Fast Track Surgery: Trauma, Orthopaedics and the ... - PasTest

Fast Track Surgery:Trauma,Orthopaedics andthe Subspecialties

Also by Manoj Ramachandran:Intercollegiate MRCS: An Aid to the Viva Examination (with Alex Maloneand Christopher Chan) published by PasTest.The Medical Miscellany (with Max Ronson) published by HammersmithPress.Clinical Cases and OSCEs in Surgery (with Adam Poole) published byChurchill Livingstone.Coming soon from Manoj Ramachandran:Basic Orthopaedic Sciences: The Stanmore Guide published by HodderArnold.Also by Aaron Trinidade and Manoj Ramachandran:Mnemonics in Surgery and Fast Track Surgery: General, Vascular andUrology both published by PasTest.

Fast Track Surgery:Trauma,Orthopaedics andthe SubspecialtiesbyAaron Trinidade MBBS MRCS(Ed) DO-HNSSenior House Officer in Otolaryngology, The Royal Free Hospital, LondonandManoj Ramachandran BSc(Hons) MBBS(Hons)MRCS(Eng) FRCS(Tr&Orth)Paediatric and Young Adult Orthopaedic Fellow, Royal NationalOrthopaedic Hospital Rotation, Stanmore, Middlesex

© 2006 PASTEST LTDEgerton CourtParkgate EstateKnutsfordCheshireWA16 8DXTelephone: 01565 752000All rights reserved. No part of this publication may be reproduced, stored in aretrieval system, or transmitted, in any form or by any means, electronic,mechanical, photocopying, recording or otherwise without the prior permission ofthe copyright owner.First published 2006ISBN: 1 904627 95 1ISBN: 978 1904627 951A catalogue record for this book is available from the British Library.The information contained within this book was obtained by the authors fromreliable sources. However, while every effort has been made to ensure itsaccuracy, no responsibility for loss, damage or injury occasioned to any personacting or refraining from action as a result of information contained herein canbe accepted by the publishers or authors.PasTest Revision Books and Intensive CoursesPasTest has been established in the field of postgraduate medical educationsince 1972, providing revision books and intensive study courses for doctorspreparing for their professional examinations.Books and courses are available for the following specialties:MRCGP, MRCP Parts 1 and 2, MRCPCH Parts 1 and 2, MRCPsych, MRCS,MRCOG Parts 1 and 2, DRCOG, DCH, FRCA, PLAB Parts 1 and 2.For further details contact:PasTest, Freepost, Knutsford, Cheshire WA16 7BRTel: 01565 752000 Fax: 01565 650264www.pastest.co.uk enquiries@pastest.co.ukText prepared by Type Study, Scarborough, North YorkshirePrinted and bound in the UK by MPG Books Ltd., Bodmin, Cornwall

CONTENTSAcknowledgementsForewordContributorsviviiviiiPART I: INTRODUCTION1: Using this book 32: Surviving trauma, orthopaedics & the subspecialties 53: Getting started: surgical jargon 9PART II: TRAUMA & ORTHOPAEDICS4: The trauma call in orthopaedics 255: Fractures 496: General orthopaedics 91PART III: THE SUBSPECIALTIES7: Paediatric surgery 1078: Otolaryngology, head & neck surgery 1459: Ophthalmology 20910: Plastic surgery 22911: Neurosurgery 26712: Cardiothoracic surgery 28113: Maxillofacial surgery 315Index 323

ACKNOWLEDGEMENTSAs always, for my wife Joanna.Manoj RamachandranThanks again for the continuing support everyone has given me in thissecond of the series, in particular, my parents. Thanks also go out to SandraDieffenthaller who gave me a love of teaching. A special thanks to Kelly –your support was fantastic. Finally, thanks to Pastest for their patienceduring this project.Aaron Trinidalevi

FOREWORDCurrent surgical training is very structured, and requires junior surgeons torapidly acquire knowledge and understanding of surgical practice, prior toprogressing into higher surgical training. This is formalised in the MRCSexam. Fast Track Surgery: Trauma, Orthopaedics and the Subspecialties isan invaluable resource in achieving this aim. The book focuses on solidsurgical principles with a structured approach to learning. This allows thejunior surgeon to clearly appreciate essential points in patient care.Broad knowledge, empathy and attention to detail are fundamental to thedelivery of good patient care. Early in one’s career, the required knowledgebase may seem daunting. However a good understanding of basic surgicalprinciples provides a solid foundation to care and facilitates further learning.This book highlights essential knowledge and provides a clear structuredmethod of learning. This mirrors the teaching of basic surgical skills in theapprenticeship style training of good surgical technique. A solid foundationin both of these arms of surgery leads to the development of a competentsurgeon. Moreover, it is this foundation that allows competent surgeons todevelop into exceptional specialists.More pressure is now placed upon the training process, to concentrate andcondense this training. Attention and stress to structured learning, and theuse of general principles and frameworks facilitates this process.Ultimately the mark of a good surgeon is judgement, both in diagnosis andinvestigation, and particularly judgement in surgical care. This is the part ofour profession that allows us to practise the art of surgery.The authors of this book are enthusiastic, well motivated surgeons. It hasbeen a pleasure to work with them. They have an excellent surgicalunderstanding, and this is reflected in this clear, concise instructional bookin surgical care.It is a privilege to be a doctor and to be fundamental to care of our patients.With this comes a sincere responsibility to provide excellent surgical care.Personal improvement in provision of patient care is an ongoing task. Thiswe all strive to achieve, through ongoing training, experience, study andresearch. This book provides a good foundation to understanding principlesof care and facilitates the learning of the art of surgery.Michael Papesch FRACSConsultant ENT SurgeonWhipps Cross University Hospital NHS TrustLeytonstone, Londonvii

