TREATMENT GUIDELINES i

REPUBLIC OF RWANDA

MINISTRY OF HEALTH

RWANDA STANDARD TREATMENT

GUIDELINES

SURGERY
Volume 3

March 2022

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FOREWORD

I have the pleasure to preface the 2022 Rwanda Standards Treatment Guidelines
and the Essential Medicines List (STGs/EML). This is the second edition after the
2013 STGs and 2015 EML.

The development of the STGs/EML is an essential part of the improvement of

the quality of health care delivery especially at the primary healthcare level.
Rwanda is committed to the attainment of the 2030 SDGs and especially goal
3 i.e. “good health and well-being” with one its target to “Achieve universal
health coverage, including financial risk protection, access to quality essential
health-care services and access to safe, effective, quality and affordable essential
medicines and vaccines for all”

To attain the above-mentioned goals, special packaging of policies and strategies

aligned to the Global Strategy for Women’s, Children’s and Adolescent’s
Health were developed through the MNCH strategic plan 2018- 2024 ensuring
coordinated action to address cross-cutting health needs of our future. These
guidelines have therefore integrated this plan accordingly

Equally important, this 2022 STGs/EML integrates Rwanda global commitment to

the implementation of the One Health Policy that set-up policies, implementation
strategies to prevent and control zoonotic diseases, plant diseases, food safety and
specifically antimicrobial resistance. Rwanda has therefore set up a One Health
Multi-sectoral Coordination Mechanism (OH-MCM) that will allow antimicrobial
resistance surveillance, guide and monitor the use of antibiotics in Rwanda.
This policy is in line with our commitment to the WHO Global Action Plan on
Antimicrobial Resistance (2018). We have therefore for the first time customized
the WHO AWARE classification of antibiotics as well as the antibiotics prescription
guidance. This will help not only reduce the current trend of antimicrobial
resistance but importantly ensure better quality of healthcare of our population
by reducing the negative impact of multi-drug resistance in Rwanda.

While the above global commitments inform our strategic choices, the STGs/EML
are grounded first and foremost in our national diseases burden and specifically
at the primary health care level. It is our hope that these guidelines will bring
more evidence-based practice, more transparency in the care provision as well
as access to efficient, affordable, and available medications in the country.

I would finally wish to acknowledge the strategic technical and financial

contribution of the WHO that made this work possible despite the challenging
environment due to Covid-19 pandemic.
This work would not have been possible without the active involvement of
the professional medical/pharmacy societies/associations, that reviewed the
literature, held numerous online discussions, peer-reviewed several drafts and
came up with the most suitable guidelines.
Several other partners provided support to this project in one way or another
and I wish to thank all of them for their usual support

Dr. NGAMIJE M. Daniel

Minister of Health

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Acknowledgement
The Ministry of Health wishes to acknowledge the support of various stakeholders in
the making of the 2022 Standards Treatment Guidelines (STGs) and Essential Medi-
cines List (EML). Without their contributions, it wouldn’t have been possible to com-
plete this work despite the restrictions made necessary by the Covid-19 Pandemics.
The World Health Organization availed the required financial and technical support
throughout the project and was flexible to adjust to the challenges brought about by
the stringent environment.
World AIDS Campaign International (WACI) Health made a significant financial input
to allowing a smooth running of the project.
The Medicines, Technologies, and Pharmaceutical services program (USAID MTaPS)
financial intervention especially in the shaping of the rational use of antibiotic guide-
lines has been a great input in the current work.
Clinton health access initiative (CHAI) have been instrumental and played a major
role especially in developing the Clinical guidelines for hypoxemia screening and ox-
ygen therapy administration in Neonates, children and adults.
The Ministry wishes to thank specifically all Rwanda Health professionals and Phar-
macy Societies and Associations for their self-less spirit and gave their time to pa-
tiently review and update the previous 2013 STGs and 2015 EML spending very long
hours online very often late in the night.
The Ministry of Health wishes to acknowledge and thank the consultants, Prof Emile
Rwamasirabo, Dr. Raymond Muganga and Dr. Richard Butare who coordinated this
2022 STG/EML updates.
The Ministry also recognizes the important contribution of tertiary Hospitals includ-
ing CHUK, CHUB and KFH that availed their microbiology data over 5 to 7 years that
helped to profiling the antimicrobial resistance in Rwanda.
Special recognition goes also to the Experts Taskforce appointed by the MOH upon
recommendation by the Medical and Pharmacy Societies and Associations. The team
is composed as follows:

Societies and Associations Coordinators

1 The Rwanda Pediatric Association (RPA) Prof. Musiime S.
2. The Rwanda College of Physicians (RCP) Dr. Muvunyi B.
2 The Rwanda Society of Obstetrics and Gynecology Dr. Ruzigana G.
(RSOG)
3 The Rwanda Surgical Society Dr. Byiringiro F.
4 The Rwanda Psychiatric Society Dr. Mudenge C.
5 The Rwanda Dental Surgeon Association (RDSA) Dr. Bizimana A.
6 The Rwanda Ophthalmology Society (ROS) Dr. Mutangana F.
7 The Rwanda Oncology Society (in formation) Dr. Rubagumya F.
8 The Rwanda Otolaryngology and Neck Surgery Dr. Mukara Kaitesi
Society (ROHNSS
9 The Rwanda Dermatology Society (RDS) Dr. Amani A.
10 The Rwanda Society of Anesthesiologists (RSA) Dr. Rudakemwa A.
11 The National Pharmacy Council Dr. Hitayezu F.

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TABLE OF CONTENTS
FOREWORD..................................................................................................................... iii
Acknowledgement............................................................................................................ v
ABBREVIATIONS.............................................................................................................xv
Clinical Practice Guidelines For Surgery............................1
--|Principles of management of traumas/injuries.....................................................1
Bones And Joints Disorders...............................................3
--|General overview of fractures................................................................................3
--|Upper Limbs Fractures ..............................................................................................6
Distal Radius & Ulna Fractures .........................................................................6
Forearm shaft fractures......................................................................................7
Distal Humerus fractures.....................................................................................8
Humeral Shaft Fracture................................................................................... 10
Fractures of proximal humerus....................................................................... 10
Tuberosity fractures.......................................................................................... 11
Clavicle Fractures............................................................................................. 11
Scapula Fractures............................................................................................. 12
--|Pelvic And Lower Limbs Fractures ....................................................................... 12
Pelvic Ring disruption....................................................................................... 12
Fractures of the Acetabulum........................................................................... 14
Trochanteric fractures....................................................................................... 15
Femoral Neck Fractures................................................................................... 16
Femoral shaft fractures.................................................................................... 17
Distal Femur Fractures...................................................................................... 17
Patellar Injuries.................................................................................................. 18
Proximal tibia fractures................................................................................... 18
Tibia-Fibula Fractures...................................................................................... 19
Fractures of the Distal end of the Tibia....................................................... 20
--|Foot Fractures........................................................................................................... 21
Ankle Fractures ................................................................................................ 21
Calcaneus Fractures......................................................................................... 22
Talus fractures.................................................................................................... 23
Midfoot fractures.............................................................................................. 24
Fore-foot fractures........................................................................................... 24
--|Fractures in Children............................................................................................... 26
Epiphyseal Fracture.......................................................................................... 26
Supracondylar Fracture of Humerus............................................................. 26
Radial Neck Fracture....................................................................................... 27
Forearm Fracture............................................................................................. 27
Pelvic and Lower Limbs Fractures .................................................................. 27
Open Fractures................................................................................................... 28
--|Critical Care ............................................................................................................ 30
Critical Care Severe Traumatic Brain Injury................................................. 30
Critical Care of Multiple Injuries..................................................................... 32
--|Dislocations............................................................................................................... 34
General considerations..................................................................................... 34
Acromio-Clavicular Joint Dislocation ............................................................. 34
Shoulder dislocations......................................................................................... 35
Posterior Dislocation.......................................................................................... 36
Elbow Dislocation............................................................................................... 37
Hip Dislocation .................................................................................................. 37
Traumatic Knee dislocation............................................................................... 39
Patellar Dislocation............................................................................................ 40

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--|Bone and Joints Infections...................................................................................... 41

Septic Arthritis ................................................................................................... 41
Acute Osteomyelitis........................................................................................... 43
Chronic Osteomyelitis........................................................................................ 45
--|Hand Surgery........................................................................................................... 46
Fracture of Wrist Bones ................................................................................... 46
Fracture of the scaphoid Bone........................................................................ 46
Perilunate dislocation and Perilunate fracture Dislocation......................... 47
Other Wrist bone fractures ...................................................................... 48
Metacarpal fractures........................................................................................ 48
Bennett’s and Rolando’s Fractures................................................................... 49
Boxer’s Fracture.................................................................................................. 50
Fractures of Phalanges..................................................................................... 50
Distal Phalanges and nail bed injuries........................................................... 51
Dislocations of the hand Joints........................................................................ 51
Burns .................................................................................................................... 52
Infections ........................................................................................................... 53
Tendon Injuries.................................................................................................... 55
Nerve injuries ..................................................................................................... 57
Vessel Injuries ..................................................................................................... 58
Skin defects ........................................................................................................ 59
--|Bone Tumor............................................................................................................... 59
Central Nervous System Disorders..................................60
--|Spinal cord injuries.................................................................................................. 60
Spinal fractures and dislocation................................................................... 62
Spinal cord injury without radiographic abnormality (SCIWORA).......... 65
Thoracic spine Fractures.................................................................................... 65
Thoracolumbar spine fracture.......................................................................... 66
Spinal seatbelt fractures.................................................................................. 67
Spinal Fracture dislocation............................................................................... 68
Cauda Equina..................................................................................................... 68
--|Cerebral vascular diseases (Spontaneous haemorrhage)............................... 70
Intracerebral Hemorrhage............................................................................... 70
Subarachnoid Hemorrhage ............................................................................ 71
--|CNS Infections And Infestations............................................................................ 73
Subdural Empyema............................................................................................ 73
Cranial Epidural empyema ............................................................................. 74
Neuro Cysticercosis............................................................................................ 75
--|Hydrocephalus in Children..................................................................................... 76
--|Myelomeningocele.................................................................................................. 76
--|Head Injury............................................................................................................... 77
General Overview ........................................................................................... 77
Severity Assesment of Head Trauma............................................................. 78
Acute subdural hematoma................................................................................ 80
Chronic Subdural Hematoma........................................................................... 80
Epidural Hematoma........................................................................................... 81
Intracranial Hematoma..................................................................................... 82
Cardio Thoracic Surgical Conditions ...............................83
--|Chest Trauma............................................................................................................ 83
Simple Rib fracture............................................................................................ 83
Flail Chest............................................................................................................ 83
Pneumothorax..................................................................................................... 84
Hemothorax........................................................................................................ 85
Cardiac tamponade.......................................................................................... 86

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Lung contusion..................................................................................................... 86
Ruptured diaphragm ........................................................................................ 87
--|Lung conditions......................................................................................................... 87
Empyema Thoracis............................................................................................. 87
Lung abscess ...................................................................................................... 89
Pulmonary fibrosis and bronchiectasis........................................................... 89
Lung cancer ....................................................................................................... 90
Foreign bodies in the lung................................................................................ 91
--|Mediastinum Masses............................................................................................... 91
--|Congenital Diaphragmatic hernias...................................................................... 92
Abdominal Injuries .........................................................94
--|General Overview ................................................................................................. 94
--|Splenic Injury ........................................................................................................... 96
--|Hepatic Injury .......................................................................................................... 97
--|Pancreatic Injury ..................................................................................................... 97
--|Duodenal Injury ...................................................................................................... 98
--|Small Bowel Injury .................................................................................................. 98
--|Colon & Rectal Injury ............................................................................................. 98
--|Abdominal Compartment Syndrome .................................................................. 99
Disorders of Gastro-Intestinal System...........................100
--|Esophageal Atresia ..............................................................................................100
--|Achalasia................................................................................................................101
--|Gastroesophageal reflux disease......................................................................101
--|Esophageal cancer................................................................................................102
--|Esophageal spasm.................................................................................................103
--|Perforation of oesophagus..................................................................................104
--|Hiatus hernia..........................................................................................................105
--|Upper Gastrointestinal bleeding........................................................................106
--|Acute abdomen......................................................................................................106
--|Peritonitis ................................................................................................................108
--|Intestinal obstruction..............................................................................................109
--|Appendicitis............................................................................................................111
--|Appendiceal mass and abscess..........................................................................112
--|Hernia......................................................................................................................113
--|Gallstones...............................................................................................................114
--|Acute cholecystitis..................................................................................................115
--|Jaundice..................................................................................................................115
--|Gastric outlet obstruction.....................................................................................117
--|Disorders of the Colon and Rectum .............................................................117
Colorectal cancer ............................................................................................117
Rectal bleeding................................................................................................118
Haemorrhoids...................................................................................................119
Perianal abscess...............................................................................................120
Fistula in ano.....................................................................................................121
Anal fissure........................................................................................................121
Anal cancer ................................................................................................122
--|Acute Pancreatitis..................................................................................................122
--|Chronic Pancreatitis .........................................................................................124
--|Breast Management..............................................................................................124
--|Neck Mass management......................................................................................125
--|Varicose veins.........................................................................................................125
--|Soft tissue masses..................................................................................................125

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GENITO-URINARY DISORDERS......................................127
--|Traumatic Emergencies.........................................................................................127
Renal injuries.....................................................................................................127
Ureteric injuries.................................................................................................128
Bladder injuries................................................................................................129
Urethral injuries................................................................................................129
Testicular injury.................................................................................................131
Penile injury.......................................................................................................131
--|Non-traumatic emergencies.................................................................................132
Acute urinary retention...................................................................................132
Testicular torsion...............................................................................................133
Renal and Ureteric colic..................................................................................135
Gross hematuria...............................................................................................136
Fournier’s gangrene.........................................................................................137
Priapism.............................................................................................................138
Paraphimosis.....................................................................................................139
--|Urinary Tract Infections.........................................................................................139
--|Benign Prostatic Hyperplasia (BPH)...................................................................141
--|Urethral Stricture...................................................................................................146
--|Common Congenital Urological Disorders........................................................147
Ureteropelvic Junction Obstruction (UPJO).................................................147
Posterior Urethra Valves (PUV).....................................................................147
Undescended testis..........................................................................................148
Hypospadias.....................................................................................................149
--|Urological Malignancies.......................................................................................150
Kidney cancers..................................................................................................150
Bladder cancer.................................................................................................152
Prostatic cancer................................................................................................153
Penile cancer.....................................................................................................153
Testicular cancer...............................................................................................154
--|Urinary Stones........................................................................................................155
Kidney/Ureter stones......................................................................................155
Bladder stones/calculi.....................................................................................155
--|Other Common urological conditions.................................................................157
Impotence..........................................................................................................157
Vesicovaginal fistulas......................................................................................158
Incontinence.......................................................................................................158
Cystocele...........................................................................................................160
Hydrocele..........................................................................................................160
Varicocele..........................................................................................................161
Phimosis..............................................................................................................161
BURNS...........................................................................162
--|Electrical Burns.......................................................................................................163
Bites and Stings of Animals and Insects........................165
--|Animal Bites ...........................................................................................................165
--|Rabies......................................................................................................................165
--|Snakebites and venom..........................................................................................166
--|Insect stings.............................................................................................................168
Spider bites .....................................................................................................169
REFERENCES .....................................................................171

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List of tables
Table 1. WFNS SAH grading..........................................................................................72
Table 2: Classification ................................................................................................... 158
Table 3. Animal bites..................................................................................................... 165
Table 4. Grading of envenomation........................................................................... 167
Table 5. Causes of insect bites and stings.................................................................. 169

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List of figures
Figure 1. physics fracture of the distal radius................................................... 7
Figure 2. Management protocol for pelvic ring disruption ........................ 13
Figure 3. Management of unstable pelvic ring fracture (Type C) ............ 14
Figure 4. Management of femoral neck fracture.......................................... 16
Figure 5. Classification of knee dislocations................................................... 39
Figure 6. Management of septic arthritis........................................................ 42
Figure 7. classification of Osteomyelitis.......................................................... 43
Figure 8. Management of blunt abdominal trauma..................................... 96
Figure 9. Management of penetrating abdominal trauma......................... 96
Figure 10. Algorhym of management of ppendiceal mass.......................113

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ABBREVIATIONS
ABG : Arterial Blood Gas
AO : Arterial Oxygen
ARDS : Acute Respiratory Distress Syndrome
BPH : Benign Prostatic hyperplasia
CBC : Complete Blood Count
CPK : Creatine PhosphoKinase
CPP : Cerebral Perfusion Pressure
CSF : Cerebral Spinal Fluids
CT : Computed Tomographic
CVP : Central Venous Pressure
DCS : Dynamic Compression Screws
DHS : Dynamic Hip Screw
DRE : Digital Rectal Exam
DRUJ : Distal Radio-ulnar Joint
DRUJ : Distal Radio-ulnar Joint
DVT : Deep Venous Thrombosis
ECG : Electrocardiogram
ERCP : Endoscopic Retrograde Cholangio-Pancreatography
FBC : Full Blood count
GA : General anesthesia
GIT : Gastrointestinal truct
GTN : Glyceryl Trinitrate
HCL : Hydrochloric
ICP : Intra Cranial pressure
ICU : Intensive Care Unit
IVC : Inferior Vena Cava
IVP : Intra Venous Pressure
LC-DCP : Limited Contact -Dynamic Compression Plate
LISS : Less Invasive Stabilization
LMWH : Low Molecular Weight Heparin
LOC : Level of Consciousness
MIPO : Minimally Invasive Plate Osteosynthesis
MRI : Magnetic Resonance Imaging
NGT : Naso-Gastric Tube
ORIF : Open Reduction and Internal Fixation
PSA : Prostate-specific antigen
PT : Prothrombin Time
PTT : Partial Thromboplastin Time
PUD : Peptic Ulcer Disease
ß HCG : ß Human Chorionic Gonadotropin
TARPO : Retrograde Plate Osteosynthesis
TBSA : Total Burn Surface Area
TIG : Tetanus Immunoglobulin
TRUS : Transrectal ultrasound
TURP : Trans-Urethral Resection Prostate
UA : Urinary Analysis
US : Ultrasound
VF : Vaginal Fistula
WBC : White Blood cells

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Clinical Practice Guidelines

For Surgery
--|Principles of management of traumas/injuries
•Primary survey and Resuscitation phase: The primary survey should identify immediate life-threatening
injuries. (C-ABCD trauma management approach). The primary survey and resuscitation of the
patient should be done SIMULTANEOUSLY.

