Discontinuation of drugs before surgery
Antidiabetic drugs:- Metformin: discontinue 2 days before and after surgery- Discontinue other oral hypoglycemics on the day of surgery and postoperatively until the patient is no longer NPO.- Insulin: Discontinue on the day of surgery but administer IV intraoperatively. Antihypertensive drugs:- Discontinue the following antihypertensives one day before surgery and continue postoperatively:→ ACE inhibitors→ ARBs→ Diuretics- Continue all other antihypertensives Antianginal drugs: Continue Statins: Continue Oral contraceptives: Discontinue 4 weeks before surgery Psychiatric drugs:- Benzodiazepines: May be continued- Lithium: Discontinue 3 days before surgery.- Tricyclic antidepressants: Discontinue intraoperatively. Antiepileptics: Continue Anticoagulant or antiplatelet drugs- Antiplatelet drugs (e.g., aspirin, clopidogrel): Discontinue all antiplatelet drugs one week before surgery.- Direct oral anticoagulants (e.g., dabigatran, rivaroxaban): Discontinue medication 2 days before surgery.- Warfarin: Discontinue warfarin 5 days before surgery.- Continue heparin and warfarin postoperatively Thyroxine: Discontinue intraoperatively and resume postoperatively.
Preoperative preparation
Discontinue certain medications Fasting:- 8 hours before surgery: no meat or fried, fatty food- 6 hours before surgery: no milk or solid food- 2 hours before surgery: nil per os (NPO) Anesthesia Perioperative antibiotic prophylaxis- Aim: to reduce the incidence of postoperative surgical site infections- First-line: intravenous cefazolin- In patients with beta-lactam allergy: clindamycin or vancomycin- Add intravenous metronidazole for: Patient with small intestinal obstruction; Appendectomy; Colorectal surgery
Postoperative fever
Temperature > 38°C in the postoperative period Etiology:- Immediate: Intraoperatively or within a few hours of surgery→ Infection acquired prior to surgery→ Febrile nonhemolytic transfusion reaction→ Thyrotoxic crisis→ Malignant hyperthermia→ Tissue trauma - Acute: Within one week of surgery→ Nosocomial urinary tract infection due to an indwelling catheter→ Ventilator-associated/Hospital acquired/Aspiration pneumonia→ Surgical site infection due to group A streptococci (GAS) or C. perfringens→ Myocardial infarction→ DVT and pulmonary embolism→ Alcohol withdrawal - Subacute: > 1 week but < 1 month after surgery→ Surgical site infection due to any organism → Febrile drug reaction→ DVT and pulmonary embolism - Delayed: > 1 month after surgery→ Surgical site infection due to indolent organisms (e.g., coagulase-negative staphylococci)→ Delayed cellulitis→ Infective endocarditis Treatment:- Discontinue all unnecessary medications and remove or change urinary catheters and peripheral venous lines.- Acetaminophen- Patients who are hemodynamically unstable: broad-spectrum antibiotic therapy
Boerhaave syndrome
Transmural rupture of the esophagus following an episode of forceful vomiting/retching or increased intrathoracic pressure. Epidemiology: Sex: ♂ > ♀ (3:1) Associations:- Excessive intake of alcohol or food in the recent past- Repeated episodes of vomiting- Childbirth- Seizures- Prolonged coughing- Weightlifting Clinical features:1. Vomiting and/or retching2. Severe retrosternal pain that often radiates to the back3. Subcutaneous or mediastinal emphysema → crepitus in the suprasternal notch or "crunching" or "crackling" sound on chest auscultation (Hamman's sign), respectively- Dyspnea, cyanosis Diagnostics:- If Boerhaave syndrome is suspected, a chest x-ray is first conducted. If inconclusive, an esophagram and/or CT scan is conducted to confirm the diagnosis- Chest x-ray findings: Widened mediastinum, pneumomediastinum, pneumothorax, pneumoperitoneum, subcutaneous emphysema, pleural effusion- Contrast esophagram with gastrografin: a confirmatory test that reveals location and size of rupture- CT scan: indicated in unstable/uncooperative patients, pneumoperitoneum on x-ray, or if x-rays and contrast esophagram are inconclusive Treatment:- Small perforation: → Nothing by mouth (NPO) and supply nutritional support→ Broad-spectrum IV antibiotics (e.g., ampicillin)→ Drain fluid collections→ IV proton pump inhibitor- Large perforation, clinical decompensation:→ Surgical repair and closure of the ruptured esophageal segment→ Last resort: esophagectomy
Small bowel obstruction
Etiology:- Adhesions (e.g., postoperative, prior abdominal surgery)- Incarcerated hernia- Malignant tumors or metastases- Strictures (e.g., Crohn's disease, congenital, radiation enteritis)- Foreign body- Superior mesenteric artery syndrome: SMA passes in close proximity anterior to the third segment of the duodenum- Additional causes in children: Congenital intestinal atresia, pyloric stenosis, intussusception Clinical features:- Nausea, vomiting (may be projectile vomiting) - Dehydration, possible fever- Constipation or obstipation with abdominal distention (tympanic abdomen)- Proximal: nausea and vomiting (worse with food intake, may be bilious) with early discontinuation of PO intake, late-onset obstipation- Distal: late-onset vomiting, possible fecal vomiting- Closed loop obstruction: lumen occluded at two points; can lead to ischemia requiring emergency surgery- Abdominal pain/discomfort: vague or periumbilical cramping, colicky pain (corresponding to peristalsis) - Increased high-pitched, tinkling bowel sounds Diagnostics:- First-line initial test: abdominal x-ray: complete survey includes erect and supine abdominal x-ray, as well as erect chest x-ray → Dilated loops of small bowel (on upright x-ray), air-fluid levels proximal to the obstruction, distal bowel collapse, minimal or no gas in colon - CT abdomen with IV and oral contrast- Abdominal ultrasound: Thickened bowel wall; distinct fecal loading; stepladder-like distended bowel loops: pendular peristalsis- Barium or gastrografin enema: Useful to diagnose patients who have had prior intestinal surgery Treatment:- Nasogastric tube for intestinal decompression- Fluid resuscitation, electrolyte correction- Bowel rest (NPO)- Surgical if complete obstruction with signs of ischemia/necrosis or clinical deterioration, persistent partial obstruction (> 3-5 days), suspected intestinal strangulation