CONTRIBUTORSRavi Koka, FRCS(Ed)Consultant Orthopaedic Surgeon, Eastborne District General Hospital, East SussexChapter 5aChapter 5dChapter 5eChapter 5fGeneral approach to managementLower limb injuriesTendinous, ligamentous and meniscal injuriesCompartment syndromeDaniel Horner, BSc MBBSSenior House Officer in Surgery, Royal Albert Edward Infirmary, WiganChapter 4The Trauma Call in OrthopaedicsDaniel Tweedie, MA MB MRCS(Eng) DO-HNSSpecialist Registrar in Otolaryngology, London Deanery (South) RotationChapter 8Otolaryngology and Head & Neck SurgeryDania Qatarneh, MA(Cantab) MBBChirSenior House Officer in Ophthalmology, Queen Mary’s Sidup NHS Trust, LondonChapter 9OphthalmologyRhiannon Day-Thompson, MBBCh MRCS(Eng)Senior House Officer in Plastic Surgery, Royal Gwent Hospital, South WalesChapter 10Plastic SurgerySwinda Esprit, BSc MBBS MRCS(Eng) DO-HNSSenior House Officer in Otolaryngology, Wrexham Park Hospital, SloughChapter 11NeurosurgeryIbnauf Suliman, BSc(Hons) BM MRCS(Eng)Senior House Officer in Cardiothoracic Surgery, Barts & The London SurgicalRotationChapter 12Cardiothoracic SurgeryJennifer Collins, BDSSenior House Officer in Maxillofacial Surgery, Royal Sussex Country Hospital,LondonChapter 13Maxillofacial SurgeryAmro Hassaan, MBBS DO-HNSSenior House Officer in Otolaryngology, Charing Cross Hospital, LondonChapter 11viiiNeurosurgery

PART IIntroduction

CHAPTER 1: USING THIS BOOKThis book is a follow-on to Fast Track Surgery: General, Vascular, andUrology. It deals with the sub-specialist areas that you will touch uponduring your time on the wards. Time spent in trauma & orthopaedics ismuch less than that in general surgery, and that spent in the othersub-specialties is even considerably less than that! Many students infact view their time spent during these areas as a bit of a holiday andend up missing out on important clinical knowledge that wouldotherwise serve them well after graduation, only to lament later that theareas were never taught well while they were in medical school. Thetake-home message is this: your time in the sub-specialties is short butimportant, so make use of it; you’ll be glad you did later on in yourcareers (especially if you do an A&E job or go into General Practice!).The bulk of this book is geared towards Trauma & Orthopaedics, but thesub-specialties are each given their due. Only the most salient pointsand concepts are presented here, with focus being on the most-likelyto-be-askedquestions. You are encouraged to read deeper into topicsin standard textbooks and use this book as a study aid. By and large, asstudents, you are only expected to appreciate the basic concepts of thesub-specialties and have an idea of how to manage the commonpathologies and emergencies.As with Fast Track Surgery: General, Vascular and Urology, this book islaid out in a two-columned fashion to allow you to cover the answercolumn when revising. It leans heavily on mnemonics, tables andrelevant in-theatre anatomy. Investigations and the reasons they areordered are given, and management plans are laid out how you’dexpect to see them written in the notes. Carry it around with you andcram from it in your precious spare moments.PART I3

IntroductionWhen studying surgery, the following mnemonic is useful to keep inmind:Dressed In A Surgeon’s Gown, A Physician Is Truly Progressing:DefinitionIncidenceAge DistributionSexGeographyAetiologyPresentationInvestigationsTreatmentPrognosisThis will form a framework on which to build your understanding of eachcase. The best way to learn is, of course, to clerk patients continuously,no matter how dull it may seem at times. Patients are a wealth ofinformation. Following up the patient reveals investigations performedand management decisions made. This serves to bring to life whatyou’ve read and reinforces this information in your mind. But most ofall, enjoy your time in surgery – medical school should be fun!4