C. Ensure the control and stopping of a catastrophic hemorrhage even before

airway control
A. Ensure an adequate airway with cervical spine protection until fractures are
excluded (immobilization). Establish a definitive airway for GCS below 8 or
hemo-dynamically unstable.
B. Ensure adequate breathing and administer O2 support if necessary and assisted
ventilation if required; rule out tension pneumothorax /manage it with needle
decompression THEN tube thoracostomy.
C. arrest any external bleeding by direct pressure and restore organ circulation
by putting 2 large peripheral IV lines and start with a bolus of 2-3L of IV
Fluids then maintenance. If required, administer type specific or O-negative
blood if no/inadequate response to fluid resuscitation. Send blood for type and
crossmatch.
D. Disability and Neurological assessment with GCS score for level of consciousness.
Treat hypoxemia and shock, and evaluate intracranial space occupying lesion
E. Expose and undress the patient to evaluate all potential other injuries; and
prevent hypothermia

•Secondary survey: Assessment of injury (Detailed history and care full physical examination from
head to toe/front and back, the mnemonics SAMPLE helps in evaluating systematically the patient)
(S-Signs & Symptoms, A-Allergies, M-Medications, P-Past medical Hx, L-Last meal, E-Events &
Exposure)

• Ensure early detection and decision making on Blunt/closed vs open/penetrating injuries

• Ensure if open injury is penetrating (Fascia/compartment compromise) or Closed/blunt (simple/

complex wall laceration but without fascia compromise/opening)

• Ensure absence of infection process or wound contamination

• Ensure hemodynamic stability, rapid clinical deterioration, dropping Hemoglobin, increasing

compartment expansion/distension (internal bleeding)

Treat shock (Cfr chapter on critical care)

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• Take the sample for FBC, Urea, creatinine, electrolytes, Blood glucose, pregnancy test (if female
childbearing)

• Ensure Oxygen supply

• Adequate pain killers

• Close monitoring of vital signs

• Do trauma work-up as per indication (Formal abdominal US, upright Abdominal x-ray, Chest
xray, Cervical x-ray, extremities imaging, or if indicated CT-scan with or without IV contrast).
Unstable patients should not be sent to radiology.

• do all differentials diagnoses, and after workups and clinical exam, confirm/Propose a working
diagnosis

• Discuss the management: conservative/non-operative or Surgery

• If Surgery, Inform theatre team to be ready accordingly, Always inform family members and sign
consent form

• If non-operative management, Adjust the required management, plan serial examination/follow

up, ensure good rehydration and analgesics, admit to the adequate disposition (General ward or
HDU)
Remember forensic issues (police investigation in case of weapons)

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Bones And Joints Disorders
--|General overview of fractures
Musculoskeletal pathologies constitute the majority of consultation in today’s medical practice,
and they must be looked at as essential and emergency services at all levels. The more people
are orthopedically fit, the more productive they become. It is, therefore, very important to equip
the District Hospital with basic arsenal to diagnose and to help in management. We are confident
that with a radiograph machine, around 90% of trauma orthopedic cases can be adequately
diagnosed. When it comes to management, having a C-arm would be a cornerstone.

Definition
Fracture is a complete or non-complete disruption of the continuity of bone tissue. Fractures can
be classified as open or closed fractures, multi-fragmented or simple and displaced or non-
displaced.

Causes:
• High energy trauma
• Motor vehicle accidents
• Sports injuries
• Fall from height
• Low energy trauma, especially in seniors and in predisposed patients
• Simple Fall (Osteoporosis, fatigue fractures, OI)
• Medical conditions

Signs and symptoms:

• Pain
• Swelling
• Wound
• Deformity
• Tenderness
• Inability to move, limited or loss of function
• Possibility of neurovascular deficit

General Investigations:
• Blood tests: Full blood count, Blood group, PT, PTT and specific tests depending on patient
condition and past medical history
• X-ray series
• Ultrasound
• CT-Scan
• MRI

General management of fractures

Assessment consists of four overlapping phases:
• Primary survey (ABCDE)
• Resuscitation
• Secondary survey
• Definitive care

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Primary survey (ABCDE) and resuscitation

This process identifies and treats life-threatening conditions as per ATLS (Advanced Trauma Life
Support) protocols:
• Airway maintenance (with cervical spine protection): Airways should be rapidly assessed for
signs of obstruction, foreign bodies and facial, mandibular, or tracheal/laryngeal fractures. A
chin lift or jaw thrust manoeuvre should be used to establish and maintain proper airway.

• Breathing and ventilation: Any four of the following conditions if present, should be addressed
as an emergency:
o Tension pneumothorax
o Flail chest
o Pulmonary contusion
o Open pneumothorax
o Massive hemothorax
o Cardiac temponade
• Circulation (with external hemorrhage control), monitor vital signs:
o Blood Pressure
o Pulse rate
o Heart rate
o Respiratory rate
o Oxygen saturation
NB: Any time there is a problem in vital signs, repeat ABCs

Secondary survey (history and head-to-toe evaluation)

• Identify life threatening injuries using the Glasgow Coma Scale:
• Alert and oriented,
• Vocal stimuli,
• Painful stimuli,
Unresponsive.
A Glasgow Coma Scale of 8 or less is an indication for the placement of a definitive airway (e.g.
Intubation). If a patient has features of Tension pneumothorax, Flail chest, Pulmonary contusion, Open
pneumothorax, Massive hemothorax, Cardiac temponate must be addressed as an emergence. There
should be no need to carry out further investigations (eg: x-rays, CT, MRI) before addressing any of
those issues).
• Abdomen (Refer to abdominal trauma management )
• Spine (Refer to spine injury Management after application of spine protection measures)
• Disability: Exposure of the whole body, ensure environmental safety and avoid hypothermia
• Complete examination of skeletal, soft tissue injuries and distal neurovascular status
• Damage control Orthopaedics
Definitive care Open fractures: There is an Open Fracture when there is a disruption of the
skin and underlying soft tissue resulting in communication between the fracture site and the
external environment.

Severity assessment of an Open fracture:

The commonly used severity classification of an open fracture is Gustilo-Anderson classification. This
classification is divided into 3 grade with grade III subdivided into three subgroups:
•Grade I: The wound is less than 1cm long. It is usually a moderately clean puncture (From inside-
out).
•Grade II: The laceration is more than 1 cm long, and there is no extensive soft-tissue damage.
There is slight or moderate crushing injury, moderate comminution of the fracture, and moderate
contamination.

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•Grade III: These are characterized by extensive damage to soft-tissues, including muscles, skin,
and neurovascular structures, and a high degree of contamination. There is bone exposure in
Grade III.
o III A: Bone is exposed but there is no periosteal stripping
o III B: Bone is exposed but there is periosteal stripping
o III C: There is association of vascular injury that requires repair

Management of an Open Fracture

• Initial management
o Adequate wound care (wash with clean water and soap and cover with a NS soaked
gauzes) and immobilization
o Drugs therapy (VAT, SAT, analgesics, Antibiotics)
o DVT prophylaxis if indicated
o Antibiotic: The choice of antibiotic to be used depends on the fracture type and the
likely contamination of the Fracture site
o Grade 1: 1st generation cephalosporin
o Grade 2: 1st generation cephalosporin + or – an aminoglycoside depending on the
level of wound contamination.
o Grade 3: 1st generation cephalosporin and an aminoglycoside
o All forms of GSW injuries are treated as Grade 3 with addition of penicillin to cover
for staphylococcal infection.

Surgical debridement and irrigation:

• Surgical debridement should be done in theatre after thorough washing of the wound with
clean water and soap;
• Debridement has been suggested to be done within 6 hours of injury;
• Note: For Gustillo type III: External fixation is the golden standard form of fracture fixation
and stabilisation

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--|Upper Limbs Fractures

Distal Radius & Ulna Fractures

Fracture Classification
No fracture classification system is comprehensive in describing all important variables of distal
radius fractures. However, based on AO classification, distal radius fractures are divided into
three groups:
•Type A: Extra-articular
•Type B: Partial articular
•Type C: Complete articular

Etiology
Almost all of the injury to the distal radius and ulna are caused by trauma in an outstretched hand:
•Fall from the height
•Sport related injury (seasonal injuries during, mostly when there are abundant fruits, eg:
mangoes, papaya, avocadoes)
• Car driving (Chauffeur’s fracture)

Management
Aim: To achieve anatomical reduction
•Anatomical Criteria of reduction: AP and Lateral radiographs are usually sufficient. Important
features to be checked are:
o Radial inclination 20-23 degrees;
o Volar tilt 11 degrees to 12 degrees;
o Radial styloid length should be 1,5 cm distal to ulnar styloid.

•Extra-articular non-displaced fractures:

o Cast immobilization for 4-6 weeks, followed by rehabilitation.
•Extra-articular displaced Fractures:
o Non Operative treatment;
o Closed reduction and immobilization;
o Operative treatment is advocated if the reduction cannot be achieved or maintained
by closed means.
• Means of fracture fixation:
o Pins (K-wires)
o Plates and screws
o External fixators (Small external fixators)
•Intra-articular fractures (AO Type B and C)
o The treatment of intra-articular fractures aims at restoring the congruity of the
articular surface which can be done by:
• Closed reduction and fixation (Pins and cast, external fixators)
• Open means (plates and screws)
Growth plate injuries
Growth plate injuries interest the growth cartilage. They are a major concern as they can interfere
with the normal growth of the upper limb. They are classified according to SALTER HARRIS. The
mnemotechnic for all 5 components of the classification are S.A.L.T.R corresponding tpo Grade I,
II, III, IV, V respectively.

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S: Grade I: Slipped
A: Grade II: Above the growth plate
L: Grade III: Lower to (be-LOW) the growth plate
T: Grade IV: Through the growth plate
R: Rammed/Ruined/c-Rushed

Figure 1. physics fracture of the distal radius

Forearm shaft fractures

* Isolated Fracture of the Ulna

It is a disruption of the bone continuity located between the distal and proximal epiphysis

Management
Non-displaced or minimal displacement:
• Long arm cast immobilization for 6 weeks
• Cast removal is followed by physiotherapy
• The time to union is about 3 months
Displaced fractures (angulation> 10 degrees or displacement > 50%):
• Open reduction and internal fixation with a 3.5 mm plate and screws
• Alternative implants: locked nail, flexible nail (Ender nails)

Isolated radial shaft fracture

It is a disruption of the bone continuity located between the distal and proximal epiphysis

Management
Non-displaced or minimal displacement:
• Long arm cast immobilization for 6 weeks
• Cast removal followed by physiotherapy
• The time to union is about 3 months
Displaced fractures (angulation > 10 degrees or displacement > 50%):
• Open reduction and internal fixation with a 3.5 mm plate and srews
• Alternative implants: locked nail, flexible nail

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Galeazzi fracture
It is a fracture of the radial diaphysis at the junction of the middle and distal thirds with disruption
of the distal radio-ulna joint (DRUJ).

Management
• Open reduction through a volar Henry approach and internal fixation with plate fixation
• Distal radio-ulna joint examination.
Twe scenario are respected:
When DRUJ is stable: immobilization in neutral /supination position (6 weeks).
When DRUJ is unstable: pinning in a position of stability
Dislocated and irreducible DRUJ: Open stabilization with repair of associated ligaments

Monteggia Fracture
It is a fracture of proximal ulna associated with radial head dislocation.

Management
•Children: Closed reduction and immobilization in Plaster of Paris (POP).
•Adult: Open reduction and internal fixation of the ulna plus closed reduction of the radial
head, followed by immobilisation for 3 weeks.
Note:
If closed reduction is not achievable, open reduction is required. Attention should be paid to the
relationship between the annular ligament, the lateral epicondyle, and the radial head.
Entrapment of the soft tissues is the most common reason for inability to obtain concomitant closed
radial head reduction at the time of open reduction and internal fixation of the ulna.
The management of those injuries are extreme emergences in orthopedics.
Fractures of both the Radius & Ulna
Fractures of both the radius and ulna usually result from high-energy injuries. These fractures are
usually displaced because of the force required to produce such an injury.

Management
Undisplaced fracture (VERY RARE):
Immobilization with long arm cast for 6 weeks with early fingers’active and passive motion
exercises at the Metacarpal-pharyngeal joints

Displaced fracture:
Open reduction and internal fixation with plate and screws
Alternative implants: intramedullary nails, flexible nails, Pins.
Note: Bone grafting can be used for severely comminuted fractures with significant bone loss.

Distal Humerus fractures

* Intercondylar fractures

Classification (Rise-borough and Radin)

Four types:
•Type I: Non-displaced fracture between the capitellum and trochlea
•Type II: Separation of the capitellum and trochlea without appreciable rotation of fragments
in the frontal plane
•Type III: Separation of the fragments with rotator deformity
•Type IV: Severe comminution of the articular surface with wide separation of the humeral
condyle

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Management
•Type I: Conservative treatment
•Type II &III: Open Reduction and Internal Fixation (ORIF)
•Type IV: Young patient: Bone reconstruction and grafting of articular defects
Elder patient (osteopenic bone): transolecranon traction or total elbow arthroplasty.
In severe cases, an elbow arthrodesis, in functional position, might be an option.

Fracture of the Epicondyles:

Treatment depends on the amount of displacement.
• If displacement is minimal, then closed reduction is appropriate, a compression screw may be
used.
• A displaced fracture may require open reduction and screw fixation

Olecranon Fractures:
Fracture of the olecranon commonly occurs with a direct blow or as an avulsion injury with triceps
contracture.

Management
No-displaced fractures, or fractures with <2 mm displacement: Immobilisation with the elbow in 45-
90 degrees of flexion for 3 weeks (7-10 days in back slab and 2weeks with a long arm cast) can be
used.
Displaced fractures: ORIF.

• The optimal method for treating this fracture is tension-banding wiring (TBW) with two
longitudinal K-wires placed across the fracture site and stabilized with a figure-of-8 wire loop.
More oblique fractures can be treated with interfragmentary screws with a neutralization plate
if the articular surface is significantly comminuted, a low-profile, limited contact compression
plate can be applied to the dorsal surface of the ulna

All these treatment modalities can generally be accompanied with early-protected range-of-motion
exercises.

* Fracture of the Radial Head

Radial head fractures are generally caused by longitudinal loading from a fall on an outstretched
hand; dislocation of the elbow is another cause.