Large bowel obstruction
Etiology:- Malignant tumors (e.g., rectosigmoid, rectal, anal)- Strictures (e.g., diverticulitis, inflammatory bowel disease, congenital)- Volvulus- Adhesions (e.g., postoperative, prior abdominal surgery)- Infective masses (e.g., appendiceal mucocele, tuberculosis)- Fecal impaction Clinical features:- Nausea, vomiting (may be projectile vomiting)- Constipation or obstipation with abdominal distention (tympanic abdomen)- Distal: vomiting often absent; obstipation- Abdominal pain/discomfort: vague or periumbilical cramping, colicky pain (corresponding to peristalsis) - Increased high-pitched, tinkling bowel sounds Diagnostics:- First-line initial test: abdominal x-ray: complete survey includes erect and supine abdominal x-ray, as well as erect chest x-ray → Air-fluid levels in the colon, bowel distention before obstruction, kidney bean appearance of bowel (e.g., volvulus)- CT abdomen with IV and oral contrast- Barium or gastrografin enema Treatment:- Nasogastric tube for intestinal decompression- Fluid resuscitation, electrolyte correction- Bowel rest (NPO)- Surgical if complete obstruction with signs of ischemia/necrosis or clinical deterioration, persistent partial obstruction (>3-5 days), suspected intestinal strangulation
Pyogenic liver abscess
Etiology:- Biliary tract (∼ 60%): Choledocholithiasis, cholangitis- Portal vein (∼ 20%): Acute appendicitis, diverticulitis, Crohn's disease, gastrointestinal malignancies, peritonitis (bowel perforation)- Hepatic artery (∼ 15%): Sepsis; bacteremia (infectious endocarditis, IV drug use)- Trauma (Rare) Microbiology:- Polymicrobial infection (most common)- E. coli is the most common causative organism- K. pneumoniae is the second most common- Fungal infection (< 10% of cases): Candida species (most common)- Amebic liver abscess (< 10% of cases): Entamoeba histolytica Clinical features:- Fever (with/without chills and rigors)- Malaise- Right upper quadrant pain- Jaundice- Tender hepatomegaly- Intercostal tenderness- Decreased breath sounds in right lower lobe of the lung- Features of sepsis Treatment: Pyogenic liver abscesses are generally treated with both IV antibiotics and percutaneous drainage of the abscess.- Broad-spectrum IV antibiotics: ampicillin + sulbactam; piperacillin + tazobactam; 3rd generation cephalosporin + metronidazole (until antibiotic susceptibility is available)- Percutaneous drainage/needle aspiration: solitary abscess→ Small (< 5 cm) abscess: percutaneous needle aspiration→ Large (> 5 cm) abscess: percutaneous drainage and intracavitary catheter placement
Rectal cancer - Treatment
Transanal excision- Procedure: minimally invasive excision of small superficial tumors- Indications: early, localized disease (stage I) Low anterior resection (LAR)- Procedure: sphincter-preserving resection of the rectum and sigmoid- Indications: locally advanced disease (Stage III-IV)- Total mesorectal excision (TME): en bloc excision of the mesorectum, regional lymph nodes, and vasculature- Resection 5 cm beyond the proximal margin of the tumor- Resection > 2 cm beyond the distal margin of well-differentiated tumors or > 5 cm beyond the distal margin of poorly differentiated tumors- Reconstruction (e.g., side-to-side anastomosis) and optional diverting ostomy Abdominoperineal resection (APR)- Procedure: resection of the rectum, sigmoid, and anus with TME and permanent colostomy- Indications: last resort if the distal margin to the rectum cancer is < 2-5 cm to the anus Systemic therapy- Neoadjuvant radiochemotherapy: locally advanced disease (stages II-III) typically followed by surgery and postoperative chemotherapy- Adjuvant chemotherapy after surgical resection depending on the pathologic work-up- Palliative chemotherapy: inoperable, metastatic disease (stage IV) Follow-up:- Patient history, physical examination, CEA level: every 3-6 months for 3 years, then every 6 months for 2 years- Colonoscopy: after surgical resection, then 1 year after surgery, then every 3-5 years
Pilonidal cyst
A pilonidal cyst (intergluteal pilonidal disease) is a skin condition caused by local inflammation of the superior midline gluteal cleft, which may progress to a local abscess or fistula. Epidemiology:- Sex: ♂ > ♀ (∼ 3:1)- Peak incidence: 15-25 years Risk factors:- Young men with excessive body hair- Obesity- Deep gluteal cleft- Poor anal hygiene/local irritation- Sedentary lifestyle- Family history Clinical features:- Simple sinus tract opening in sacrococcygeal region, ∼ 5 cm from the anal verge- Acute inflammation (e.g., abscess)→ Possible purulent discharge and fever→ Can be very painful→ Fluctuant, erythematous swelling- Chronic inflammation→ Discharge (purulent, mucoid, or blood‑stained) from abscess or fistula opening→ Localized pain in sacrococcygeal region or at fistula opening Treatment:- Asymptomatic patients: Improved local hygiene, local hair control (e.g., laser epilation), observation for signs of infection- Symptomatic patients→ Acute pilonidal cyst: incision and drainage, with secondary wound closure→ Chronic or recurrent pilonidal cyst: surgical resection
Anal fissure
