequisites of urinary
incontinence include; - The commonest is stress oincontinence
secondary to laxity of the pelvic floor with
- Anatomical intergrity incompetence of the bladder neck and sphincter
- Cerebral awareness mechanism. It most commonly occurs in the late
- A degree of mobility and multiparous group. The pt complains of loss of
162
 urine associated with coughing, sneezing and - To decrease strength of neck ( adrenergic
even with change in positure. blockers)
- Cystocele. - Mixed action on bladder neck and CNS
(tricyclic drugs)
Common on both sexes; 2. Intermittent self catheterization
1. Congenital; 3. Devices for collection or control;
- Ectopiae viscae and severe epispadiasis - Condoms
- Abnormal entry of a ureter below the - Indwelling catheters
sphincter complex or into the vagina in females - Penile clamp (cunnigham device)
2. Trauma from pelvic injury or pelvic 4. Outlet surgery;
surgery - Prostatectomy
3. Infection – simple cystitis especially - Bladder neck widening
women - Sphinctectomy
4. Endocrine – occasionally women suffering 5. Denervatio n of bladder;
from thyroitoxicosis - Neurectomy
5. Neoplasia – local advanced cas in the - Transection of bladder
pelvis. 6. Augumentation of bladder capacity;
- Ileocystoplasty
Other causes : - Caecocystoplasty
7. Artificial sphincter
a) Neurogenic ;
8. Urinary diversion –ureteroileostomy
- Myelodysplasia
9. Correction of bladder neck distortion;
- Multiple sclerosis
- Raising bladder neck
- Spinal cord injuries
- Correction of cystocele
- Cerebral dysfunction (CVA, Dementia)
- Levatoplasty procedures
10. Control of infection

b) Psychogenic;
- As in hysteria in women or
URINE RETENSION
- Depressive illness in both sexes
c) Capacity disorders – reduced bladder
capcity as in TB bladder which heals with fibrosis.
d) Drug induced; It can be acute or chronic
- Anticholinergics Chronic leads to ultimate retension with overflow.
- Tricyclic anti-depressants
- Lithium ACUET RETENSION:
- Some anti-depressants
- A side effect of phenothiazides Aetiollogy;

Treatment of functional incontinence: In males:

1. Drugs; Prostatic enlargement

- To increase strength of bladder neck Urethral stricture
(adrenergic agonists)

163
Post operative  Always admit for observation for at least
24hrs to;
In females:  Relief anxiety – chemotherapy
Retroverted gravid uterus  Warm bath usually reliefs ( pt may void)
 Pass a urethral catheter using aseptic
Multiple sclerosis technique

Hysteria If catheterization fails the the other option will be

tried i.e;
In male child:
1. Suprapubic puncture—with a wide bore
Meatal ulcer with scabbing
needle to relief acute retension
Other causes; 2. Suprapubic cystostomy with
catheterization- through a 1.25 cm incision made
Following spinal analgesia under L.A 2.5 cm below the level at which the
anterior surface of the bladder curves upwards
Blood clot in bladder
and backwards to form a dome.
Rupture of the urethra 3. Immediate prostatectomy incase of
benign enlargement of the prostate if the pt fit.
Neurogenic (injury to the spinal cord) 4. Urethral instrumentation- incase of
stricture to dilate the stricture. A catheter is
Fecal impaction in the rectum
usually passed afterwards to empty the bladder
Acute urethritis/prostatis
After catherterization it is important to record the
Urethral calculus volume drained and a pt’s abdomen examined, a few
minutes after the procedure to rule out any intra
Phimosis abdominal pathology.
Certain drugs
CHRONIC URINE RETENTION:
Muscular atony due to advanced age
e) Distension is usually painless
Anal pain (e.g. following haemorrhoidectomy)
f) Bld urea must be estimated before any
Clinical features: attempt is made to relief the retension. If urea is <
70 mg% (12mmol/l) treatment is as outlined for
- History of not passing urine for some hrs retension. > 70mg% slow decompression is
and is unable to do so. advisable.
- Suprapubic sweeling by a full bladder
which is tender on palpation and dull on RETENSION WITH OVERFLOW:
percussion above the symphysis pubis.
The pt has no control over his urine, small amounts
- Acute pain due to spasm.
passing involuntarily from time to time from an
Treatment: overflowing bladder. It may follow a neglected acute
retension or chronic retension. Treatment is as for
NB- never relief or attempt to relief acute retension acute retension but decompression of the bladder
and send the pt home. must be done slowly.
164
Summary of digfferentials of urine retension It lies in the pelvis infront of the rectum and behind
the symphysis pubis
1. Intraluminal:
- blood clot It surrounds the first part of the urethra
- Stone (rare): acute pain in the penis and
glans. It sits at the base of the bladder
- Prolapsing bladder tumor Seminal vesicle lies posteriorly and receives the vas
- Congenital Urethral valves- neonates, deferens from the testis and drain into the posterior
males, recurrent UTI prostatic urethra.
- Foreign body (rare)
- Tumours (rare): TCC or squamous cell Seminal vesicles don’t store sperms but produce
carcinoma. History of haematuria, working in dye secretions which nature the spermatozoa
or rubber industry.
The prostate gland lies in the fibromuscular stroma
2. Intramural:
and their ducts open into the posterolateral grooves
- BPH: frequency, nocturia, hesitancy, poor
on either side of the veromentosum. The epithelium
stream, dribbling, urgency.
is columnar commencing peripherally, and passing
- Prostatitis
centrally, beneath the anatomical capsule lie the long
- Prostate carcinoma
branched prostatic gland proper.
- Urethral stricture: history of trauma or
serious infection, gradual onset of poor stream This region is named as carcinomatous zone. Beneath
- Urethral trauma: blood at meatus this envelop, and separated from it by an indefinite
3. External: capsule, lie another mass of secreting elements, also
- Ovarian cyst: mobile iliac fossa mass branched (the submucosal gland). The zone that they
- Pregnancy occupy is known as the adenomatous zone. Nearer
- Fibroids: palpable, bulky uterus, the urethra are the unbranched urethral glands
menorrhagia, dysmenorrhoea whose mouths opens directly into the urethra.
- Pelvic mass
- Faecal impaction: spurious diarrhoea Into the urethra therefore, open the prostate ducts
4. Neurological proper, the ducts of the submucisal and mucosal
- Spinal injury: acute phase is lower motor glands, and the common prostatic duct. That is
neurone type, late phase is upper motor neurone whyinfection of the prostatic urethra is difficulty to
type eradicate.
- Multiple sclerosis
The middle lobe is that part of the prostate between
- Polio
the common ejaculatory ducts and prostatic urethra.
- Prolapsed disc
- Diabetes: progressive upper motor An enlarged prostate is invested with three capsules;
neurone lesion
- Drugs: narcotics, anticholinergics,  The compressed outer zone (true capsule)
antihistamine, antipsychotics  The anatomical capsule (false capsule)
- Postoperative: pain, drugs, pelvic nerve  The prostatic sheath of pelvic fascia
disturbance
Between the anatomical capsule and the prostatic
sheath lies the prostatic venous plexus.
FUNCTIONAL ANATOMY OF THE PROSTATE:
PHYSIOLOGY:
165
The prostate is purely a genital organ because is confined to the gland and almost never in BPH slightly
usually rudemental except during the increased values commonly occur in;

rutting season in animals (as goats).  Acute prostatitis

 Paget’s disease of bones
Hormonal influence;  Liver cirrhosis.
The prostate is governed by two hormones, thus,

1. Male (androgenic) – usually the one in BENIGN ENLARGEMENT OF THE PROSTATE:

large amount and most important testicular
hormone. It is supplemented by the adrenal BENJAMIN BRODIE’S THEORY;
glands.
2. Female (estrogenic) – causes “When the hair becomes grey and scanty, when
retrogressive changes. specks of earthly matter begins to be deposited in the
artery and when a white zone is formed of the
Semen; cornea, at this same time the prostate gland becomes
increased in size."
This is the fluid ejaculated at the time of orgasm
Incidence:
It contains sperms, secretions from seminal vesicals,
prostate, cowpers glands and urethral glands Usually occurs in men above 50yrs of age

The volume is approximately 2.5 3.5 ml after several Most often between 60 and 70yrs
days of continence
Is less frequent in Indians and more often in
The volume decreases with repeated ejaculations younger age groups

Normally 100million sperms per ml Rare in Negroes (the reason for these discrepancies is
not known)
Acid phosphatase:
Aetiology:
These are enzymes that split organic phosphates and
most active at a PH of 5. 1. Hormonic theory – as age advances the
male hormones dimish while the quantity of
They are present in many human tissues but their estrogenic hormone is not decreased equally. The
concentrations in the adult prostate are greater than prostate therefore, enlarges due to predominance
in any other organ or tissue. of the oestrogenic hormone.
These higher levels are attained after puberty. 2. The neopllastic theory – the prostatic
enlargement is a benign neoplasm because the
Most of the acid phosphatasesecreted by the prostate prostate is composed of fibrous tissue, muscle
drains along the prostatic duct into the urethra to tissue, and glandular tissue, the neoplasm is a
keep the bld levels low. fibromyoadenoma.

When the cells producing this enzyme cannot Pathology:

discharge their products externally, the serum levels
of acid phosphatase rises. The serum acid Hyperplasia affects the glandular element and
phosphatase is usually normal if the growth is connective tissues but in variable degrees. The

166
changes are similar to those occurring in breast If no relief to the obstruction the bladder
dysplasia where adenosis, epitheliosis, and stromal hypertrophies to become atonic and tired bladder and
proliferation occur in different proportions. Benign makes no attempt to overcome the obstruction.
adenomatous hyperplasia affects the submucous
group of glands, forming a nodular enlargement, “the URETERS AND KIDNEYS:
typical lateral lobe” which compresses the external Increased intravesical pressure causes dilatation of
group of glands into a false capsule. As the gland the ureters, followed by some degrees of
enlarges extravesically, it it tends to displace the hydronephrosis. The bladder hypertrophy wanes and
seminal vesicles so that instead of lying on the base of the sphincter mechanism around the ureteric orifice
the bladder, these structures become a direct ceases to function leading to reflux of urine from the
posterior relation of the upper limit of the prostate. bladder to the dilated ureters. This progresses leading
When the hyperplasia affects the subcervical glands a to ascending infection
“middle” lobe develops which projects into the
bladder within the internal sphincter. Sometimes both SEXUAL ORGANS:
the lateral lobes project into the bladder, so that
In the early stages of prostatice enlargement there is
when viewed from within the sides and back of the
increased libido.
internal urinary meatus are surronded by an
intravesical prostatic collar. Later impotence is the rule.

Clinical features of urine retension:

SECONDARY EFFECTS OF PROSTATIC ENLARGEMENT: 1. Frequency;
URETHRA; Is the earliest symptom
Prostatic urethra becomes elongated At first norcturnal
The canal is compressed laterally It becomes progressive and then becomes present
day and night
BLADDER:
When the vesical sphincter becomes stretched a little
The musculature hypertrophies to overcome
urine escapes into the normally empty prostatic
theobstruction
urethra, causing an intense reflex desire to void and
When the middle lobe projects upwards into the uregency is added to the frequency.
bladder it acts as a dam to the last ml of urine which
Later on, as residual urine increases frequency
remains in the prostatic pouch.
becomes more and more evident leading to terminal
Calculi are prone to form in the stagnant pool of drippling.
urine.\the enlarged prostate may compress the
Lastly cystitis and nocturia develops due to renal
prostatic venous plexus leading to congestion of veins
insufficiency.
(vesical piles) at the base of the bladder and may
cause haematuria. 2. Difficulty in micturition – pt waits
patiently for urination to start. It is useless to
strain.
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 3. Variable stream – usually weak, tends to If benign;
stop and start and dribbles towards the end of
micturition. - The lateral lobes are increased in size
4. Pain – due to cystitis or acute retension of - They are smooth, convex, typically elastic
urine. Dull pain in the loins is indicative of but may feel firm due to fibrous tissue
hydronephrosis - Rectal mucosa is moved off the prostate
5. Fullness of the perineum or rectum - Median sulcus is lost
6. Acute retension of urine is usually the - Feels rubbery.
first symptom that compels the pt to seek relief - Bimanually an intravesical lobe can be felt
7. Retension with overflow – urine - If pressure is exerted on the apex of the
constantly dribbles away. Norcturnal enuresis prostate while finger already in the rectum, there
should be a warning will be a degree of mobility of the gland.
8. Haematuria – from an enlarged prostatic - Residual urine may be fely as a fluctuant
vein or ulceration of the prostate. mass over the prostate
9. Renal insufficiency. If due to prostitis;
Examinations: - Indurated and tender
Pt lies supine on the bed or couch If due to carcinoma;
Inspection; - Stony hard and nodular
- Suprapubic distension may be seen If due to prostatic calculi
- Loss of suprapubic transverse skin crease
- Tongue may be dry and brown, a sign of - Stony hard and nodular
renal insufficiency
Conditions which mimmick prostatic obstruction;
Palpation;
- Diabetes mellitus
- Suprapubic mass - Tabes dorsalis
- Renal areas for tenderness and possible - Disseminated sclerosis
enlargement of the kidneys - Cervical spondylitis
- Epididymis for signs of inflammation - Parkinson’s disease and other
neurological states
Percussion;
Investigations:
- Dull percussion note suprapubically
1. Micturography to record pt’s stream and
Urine; volume
- Low specific gravityindicates renal 2. Bld urea
insufficiency 3. Bld count
4. Serological tests for syphilis
Rectal examination: 5. Urinalysis for glucose, bacteria, albumin,
c/s
- Done in absence of full bladder 6. i.v.u
- Done bimanually on dorsal position 7. plain abdominal X-ray – K.U.Bultrasound

168
 8. cystourethroscopy 3. Infection
4. Incontinence due to damage to external
Management of retension: sphincter
 Acute retension is painful and should be 5. Retrograde ejaculation and impotence
relieved by decompression by the passage of 6. Stricture
urethral catheter. 7. Bladder neck contracture
 Chronic retension is painless and if no 8. Osteitis pubis
symptoms of coexisting infection and have normal General complications:
creatinine (serum), they do not necessarily
require catheterization 9. Cardiopulmonary;
 In uraemic pts decompressing is a must 10. Pulmonary atelectasis
 Uraemic pts are usually dehydrated and 11. Pneumonia
therefore should be rehydrated 12. Myocardial infarction
 Due to the chroinic back pressure on the 13. CCF
dilated tubules within the kidney salt and water 14. DVT
are not properly reabsorbed hence post 15. Water intoxication – reabsorption of
obstructive diuresis (so replace the fluid) water during transurethral irrigation which may
 Pts are usually anaemic (transfuse) lead to ccf, hyponatraemia and haemoptysis.
 Catheterization or 16. Confusion
 Suprapubic puncture
 Prostatectomy

Indications for prostatectomy: URETHRAL STRICTURE:

 Prostatism – difficulty in micturition,

increased, delay in starting, and a poor stream. Causes;
 Frequency alone is not an indication
 Enlargement rarely gets worse after 10 1. Congenital
yrs 2. Traumatic(accidental) – bulbous –
 Acute retension unrelieved by membranous
catheterization, emptying the bladder, and 3. Inflammatory – post gonococcal –
immediately removing the catheter. posturethral chancre - tuberculous
 Chronic retension – residual urine of 4. Instrumentation - indwelling catheter -
200ml or more, raised bld urea, hydronephrosis following passage of large caliber endoscope,
and uraemia notably a rectoscope
 Complication – stone, infection, 5. Postoperative – postprostatectomy –
diverticulum formation amputation of penis
 Haemorrhage 6. Postgonococcal stricture:(It has reduced
since the advent of antibiotics)
Complications of prostatectomy:
Sites;
Local:
- In the bulb – 70%
1. Reactionary haemorrhage - At the penoscrotal junction
2. Perforation of the bladder
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 - Distal part of the spongy urethra (in The stream becomes progressively narrower
that order).
Micturition is prolonged and dribbling occurs after the
NB; the membranous and prostatic parts are excempt end of stream due to trickling of urine from the
dilated urethra above the stricture
Multiple strictures are common
Frequency of micturition at first during the day and
Where there are two strictures, the deeper is the then both day and night and this is due to incomplete
narrower emptying of the bladder at each act of micturition,
When the strictures are three, the deepest is the cystitis or both
narrowest The stricture may be palpated as an induration in the
If a penile urethral stricture orifice is very narrow, there is urethral floor in long standing cases.
rarely another stricture behind it. If untreated, sooner or later retension of urine
Pathology: ensues.

Usually follows an inadequately treated gonorrhoea. The In some cases, narrowness of the stricture leads to
infection persists in the periurethral glands and spreads to inability to expel residual urine, and acute on chronic
the periglandular tissues. The tissues become infiltrated retension, or retension with overflow occurs.
with round cells and fibroblasts. The infiltrated tissues Investigations:
then contract with the formation of scar tissue. There is
also localized thrombophlebitis of the corpus spongiosum 1. Urethras copy
as seen in more dense varieties. Fibrosis in the bulbous – locates the precise site of the stricture
urethra is mostly seen in the roof, while it predominates – May show false passages of recent
in the floor of the penile urethra. Most strictures are said penetration of the urethra infront of the stricture
to develop in the first yr aftergonorrheal infection and due to unskillful attempt to pass a bougie. The
may not give rise to difficult in micturition for 5-15yr. false passages are bound to bleed.
2. Urethrography – gives information
Clinical features: concerning the length of the stricture
In large caliber stricture; Treatment:
Passage of flakes (desquamated epithelium) in urin A. Instrumentation treatment:
There may be varying amount of urethral discharge Intermittent dilation carried out gently with bougies
(gleet) which is evident in the early mornings “dew of increasing size.
drops”.
 Don’t forcibly dilate or overdilate the
The above symptoms are neglected until the caliber stricture as they may result in inflammatory
narrows causing difficulty in micturition. oedema and subsequent formation of more
NB; unlike obstruction due to an enlarged prostate, fibrous tissue
the pt feels he must strain to empty the bladder  Small strictures should be dilated twice a
week at first, then once a week for a month and
Another distinguishing feature is the age. The pt is then once a month for a yr.
often younger than the prostate sufferer.