Classification
These fractures are classified according to Mason. He proposed a classification scheme for radial
head fractures as follows
•Type I is a non-displaced fracture
•Type II is a fracture that is displaced usually involving a single large fragment
•Type III is a comminuted fracture
•Type IV is a fracture associated with an elbow dislocation

Management
•Type I: Non operative treatment with early motion
•Type II:
Displacement less than 2 mm step-off: non-surgical treatment
Displacement more than 2mm step-off: ORIF; Open reduction and internal fixation can be performed
with pins or articular screws

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•Type III: Early radial head excision/arthroplasty

•Type IV: Reduction of elbow dislocation + excision if comminuted fracture/retain and fix radial
head if no comminution.

* Capitellar Fractures

Classification
•Type I: Hahn-SteinthalI : Osteochondral injury or complete fracture
•Type II: Kocher-Lorenz: Articular-cartilage-only injury
•Type III: Hahn-Steinthal II: Comminuted fracture or a fracture line extending into the trochlea.
CT reconstructions are useful to further understanding of fracture characteristics and for surgical
planning.

Management
Open reduction and internal fixation with K-wire or articular screws

Humeral Shaft Fracture

Management
Non-operative methods
Cast immobilization (shoulder spica, U-slab, Sarmiento cylinder cast etc.): lead to good results with
high union rates.

Operative treatment
Special circumstances may merit open reduction and fixation. Those are:
• Selected segmental fractures,
• Inadequate closed reduction,
• Floating elbow
• Bilateral humeral fractures,
• Open fractures,
• Multiple trauma,
• Pathologic fractures
• Humerus fracture with associated vascular injuries requiring exploration may benefit from
internal fixation.
There are two general forms of internal fixation;
Compression plate and screw fixation
Intramedullary nailing: especially useful in osteopenic bone, segmental and external fixator if
contaminated open fractures
Note: Be aware of radial nerve injury especially in mid-shaft fractures.

Fractures of proximal humerus

Classification (Duparc and Neer)
Fractures are classified by the number of parts that are displaced more than 1 cm or angulated
more than 45 degrees.

Duparc-Neeer Grade I: Two parts fractures

• Anatomic neck fracture
• Tuberosity fracture
• Surgical neck fracture
Duparc-Neer Gdare II: Three parts fractures
Duparc-Neer Grade III: Four parts fractures

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Management
Non-displaced fractures (85%)
• Non operative treatment with an arm sling or Shoulder immobilizer is a gold standard
• Early mobilisation (3-6 weeks)
Displaced fractures: operative treatment,
Two parts fractures with anatomic neck fractures:
• Young patient: ORIF(pins /screws)Elderly patient: Hemi-arthroplasty
Note:
• Closed reduction is difficult because of controlling the articular fragment
• High risk of avascular necrosis of the humeral head

Tuberosity fractures
a) Greater tuberosity
• Attempt closed reduction and immobilization
• If irreducible fracture: ORIF (pins /screws)
• If associated with shoulder dislocation: Simple reduction of the dislocation may reduce the
tuberosity fracture. ORIF is recommended if non-opetrative management is not successful. ORIF
b) Lesser tuberosity
• If small fragment, closed reduction
• If larger fragments: ORIF

c) Surgical neck fracture

• Impacted fracture with < 450 angulation : Sling immobilisation plus early mobilisation

d) Displaced, unstable, or fracture >450 angulation requires Closed Reduction + percutaneous

pinning or intramedullary pinning under fluoroscopic control. If the closed reduction fails: ORIF
(plates and screws).

e) Three parts fractures

• Open reduction and internal fixation (Plates and screws)
• Hemiarthroplasty should be considered in the elderly

f) Four-Parts Fractures
• Open reduction and internal fixation
• Hemiarthroplasty in elderly, particularly because the avascular necrosis rate may be as high
as 90% and the bone is usually osteoporotic.
• Repair of any rotator cuff defects is necessary to prevent proximal migration of the humeral
component as well as loss of rotator cuff power.
• Early post-operative rehabilitation is recommended

Clavicle Fractures
Classification (Allman)
• Type I: fracture of the middle third (80%)
• Type II: fracture of the distal third (15%)
• Type III: Medial clavicle fractures (close to the sternum) (5%)

Management
Non-operative treatment (arm sling, figure-of-eight brace or universal shoulder immobilizer)

Indications of operative treatment (ORIF)

• Clavicle fracture associated with neurovascular injury

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• Floating shoulder
• Open fracture
• Bilateral clavicle fractures
• Threatened underlying skin

Scapula Fractures

Classification (AO/OTA)
• Type A: Extraarticular
• Type B: Body of scapula fracture
• Type C: Intraarticular glenoid fracture

Management
Non-operative treatments: Sling use and early range of motion
Operative treatment indications are:
• Displaced intra-articular fracture involving more than 25% of the articular surface
• Scapula neck fracture with associated displaced clavicle fracture
• Fracture of the acromion that impinge on the subacromial space
• Fracture of the coronoid process that result in a functional acromio-clavicular separation
• Comminuted fracture of the scapula spine

--|Pelvic And Lower Limbs Fractures

Pelvic Ring disruption

Classification (Tile)
Clinical and radiological evaluation of the Pelvis based on identification of the grade of stability
or instability is the platform for further decision-making.

•Type A: Stable pelvic ring injury (50-70%)

A1: Avulsion of the innominate bone
A2: Stable iliac wing fracture or stable minimally displaced ring fractures
A3: Transverse fractures of the sacrum and the coccyx

•Type B: Partially stable (20-30%)(rotationally unstable, vertically stable)

B1: Open book injury
B2: The lateral compression injury
B3: Bilateral B injuries

•Type C: Unstable (10-20%0 (both rotationally and vertically unstable)

C1: Unilateral
C2: Bilateral, one side B one side C
C3: Bilateral C lesions

Management protocol for Pelvic ring disruptions

After rapid resuscitation, assess of personality of injury including stability of the ring. The decision
on whether or not to operate can be based on the fracture types:

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Figure 2. Management protocol for pelvic ring disruption

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Pelvic ring-Stable (Type A or B)

Figure 3. Management of unstable pelvic ring fracture (Type C)

Pelvic ring Unstable (Type C)

Unstable pelvic ring fracture (Type C)

Fractures of the Acetabulum

Classification (Letournel)
•Type A: Partial articular fractures, one column involved
A1: posterior wall fracture
A2: posterior column fracture
A3: anterior wall or anterior column fracture

•Type B: Partial articular fractures (transverse or T type fracture, both columns involved)
B1: transverse fracture
B2: T-shaped fracture
B3: anterior column plus posterior hemi transverse fracture
•Type C: Complete articular fracture (both column fracture, floating acetabulum)

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C1: Both-column fracture, high variety
C2: Both column fractures, low variety
C3: Both column fractures involving the sacro-iliac joint

Treatment:
The goal of treatment is to attain a spherical congruency between the femoral head and the weight-
bearing acetabular dome, and to maintain it until bones are united again.

Trochanteric fractures

* Isolated Lesser Trochanter Fracture: (rare)

A symptomatic non-union may require fragment fixation or excision.

* Isolated Greater Trochanter Fracture

Management
• Displacement less than 1 cm and no tendency to further displacement;
Bed rest until acute pain subsides
Activity can increase gradually to protected weight bearing with crutches
Full weight bearing is permitted as soon as healing is apparent, usually in 6–8 weeks
• Displacement greater than 1 cm and increases on adduction of the thigh: ORIF

* Intertrochanteric Fractures
These fractures usually occur along a line between the greater and the lesser trochanter.

Classification (Boyd & Griffin)

•Type I: a single fracture along the intertrochanteric line
•Type II: Intertronchanteric line fractures with comminution
•Type III: Fracture at the level of the lesser tronchanter with variable comminution and extension
into the subtronchanteric region (reverse obliquity)
•Type IV: Fracture extending into the proximal femoral shaft

Management
•Initial treatment: Skin traction to minimize pain and further displacement.
Definitive treatment: the selection of definitive treatment depends upon the general condition
of the patient and the fracture pattern. Operative treatment within 48 hours preferable
•Reduction and internal fixation with sliding hip screw (DHS, RSP,etc…)
The patient can be taken out of bed the next day
Weight bearing with crutches or a walker is begun as soon as pain allows.
The fracture usually heals in 6–12 weeks
•Alternatives: Second-generation interlocked nails (PFN, IMHS, Gamma nails etc.)

a) Sub-trochanteric fractures

Classification (Russell & Taylor)

•Type IA:
Fractures do not involve the piriformis fossa
Lesser trochanter attached to the proximal fragment

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•Type IB:
Fractures do not involve the piriformis fossa
Lesser trochanter is detached from the proximal fragment
•Type II:
Fractures have fracture extension into the piriformis fossa

Management
•Type I: ORIF with cephalo-medullary nail (“gamma nails,” intramedullary hip screws, PFN,
Russel-Taylor and Trigen reconstruction nails etc).
•Type II: and are best treated with a sliding hip screw or fixed angle plate

Femoral Neck Fractures

Classification (Garden)
•Type 1: Valgus impaction of the femoral head
•Type 2: Complete but non displaced
•Type 3: Complete fracture, displaced less than 50%
•Type 4: Complete fracture displaced greater than 50%
This classification is of prognostic value for the incidence of avascular necrosis: The higher the Garden
number, the higher the incidence.

Fracture of fumeral neck

Young patient Elderly patient

Stable fracture Unstable fracture

Garden I & II Garden III & IV

Ostesythesis with screws within 6hrs

in any type of the fracture
mal
Bed ridden Out patient

Osteosynthesis with screws

Necrosis or

Malunion Necrosis or

Malunion

Hip prosthesis or osteotomy Hip prosthesis

Figure 4. Management of femoral neck fracture

Management: Check with the algorithm below:

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Femoral shaft fractures
Classification (Winquist):
•Type 1: Fracture that involves no, or minimal, comminution at the fracture site, and does not
affect stability after intramedullary nailing
•Type 2: Fracture with comminution leaving at least 50% of the circumference of the two major
fragments intact
•Type 3: Fracture with comminution of 50–100% of the circumference of the major fragments.
•Type 4: Fracture with completely comminuted segmental pattern with no intrinsic stability

Management
Treatment depends upon the age and medical status of the patient as well as the site and
configuration of the fracture.
Conservative Treatment: is rarely indicated in adult. However, in children, Conservative is the
Gold standard. The emphasis is put in avoiding rotation of distal fragments.

Operative Treatment: interlocking intramedullary nailing is the Golden standard treatment of

femoral shaft fracture.

Alternative treatment:
Plates and screws: Require significant soft-tissue dissection and opening of the fracture hematoma and
can be associated with high rate of infection.
External fixation: Remains indicated in some open fractures and in polytrauma patients as means of
Damage control;
Flexible nail (eg Ender nails) are used in children
Non-locked intramedullary nails (Kuntscher nail, AO nails etc.), do not provide ideal stable fixation.
In children, management may consist of:
+ Gallows’ traction/Zenith Traction
+ Flexible nail? Ender nails

Distal Femur Fractures

These fractures involve the distal metaphysis and epiphysis of the femur.

Classification (AO/OTA)
•Type A: Extra-articular
A1: Simple fracture
A2: Metaphyseal wedge fracture
A3: Metaphyseal complex fracture

•Type B: Unicondylar partial articular

B1: Lateral condylar fracture
B2: Medial condylar fracture
B3: Frontal fracture

•Type C : Intercondylar/bicondylar, complete articular

C1: Articular simple, metaphyseal simple
C2: Articular simple, metaphyseal complex
C3: Multi-fragmentary articular fracture

Management of distal femoral fractures

Extra-articular Fractures
Non-Operative

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•Conservative treatment: Skeletal traction treatment is reserved for patients for whom surgery
is not possible due to comorbidities.

Operative treatment

• Retrograde intramedullary nailing;

• Plates & screws (Blade plates, locking plates, sliding plates);
• External fixator (Ilizarov frame etc)

Intra-articular Fractures
Maximal functional recovery of the knee joint requires anatomic reduction of the articular components
and restitution of the mechanical axis.
Undisplaced inta-articular fractures: cast immobilization (6-8 weeks)
Displaced intra-articular fractures usually require open reduction and internal fixation with a variety
of methods including Dynamic Compression Screws (DCS)
Plates & screws (Reconstruction and locking plates)
New generation IMN are also used.

Patellar Injuries

Transverse Patellar Fracture

Transverse fractures of the patella are the result of an indirect force, usually with the knee in flexion.

Management + Conservative management: Non displaced fractures

• Walking cylinder cast or brace for 6–8 weeks
• Knee rehabilitation

Surgical management: Displaced fractures

•Open reduction + immobilization by figure-of-eight tension banding over two longitudinal
parallel K-wires;
•If the minor fragment is small (no more than 1 cm in length) or severely comminuted, it may be
excised and the quadriceps or patellar tendon (depending upon which pole of the patella is
involved) sutured directly to the major fragment.

Comminuted Patella Fracture

Comminuted fractures of the patella are usually caused by a direct force.

Management
Undisplaced or minimaly displaced/too comminuted to be fixed: Conservative treatment by Cylinder cast
immobilization for 6-8week
Severe displacement:
• + Operative treatment by tension band wiring (TBW);
• + Alternative: excision of the patella and repair of the defect by imbrication of the quadriceps
expansion

Proximal tibia fractures

* Tibial plateau fractures

Classification (Schatzker)
• Type I: split fracture of the lateral plateau

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• Type II: split-depression of the lateral plateau
• Type III: depression of the lateral plateau
• Type IV: medial plateau fracture
• Type V: bicondylar fracture
• Type VI: plateau fracture with metaphyseal-diaphyseal dissociation

Management
Conservative treatment: cast immobilization
Articular step-off of 3 mm or less and condylar widening of 5 mm or less can be treated conservatively
Lateral or valgus tilt up to 5 degrees is well tolerated

Operative treatment
Tibial plateau fractures with any significant displacement
Articular step-off >3 mm.
Bicondylar fractures with any medial displacement, valgus tilt >5 degrees or with significant articular
step-off.
Open tibial plateau fracture

Minimal invasive treatment

Closed reduction under fluoroscopy plus percutaneous pinning/screws
Minimally Invasive Plate Osteosynthesis (MIPO) and the Less Invasive Stabilization Systems (LISS) are
being used in the treatment of these injuries
•Open reduction: ORIF with plates & screws
•External fixation
Monolateral or ring fixator
Hybrid-Ring external fixators

Recommendations:
Bone defects should be grafted
Early range of motion with weight bearing is allowed at 6–8 weeks

Tibia-Fibula Fractures
The Tibia has a subcutaneous antero-medial border and is bound to be associated with significant
soft tissue injury.

Classification (Tscherne and Oestern): classified the soft tissue injury in ascending order of severity
Grade 0: Soft-tissue damage is absent or negligible.
Grade 1: There is a superficial abrasion or contusion caused by fragment pressure from within.
Grade 2: A deep contaminated abrasion is present associated with localized skin or muscle
contusion from direct trauma. Impending compartment syndrome is included in this
category.

Grade 3: The skin is extensively contused or crushed and muscular damage may be severe.
Also, compartment syndrome and rupture of a major blood vessel may be present.

Isolated Fibula Diaphysis Fractures: The isolated fibular fracture usually heals independently
of the form of treatment.

Isolated Tibia Diaphyseal Fractures: There is a tendency for the tibia to displace into varus
angulation because of an intact fibula.

Fractures of both the tibia and fibula

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Criteria for reduction of a tibial shaft fracture in adults:

Apposition of 50% or more of the diameter of the bone in both anteroposterior and lateral
projections
Not more than 5 degrees of varus or valgus angulation
Not more than 5 degrees of angulation in the anteroposterior plane
Not more than 10 degrees of rotation
Not more than 1 cm of shortening

Management
The goal of treatment is to allow the fracture to heal in an acceptable position with minimal negative
effect on the surrounding tissues or joints

•Undisplaced fractures: Conservative treatment with a long leg cast.

•Displaced fractures: Reduction in emergency room
If acceptable and stable: long leg non-weight–bearing cast (6-8 weeks). At 6 weeks, some shaft
fractures are stable enough to be put in a short leg weight-bearing cast (Sarmiento).
If unacceptable or unstable reduction: Attempt reduction under anesthesia

Reduction under anesthesia

If acceptable and stable: long leg non-weight–bearing cast (6-8 weeks). At 6 weeks, some shaft
fractures are stable enough to be put in a short leg weight-bearing cast (Sarmiento).
If unsuccessful reduction by closed means: operative treatment

Operative treatment
Intramedullary nailing (best with interlocking devices)
Alternative: plates & screws

Fractures of the Distal end of the Tibia

Also referred to as Pilon or Plafond fractures, these fractures involve the distal articular surface
of the tibia, the tibiotalar joint and usually the shaft of the fibula.