Longitudinal tear of the anal canal; distal to the dentate line. Primary (due to local trauma)- Location: 90% of all anal fissures located at the posterior commissure (6 o'clock in the lithotomy position)- Chronic spasm/increased tone in the internal anal sphincter- Chronic constipation or diarrhea- Anal sex- Vaginal delivery Secondary (due to underlying disease)- Location: may occur lateral or anterior to the posterior commissure- Previous anal surgery (e.g., possible stenosis of anal canal)- Inflammatory bowel disease (IBD; e.g., Crohn's disease)- Granulomatous disease (e.g., tuberculosis)- Infections (e.g., chlamydia, HIV)- Malignancy (e.g., leukemia) Clinical features: - Sharp, severe pain during defecation- Rectal bleeding (often bright red and minimal; should not be confused with other types of bleeding such as in colorectal cancer or hemorrhoids)- Perianal pruritis- Chronic constipation Diagnostics:- Clinical examination- Anoscopy Treatment:- Dietary improvement (e.g., adequate ingestion of dietary fiber and water)- Stool softeners (e.g., docusate)- Anti‑inflammatory and analgesic creams and/or suppositories (e.g., 2% lidocaine jelly)- Sitz baths- Topical vasodilator therapy: calcium channel blocker gel (e.g., nifedipine) or glyceryl trinitrate ointment (GTN)- Persistent symptoms despite > 8 weeks of conservative therapy → endoscopy to exclude IBD- Low risk: Sphincterotomy (e.g., lateral internal sphincterotomy); Anal dilatation (although there is a high risk of fecal incontinence with this procedure)- High risk: Anal advancement flap; Fissurectomy (excision of the fissure)
Hemorrhoids
Etiology: - Excessive straining (e.g., from chronic constipation, frequent bowel movements, chronic cough, heavy lifting, benign prostatic hyperplasia)- Extended periods of sitting (e.g., due to occupation or sedentary lifestyle)- Connective tissue disorder (e.g., Ehlers‑Danlos syndrome, scleroderma)- Pregnancy Internal hemorrhoid stagesI: Hemorrhoids do not prolapse (only project into the anal canal); above the dentate (pectinate) line; reversible; often bleedII: Prolapse when straining, but spontaneously reduce at restIII: Prolapse when straining; only reducible manuallyIV: Irreducible prolapse; may be strangulated and thrombosed with possible ulceration Internal hemorrhoids:- Often painless, bright red bleeding at the end of defecation (potentially dull, aching pain with severe sphincter spasm)- Perianal mass in the event of prolapse- Pruritus- Discharge (containing mucus or fecal debris)- Ulceration (in grade IV)External hemorrhoids:- Painful perianal mass- Pruritus Treatment:- Grade I-II internal hemorrhoids and external hemorrhoids: Conservative→ Lifestyle modifications: weight loss, exercise, high fiber diet, increase water intake→ Alter stool habits (e.g., avoid excessive straining or > 5 min periods on the toilet)→ Sitz baths→ Stool softeners (e.g., docusate)→ Topical or suppository analgesia (e.g., lidocaine)→ Topical anti‑inflammatory (e.g., hydrocortisone, especially with pruritus, but no longer than 1 week)→ Topical antispasmodic agents (e.g., nitroglycerin)- Internal hemorrhoids with symptoms persisting despite conservative treatment and grade III internal hemorrhoids→ Rubber band ligation (RBL) = rubber band triggers an inflammatory response → fibrosis→ Sclerotherapy→ Infrared coagulation- Grade IV internal hemorrhoids and no improvement of condition after clinical interventions→ Arterial ligation of hemorrhoids (HAL)→ Submucosal hemorrhoidectomy→ Stapled hemorrhoidopexy (e.g., using the Longo procedure)
Venous leg ulcers
Chronic defects of the skin that do not heal spontaneously Etiology: usually caused by chronic venous insufficiency Clinical features:- Most frequently occur just above the ankle (gaiter region)- Shallow ulcer with irregular borders- Usually only mild pain, pruritic Diagnostics:- Ankle-brachial index (ABI) to exclude peripheral artery disease- Evaluate patients for diabetes mellitus- Biopsies should be performed in any nonischemic wound that fails to improve after 3 months of treatment.- Culture if wound appears infected Treatment:- Treat underlying disease - Topical wound treatment: debridement, skin care, wound dressings- Systemic antibiotics in signs of infection (see cellulitis and erysipelas)- Skin graft in large or refractory ulcers Differential diagnosis:- Arterial ulcer- Diabetic foot wounds (Malum perforans)- Pyoderma gangrenosum- Vasculitis
Arterial ulcer
Skin defect due to impaired blood flow to the lower extremities Etiology: most often seen in peripheral arterial disease Clinical features:- Punched-out ulcer with well-defined borders- Usually involves the foot, particularly pressure points (e.g., lateral malleolus, tips of the toes)- Often severe pain Diagnostics:- U/S followed by CT Angiogram Treatment:- Stent vs Bypass - Stop Smoking - Cilostazol
Diabetic foot
Neuropathic diabetic foot- Warm, dry skin, foot pulses are palpable- Neurological examinations: evaluation of peripheral neuropathy- Malum perforans: painless neuropathic ulcers (usually located on the plantar pressure points of the foot: over the head of the metatarsal bones or the heel)→ Major risk factors include peripheral sensory neuropathy, autonomic neuropathy, microvascular changes, as well as macrovascular disease.→ Secondary infection of foot ulcers may lead to cellulitis and acute or chronic osteomyelitis.- Diabetic neuropathic arthropathy (Charcot foot): deformation of joints and bones→ Tarsus and tarsometatarsal joints most commonly affected→ Acute: swelling, warmth, erythema→ Chronic: painless bony deformities, midfoot collapse, osteolysis, risk of fractures Ischemic diabetic foot- Cool, pale foot with no palpable pulses- Prevention:→ Glycemic control→ Regular foot examinations→ Self-monitoring and proper foot care Treatment of foot ulcers:- Surgical debridement- Regular wound dressing- Mechanical offloading: fitting of therapeutic footwear or total contact cast- Antibiotic therapy if foot ulcers become infected- Interventional or surgical revascularization: in patients with underlying peripheral artery disease- Amputation if all else fails or severe life-threatening complications arise