CHAPTER 2: SURVIVING TRAUMA,ORTHOPAEDICS & THE SUBSPECIALTIESDepending on the sub-specialty, life on the wards can be pretty chilledout (eg otolaryngology) or can be really demanding (eg trauma &orthopaedics). Use the following tips to help you cope.APPEARANCEDress smartly and make an effort to appear neat. You will see hundredsof patients, but the patients only see a few of you. White coats help,but be willing to take yours off if it makes a patient anxious (white coathypertension). Remember you’re on a ward dealing with patients, andnot in a fashion show. Conservative is always better.PART IATTITUDEYou must be a keener, but in measured amounts so as not to nauseatefellow students and junior doctors! Strike a balance. A lacklustreattitude leads to lacklustre teaching. Develop thick skin quickly.Sarcasm is common in surgery. Take things in your stride, not personally(unless it was meant to be personal). Be polite, especially to the wardsister who runs the show. Offer to do jobs. Speak up when spoken to,but never backchat. Humility is a virtue. If you can’t be humble withyour knowledge (or lack thereof), be confident with caution, but nevercocky. Share information with colleagues and never show others up.Keep skiving to a minimum and make sure everyone pulls his or herweight: the adage ‘one bad apple spoils the whole lot’ rings true wheremost busy consultant surgeons are concerned, and you’ll then have toreally shine to avoid being grouped with slackers.WHAT TO CARRYHave the following handy at all times:• Notebook and pen (have one extra for junior doctors)• Stethoscope• Tongue depressors (while in ENT)• Penlight (handy for lumps and bumps and looking in throats)• Blood and X-ray forms• This book!5

IntroductionFIRST THING IN THE MORNING, DON’T LOITER!• Make sure you’re there first and say good morning to nursing staff• Update your personal list of the firm’s patients (new admissions, etc)• Check patients’ vitals, blood results and X-rays and have them handy• Ask the nurses if anything happened overnight• Have blank blood and X-ray forms handy for the ward round (unlessthe hospital ordering system is digitalised)PRESENTING ON THE WARD ROUNDPresenting is an art form to try to perfect. Keep focused and presentrelevant positives and salient negatives only, but be prepared to answerany question asked (eg knowing who an elderly woman with a hipfracture lives with is important but need not be presented in the samebreath as her current clinical status!). During a presentation, eventsshould be given in a chronological sequence. The following is anexample of how a patient should be presented:[MR LG, FRACTURED LEFT ANKLE]‘This is Mr LG, a 28-year-old mechanic who was out drinking last nightwhen, on leaving the pub, he stumbled and had a mechanical fall atapproximately 1 am, resulting in an inversion injury to his left ankle.There was immediate swelling and pain with obvious deformity at thejoint, and he was not able to weight-bear. He sustained no furtherinjuries. He was brought to the A&E by ambulance. On examination, hisvitals were all normal and his clinical status was stable. His ankle wasdeformed [describe] and there was bruising [state where]. The skinoverlying the ankle was [breached/intact]. Pulses were [present/absent].X-rays showed [describe; see Chapter 5a]. The fracture wasmanipulated under sedation and immobilised in a [type of plaster cast].Besides his injury, he is a fit and healthy man with no other medicalhistory and has been NBM since [time].’Presentation time is about 5 minutes, giving plenty of time forquestions!6

Chapter 2: Surviving trauma, orthopaedics & the subspecialtiesOPERATING THEATRE: DOS AND DON’TSDO have a good night’s sleep and a proper breakfast before attendingDO review the relevant anatomy beforehandDO ask the theatre sister to teach you how to scrub up properly (arriveearly for this)DO know the patients inside out before they arriveDO make sure that there is a medical student scrubbed for every caseDO use time between cases wisely by either reviewing cases orpractising knotsDON’T disturb the surgeon without asking permission firstDON’T annoy the scrub nurse: do as she saysDON’T chit-chat with other students during an operation if not scrubbedDON’T touch instruments unless given explicit instruction to do soDON’T look bored no matter how long and tedious the operation isPART IPOST-OPERATIVE ROUNDIf asked to present a patient on post-op rounds, don’t panic. Start bystating the procedure the patient had and then use the following list ofthings that you should be interested in post-operatively:• General clinical status of patient (alert, vomiting or in pain?)• Examination (in particular, wound site, chest, calves and bowelsounds)• Vital signs (look at trends as opposed to single values)• Fluid charting and input-output balance (is the patient producingurine?)• Drains (function and contents)• Post-operative blood results• Drug chart (receiving appropriate medications in the appropriatedosages?)Have gloves for everyone handy in your pockets. Always be the first oneto pick up the nursing chart and make a show of checking the vitals.Ask if wounds need to be observed and, if so, take the initiative toremove the dressing yourself (don’t forget gloves!).7