Classification (Ruedi and Allgower):

•Type I: non displaced fracture with non-significant articular incongruity
•Type II: articular displacement less than 5mm
•Type III: Displaced and comminuted fracture with significant articular comminution.

Management
The goal of treatment is to restore an anatomic articular surface. This can be difficult and sometimes
impossible. Bone graft can be added to metaphyseal defects to support the articular surface.
Type I: Long leg cast and leg elevation
Type II: ORIF of the fibula. ORIF of the tibia. Once soft-tissue swelling subsides, minimally invasive
open reduction and percutaneous techniques should be attempted.
Type III: either one can consider:
+ ORIF of the fibular fracture to restore length followed by ORIF of the tibia
+ Closed reduction and external fixation of the tibia
+ Combination of ORIF and external fixation of the tibia

If risk of over swelling

• Prevention or treatment of swelling by prolonged leg elevation
• Open surgical treatment should be deferred until the soft tissue condition improves (7-14 days)
• Weight bearing if radiologic evidence of bone healing

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--|Foot Fractures
Ankle Fractures

Classification (Weber):
Type A
• Avulsion of the fibula to the joint line
• Syndesmotic ligament intact
• Medial malleolus undamaged or fractured in a shear –type pattern with the fracture line
angulating in a proximal-medial direction from the corner of the mortise.

Type B
• Oblique or Spiral Fracture of the fibula beginning at the level of the joint up to the shaft of
the fibula
• The syndesmotic ligament complex can be torn, but the large interosseous ligament is usually
left intact so that no widening of the distal tibio-fibular articulation occurs.
• Medial malleolus intact or sustain a transverse avulsion fracture. If the medial malleolus is left
intact there can be a tear of the deltoid ligament.
• Posterior malleolar avulsion fracture can also occur

Type C
• Fracture of the fibula proximal to the syndesmotic ligament complex
• Disruption of the syndesmosis.
• Medial malleolar avulsion fracture or deltoid ligament rupture.
• Posterior malleolar avulsion fracture can also occur.

Note:
Fracture of the medial malleolus with complete disruption of the syndesmosis and a proximal fibular
shaft fracture (Maisonneuve’s fracture) are also considered bimalleolar fractures on a functional basis.

Management:
Principles of initial treatment of ankle fractures:
•Immediate closed reduction and splinting, with the joint held in the most normal position possible
to prevent neurovascular compromise of the foot.
•An ankle joint should never be left in a dislocated position.
•If the fracture is open, the patient should be given appropriate intravenous antibiotics and
taken to the operating room on an urgent basis for irrigation and debridement of the wound,
fracture site, and ankle joint. The fracture should also be appropriately stabilized at this time.
•Conservative treatment: well-molded short leg cast for 6 weeks.

Indications for non-operative treatment include;

•Non displaced stable fracture patterns with an intact syndesmosis
•Displaced fractures for which stable anatomic reduction is achieved
•An unstable or multiple trauma patients in whom operative treatment is contra-indicated due
to the conditions of the patient or the limb.

Operative treatment: ORIF + well-molded short leg cast for 6 weeks.

ORIF is indicated if:
• Failure to achieve or to maintain closed reduction
• Displaced or unstable fractures
• Fractures that requires abnormal foot positioning to maintain reduction

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Trimalleolar fractures
After the lateral and medial malleolar fractures have been internally fixed, ligamentotaxis
often will anatomically reduce the posterior malleolar fragment.
If this fragment represents less than 25% of the articular surface of the tibial plafond and
there is less than 2 mm of displacement, internal fixation is not always required.

Calcaneus Fractures

Classification (Essex-Lopresti): Classification based on radiologic image

Type I: extra-articular fractures
•Anterior process fracture
•Tuberosity fracture
•Medial process fracture
•Sustentacular fracture
•Body fracture

Type II: Intra-articular fractures

•Depression type
•Tongue type
•Comminuted

Classification (Sanders): Classification based upon coronal CT- scan images

•Type I: All non-displaced fractures regardless of the number of fracture lines
•Type II: Fractures are two-part fractures of the posterior facet and are divided into A,
B, and C based upon the location of the fracture line.
•Type III: Fractures are three-part fractures with a centrally depressed fragment, also
divided into A, B, and C.
•Type IV: Fractures are four-part articular fractures with extensive comminution.

Management
Extra-articular Fractures:
Fracture of the Anterior Process: Treatment is by a non-weight–bearing short leg cast in neutral
position for 4 weeks

Fracture of the Tuberosity: Isolated fractures of the calcaneal tuberosity are rare.
o Horizontal Fracture: If the fragment is big enough, the application of skeletal traction
can reduce it to the plantar-flexed foot, and the pin is incorporated in a long leg cast
with the knee flexed at 30 degrees. For smaller fragments or when closed reduction is
unsuccessful, ORIF with screws, wires, or pullout sutures is indicated

o Vertical Fracture: Because the minor medial fragment normally is not widely displaced,
plaster immobilization is not required but may reduce pain. Limitation of weight
bearing with crutches will also be helpful.

•Fracture of the Medial Process: Conservative treatment with a well-molded short leg
walking cast is usually successful
•Fracture of the Body: Marked displacement may benefit from closed reduction to improve
heel contour
•Fracture of the Sustentaculum: Conservative treatment is usually successful. In the rare
instance of symptomatic non-union, careful excision is indicated

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Intra-articular fractures:
Treatment of displaced intra-articular fractures remains controversial;
Some surgeons still advise conservative treatment
Other surgeons advocate early closed manipulation of displaced intra-articular fractures, to at
least partially restore the external anatomic configuration of the heel region. Internal fixation with
percutaneous pins (Essex-Lopresti technique) may be performed.
Open reduction and internal fixation with pins, screws, or plates, with or without bone grafting,
has gained acceptance. The aim of ORIF is to restore Böhler’s angle and improve heel alignment
through stable fixation.
Some authors advocate primary subtalar arthrodesis for severely comminuted fractures.

Talus fractures
Three fifths of the talus is covered with articular cartilage. The blood supply enters the neck
area and is tenuous. Fractures and dislocations may disrupt this vascularization, causing delayed
healing or avascular necrosis.

Fractures of the Neck of the Talus:

Hawkins classification;
•Type 1: Non displaced vertical fracture
•Type 2: Displaced fracture of the talar neck with subluxation or dislocation of the subtalar joint
•Type 3: Displaced fracture of the talar neck with dislocation of the body of the talus from both
the tibiotalar and subtalar joints
•Type 4: Later, a type 4 fracture was described by Canale and Kelly to include rare variants
which are essentially type 3 injuries with talo-navicular subluxation or dislocation.

Management;
•Type 1 fractures: Non-weight–bearing below-knee cast for 2–3 months until clinical and
radiologic signs of healing are present.
•Type 2 fractures: Closed reduction. In about 50% of cases, closed reduction is unsuccessful and
open reduction and internal fixation with K-wires, pins, or screws is indicated.
•Types 3 and 4 fractures: Closed reduction is almost never successful; ORIF is the rule.

Fractures of the Body of the Talus:

Hawkins classification;
•Type 1: Osteochondral fracture
•Type 2: Coronal, sagittal or horizontal fracture
•Type 3: Posterior process fracture
•Type 4: Lateral process fracture
•Type 5: Crush fracture of the body

Management;
•Un-displaced and Minimally displaced fractures; do conservative treatment
•Significant displaced fractures;
o Closed reduction + short leg cast with foot in plantar flexion
o If closed reduction is not successful then open reduction.

Osteochondral Fractures of the Talar Dome:

Berndt and Harty classification;
•Stage 1: Localized compression
•Stage 2: Incomplete separation of the fragment
•Stage 3: Completely detached but non displaced fragment
•Stage 4: Completely detached, displaced fracture

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Management;
•Stage1, 2, and 3: Immobilization and restricted weight bearing.
•Stage 4 and failed conservative treatment stage 1,2,3: Reduction and pinning or fixation with
screws and excision with or without drilling
•Arthroscopic management seems to give as good a result as arthrotomy, with fewer complications
•Compression fractures of the talar dome are rare injuries. They cannot be reduced by closed
methods. If open reduction, with or without bone grafting, is elected, prolonged protection from
weight bearing is the best means of preventing collapse of the healing area.

Midfoot fractures

* Navicular fractures
Classification (AO/OTA)
•Type A: Extra-articular
•Type B: Partial articular (talon-navicular joint involved)
•Type C: Articular (talo-navicular & naviculo-cuneiform involved)

Management:
•Undisplaced /incomplete fractures: short leg cast (non-weight bearing for 4-6weeks)
•Displaced /complete fractures: ORIF (lag screws) + short leg cast (non-weight bearing for 4-6
weeks).

Cuboid fractures:
Classification (AO/OTA)
•Type A: Extraarticular
•Type B: Partial articular (calcaneo-cuboid or cubo-talsal joints involved)
•Type C:Articular (calcaneo-cuboid and cubo-talsal joints involved)

Management:
•Undisplaced /minimal impacted fractures: short leg cast (non-weight-bearing for 6weeks)
•Displaced: ORIF (K-wire/lag screws) + short leg cast

Fore-foot fractures
* Metatarsal Fractures
Metatarsal Shaft Fractures:
•Undisplaced fractures: short leg walking cast.
•Displaced fractures: Closed reduction +short leg walking cast
•If significant angulation or intraarticular displacement persists: ORIF

Metatarsal Neck & Head Fractures:

•Traction (Chinese finger traps)
•Unstable reductions: percutaneous pinning under fluoroscopic imaging
•If reduction is unacceptable, ORIF with K-wires or plates and screws
•Fracture of the Base of the Fifth Metatarsal:

Three distinct patterns occur;

•Avulsion fracture
•Jones fracture
•Transverse fracture of the proximal metatarsal diaphysis

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Management:
•Short leg cast
•In the rare event of a significant displaced intraarticular component, ORIF may be indicated.

* Lisfranc injury
It is a tarso-metatarsal fracture dislocation characterized by traumatic disruption between the
articulation of the medial cuneiform and base of the second metatarsal. Diagnosis is confirmed by
radiographs, which may show widening of the interval between the 1st and 2nd ray.

Myerson classification:
•Total incongruity (type A) - can be either medially or laterally displaced
•Partial incongruity, either medial (type B1) or lateral (type B2) – the commonest group
•Divergent displacement, either partial (type C1) or total (type C2)

Management of Lisfranc injury

Nonsurgical Treatment
•When no fractures or dislocations in the joint and the ligaments are not completely torn;
•Wearing a non-weight bearing cast or boot for 6 weeks;
•Strict about not putting weight on injured foot during this period

Surgical Treatment
Surgery is recommended if there is:
•Fracture in the joints of the mid-foot
•Abnormal positioning (subluxation) of the joints.

Means of surgery

a. ORIF
•ORIF with plates and screws
•ORIF with screws
NB: Plates and/or screws may break, due to fine and frequent bone movement. No panic. This
usually does not affect healing that occurs 3-5 months post fixation.

b. Fusion:
Essentially a “welding” process. The basic idea is to fuse together the damaged bones so that they
heal into a single, solid piece.
Indicated when:
•Joints cannot be repaired with screws or plates
•The ligaments are severely ruptured.

* Fractures of the Phalanges of the Toes

Management:
•A weight-bearing removable immobilization
•Spiral or oblique fracture of the proximal or middle phalanges of the lesser toes can be
treated adequately by binding the involved toe to the adjacent uninjured toe (buddy taping).
•Comminuted fractures of the distal phalanx are treated as soft-tissue injuries.

* Fracture of the Sesamoids of the Great Toe

Management:
•Un-displaced fractures: hard-soled shoe or metatarsal bar

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•Displaced fractures: immobilization in a walking boot or cast, with the toe strapped in flexion
•If conservative modalities have been exhausted: the last resort treatment is excision

--|Fractures in Children
The treatment of fractures in children: The treatment of the majority of fractures in children
and adolescents will be conservative. Indications for surgical treatment of fractures in children
include;
•Open fractures
•Polytrauma
•Patients with head injuries
•Femoral fractures in adolescents
•Femoral neck fractures
•Certain types of forearm fractures
•Certain types of physeal injuries
•Fractures associated with burns

Epiphyseal Fracture
The cartilage physeal plates are a region of low strength relative to the surrounding bone and
are susceptible to fracture in the child. Those injuries, if missed or nit treated accordingly may
result in poor growth or limb deformity.

Classification (Salter-Harris)
•Type I: Transphyseal fracture involving the hypertrophic and calcified zones
•Type II: Transphyseal fracture that exits the metaphysis
•Type III: Transphyseal fracture that exits the epiphysis
•Type IV: The fracture that traverses the epiphysis and the physis, exiting the metaphysis
•Type V: Crush injuries to the physis

Treatment:
Because physes are near joints and physeal fractures are common, children may suffer injuries
to joint surfaces that require careful surgical repair and realignment.
Treatment options
• Close reduction und fluoroscopy guidance with aim to achieve anatomical reduction plus
cast os Kwire stabilization
• Open reduction (if close reduction failed) is more likely in fractures involving physes and
joints than in other paediatric fractures.

Supracondylar Fracture of Humerus

The mostly used classification is Gatland classification due to its inter-users duplicability.

Classification (Gartland):
Extension type;
•Type I : Non displaced;
•Type II: Displaced with intact posterior cortex, may be slightly angulated or rotated;
•Type III: Complete displacement, posteromedial or postero-lateral.

Flexion type;
•Type I: Non displaced
•Type II: Displaced with intact anterior cortex
•Type III: Complete displacement, usually anterolateral

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Management (for both Flexion and extension):
•Type I: Immobilization in a long arm cast for 2 to 3 weeks
•Type II: Closed reduction and immobilization
•Type III:
o Closed reduction + pinning and immobilisation
o ORIF
o Lateral Condyle Fracture (Jakob):
•Stage I: Non displaced fractures with intact articular surface
•Stage II: Complete fracture with moderate displacement
•Stage III: Complete displacement and rotation with elbow instability

Management:
•Stage I: Immobilization for 3 to 4 weeks
•Stage II & III: Closed reduction and immobilization.
NB: If the reduction is unable to be held percuteneous pins may be placed

Radial Neck Fracture

Classification (O’BRIEN) Based on degree of angulations
•Type I: 00 - 300
•Type II: 300 - 600
•Type III: More than 600

Management
•Type I: Immobilisation for 7 to 10 days followed by early range of motion
•Type II:
o Manipulative closed reduction + immobilisation for 10 to 14 days.
o Manipulative closed reduction + pinning
Type III: ORIF

Forearm Fracture
In children, most forearm fractures that involve both bones can be treated successfully by
closed reduction and casting. Minor angular mal-alignment can easily be tolerated if rotational
alignment of the bone end is accurate. Minimal invasive fixation in case of conservative treatment
failure is advocated.

Metacarpal & Phalangeal fractures:

Fractures of the metacarpals and phalanges commonly occur from crush injuries in children (eg,
catching a hand or finger in a door) and are generally quite stable because the periosteum
remains intact.
Rarely severely angulated or rotationally mal-aligned can be managed by immobilization for
2–3 weeks.

Pelvic and Lower Limbs Fractures

* Pelvic Fracture
Pelvic fractures in children are usually seen in conjunction with major blunt trauma. Gross
displacement is fairly uncommon and usually can be treated symptomatically because the intact
periosteal stabilizes the large flat bones.

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* Hip Fracture
As in the adult, the fracture pattern may disrupt the blood supply of the proximal femoral head
and lead to avascular necrosis of the proximal femoral epiphysis.
Femoral neck fractures in children are generally treated by reduction + fixation.

* Femoral Shaft Fracture

Femoral shaft fractures in children involves subtrochanteric, shaft and supracondylar region.

Management approach:
•Newborn to 2 years: + Early Hip spica cast
•From 2 to 10 years of age:
o + Early Hip Spica
o + Skin traction (> 2 cm overriding)
•From 10-15 years of age: + Undisplaced: Conservative treatment
•Displaced: +Operative treatment (flexible nails)

* Tibia Shaft Fracture

Most tibia fractures in children can be adequately aligned and immobilized in above-knee
casts.
Rare, unstable cases, some open fractures, or fractures in older children also may require
operative treatment with either plates or screw or Flexible nail.