Marjolin's ulcer
An aggressive form of cSCC that typically develops from areas of chronically damaged skin such as ulcers (e.g., pressure ulcers, osteomyelitis) and scars (e.g., burn scars)
Peripheral arterial disease
Etiology: - Insufficient tissue perfusion due to atherosclerosis in the aorta and peripheral arteries- Often coexists with coronary artery disease (CAD), stroke, atrial fibrillation, and renal disease Fontaine Classification of PADStage I: Asymptomatic PADStage II: Pain on exertion→ IIa: claudication at a walking distance > 200 m→ IIb: claudication walking distance < 200 mStage III: Ischemic pain at restStage IV: Necrosis/gangrene/ulcers→ IVa: dry necrosis, trophic disorders→ IVb: infection of necrotic tissue, humid gangrene Clinical features:- Up to 20-50% of patients with PAD are asymptomatic!- Intermittent claudication (10-35% of patients)1. Femoropopliteal disease (most common) → calf claudication2. Aortoiliac disease (Leriche's syndrome): Triad of bilateral buttock, hip, or thigh claudication; erectile dysfunction; and absent/diminished femoral pulses3. Tibiofibular disease→ foot claudication- Absent or diminished pulses- Trophic: ↓ Skin temperature, ↓ Perspiration, ↓ Hair on legs, Brittle nails, ↓ nail growth, Atrophied muscles, Dry atrophic, shiny skin and/or bluish skin discoloration, Skin pallor when limb is elevated and reactive hyperemia of dependency → Buerger test for examination, Livedo reticularis (advanced disease)- Rest pain: Typically in distal metatarsals, Worse at night, Improved when hanging feet over bed or standing Diagnostics:- Ankle-brachial index = ratio of systolic ankle blood pressure (BP) to systolic brachial BP> 1.3 = medial sclerosis with incompressible vascular wall (generally calcified vessels)1.0-1.30 = normal value0.91-0.99 = borderline0.40-0.90 = mild to moderate PAD → claudication< 0.40 = severe PAD → resting pain, gangrene (critical limb ischemia)- Color-coded duplex ultrasonography- Digital subtraction angiography (DSA): gold standard Treatment:- Smoking cessation!- Supervised graded exercise therapy- Foot care (especially in diabetic patients)- Antiplatelet therapy: Aspirin; Clopidogrel, Ticagrelor- Lipid-lowering agent (usually statins)- Antihypertensive treatment- Hyperglycemia control- PDE inhibitors: Cilostazol- Minimally invasive interventional radiology: percutaneous transluminal angioplasty (PTA) with or without stenting- Operative vascular reconstruction (bypass surgery)- Endarterectomy- Amputation
Breast cancer
Women < 30 years with a self-palpated breast lump- Ultrasound in women with a high probability of malignancy- In women with low probability of malignancy reexamine within 3-10 days after the onset of their menstrual period for reexamination!Women > 30 years with self-palpated breast lump or mammographic abnormalities detected during breast cancer screening- Clinical assessment and mammography (ultrasound if mammography is inconclusive) Mammography- Benign→ Well-defined, circumscribed mass→ Radiolucent ring surrounding the lesion (halo sign)→ Diffuse microcalcification or coarse calcification- Malignant→ Focal mass or density with poorly defined margins→ Spiculated margins→ Clustered microcalcifications Core needle biopsy (CNB): confirms the diagnosis (preferred test) and can distinguish between noninvasive and invasive carcinoma based on histology; indicated for a suspicious breast mass on ultrasound or mammography. Receptor testing of biopsy samples Tumor markers: CA 15-3, CA 27-29 (Axillary) lymph node status
Breast cancer - Prevention
Breast cancer screening- Mammography: every 2 years in average-risk women aged 50–74 years→ Two views of the breast are obtained: mediolateral oblique and craniocaudal- Physical examination plays a minor role in screening for breast cancer. Protective factors:- Early first pregnancy, several pregnancies before the age of 30 years- Breastfeeding- Physical activity Prevention in high-risk women- BRCA1/BRCA2 mutation-positive women- Women with a first-degree relative with a BRCA1/BRCA2 gene mutation- Women who have a family history of breast cancer- Women with a history of chest radiation therapy (between age 10-30 years)- Women with personal or family history of familial cancer syndromes (e.g., Li-Fraumeni syndrome, Cowden syndrome)- Women ≥ 35 years of age with previous invasive breast cancer or carcinoma in situAll women should be offered:- Genetic counseling- Annual mammography and MRI Prevention measures:- Prophylactic surgery: Bilateral prophylactic mastectomy + Bilateral salpingo-oophorectomy (BSO) by age 35-40 years and/or when childbearing is no longer desired- Alternative: selective estrogen receptor modulator→ Tamoxifen: In high risk premenopausal women→ Tamoxifen or Raloxifene: In high risk postmenopausal women
Aortic dissection