CHAPTER 3: GETTING STARTED:SURGICAL JARGONSURGICAL ABBREVIATIONS# Fracture1ry, 2ry, etc . . . Primary, secondary, etc . . .a/aaAAABGABPIAb/AdPL/BAbxACACTHAFAK[A]AIDSALPAmpAOEAOMAPaPTTARDSASAASDASISASTAXRBCbdBEBK[A]BLSBPCACABGartery/arteriesAlcoholics AnonymousArterial blood gasAnkle-brachial pressure indexAb/ad-ductor pollicis longus/brevisAntibioticsAir conductionAdrenocorticotrophic hormoneAtrial fibrillationAbove knee [amputation]Acquired immunodeficiency syndromeAlkaline phosphataseAmpicillinAcute otitis externaAcute otitis mediaAntero–posterior X-rayActivated partial thromboplastin timeAdult respiratory distress syndromeAmino-salicylic acid (aspirin)Atrial septal defectAnterior superior iliac spineAspartate aminotransferaseAbdominal X-rayBone conductionbis die (twice daily)Below elbowBelow knee [amputation]Basic Life SupportBlood pressureCarcinomaCoronary artery bypass graft(cabbage)PART I9

IntroductionCCFCefchrmCISCMVC/OCOPDCRPCRTCSOMCTCVACVPCXRD5WDHxDICDIPJDMDREDTDVTDxECGEchoENTEPB/LESRETOHEUAEx-FixFBCFDPFDP/SFESSFFPCongestive cardiac failureCefuroximechromosomeCarcinoma in situCytomegalovirusComplains ofChronic obstructive pulmonary diseaseC-reactive protein (inflammatorymarker)Capillary refill timeChronic suppurative otitis mediaComputed tomographyCerebrovascular accident (stroke is abetter term)Central venous pressureChest X-rayDextrose 5% in waterDrug historyDisseminated intravascularcoagulationDistal interphalangeal jointDiabetes mellitusDigital rectal examinationDelirium tremensDeep vein thrombosisDiagnosisElectrocardiogramEchocardiogramEar, nose & throatExtensor pollicis brevis/longusErythrocyte sedimentation rateAlcoholExamination under anaesthesiaExternal fixationFull blood countFibrin degradation productsFlexor digitorum profundus/superficialisFunctional endoscopic sinus surgeryFresh frozen plasma10

Chapter 3: Getting started: Surgical jargonFNA[C]FOOSHFTSGGAGCSGentGPG&SGTNGXMHIVHPVHTNHZOICPI&DIHDIMNIOPITUIVCIVDUIVFIVP/UJVPKUBLAlatLFTLUQMAX FAXMCM/C/SMetroMIMOFMSUMUAFine needle aspirate [cytology]Fall on the out-stretched handFull thickness skin graftGeneral anaestheticGlasgow Coma ScaleGentamicinGeneral PractitionerGroup & saveGlyceryl trinitrateGroup & cross matchHuman immunodeficiency virusHuman papilloma virusHypertensionHerpes zoster ophthalmicusIntracranial pressureIncision & drainage (abscesses)Ischaemic heart diseaseIntramedullary nailingIntra-ocular pressureIntensive Therapy UnitInferior Vena CavaIntravenous drug userIntravenous fluidsIntravenous pyelogram/urogramJugular venous pressureKidneys, ureters & bladder (plain film)Local anaestheticLateral X-rayLiver function testLeft upper quadrantMaxillo-facial surgeryMetaCarpalMicroscopy, culture & sensitivityMetronidazoleMyocardial infarctionMultiorgan failureMid stream urineManipulation under anaesthetic11PART I

Introductionn/nnN/ANADNBMNGTNOFN/SNSAIDsOAOCPodqdsOGDOPGORIFOTPANPCAPCWPPDAPEPEEPPERLAPICUPIPJPMHxPOPOPPRPRNPSISPTPTCAPUDPVNerve/nervesNot applicableNil abnormality detectedNil By mouthNasogastric tubeNeck of femurNormal salineNon-steroidal anti-inflammatory drugsOsteoarthritisOral contraceptive pillOmni die (once daily)Quater die sumendus (4 times daily)OesophagastroduodenoscopyOrthoPantoGramOpen reduction and internal fixationOperating Theatre/OccupationalTherapistPolyarteritis nodosumPatient controlled analgesiaPulmonary capillary wedge pressurePatent ductus arteriosusPulmonary embolismPositive end expiratory pressurePupils equal and reactive to light andaccommodationPaediatric intensive therapy unitProximal interphalangeal jointPast medical historyPer os (orally)Plaster of ParisPer rectum (rectally)Pro re nata (as needed)Posterior superior iliac spineProthrombin timePercutaneous transluminal coronaryangioplastyPeptic ulcer diseasePer vaginum (vaginally)12

Chapter 3: Getting started: Surgical jargonqds Quater die sumendus (to be taken 4times daily)qxh Every x hours (eg q3h = every 3hours)RAPDRBSr/oRTARUQRxSCCSIRSSLESNHLSOBSSGstatSTDSVCSxSXRRelative afferent pupillary defectRandom blood sugarRule outRoad traffic accidentRight upper quadrantTreatmentSquamous cell carcinomaSystemic inflammatory responsesyndromeSystemic lupus erythematosusSensoriNeural hearing lossShortness of breathSplit skin graftImmediatelySexually transmitted diseaseSuperior vena cavaSurgerySkull X-rayTBTuberculosistds Ter die sumendus (to be taken 3times daily)TIATransient ischaemic attackTMTympanic membraneTMJTemporoMandibular jointTOETransoesophegeal echocardiogramTPNTotal parenteral nutritionTRAMTransverse rectus abdominis muscleTTETrans-thoracic echocardiogramUCU&EsU/OURTIUSSUTIUlcerative colitisUrea & electrolytes (and creatinine)Urine outputUpper respiratory tract infectionUltrasound scanUrinary tract infectionPART I13