* Ankle Fracture & Distal Tibial Fracture

Ankle fractures and distal tibia fractures in younger children are often either metaphyseal
or Salter-Harris type II distal tibial physeal injuries that heal rapidly (Refer to Salter-Harris
classification related treatment).

Open Fractures

Definition
An Open Fracture is when disruption of the skin and underlying soft tissue that results in
communication between the fracture and the outside environment.

Causes:
•Motor vehicle accidents
•Farm accidents
•Construction sites injury
•Sports accidents
•GSW
•A force large enough to cause a fracture

Clinical signs and Symptoms:

•Associated with neuro-vascular injury, in severe cases.

Diagnosis:
•Clinical Examination specific for the fracture should include the site of the fracture, mechanism
of injury, duration and severity of the fracture among others.

Investigations:
•FBC
•Blood group and cross match

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•PT, PTT, U+E
•Swab from the area
•X-ray of the limb (Lateral & AP views)

Severity assessment (Gustilo-Anderson classification):

•Grade I: The wound is less than 1cm long. It is usually a moderately clean puncture (From inside-
out)
•Grade II: The laceration is more than 1 cm long, and there is no extensive soft-tissue damage.
•Grade III: These are characterized by extensive damage to soft-tissues, including muscles, skin,
and neurovascular structures, and a high degree of contamination.

Management:
Emergency management:
•Emergency ATLS resuscitation
•Monitor level of consciousness (LOC)
•Analgesia preferably an Opioid Analgesic
•Antibiotics
•Remove gross contamination and apply a moist sterile dressing e.g. Betadine dressing.
•Splint the limb
•Tetanus Toxoid prophylaxis
•Urgent Surgical debridement, washout and stabilization of the fracture
•Call the orthopedic specialist after stabilizing the patient and emergency fracture care

Definitive management
•Early administration of Systemic Antibiotics, timely Surgical Debridement, Skeletal stabilization
and delayed wound closure
•Consent form must be signed before any procedures
•Provide nutritional support to critically ill patient to promote healing process
•Promote patient hygiene to minimize nosocomial infections
•Control of FBC
•Maintain analgesic treatment if required
•Promote psychology support both patient and family members to release anxiety
•Prevent thrombosis by using anti-coagulant drugs such as Lovenox, etc

Antibiotic choice
•Grade 1: 1st generation cephalosporin
•Grade 2: 1st generation cephalosporin + or – an aminoglycoside depending on the level of
wound contamination
•Grade 3: 1st generation cephalosporin and an aminoglycoside
•Treat all contaminated injuries as grade 3 with addition of penicillin and aminoglycosides
•Surgical debridement after thorough washing of the wound and irrigation

Internal fixation versus external fixation:

OREF is more advocated in Open fractures. ORIF is attempted in specialized Center where
multidisciplinary teams of Orthopedic, Vascular, General and Plastic surgeons are available.

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--|Critical Care
Critical Care Severe Traumatic Brain Injury

Definition
A traumatic brain injury (TBI) is defined as a blow or jolt to the head or a penetrating head injury
that disrupts the function of the brain. Concussions, also called “closed head injuries”, are a type
of TBI.
Assessment of brain injury hinges on evaluation of the Glasgow Coma Score (GCS) and examination
of the pupils. Traditionally a GCS of below 9 is considered to reflect severe brain injury.

Classically, TBI has been divided into two distinct periods: primary and secondary brain injury. The
primary injury is the result of the initial, mechanical forces, resulting in shearing and compression
of neuronal, glial, and vascular tissue. The secondary injury is described as the consequence of
further physiological insults, such as ischaemia, re-perfusion and hypoxia, to areas of ‘at risk’
brain in the period after the initial injury.

Causes:
• Falls
• Motor vehicle crashes
• Assaults

Signs/symptoms
• Headache with or without traumatic wounds
• Subcutaneous hematoma
• Haemorrhage (Otorrhagia, rhinorrhagia)
• CSF leak (rhinorrhea, otorrhea)
• Seizures
• Pupil dilatation
• Focal deficit (hemiparesis, monoplegia, unilateral mydriasis)
• Lucid interval
• Coma (agitation, confusion or deep coma)
• Skull base fracture (raccoon eyes, battle’s sign (after 8-12 h), CSF rhinorrhea/otorrhea,
hemotympanum)
• Facial fractures (auscultate the carotids for bruit/possible carotid dissection)

Diagnosis
• Clinical

Investigations
• Head CT-Scan
• Cervical spine X-ray or CT-scan
• Chest X-ray
• Abdominal US
• Transcranian Doppler US
• FBC, coagulation tests, Biochemistry
• Arterial Blood Gas (ABG), central venous blood gas (internal jugular Saturation venous O2)
• Any other investigation for associated injuries

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Complications:
• Posttraumatic seizures
• Hydrocephalus
• Deep vein thrombosis
• Spasticity
• GI and GU complications
• Gait abnormalities
• Autonomic dysfunction syndrome
• Diabetes insipidus
• Brain herniation and Death

Management:
• Treatment of first choice;
• Early detection and minimization of any secondary insults
• Cervical spine stabilization
• Avoid moving the patient if at all possible
• Secure and preserve the airway
• Maintain and support breathing
• Intubation and mechanical ventilation
• Maintain effective circulation with IV fluids with isotonic solutions
• Maintenance of adequate mean BP in order to sustain an adequate cerebral perfusion
pressure (CPP) ; CPP=MAP-ICP (targeted CPP:70-110mmhg)
• Effective pain relief
• Arrest bleeding
• Regular evaluation of GCS and Pupillary asymmetry and reaction to light
• Ensure Normoxemia, normoglycemia, normo or mild hypothermia,normonatremia and
normocapnia (35-38mmhg)
• Head straight and elevated at 300C
• Prevention of seizures with Phenytoin 5mg/kg/24hrs or Phenobarbital 5mg/kg/24hrs Slow
IV
• Surgical Treatment:
o Surgical decompression or craniectomy are indicated in:
• Open, depressed skull fracture
• Subdural or epidural hematomas
• Intraparenchymal hemorrhages or contusions resulting in significant mass effect
or midline shift Preoperation Considerations include associated injuries like
intra-abdominal,Orthopedic, Spinal cord and Other organ trauma
•Ventilation & oxygenation may be inadequate

Choice of Anesthesia (GA):

Rapid sequence Induction (RSI): Lidocaine IV (1.5 mg/kg) and/or Fentanyl (1-4 mcg/kg) IV, Barbiturates
(thiopental 3-5mg/kg) or Etomidate 0.3 mg/kg, Maintenance with Isoflurane or Sevoflurane,; Muscle
relaxants: vecuronium 0.1 mg/kg or pancuronium 0.1 mg/kg or tracurium 0.5 mg/kg

Intraoperative monitoring: Monitors/Line Placement, Standard monitors plus intra-arterial BP monitor,

ideally placed prior to induction, CVP monitoring, ICP monitor may be placed by neurosurgeons, Maintain
CPP above 70mmHg, Avoid increasing ICP, Maintain mild hypothermia, Avoid hypoxemia & hypercarbia,
Treat anemia, coagulopathy, Volume resuscitate with isotonic, glucose-free solutions or colloids and , blood
or blood products if indicated, Avoid hyperglycemia (keep glucose <150 mg/dL) and hypoglycemia

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Management of elevated ICP: Hyperventilate to PaCO2 of 25-30 mmHg, Increase depth of

anesthesia with thiopental; avoid high levels of volatile Osmotic dieresis with mannitol 0.25-1 gm/
kg IV bolus over 10-20 min or loop diuretics (furosemide), Drain CSF through ventricular drainage
catheter placed by neurosurgeons, Maintain temperature at 33-350 C.

Management of hypotension: use vasopressors (norepinephrine 0.01-0.1 µg/kg/min Postoperative

period, Manage pain, Sedation with midazolam 5-15 mg/hour + Fentanyl 50-150 µg/hour may be
required if patient is left intubated.

Critical Care of Multiple Injuries

Definition
Multi-trauma are physical insults or injuries occurring simultaneously on several parts of the body.

Causes:
•Mechanical or kinetic energy- blunt or penetrating injury
•Thermal energy- injury due to heat or cold
•Chemical energy- acid or alkaline exposure
•Radiant energy- exposure to radiation
•Electrical energy- electrocution
•Oxygen deprivation- smoke inhalation or drowning

Clinical Signs/symptoms:
•Pain and swelling
•Deformity
•Lesions with bleeding
•Altered mental status or unconsciousness
•Hypotension or shock

Life threatening features include:

•Chest Tension pneumothorax,
•Flail chest,
•Pericardial tamponade,
•Myocardial contusion,
•Open chest wound,
•Hemothorax,
•Intra-abdominal bleeding,
•Pelvis / Femur fracture, Spine fracture / Cord injury,
•Head injury (see Severe Head Injury),
•Extremity fracture /
•Dislocation,
•HEENT (Airway obstruction).

Diagnosis
•Clinical Hypothermia
•Investigations
o Xrays of the Chest, Pelvic & C-spine
o Abdominal US
o Head CT-Scan if head Injury
o Body scan

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o X-ray of affected limbs
o FBC, Blood group and cross-match, coagulation tests
o Chemistry (electrolytes, transaminases, CPK, Troponin)

Complications
•Haemorrhage/Infection/ Sepsis
•Multi organ failure
•Deep venous thrombosis
•Fat air embolism

Management:
Treatment of first choice:
•Adult Assessment Procedure focusing on initial C-spine, ABCD and level of responsiveness (see
ATLS)
•Spinal Immobilization
•Airway protection and/or maintenance if appropriate
•Assess Vital Signs and GCS

If hypotension;
• Give IV fluids: Normal saline until you get a mean arterial pressure > 60 mmHg Splint

Suspected Fractures: Consider Pelvic Binding/ Radiological embolization if available

•Control External Hemorrhage
•Tension Pneumothorax: Chest Decompression
•Laparotomy if abdominal injuries
•Head Injury Protocol if head injury
•Blood and/or blood components transfusion if needed

Supportive treatment:
•Dialysis in case of renal failure
•Mechanical ventilation in case of ALI/ARDS
•Inotropic drugs like dobutamine 5-20 µg/kg/min in case of cardiogenic shock due to myocardial
contusion
•NGT for enteral feeding
•Prevention of DVT with LMWH e.g Enoxaparine 40mg SC/day (starting from day5 if no
contraindications).

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--|Dislocations
General considerations

Definition
Complete separation and loss of 2 articulating bone contact surfaces. A partial or incomplete
dislocation is known as a Subluxation.

Causes:
• Direct Trauma
o High Energy trauma
• Road traffic accident
• Fall from Heights
• Sports injuries
• Industrial injuries
o Low Energy Trauma
• Sports injuries
• Indirect Trauma
o Varus, Valgus and Rotational stress

Signs and symptoms:

• Pain
• Tenderness
• Deformity
• Swelling
• Decreased Range of motion
• Shortening
• Effusion

Diagnosis:
• Clinical
• Investigations
• X-Rays (Lateral view, Anteroposterior View)
• CT Scan
• MRI

Acromio-Clavicular Joint Dislocation

Definition
Classified in 6 different types depending on which ligaments are sprained or torn.

Type 1- Sprain of the acromioclavicular ligament

o Joint tenderness
o Minimal pain with arm motion
o No pain in Coraco-Clavicular Interspace
Type 2- Torn Acromioclaviclar Ligament with sprain Coraco-Clavicular Ligament
o Joint Tenderness in both acromioclavicular and coracoclavicular interspace
o Distal Clavicle is slightly superior to Acromion and mobile to palpation

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Type 3 – Torn both Acromio-clavicular and Coraco-Clavicular ligament
o Acromio-clavicular joint tenderness and coraco-clavicular widening is evident
Type 4 – Type 3 + Posterior displacement of the distal Clavicle into or through the Trapezius
o More pain exists than in type 3 and distal clavicle is displaced posteriorly away from
the clavicle.
Type 5- Type 3 + glossily and severely displaced distal Clavicle superiorly (Radiography demonstrates
the Coraco-clavicular inter-space to be 100% to 300% greater than normal)
o Symptoms as in type 3 but this type is typically associated with tenting of the skin
Type 6 – dislocated Acromio Clavicular Joint with Clavicle displaced inferiorly. (Shoulder has Flat
appearance with a prominent Acromion)
o Shoulder has flat appearance with a prominent Acromion
NB: Associated clavicle, Upper Rib Fractures and brachial plexus injuries are due to high energy
trauma in this type.

Investigations:
• Antero-Posterior x-ray for both shoulders (Comparison)
• Stress x-ray of the affected shoulder (Holding weight) in case of Doubt
Complications
• Associated Fractures (Clavicle, Acromion and Coracoids process)
• Post Traumatic osteoarthritis
• Type 6 could be associated with a pneumothorax

Management:
• Type 1: Rest 7-10 Days with an Arm sling (Refrain from full activity for 2 weeks)
• Type 2: Use of Arm sling for 1-2 weeks (Refrain from Heavy activity for 6 weeks)
• Type 3: Conservative Treatment (Arm sling) or Surgical Treatment (Surgical Repair)
• Type 4, Type 5 and Type 6: Open reduction and surgical Repair of the Coraco-Clavicular
Ligament

Shoulder dislocations

Description:
• Most common dislocated joint of the body.
• Most Shoulder dislocations are anterior
• Posterior dislocations are less frequently and difficult to diagnose
• Inferior and superior dislocations are very rare.

Signs and Symptoms:

Anterior Dislocation:
• Pain, tenderness and swelling of the affected shoulder
• Arm of the affected shoulder is held in Abduction and External Rotation
• Decreased Range of motion
• Loss of deltoid contour compared with contralateral side.
• Prominence of the Acromion and palpable head of the Humerus anteriorly in the Axila
NB: Careful assessment of the neurovascular status. (Evaluate sensory and motor function of the
musculocutaneous and radial nerves and do ompare distal pulses on both extremities)

Investigations:
• Antero posterior and lateral X-rays
• CT Scan and MRI (to assess the Rotator Cuff)
Complications:

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• Recurrent dislocation
• Soft tissue injuries(Rotator Cuff Injury and labrum lesions
• Vascular Injury- Axillary Artery (Rare: Only in elderly patients with arthrosclerosis)
• Nerve Injury especially the Musculocuteneous and Axillary Nerve
• Osseous lesions
• Post traumatic osteoarthritis

Management:
• Conservative (Closed reduction):
o Analgesics and/Or Sedation
o Always conservative for acute anterior shoulder dislocations.
o Arm sling after closed reduction for 2-3 weeks (Elderly patients) and 6 weeks for
(Young patients)
• Surgical:
o Indication: Chronic Dislocation, Soft tissue interposition, Fracture dislocation

Posterior Dislocation

Signs and symptoms

• Arm of the affected shoulder is held in Adduction and Internal Rotation
• Pain, tenderness and swelling of the affected shoulder
• Decreased Range of motion
• Most commonly missed injury (60-70% are missed)

Investigations:
• Antero posterior and lateral X-rays
• CT Scan (to assess the associated Fractures: Humeral Head)

Complications:
• Recurrent dislocation
• Nerve Injury especially the Axillary Nerve
• Osseous lesions
• Post traumatic osteoarthritis

Management:
• Conservative (Closed reduction):
o Analgesics and/Or Sedation
o Always conservative for acute posterior shoulder dislocations.
o Arm sling after closed reduction for 2-3 weeks (Elderly patients) and 6 weeks for
(Young patients)
• Surgical:
o Indication: Chronic Dislocation, Soft tissue interposition, Fracture dislocation

Recommendations:
• Physical therapy under supervision post immobilization removal
• Pre and post reduction: X-Ray and Neuro-Vascular status evaluation is mandatory

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Elbow Dislocation

Description:
• Posterior dislocations account for most elbow dislocations.
• Most common in young population

Classification:
• Posterior 90% of elbow dislocations
• Anterior
• Lateral
• Medial
• Divergent

* Posterior Dislocations
Signs and Symptoms:
• Pain - Intense, focused around the elbow joint
• Extremely limited range of motion
• Massive ante-cubital swelling (Be aware of compartment syndrome)
• Elbow is flexed, with an exaggerated prominence of the olecranon

Investigations:
• X-ray Antero- posterior and Lateral Views

Complications:
• Compartment syndrome(Vascular or Neuro: compromise)
• loss of Motion (Stiffness ) due to long term immobilization
• Instability/ Re-dislocation
• Heterotopic ossification

Management:
• Conservative (Closed reduction):
o Analgesics and/Or Sedation
o Always conservative for acute posterior elbow dislocations
o Above elbow posterior splint for 3 weeks (Young patient) and up to 10 days (for
elderly)
• Surgical:
o Indication: Chronic Dislocation, soft tissue and/or Bony entrapment, Fracture dislocation,
recurrent instability.