Etiology:- Hypertension- Trauma (e.g., deceleration injury in a motor vehicle accident, iatrogenic injury during valve replacements)- Vasculitis with aortic involvement (e.g., syphilis)- Use of amphetamines and cocaine- Third-trimester pregnancy (or early postpartum period)- Atherosclerosis- Connective tissue disease (Marfan syndrome, Ehlers-Danlos syndrome)- Bicuspid aortic valve- Coarctation of the aorta Stanford classification:- Type A (proximal): ascending aorta dissection, including retrograde extension from the descending aorta (independent of the site of origin and propagation)- Type B (distal): descending aorta dissection, originating distal to the left subclavian artery Clinical features:- Sudden and severe tearing/ripping pain- Character: migrates as the dissected wall propagates caudally- ↑ BP (if the patient is hypotensive, consider shock from blood loss or a cardiac tamponade)- Asymmetrical blood pressure and pulse readings between limbs- Syncope, diaphoresis, confusion or agitation - A heart murmur (an aortic regurgitation in a proximal dissection) Diagnostics:- Initial imaging: Chest x-ray (AP view) showing a widened mediastinum (> 8 mm)- In stable patients → Contrast-enhanced CT angiography (gold standard) - In unstable patients, renal insufficiency, contrast allergy → Transesophageal echocardiography (TEE) Treatment: - Stanford A dissections (involvement of the ascending aorta) require immediate surgery, while Stanford B dissections are generally treated conservatively unless complications (e.g., rupture or occlusion) occur.- Conservative:→Target value of the systolic blood pressure is ∼ 90–120 mm Hg→ IV labetalol, esmolol, or propanolol (best initial)→ Followed by IV sodium nitroprusside (vasodilator)- Surgery:→ Open surgery with a polyester graft implantation→ Possibly, endovascular treatment: aortic stent implantation (only in type B dissections and if the operative risk is too high)
Acute limb ischemia
Etiology:- Arterial embolism (∼ 80% of cases)- Arterial thrombosis (∼ 20% of cases)- Dissecting aneurysm Clinical features: - The 6 Ps (according to Pratt): Pain, Pallor, Pulselessness, Paralysis, Paresthesia, Poikilothermia- Embolism: acute onset; medical history of heart disease (e.g., atrial fibrillation)- Arterial thrombosis: subacute onset; medical history of arterial occlusion- Exam shows decreased peripheral sensitivity, pulse, and motor skills Diagnostics: - Best initial test: arterial and venous doppler- Confirmatory test: Digital subtraction angiography (DSA) is the imaging modality of choice. Treatment:- Systemic anticoagulation with an IV heparin bolus followed by continuous infusion- Viable, non-threatened limb1. Urgent angiography to localize the site of the occlusion2. Revascularization procedure (open or catheter-directed) within 6-24 hours- Threatened limb: emergent revascularization procedure within 6 hours→ First-line: catheter-directed thrombolysis and/or percutaneous mechanical thromboembolectomy (e.g., balloon catheter embolectomy)→ Second-line: open thromboembolectomy- Non-viable limb: limb amputation
Rib fracture
Etiology: mostly blunt trauma, pathologic fractures, nonaccidental trauma (child abuse) Clinical features:- Pain on inspiration- Focal chest wall tenderness- Crepitus- Chest wall deformity- Flail chest: multiple (≥ 3) rib fractures in 2 or more places, resulting in a floating section of ribs and soft tissue within the chest wall→ Paradoxical movement: the floating segment moves inward during inspiration and outward during expiration- Respiratory distress, tachypnea, and shallow breaths Diagnostics:- Chest x-ray (AP and lateral view): fracture lines, displaced fractures- Possible CT if complications are suspected Treatment:- Usually no surgery necessary- Analgesia: NSAIDs, opiates, local nerve block or epidural catheter- Intubation with positive pressure ventilation in severe flail chest (bridge to surgery)- In case of pneumothorax or hemothorax: thoracic drainage and thoracic surgical intervention Complications: Atelectasis, pneumonia
Lung transplantation - Contraindications
- Malignancy in the last 2 years.- Acute medical instability such as acute sepsis, myocardial infarction, and liver failure.- Uncorrectable bleeding diathesis.- Active Mycobacterium tuberculosis infection.- Significant chest wall or spinal deformity expected to cause severe restriction after transplantation.- Obesity (body mass index ≥35.0 kg/m2).- History of repeated or prolonged episodes of non-adherence to medical therapy that are perceived to increase the risk of non-adherence after transplantation.- Psychiatric conditions associated with the inability to cooperate with the medical/allied health care team and/or adhere with complex medical therapy.- Absence of an adequate or reliable social support system.- Severely limited functional status with poor rehabilitation potential.- Substance abuse or dependence.
Humerus fracture
Classification:1. Proximal humerus fracture (common in the elderly) - The proximal humerus has four major segments: the anatomical neck, the humeral shaft, the greater tuberosity, and the lesser tuberosity (the surgical neck is distal to the lesser and greater tuberosity)- Commonly used classification (Neer) is based on whether one or more of these four segments have been displaced2. Humeral shaft fracture- Classified according to location: proximal third, middle third (most common location), distal third3. Distal humerus fracture- Lateral/medial fractures- Supracondylar fractures (supracondylar fractures are the most common pediatric elbow fracture) Diagnostics:- X-ray (AP and lateral views of the humerus as well as transthoracic and axillary views of the shoulder)- A supracondylar fracture may also reveal:→ Positive posterior fat pad sign (not normally visible)→ Sail sign: positive anterior fat pad sign (normally visible, but not elevated)- CT if x-ray is not diagnostic- MRI if pathological fracture is suspected Treatment:- Conservative: Hanging-arm cast or coaptation splint and sling for approx. one to two weeks; subsequent follow‑up X‑ray and brace- Surgical:→ Internal fixation using plates and screws, or intramedullary implants (especially supracondylar fractures) → External fixation (e.g., open fracture, polytrauma)→ Arthroplasty of humeral head or elbow (complex fractures or poor quality bone), especially in elderly patients Complications:- Proximal humerus fracture→ Adhesive capsulitis→ Avascular necrosis of humeral head (axillary artery injury)→ Heterotropic bone formation- Humeral shaft fracture: Radial nerve palsy (common)- Distal humerus fracture→ Malunion and varus deformity of elbow→ Brachial artery injury (common): Absent radial pulse suggests brachial artery entrapment (especially following reduction!) and compartment syndrome → Volkmann's ischemic contracture (late complication)→ Median nerve, ulnar nerve, or radial nerve palsy