Introductionv/vvVancVEVSDVUJWBC/WCCVein/veinsVancomycinVaginal examinationVentricular septal defectVesico–ureteric junctionWhite blood cells/white cell countGLOSSARY OF SURGICAL TERMINOLOGYAbductAdductAdeno-AfferentAnastomosisAngio-AnomalousAsepticAtelectasisAtresiaBiopsyCachexiaCalculusCalorMovement of any extremity awayfrom the midline of the bodyMovement of any extremity towardsthe midline of the bodyPertaining to glandsTowardSurgically created connectionbetween two tubular structures(eg bowel, blood vessels, etc)Pertaining to blood vesselsDeviating from the normComplete absence ofdisease-causing micro-organisms.Alveolar collapseCongenital absence of abnormalnarrowing of an opening or lumen(adj. atretic)Tissue sample obtained and sent forhistopathologyGeneralised wasting associated withchronic disease or malignancy(adj. cachectic)StoneOne of the classic signs ifinflammation; signifies warmth14

Chapter 3: Getting started: Surgical jargonCaseationCaudalChepal-CicatrixColicCurettageCystDiaphoresisDiverticulumDolorDysphagiaEcchymosis-ectomyEpistaxisExcision biopsyFistulaBreakdown of diseased tissue intocheese-like material (adj. caseous)Relating to lower part of the bodyPertaining to the headScarPain which occurs in waves; usuallyoccurs in tubular organsScraping of the internal surface of anorgan or body cavity with a spoon-lineinstrument (curette)Abnormal sac lined by epithelium andfilled with fluid or semi-solid materialExcessive sweatingA small sac or pouch projection fromthe wall of a hollow organ. The wall ofa true diverticulum comprises allthe layers of the parent organ (egMeckel’s diverticulum). The wall of apseudo-diverticulum contains onlysome of the layers (eg diverticulardisease of the colon)One of the classic signs ofinflammation; signifies painDifficulty swallowing (as opposed toodynophagia which is painfulswallowing)BruisingSurgical removal (eg parotidectomy)NosebleedBiopsy in which entire tumour isremovedAn abnormal, epithelialisedcommunication between twosurfaces15PART I

IntroductionFrequencyFunctio laesaHaemangionaHaematemesisHaematomaHaematuriaHaemoptysisHaemothoraxHesitancyIcterusIncisional biopsyIndurationIntussusceptionLaparoscopyLaparotomyLumenMelaenaNocturiaAbnormally increased urinationOne of the classic signs ofinflammation; signifies loss offunctionBenign tumour of blood vesselsVomiting of bloodBlood clot within tissues which formsa solid mass. May resolve or becomesuper-infectedBlood in the urineCoughing-up of bloodBlood within the pleural spaceDifficulty in initiating urinationJaundiceBiopsy in which only a core of thetumour is removedAbnormal hardening of a tissue ororganTelescoping of one part of the bowelinto adjacent bowelVisualisation of peritoneal cavity witha laparoscope (makes use of fibreoptics)Opening the abdominal cavity via asurgical incisionCavity within a tubular organ(adj. luminal)Black, tarry stool representingdigested blood, most commonlyoccurring due to an upper GI bleed(must be more than 100 ml)Abnormal urination at night usuallyinterrupting sleep16

Chapter 3: Getting started: Surgical jargonObstipationOdynophagiaOrchid--orraphy-ostomy-otomy-pexyPhlegmonPneumaturiaPneumothoraxPusRuborSinusStenosisSuppurationTransectionVolarTotal failure to pass either flatus orstoolPainful swallowingPertaining to the testiclesSurgical repair (eg herniorraphy)Surgically created opening(eg colostomy) (from stoma whichmeans mouth)Surgical incision into an organ(eg laparoscopy)Surgical fixation (eg orchidopexy)Solid, swollen, inflamed pancreatictissue massAir in the urine (usually due to anenterovesical fistula)Air within the pleural spaceFluid product of inflammation(see Chapter 25) (adj. purulent,not pussy!)One of the classic signs ofinflammation; signifies rednessAbnormal, blind-ending, epithelialisedtract in an organAbnormal narrowing of a lumen,passage or openingFormation of pusTransverse divisionPertaining to surface of palm or solePART I17