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 B. Operative treatment: 4. Periosteal artery which enters bone
 Urethrotomy through minute canaliculi (volkmann’s canal) and
 Urethroplasty supplies the outer 2/3 of the cortex.
5. From attached soft tissues, muscles and
Complications of urethral stricture: ligaments.
1. Retension of urine Functions of bone:
2. Urethral diverticulum- due to increased
pressure behind the stricture a) It forms the rigidy framework of the body
3. Periurethral abscess b) Levers muscles
4. Urethral fistula c) Protection of the;
5. Hydronephrosis > urinary infection>
urinary calculi Brain and spinal cord
6. Due to straining the following may be Heart and lungs
induced;
 Hernia Liver and spleen
 Haemorrhoids
Urinary bladder
 Rectal prolapsed
d) Contains marrow which produces Rbcs,
Wbcs, and Platelets.
e) Stores calcium, phosphorous, magnesium
and sodium

Biochemical composition of a bone:

Organic substances - 35%

Inorganic substances - 45%

TRAUMATOLOGY: Water -- 20 %

Introduction: Histologically bones are;

Bone- This is a supporting connective tissue forming the 1. Immature (woven)

frame work of the body. Apparently it may look inert but 2. Mature i.e. cortical (compact) or
it is in dynamic equilibrium with body metabolism. It is cancellous(spongy)
the main store house of calcium and phosphorous. It
FRACTURE:
grows in length by endochondral ossification and in width
by intramembranous ossification. It has bld vsls, nerves, Defition:
and lymph vsls.
It is a complete or incomplete break or crack in the
Blood supply: continuity of a bone or

1. Nutrient artery A structural break in the normal continuity of bone

2. Epiphyseal artery
3. Metaphyseal artery The fracture may also occur through cartilage,
epiphysis, and epiphseal plate.
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Dislocation: bone rapidly. In adults it is thin, adherent to the
cortex and produces new bone less rapidly. For these
- A partial disruption of a joint with partial differences healing of fractures in children is rapid.
remaining, but abnormal contact between the
articulating plates. The articular surfaces are PAHOLOGY OF FRACTURES AND FRACTURE HEALING:
nolonger in contact.
A fracture can be;
Sublaxation:
Simple (losed) – The overlying skin remains intact, the
- This is a partial dislocation. Some of the bone is incompletely divided and the periostuem in
articular surface is in contact, the congruence of continuity. This is what happens in greestick and
the two joints has been lost. compression fractures.

Mechanism of injury: sufficient violence is required to An open (compound) fracture -- the skin or one of the
cause a fracture of normal bone, but trivial (minimal) body cavities is breached and is liable to
trauma can cause fracture in a fragile bone. The contamination and infection.
violence can be;
Classification of fractures:
 Direct- when violence is applied directly
and causes fracture at site of violence. The bone Classification of fractures is wide and varied. It may
breaks at the point of impact and soft tissues are take any of the following the modes;
also damaged. A direct bow usually causes a  Classification by quality of bone in
transverse fracture and damage to overlying skin. relation to load;
 Indirect – violence is transmitted to
distant part. The bone breaks ata distance from Here the fracture occurs when the load to which they
where the force is applied for example when the are subjected exceeds their intrinsic strength.
head of the radius is fractured in a fal on an
- Simple fracture which is produced when
outstretched hand or fracture clavicle in a fall on
an excessive load is applied to normal bone.
the shoulder.
- Pathological fracture which is produced
Tubular bone may be broken either by direct or when the strength of the bone is reduced by
indirect violence. Cancellous bone may be fractured disease. In this case a force which is within normal
either by compression or by tension. May limits leads to a fracture as in osteoporosis and
compression fractures may occur if a pt falls from a metastasis of tumours.
height and lands on his heels. Traction injuries only - Stress fracture in which is fatigued and
occur in cancellous bones to which a ligament or then breaks due to continous mechanical stress as
tendon is attached for example medial malleolus. in people playing high levelsport.
- Partial or greenstick. Bones in young
Periosteum: people are flexible. Th ey bend and may buckle or
A dense fibrous tissue covering a bone. It is connected partially break, instead of breaking cleanly when
to marrow space with connective tissue through overloaded.
volkmann’s canals. It supplies bld to bone and  Classification by direction of force;s
stimulates osteogenesis. It has two layers, thu fibrous - Compression fractures. The load applied
(outer) and cellular (inner). In children the periosteum along the length of the bone exceeda that of its
is thick, loosely attached to cortex and produces new strength then it may collapse into itself. This is
common in the elderly due to osteoporosis
172
 - Avulsion or distraction fractures. Here bone gives way from trivial violence or even
two fragments of bone are pulled apart. They are spontaneously. It is produce when the strength of
common where srong muscles insert into small the bone is reduced by disease. In this cause the
bones. Examples are the patella ( the quadriceps), force which is within normal limit leads to a
olecranon(triceps). fracture. The disease could be generalized
- Spiral fractures. When a long bone is osteoporosis or a localized lytic lesion from
twisted along its axis metastasis.
- Transverse fractures. When a long bone
is bent along its axis Causes;
- Butterfly fractures. If a bone is struck by a 4. Infection
direct blow, a more complex fracture may follow
where two break lines spread outward from the - pyogenic osteomyelitis usually the chronic form.
point of contact of the blow, producing a free
- syphilitic infection (syphilitic metaphysitis).
floating “butterfly” fragmentbetweenthe two
fractures > Benign tumours
- Comminuted fractures. They occur when
a large amount f energy is dissipated - haemangioma
(unrestrained) into a bone. The bone breaks into
- chondroma
fragments which may impact into each other or
separate and become displaced. - giant cell tumours (osteoclastoma)
 Classification by anatomical site
> malignant tumours
A long bone is divided into three main zones;
- osteosarcoma
- The diaphysis which is the marrow part of
the shaft. It has a thick cortex and a medulla filled - Ewing’s tumour
with trabecular bone
- Solitary myeloma
- The metaphysic the part which flares at
each end between the diaphysis - Metastatic carcinoma( from the lungs, breast, thyroid,
- The epiphyseal plate. In infants and kidneyand prostate)
children, in whom the bones are still growing, the
epiphyseal plate will be open. The plate is weaker > Miscellaneous
than the bone around it and so fractures tend to
- Simple bone cyst
track along it or even across it.epiphyseal
fractures are important because they can have a - Monostatic fibrous dysplasia
poor prognosis.
A. Etiological - Bone atrophy in paralytic conditions such as polio
i) Traumatic fracture (a single traumatic - Tabes dorsalis
incident). It is due to sudden injury and is by far
the largest group and may be direct or indirect. A - Eisinophilic granuloma
simple traumatic fracture occurs when excess
load is applied to a normal bone. - Brittle state after irradiation
ii) Pathological fracture: The term is applied General affection of the skeleton
to a bone already weakened by disease. Often the
173
7. Congeneital disorders like osteogenic D. In children (radiological)
imperfecta i) Epiphyseal separation
8. Diffuse rarefaction as in senile ii) Epiphysealfracture separation
osteoporosis, cushing syndrome, infantile rickets, iii) Greenstick fracture
uraemic osteodystrophy (renal rickets), cystinosis m) fracture of one cortex and bending of the
(fanconi syndrome) and nutritional osteomalacia. appropriate cortex
9. Miscellaneous – including pagets disease, iv) Buckle fracture – cortex is punched out by
polyostotic fibrous dysplasia, Gauchers disease force along a long axis.
and Hand-Schiiler-christian dsease.
Site of fracture:

Other than recording the actual bone which is

iii) Stress (fatique) fractures: This is due to fractured it is necessary to describe the situation
repeated trauma at same site. The bones are within the bone. The fracture may be at an end of the
subjected to a large number of loads, none of bone in which case it will involve the joint in which
which could be enough to break the bone. The the bone articulates. These are known as articular
mechanical structures of the bone can gradually fractures. Such fractures in children are known as
fatique and the bone will then break. Cracks cann epiphyseal fracture.
occur in bone, as in metatarsals and attached
materials due to repeated stress. This is commony Displacement:
seen in tibia, fibular metatarsals and neck of It refers to the deformity which may be present
femur especially in athletes dancers army recruits following a fracture or dislocation. It describes the
who go on long route matches with a few position of the distal component relevant to the
exceptions. This fractures are usually confined to proximal component. The causes of deformity
bones of lower limbs with a great majority include;
occurring in the metatarsals.
B. Clinical Initial force
i) Simple or closed
Gravity
ii) Compound or open
iii) Complicated – the nerves, vsls and vital Effects of contraction of muscles attached to the
organs are affected. fractured fragment.
C. Radiological
i) Transverse fracture due to angulation Movement of the pt during administration of first aid,
force transport to hospital and during the cause of initial
ii) Oblique fracture due to twisting force assessment is also an important cause of deformity.
iii) Spiral fracture due to twisting force This can be diminished by early application of
iv) Comminuted fractures – more than 2 temporary splintage. The fragments may be shifted
fractures sideways, backwards or forward in relation to the
v) Avulsion fractures- a small fragment other fragment, such that the surfaces lose contact.
pulled and shifted by muscles The fracture heals even if apposition is imperfect or
vi) Impacted fracture – force a long axis of even if the bone ends lie side by side without making
bone e.g. neck of femur or humerus contact with the fracture surfaces.
vii) Burst/ shattered – multiple small
Types of displacement:
fragments with separation.
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 1. Shift – There is loss of alignment of the (b) Stage of periosteal and endosteal cellular
cortices of the shafts proliferation:
2. Angulation - Loss of normal longitudinal
axis of the shaft.
3. Shortening – There is overlap of the bone In the early stages there is proliferation close to the
fragments but may result from impaction of one fracture
fragment onto the other.
4. Twist (rotation) – Rotation of the distal These cells or precursors of the endoblasts which will
fragment around the long axis of the bone, either later tay down the intercellular substance
external or internal.
They form a collar of active tissue that surround the
5. Distraction – Prolonged by overvigorous
fragments
traction during treatment.
Simultaneously( at the same time)with the
Fracture healing:
subperiosteal proliferation there is cellular
It starts to heal as soon as the bone is broken. Repair activitywithin the medullary canal, where the
of tubular bones occurs in five stages; proliferating cells appear tobe derived from the
endosteum and the marrow tissue of the fragment.
i) Stage of haematoma formation This tissue grows forward to meet and blend with
ii) Stage of periosteal and endosteal cellular similar tissue growing from the other fragment.
proliferation
iii) Stage of callus formation (c) Stage of callus formation:
iv) Stage of consolidation
As cellular tissue that has grown out from each
v) Stage of remodelling
fragment matures, the basic cells give origin to to
osteoblast, chondroblasts which form the cartilage.

(a) Stage of haematoma formation: The osteoblasts lay down intercellular matrix of
collagen and polysaccharide which soon become
impregnated with calcium salts to form the inactive
When the bone is fractured bld seeps out through bone of fracture callus. This from its tyexture has
torn vsls and forms a haematoma between and been termed woven bone
around the fractured surface. The formation of this bridge of woven bone imparts
The haematoma is contained by the surrounding soft obvious rigidity to the fracture and when an injured
tissue – periosteum and muscles which may be stripped bone is a superficial one the callus may be felt as a
up from the bone end to a variable extent. hard mass surrounding the fracture.

The fracture divides most of the capillaries that run The mass of a bone is also visible in the radiographs
longitudinally in the compact bone, a ring of bone and gives the 1st radiological evidence of bone union.
adjacent to the side of the fracture becomes (d) Stage of consolidation:
ischaemic over a variable length, but usuall few mm,
deprived of bld supply the osteocytes near the surface The woven bone that forms the primary callus is
die. gradually transformed by activity of the oateopblasts
into mature bones which has a typical lamella
structure.
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 (e) The stage of remodeling: Fatique fractures are seen in the 2nd and 3rd
metatarsal, fracture of tibia, fibula. Fractures of
When union is complete, the newly formed bone carpal bones like the scaphoid and greenstick
forms a bulbus collar which surround the bone and fractures of the forearm
obliterates the medullary canal b) Clinical examination:
Callus is usually profuse in children because the The following features are fairly constant findings;
periosteum is easily stripped from the bone by
extravastated bld, allowing bone to form beneath it. (i) Is there a wound communicating with the
fracture
In the months that follow, union is strengthened (ii) Is there any impairement of circulation
along the lines of stress which is slowly removed and distal to the fracture
reabsorbed elsewhere and the bone is thus restored (iii) Is there any evidence of nerve injury
more or less to original form. The process of (iv) Is there any evidence of visceral injury
remodeling is going on constantly, but
inconspicouslyin every bone throughout life but it Some positive findings above may make a case a
becomes especially obvious after a fracture. surgical emergency or influence the outcome of
treatment.
Clinical and radiological features of fractures:
NB: The presence of skin laceration does not
a) History – necessarily mean that the fracture is open.
A statement that the pt is unable to stand or walk State of circulation:
after an injury or to use the injured part should
arouse suspicion of a fracture. The part of the limb distal to the fracture must be
examined for evidence of circulatory impairement.
A history of visible bruising appearing a day or so after
an accident is also suggestive. The examination should be repeated frequently in the
1st 48 hrs after a fresh fracture that has been
In fatique or pathological fractures there may be immobilized in a p.o.p or that has been operated on.
spontaneous onset of pain and disability without any
causative agent Severe pain within a P.O.P or markedswelling of the
digits should arouse suspicion and therefore the
And incase of a malicious injury to a baby an accurate following tests should be done;
account is deliberately withheld
1. Colour:
Caution:
Pink colour is reassuring
A clinician is often misled to belief that no fracture
exists because the pt has retained the use of painful A blue, grey or white colour should arouse suspicion.
limb in certain causes function is preserved despite
the fracture such fractures include; fatique fractures, 2. Warmth:
impacted fractures, fractures of small bones. Warm digits suggest circulatory flow
When common sites for these fractures are borne in Cold digits do not necessarily cause alarm especially if
mind, diagnostic mistakes can be avoided. Impacted the limb is encased in a fresh P.O.P that is still damp.
fractures of the neck of the femur, neck of humerus
and lower end of the tibia. 3. Arterial pulses:
176
It is a reliable guide to the state of circulation Incase of doubt the clinical tests about the intergrity
arterial circulation;
Where necessary the pop should be trimmed
sufficientlyto allow access to pulse 1. Doppler ultrasound or arteriography

In compartment syndrome in which tension from State of the spinal cord and peripheral nerves:
oedema and haematoma within a closed fascial Simple tests of sensibility, motor function, sweating is
compartment in the forearm/leg builds up to the sufficient to indicate whether or not there has been
extent that the viability of contained tissues become an injury to the nervous system or cauda equine.
impaired, the pulse may be present. In such case
severe and unremitting pain is an important clue to State of the viscera: - Investgate the state of bladder/
the the compartment syndrome. urethra in every fracture involving the anterior part of
the pelvis.
When digital bulb or a nailbed is compressed with a
finger nail, and blanching can be seen around the
point of pressure. If on release bld flows back briskly
into the blanched area in a pink flush means that
circulation is adequade. MANAGEMENT OF FRACTURES:

4. Nerve conductivity: At the hospital;

An ischaemic nerve quickly loses ability to transmit Assessment is required to determine

impulses
Whether there is a wound communicating with the
Loss of sensibility in the digits in the absence of fracture
physical injury to the nerve suggests ischaemia
Whether there is evidence of nerve injury
In deciding whether sensory impairement is caused by
Whether there is evidence of vascular injury
trauma to a nerve or by ischaemia it should be
remembered that in ischaemic lesions all nerve trunks Whether there is evidence of visceral injury
in the limb are likely to be affected. Whereas it is
unusual for all nerve trunks to be involved in an Resuscitation;
injury.
Many pts with severe or multiple fractures are
Total sensibility of a hand or foot suggests ischaemia, shocked on arrival at hospital
whereas insensibility in the territory of a single nerve
Time must be spent on resuscitating the pt before
denotes mechanical injury.
definitive treatment of the fracture is begun
NB: Motor tests are less valuable than tests of
The mainstay of antishock treatment is immediate
sensibility because the long extensors and flexors are
replenishment of the circulating blood to restore a
innervated high up in the forearm and leg and will
normal blood volume and electrolyte balance, clear
continue to move the digits despite complete
airway and pulmonary ventilation.
ischaemia in the distal part of the limb.
Treatment of uncomplicated closed fractures;
Specific tests:
The 3 fundamental principles of fracture management
are:
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 1. Reduction certain types of fracture displacement of cervical
2. Immobilization spine.
3. Preservation of fuction (rehabilitation)
Traction may be applied by wt (or by screw devices)
(fixed traction)

A. REDUCTION: The aim is to gain full reduction GA or gradual

reduction by prolonged traction without anaesthesia.
This 1st principle must be qualified with the words The wt applied is 10% of the body wt.
if necessary because in many fractures reduction is Open Operative reduction:
unnecessary
This is indicated when other methods failand
If judged that perfect function can be restored in occasionally as a method of choice, the fragments are
some of the uncorrected displacement of fracture reduced under direct vision at open operation.
fragments, there is no object in striving for perfect
anatomical reduction for example broken fragments When operative reduction is restored the fragments
of a child’s clavicle and the same applies to most are fixed internally to ensure their position is
fractures of the clavicle in adults. maintained.