Idiopathic scoliosis
Deformity of the spine occurring during growth, characterized by a lateral curvature (Cobb angle > 10°) and simultaneous rotation of the vertebrae. Epidemiology: - Sex: ♀ > ♂ (∼ 5:1)- Peak incidence: 10-12 years Clinical features:- Adam's forward bend test (most important clinical test) may show:→ Thoracic rotation ("rib hump")→ Lumbar rotation ("lumbar hump")→ Asymmetry of the waistline, leg length discrepancy→ Asymmetry of the shoulder girdles, protrusion of the scapulae- Assessment of severity based on scoliometer measurements - Respiratory and cardiopulmonary impairment in cases of severe thoracic deformity→ Dyspnea, difficulty breathing (thoracic restriction)→ Cor pulmonale with right heart failure as a late sequela- Pain occurs secondary to degeneration, compression, or irritation of spinal discs and nerves. Diagnostics: Conventional x-ray- Cobb angle: refers to the angle between the following lines 1. Perpendicular to a line drawn across the superior endplate of the highest affected vertebra2. Perpendicular to a line drawn across the inferior endplate of the lowest affected vertebra Treatment:- Treatment based on the Cobb angle:→ Cobb angle < 10°: per definition not scoliosis, and therefore not monitored→ Cobb angle 10-19°: continual monitoring for progression→ Cobb angle 20-29°: monitoring or bracing→ Cobb angle 30-39°: bracing→ Cobb angle > 40° or rapidly progressing scoliosis: surgery- Bracing: 18 hours/day, if possible- Surgery
Hip dislocation
Posterior hip dislocation (90% of cases):- Dashboard injury in which a posteriorly directed force (e.g., dashboard during a motor vehicle accident) is directed towards an internally rotated, flexed, and adducted hip- Hip pain which radiates to the knee- Complications: Sciatic nerve injury or peroneal nerve injury (branch of the sciatic nerve) Anterior hip dislocation (10% of cases):- Direct blow to the posterior hip or to an abducted leg- Hip pain which radiates to the knee- Lengthened, externally rotated leg- Complications: Femoral nerve injury Diagnostics:- X-ray- CT/MRI to exclude associated (especially pathological) fractures Treatment:- Closed reduction within 6 hours to prevent avascular necrosis of the femoral head- Open reduction if closed reduction is unsuccessful, the joint is unstable, or if bony fragments/tissue sit within the joint space
Pelvic fracture
Clinical features:- Pelvic pain caused by movement, weightbearing, and compression of the iliac crests- Tilted pelvis and unequal leg length with reduced range of motion in the hip joint- Pelvic instability- Labial, scrotal, flank, and inguinal hematomas- Concomitant injuries may occur→ Urethral injury: blood at urethral meatus, high-riding or nonpalpable prostate, perineal swelling→ Bladder injury: frank hematuria→ Rectal, vaginal, perineal lacerations suggest an open fracture→ Acute abdomen in abdominal trauma (bowel perforation, spleen, liver rupture)→ Neurovascular injury: increased rectal tone, perianal paresthesia, compromise of lower limbs Diagnostics:- Pelvic x-ray: anterior-posterior, as well as special inlet and outlet views; views of the obturator and ala- CT: in stabilised patients- Angiography: diagnostic and therapeutic of vascular injury and active hemorrhage (e.g., superior gluteal artery)- Suspected injury of the urinary tract: → Retrograde pyelourethrogram→ Only consider suprapubic catheterization, not transurethral, if confirmed! Conservative treatment:- Indication: stable pelvic fracture- Methods: bed rest, analgesia, thrombosis prevention, early physical therapy, periodic blood pressure and hematocrit check Surgical treatment:- Indication: open or unstable fractures, complications (e.g., urological injury), hemorrhage- Emergency surgery in the case of massive bleeding: angiography with embolization of affected blood vessels, external fixation, or pelvic C-clamp if needed
Post-amputation pain
Acute stump pain:- Tissue & nerve injury- Severe pain lasting 1-3 weeks Ischemic pain:- Swelling, skin discoloration- Wound breakdown- ↓ Transcutaneous oxygen tension Post-traumatic neuroma:- Weeks to months after amputation- Focal tenderness, altered local sensation- ↓ Pain with anesthetic injection Phantom limb pain:- Onset usually within 1 week- Increased risk in patients with severe acute pain- Intermittent cramping, burning felt in distal limb
Tracheobronchial injury
Clinical features:- Dyspnea, hoarseness, dysphonia, bloody tracheal secretions- Subcutaneous emphysema- Treatment-resistant pneumothorax- Pneumomediastinum: Hamman's sign (= precordial crepitation that is audible synchronous to the heartbeat) Diagnostics:- Chest x-ray- Bronchoscopy: visualization of the lesion Complications: chylothorax Treatment: mostly surgical repair
Extremity vascular trauma
Hard signs:- Observed pulsatile bleeding- Presence of bruit/thrill over injury- Expanding hematoma- Signs of distal ischemia (eg, absent pulses, cool extremities) Soft signs:- History of hemorrhage- Diminished pulses- Bony injury- Neurologic abnormality If hard signs or hemodynamic instability:- Surgical exploration Otherwise:- Injured extremity index- CT scan or conventional angiography- Duplex Doppler ultrasonography
Frostbite