IntroductionSURGICAL SIGNS, TESTS, LAWS, SYNDROMESAND EPONYMSAllen’s testArgyll-Robinson’s pupilBarton’s fractureBattle’s signBeck’s triadBell’s palsyChvostek’s signTest of hand circulation. Ask pt. todrain hand by forming a fist, andcompress radial and ulnar aa. Ask pt.to open blanched fist. Release oneartery and observe for palmar flushing(arterial patency). Repeat test forother arteryA pupil that contracts or expands toaccommodate changes in focallength but does not respond to light.Mnemonic: Argyll-Robinson Pupiltaken backwards then forward gives:ARP, PRA, which then translates to:Accommodation Reflex Present,Pupillary Response AbsentFracture-dislocation of the distalradius, sometimes mistaken for aColles’ fracture. The fracture line runsacross the volar lip of the radius andinto the wrist joint. The hand and thefragment of distal radius undergo aproximal and volar displacementPeriorbital ecchymoses in basalskull #Seen in cardiac tamponade.Consists of:1. Jugular venous distension2. Muffled heart sounds3. ↓ BPAn acute lower motor neurone facialnerve palsy of unknown aetiology(diagnosis of exclusion)Seen in hypocalcaemia. Tapping overfacial n. causes twitching of facialmuscles18

Chapter 3: Getting started: Surgical jargonColles’ fractureCompartment syndromeCushing’s triadDeQuervain’s tenosynovitisFinkelstein’s testFrey’s syndromeFracture of the distal 2 cm of theradius with dorsal displacement ofthe distal fragment, givingcharacteristic dinner-fork deformityCondition of increased pressure in aconfined anatomical space adverselyaffecting circulation and threateningthe function and viability of tissuesthereinSeen in raised ICP. Consists of:1. ↑ BP2. Bradycardia3. Irregular respirationsInflammation of EPB and AbPLsecondary to overuse. Elicited usingFinkelstein’s testPassive extension of the wrist withthe thumb clenched in the fist,causing pain due to stretching ofEPB and AbPLWarmth and sweating in the malarregion of the face on eating orthinking or talking about food(syn. gustatory sweating). It mayfollow damage in the parotid regionby trauma, mumps, purulent infectionor parotidectomy. Following initialdamage, autonomous fibres tosalivary glands become re-connectedin error with the sweat glands.Stimulus for salivation hence causessweating and flushing. Flushingprevalent in females, sweating inmales. Gustatory tears is alsosometimes seen (syn. crocodiletears)PART I19

IntroductionGaleazzi fractureGradenigo’s syndromeHistelberger’s signHorner’s syndromeMonteggia fractureOsler–Rendu–WebersyndromePendred’s syndromeRadial shaft fracture with associateddislocation of the distal radioulnarjoint, which disrupts the forearm axisjoint (syn. reverse Monteggiafracture)Seen in suppurative otitis media.Consists of:1. Signs of acute suppurative otitismedia2. Ipsilateral abducens nerve palsy3. Pain in the distribution of theipsilateral trigeminal nerveHyperaesthesia of the posteriorexternal ear canal and ipsilateralhearing loss in acoustic neuromaSyndrome of the following ipsilateralsigns:1. Ptosis2. Miosis (constricted pupil)3. Anhidrosis (loss of sweating)4. EnophthalmosCaused by disruption of the ipsilateralsympathetic nerve supply to the eye(classically caused by Pancoasttumour, an upper lobe lung tumour)Dislocation of radial head withfracture of proximal 1/3 of the ulnaFamilial haemorrhagic telangiectasiacausing telangiectasiae (spider naevi)in all mucosal surfaces, but mostcommonly presenting as epistaxis(still a rare cause!)An autosomal recessive syndrome ofcongenital sensorineural hearing loss(SNHL) and a thyroid goitre20

Chapter 3: Getting started: Surgical jargonPierre–Robin syndromeRaccoon eyesRefsum’s diseaseRamsay–Hunt syndromeSmith’s fractureSuperior vena cavasyndromeThoracic outlet syndromeAutosomal dominant conditionconsisting of the following:1. Hypoplastic mandible2. Cleft palate3. Glossoptosis (downwarddisplacement of the tongue whichmay cause obstructive sleepapnoea)4. External, middle and inner earproblemsSeen in basal skull #. Bilateralperiorbital ecchymoses(syn: Panda eyes)A disease consisting of the following:1. Retinitis pigmentosa2. Cerebellar ataxia3. Peripheral neuropathy4. SNHLFacial nerve palsy caused by Herpeszoster infection of the facial nerve.Presents as a facial nerve palsy andpainful, haemorrhagic blistering ofthe ipsilateral tympanic membrane(tympanica haemorrhagica)(syn. herpes zoster oticus)A fracture of the distal radius whichoccurs if the patient lands with thewrist in flexion. The radial fragment isdisplaced anteriorly, and the fracturedoes not extend into the joint(syn. reverse Colles’ fracture)SVC obstruction (eg by tumour,thrombosis) causing engorged face,neck and upper chest veins (SVCdistribution)Compression of structures exitingthoracic outlet (eg cervical rib)PART I21