In general imperfect apposition of fragments may be B. IMMOBILIZATION:

acceptable than imperfect alignment e.g. in the shaft
of the femura loss of ½ a diameter may be acceptable Like reduction this second great principle must be
whereas an angular deformity of 20degrees would qualified by the words “ if necessary”
demand reduction. Whereas some fractures must be splinted rigidly
Methods of reduction: there are many that do not require immobilization to
ensure union and there are some in which ecxcessive
1. By closed manipulation immobilization is harmful.
2. By mechanical traction with or without
manipulation Indications for immobilization;
3. By open reduction 1. To prevent displacement or angulation of
Manipulative reduction: fragments
2. To prevent movement that might
Closed reduction is usually done under GA but local or interfere with union
general anaesthesia is appropriate. 3. To relief pain

The technique is to grasp fragments through soft Methods of immobilization:

tissues to disimpact them if necessary and then to
adjust them as nearly as possible to correct position. 1. By P.O.P or other external splints
2. Continous traction
Reduction by mechanical traction: 3. By external fixation
a. Immobilization by pop, splint or brace
The contraction of large muscles exerts a strong
displacing force, mechanical aid is necessary to draw In most fractures the standard method of
the fragments out to the normal length of the bone immobilization is by pop cast
especially fractures of the shaft of the femur and to
178
For some fractures a splint made from metal, wood or Continous traction is often combined with some form
plastic is more appropriate e.g Thomas splint for splintage to give support to the limb against
fractures of the shaft of femur or plastic collar for deformity – usually a Thomas splint or modified
certain injuries of the cervical spine. Thomas splint in case of a femoral shaft fracture,
Braun’s splint in case of tibia fracture.
Caution – When pop is aaplied on a fresh fracture or
after operation on alimb, always monitor circulatory The Gallow’s or Bryant method of traction for fracture
impairement or undue swelling within the pop. femoral shaft in young children embloy principle of
immobilization by traction without any additional
Arterial supply to the distal part of the limb splintage (children up to the age of 3yrs)
The period of greatestdanger is between 12-36hrs Also in this category is traction upon the skull for
after the injury or operation. cervical spine injuries.
Severe pain within the plaster and marked swelling c. Immobilization by external fixation:
are warning signs calling for a careful reassessment of
peripheral circulation This is rigid anchorage of bone fragments to an
external device such as a metal bar through a medium
Take note hat after the operation upon the limbs a of pins inserted into the proximal and distal fragments
coagulated blood soaked dressing may act in exactly of a long bone # (external fixator).
the same way as a tight plater and may seriously
obstruct the circulation External fixator finds its main application in the
management of open fractures or infected # where
Cast bracing (functional bracing): the use of internal fixation devices such as plaster or
A brace is a supportive device that allows continued nails is undesirable because of the risk of promoting
function of the part, in this case a fractured long bone or exacerbating infection.
(e.g. # of the femoral shaft or tibia)is supported It may be used in the treatment of certain closed #s of
externally by pop or by mouldable plastic material in long bones as an alternative to internal fixation
such a way that the function of adjacent joints are
preserved and use of the limb for its normal purpose Immobilization of internal fixation:
can be resumed. The technique entails snug fitting of
the plater or plastic material over the appropriate May be adviced in the following circumstances;
limb segment incorporation of hinges at the level of 1. When it impossible in a closed # to
adjacent joint. This procedure is carried out the maintain an acceptable position by splintage
fracture is already becoming “sticky” usually 5-6/52. alone or in combination with traction.
b. Immobilization by continous traction: 2. When it becomes necessary to operate
upon a # to secure adequate reduction
In some fractures especially those of femoral shaft, 3. As a method of choice in certain #s to
tibia, lower humerus may be difficulty or impossible secure rigid immobilization and allow earlier
to hold the fragments in position by pop or external mobility of the pt.
splintsalone.
Methods used;
In such case the pull of muscles must be balanced by
continous traction upon the distal fragment either by a. Plates held by srews
a wt or other mechanical device. b. Bone graft held by screws

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 c. Intramedullary nail They are considered in two groups thus;
d. Compression screw plate
e. Nail-plate (combined nail and plate) 1. Those involving the fracture itself
f. Transfixion screws (intrinsic group)
g. Circumfrential wires and bands 2. Those attributable to associated injury
h. Suture through attached soft tissues involving other tissues (extrinsic group)

TEST OF UNION OF FRACTURES: Intrinsic group:

A. Clinical test; i. Infection

ii. Delayed union
There are 3 clinical tests of union, i.e, absence of iii. Non union
iv. Avascular necrosis
i) Mobility between # fragments v. Mal – union
ii) Tenderness on firm palpation over the vi. Shortening
site of #
iii) Pain when angulation stress is applied at Extrinsic group:
the site of the #
i. Injury to major blood vessels
These tests together are reliable but should always be ii. Injury to nerves injury to viscera
confirmed by radiological studies. iii. Injury to tendons
iv. Injury and post traumatic affection of the
B. Radiological criteria of union joints
They are two, i.e, v. Fat embolism
A. Infection;
1. Visible callus bridging the # and blending
with both fragments Usually confined to open #s, the wound is
2. Continuity of bone trabeculaeacross the contaminated by organisms carried in fromm outside
fracture the body

Visible callus in generally early and more reliable Closed fractures may become infected when it is
converted into an open fracture by operative
Trabecular continuity across the # is evidence of intervention
mature union.
More often the infection extends to the bone giving
Principles of fracture treatment: rise to osteomyelitis. This is a serious complication
because infection by pyogenic organisms tends to
Initial management ( first aid) at the scene of the
become chronic.
accident;
Part of the bone may die due to impairement of blood
1. Ensure clear airway
supply forming a sequestra.
2. Cover any wound with clean dressing
3. Provide some form of immobilization Infection is a potent factor in delaying or preventing
4. Make the pt comfortable while awaiting union
for hospital help.
Treatment:
Complications of fractures:
In acute recent infection;
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Provide adequate drainage usually bone grafting operation offers the best
prospect of promotinunion.
Antibacterial indication
C. Non union:
The wound is left open to eliminate potential pockets
of pus by appropriate incision or excision of tissue When fracture remains ununited for many months
distinctive radiological changes take place which
Between dressings the limb is immobilized in POP indicate apermanent state of mal- union, the bone
with external fixation ends at the site of the fracture become dense and
When the infection is overcome and wound becomes rounded and the rounded # line is a clear cast.
lined by healthy granulations, wound closure may be Pathologically the healing process appears to have
attempted by secondary suture or skin graft come to an end , there is no attempt to bridge the #
with callus, the gap between the bone fragments ius
Antibiotics e.g flucloxallin + fusidin acid, erythromycin filled with fibrous tissue, in some cases a cavity may
+ fusidic acid. The choice antibiotics depends on c/s form in the fibrous bridge, Suggesting an attempt to
for a false joint (pseudo arthrosis)
In chronic osteomyelitis, pus continous to discharge
and fragments of bone may die and separate as Causes of non union;
sequestra. All sequestra must be removed and bone
that is honey comb with small pus containing with 1. Infection of bone
muscle flap or in case of a superficial bone such as 2. Inadequate bld supply to one or both
the tibia by lining the saucerized cavity with skin graft fragments
direct to the raw bone by a cancellous bone graft 3. Excessive shearing movement between
from the iliac bone. the fragments.
4. Interposition of soft tissues between the
B. Delayed union fragments
5. Loss of apposition between the fragments
There is no absolute time beyond which a # in a
(including over distraction by traction apparatus)
delayes union are freely mobilized 3-4 months after
6. Dissolution of fracture haematoma by
the injury. If a state of delayed union persists for
synovial fluid (in fractures within joints)
many months, it eventually passes into a state of mal-
7. Presence of corroding metal in the
union. The distinction between delayed in the
immediate viscinity of the fracture
condition of the bone to indicate that union will fail
8. Pathological fractures ( destruction of
altogether. In non union characteristic changes are
bone as by tumour)
observed, radiologically which suggest union will
never occur. NB sometimes two or more of these factors may act
together. Acting in slight degree, some of these
Causes of delayed union: the causes are like those of
factors may be responsible for delayed union.
non union but acting in a less degree
Treatment of delayed union;
Treatment:
Depends on the site of the fracture and the degree of
Treatment is expectantant at 1st, for one hopes will
the disability
eventually without surgical intervention
If the disability is slight, it is best left untreated e.g.
6 months or more union doesn’t appear to be
fracture of scaphoid bone.
progressing surgical, treatment must be considered,
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When surgical treatment is desirable most ununited 3. Body of the Talus after # through the neck
#s of long bones tend to respond well to treatment by of the Talus
bone graft 4. Lunate bone

In certain #s within or near a joint excision of one of Diagnosis:

the fragments or its replacement by a prosthesis is
appropriate. Radiographs after 1-3 months after injury

D. Avascular necrosis Radioisotope scanning with 99cm technetium. The

affected part is devoid of bld vsls, the isotope is not
This is death of bone from deficient bld supply. It may taken up and the avascular bone may be shown as a
cause intractable non union, disabling osteoarthtritis, void area.
total disorganization of a joint.
Treatment:
Pathology:
AVN demands early operation because of the
AVN occurs when bld supply to a bone or part of likehood of disorganization of adjacent joints; excision
abone is interrupted by injury (or rarely by disease). It of the fragment is undertaken.
may occur as a complication of a fracture articular
surface where terminal fragment is devoid of vascular If necessary reconstruction of the joint by some form
tissue attachment and depends for its nutrition of arthroplasty or stabilize it by arthrodes.
almost entirely upon the interosseous vsls which may
be torn at the time of injury, dislocation if vital bld vsls
supplying the bone are torn or occluded. E. Mal- union:

The immediate consequence of ischaemia is that the This is imperfect position of union of the fragments.
bone cells die and if the part affected is within a joint
The union may be by angulation, rotation, loss of end
cavity, there is little chance that it can be
to end apposition, overlap and consequent
revascularized from surrounding tissues before
shortening.
irreversible changes occur.
Treatment:
The avascular bone loses its rigid trabecular structure
and becomes granular; in this state the bone Each case is considered on its merit
crumbles easily and under stress imposed by muscle
tone or body wt and eventually collapses into an Slight deformity may be acceptable without
amorphous mass. treatment in others correction of deformity by
refracturing or dividing the bone and after correction,
In most cases a joint whose surface suffers AVN is fixing the fragments by appropriate means.
doomed to crippling osteoarthritis whether or not
fractured eventually unites. F. Shortening: Arises from 3 causes;
a) Malunion- union of fragments with
Sites: overlap or marked angulation
b) Crushing or actual loss of bone as in
1. Head of femur after the # of the femoral
severely comminuted compression #s or in gun
neck or dislocation of the hip.
shot wounds when a piece od bone is shot away.
2. Proximal ½ of the scaphoid bone after #
through the waist of the bone.
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 c) In children, interfering with growing Brachial artery- # supracondylar of the humerus and
epiphyseal plate. As a rule epiphyseal growth dislocation of elbow
plate will be impaired by crushing injury than by
avulsion injury with a fracture separation of the Politeal artery- dislocation of the knee and displaced #
epiphysis. of upper end of tibia.

Shortening is important only in lower limbs. Rupture of medial meningeal artery from # of
Shortening of up to 2cm is not significant and may not temporo-parietal region of the skull also comes in this
be noticed. If more than 2cm it should be correcte by category.
appropriate raising of the shoe or by a leg shortening Clinical features:
operation on the opposite side.
1. Peripheral circulation (after # of a long
Uncorrected shortening may cause aching in the back bone)
from tilting of the pelvis and consequent scoliosis.  Ischaemia – pain on attempted extension
G. Injury to major bld vsls: of toes and fingers
 Numbness and sensation of digits
A fracture can result to injury of adjacent tissues e.g.
muscles, fair and minor bld vsls, but results to Treatment:
spontaneous healing of the # Should be immediate before ischaemia which is
Sometimes an important artery may be damaged by irreversible
either the agent causing the fracture or by the sharp Occlusion can be primary or secondary( after
edge of the bone fragment. reduction or immobilization).
Serious complications that may lead to loss of the 1st step:
limb
Remove the bandage. Gross displacement of
The vsls may be torn, occluded by thrombosis, fragment, if not reduced, gentle manipulation is
contused or may merely be temporarily sealed by made.
aneurysm.
If adequate circulation is not achieved within ½ hr the
The effect may be; next step is taken.
1. Traumatic aneurysm 2nd:
2. Impaitred bld supply leading to gangrene;
ischaemic paralysis of the nerves or contractures Damaged artery is exposed and nature of injury
of muscles (volkman’s ischaemic contracture) determined

NB: vascular occlusion may be caused by tissue If the occlusion is kinking or spasm of artery an
edema within closed fascial compartment or by attempt is made to free the vsls, by applying
overtight plaster or bandage especially 2/7 after papaveritne (an arterial relaxant)
injury or operationwhen swelling reaches its peak.
Heparinized saline may be injected between the
Examples; clamps

Axillary artery- # dislocation of the shoulder If the vsl is divided restoration of patency using
freshened end sutures is made
183
If the occlusion of a thrombi following damage to the  Cauda equine (lumbar spine)
intima then end arterectomy with repair using a vein  Sciatic nerve ( hip dislocation with #ed
can be made. acetabulum)
 Common peronial nerve (knee especially
H. Compartment syndrome: the lateral ligament torn)
Miscles are enclosed within a fascial compartment. Nerve injuries were classified by seddon into 3 types;
This is swelling occurring within a compartment as
aconsequence of a injury and a viscious circle isset up; i. Neuropraxia

The swelling occludes smaller arteries or veins Damage is slight and causes only transient
supplying the muscle physiological block

Muscle becomes ischaemic and thus promotes Recovers spontaneously within a few wks
swelling
ii. Axonotmesis
Within a few hrs irreversible changes occur; muscle
becomes necrotic and nerves in the compartment Internal architecture of the nerve is preserved
lose their conductivity because of ischaemia. Axons are badly damaged that peripheral
The muscles are eventually replaced by fibrous tissue degeneration occurs
threatens to produce contractures (volkman’s Recovery occurs but depends upon regeneration of
ischaemic contracture ) seen in most flexor muscles of axons and may take months (2-3cm per month.
the fore arm and leg.
iii. Neurotmesis
Compartment syndrome shows that peripheral pulses
may be present and this may deflect the unwary from Structure of the nerve is destroyed by actual division
the true diagnosis. or severe scarring

Treatment: Recovery is possible after excision of the damaged

section; with end to end suture of stumps orbridging
It demands immediate operation to decompress the by nerve graft.
whole length of the affected compartment by
fasciotomy. Treatment:

I. Injury to nerves:  Expectation especially in closed #s but

recovery is not observed within the expected time
Peripheral nerves are injured moreoften than major exploration is made; so that repair can be made.
arteries  In open #s with suspect that the wound is
Common sites are; severed then the ends are tackled together and
definitive repair made. In most cases a nerve
 Brachial plexus ( forcible depression of repair is postponed until a wound healed. Best
the shoulder) time is 3-4 wks after injury.
 Circumflex nerve (shoulder nerve) J. Injury to viscera:
 Humerus (radial nerve)
 Ulnar nerve ( medial epicondyle) Caused by the agent causing the injury or implement
 Spinalcord (cervical/ thoracic spine) upon a sharp fragment of bone

184
Examples are; High tendencies is also in the lowerlimbs in pts with
prolonged or permanent brain damage from head
 Laceration of pleura injury and in pts with paraplegia from spinal injuries
 Lung complicating # of the ribs
 Rupture of the bladder or urethra Treatment:
 Penetrationof colon or rectum
 Complicating # of the pelvis Minimize the formation of haematoma by enforcing
 Rupture by direct trauma to the trunk complete rest from the joint, preferably in plaster for
without # 3-4 wks

Treatment: Treatment should consist of active excercises with

avoidance of strains or stretching that might provoke
Follow general surgical principles further bleeding beneath the soft tissues

Inury to tendons: After several months it may be necessary to excise a

mass of bone that is blocking movement but the
In open fractures tendons may be severed by the operation is not successful but must be done with
agent causing the fracture caution.
Injury to the joints: Osteoarthritis (degenerative arthritis):
Acute joint injuries such as dislocation, sublaxation or Any roughening or irregularity of a joint surface is
ligamentous strain are common complications of liable to precipitate the wearing and tear changes that
fractures. form the basis of osteoarthritis
Post traumatic ossification: It involves an articular surface unless the fragments
Also known as myositis ossificans are replaced so perfectly in that thee smooth contour
of joint surface is unimpaired
It is a rare cause of joint stiffness after # or dislocation
Even in slight step between fragments may lead to
Occurs in case of severe injury of a joint especially serious subsequent disability from arthritis especially
when the capsule and periosteum have been stripped in wt bearing joint
soft tissues, forming a large haematoma about the
joint Avascular necrosis is a cause of severe osteoarthritis
or of total disorganization of a joint.
Instead of being absorbed it is invaded by osteoblasts
and becomes ossified If fragments unite with angular deformity, throwing
the joint out of its correct alignment, because of mal-
If a large mass is formed, then restriction of joint alignment of joint surface causes excessive stress at
movement is severe one part of the joint and consequently accelerates
wear and tear changes thus creating a high risk of
It is a complication encountered mostly in the elbow
osteoarthritis.
after # dislocation, also in the hip dislocation
Examples of circumstances above include knee after
There is risk of its occurance in children than adults
mal-union of # of the femoral shaft.
because children the periosteum is only loosely
attached to the long bones and easily stripped from The risk of osteoarthritis is higher in wt bearing joint
them. of the lower limb.
185
After severe damage in a joint, osteoarthritis may Another clinical manifestation include petechial rash
become clinically evident within 6-9 months of the usually infront of the neck, anterior axillary fold or
injury whereas in slight damage or mal-alignment it chest or in the conjunctiva
may become apparent for 15-20 yrs.
The finding of such a rash strongly supports a
FAT EMBOLISM: diagnosis of fat embolism syndrome.

It is uncommon Diagnosis:

A serious complication of # Arterial bld gas analysis which may show reduction in
partial pressures of oxygen in the bld vsls (often
The essential feature is the occlusion of small bld vsls below the critical level of 60mmhg at which respiratoy
by fat globule failure is likely).
Pathology: Treatment:
More significantly affects the lungs and the brain Spontaneously ,reversible if the pt can be handled
In the lungs there is oedema and haemorrhages in the over the dangerous period of hypoxia which may be
alveoli, so that transfer of oxygen from alveoli to corrected by administration if necessary with positive
arterioles is impaired pressure respirations

This thus leads to hypoxaemia which may be severe The oxygen requirement should be controlled by
repeated bld gas analysis
In the brain there may be multiple petechial
haemorrhages which occur in other organs and the The administration of methylpredinisolone in pts with
skin severe multiple injury may help toprevent and correct
adverse effects of fat embolism by maintaining bld
Clinical features: oxygen tension and stabilizing the free fatty acids

Occurs after severe fractures in the lower limbs Heparin or dextran 40 may also be administered
particulary the tibia and femur intravenously to improve capillary flow.

Onset is within 2 days of injury but note that there is a

symptom free period between injury and onset an
important part of distinction of cerebral contusion

The presenting feature of breathlessness, usually

associated with cerebral disturbance in the form of
marked restlessness, contusion, drowsiness and
coma.

The above syndromes may be caused partly by

petechial haemorrhage in the brain but in large
measure they are secondary to hypoxia from
occlusion of small vsls in the lungs. Associated
features are tarchypnoea and dyspnoea AMPUTATION:
186
Definition: Classical amputation: These are planned amputations
where regular skin flaps are raised and the wound is
Indications: Ablation of a limb is an extreme step and an closed after ablation of the limb.
irreversible operation and every care should be
Revision amputation: They are done;
Amputation should be considered only if the limb is;
As a second stage in guillotine amputation

Dead (gangrenous), To those with very unsatisfactory stumps following a
previous amputation.
 Dying (grossly ischemic),
 Dangerous (due to malignancy) or Selection of level of amputation: The classical sites of
 Dud (useless limb) amputation of limbs are determined on the basis of the
following considerations;
Common indications for amputation are;
The disease process for which the amputation was done
 Traumatic conditions: Crash injuries to to eradicate the pathology.
the limb
 Vascular conditions: Ischemic conditions The vascular supply to the skin flaps.
of limbs; The requirement of limb fitting procedures and
 Thromboangitis obliterans (buerger’s techniques available at that time.
Disease)
 Arteriosclerosis: Senile and diabetic Radiography of the part is done to see the extent of the
 Gangrene: Dry and Moist malignant disease. In some cases arteriography may be
 Neoplastic conditions: Malignant tumors used to assess the vascularity of the limb and level of
of bones or soft tissues (Osteosarcoma, viability.
Synoviosarcoma)
Levels of amputation:
 Infective conditions:
– Leprosy: When the leg is totally useless Lower limb;
and grossly destroyed
– Actinomycosis of the foot or hand Hind quarter amputation
– Filarial elephantiasis
Hip disarticulation
 Congenital conditions: when the limb is
grossly deformed and useless. Above knee amputation

Types of amputations: Through knee amputation

Guillotine amputation: This is an emergency amputation Below knee amputation

done as a life saving measure. It is done in cases of gross
crush injuries of the limb. It is also indicated in cases of Syme’s amputation
gas gangrene, when a rapid removal of the dangerously
Fore foot amputation
infected part is a life saving procedure. In Guillotine
amputation the incision is circular around the limb at the Toe amputation
site of bone section and all the wound is cut at the same
level and the wound is left open to provide free drainage. Upper limb;

187
Foerquartet amputation locomotion and sensory feedback. The wt bearing could
be (a) end bearing, (b) side bearing or (c) proximal
Shoulder disarticulation bearing.
Above elbow amputation A good stump should be neither too long nor too short. It
Elbow disarticulation should have good muscle power with full movement in
the proximal joint and a healthy non adherent scar. It
Below elbow amputation should a fleshy end with no bony spurs. The care of the
stump consists of;
Wrist disarticulation
Stump bandaging with crepe bandage to improve its
Finger amputation
shape for limb fitting.