Severe localized tissue injury due to freezing of interstitial and cellular spaces after prolonged exposure to very cold temperatures. Clinical features:- Areas most frequently affected: Face, fingers, toes, - Cold and paresthesia of affected region- Pale (white or grayish-yellow), blue-red, or blistered hard or waxy skin Treatment:- Remove wet clothing; avoid walking on frostbitten feet- Evaluate for concurrent hypothermia and treat that first- Rewarming→ Passive: remove wet clothing, cover with blankets, warm room (preferably 28°C)→ Active: immerse affected extremity in a warm (preferably 37-39°C) circulating water bath- Analgesia and tetanus prophylaxis
Drowning injuries
Complications:- Acute respiratory distress syndrome- Cerebral edema- Arrhythmia Poor prognoistc indicators:- Submersion time > 5 min- Delay in initiation of CPR- Prolonged resuscitative efforts- Age > 14- Arterial blood pH < 7.1
Bite wound
Bite wounds (caused by animals or humans i.e., “fight bite”) are associated with an increased risk of infection, as the bacterial flora of the oral cavity hinders wound healing. Common pathogens: Streptococcus, staphylococcus, Pasteurella multocida, Capnocytophaga canimorsus, Haemophilus influenzae, anaerobic bacteria Rabies: must be considered in the case of dog bites. If rabies is suspected, active and passive immunization according to vaccine recommendations should be performed. Wound management:- Irrigation and debridement- Primary surgical closure if wound meets ALL of the following criteria:→ Clinically uninfected→ < 12 hours old (< 24 hours if on the face)→ Locations other than the hand or foot- Allow spontaneous closure (secondary intention) if:→ Cat or human bite NOT on the face→ Puncture wounds→ Wounds > 12 hours old (> 24 hours if on the face)→ Bites involving the hands or feet- Antibiotic therapy:→ Indications: deep puncture wounds, moderate to severe wounds with crush injury, wounds in areas with venous/lymphatic compromise, wounds on the hands/face/close to a bone or joint, wounds requiring closure, bite wounds in the immunocompromised→ Use broad‑spectrum antibiotics, e.g., amoxicillin and beta‑lactamase inhibitor (amoxicillin‑clavulanate) or cephalosporin of 2nd or 3rd generation- Tetanus protection
Preoperative evaluation
Cardiac risk: - Contraindications: EF < 35%, MI within 6 months- Cardiac risk calculated with Goldman Index→ JVD is the worst prognostic factor on the index- Consider EKG, Echo, Angiogram, CABG Pulmonary risk:- FEV1/FVC (best prognostic indicator)- Blood gases- Smoking cessation 8 weeks before surgery Hepatic risk:- Child-Pugh score: Bilirubin, Albumin, PT (or INR), Encephalopathy, and Ascites
Postoperative urinary retention
Failure to void > 4 hours after surgery Risk factors:- Age > 50 years- Male patient- Pre-existing obstructive urinary tract symptoms (e.g., BPH)- Neurological disease (e.g., multiple sclerosis, diabetic neuropathy)- Long duration of procedure- Inguinal hernia repair, gynecological, anorectal surgery, joint arthroplasty- Severe postoperative pain- Excessive administration of intravenous fluids (> 750 mL)- Spinal or epidural anesthesia- Use of sedatives and or opioid analgesics- Perioperative administration of α-blockers or anticholinergics (e.g., atropine) Diagnostics: Bladder ultrasound is not required but may be performed to assess the bladder volume. Treatment:- If the patient is catheterized preoperatively→ Check the catheter for kinking or blocks in the lumen.→ If no kinking is present, consider acute kidney injury.- If the patient is not catheterized preoperatively→ First-line: Trial of voiding→ Second-line: intermittent catheterization or the placement of an indwelling catheter
Postoperative ileus
Risk factors:- Open surgery- Excessive bowel handling during intra-abdominal surgery- Electrolyte imbalances (e.g., hypokalemia)- Use of opiates Clinical features:- Failure to pass flatus- Nausea and vomiting may be present.- Abdominal distention may be present.- Absence of bowel sounds on auscultation Differential diagnosis: early mechanical bowel obstruction Management:- Conservative measures only- Avoid excessive fluid administration.- Preferential use of NSAIDs (e.g., ketorolac) over opiates- Early mobilization if possible- Early initiation of enteral feeding if possible- Nasogastric tube only if abdominal distention is prominent
Pancreatitis - Complications
Necrotizing pancreatitis:- Diagnosis: CT-guided percutaneous drainage + culture of the aspirate- Treatment: surgical debridement, antibiotics (e.g., meropenem) Pancreatic abscess:- Walled-off infected necrotic tissue or pancreatic pseudocyst; typically develops > 4 weeks after an attack of acute pancreatitis- Abdominal CT: visible contrast-enhanced abscess capsule with evidence of fluid (pus)- Ultrasound: complex cystic, fluid collection with irregular walls and septations- Treatment: cannulation and drainage; necrosectomy if other measures are not effective Pancreatic pseudocyst:- No epithelial lining- Diagnosis with CT scan- If < 6 cm AND < 6 weeks old: watch and wait- If > 6 cm OR > 6 weeks: Drain to the skin (percutaneous), the GI tract (cystogastrostomy), or surgically (open) Abdominal compartment syndrome Systemic- SIRS, sepsis, DIC- Pneumonia, respiratory failure, ARDS- Shock- Prerenal failure due to volume depletion- Hypocalcemia- Pleural effusion, pancreatic ascites- Paralytic ileus
Pancreatitis - Predictors of severity
- Age > 55- Gastrointestinal bleeding- Abnormal hematocrit within 48 hours→ Acute hemorrhagic pancreatitis: ↓ Hct→ Third space fluid loss: ↑ Hct- Hypocalcemia and/or hyperglycemia- Inflammatory markers: ↑↑ CRP, ↑ IL-6, ↑ IL-8- Evidence of shock and/or organ failure→ ↑ AST, ↑ ALT→ ↑ BUN, creatinine→ ↑ LDH- ABG: pO2 < 60 mmHg, metabolic acidosis with a base deficit > 4 mmol/L- CT findings: pancreatic edema, peripancreatic fluid collection, and/or necrosis of > 33% of the pancreas Amylase and lipase, which are used for the diagnosis of pancreatitis, cannot be used to predict the prognosis!