IntroductionThornwald’s cystTreacher–Collins syndromeTrousseau’s signWaardenburg’s syndromeA benign swelling of the nasopharynx,uncommon especially in adults. It isa cyst of the pharyngeal bursalocated in the supero-posteriornasopharynx.May cause occlusion of the orificeHypoplasia of the maxilla andmandible with microtia (small ears)and external/inner ear problems(autosomal dominant)Seen in hypocalcaemia. Carpopedalspasm after blood occlusion (with BPcuff) in forearm or legAn autosomal disorder consisting ofthe following:1. Telecanthus [↑ distance betweenthe inner corners of the eyes (thecanthi; sing. canthus)]2. Pigment disorder [white forelockand heterochromia iridis(different coloured irises)]3. SNHL22

PART IITrauma & orthopaedics

CHAPTER 4: THE TRAUMA CALL INORTHOPAEDICSWhat are the principles ofATLS?What is the primary survey?What life-threateninginjuries must be identifiedand treated in the primarysurvey?Advanced Trauma Life Supportprinciples advocate a thorough andreliable system of examination andinitial resuscitation in order to identifyand immediately treat potentiallyfatal injuries in trauma, followed by amore thorough and detailedassessment of the whole bodyleading eventually to complete anddefinitive care. These two processesare divided into a primary andsecondary survey.It is the initial assessment of thetrauma patient, designed to identifyand treat life-threatening injuriesimmediately so that initialresuscitation is maximally effective.Remember assess A,B,C,D and E:• Airway and cervical spineimmobilisation• Breathing (respiratory system)• Circulation and haemorrhagecontrol (Cardiovascular system)• Disability• ExposureMnemonic: ATOMICAirway compromise resulting ininadequate ventilationTension pneumothoraxOpen pneumothorax/sucking chestwoundMassive haemothoraxIncipient flail chestCardiac tamponadePART II25

Trauma & orthopaedicsWhat are the aims of thesecondary survey?What X-rays are included ina standard trauma series?A thorough head to toe assessmentafter initial resuscitation to identify allinjuries caused by trauma and outlinea plan for full treatment anddefinitive careThe following films:1. C-spine2. CXR3. Pelvic XRTHE PRIMARY SURVEYAIRWAY AND C-SPINE CONTROLWho is at risk of C-spineinjury and subsequentneurological damage?How is the C-spine initiallymanaged?How is the C-spinedefinitively investigated?All patients involved in trauma mustbe assumed to have an unstableC-spine # until excluded clinicallyand radiologicallyIn the following ways:1. C-spine hard collar: reducesvoluntary movement by around30%2. Bilateral sandbags/struts tapedacross bed to secure hard collarin fixed position. Suboptimal immobilisation in ahard collar only is used in arestless agitated patient, as this ispreferred to splinting the C-spineof a thrashing torso/lower bodyWith radiological assessment whichincludes the following three views:1. Lateral C-spine: picks up 80% ofC-spine injuries. Must include allseven cervical vertebrae and theC7–T1 junction to be anadequate film2. AP view – picks up 95% of bonyinjuries when combined with thelateral view26

Chapter 4: The trauma call in orthopaedicsWhat types of injuriescompromise the airway?How is the airway evaluated?3. Open mouth/odontoid peg view –picks up 99% of injuries whenused with above viewsFurther management is based onfindings and includesflexion-extension views and CTscanning.Two main groups:1. Facial/neck trauma: stabwounds to the neck, facial traumapost-assault or unrestrainedpassengers in head-on collisions,causing oropharyngeal loosebodies/haematoma/bruising2. Head injury with low GCS andimpaired laryngeal/pharyngealreflexes: GCS < 8 withimpaired cough or gag refleximplies inability to self protect theairway against aspiration ofvomit/blood. The airway musttherefore be cleared and securedAsk a simple question. A lucidresponse in a normal voice impliesan intact airway with no laryngealcompromise. If no response:Look: for any misting of the oxygenmask, facial trauma, blood or foreignbodies in the oropharynx and signs ofany ventilatory obstruction, such astracheal tug, see-saw breathing(abdominal retraction on inspirationwith no chest movement) orcomplete apnoea/cyanosisListen: for signs of air movement,cough reflex and evidence of upperairway obstruction such as:• Stridor (hoarse inspiratory soundcaused by extrathoracic largeairway obstruction)• Gurgling27PART II

Trauma & orthopaedicsWhat basic airwaymanoeuvres do you know of?If these fail, what next?What types do you know of?How would you definitivelysecure the airway?• Wheeze (expiratory sound causedby intrathoracic small airwayobstruction – implies pathologywithin chest rather than at airwaylevel)Feel: for breath on your cheek;assess chest expansion/symmetry atthe same time by looking down thechest wall. Gag reflex can also betested with utilisation of airwayadjuncts (see below)1. Head tilt, chin lift: suitable only. when there is no suspicion ofC-spine injury2. Jaw thrust3. Yankauer suction of blood/liquidobstructing airwayUse an airway adjunct1. McGill forceps: angled forcepsused to retrieve obstructingforeign bodies2. Nasopharyngeal airway:contraindicated with suspicion ofbasal skull or cribriform plate #s;or severe nasal trauma (risk ofcreating false passage)3. Oropharyngeal (Guedel) airwayEndotracheal (ET) tube placementBREATHINGWhen should the teamassess breathing?What type of injuriescompromise breathing?Only when the airway has beencleared and securedThree categories:1. Blunt trauma:. • Direct impact. • Shear forces (if a patient is runover by a motor vehicle)28