Stump exercises to improve its motor power and

Basic principles in amputation; movements in the proximal joint.

The following steps are applicable to all levels of Stump hygiene to maintain the skin and scar in good
amputation on the limbs; condition.

Mark out and raise appropriate skin flaps. Complications of amputation;

Cut muscles and soft tissues 1/2@” proximal to skin Immediate:

section.
Infection
Cut bone 1” proximal to skin section.
Secondary hemorrhage
Identify blood vessels and ligate.
Skin sloughing.
Cut nerve ends and allow them to retract.
These are preventable by control of infection and proper
Remove tourniquet and obtain hemostasis technique in suturing.

Suture the muscles and cover the bone end Late:

Place a drainage within the wound Stump neuroma

Suture deep fascia and skin. Phantom limb

Apply dressing and compression bandage Contractures

Provide a splint to rest the stump Neuroma: This is the development of a bulbous swelling
at the cut nerve end. It is tender and causes pain on wt
Stump and its management: bearing. Pain may be relieved by local hydrocortisone
injection or in some cases by ultrasonic therapy.
The stump is the residual part of the limb left after the
amputation. It should be just an anatomical residue but Phantom limb: In this condition the pt feels that the limb
should be an active motor organ to move the prosthesis is still present and he may feel even pain in some areas in
and also give some sensory feedback. In the lower limb the non existent foot or toes. It usually clears up with
amputation, the function to be restored are wt bearing,

188
reassurance, analgesics, stump exercise and regularity in At deliverly, hold foot of baby in neutral position and
the use of prosthesis. evert and dorsiflex it. Normally the foot can touch the
shin bone. If there is antagonism in this movement
then a diagnosis is made.

Treatment:

ORTHOPAEDICS: Should be started as early as possible to avoid later

complications.

Unit 1: conditions of the soft tissues, bones and joints. In mild cases the correction should be made by 6/12.

Congenital deformities: Passive manipulations under nothing

1. Talipes equino varus/valgus (club foot) In moderate cases, manage ment is by manipulation
and splinting under local anaesthesia and splint in
Definition: a congenital deformity that presents as a Denis Browne splint or P.O.P. leava it for 1/52,
club foot i.e inward twisting (inversion), adduction of remove P.O.P, manipulate and reapply the p.o.p. later
the forefoot and plantar flexion (equino). It is continue at every 2/52 up to 6/52.
common in boys than girl
Metatarsal varus is corrected by stabilizing the talus
Causes; and abducting and everting the foot.
It appears to be a combination of geneticand The equinous is corrected by pulling down the
environmental factors ( intrauterine positioning) calcaneumand pushing the metatarsal bases upwards.
Is associated with hypohydromnious or If the deformity persists,
polyhydromnious
Manipulation under anaesthesia, then the deformity
Clinical features: is corrected and held in desired position in long leg
n) Common in boys trhan girls plaster with the knee joint in a flexed position at 90
degrees. The pop will be left for 1/12 and removed at
-Shortening of tendo-Achilles the age of 9 monctomyths when the child starts to
step on the ground on his soles. Orthopaedic shoes
Calcaneous is smaller and points downwards
are advised.
The heel doesn’t step down and there is inversion of
Surgical:
fore foot
1. E.T.A (elongation of tendo Achilles)
Internal rotation of the tibia
2. Muscle slide ( tendons of tibialis
Wasting of the cuff muscles due to disuse posterior) should take about 3/12.
3. Arthrodesis
Shortening and thickening of soft tissues especially 4. Wedge tarsectomy.
the Talo-Navicular capsule which will give riise to
Navicular dislocating medially

Diagnosis: 2. Genu varus/ valgus Recaurvatum

189
Genu varus: a deformity where one presents with As a clinician refer all these pts.
bow legs.
3. Pes cavus:
Genu valgus: where one presents with knock knee
Definition:- refers to a hollow foot where the
Recurvatum: longitudinal arch is raised or exaggerated.

pt presents with hyperextension of the knee joint. Causes

In children this deformities correct spontaneously i. Congenital abnormality where the

with or without treatment. muscles of the dorsum c xare stronger than those
of the plantar aspect (heredity)
Causes: ii. Could be due to any form of neurological
1. Fracture of lower femur or fracture upper disorders (e.g. polio, spina bifida) with resultant
tibia paralysis giving rise to muscle imbalance.
2. Rarefying of bones due to some diseases Pathology:
e.g. rickets, osteomalacia causing postural
defects due to tear and wear, leaving some debri 1. Metatarsal heads are lowered in relation
which are deposited at the articulating surfaces. to the hind part of the foot with increased
3. Uneven growth of epiphyseal plates due longitudinal arch
to diseases like osteoarthritis 2. Shortening of the soft tissue leading to
3. Clawing of toes due to defective action of
Diagnosis: intrinsic muscles leading to
It is not easy because of underlying diseases. Patient 4. Functionless toes (wt bearing is lost)
lies supine, puts legs together and check on the 5. Excessive wt borne on the metatarsals
posture. head
6. Malalignment of the structures of bones
Management: (joints) complicating development of
osteoarthritis due to tear and wear.
Treatment is generally conservative.
Clinical features:
Orthopaedic boots
It may present in one or both feet
If in genu valgus, inner raise is put.
Symptoms:
If in genu varus, outer raise is put
1. Painful callosities beneath the metatarsal
If there is any underlying cause like rickets,
heads
chemotherapy is given.
2. Tenderness over deformed toes due to
In severe cases there are three types of operations pressure against the shoes
done,
Signs:
i) Epiphysiodesis:- fusing the epiphysis so
1. Longitudinal arch is raised
that they don’t grow any more
2. Thick fore foot
ii) Supracondylar femoral osteotomy
3. Clawed toes
iii) Tibial osteotomy.
4. Metatarsal heads are prominent on sole
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Management: Definition: the pt presents with hyperextension of the
knee joint. In children with this deformity correct
1. Conservative spontaneously with or without treatment.
Sponge rubber pad Causes;
Surgical boots 1. Fracture lower or upper tibia
2. Surgical treatment 2. Rarefying of bones due to some diseases
a) Arthrodesis – making an artificial fracture e.g. rickets, osteomalacia causing postural defects
then the bone fused together at all due to tear and wear leaving some debris which
interphalangeal joints. are deposited at the articulating surfaces causing
b) Long flexor tendon transplantation into postural deformities.
the extensor expansion (muscle slidig operation), 3. Uneven growth of epiphyseal plates due
p.o.p immobilization and removed later and pt to disease like osteoarthritis.
trained by physiotherapist. Diagnosis;
PES PLANUS: Usually not easy due to underlying cause (disease).
Definition: it is characterized by reduced longitudinal Between 1-3 yrs they are known as false (benign)
arch of foot. The medial borderis close to or in contact equino- varus.
with the ground. Pt lays spine, puts legs together and check on the
Cause: posture.

1. Congenital Management;
2. Neurological disorders resulting in muscle The treatment is generally conservative
imbalance
Orthopaedic boots
Pathology
- If in equinovalgus – innerraise is put
The tarsals when articulating take a form of a straight - If in equinovarus an outer raise is put
line rather thanan arch. - If there is any underlying cause like rickets
Clinical features: , chemotherapy is adviced.
- In severe cases there are three types of
i. Symptomless in children operation done;
ii. Symptomless in adults except foot strains 1. epiphysiodesis – fusing the epiphysis so
could be common which may develop to that they don’t grow any more
osteoarthritis later. 2. supracondylar femoral osteotomy
3. Tibial osteotomy.
Treatment:
As a clinical officer just refer them.
a) Conservative:- (i) inner (medial) raise (ii)
fitting an arch support in the shoes
b) Surgical – arthrodesis of the talocalcaneal
joint CONGENITAL HIP DISLOCATION (CHD)

GENU RECARVATUM
191
Definition : a condition in which a child is born with the Clinical features:
dislocation of the hip (one or both hips). It is common in
girl ifants. The causes are unknown Commonest age is between 6 months and 3yrs

Points of diagnosis (ostolan’s test) Head is tilted to one side

Shortening of the limb Contracted muscle feels as a tight cord

Broad perineum Ear of the affected side is approximated to the

corresponding shoulder
Skin creases
Retarded development of the face on the affected
Limited abduction side

NB x-rays are misleading Diagnosis:

If with the above features and is; History of the above feature in a period of <.> 6/12-
3yrs
0-5 yr = septic arthritis
There should be a tight contracted
5-10 yrs = perthes disease sternocleidomastoid
10- 15 =slipped epiphysis Underdevelopment of the face in the affected side
5. 15yr = osteoarthritis ( facial asymmetry)

Treatment: DDX:

Conservative - Trauma

At birth the baby is put on an abduction splint for 3 - Lesions in the cervical nerve roots
months - Abnormal development e.g. cervical wing
In older children it can be reduced under G.A and - Hemivertebra
then put on P.O.P for abduction for 3months
- Infection of the cervical gland
TORTICOLLIS:
- Psychogenic disorders.
Def. it is the commonest form of “ wry
neck”(amusing ) characterized by tilted head as a TREATMENT:
result of the contracted sternomastoid muscle.
In early stages;
Causes
Passive stretching of the muscle
Uncertain but a possible assumption (cause ) is the
interfearance of bld suppl to the sternomastoid. Heat treatment

Pathology: formation of fibrous tissue in mid1/3 of Manipulation

the muscle. Tumour around an infarcted segment of In late stages;
the tumour due to trauma.

192
Surgical- the affected muscle is split at its lower It can be primary or secondary.
attachment to release the contractures.
Primary is due to causal pathology while secondary is
KYPHOSIS: due to a compensatoyr mechanism.

This is a general term used to define excessive Types:

posterior curvature of the spinal column
1. Postural:-
Presentation:
Caused by muscle spasms associated with PID
The deformity can take a form of long rounded curve
Compensatory mechanism (due to leg shortening)
There might be a sharp posterior angulation “hump
back”

In the cervical and lumbar region there is lodosis 2. Structural: Caused by;
K. Osteogenic (congenital) - children born
When localized at the thoracic spine it is called with hemivertebra
thoracic kyphosis 3. Neurogenic paralysis. Common in;
anterior poliomyelitis, severe spina bifida,
Reversing of cervical and lumbar lodosis can lead to neurofibromatosis, syringomyelia, cerebral palsy
cervical and lumbar kyphous. and spinal muscular atrophy
Causes:

1. Tb spine
2. Unreduced vertebral compression
fracture 4. Myogenic: - Generalized muscle weakness
3. Osteochondritis as seen in cases of muscular dystrophy( they
4. Ankylosing spondylitis never survive beyond the age of 17yrs.
5. Senile (old age) osteoporosis 5. Thoracogenic: - It penetrates to the
6. Tumours of spinal column thoracic spine as in Tb spine, ca lung, and
intrathoracic drainage tube.
Treatment 6. Idiopathic: examples here include,
It depends on the cause; rotated vertebra. Rib are prominent posteriorly
“rib hump”.
Treat the cause
When it occurs up to the age of 3yrs it is called
For example if due to TB streptomycin3 months)+ infantile scoliosis and males show more than females
thiazina(18 months)= note that this tregimen has (2/1000 in population).
changed
4-10yrs it is called juvenile scoliosis and females show
Fracture spine must be corrected more than males

SCOLIOSIS: Above 10yrs it is called adolescent scoliosis.

Def. lateral curvature of the spine (S shaped) Investigations:

It could be postural or structural a. Conservative

193
Constant assessment of degree of curvature In 20% of the cases, the condition is degenerative in
origin. There is no history of injury. A small portion of
Measuring of the cardiopulmonary functions the nucleus polposus herniates through it. The
Excercises coupled with spinal braces mechanism of prolapse demands a combination of
stress and mobility. Therefore it is common in mobile
b. Surgical: fusion of the facet joints portions of the spine which are subject to greatest of
stabilized by Harringtout’s distraction rods. stress.

PROLAPSED INTERVERTEBRAL DISC (P.I.D): 19% of the cases occur in the cervical spine at C5/6,
C6/7
Intervertebral discs are interposed between the
vertebral discs. 1-2 % occur in the immobile thoracic spine

Functions: 80% occur in the lumbar region at level L4/5, L5/S1

1. Serve as shock absorbers for the spinal Escape of material leads to;
column.
2. Provide the normal mobility between the 1. Narrowing of the intervertebraljoint
adjacent vertebrae. space which is visible in 50% of the cases
2. Slackening of the anterior common
Each disc consists of a soft central portion of spongy ligamentous vertebrae producing abnormal
material nucleus (polposus) which is surrounded by mobility betweenthe vertebrae of with local joint
tough fibrous ring(annulus fibrosus) which is attached pain and ultimately development of intervertebral
to the adjacent vertebral bodies, the whole being arthritis.
enclosed between fibrocartilaginous plates above and
below. During normal flexion of the spine, the disc is Osteophytes form on the anterior aspect of the major
deformed and the annulus fibrosus and nucleus bulge cervical injuries.
backwards slightly into the neural canal. Alternatively, when spinal ligaments are softened at
Intervertebral disc protrution is produced by the the end of pregnancy tha strain of labour may force
effect of flexion forces acting upon the most mobile out a massive protrution in the lumbar giving rise to
portions of the spine a sudden strain with the spine in the form of obstetric paralysis.
an unguarded position will rupture the tough annulus,
allowing portions of the torn annulus and soft nucleus LUMBAR DISC PROLAPSE:
to escape into the spinal canal and form either a
central protrusion in the midline under the posterior It usually occurs above or below L5. Rarely the disc
common ligament of the vertebrae, or a lateral between 3rd and 4th may be affected. There is low back
protrusion at the side of the posterior common ache with evidence of compression of the 5th lumbar
ligament adjacent to the intervertebral foramen. nerve. If the 1st sacral nerve root is compressed there
is pain and loss of sensation in the back of the leg,
In 80% of the cases, the protrusion is traumatic in sole, side of the foot.
origin and there is either a history of sudden severe
stain or the pt’s occupation is one in which flexion If the 5th lumbar nerve root is affected there is pain
strain must be resisted, such as a packer, porter, and loss of sensation at the back of the thigh, lateral
fireman, etc. the condition is therefore more common aspect of the leg, dorsum of the foot.
in men.

194
Acute prolapsed causes severe pain often following 5th lumbar back of thigh, most of
lifting of heavy wts. The spinal muscles go into anterior tibialis, weak Nil
spasms, the pt is in agony, unable to walk or bend.
The lumbar spine is flattened and sometimes Lateral aspect of leg
sclerotic. dorsiflexion

A prolapsed in the midline presses the cord and Dorsumof foot to big toe
causes back ache alone. 4th lumbar side of thigh, front of
A lateral prolapsed may press on the adjacent nerve quadriceps and diminished knee jerk
roots leading to numbness of foot and diminished Inner aspect of leg
ankle reflex.prolapse of the disc between L5 and S1 anterior tibial, weak
typically produces pain which radiates down the leg,
soleof foot and big toe and is called SCIATICA. dorsiflexion and

Prolapsed of disc between L1 and L2 is less common

but may cause pain in the flanks with radiating pain to extension of knee
the groin which may mimic renal colic or billiary colic.
3rd lumbar front of lower thigh
Prolapsed is often accompanied with scoliosis. This quadriceps diminished knee jerk
scoliosis may change from one side to the other as
2nd lumbar front of mid thigh
the pt bends and extends and is calle ALTERNATING
quadriceps diminished knee jerk
SCOLOSIS.
1st lumbar Groin Nil
Characteristically a pain of prolapsed disc is
Nil
aggravated by cough, sneezing etc.
Treatment:
In the early phase it is often worsened when the pt is
resting in bed. An important feature of disc prolapsed 1. Confinement to bed until symptoms
that distinguishes it from an inflammatory disease e.g. abate, usually 2-4 wks. Majority of cases are
Tb, spondylitis is that in this prolapsed some joints are cured by this method
very mobile and painless unless symptoms are very 2. Surgery is indicated when;
acute whereas in Tb all movements cause pain. In o) Symptoms persist
addition there are no signs of a systemic disease in p) If severe pain reccurs
prolapsed. q) If weakness, sensory loss or sphincter
disturbance develop.
Clinical features relating to level lambosacral disc
compression Operation approaches available are;
N.root affected pain and sensory loss i) Laminectomy
motor weakness reflex change ii) Hemilaminectomy
iii) Fenestration(interlaminar)
1st sacral back of leg, sole and side
iv) Microdisectomy
Gastrocnemius, weak absent Aj
Complications:
Of foot
plantar reflex
195
Even after satisfactory removal of PID, symptoms or Pt presents with pain poften in the anterior thigh and
physical signs are not always alleviated. knee

a) Prolonged compression of the nerve may Pt limbs particularly in the evening and after exercise
have resulted in interstitial neuritis resulting in
sensory loss or motor weakness or There may be history of injury in the past but there is
b) The intervertebral joint may be unstable commonly a silent period between this incident and
or become affected by osteoarthritis. the onset of symptoms

PERTHES DISEASE: Clinically:

Def. this is the infarction of the proximal femoral Shortening of the limb
epiphysis and is known as Legg-calve- perthes disease. Wasting of the quadriceps
The epiphyses of other bones are not spared, for Restriction of hip movement by muscle spasm with
example, involvement of the distal epiphysis of the 2nd pain at the extremes of movement. This muscle
metatarsal it is known as Freiberg’s disease spasm will commonly resolve in a few days of bed rest
Navicular bone – Kohler’s disease with skin traction.