Recommendation:
• Physical therapy under supervision post immobilization removal.
• Pre and post reduction: X-Ray and Neuro-Vascular status evaluation is mandatory

Hip Dislocation

Description:
• Traumatic Hip dislocation of the hip joint may occur with or without fracture of the acetabulum
of the proximal end of the Femur. Hip dislocations are classified based on the relationship of
the femur head to the Acetabulum and on whether associated fractures are present.

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Causes of hip dislocations:

• High Energy Traffic Accidents
• Fall from Heights
• Industrial injuries

Investigation:
• X-ray Antero posterior of the pelvis
• Oblique radiographic projections (Judet views)
• CT Scan ( Preferably post reduction)

* Posterior hip dislocation

Classification;
• Posterior dislocation is the most common and accounts for 90% of all Hip dislocations.
• Classification of Posterior dislocations (Thompson and Epstein Classification)
o Type 1- Simple dislocation with or without any significant posterior wall fragment
o Type 2- Dislocation associated with a single large posterior wall fragment
o Type 3- Dislocation with a comminuted posterior wall fragment
o Type 4- Dislocation with fracture of the acetabular floor
o Type 5 – Dislocation with fracture of the Femoral head
Signs and Symptoms:
• Severe Pain
• Shortening, adduction flexion and internal Rotation of the affected limb
• Decreased motion of the lower extremity on the affected side
NB: Full trauma survey is critical due to the high energy nature of the injury.

* Anterior Hip dislocation

Classification;
Anterior Dislocations are not very common
• Type I: superior dislocation including pubic and subspinous
• Type II: inferior dislocation including obturator and perineal

Signs and symptoms:

• Severe Pain
• Abduction flexion and external rotation of the affected limb
• Decreased motion of the lower extremity on the affected side

Complications of hip dislocations:

• Neurovascular injury
• Thromboembolism
• Avascular Osteonecrosis

• Post traumatic osteoarthritis

• Recurrent dislocations
• Heterotopic ossifications

Management of hip dislocations:

Reduction should be expedient to decrease the risk of osteonecrosis of the femoral head.
• Conservative treatment
o Closed reduction under anesthesia
o Skin or skeletal traction ( 2-3 weeks)
• Open reduction

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Indications for open reduction;
o Failure of closed reduction
o Non concentric reduction
o Fracture of the acetabulum or femur head that requires either excision or ORIF
o Ipsilateral femoral neck fracture

Traumatic Knee dislocation

Definition
Is the complete displacement of the tibia with respect to the femur and with disruption of 3 or more
of the stabilizing ligaments.
• Extremely rare but may be limb threatening (Associated with vascular injuries -Popliteal
Artery)
• Should be treated as an orthopedic emergency

Causes:
• Motor Vehicle Accidents
• High height falls
• Industrial-related accidents
• Sports-related injuries

Signs and Symptoms:

• Severe pain
• Extreme swelling and gross Knee derformity with or without Neurovascular compromise

Investigations:
• Anteroposterior and lateral X-rays
• MRI

Complications:
• Neurovascular
• Ligamentous instability
• Stiffness(Due to prolonged Immobilisation and extend of soft tissue injury)

Classification:

Figure 5. Classification of knee dislocations.

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• Anterior: Anterior dislocation often is caused by severe knee hyperextension

• Posterior: Posterior dislocation occurs with anterior-to-posterior force to the proximal tibia,
such as a dashboard type of injury or a high-energy fall on a flexed knee
• Lateral: Valgus force with disrupted medial supporting structures and Often with tear of both
cruciate ligaments
• Medial: Varus Force with disruption of lateral and post lateral structures
• Rotational: Varus and Valgus with rotatory component.

Management:
A knee dislocation is potentially limb-threatening condition therefore immediate reduction is
recommended even before radiography evaluation.

Conservative:
• Immediate closed reduction and immobilization at 20-30o of Flexion for 6 weeks
• Range of motion/Exercise should be instituted after adequate soft tissue healing 6-12 weeks

Surgical:
Indications:
• Unsuccessful closed reduction
• Open Injuries
• Vascular Injuries
• Residual soft tissue interposition

Recommendations:
• Acute repair of lateral ligament followed by early functional bracing is advised (meniscal
injuries to be addressed at time of surgey;
• Medial collateral injuries generally heal without surgery;
• The role of cruciate reconstruction in the acute setting remains controversial

Patellar Dislocation

Description: Patella dislocation is more common particularly in females due to physiologic laxity and
in patients with hyper mobility (athletes)

Causes:
• Physiological laxity
• Direct trauma to the patella
• Connective tissue disease (Marfan Syndrome)
• Congenital abnormality of the patella and Trochlea
• HYpoplasia of the Vastus Medialis Muscle
• Hypertrophy of the lateral Retinacular

Signs and symptom:

• Pain focused around the Knee joint
• Inability to flex the knee
• Hemarthrosis
• Swelling with tenderness of the knee
• Palpated displaced Patella

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Investigations:
• X-ray of the knee (Anteroposterior and Axial views)
Complications:
• Recurrent dislocation
• Re-dislocation
• Patella-femoral Arthritis

Management:
• Conservative:
o Closed reduction with Cylinder casting for2- 3 weeks
o Isometric quadriceps exercises after removal of the cast
• Surgery:
o Recurrent episodes require operative repair

--|Bone and Joints Infections

Septic Arthritis

Definition
Septic arthritis is the inflammation of a synovial membrane with purulent effusion into the joint space
usually caused by bacteria. It is a surgical emergency. Typically it affects mono-articular joints.
Commonly affecting the knees, hips and shoulder

Pathophysiology:
• Bacteria can gain entrances to a joint via three routes:
o Hematogenous spread
o Direct Inoculation
o Direct extension from an adjacent focus of infection
• Hematogenous infection is the most common type and usually affects people who have an
underlying medical illness.
• Predisposing factors include:
o Immune deficiencies
o Chronic disease
o Intravenous drug abuse
o Local joint trauma
o Recent sexual contact (gonococcus sepsis)

Causes:
• Staphylococcus Aureus
• Streptococcus
• Gram negative bacteria

Signs and symptoms:

• Warm, Painful and swollen joint
• Erythema and tenderness
• Limitation of motion
• Pyrexia
• Antalgic posture of the limb.

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Investigations:
• FBC: Often leucocytosis with a left shift
• ESR and CRP
• Blood cultures: 50% positive in S.aureus infection, very poor for N. gonorrhoea
• urethral, cervical, pharyngeal and rectal swabs
• Synovial fluid analysis: Gram stain, culture, cell counts, crystal analysis
• X-ray of the joint
o Often normal initially
o Soft tissue swelling around the joint, widening of the joint space, displacement of tissue
planes.
o Bony erosions and joint space narrowing, sclerosis, and patchy demineralization all in
later stages.
• Ultrasound of the joint

Complications:
• Septicemia
• Dislocations
• Growth plate damage in children
• Osteomyelitis
• Degenerative arthritis
• Avascularis necrosis in hip and shoulder

Management:

Figure 6. Management of septic arthritis.

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Acute Osteomyelitis

Definition: Osteomyelitis is the synonym of a bone infection.

Cause/Etiology:
• Bacterial especially S. aureus.

Pathogenesis:
• Inflammation
o Acute inflammatory reaction with vascular bacterial congestion
o Rise in intra-osseous pressure causing intense pain
• Suppuration
o At 2-3 days pus forms within the bone and forces its way down the haversian canals
to the surface where it forms a sub-periosteal abscess
o The pus can spread from here back into the bone, into an adjacent joint or into the soft
tissues (Where there is an intra-articular physis)
o Vertebral infection can spread through the end plate, disc and into the next vertebral
body
• Necrosis
o At 7 days, rising pressure, vascular stasis, infective thrombosis and periosteal stripping
compromise the blood supply to the bone resulting in bone death resulting in a
sequestrum
o New bone formation
o At 10-14 days this forms from the deep surface of the stripped periosteum forming
the involucrum
• Resolution
o With release of the pressure and appropriate antibiotics healing can occur
o There may be permanent deformity
o Unpublished work (quoted in Dee) shows that experimentally bacteria injected
intravenously will settle in the metaphyses of bone preferentially
• NB - in 10% of cases there is more than one site of infection.

Figure 7. classification of Osteomyelitis.

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Signs and Symptoms:

• Children (invariably)
o Pain, malaise, fever
o Limp or not weight bearing
• Infants
o Failure to thrive, drowsiness, irritable
• Adults
o The commonest site is long bones
o Local erythema, swelling and tenderness indicates that the pus has broken through the
periosteum

Investigations:
• FBC: Often leucocytosis with a left shift
• ESR and CRP
• Blood cultures
• X-ray of the joint
o Often normal initially
o Soft tissue swelling around the joint, widening of the joint space, displacement of tissue
planes.
o Bony erosions and joint space narrowing, sclerosis, and patchy demineralization all in
later stages.
• Ultrasonography

Complications:
• Recurrent bone infection
• Pathologic fractures
• Bone destruction
• Chronic osteomyelitis
• Impaired bone growth

Management:

Non-Operative
o ANTIBIOTIC ADMINISTRATION:
• It is recommended to start empiric treatment with a regimen that caters for S.aureus as the
culture results are awaited
• Empiric regimen
o IV CLOXACILLIN and A 3RD GENERATION CEPALOSPORIN (e.g. ceftriazone)
OR
o IV OXACILLIN can be used in the place of cloxacillin with the 3rd generation cephalosporin.
• Culture results to guide definitive antibiotic therapy
• The change to oral medication will depend on the clinical response i.e. fevers ceasing and
decreasing CRP and ESR, with the generally accepted course being of 1week IV treatment
then a change to oral medication.
• The recommended minimal duration of drug therapy is 6 weeks

Operative
• Periosteal abscess should be managed surgically.

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Chronic Osteomyelitis

Definition:
Exogenous or hematogenous infection that has gone untreated of has failed to respond to treatment.

Signs and symptoms:

• Pain
• Swelling/oedema
• Often draining sinus
• Sometimes deformity

Investigations:
• FBC
• ESR and CRP
• Blood cultures
• Tissue culture and sensitivity
• X-ray (Anteroposterior and lateral views)
• CT Scan
• MRI
• Scintigraphy

Complications:
• Recurrent bone infection
• Pathologic fractures
• Bone destruction
• Impaired bone growth
• Skin neoplasm

Management:
• Surgical debridement (Sequestrectomy and curettage): an attention on timing of surgery. One
must differenciate a dead bonerom an Inviolcrum.
• Systemic and local antibiotics guided by the results of the antibiogram
• Analgesics and immobilization
• Dead space management (Irrigation, Muscle Flap, Beads or spacers)

•Amputation
o Indication: Association of any of the following
•Septicemia
•Extreme deformities and Extensive Infection
•Severely compromised soft tissue

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--|Hand Surgery
Fracture of Wrist Bones
Description:
Carpal/wrist bones are in 2 rows:
• A wrist fracture is a break in one or more of the bones in the wrist.
• The proximal row that is made from radial to ulna sides of the scaphoid, lunate, triquetrum
and pisiform bones.
• The distal row that is made from radial to ulna of the trapezium, trapezoid, capitate and
hamate bones.
Causes
• Fall on the outstretched hand and extended wrist
• Motor vehicle accident
• Sports contact injury

Fracture of the scaphoid Bone

Description:
Scaphoid fractures are by far the most common of the carpal fractures, estimated at 70-79%.

Herbert classification of scaphoid fractures:

• Type A fractures are stable acute fractures, including:
o A1: Fracture of the tubercle
o A2: incomplete fractures of the scaphoid waist.
• Type B fractures are unstable and include:
o B1: distal oblique fractures
o B2: complete fracture of the waist
o B3: proximal pole fractures
o B4: trans-scaphoid peri-lunate fracture dislocation of the carpus.
• Type C fractures are characterized by delayed union.
• Type D fractures are characterized by established non-union
o D1: Fibrous union
o D2: Pseudarthrosis.

Signs and Symptoms

• Pain and swelling of the radial wrist
• Swelling and pain on palpation of the anatomic snuff box
• Limited range of Motion of the wrist
• Radial deviation and flexion of the wrist elicit pain
• Axial load to the first metacarpal elicit pain
• Diminished Grip compared to the other hand.

Investigations
• Plain x-ray: (Poste-Anterior, True Lateral and Semi-pronate oblique)
• CT Scan and MRI: Only for suspected Fractures that can’t be found on plain x-ray

Complications
• Bone Necrosis
• Pseudo Arthrosis
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Management:
Conservative treatment:
• Short arm casting for 12 weeks
• Physiotherapy after removal of casting
Surgical:
• Open reduction and internal Fixation (ORIF) ± bone grafting associated with Short Arm
casting for 8 weeks
• Physiotherapy after removal of casting

Recommendations:
• If patients still feels pain after conservative treatment refer to Hand or Orthopedic surgery.
• If plain x-ray seems normal despite clinical suspicion of fracture, repeat after x-ray after a
week.
• Refer all unsure cases to an orthopedic/Hand surgeon.

Perilunate dislocation and Perilunate fracture Dislocation

Definition:
Perilunate dislocation and Perilunate fracture Dislocation are injuries that involve traumatic rupture
of the radio-scaphal Capitate (RSC) ligament, the scapholunate interosseous and lunotriquetral
interosseous ligament.

Signs and symptoms

• Pain and marked swelling of the wrist
• Wrist is dislocated dorsally and Radius is prominent volarly.
• Paresthesia in the median Nerve territory
• For Lunate dislocation the lunate alone is prominent volarly.

Investigations
• Plain x-ray: (Poste-Anterior, True Lateral and Semi-pronate oblique)
• CT Scan and MRI

Complications
• Median nerve palsy
• Post traumatic athrosis
• Open fracture

Management
• Closed reduction and casting for 8 weeks if reduction is stable
• Unstable Reduction: Closed reduction and percutaneous pin fixation
• Severe Ligament injuries: Open reduction, Ligament Repair and Fixation.
• Physiotherapy after removal of casting

Recommendations
• CT scan and/or MRI should be prescribed by the Surgeon who is going to operate.

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Other Wrist bone fractures

Description:
Commonly associated with above carpal bone fractures.

Signs and symptoms

• Decreased range of motion of the wrist
• Most pain can be radial or ulna depending on the bone involved
• Pain and swelling of the wrist
• Decreased hand grip
Investigations
• Plain x-ray: (Poste-Anterior, True Lateral and Semi-pronate oblique)
• CT Scan and MRI

Management:
• Conservative: Short arm casting for 8 weeks
• Surgical: ORIF with short arm casting.
• Physiotherapy after removal of casting

Metacarpal fractures

Description:
Metacarpal Bones are located between carpal bones and Phalanges. From Radial to Ulna we have
Thumb (First) Metacarpal and second to fifth metacarpal.

Fractures will be described according to:

• Whether Closed or open
• Finger involved
• Site (Base, Shaft, Neck and Head)
• Type of Fracture (Horizontal, oblique, Spiral and comminuted)
• Joint Involvement

Causes
• Falls
• Blunt injuries
• Penetrating Injuries
• Sport contact injuries

Signs and Symptoms

• Pain
• Swelling of the hand, hematoma and bruising overlying skin
• Decreased range of motion of the fingers
• Shortening of fingers involved
• Rotation of finger
• Angulation

Investigations
• Plain x-ray (Antero-posterial and Oblique views)

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Management

Conservative:
• Closed reduction and volar splinting in functional position for 6 weeks
• Physiotherapy after removing the splint

Surgical:
• Closed reduction and percutaneous pin fixation.
• Open reduction and internal fixation.

Recommendations
• Keep the hand elevated to decrease pain and swelling
• Make sure the finger is not rotated after fixation.