Jersey finger
Affected tendon: Flexor digitorum profundus tendon Mechanism of injury- Sudden hyperextension of a flexed DIP (forced extension)- Avulsion injury/rupture of the FDP tendon from its point of insertion Clinical features:- Pain, swelling of the DIP (palmar aspect)- Loss of DIP flexion → the affected finger does not flex when making a fist Treatment:- Always surgical→ Primary repair→ Tendon graft
Mallet finger
Affected tendon: Extensor digitorum tendon Mechanism of injury:- Sudden hyperflexion of the DIP (forced flexion) → avulsion/rupture of the distal portion of the ED tendon from the distal phalanx- May be associated with an avulsion fracture of the distal phalanx Clinical features:- Loss of extension of the DIP- The DIP rests in a flexed position (curving of the distal phalanx). To test for extension loss the examiner holds the PIP joint (to minimize DIP extension) by the central band and asks the patient to actively extend the DIP. Treatment:- Conservative: splint in extension position- Surgical repair for: Displaced fracture; ≥ 45-degree extension deficit
Trigger finger
Epidemiology:- Sex: ♀ > ♂ (6:1)- Age: > 40 years Pathophysiology: fibrocartilagenous metaplasia of the tendon sheath of the A1 annular pulley → loss of smooth gliding of the finger flexor tendons under the annular pulley → finger gets locked in flexed position Clinical features:- Painful locking of a finger in flexed position; releases suddenly with a snap/pop on extension- Often associated with tenderness and a palpable nodule at the base of the metacarpophalangeal joint- Mostly affects thumbs and ring fingers Treatment: - NSAIDs, splinting (immobilization) of the affected finger for 6 weeks- If conservative treatment fails, glucocorticoid injection into the tendon sheath (effective in 90% cases, esp. if the tenosynovitis has been present for less than 6 months)
De Quervain's tenosynovitis
Thickening of the abductor pollicis longus and extensor pollicis brevis due to myxoid degeneration Epidemiology:- Sex: ♀ > ♂- Age: 30-50 years Etiology:- Repetitive/prolonged abduction and extension of the thumb- Rheumatoid arthritis Clinical features:- Pain with or without swelling of the radial styloid; pain may radiate to thumb or elbow, exacerbated on movement/grasping objects- Positive Finkelstein test: examiner grasps the affected thumb and exerts longitudinal traction towards the ulnar side → pain Treatment: - NSAIDs, splinting (immobilization) of the affected finger for 6 weeks- If conservative treatment fails, glucocorticoid injection into the tendon sheath (effective in 90% cases, esp. if the tenosynovitis has been present for less than 6 months)
Dupuytren's contracture
Dupuytren's contracture (palmar fibromatosis) is a fibroproliferative disorder of the palmar fascia Epidemiology:- Peak incidence: 40-60 years- Sex: ♂ > ♀ Risk factors: these factors may cause ischemic injury of the palmar fascia → development of Dupuytren's contracture in genetically predisposed individuals- Cigarette smoking- Recurrent trauma (e.g., use of pneumatic tools used in construction, manual labor)- Scandinavian- Diabetes- Alcohol abuse- Liver cirrhosis Clinical features: - The 4th and 5th fingers are most commonly involved- Skin puckering near the proximal flexor crease: earliest sign- Palmar nodule - Palmar cords- Flexion contracture of affected finger/s- Up to 8% of patients with Dupuytren's contracture can have Peyronie's disease. Treatment:- NSAIDs, splinting (immobilization) of the affected finger for 6 weeks- If conservative treatment fails, glucocorticoid injection into the tendon sheath (effective in 90% cases, esp. if the tenosynovitis has been present for less than 6 months)
Felon
Definition: distal pulp space infection of the fingertip Etiology:- Wooden splinters, minor cuts, paronychia → cellulitis of fingertip pulp → abscess formation and edema Pathogen: Staphylococcus aureus (most common) Clinical features:- Commonly involves the thumb and index finger- Localized edema at the fingertip associated with pressure, prickling, or throbbing pain Diagnosis:- Clinical diagnosis- Culture wound fluid: to identify the causative pathogen Treatment:- Early oral antibiotic treatment, decompression, and elevation should improve the condition in 12-24 hours.- Tetanus prophylaxis- If severe or blood flow is compromised: IV antibiotics and surgical drainage Complications: necrosis, osteomyelitis, tenosynovitis, septic arthritis
Shoulder dislocation
Anterior dislocation:- Most common- Risk of axillary nerve injury- Patients hold arm in slight abduction and external rotation Posterior dislocation:- Rare- Associated with seizure and electrocution- Patients hold arm in adduction and internal rotation Diagnosis: X-ray Treatment: Reduction followed by a sling and swath. Recurrent dislocations may need surgical treatment.It is important to assess for the presence of axillary nerve palsy before attempting reduction; otherwise it would be impossible to determine whether an axillary nerve palsy discovered after reduction resulted from the dislocation or the reduction.
Colles fracture
Involves the distal radius. Often results from a fall onto an outstretched hand, leading to a dorsally displaced, dorsally angulated fracture. Commonly seen in the elderly (osteoporosis) and children. Treatment:- Closed reduction followed by application of a long-arm cast. - Open reduction if the fracture is intra-articular.
Monteggia fracture
Proximal ulnar shaft fracture with anterior dislocation of the radial head Mechanism of injury: Defensive injury- Low-energy trauma, e.g., fall on outstretched and pronated forearm- High-energy trauma, e.g., direct blow to the forearm from a motor vehicle accident Clinical features:- Pain, deformity, and limited range of movement of the elbow joint- Paresthesia at or below the elbow joint Diagnosis: X-ray Treatment:- In children with uncomplicated fractures: closed reduction and casting- In adults or complicated fractures: open reduction and internal fixation (plating, K-wire fixation)
Galeazzi fracture
Radial shaft fracture with dislocation of the ulna - More common in children Mechanism of injury: fall on outstretched and pronated forearm Clinical features:- Pain, deformity, and limited range of movement at the distal-third radial fracture site and wrist joint- Anterior interosseous nerve (AIN) palsy can occur. Diagnosis: X-ray shows a fracture of the junction of the distal third and middle third of the radius shaft with subluxation or dislocation of the distal radioulnar joint and a tear in the interosseous membrane. Treatment:- In children with uncomplicated fractures: closed reduction and casting- In adults or complicated fractures: open reduction and internal fixation (plating, K-wire fixation)
Scaphoid fracture
Most commonly fractured carpal bone. Results from a fall onto an outstretched hand.May take 2 weeks for radiographs to show fracture. Assume fracture if there is tenderness in the anatomic snuff box with axial loading. Treatment:- Thumb spica cast. If displacement or scaphoid nonunion present, treat with open reduction.- With proximal-third fractures, avascular necrosis may result from disruption of blood flow.