Lunate bone – Kienbock’s disease DDX:

Of these, perthes disease is the most common and Inguinal hernia

has the most serious consequences for the pt. Genitor-urinary abnormalities
Pathology: Radiological features:
The presence of an epiphyseal plate results ina Joint space becomes greater than the opposite side.
peculiarity of bld supply to the boe of the epiphysis, This is due to effusion or continuing growth of the
for bld vsls don’t cross the epiphyseal plate. The bld cartilaginous portion of the femoral head.
supply to the epiphysis is derived entirely from vsls
passing around the periphery of the plate and along In the 2nd stage, part or all bony epiphyses become
the ligamentum teres. Since the epiphysis is entirely crushed or fragmented, protruding a broad and
intraarticular all epiphyseal vsls run beneath the flattened femoral head in many cases.
synovial membrane before entering the epiphysis
In the 3rd phase the crushed area is reabsorbed and
itselfand thus the epiphysis could be infracted if, for
finally replaced bone.
example, fluid collected in the joint under sufficient
pressure to occludethe vsls. This is the mechanismof Prognosis:
infarction in perthes disease.
The longterm prognosis of this disease is ostoarhritis
Clinical features: of the hip.
Boys are affected more than girls in the ratio of 4:1 The symptoms may be delayed for 30-40 yrs. The
(reason is unknown) more deformed the femoral head at the time of
healing the greater the chances of early symptoms.
Condition usually present between 3 and 10 yrs
Girls have a worse prognosis than boys
18% of the cases are bilateral
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Treatment: i) Involvement of the pre-patela bursa
givingrise to “ housemaid” knee
No specific treatment for the underlying pathology. ii) Olecranon bursa giving rise to student or
The objective of treatment must be to prevent severe miner’s elbow
flattening of the femoral head. The principles of iii) Satorreal bursitis involves the satorrius
treatment are divided as; muscle of the thigh which flexes one leg over
1. Restoration of movement by; another.
a) Containing the femoral head within the The above three are anatomical bursae.
acetabulum
b) Mobilization of the reduced hip Semi-membranosus, which occur in children posterior
2. Prevention f further ischaemia by; to the knee joint. The cyst is aspirated if it causes
a) Relief of further stress to the hip disability but most cysts disappear spontaneously. If
b) Prevention of injury semi-membranosus communicate with the knee joint
they enlarge when there is an effusion in the joint and
Containment of the femoral head within the form one variety of “ Baker’s” cyst. In general synocial
acetabulum may beachieved by holding the legs apart cysts in the popliteal fossa which are known as
in abduction and internal rotation (broomstick Baker’s cysts may arise from a semimembranosus
plaster). Active movement is encouraged while the bursa or rheumatoid arthritis of the knee as a result of
legs are in the plaster, to restore the normal range of posterior rupture of the joint (another form of Baker’s
movement to the hip. cyst).
BURSITIS: ACUTE SUPPURATIVE BURSITIS:
Def. Comes from the word bursa which is a fibrous sac Is due to acute infection of the bursae by penetrating
lined with synovial membrane containing a small wound or spread of local cellulitis. The most
quantit of synovial fluid. commonly involved is the pre-patela bursa. It should
Sites: It occurs in three main sites; not be confused with infective arthritis because in
infective arthritis any attempt to move the joint is
Between tendons and bone painful and the pain is elicited by pressure on the
popliteal fossa. Asympathetic effusion in the knee
Between muscles and muscles
joint sometimes follows.
Between skin and bone
Treatment:
Functions: To facilitate movement without
1. The infection usually responds to
frictionbetween the surfaces involved
chemotherapy but
Simple bursitis: ( acute traumatic bursitis)---- It follows 2. If pus is already present incision and
injury or unaccustomed exercise e.g. inflammation of drainage will be necessary.
the bursa from anterior to the tendo-Achilles may
ADVENTITIOUS BURSA:
occur following cross country.
It forms as a result of prolonged pressure over bony
Chronic bursitis: occurs as a result of repeated
eminencies. It means that no anatomical bursa where
pressure or slight injuries to bursae e.g.
a cyst has formed and that it was generated in
connective tissue as aresult of repeated motion in the

197
tissue. The commonest is that over the medial aspect This is the most feared of the infections in the
of the 1st metatarsal bone which is found in a hand.pus within the tendon sheath destroys the
condition called Hallus Valgus, a condition inititated gliding mechanism, creates adhesionsand leads to loss
by too narrow foot wear. It is characterized by of tendon function and reduced movement.
deviation of the big toe. It can be come infected.
Acute fulminating tenosynovitis involves the whole
Excision of the bursae: sheath rapidly and nearly always the infecting
organism is staphylococcus aureus or streptococcus
Persistent trouble with a subcutaneous bursa is pyogens. The classical local signs are;
solved by totalexcision of the whole of the endothelial
lining under G.A. Symmetrical swelling of the entire finger

TENOSYNOVITIS: Flexion of fingers (hook sign) with severe pain on

extension
Simple tenosynovitis: It follows excessive or
unaccustomed use and is commonly seen in Tenderness over the sheath
connection with the extensor tendons of the hand
and the Achilles tendon. Treatment:

Clinical features: This condition must be treated aggressively. There is

no time for conservative management.
Pain and local oedema are present and a
characteristic soft crepitus is sometimes palpable 1. Transverse incisions at opposite end of
when the fingers are moved. the tendon sheath are required. The tendon
sheath should be thoroughly irrigated at the time
Treatment: of surgery with isotonic saline using a ureteric
catheter. There is no need to leave a catheter in
Resting of the tendon involved which in the case of situ for post operativeirrigation. In late cases that
the extensors of the hand must involve the fingers require excision of necrotic tissue exposure is best
A minimum of 3/52 absolute rest in a splint is usually obtained by mid lateral incision but the outcome
required, followed by a period of gentle but is likely to be a stiff joint.
progressive activity. 2. Antibiotics (sensitive to the organisms
that have been cultured).
In appropriate cases, steroid injections into the 3. Analgesics.
tendon sheath can be very effective.
Complications of suppurative tenosynovitis:
Suppurative tenosynovitis:
a) Involvement of the forearm from the
This condition affects particularly the flexor tendons hand ( spread)
of the hand since these sheaths are far more b) Continuation of suppuration chronicity
commonly injured than those elsewhere in the body. should suppuration continue for more than 14
Infection is by bacteria introduced by the point of days, the hand should be x-rayed to rule out bone
needle or other sharp object penetrating the tendon involvement (osteomyelitis).
sheath. The sheath may be infected by extension from c) Suppurative arthritis in a related joint . in
its terminal, pulp space or in some cases from the these circumstances timely amputation of any
scalpel transgressingthe hallowed ground of the digit except the thumb will reduce the period of
septum that closes the proximal end of the space. disability.
198
 d) Stiff digit – Total amputation of digit is A benign tumour arising from the connective tissue of
less of a handicap than a stiff finger but the nerve sheath.
amputation should be done when the
infectionhas subsided. Varieties:
e) Paralysis of the median nerve.
i) Local neurofibroma – this tumour is
OSTEOGENIC IMPERFECTA: usually found in the subcutaneous tissue. It is a
painful subcutaneous nodule which forms a
Def. A congenital and inheritable condition in which smooth firm swelling which may be moved in
the bones are abnormally soft and brittle (fragile) alateral direction, but otherwise fixed by the
nerve from which it arise. Paraesthesia or pain is
Clinical features:
likely to occur from the pressureof the tumour on
1. In severe cases; the nerve fibres which are spread over its surface
cystic degeneration or sarcomatous changes
The child may present with multiple fractures occur occasionally. As the nerve fibres are part
Survival is very limited and parcel of the tumour they are difficult to
remove without removal of the itself. In major
2. In mild cases; nerve recurrence is known, also malignanant
(sarcomatous) change.
Fractures occur at birth or after a slight violence
ii) Generalized neurofibromatosis: This is an
Later on present with very bad deformities due to inherited (autosomal dorminant) disease. Any
mal- union cranial, spinal, or peripheral nerve may be
diffusely or nodulary thickened. Overgrowth
Later on there is a marked bluecolouration of the occurs in connection with the endoneurium.
sclerotic bone Associated pigmentation of the skin is common.
Sarcomatous change may occur.
Deafness due to the osteosclerosis
b) FIBROMA:
Laxity of ligaments
A true fibroma contains only fibrous connective tissue
Treatment: and is rare. Most fibromas are combined with other
mesodermal tissues such as muscle (fibromyoma), fat
- Immobilization (fibrolipoma), nerve sheaths (neurofibroma) etc.
Multiple tumours are not uncommonas in
- P.O.P application
neurofibromatosis. Fibromas are either soft or hard
- in severe cases intramedullary nailing of long bones depending on the proportion of fibrous to the other
and immobilize either by P.O.P ( for children about cellular tissue. Soft fibromas are common in the
6/52) subcutaneous tissue of the face, and appear as a
soft,brown swelling.
- Protective/supportive appliances e.g walking
calipers, clutches so that there is no direct wt Keloid: this overgrowth of fibrous tissue commonly
transmission to the fractured area. occurs inscars especially of black people.

BENIGN TUMOURS OF SOFT TISSUES: c) LIPOMA:

a) NEUROFIBROMA:
199
This is a slowly growing tumour composed of fat cells May be present over the site of a spina bifida
of adult type. They may be encapsulated or diffuse.
They occur anywhere int the body where fat is found Occasionally become penduculated
and earn the tittle of the “universal tumour” or
i) Subfascial:
“ubiquitous tumour”. Common areas include, head,
neck, abdominal wall, and the thighs. Occur under the plantar and palmar fascia

Encapsulated lipoma: Liable to be mistaken for Tb tenosynovitis as the

tough overlying fascia masks the definite edge and
Are among the commonest tumours.
lobulation of the tumourdifficulty is encountered in
-The chractaristic features are the presence of a complete removal as pressure encourages the tumour
definite edge and lobulation ramify(move).

May be fluctuant ii) Sub-synovial:

Deeply seated (situated) lipomas may be miatsken for From the faty padding around joints especially the
other swellings knee

Most lipomas are painless, but some give rise to an May be mistaken for Baker’s cyst ut easily
aching sensation which may radiate. distinguished as in distinction toa cyst or bursa, their
consistency is constant whether the joint is in
Multiple lipomas: extension or flexion.

They are not uncommon iii) Intraarticular

iv) Intermuscular
They remain small or moderate in size v) Periostel –occasionally occur under the
periosteum of the bone.
Are sometimes painful
vi) Subserous –sometimes beneath the
Should a lipoma contain an excessive fibrous tissue it pleura, where they constitute onevariety of
is termedas fibrolipoma inocent thoracic tumours.
viii) Sub mucous
If considerably vascular and often with considerable ix) Extradural – a lipoma is a rare variety of
telangiectasisof the overlying skin the tumour is then spinal tumour. Owing to the absence of fat within
called naevolipoma. the skull, intracranial lipomas do not occur.
x) Intraglandular – lipomas have been found
Large lipomas of the thigh, the shoulder and the occasionally in the pancrease, under the renal
retroperitoneum occasionally undergo sarcomatous capsule and in the breast.
changes.
Treatment:
Clinical classification of lipomas (according to
situation) If it causes trouble on account of its size, site,
appearance, or the presence of pain removal is
I) Subcutaneous: indicated. During operation any fingerlike projections
of the tumourinto the surroundingtissue should also
Commonly found on the shoulder or back be removed. Although the tumour is relatively
200
avascular, care is needed to obtain complete It is relatively uncommon. It presents at birthand
haemostasis in the resulting cavity; otherwise a consists of multiple venous channels of varying clibre.
haematoma is common which may be followed with Usually shows no tendency to involution and may
infectionand delay in wound healing. Drainage is become larger and more troublesome later.
often necessary. Sometimes the whole of one limb and the adjacent
part of the trunk is affected. It is occasionally
d) Hamaegioma: associated with a lipoma (naevolipoma). In some
cases, arteriovenous communications are present.
This is a developmental malformation rather than a
The skin overlying the naevus may be atrophic, and
true tumour. It is an example of a Harmatoma. It may
may be in danger of developing severe haemorrhage
occur in any tissue of the body but most common in
from trauma. The patient mat suffer from septicaemia
the skin and subcutaneous tissue. A haemangioma is
if organisms gain entry, in which case the energetic
either capillary, venous (carvenous) or arterial in type.
use of antibiotics is an urgent matter.treatment is
Capillary haemangioma: generally conservative. Injection of sclerosing agents
as for varicose veins is followed by variable results.
(i) Salmon patch (stork bites) is present at
birth over the forehead in the midline, and over Arterial (plexiform) angioma:
the occiput. It disappears by the age of 1yr.
It is a type of arterivenous fistula. The pulsating
(ii) Port wine stain (naevus flameus) it
swelling of arteries and arterialized veins is often
presents at birth, it changes very little throughout
called a crisoid aneurysm.
life,although the colour may alter a little and it
may become nodular in some areas. Treatment is Spider naevus: may be associated with liver diseases
for cosmesis skin texture is quite normal. and may present in the skin over the manubrium
(iii) Strawberry angioma: sterni, but may occur quite innocently. It shows the
characteristic sign of emptying.
It is common
Naevus tardes: are small angiomas occurring in
Has a typical history i.e. the baby is normal at birth
adults, often around the mouth. They may be
and at the age of 1-3 wks is noted to have a red mark.
associated with vasospastic and scleroderma.
It rapidly increases for some wks or even up to 3
months, until the typical straw berry- like swelling is Lymphangioma: they affect the lymphatic channels.
present. The lesion is composed of immature Sometimes associated with haemangioma
vasoformative tissue. The subcutaneous tissue as well (haemolymphangioma).
as the skin is often involved, and in severe cases the
mm may be affected. Submucous naevi are prone to
haemorrhage, which is sometimes alarming. From the
age of 3 months to 1yr the naevus grows with the
child and then it caeses to grow. Eventually the colour
fades and flattening occurs so that at the age of 7-8
yrs involution is complete.

Venous angi oma (carvenous):

201
 possible benign tumours should be left alone. But

Tumours there are three indications for surgical intervention in

benign tumours.

1. When there is doubt as whether benign

or malignant and a biopsy is required to
determine the type of tumour. When removing a
biopsy in this case, it should be treated as a
malignant and therefore excisional biopsy is
adviced to avoid another surgery later.
2. When the tumour has weakened a bone
and a pathological fracture has occurred or is
likely to occur.
3. If the bony protruberance is so prominent
TUMOURS OF THE BONE:
that it creates a cosmetic deformity or interferes
BENIGN TUMOURS: with muscles or joints and the function of the
limb is interfered with.
Benign tumours of the musculoskeletal system are
common and frequent. Difference between benign and malignant tumours:

They appear to have been present from birth and It is usually not easy in a growing child.
they grow with the child.
1. History: - Benign tumours are usually
They may be multiple painless while in the malignant tumours pain is
noticeable at rest particulary at night (very
If truly benign they stop growing when the child stops
characteristic)
growing.
2. Examination: - A swelling which has been
They are incidentally found on an X-ray taken for present for a long time is likely to be benign.
other reasons. However some benign tumours can turn
malignant.if this kind of lumps suddenly change in
Most benign tumours of bone occur in children and size or increase in tenderness then malignancy
young adults and often stop growing with the should be suspected.
cessation of skeletal growth. 3. X-rays: - Benign tumours have a well
defined margin unlike the malignant ones which
Such lesions might more probably be regarded as have irregular margins. Periosteal lifting over the
localized dysplasias rather than neoplasia. site of lesion indicates inflammation and can be a
clear sign of malignancy. Periosteal elevation may
also occur over a stress fracture or if there is
Nomenclature and classification underlying infection, so rule them out.
a) Osteochondroma:
These tumours are named after dorminant type of
tissue from which they have arisen. They can be A common benign tumour.
identified from their shape and their staining. The
Usually multiple,
benign tumours take the suffix “OMA”. Where

202
 They are overgrowths of bone, which may look much This tumour consists of a center of cellular, highly
smaller on x-ray than they feel on clinical vascular tissue with randomly arranged osteoid
examination. This is because the overgrowth of bone trabeculae.
has a large cartilage cap over it.
It is usually less than 1 cm in size and provides dense
They are commonly on a bony pedicle which gros new bone formation around it. It is most commonly in
away from the epiphyseal plate and which is covered pts between 5-25yrs old.
in a large cartilage cap.
It is slightly more common in males and usually
The common site is the femur or the tibia around the occurs in the long bones.
knee. If large enough they can interfere with the
function of the knee. The only abnormal physical sign is bone tenderness;
and even this is often absent so that pt may
Occasionally they become malignant. sometimes be regarded as hysterical.

Therefore if they become painful malignancy should Surgical excision relieves the pain but they can be
be suspected. difficult to find at surgery.

Usually it ceases to grow when skeletal growth is

complete.
c) Chondroma:
The lesion may be solitary or multiple
They are mainly made of up of cartilage and are
Compact osteoma (ivory exotosis): It consists of a common in the hands and feet’
small knob of extremely hard, dense, but otherwise
normal bone usually arising on the inner or outer table The medulla of the bone may be scalloped out (eaten
of the skull. out) and this is known as enchondroma. There may be
thinning of the cortex causing pathological fracture.
b) Osteoid osteoma:
When there are multiple enchondromas the condition
They occur in children and adults. is known as Oilier’s disease.

They are commonest in the femur and tibia but can Malignant change is not common but when many
occur elsewhere (even in the spine) chondromata are present this risk is increased.It
consists of a lobulated mass of cartilage. It may arise
They differ from other benign tumours because they in any bone, but is more frequent in the metacarpals,
produce constant aching pain commonly at night phalanges or metatarsals. Occasionally arise in
unrelieved by rest but synovial membrane. if situated in medulla
(endochondroma), the bone is thinned and expanded
The pain is specifically relieved by salicylates. by the tumour causing pain and
deformity.pathological fracture is common. Tumours
They are difficulty to see in an x-raywhere they look
on the surface of the bone are known as
like an area of slight sclerosis.
ecchondroma. The matrix of the tumour may calcify
Tomography shows a characteristic radioluscent and sometimes ossify. They may be solitary or
center. multiple. Malignancy is rare in solitary tumours but
may occur when the tumours are multiple.