Bennett’s and Rolando’s Fractures

Description:
• Bennett’s fracture is an Intra articular fracture of the base of the thumb metacarpal
characterized by one small ulna fragment
• Rolando’s fracture is a comminuted intra articular fracture of the base of the thumb metacarpal

Causes
• Fall with axial loading through the thumb metacarpal
• Direct blow of the thumb metacarpal
• Injury involving forced abduction of the thumb

Signs and symptoms

• Pain and swelling
• Decreased range of motion of the thumb
• Shortening of the thumb
• Dorsal and radial displacement of the metacarpal bone

Investigations
• Plain x-ray (Antero-posterial and Oblique views)

Management
Surgical:
• If the Bennett’s fragment is less than 15-20% of the articular surface: Closed reduction and
percutaneous pin fixation followed by a thumb spica Splint for 4-6 weeks.
• Open reduction and internal fixation. (If the Bennett’s fragment is greater than 20% or
articular step off after pin fixation is greater than 1 mm)
• For Rolando’s fracture: Always do Open reduction and internal fixation (ORIF)

Recommendations
• Always refer Bennett’s or Rolando’s fractures to the orthopedic surgeons after immobilization
in a splint

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Boxer’s Fracture

Description
Fracture of the neck of the fifth metacarpal.

Causes
• Direct blow
• After Punching a person or object such as a wall

Signs and symptoms

• Pain and swelling at the base of small finger
• Decreased range of motion
• Deformity over the dorsal aspect of the metacarpal
• Loss of the knuckle definition
• Volar displacement of the head of the metacarpal

Investigations
• Plain x-ray (Antero-posterial and Oblique views)

Management
• If angulation is less than 40%: Closed reduction and splint
• If angulation is more than 40% : Closed reduction and percuteneous pin fixation or open
reduction and ORIF (Open reduction and Internal Fixation).

Recommendations
• Check for rotation deformity after fixation.

Fractures of Phalanges
* Proximal and Middle phalanges
Definition/Description:
Fracture of the bones of the proximal or middle phalanges of the fingers. Fracture can be extra-
articular or intra-articular.

Causes
• Falls
• Direct blows
• Sport contact injuries
• Machinery injuries

Signs and symptoms:

• Pain and swelling of the fingers involved
• Decreased range of motion
• Ecchymosis
• Rotation deformity
• Angulation
• Shortening f the fingers

Investigations
• Plain X-ray (AP, lateral and oblique views)

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Complications:
• Digital neuro-vascular bundle injuries

Management
Conservative (Exra-articular fractures)
• Closed reduction,
o if stable do buddy strapping for 4 weeks
o If reduction not stable then do surgery
• Surgical (Unstable Fractures and/or Intra-articular Fractures)
• Closed reduction with per-cutaneous pin fixation
Or
• Open reduction and internal fixation with plates and screws

Recommendations
• Always check sensation and perfusion of the fingers before and after treatment

Distal Phalanges and nail bed injuries

Description:
Distal phalanges fractures are often associated with nail bed laceration.

Causes
• Crush injuries (From Doors mostly in children)
• Work related trauma
• Falls

Signs and symptoms

• Pain and swelling of the fingertip
• Lacerations and/or hematoma of the nail bed
• Deformity of the fingertip

Investigations
• Plain x-ray (AP and lateral views)

Complications
• Traumatic amputation of the fingertip

Management:
• If fracture is associated with nail bed laceration, repairing the laceration will reduce the
fracture. Then stabile with a Zimmer splint for 4 weeks
• Otherwise do fixation with an axial per-cutaneous pin if the distal fragment is big enough.

Dislocations of the hand Joints

Definition:
A dislocation is a misalignment of the bones forming a joint. Metacarpophalangeal joints and
interpharlangeal are the most commonly involved.

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Causes
• Falls
• Sport injuries

Signs and symptoms

• Pain and swelling of the joint involved
• Decreased range of motion
• Ecchymosis
• Joint deformity

Investigations
• Plain x-ray (AP, lateral and/or oblique views)

Complications
• Nerve injuries

Management
Conservative
• Relocate under nerve block or general anesthesia. If relocation is difficult under those
circumstances do an open reduction
• Splinting in functional position for 4 weeks and then physiotherapy
Surgical
• Sometime the volar plate or tendons can be entrapped into the Joint and that is why it may
be impossible to do a closed reduction

Recommendations
• Refer to orthopedic surgeon or hand surgeon any dislocation that can’t be relocated
conservatively.

Burns

Wound management of the burned hand follows the general principles of burn wound management.
But there are a few things that are specific to the hands. For the general principle please refer to the
burns chapter
Specifics to hands in acute burn management
• Every burned hand must be splinted in functional position
• Every finger must be dressed separately to avoid synechia
• Daily mobilization of fingers
• Early skin grafting when required ( do not use skin staples in hands)
Specifics to hands in post burn reconstruction
• When releasing scar contractures, do not use split thickness skin grafts. Cover defects with full
thickness skin grafts or flaps.
• Release scar contractures in stages from proximal to distal

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Infections

* Paronychia abcess

Definition
It is the infection of soft tissue fold around the nail. It is the most common infection of the hand

Causes
• Splinters
• Manicure instruments
• Nail biting

Signs and symptoms

• Erythema, Swelling, and tenderness immediately adjacent to the nail
• If left untreated the abscess may extend below the nail bed and track into the pulp

Investigations
• Plain X rays to exclude bone involvement in late or advanced presentations
• Microbiology Culture and sensitivity of pus and/or necrotic tissue

Complications
• Pulp abscess
• Bone involvement
• Extensive soft tissue necrosis

Management
Conservative
For early presentations: warm soaks and systemic antibiotics
Surgical
• Abscess drainage
• Debridement of necrotic tissues
• Systemic antibiotics for 6 weeks if the bone is involved

* Pulp abscess (Felon)

Definition
It is a subcutaneous abscess of the volar aspect of the fingertip

Causes
- Splinters
- Thorns
Signs and symptoms
- Severe throbbing pain
- Tension
- Swelling of the entire pulp but does not extend proximal to the distal inter phalangeal crease

Investigations
- Plain X rays to exclude bone involvement
- Microbiology Culture and sensitivity of pus and/or necrotic tissue

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Complications
- Bone involvement
- Extensive soft tissue necrosis

Management
- Lateral incision and drainage
- Systemic antibiotics

* Tenosynovitis
Definition
It is the infection of the flexor tendon sheath

Cause
• Wound bite
• Any other penetrating injury

Signs and symptoms

• Semi flexed position of the finger
• Fusiform swelling (Sausage type)
• Excessive tenderness limited to the course of the flexor tendon sheath
• Excessive pain on passive extension

Investigations
• Plain X rays to exclude bone involvement
• Microbiology Culture and sensitivity of pus and/or necrotic tissue

Complications
• Proximal extension of the infection to the hand and forearm
• Extensive soft tissue destruction
• Bone involvement

Management
• Incision and drainage of the tendon sheath (Refer to text books for description of proper
technique)
• Systemic antibiotics

* Human bites (Punch bites)

Definition
It is the infection of the metacarpal phalangeal joint as a result of an injury by tooth.

Causes
• Human bites
Signs and symptoms
• Excessive tenderness and swelling over the involved knuckle
• Decreased range of motion
• Pus discharge from the wound

Investigations
• Plain X rays
• Microbiology Culture and sensitivity of pus and/or necrotic tissue

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Complications
• Complete destruction of the joint
• Extensive soft tissue destruction

Management
• Opening of the joint and adequate debridement ( As many as required)
• Systemic antibiotics

* Deep space infections of the hand

Description
The hand has three anatomically defined potential spaces and one forearm potential space.
These spaces are the thenar, midpalmar and hypothenar spaces in the hand and Parona’s space
in the forearm. A deep seated infection can involve those spaces

Causes
• Penetrating injuries
• Retained foreign bodies

Signs and Symptoms

• Excessive pain
• Tension and swelling of the hand
• Decreased range of motion

Investigations
• FBC
• MCS (Microbiology culture and sensitivity) of pus and/or necrotic tissue
• US
• X Ray

Complications
• Extension of the infection into the forearm
• Extensive soft tissue destruction
• Frozen hand

Management
• Adequate incision and drainage plus debridement of necrotic tissue
• Systemic antibiotics
• Splinting
• Early mobilization

Tendon Injuries

Definition
A tendon is a fibrous structure that connects a muscle to a bone. A tendon injury is the laceration of a
tendon

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Causes:
• Penetrating injuries
• Traumatic forced extensions
• Pathologic ruptures
Flexor and Extensor tendon injuries will be discussed separately

* Flexor tendon injuries

Definition: Laceration or rupture of tendons that flex the wrists and fingers.

Signs and symptoms

• Pain
• Swelling
• Tenderness
• Loss of active flexion of the wrist or fingers
• The finger involved is in extension compared to the other fingers
• Presence of laceration on the volar aspect of the forearm, wrist, hand or fingers
• Look for loss of sensation to exclude associated nerve injury
• Check for perfusion to exclude associated arterial injuries

Investigations
• Plain X rays to exclude associated fractures
• FBC

Management
• Before transferring the patient to a hand or orthopedic surgeon do the following;
o Saline wash of the wound
o Removal of foreign bodies
o Dress the wound and put the hand in a volar splint
• Exploration of the laceration and repair ruptured tendons
• Postoperative hand protocol for flexor tendon injuries

Complications
• Arterial injuries
• Nerve injuries
• Infections
• Rupture of repaired tendon
• Adhesions
• Late flexion deformity

* Extensor tendon injuries

Definition: Laceration or rupture of tendons that extend the wrists and fingers.

Signs and symptoms

• Pain
• Swelling
• Tenderness
• Loss of active extension of the wrist or fingers
• Presence of laceration on the dorsal aspect of the forearm, wrist, hand or fingers

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Investigation
• Plain X rays to exclude associated fractures
• FBC

Management
• Before transferring the patient to a hand or orthopedic surgeon do the following;
o Saline wash of the wound
o Removal of foreign bodies
o Dress the wound and put the hand in a volar splint
• Exploration of the laceration and repair of ruptured tendons
• Postoperative hand protocol for extensor tendon injuries

Complications
• Arterial injuries
• Nerve injuries
• Infections
• Rupture of repaired tendon
• Adhesions

Nerve injuries

Definition: Rupture or contusion of nerves

Causes:
• Penetrating injuries
• Compression neuropathies

Signs and symptoms

Will depend on which nerve is involved and at which level is injured
• Numbness
• Pain
• Weakness
• Twitching
• Sensitivity
• Paralysis:
o High radial palsy: Loss of extension of wrist and fingers
o Low radial palsy: extension of wrist is preserved
o High median palsy
• Paralysis of long flexors of the thumb, index and middle finger
• Loss of thumb opposition
• Paralysis of pronator teres
o Low median palsy
• Power loss of thumb opposition
• Loss of skin sensation to the palmar surfaces of the thumb, index and middle
finger
o Low ulna palsy
• Paralysis of most of intrinsic muscles of the hand causing:
- Loss of adduction and abduction of fingers
- Loss of precision movement of fingers
- Loss of sensation to ring and little fingers
- Clawing deformity
o High ulna palsy: It is like low ulna palsy except that there is no clawing deformity

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Investigations
• FBC
• Plain X rays
• EMG (Electromyography)

Management
For non-penetrating injuries, follow up patients for 3 months to rule out neuropraxia that will
recover spontaneously;
For penetrating injuries, if nerve injury is suspected, refer the patient to a unit that can explore
the wound and repair damages.

Complications
• Associated arterial injuries
• Paralysis
• Neuromas
• Hyper or hyposensitivity

Vessel Injuries

Definition: Laceration to the arterial supply of the hand or fingers

Causes:
• Penetrating injuries
• Fractures

Signs and symptoms

• Profuse bleeding
• Pain
• Compartment syndrome
• Sluggish capillary filling
• Cold hand
• Loss of sensation (associated nerve injury)

Investigations
• FBC
• Plain X ray

Management
What to do in case of profuse arterial bleeding:
• Follow ATLS protocol
• Elevate the hand
• Put a tourniquet proximal to the laceration
• Explore the wound or put a compressive dressing just on the spot that is bleeding just enough
to control bleeding
• Remove the tourniquet
• Take the patient to theater for selective ligation of the artery or its repair
If compartment syndrome is suspected, do compartment release with appropriate fasciotomy.

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Complications
• Associated nerve injuries
• Compartment syndrome
• Loss of hand or finger (Gangrene)

Skin defects

Definition: Loss of skin tissues

Causes:
• Burn
• Trauma
• Tumor excisions
• Debridement

Signs and symptoms

• Assess the size of the defect
• Assess the depth of the defect
• Assess whether underlying vital structures are exposed or involved

Management
• If the wound can be closed without compromising the function of the hand or the anatomy of
the hand, do a primary closure
• If a primary closure is not feasible and there is no underlying vital structures exposed, do skin
graft
• If underlying structures are exposed, cover with a flap
• If underlying structures are involved, repair them and cover with a flap

Complications
• Scar contractures
• Damage of vital structures

--|Bone Tumor
A mass of unusual cells growing in a bone and most of them are benign. Causes of bone tumors
include abnormal healing of an injury, inherited conditions and radiation therapy. They can also be
caused by bone cancer or another cancer that has spread to the bone from other parts of the body:
Metastases. The danger of bone tumors is that they can be painless masses. Some people, however,
have dull, aching pain. Sometimes, a bone tumor is found during an investigation of minor injury that
caused a fracture.

Treatments include surgery and radiation, neo-adjuvant chemotherapy and chemotherapy, mainly in
combination.

Investigation: x-rays, CT and MRI are the main investigations are sufficient for diagnosis.

Mnemonics for the differential diagnosis of lucent/lytic bone lesions include:

• Fegnomashic
• Fog machines

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Fegnomashic
• F: fibrous dysplasia (FD) or fibrous cortical defect (FCD)
• E: enchondroma or eosinophilic granuloma (EG)
• G: giant cell tumor (GCT) or geode
• N: non-ossifying fibroma (NOF)
• O: osteoblastoma
• M: metastasis(es)/myeloma
• A: aneurysmal bone cyst (ABC)
• S: simple (unicameral) bone cyst
• H: hyperparathyroidism (brown tumor)
• I: infection (osteomyelitis) or infarction (bone infarction)
• C: chondroblastoma or chondromyxoid fibroma

Fog Machines
• F: fibrous dysplasia (FD) or fibrous cortical defect (FCD)
• O: osteoblastoma
• G: giant cell tumor (GCT) or geode
• M: metastasis(es)/myeloma
• A: aneurysmal bone cyst (ABC)
• C: chondroblastoma or chondromyxoid fibroma
• H: hyperparathyroidism (brown tumor)
• I: infection (osteomyelitis) or infarction (bone infarction)
• N: non-ossifying fibroma (NOF)
• E: enchondroma or eosinophilic granuloma (EG)
• S: simple (unicameral) bone cyst

These lists are not exhaustive (e.g. intraosseous lipoma is omitted)

Central Nervous System Disorders

--|Spinal cord injuries
General Considerations

Definition
physical trauma to the spinal cord from craniocervical junction to the sacrococcygeal region. It may
be complete or partial.

Complete: There is no neurological function below the level of the lesion.

Partial: There is preservation of some neurological function which may be motor, sensory or both.
Cervical cord injuries are divided into two; High cervical and low cervical injuries.
High cervical injuries are from C3 and above and are associated with high mortality rates due to cut
off of phrenic nerve (C3, 4 and 5 that results in respiratory failure)
Low cervical injuries are from C5 and below
Spinal shock is transient loss of neurological function and evidence is flaccid paralysis and areflexia
that may last up to 2 weeks

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Causes:
• Trauma
• Tumors
• Infections
• Vascular conditions

Signs and symptoms

Complete:
• High cervical injury; most of the patients will die at the scene of the accident because of
respiratory failure.
o Gasping for air
o Urinary retention
o Reduced GIT function
• Low cervical injury
o Low BP due to sympathetic cut off
o Abdominal breathing
o May have Upper limb function e.g. injury at C7 will be able to lift arms
o Extremities are warmer than usual with dilated vessels
Partial:
Partial Cord injuries are composed of the following syndromes:
• Central cord syndrome: Greater motor deficit in upper limbs than lower limbs
• Brown Sequard (Cord hemisection) syndrome: motor paralysis and loss of proprioception
and vibratory sense ipsilateral to the lesion with loss of pain and temperature sensation
contralateral to the lesion 1 or 2 segments below
• Anterior cord syndrome: Loss of motor function with preservation of proprioception and
vibratory sensation
• Posterior cord syndrome: Loss of proprioception and vibratory sensation with preservation of
motor function
Investigations
• FBC, CRP and ESR (when suspecting infection)
• X-rays and CT scan may show the bony cause of spinal cord injury
• Investigation of choice is MRI

Management
• For spinal trauma manage according to ATLS (Adult trauma life support)
• Put hard cervical collar,
• Hard board for thoracic and lumber suspected injuries (Prevent pressure sores)
• For Blunt trauma give Methyl prednisolone 30mg/kg IV for 30min and rest for 30min give
5mg/kg/hr 23hrs for those seen within first 5hrs of injury and for 48hrs for those seen between
5 -8 hrs of injury
• Patients should have immediate decompression and stabilization (fusion) where there is cord
compression by a neuro surgeon or Spine orthopedic surgeon

Complications
• DVT which may lead to Pulmonary embolus: initiate prophylactic anticoagulation asap,
sequential compression device (SCD), compressive stocks
• Pressure sores: position change, pressure matelas
• Respiratory tract infections
• Urinary tract infections

Recommendation:
• Complications are best managed by anticipatory preventive measures

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Spinal fractures and dislocation

Definition
Refers to disruption of vertebra column caused by physical trauma. Fractures may be stable or
unstable.
Stable fractures are those with minimal or no risk of neurological damage whereas unstable
fracture are those with high likelihood of neurological damage with slight movement.