Chapter 4: The trauma call in orthopaedicsHow is breathing assessed?. • Deceleration injuries(high-speed RTA/fall fromheight)2. Penetrating trauma:. • Stab wounds. • Gun shot wounds (GSW)3. Blast injuries: a proximalexplosion results in pulmonarydamage secondary to capillaryhaemorrhage and alveolar ruptureLook:• Cyanosis• Increased respiratory rate• Asymmetrical chest expansion• Use of accessory muscles/trachealtug/increased work of breathing• Paradoxical chest wall movement(a section of the chest wall movinginwards on inspiration, secondaryto multiple rib fractures)• Superficial signs of trauma(bruising, GSW, stab wounds,seatbelt marks)Listen:• Areas of inadequate air entry (allzones must be auscultated)• Bronchial breathing• Wheeze (bronchospasm secondaryto intrathoracic injury)Feel:• Air movement (is the patientbreathing spontaneously?)• Tracheal deviation• Percuss chest for dullness/hyperresonant areas• Subcutaneous emphysema (a signof likely pneumothorax withparietal pleura rupture)PART II29

Trauma & orthopaedicsWhat life-threateningproblems must be excludedimmediately?How are these conditionsdetected clinically?The following:1. Tension pneumothorax: build up. of air under pressure in thethoracic cavity, compressing theipsilateral lung and displacing themediastinal contents andcontralateral lung.Occurs due to a one-way valvemechanism introducing air oninspiration, but blocking itsrelease during expiration2. Open pneumothorax: openchest wall wound connected tothe thoracic cavity. If chest walldeficit is of a significant diameter,air will follow the path of leastresistance and enter the thoraciccavity here on inspiration, ratherthan down the trachea. Syn.sucking chest wound due to thenoise produced as the aboveoccurs3. Massive haemothorax:collection of >1500 ml blood inthe thoracic cavity secondary tointercostal artery/large vesselrupture4. Flail chest: multiple rib fracturescausing a portion of the chestwall to move paradoxicallyinwards on inspiration due to alack of continuity with theremaining bony chest wallMust have a high index of suspicion.Also, obvious distress and hypoxia,and the following during the primarysurvey:Tension pneumothorax:• Decreased ipsilateral chestexpansion30

Chapter 4: The trauma call in orthopaedicsHow is tensionpneumothorax treated?What are the anatomicallandmarks forthoracocentesis?What are the anatomicallandmarks for chest draininsertion?• Tracheal deviation to contralateralside• Hyperresonance to percussionover ipsilateral side• Decreased ipsilateral air entry onauscultation• Tachycardia, tachypnoea anddistended neck veinsOpen pneumothorax:• Obvious chest wall defect withsucking noise on inspiration• Decreased air entry and expansionon ipsilateral side• Tachycardia and tachypnoeaMassive haemothorax:• Decreased ipsilateral chestexpansion• Dull percussion note on theipsilateral side• Decreased air entry on theipsilateral side• Tachypnoea, tachycardia and signsof hypovolaemiaFlail chest:• Paradoxical chest wall movement• Crepitus on palpation of damagedarea• Decreased air entry on ipsilateralside• Tachypnoea and tachycardiaImmediately by decompression byneedle thoracocentesis, thendefinitively by chest drain insertion(thoracostomy) at a later stage2nd intercostal space at themanubriosternal junction in themid-clavicular line5th intercostal space, mid-axial line31PART II

Trauma & orthopaedicsHow is open pneumothoraxtreated?What further investigationsshould be obtained?Occlusive dressing is applied to thesucking wound and taped on threesides only. This creates a one-wayvalve, through which expired air canescape, but limits air entry to thethoracic cavity.Followed by chest drain insertion onthe ipsilateral side at a clean siteaway from wound.Blood investigations:1. GXM: for transfusion as necessary2. ABG: provides invaluableinformation regarding oxygenationand lung function as well as animmediate Hb estimation. Canalso providecarboxyhaemoglobin estimationin cases of smoke inhalationImaging:CXR: still the most important:Pneumothorax: loss of outer lungmarkings (1 cm rim of lucencyapprox. equal to 10% loss of lungvolume)Haemothorax: blunting ofcostophrenic angle on erect chestimplies 300–400 ml blood in thepleural spaceAlso in diagnosis of contusion,parenchymal injury and otherpathologyCT scan: used as necessary toprovide specific information only in apatient stable for transfer and afterthe secondary survey32