203
 DDx
 Soft-tissue haematoma
d) Osteoclastoma( giant cell tumour)
 Myositis ossificans
 Stress fracture
They are benign tumour filled with undifferentitated
 Tendon avulsion injuries
spindle cells and multinucleated giant cells.
 Bone infection
Commonly found in the epiphysis of a bone, lying  Gout
close to the epiphyseal plate.the cortex over the  Other bone lesions e.g. fibrous cortical
tumour may be destroyed and there may be defects, medullary infarcts & 'bone islands'
periosteal elevation. They can be treated block
Enneking System of Classifying
excision but, unfortunately, they are closely
associated with a joint. When rapidly growing or recur
Musculoskeletal Tumours
I. All low-grade sarcomas with <25% chance of
after excision they may be malignant and require
metastasis e.g. 2° chondrosarcoma, Parosteal
more aggressive treatment. osteosarcoma
II. Histologically high-grade lesions with >25%
Mechanisms of spread chance of metastasis e.g. osteosarcoma &
 Local fibrosarcoma
 Haematogenous III. Sarcomas which have metastasized
 Lymphatic +
 Intramedullary A. Intracompartmental e.g. A lesion contained
 Others e.g. injections, transfer (iatrogenic) in a single muscle belly or a bone lesion that has not
broken out into the surrounding soft tissue
Clinical Diagnosis of tumours B. Extracompartmental e.g. A lesion in the
a. Age of patient; popliteal space, axilla, pelvis, or midportion of the
 < 5yrs old - Malignant hand or foot.
 5-30yrs old - Benign; Also Ewing's
sarcoma & Osteosarcoma MANAGEMENT
 30-60yrs - Mixed - Chondrosarcoma,
Fibrosarcoma
 > 60yrs - Secondaries (malignant);
Multiple myeloma
a. Symptoms;
 Benign - No pain
 Malignant - Vascular pain - Worse
at night & throbbing due to ischemia due to
increased blood demand; Also 2° to pressure effect
on bone & soft tissue
a. Duration of symptoms;
 3 months - Malignant
 6 months - Borderline
 1 year - Benign
a. Imaging;
 Benign - well defined transitional
zone with regular/Scalloped margins e.g.
Osteochondroma which are mostly metaphyseal
especially around the knee & may be pediculated
or sessile
 Malignant - Diffuse transitional zone
204
C. into the soft tissues with ossification at the periosteal
margins & streaks of new bone extending into the
extra-osseous mass. The tumour spreads mostly
haematogenously > intramedullary > local spread.
Rarely lymphatic.
Classification
a. Primary;
 Central (classical)
 High grade - Distal femur,
proximal tibia & proximal humerus
 Juxtacortical;
 Low grade (Parosteal) -
Distal femur
 Intermediate grade
(Periosteal) - Shaft of long bones
 High grade (surface sarcoma)
- Shaft of long bones
 Haemorrhagic or Telangiectatic;
 High grade - Epiphysis
a. Secondary;
 Paget's disease
 Radiation
 Fibrous dysplasia
C/P
 Pain - constant, worse at night & gradually
increases in severity
 Swelling
 Local tenderness
Osteosarcoma ** Pathological fracture is rare
In its classic (intramedullary) form, osteosarcoma is
a high grade malignant tumour arising within the Ix
bone & spreading rapidly outwards to the periosteum X-Ray;
& surrounding soft tissues. i. Hazy osteolytic lesions alternating with
unusually dense osteoblastic areas
Epidemiology ii. The endosteal margin is poorly defined
 Children > Adults - 5-19yrs; 22-26yrs - This iii. The cortex is breached & the tumour extends
has been attributed to increased bone growth into the adjacent tissues; when this happens, streaks
 Adults - ≥60yrs - History of exposure to of new bone appear radiating outwards from the
radiation when young &/or bone infection cortex - Sunburst effect
 M:F - 2:1 iv. Where the tumour emerges from the cortex,
Pathogenesis reactive new bone forms at the angles of periosteal
The tumour is usually situated in the metaphysis of a elevation - Codman's triangle
long bone, especially around the knee & at the
proximal end of the humerus, where it destroys &
replaces normal bone. Areas of bone loss &
cavitation alternate with dense patches of abnormal
new bone. The tumour extends within the medulla &
across physeal plate. There may be obvious spread

205
 e are present in about 10% of patients at
presentation.
 Liver ultrasound
 Scintigraphy using Methyldiphosphonate PC99
(MDP)- For skip lesions
 Biopsy;
 FNAC
 Incisional biopsy - All layers from skin
to bone
 Excisional biopsy - Wide margin (at
least 2mm)
 MRI is NOT very useful
DDx
 Stress fracture
 Infection - Acute osteomyelitis
 Post-traumatic swelling
 'Cystic' lesions
 Other tumours
Mx
Supportive
Specific
 Multi-agent neo-adjuvant
chemotherapy is given for 8-
12wks;
 Eliminates
micrometastasis
 Reduces size of
tumour reactive zone
 Causes tumour
necrosis
Then provided the tumour is
resectable & there are no skip
lesions, a wide resection is carried
out. The tumour responds well to
Methotrexate, Adriamycin,
Cisplatin, Ifafosphamide (MAC-
i)
 The segment of bone is
replaced with either a large bone
graft or a custom made implant;
in some cases, amputation may be
more appropriate.
 Blood;  The tumour specimen is
 FHG + ESR examined to asses response to pre-
 ↑ ALP + LDH op chemotherapy & if tumour
 CT for staging - Pulmonary CT is a much necrosis is marked, chemotherapy
more sensitive detector of lung metastases which is continued for another 6-

206
 12months; if response is poor, a condition must be excluded by biochemical and
different chemotherapeutic agent is radiological investigations.
substituted.
 Pulmonary metastases, It occurs between the age of 30-40yrs.
especially if they are small &
peripherally situated, may be It is common in women
completely resected with a wedge
of lung tissue. The epiphyseal regions of the long bones, especially
Prognosis around the knee, are the most common sites of origin
Long-term survival after wide resection & but humerus, radius and ulna are occasionally
chemotherapy - 50-60% if treated early & <10% affected. A tumour arising from the metaphysic is
if late presentation. uslikely to be a giant cell tumour.

The tumour is osteolytic

MALIGNANT TUMOURS OF THE BONE: It expands the bone with thinning, often perforation,
of the cortex to cause a pathological in some cases.
Majority bone tumours are secondaries and their
management is significantly palliative. A pathological The bone is destroyed irregulary so that the tumour is
fracture through a metastatic tumour may be the first traversed by remnants of the original bone and comes
clue that a pt has malignant disease. The primary to lie in the cavity with heavyily trabeculated walls.
lesion may never be found. In some cases metastasis
occurs sometimes after treatment of the primary As a consequence, it has a typical “soap bubble”
tumour. The commonest source of metastasis in bone radiologica appearance.
is tumours of the breat, prostate, and kidney.
Malignant tumours take the suffix “SARCOMA”. Rarely invades soft tissues but may do so when
Tumours forming a cartilaginous matrix are named fracture occurs.
chondrosarcoma, the fibrous series 0 fibrosarcoma .
Locally the tumour is only of low grade malignancy.
Primary malignant tumours:
Metastasis is rare but occurs via the blood stream to
They are very rare. The commonest is osteosarcoma. the lungs.
They have very variable histology and occur either in
Reccurence following local removal is common and
adolescents or in the elderly secondary to paget’s
such reccurences are more likely to be frankly
disease.
malignant than the original tumour.
Giant cell tumour (osteoclastoma):
OSTEOSARCOMA:
It is uncertain from which cell the tumour arises.
This is the commonest among the rare malignant
It is composed of undifferentiated spindle cells and tumours.
multinucleated giant cells in a vascular stroma.
It has a variable history
Microscopically it is distinguished from the so called
It is common in adolescents or in the elderly
brown tumour of hyperparathyroidism and this
secondary to paget’s disease

207
It is usually metaphyseal (commonly the tibia or FIBROSARCOMA:
femur)
They occur most commonly in the metaphysic or
It is to confuse it with a stress frature or an infected diaphysis of the tibia or femur. They may
haematoma.
A highly malignant tumour. Metastases through the
If suspected the tumour must not be biopsied blood stream and lymphatics. Five yr survival rate is
low regardless of the treatment offered.
Imaging:
EWING’S TUMOUR:
Characteristically there is periosteal lifting (codman’s
triangle) and a sun ray specules of new bone within Common in children
the tumour. MRI and CT scan may be helpful in
determining the true extent of the tumour within the Arises in the mid shaft or metaphysis of long bones.
medulla.
Child may present with pyrexia
Treatment:
They usually present with high sedimentation rate
Choice of treatment depends on the histological and can be confused with osteomyelitis
grading of the tumour, age of the pt, the presence or
X-ray may show multiple layers of subperiosteal new
absence of secondaries and the wishes of the pt.
bone producing an “onion”arrangement. The tumour
If no evidence of secondaries, an amputation is the is highly malignant but aggressive treatment with
treatment of choice with chemotherapy to destroy chemotherapy and radiotherapy has produced some
micrometastasses. survivors.

Alternatively, RT and chemotherapy to shrink the NB:

lesion followed by a massive joint replacement( there
Bone tumours are rare. Most of them are secondary
is high risk of recurring but more acceptable
tumours, which to be primary bone tumours should
cosmetically and functionally
only be investigated and treated at specialized
Prognosis: Survival depends on the histological centers. The quality of life of pts with bonne
grading and the degree of spread. Cure rates of about secondaries can be improved dramatically with
50% can be achieved. internal fixation followed by radiography. Pain will be
reduced and mobility maintained.
CHONDROSARCOMA:
OSTEOMYELITIS:
Commonly occurs in the pelvis, ribs, or proximal large
bones in middle aged people. The tumour is lytic with Definition: infection of the bone and bone marrow.
ill defined boundaries and has speckled (coloured or
Types:
spots) calcification within its substance. The grade of
malignancy is very variable and closely linked to the Occurs in two forms;
prognosis. Low ,grade tumours mhave a survival rate
of 75% at 5yrs. High grade tumours have a survival a) Acute osteomyelitis
rate of less than 10% at 5yrs b) Chronic osteomyelitis

208
 Aetiology: through the skin. The pus is then discharged through
a sinus which connects bone with skin surface.
Acute haematogenous osteomyelitis: The bacteria
reach the bone through the blood stream.a primary Clinical features:
focus may be obvious in the form of a bil or infected
wound. However sometimes may occur without - Pain of sudden onset
obvious source of infection. May rarely occur - Fever
secondary to septicaemia. - Localized tenderness
- Irritable pt that resists examination
Causative organisms include; - Adjacent joint may contain an effusion
(but not tender)
Staph. Aureus (the commonest) - Swelling
- Inability
Streptococcus
- Inability to use the affected limb
Pneumococcus - Discharging sinus.

Haemophilus influenza Investigations:

Staph. Albus 1. Blood cultures: Thye should be done

before commencement of antibiotic treatment.
Salmonella Three separate venepunctures should be made
and cultured to provide maximum positive.
Pathology: Others include ,( but of no diagnostic value)
2. ESR which shows raised WBc (non
The disease nearly always begins at the metaphysic. specific)
The infective processs progresses through the 3. X-ray
thickness of the cortex via the Harversian canals. This
leads to thrombosis of the blood vessels in the bone Is normal in the first few days of infectiont
leading to infarction of the cortex. In the first 24-048
hrs of infection, an inflammatory exudates forms Involucrum deposited by the elevated periosteum but
deep to the periosteum, elevating the membrane is seen after the 10th day of infection.
from the bone. Periosteal elevation is paiful and, since
the eriosteum is ineslastic, the inflammatory exudates Periosteal elevation.
deep to it is under tension. This leads to rapid
Treatment:
development of toxic signs. Farnk pus develops
subperiostially after 48hrs. the inflammatory process 1. Exercabations - Immobilzation and
progresses along the length of the medulla causing antibiotics ( signs subside but only to recur again
venous and arterial thrombosis. Subperiostially, pus in life)
tracks both longitudinally and circumfrentially around 2. Surgical intervention whose objective is;
the bone sripping the periosteum and interuupting - To remove the dead bone
the periosteal vessels consequently, larger areas of (sequestrectomy)
the cortex become infracted and involved in the - To eliminate the dead space
inflammatory process. Without treatment pus finally
bursts through the periosteum and tracks through the The soft tissues are stripped from the bone and the
muscles to present subcutaneously and eventually involucrum is removed to reach the sequestrum. If
209
cavity is present, the overhanging walls are removed 1. Acut suppurative arthritis – sepsis is
with an osteome. The wound is drained and closed in intraarticular
such a way as to eliminate dead space as far as 2. Acute rheumatic arthritis – Polyarticular,
possible. fleeting, history of sore throat and cardiovascular
signs are present
Modern approaches; 3. Haemathrosis – may be due to
haemophilia
- Debridement of affected area
4. Scurvy
- Insertion of gentamycin impregnated
5. Acute exanthemous and typhoid fever
beads for 14/7
6. Ewing’s tumour
- Dead space obliterated by packing the
cavitywith cancellous bone chips or filling it with a ACUTE TRAUMATIC OSTEOMYELITIS:
local muscle flplap.
It occurs as a result of infected wounds like
NB: compound fractures and operaton on bones. General
disturbance are less severe than in acute infective
- Operative intervention may not cure
osteomyelitis because the causative wound provides
osteomyelitis if large volume of bone is involved.
some drainage.
- The most feared complication is amyloid
disease Treatment:

Amputation is considered when; - More extensive opening of the wound

- Removal of dead bone
 There is frequent or pprolonged
- Antibiotics
exacarbations to rid pt of repeated painful
disability and prevent amyloid disease. Prevention:
 A brodie’s abscess should be treated by
surgical evacuation and curettage of the cavity 1. Adequade initial treatment of compound
under antibiotic cover followed by packing with fractures
cancellous bone chips if cavity is big. 2. Sterile operating conditions

Complications: CHRONIC OSTEOMYELITIS:

General Pathology:

1. Septicaemia Acute haematogenous osteomyelitis may complicate

2. Pyaema to chronic osteomyelitis if treatment is not adequate
or not available. The bone dies to form involucrum.
Local

3. Secondary involvement of adjacent joints

4. Spontaneous pathological fractures The pathology may take two forms;
5. Deformity
6. Chronic osteomyelitis a) A large volume of bone may be involved
which has been explained under acute
DDX:
210
 osteomyelitis. However this has reduced greatly - Chronic ulcers – non haeling with exposed
due to the advent of modern antibiotics bone
b) The infection may closely contain to - Brodie’s abscess –this is a special form of
create a chronic abscess within the bone. This chronic osteomyelitis which arises insidiously,
abscess is known as Brodie’s abscess. It contains without a preceding acute attack. There is a
pus or jelly like granulationtissue surrounded by localized abscess within bone, often near the site
sclerotic bone. This abscess could be as a result of of the metaphysic. Its signs and symptoms include
pyogenic septicaemia from which the pt has a deep “boring” pain is a predominant symptom.
removed leaving a bone abscess which may X-ray shows a circular or oval cavity surrounded
remain dormant for yrs. alternatively it may be by a zone of sclerosis. The treatment is surgery to
found in apt who has had osteomyelitis affecting a deroof and pus evacuated and if possible the
bone other than the one in which the Brodie’s cavity filled with a flap of muscle to obliterate the
abscess is discovered. dead space.

Risk factors (conditions which predispose to bone X-ray shows a sequestrum which has separated
infarcts) from the space of the bone or lies a cavity

- Open fractures - Tomographs may show a sequestrum

- Local trauma - Sonograms may delineate an abscess
- Presence of prosthetic orthopaedic cavity in the bone.
implant
- Vacular insufficiency Management of chronic osteomyelitis:
- Neuropathy
 Antibiotic therapy;
- Sickle cell disease
- - Diabetes mellitus – Fusidin acid, clindamycin and cephalosporins, to
- I.v drug use stop the spread of infection to healthy bone and to
- Haemodialysis ontro acute flares.

Clinical features:  Local treatment;

- A sinus may be painless and need
It may remain quiescent for months or yrs. But acutor
dressing simply to protect the clothing.
sub acute exercabations occur from time to time.
- Colostomy paste may be used o stop
Constitutional (general) features; excoriation of the skin.
- An acute abscess may need urgent
- Generally sick looking incision and drainage as a temporary measure.
- Weak
- Febrile etc Surgical operation;

Local features; 1. The periosteum is incised to release any

subperiosteal abscess. If none is found, the bone
- Inflammation should be drilled to decompress the marrow and
- Chronic abscess with discharging sinus; drain any intraosseus abscess.
changing in scar – hyperpigmentation, adherent 2. Removals of dead bone – sequestrectomy
to the underlying tissues. and non-viable necrotic tisse (not bleeding or

211
 moving on touch) - are of utmost importance to fibrous tissue. The articulating surfaces are replaced by
effect cure. Pack the medullary cavity with local fibrous tissue. Always assume involvement of both the
antibiotics e.g. gentamycin beads. synovial membrane and bone if a diagnosis of TB arthritis
3. In pts with vascular insufficiency or severe is made. This is because the synovial membrane is rapidly
gangrenous infection, amputation may be the involved if the disease starts in the articular bone.
only effective treatment.
4. If alarge part is involved, wait for the Tb spine is rarely diagnosed until significant involvement
involucrum to become strong and bigger than the of neighbouring two vertebrae. Should ttreatment for Tb
sequestrum (3-6 months) then remove spine be delayed an abscess is formed and the vertebral
sequestrum otherwise you end up with septic bodies collapse. The pus from the abscess may track along
non-union. the psoas muscle to present in the groin. Kyphosis and
abscess formation compresses and may damage the
spinal cord. This may produce paraplegia (pootts
ARTHRITIS paraplegia).

TUBERCULOUS ARTHRITIS (TB ARTHRITIS) AND TB Clinical features:

OSTEOMYELITIS:
a) Symptoms;
PATHOLOGY;
They could be from the diseased joint, primary focus
Bone and joint tuberculosis is haematogenous in or systemic effects of the disease.
origin. The primary focus is from;
Locally:
i) G astrointestinal tract – if the disease is
acquired by ingestion of bovine tubercle or - Aching joint initially mild in nature, but
ii) Lungs – if acquired by inhalation of the worse on exertion or at night
human strain - Joint swelling if superficial and is more
obvious when associated muscles are wasted.
The disease starts in either in the synovial membrane or - Joint stiffness as the disease progresses
in the intra-articular bone. Tb may develop in any synovial (can also be due to pain)
joint especially those with extensive membranes like hip - Joint dislocation
or knee joints. It may alsoaffect tendon synovial sheaths - Local deformity may be obvious
especially those of finger flexors or bursae like that - In Tb spine a mild ache may be a
overlying the greater trochanter. symptom of a potentially crippling disease.

The spine is not spared and here it is described as “potts Systematically:

disease”. The vertebral bodies of the neighbouring
vertebrae are almost always involved first. Typical - Pt feels unwell
tubercles develop in the synovial membrane. It becomes - Listless
bulky and inflamed with an infected effusion collecting in - Febrile especially at night
the synovial cavity. If diagnosed and cured at this stage - Night sweats
then full function of the joint may be restored. But if the b) Physical signs;
pathology progresses, articular cartilage and adjacent - Synovial thickening and effusion if joint is
bone is involved or destroyed. Loss of function is superficial
therefore certain due to healing by fibrous ankylosis by

212
 - Wasting of muscles associated with If the infection goes untreated, it will spread to the
affected joint underlying bone or burst out of the joint to form
- Joint held at its position of ease abscesses & sinuses.
- Moderate tenderness over affected joint With healing there may be;
 Complete resolution & a return to
- Reddening of skin overlying the joint
normal
- Slightly warm a feature of a cold abscess
 Partial loss of articular cartilage &
fibrosis of the joint
Septic Arthritis  Loss of articular cartilage & bony
ankylosis
 Bone destruction & permanent
Mechanisms of infection
deformity of the joint
 Direct invasion through a penetrating
wound, intra-articular injection or
arthroscopy
 Direct spread from an adjacent bone
abscess
 Blood spread from a distant site

Causal organisms
 Staph. Aureus - Most common
 Infants - Haemophilus influenza
 Neiserria gonorrhoea - commonest
cause of septic arthritis in adults C/P
 Others - Streptococcus, E.Coli, Proteus  Children - Usually a large joint,
Predisposing Conditions commonly the Hip
 Rheumatoid arthritis  Adults - Superficial joints - Knee,
 IV drug abuse Wrist or Ankle
 Immunosuppression - Chronic  Acute pain
debilitating disorders;  Swinging fever
Immunosuppressive drug therapy; AIDS  Rapid pulse
 The overlying skin looks red
Pathology  Local warmth & marked tenderness
The usual trigger is a haematogenous infection  Reluctance to move the limb
which settles in the synovial membrane; there is an ('pseudoparesis') - All movements are
acute inflammatory reaction - acute synovitis, with a restricted, & often completely abolished,
serous or seropurulent exudate & an increase in by pain & spasm
synovial fluid. As pus appears in the joint, articular
cartilage is eroded & destroyed partly by enzymes DDx
released from synovium, inflammatory cells &  Acute osteomyelitis
pus.  Gout & pseudogout
In infants, the entire epiphysis, which is still largely  Trauma - Traumatic synovitis or
cartilaginous, may be severely damaged; in older haemarthrosis
children, vascular occlusion may lead to necrosis of  Irritable joint
the epiphyseal bone. In adults, the effects are  Haemophilic bleed
usually confined to the articular cartilage, but in  Rheumatic fever - typically pain flits
the late cases, there may be extensive erosion due to from joint to joint
synovial proliferation & growth.

213
  Gaucher's disease - Presents as acute  In children, give cod-liver oil which reduces
joint pain & fever without any organism inflammation by supplying Omega 3 reducing the
being found ('pseudo-osteitis') formation of arachidonic acid necessary for the
 Bursitis formation of prostaglandins that mediate
 SCD in crises inflammation.
 Surgical eradication;
Ix a. Under anaesthesia the joint is opened
through a small incision, drained & washed out with
 X-ray - Normal physiological saline. A small catheter is left in place
 FHG - ↑WBC & ESR & the wound is closed; suction-irrigation is
 Blood culture - May be positive continued for another 2-3days. This is advisable;
 Ultrasound;  In very young infants
 Joint effusion  When the hip is involved
 In children the joint 'space' may seem (Joint is opened from behind)
to be widened (because of the fluid in the joint) &  If the aspirated pus is very
there may be slight sublaxation of the joint. thick
 With E. coli infections there is b. For knee, arthroscopic debridement
sometimes gas in the joint. from the lateral aspect & copious irrigation may be
 Narrowing or irregularity of the joint equally effective
space are late features. c. Older children with early septic
 Joint aspiration m/c/s - Leukocyte counts arthritis (symptoms for <3days) involving any joint
>50,000/ml except the hip - Repeated closed aspiration of the
 Normal synovial fluid leukocyte count joint; however, if there is no improvement within
- <300/ml 48hrs, open drainage will be necessary.
 Non-infective inflammatory disorders -
>10,000/ml Post-op;
 Intact articular cartilage - Physiotherapy
Mx  Destroyed articular cartilage - The joint is
 Aspirate joint splinted in the optimum position awaiting ankylosis
 Give analgesics for pain & IV fluids for (stiffness or fixation of a joint by disease or surgery)
dehydration
 Rest the joint on a splint or in a widely split Complications
plaster; with hip infection, the joint should be  Bone destruction
abducted & 30° flexed, on traction;  In adults, partial destruction of the joint will
 To manage pain result in 2° Osteoarthritis
 To prevent dislocation  Cartilage destruction -may lead to either
 To keep the synovial cavity open to fibrous or bony ankylosis
allow circulation  Growth disturbance - presents either as a
 In children; localized deformity or as shortening of the bone
 To prevent slipping of the  Dislocation of the hip
upper femoral epiphysis  Osteomyelitis
 To strengthen the perichondral
ring
 Antibiotics; Osteoarthritis
 <4years - Ampicillin or 3rd generation Is a chronic joint disorder of post middle age
cephalosporins in which there is progressive softening &
 Older children & Adults - disintegration of articular cartilage
Flucloxacillin & Fusidic acid IV for 2-7days & then accompanied by new growth of cartilage &
orally for another 3wks
214
bone at joint margins (osteophytes) & capsular  Endocrine
fibrosis.  Diabetes mellitus
Epidemiology  Hypo/Hyperthyroidism
Most patients are past middle-age (50yrs);  Acromegaly
M:F - 3:1  2° to Inflammatory Disorders
When it occurs in younger patients, it is usually  Septic arthritis
2° & develops if articular cartilage is damaged  Rheumatoid Arthritis
or subjected to abnormal stress.  Ankylosing spondylitis
>80% of persons 55 years old show radiological  Psoriatic arthritis
evidence of osteoarthritis but only 25% have  Trauma
clinically significant symptoms.  Fractures (particularly
osteochondral fractures)
Causes  Joint instability (e.g. cruciate
1. Primary ligament injury, joint
Develops without any obvious underlying cause hypermobility syndromes)
& is best characterized by 1° generalized nodal  Post meniscectomy
osteoarthritis, a disorder affecting many joint  Osteochondritis dissecans
groups, including;  Neuropathic joints (Charcot
 Hips joints)
 Knees  Mechanical causes including
 Zygapophyseal joints of the spine leg length discrepancy,
Also; instability, repetitive
 Elbow/Ankle (occupational) injuries
 IP joints of the fingers & toes Pathogenesis
Studies have shown that there is a significant This is thought to be as a result of intrinsic
increase in bone density in people with disturbances in the metabolism of cartilage which
osteoarthritis which is determined by a variety leads to increase in water content of the cartilage &
of genetic, hormonal & metabolic factors easier extractability of the matrix proteoglycans
which may also influence cartilage metabolism which leads to chondrocyte damage & cartilage
independently of any effect due to bone density. deformation.
Women with osteoporosis seldom have
osteoarthritis.
1. Secondary - This is as a result of
increased stress, weakened cartilage or
abnormal support of cartilage e.g. avascular
necrosis
 Genetic or developmental
 Congenital hip dislocation
 Slipped upper femoral
epiphysis
 Chondrodysplasia
 Perthe's disease Cardinal features;
 Genu valgum or varum i. Inflammation leads to progressive cartilage
 Haemophilia destruction forming an area of fibrillation, which is
 Metabolic a hair-like patch where the cartilage matrix
 Hyperuricaemia components are lost, leaving only a skeleton of
 CPPD arthropathy disrupted collagen fibres attached to the bone below.
 Alkaptonuria ii. Subarticular cyst formation in the marrow
 Gaucher's disease below the subchondral bone from extrusion of joint
215
 fluid through the hyaline cartilage clefts into the  Knee
marrow, with a fibroblastic and osteoblastic cellular
Early Osteoarthritis
reaction leading to granulation tissue formation in
 Pain/Tenderness (worse at the end of
the cyst.
the day; background pain at rest) due to;
iii. Sclerosis of the surrounding bone due to
 Exposure of nerve endings 2°
increased synthesis of bone by subchondral
to bone erosion
osteoblasts, presumably prompted by intercellular
 Capsular fibrosis → shrinking,
communication by cytokines between chondrocytes
with pain on stretching
and osteoblasts. With increased bone formation in the
 Bone pressure due to vascular
subchondral area, physical properties change; the
congestion
bone becomes stiffer with decreased compliance, and
 Muscular fatigue
microfractures occur, followed by callus formation,
more stiffness, and more microfractures. The term Moderate Osteoarthritis
eburnation applies to the glistening appearance of  Stiffness - In larger joints, movement
the polished sclerotic bone surface. is accompanied by palpable or audible
iv. Metaplasia of the peripheral synovial cells coarse crepitations.
results in peri-articular formation of osteophytes (or,  Swelling due to;
more correctly, osteochondrophytes, consisting of  Intermittent - Effusion
bone and a mixture of connective tissues with a  Continuous;
coating of fibrocartilage and sometimes islands of  Capsular thickening
hyaline cartilage within the osteophyte) and in  Large osteophytes
subchondral bone, especially in areas denuded of  Gives the
cartilage. appearance of
v. Capsular fibrosis - There is NO primary nodes in the PIP -
change in the capsule or synovial membrane, but the Bouchard's
recurrent strains to which an osteoarthritic joint is nodes
subjected to often leads to slight thickening &  "
fibrosis of the capsule or synovial membrane
Severe osteoarthritis
 Deformity due to;
 Capsular contracture
 Joint instability
Fixed deformity (inability of the joint to
assume the neutral anatomical position)
is often found in the Hip, & sometimes
at the Knee & in other joints.
 Loss of function

Ix
 Cardinal features on X-Ray;
i. Asymmetric narrowing of
S/S joint space
Symptoms characteristically wax & wane, & pain ii. Sclerosis of subchondral bone
may subside spontaneously for long periods. under the area of cartilage loss
Commonly affected joints iii. Subchondral cysts
 DIP
iv. Osteophytes at margins of
 Thumb MCP
joints
 Cervical & lumbar spine
Also features of previous disorders.
 ↑ CRP
216
  Radionuclide scanning (99mTc) -  By transecting the bone, to reduce
shows increased activity during the bone intraosseous hypertension & relieve
phase in the subchondral regions of the pain
affected joints. This is due to increased  An unintentional & poorly understood
vascularity & new bone formation. consequence is fibrocartilaginous repair
of the articular surface.
Mx i. Arthrodesis (surgical immobilisation of a joint
a. Early treatment principles; so that the bones grow solidly together) - is
 Relieve pain - Analgesics & indicated if the stiffness is acceptable &
Anti-inflammatory therapy neighbouring joints are not likely to be
 Reduce rate of degeneration - prejudiced e.g. Lumbosacral tilting & rotation.
Proteoglycan matrix This is a practical solution for young adults with
supplements e.g. Glucosamine marked destruction of a single joint.
sulphate, Chondroitin sulphate ii. Total joint replacement for hip & knee -
 Protect the joint from because of the tendency for implants to loosen
'overload' with time, joint replacement is usually reserved
 Reduce weight for patients aged ≥65yrs
 Supportive footwear Mechanical considerations;
 Walking aids  The prosthetic implants must be
 Modify daily activities durable
 Exercises  They must permit slippery movement
a. Intermediate treatment at articulation
 Maintain movement & muscle strength  They must be firmly fixed to the
– Physiotherapy skeleton
 Injection of depot intra-articular long  They must be inert & not provoke
acting steroids 6monthly (S/E - unwanted reaction in the tissues
Osteoporosis) The usual combination is a metal femoral
a. Late treatment; component (stainless steel, titanium, cobalt-
Indications; chrome alloy) articulating with a polyethylene
 Must be demanded by the patient socket
 Keeps patient awake at night Complications;
 Reduced walking distance to <100m Intra-op;
 Confinement of activity  Perforation/fracture of the
i. Minimally invasive procedures - Arthrotomy, femur or acetabulum
Arthroscopy  Sciatic nerve palsy (usually due
ii. Intertochanteric Realignment Osteotomy - It to traction but occasionally
must be done while the joint is still stable & caused by direct injury)
mobile (usually in patients <50yrs old) & x-rays Early;
show that a major part of the articular surface  Infection
(the radiographic 'joint space') is preserved.  DVT
Objectives;  Dislocation
 To change the orientation of the  Myositis ossifican
femoral head in the socket so as to Late;
reduce mechanical stress in a damaged  Aseptic loosening due to
segment granuloma formation of either
 By realigning the proximal femur, to the acetabular socket or the
improve joint congruity femoral stem is the commonest
cause of long-term failure

217
  Stress shielding - Aggressive d) Sensory paralysis
osteolysis with or without e) Pressure sores even at birth
implant loosening
 Infection Visceral paralysis mainly the bladder and the bowels
 Dislocation leading to Incontinence of urine and stool

f) Hydrocephalus due to malformations of

the ventricles in the cerebellum affecting the flow
of CSF mainly the 4th ventricles.
SPINA BIFIDA
Principles of treatment:

Def. a congenital condition inwhichthe elements 1. Correction of the deformity

2. Maintainance of the correction
Pathology:
3. Promotion of possible function in the
There is failure of total closure of the embryonal affected limb.
neural tube or the mesodermal tissue.

Closed lesion which denotes an intact skin

Open lesion which denotes deficiency in the skin

hence exposure of nerve tissue posing a danger of
infection leading to primary or secondary paralysis.

1. Primary paralysis will present at birth due

to failure of part of the spinal cord to develop and GLANDS:
this is called myelodysplasia.
THE BREAST:
Meningomyelocele – it is a meningeal sac containing
both the meninges and the nerve root. If the nerve Comparative and surgical anatomy:
tissue remains in the primitive state then it is called a
This is the protruberant part of the human breast which
myelocele giving rise to leakage of CSF leading to
overlies the 2nd to the 6th ribs. It extends from the lateral
hydrocephalous. It may lead to functional
border of the sternum to the anterior axillary line. In
impairement or complete paralysis of the muscles of
actual fact a thin layer of mammary tissue extends
the lower limbs.
considerably further from the clavicle above to the 7th to
2. Secondary paralysis due to infection 8th rib below and from the midline to the edge ot
lattismus dorsi posteriorly. This fact is important when
Clinical featurd more and es; performing a mastectomy, the aim of which is to remove
It is difficulty to assess in infants the whole breast.

c) Motor paralysis: happens in the lower The breasts are modified sweat glands in that they are
limbs and the trunk. It can be very severe or mild. embryologically derived from a downward growth of
ectoderm into the underlying messemchyme. The first
Severe- flexors of the hip are affected more and stage of development occurs at 6th or 8th wk of gestation,
adductors, quadriceps and tibialis anterior are spared. when two strips of thickened ectoderm, the mammary
ridges grow in aline extending from the embryonal axilla
218
to the inguinal region. In many animals breasts develop Branches of the axillary artery i.e.
along a whole length of the ridge, but in humans true
breast tissue occurs only in the pectoral region. The The thoracoacromial
breast overlies the pectoralis major, seratus anterior, and Subcapsular
external oblique muscles. Medially, the breasts reach the
sterna edge and laterally the midclavicular line. The Lateral thoracic.
pyramidal axillary tail extends into the axilla. The tail is of
Innervations:
surgical importance. In some cases it is palpabl, and in a
few it can be seen premenstrually or during lactation. A It is primarily by sensory and sympathetic nerves. The
well developed axillary tail is sometimes mistaken for a nipple has a rich sensory supplty while most of the
mass of enlarged lymph nodes or lipoma. sympathetic innervations are to the breast parenchyma.
Nerves of the breast are principally derived from the 4th,
The lobule is the basic unit of the mammary gland. The
5th and 6th intercostals nerves.
number and size vary enormously. They are most
numerous in young women. From 10-100 lobules empty Cyclic changes during the menstrual cycle:
via ductules into a lactiferous duct of which there are
from 15-20. Each lactiferous duct is lined by a spiral Volume varies during the menstrual cycle. The volume is
arrangement of contractile myoepithelial cells and is greatest in the second half of the cycle, after a
provided with a terminal ampulla- a reservoir for milk or premenstrual increase in size, nodularity, density and
abnormal discharge. sensitivity. Progesterone may stimulate glandular growth
in the lateral phase than the follicular phase.
The ligaments of cooper are hollow conical projections of
fibrous tissue filled with reast tissue, the apices of the In pregnancy:
cones being attached firmly to the superficial fascia and
There is dramatic increase in secretion and release of
thereby to the skin overlying the breast. These ligaments
circulatingovarian and placental estrogen and
account for the dimpling of the skin overlying a
progesterone. The gland enlarges. The areola skin
carcinoma. The areola contains involuntary muscles
darkens. The areola glands become prominent as ducts
arranged in concentric rings as well as radially in the
and lobules proliferate. The proliferating glandular
subcutaneous tissue. The areola epithelium contains
epithelium replaces connective tissue and the
numerous sweat glands and sebaceous glands enlarge
components of adipose tissue.
during pregnancy and serve to lubricate the nipple during
lactation (Montegmery’s gland) Postmenopausal breast:

The nipple is covered by thick skin with corrugations. Near There is concomitant decrease in ovarian secretion of
its apex lies the orifice of the lactiferous ducts.the nipple estrogen and progesterone. There is involution of
contains smooth muscle fibres arranged concetricallyand ductular and glandular components.there is loss of fat
longitudinally, thus is an erectile structure which points content and supporting stroma, therby initiating loss of
outwards. Lymphatics of the breast drain predominantly lobular structure, density, form and contour.
into the axillary and internal mammary lymph nodes
receive approximately 75% of the drainage. Gynaecomastia:

Blood supply: Presence of female type mammary gland in the male. In

most cases it should not be considered a disease because
Internal mammary artery male breast enlargement is common. Physiologic
gyneacomastia occurs mostly during three phases of life;
219
 i) Neonatal period bilateral. It usually involves the upper outer quadrant
ii) Adolescence of the breast and radiates to the axillae down the
iii) Senescence (growing old) arms. It tends to be more severe immediately before
the menses. Non cyclic pain occurs in postmenopausal
women or when seen in premenopausal women,
bears no relationship to the menstrual cycle. It is
more commonly unilateral, localized and described as
It is usually due to excess estrogen in relation to sharp and stabbing or burning. Mondor’s
circulating testerone. disease( thrombophlebitis of the lateral thoracic or
superior thoracoepigastric vein)may cause breast
Neonatal type is due to the action of placental
pain.
estrogen on neonatal breast parenchyma
b) Nipple discharge:
In adolescence there is an excess of estradial relatve
to testerone This is a common complaint but an uncommon sign of
carcinoma of the breast. Only 3-11% of women with
With aging the plasma testerone levels fall with a
ca breast have an associated nipple discharge. 99% of
relative hyperestrinigism.
women presenting with nipple discharge, the cause is
Drugs with estrogens or estrogenic activity (digitalis, benign. It is good to determine whether they are
estrogens, anabolic steroids, marijuana) may cause physiologic or pathologic.
gynaecomastia.
Discharges are classified as if they are spontaneous
Drugs that inhibit the action or synthesis of testeroe and localized to one duct. Pathologic diseases may be;
(cimitidine, ketoconazole, phenyntoin, spirinolactone,
Bloody or
antineoplastic agents, and diazepam) may also be
implicated. Serous and

Clinical breast problems: Are almost always unilateral.

Most breast complaints that cause a woman to seek Physiologic discharges occur only with nipple
medical attention are benign. The problems may be compression
divided into four general categories of;
Frequently originate from multiple ducts, and
a) Breast pain
b) Nipple discharge Usually bilateral
c) Breast masses Fluid can be expressed from the nipples of
d) Breast infections. approximately 80% premenopausal women.
a) Breast pain (mastalgia):
5. Pts with physiologic discharge should be
It is a common problem which is rarely a presenting advised against squeezing their nipples and there
sign of breast carcinoma. It may originate from the is no therapy required.
breast itself or reffered from extramammary 6. Pathologic discharges should include
structures like ribs, vertebrae, or occasionally the testing the fluid for occult blood and identifying
teeth. The pain can be cyclic or non cyclic on the basis the quadrant of the breast from which the
of its relationship to the menstrual cycle. The cyclic discharge originates.
pain wanes with the menstrual cycle and is frequently
220
 7. 70-80% of discharges associated with ca what the patient perceives as a breast mass is actually
contain blood. a normal variant of breast tissue.

A non bloody discharge that meets the other criteria d) Cysts:

of pathologic discharge is an indication for breast
biopsy. They are a common cause of dorminant breast mass.

Cytology is not usually useful in the evaluation of Peak incidence in women in their 40s and
nipple discharge because the absence of malignant perimenopauseal yrs.
cells does not reliably exclude. They are;
Galactorrhea: This is a non puerperial discharge of Well demarcated from the surrounding breast
milky fluid from both nipples. It differs significantly
from that of other forms of nipple discharge. It is not Mobile and
a sign of primary breast pathology and should prompt
Firm.
a work up to exclude an underlying endocrine
disorder. It is normal if intermittently secreted up to Difficult to distinguish from solid lesions on physical
2yrs after breast feeding has stopped. Galactorrhoea examination although yheu fluctuate with the
may be secondary to; menstrual cycle, but solid lesions do not. Cystic
lesions in postmenopausal women who are not on
Hypothyroidism
hormone replacement therapy are uncommon and
Pituitary adenoma should be regarded with a high degree of suspicion
than those in premenopausal women because they
Chest trauma (including thoracotomy) may be secondary to ductal obstruction by a
A variety of medications- including oral malignant lesion. It should be evaluated by aspiration.
contraceptives, phenothiazines, tricyclic If fluid is not groosly bloody and the mass restores
antidepressants, metoclopromide, and reserpine, also completely, no further therapy than follow-up
cause galactorrhoea. examination.

Causes of nipple discharge: SOLID MASSES OF THE BREAST:

Solitary papilloma is the most common cause FIBROADENOMA:

Ductal ectasia is classically thick and cheesy “ tooth It presents most frequently in pts between the age of
paste” and common in the aging women above 50yrs. 20 and 50 yrs characteristic clinical presentation.

Carcinoma but not common It is a well defined palpable mass that is rubbery in
texture and mobile.
c) Breast mass:
It is usually solitary but may be multiple in 10-15% of
It may be cystic or solid and are characterized by their cases.
persistency throughout the menstrual cycle.
They are thoyght to be the result of a minor
They may descrete or poorly defined but they differ in aberration in the process of lobular development.
character from the surrounding breast tissue. Often
Hormonal factors appear to be important in their
growth, because they involute after menopause and
221
they dramatically increase in size during pregnancy. In 2. Gender;
postmenopausal women receiving only estrogen e) Breastcancer is 100 times more common
fibroadenomas may increase in size relative to the in women than in men. Female sex is therefore a
surrounding breast parenchyma. major risk factor.
3. Family history;
Fibroadenomas typically stop growing when they
reach 2-3 cm in diameter. Approximately 20-30% of women with breast cancer
have a family history of the desease. But only only 5-
Blacks are more affected than whites and in early age 10% have an inherited mutation in a breast cancer
in rare circumstances, fibroadenomas have been susceptibility.
associated with carcinoma.
4. Hormonal factors;
FIBROCYSTIC DISEASE:
Studies have linked breast cancer risk to age at
This is a common term used to describe a variety of menarch, menopause and pregnancy.
benign breast disorders. It is not a clinical entity
because it encompasses a heterogenous group of The increased number of ovulatory cycles associated
processes some pathologic and some physiologic, with early menarch, nulliparity, and late menopause
with a wide varying cancer risks. The term fibrocystic appears to be the common mechanism of risk.
change is not a synonym for lumpy breast. It should Women who undergo bilateral oophorectomy before
be reserved for women in whom a breast biopsy has menopause are at decreased risk. Generally
demonstrated one of the histologic components of hormornal risk factors are associated with relative
fibrocystic change. When a breast biopsy is performed risks in the range of 1.5- 2.0. Long duration of
for vague areas of nodularity that lack mammographic lactation appears to reduce risk in menopausal
or ultrasonographic correlates a fibrocystic process is women. Post menopausal obesity has also been
the diagnosis. shown to increase risk perhaps through an increase in
peripheral estrogen production.
BREAST CANCER:
5. Dietary:
It is the most commoncancer in American women and
the second most common cause of death. It a major There is a relationship between dietary mammal fat
cause of cancer death in most industrialized nations. and the incidence of breast cancer. Fried high fat
foods can increase the risk of developing breast
Risk factors: cancer approximately twofold.
1. Age; 6. Breast feeding and menopause:
Age is the most common risk factor Women in whom menopause occurs after the age of
Half of women’s lifetime risk for breast cancer 55yrs the risk is twice as those women whose
development occurs after age 65yrs. menopause started below the age of 45yrs. Artificial
induced menopause appears to be protective for
Between the age of 35-55yrsthe risk for breast cancer breast cancer and the protection is lifelong. Breast
development is only 2.5% feeding of long duration ( < 36 months in a lifetime)
was thought to reduce the risk of breast cancer.
Breast cancer at a young age is more common in black
women than in white women. 7. Child bearing and fertility:

222
Infertility and nulliparity are associated with a high In the slow growing tumour the cells double in 309
probability (30-70%) for ca btreast. Women days. If the range of doubling is constant and then the
impregnate before 18yrs of age whom have a full ca cellsrise from one cell of origin for the tumour to
term pregnancy have a breast cancer risk. Women grow 1cm in diameter and clinically be detectable it
who have their first full term pregnancy after age will take about 8yrs. The slow growing tumours will
30yrs have an even more risk for breast cancer than take even between 15-30yrs and sometimes the the
nulliparous. tumour can change its course, i.e. remain a benign
breastlump for life. The normal periods of 5yr survival
8. Multiple primary neoplasms: rate for untreated ca is 3yr but some take 4-5yrs and
Women with a history of primary breast cancer have a survive longer than that.
risk three – four times higher for primary cancer in METASTASIS:
the contralateral breast.
It .will determine the method andchoice of treatment
9. Irradiation:
1. Regional lymph nodes:
Exposure to ionizing radiation, whether from nuclear
or medical procedures increases the risk for breast Axillary and internal mammary nodes are the major
cancer. The level of risk varies with age at exposure routes of spread. Supraclavicular nodes are involved
being greatest for exposure in childhood and secondarily because they are in continuity with the
adolescence, and minimal foe exposures in after axillary nodes. If the supraclavicular nodes are
40yrs. Pts who were treated with irradiation for involved, it shows that there is distant metastasis and
Hodgkin’s lymphoma in their adolescent or childhood surgery here becomes a waste internal and axillary
yrs are the group at risk on the basis of radiation glands may be involved differently or both. When the
exposure most commonly encountered today. axillary nodes are involved the ca in this case is
operable.
10. Benign breast disease:
2. Distant metastasis
Benign breast lesions are classified as non
proliferative, proliferative, or proliferative with atypia. This is mostly by haematogenous spread. The
Proliferative without atypia are associated with a following sitesare common;
small increase in breast cancer risk. Proliferative
lesions with atypia are uncommon. The bones especially in the spine, pelvis, ribs, femur,
skull, humerus,
HOST TUMOUR RELATIONSHIP:
Lungs (most frequently involved)
The growth rate of ca breast and the ability to
metastize are determined bythe balance between the Liver “ “ “
biological behavior of the tumour and the immune The haematogenous spread affects the 5yr survival
response of the host. The growth potential of the rate because it is fast in growing of the tumour.
tumour and resistance of the host vary over a
widevrange from pt to pt and may be altered during CLINICAL FINDINGS:
the course of the disease.
Always start with history ecause it will give you 80%
In arapidly growing tumour, its cells double to about of the diagnosis. Combined with physical
23days from one cell to two cells. examination, characteristics of the lesion and if there
is any meastasis will help you in spot diagnosis.
223
There is always a lump in the breast.sometimes the Examination of the breast: refer to your clinical
patient may come very latewhen an ulcer has already methods but note the following;
developed, fungating with axillary lympadenopathy or
oedema of the arm confirms the diagnosis. Variation in size – compare with the normal one and
colour of the breast
It can be confirmed more by histopathology in
addition to other investigations. Minimal nipple retraction because with ca are
retracted upwards because of the ca fixation to the
All these will help determine the method or choice of skin.
treatment after stagin;
Palpate the lymph nodes – size, mobility, fixed?,
a) Symptoms: Note the following apart from tender.
the history of the patient.
Mass – size, mobility, fixed, tender, firm, fixed to the
Menarch chest wall or the skin.

Pregnancy (parity) Breast ca usually presents with the following;

Artificial or natural menarch Non tender mass

Date of last normal, menstrual period Firm as tip of your nose or

Any previous lesions Hard lump with poorly defined margins because of
local infiltration
Family history of ca breast
Skin or nipple retraction
Pains of metastasis especially systemic complaints e.g
cough, haemoptysis shows diatant metastasis. About Breast may be asymmetrical
80% of the patient will complain of a painless breast
lump and 90% will diagnose themselves. Waterly,serous or bloody discharge from the nipple

Less frequent symptoms: In advanced cases it may present with the following;

Nipple discharge Oedema of the arm

Redness Peau de orange

Generalized hardness of the breast Redness

Shrinking of the breast Nodularity with laceration of the skin

Rare symptoms: Presence of a large fungating tumour

Axillary mass Fixation to the chest wall

Swelling of the arm or Marked axillary lymphadenopathy

Bone involvement may be the 1st symptom/ sign. Supraclavicular lymphadenopathy and distant
metastasis

The breast is divided into four quadrants i.e

224
Lateral upper – 45% When the redness is more than1/3 of the underlying
skin of the breast
Lateral lower – 10%
DDX:
Medial upper – 15%
g) Any infective process of the skin like
Medial lower – 5% cellulitis.
Around the nipple – 25% Treatment: difficulty as metastases are rapid and very
The commonest site is the lateral upper quadrant. early hence it is rarely curable but you can do radical
mastectomy but the cure rate is very low and
OTHER CLINICAL FORMS OF Ca BREAST: therefore;

a) Paget’s disease; Irradiation

Incidence -3% of all breast ca Cytotoxic drugs or

It is an intraductal ca well differentiated, mid-centric Hormonal therapy

in the nipple and ducts
c) Mastitis carcinomatosis:
The nipple epithelium is also infiltrared
This is ca occurring during pregnancy
Symptoms:
Incidence – 1-2% of all breast Cas
Itching or burning of the nipple
Usually occurs in women at the age of < 35yrs,
Erosion and ulceration but superficial and is concurrent with pregnancy
confirmed by biopsy.
Diagnosis:
DDX
Is delayed because of physiological changes (in the
Dermatitis artefacta breast) due to pregnancy

Bacterial infection of the nipple DDX:

b) Inflammatory ca: Physiological changes of breast in pregnancy.

clinical findings
Laboratory findings in ca breast:
Rapidly growing tumour
If confined to the breast and axillary lymph nodes it
Painful +/- enlargement of breast causes no abnormalities. However if the blood
findings are abnormal e.g. ^ ESR and low Hb it shows
The skin becomes erythematous, oedematous and
disseminated ca.
warm
Liver metastasis may be associated with increased
Incidence – is 3% of all breast Cas
alkaline phosphayases
Diagnosis:
Hypercalcaemia is another finding in advanced ca. i.e
L.F.Ts will be abnormal.

225
X-ray findings: It depends on the operation;

Lungs, spinal column and long bones will be affected a) Needle biopsy (Vim Silverman needle)
due to metastasis. b) Open biopsy

Scanning of the bones: Frozen biopsy takes about ½ hr(not reliable)

Ct scan detects early bone metastasis to the liver, Paraffin wax biopsy (reliable)
lungs and brain
Cytology:
Mammography:
Examination of the nipple discharge or cystic fluid,but
Soft tissue x-ray will detect the ca before the mass is must be confirmed with open biopsy of paraffin wax.
palpable as early as 2yrs before the ca becomes
palpable. It is also good for screening. DDX OF CA BREAST:

Indications for screening: In order of frequency;

1. Evaluate the opposite breast when the 1. Mammary dysplasia (cystic disease of the
diagnosis is confirmed in the other breast. breast)
2. To evaluate ill defined masses, nipple 2. Fibroadenoma
discharges, erosions or retractions of the nipple 3. Intraductal papilloma
or skin, skin dimpling or breast pain. 4. Fat necrosis (following trauma)
3. To search for occult breast (mass screen) 5. Breast abscess
for all child bearing groups (14-45yrs). Management of ca breast:
Dangers of mammography: Tou should start with staging of the ca. it will help in
a) Repeated ionization may cause ca of the the managementbecause mxn varies with every
breast as radiationsare carcinogenic. stage.
b) Dangers of false positives may subject the Stage I:
woman to unnecessary breast operations
c) Dangers of false negatives as in lobular ca Tumour is less than 5cm in its greatest diameter
mammography should be done to both breasts i.e
Skin fixation is absent or incomplete
the normal and diseased.
No fixation to the underlying muscles
Biopsy:
Axillary nodes not palpable
For histopathology is the gooa method to any ca of
the body Stage II:
Specific indications for breast biopsy: As in stage I above but with palpable mobile nodes in
the homolateral.
i) Persistant mass
ii) Bloody nipple discharge Stage III:
iii) Eczematoid nipple
Tumour more than 5cm in its greatest diameter or
Methods of biopsy:

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Skin fixation complete or Stage IV:

Skin involvement + wide fixation This is only palliative. Do the following;

Palpable mobile nodes Raise the nutritional status of the pt i.e. HPD, BT,
Haematenics
Peau de orange
Simple mastectomy( in fungatingpart) + RT
Fixation to underlying muscle
Other metastasis like pleural effusion may be
Palpable axillary and supra clavicular nodes or removed by RT
Oedema of the arm because of the lymphatic Dress the wound with antiseptics
drainage.
Cover with antibiotics to treat all infectios promptly
Stage IV:
Progress of the disease may be controlled by
Distant metastasis regardless of condition of the
primary and the regional nodes 8. Hormonal therapy
9. Endocrine surgery
Treatment may be curative or palliative. 10. Cytotoxic drugs
1. Stage I and II cases Hormonal therapy and endocrine surgery:
3. Treatment is curative. Excision offers the
best method of cure. Halsted radical mastectomy Hormonal therapy is applied because 40% of the
or local simple mastectomy combined with RT in breast cas are hormone dependent. So the course of
all cases. Local simple mastectomy is also called the disease may be slowed down or regressed by
standard radical mastectomy where lymphnodes altering the pt’s hormonal balance. Then the pt will be
are also removed especially the intermammary relieved of pain.
l’nodes.
4. Can also do simple mastectomy which is Nutrition of the pt will improve
best for the ca which is confined to the breast The tumour will regress locally
without spreading to adjacent organs (not beyond
stage I) Osteolytic lesion will calcify
5. Local excision is known as lumpectomy.
Pathological fractures will heal
Stage III:
Unfortunately the disease always procedds
Usually palliative but this stage is sometimes very fast after the tumour cells have lost
sometimesborderline. Radical mastectomy is their dependency on the hormones about 4-6
contraindicated here since we are most likely not months.
going to eradicate the tumour because of the
Two types of hormones are used;
metastasis. Instead the lymphatic channels are
opened up and this will end up spreading the tumour a) Pre-menopausal women:
cells to the rest of the body. What is done here is
simple mastectomy followed with RT post operatively. Here surgry is used by removing the ovaries. This will
Some centers do pre-opRT then post- op RT then always delay the progress of the disease. Advise the
followed by Halsted method. pt to admit to have oophorectomy. The ovaries can be
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removed by minilaparatomy or by radiation which is anastomosing networkwhich is continous across the
good for the weak pts midline with that of opposite site below with that of
the abdominalwall. They all correspond to the arteries
b) Postmenopausal women: supplying the glands. Hence this part of the breast/
Oestrogen is used in this pts. Before its usage make chestwall have got extensive supply of lymphatic vsls
sure that there is no estrogen activity or else you will as compared to the other quadrants. Breast ca is
aggravate the condition. You must make several more malignant in the old (440% are hormone
vaginal smears to ascertain the estrogen activity has dependent cancers).
stopped. Tumour remission rate from estrogen (also
to androgens as well) tend to increase with increasing
number of yrs past the menopause. If the therapy is
given for 6 months and there is no response, stop the
procedure and peoceed with other methods or
sometimes you can combine with adrenolectomy or
hypophysectomy.

c) Corticosteroids:

Are also of help e.g. cortisone about 150mg or

predinsolone 30mg bd or tid. They reduce pain. Other
symptoms disappear.

d) Chemotherapy:

Cytotoxic drugs which are only used for palliation in

advanced metastasis and also when the hormonal
therapy has failed. The drugs include the following;

Durorubicin (adriamycin) i.v 40-50 % good response

although it is short. Combinations also show good
results e.. dororubicin + cyclophophamide.

Others: cyclophosphamide + vincristine or

methotrexate or flurouracil.

Prognosis:

Usually poor in males because of the tumour attaches

directly to the chestwall even if inearly stage. The
crude 5yr survival rate is about 36- 17 %. In women
when the ca is confined to the breast the 5yr cure
rate by radical mastectomy is 75-90%. Involvement of
the axillary nodes is between 40-66% at 5yrs. The
course by anatomical site for the breast ca is the
medial portion of the inner lower quadrant.
Lymphatic drainage or capillaries of the breast form
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