Causes
• Fall from height
• Motor accidents
• Sports injuries
• Projectiles

Specific types of fractures

• C1 - Jefferson
• C2 - Odontoid fractures (Types 1,2and 3)
• Hangerman’s fractures
• Subaxial spinal injuries
o Single facet dislocation
o Bifacet dislocation
• Thoracic
o Upper
o Middle
o Thoraco-lumbar
• Lumbar
o Wedge compression fractures
o Burst fractures
o Fracture dislocations
o Seatbelt fractures

* C1 Fractures
There are three types of C1 fractures, types I to III, the most common is type II (Jefferson)
JEFFERSON:

Definition: It is a burst fracture of C1 ring; at 2 or more points on C1 ring

Causes:
• Loading force directly over the head (in neutral position)

Signs and symptoms:

• History suggestive
• Neck pains
• Neurological deficits are rare

Investigations:
• X Ray of C spine
• C T scan (best choice)
• MRI

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Management:
• Analgesia
• Hard collar or SOMI brace (Sternal Occipital Mandibular immobilization)
• Surgical intervention indicated when there is disruption of transverse ligament

* Fractures
Odontoid fractures:
• Type 1: fracture through the tip
• Type 2: fracture through the base of odontoid
• Type 3: involves both odontoid and body of C2

Causes:
• Fall from height
• Motor accidents
• Sports injuries
• Projectiles

Signs and symptoms:

• High posterior cervical pain sometimes radiating to occipital region
• Paraspinal muscle spasm
• Reduced range of motion of the neck
• Tenderness to palpation over the upper cervical spine
• Tendency to support the head with the hands
• Paraesthesias in upper limbs

Investigations:
• C – X ray with open mouth views
• CT scan

Management:
• Type1. The commonest is immobilization with SOMI brace or hard collar. Sometimes needs
surgery because of associated ligamentous injury
• Type 2. If there is displacement more than 4mm needs surgery
• Type 3. Treated by immobilization with SOMI brace or hard collar for 6 -12 weeks

* Hangerman’s fractures:
Description: Bilateral fracture through the pars interarticularis with traumatic sublaxation on C2
and C3, most of them are stable with no neurological deficits. It has three types; type1, type2,
type 3 (Levine classification) type 1 is stable, types 2 and 3 are unstable

Causes
• Fall from height
• Motor accidents
• Sports injuries
• Projectiles

Signs and symptoms

• Neurotically intact if any they are minor
• Neck pain
• Commonly associated with head and cervical injuries

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Investigations
• X rays
• CT scan with CTA (CT angiography)
• MRI/MRA (MR angiography)

Management
• SOMI brace or hard collar for 8- 14 weeks
• For Type 2 may requires closed reduction with external immobilization
• Type 3 requires ORIF

* Sub axial spinal injuries (from C3 – C7)

Types:
• Unifacet sublaxation (Jumped facet)
• Bifacet sublaxation

Unifacet sublaxation:
Discription: Commonly associated with less neurological deficit, the affected facet has its capsule
disrupted

Causes
Flexion + rotation of the neck

Signs and symptoms:

• Neck pain
• Neurological deficit

Investigations
• C – spine Xrays
o AP view Spinous process above sublaxation they rotate to the same side of the jumped
facet
o Lateral view shows bow tie sign (Visualisation of left and right facet joint instead of
usual superimposed position
o Oblique view may demonstrate jumped facet blocking neuro foramen
• CT scan shows naked facet sign (reversed Hamburg sign)
• MRI to rule out disc prolapse

Management:
• Initial treatment may be open or closed reduction

Bifacet sublaxation:
Descriptions: occurs with disruption of ligaments of apophysial joints, ligamentum flavum, longitudinal
and interspinous ligaments and annulus, most common at C5/ C6 or C6/C7, associated with 65- 87%
complete quadriplegia

Causes: Caused by hyperflexion of the neck

Signs and symptoms:

• Associated with 65- 87% complete quadriplegia
• 15-25% may have incomplete quadriplegia

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Investigation
• C spine Xray (Lateral view showa vertebral body over the adjacent one)
• CT scan
• MRI to rule out prolapsed disc

Management
• Closed reduction by putting patient on prolonged tongs traction
• ORIF

Spinal cord injury without radiographic abnormality (SCIWORA)

Description
It happens in a subgroup of children with neurological deficit but radiographic investigations show no
abnormality (Both static and dynamic). This is attributed to normally increased elasticity of the spinous
ligaments and intervertabral soft tissues in young population

Causes
• Fall from height
• Motor accidents
• Sports injuries
• Projectiles

Signs and symptoms:

• Gasping for air
• Urinary retention
• Reduced GIT function
• Low BP due to sympathetic cut off
• Abdominal breathing
• May have Upper limb function eg injury at C7 will be able to lift arms
• Extremities are warmer than usual with dilated vessels

Investigations:
• MRI is the investigation of choice

Management
• Commonly supportive
• Surgical intervention has shown no improved outcome

Thoracic spine Fractures

The thoracic canal is smaller compared to other spinal regions making it more vulnerable to even
a small compressive lesion. Having a ribcage makes it more rigid and less susceptible to unstable
fractures
Commonly associated with chest injuries

Causes:
• Fall from height
• Motor accidents
• Sports injuries
• Projectiles
Signs and symptoms:

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• Bruising around the area

• Tenderness on affected area
• Bump along the spine
• Partial or complete paraplegia
• Bladder and bowel dysfunction

Investigation:
• Thoracic X rays
• CT thoracic spine
• MRI

Management
• Initial assessment and management according to ATLS
• Definitive treatment in specialized centres

Thoracolumbar spine fracture

Thoracolumbar fructure is a transition zone between the rigid thoracic spine and mobile lumbar spine.
It is between T10 to L2. This is among the most commonly susceptible regions to fractures

Common Types of fractures:

• Compression fractures
• Burst fractures
• Seat belt fractures
• Fracture dislocation

* Compression fractures
Definition: it’s a wedge compression of anterior part of vertebral body

Causes:
• Flexion injury to thoraco-lumbar region

Signs and symptoms:

• Bruising around the area
• Tenderness on affected area
• Bump along the spine

Investigation:
• Plain thoracolumbar X-rays (AP &Lateral Views)
• CT Scan

Management:
Indications for surgery
• Wedge pointing
• Excessive Kyphosis
• When there are 2 or more contiguous fractures
• if there is any neurological deficit
• progressive kyphosis
Recommendations:
• Bed rest

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• Analgesia
• TLSO (Thoracolumbar sacral orthosis)

Spinal Burst Fractures

Description: there is a pure axial loading force leading to compression of the vertebral body.
Causes:
• Fall from height
• Motor accidents
• Sports injuries
• Projectiles

Signs and symptoms:

Will depend on patency of the spinal canal
• Severe pain
• Tenderness to palpation
• Bruising
• May or may not have Neurological deficit (50 % of patients will remember some form of
neurological dysfunction, that subside during transfer to hospital

Investigations:
• X Rays
o Lateral xrays show; cortical fracture of posterior VB
o retropulsion of bone fragments into canal
o AP View show increase in interpeducular distance, laminae fractures, spraying of facet joints
• CT scan
• MRI

Management:
• Manage according to ATLS protocol
• Specialized surgical intervention

Spinal seatbelt fractures

Definition
It’s a flexion injury sustained on a fulcrum that may be bony, ligamentous or both.
Has four subtypes; type I is Chance fracture (purely through bone)

Causes:
• Seatbelt injury
• Fall from height
• Motor accidents
• Sports injuries
• Projectiles

Signs and Symptoms:

• Severe pain
• Tenderness to palpation
• Seatbelt bruising
• Abdominal injuries
• May or may not have neurological deficit

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Investigations
• X rays
• CT scan
• MRI

Management
• Manage according to ATLS
• TLSO in extension for patients with no neurological deficit
• Specialized surgical intervention

Spinal Fracture dislocation

Description
It is due to failure of the three columns due to compression, tension, rotation or shear leading to
subluxation or dislocation. It is the worst type of thoracolumbar fractures

Causes:
• Fall from height
• Motor accidents
• Sports injuries
• Projectiles

Signs and symptoms

• Severe pain
• Tenderness to palpation
• May have abdominal injuries
• Neurological deficit

Investigation
• X rays
• CT scan
• MRI

Management
• Manage according to ATLS
• Specialized surgical intervention

Cauda Equina

Definition
It is a clinical condition arising from dysfunction of multiple lumbar and sacral nerve roots compression
within lumbar spinal canal. Usually due to compression of cauda equina.

Causes:
• Massive herniated lumber disc
• Tumors
• Free fat graft following discectomy
• Trauma
• Spinal epidural hematoma
• Infection eg epidural abscess, septic thrombophlebitis

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• Neuropathy (inflammatory or ischemic)
• Enkylosing spondolytis

Signs and symptoms

• Sphincter disturbance
• Saddle anesthesia
• Significant motor weakness (usually involves more than a single nerve root if not treated may
progress to paraplegia)
• Bilateral absence of Achilles reflex
• Low back pain and/or Sciatica usually bilateral
• Sexual dysfunction

Investigation
• Infection screening
• Xray
• CT scan
• MRI

Management
• Refer immediately for surgical intervention in specialized centers in case of compression,
which must be performed within 24hrs
• Conservative management in case of inflammatory and ischemic neuropathies

Complications:
• Paraplegia
• Persistent sphincter dysfunction
• Pressure sores
• Urinary infection
• DVT

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--| Cerebral vascular diseases

(Spontaneous haemorrhage)
Intracranial hemorrhage may be Subdural, subarachnoid and intracerebral (intra parenchymal)
Subdural hemorrhage is discussed under traumatic causes of intracranial hemorrhages

Intracerebral Hemorrhage

Definition
It is a hemorrhage within brain parenchyma, commonly referred to as hypertensive hemorrhage, second
most common form of strokes (15-30%) but most deadly. Occurs at Common sites for hypertensive
bleeds (putaminal, thalamic, cerebellar and lobar)

Causes/Risk factors:
• Age (> 55yrs)
• Gender common in females
• Previous stroke
• Alcohol consumption
• Drug abuse
• Cigarette smoking
• Liver dysfunction

Causes:
• Chronic poorly treated hypertension
• Amyloid angiopathy
• Ischaemic transformation
• Rupture of an aneurysm
• AVM (Arterio Venous malformation)
• Coagulopathies
• Tumors
• Idiopathic

Signs and symptoms:

• Headache of sudden on set
• Gradual neurological deterioration ( consciousness, slurred speech, extremity weakness)

Causes:
• Hypertension
• Trauma

Investigations
• Coagulation screen (LFTs, PI/PTT or INR etc)
• RFTs
• Glycemia
• ECG
• CT scan without contrast
• CT angiography in suscipicious cases (AVM, aneurysm)
• MRI (Not very necessary in acute phase)

Management
• Manage according to ACLS (Advanced cardiac life support)

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• Manage specific to cause
o Anuarysm (see Sub Arachnoid haemorrhage (SAH))
o AVM; do clipping or embolization or both
• Control hypertension by 20% of initial systolic pressure
• Admit comatose patients to ICU (GCS = 9 < from 13-10 to HDU)
• Control and maintain Euglycemia, Euvolaemia
• Normal temperature
• Anticonvulsants
• Medical Control of intracranial hypertension

Guidelines for considering surgery versus medical management:

• Non surgical
o Minimally symptomatic lesions (GSC >10)
o Situations with little chance of good outcome such as poor prognostic factors; renal failure
, heart failure, poor neurological dysfunction etc
o Severe coagulopathies
o Basal ganglia or thalamic hemorrhage
• Surgical
o Lesion with marked mass effect, oedema, midline shift
o Lesions where symptoms appear to be due to increases ICP
o Volume of hematoma (Types minor < or = 10mls, moderate 10-30mls, severe > 30mls)
surgery is indicated for moderate volumes
o Cerebellar hematomas surgery is indicated for hematomas > or = 3cm in widest diameter
o Failure of medical management
o Rapid deterioration regardless of hematoma location and size.
o Favorable location eg lobar, cerebellar, external capsule and non dominant hemisphere
o Age less than 50yrs
o Early intervention (less than 24hr)

Subarachnoid Hemorrhage

Description: It occurs as a result of bleeding from aneurismal rapture in 5% from perimesencephalic

Causes/Risk factors:
• Hypertension
• Smoking
• Excessive alcohol consumption

Signs and Symptoms:

• Sudden onset headache (Described as the worst headache of my life
• Nausea and vomiting
• Photophobia
• Neurological dysfunctions
• Seizures

Investigation
• Coagulopathy screen
• CT Scan without contrast

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• CTA

Management:
Management is based on grade of patient.

PATIENT GRADING

Table 1. WFNS SAH grading

11. Grade 12. GCS 13. Focal neurological deficit 14. Modified WFNS
15. I 16. 15 17. Absent 18. 15
19. II 20. 13-14 21. Absent 22. 14
23. III 24. 13-14 25. Present 26. 13
27. IV 28. 7-12 29. Present or absent 30. 7-12
31. V 32. <7 33. Present or absent 34. 3-6

General measures:
• Fluids additional 3l to the usual maintenance
• Adequate analgesia
• Elevate head to 30 degrees
• Quiet rooms and dim light
• Anticonvulsants
• Stool softeners
• Nimodipine 60mg Per Os 4hrly for 21days or when aneurysm is clipped
• Aneurysm clipping or coiling (specific measure) asap

Complications:
• Vasospasms occurs between day 3 – 14 , Treated with hydration and Nimodipine, do not
initiate hydration before securing the aneurysm
• Rebleeding on day 1, 15%, by 1 month 40%, after 6months 3%
• Hydrocephalus which can occur immediately or after 15-20%
• Delayed cerebral ischemia
• seizures
• Hyponatremia, hypomagnesemia due to salt wasting
• Cardiac dysfunction: myocardial stun
• Pulmonary complications: respiratory failure, neurogenic pulmonary edema
• Central fever

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--|CNS Infections And Infestations
Brain abscess

Definition: is a pus containing cavity in brain, it goes through stages

Causes:
• Hematogenous spread
• Contagious spread

Signs and symptoms

• Direct inoculation
• Nonspecific signs
• Fever
• Headache
• Nausea
• Lethargy
• Neurological deficit
o Papilloedema
o Seizures

Investigation
• Infection screen
• CT scan with contrast

Complications
• Seizures
• Permanent neurological deficit

Management
Management may be medical alone or medical with surgical drainage/surgical excision

Medical management
• Fluid resuscitation
• Anticonvulsants
• Antibiotics
• ICU admission may be necessary depending on GSC

Subdural Empyema

Definition: collection of pus in subdural space

Causes:
• Hematogenous spread
• Contagious spread
• Direct inoculation

Signs and symptoms

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• Swelling on the fore head (Pott’s puffy tumor)

• Nonspecific signs
• Fever
• Headache
• Nausea
• Lethargy
• Neurological deficit
• Papilloedema
• Seizures

Investigation
• Infection screen
• CT scan with contrast

Complications
• Seizures
• Permanent neurological deficit

Management
Management may be medical alone or medical with surgical drainage

Medical management
• Fluid resuscitation
• Anticonvulsants
• Antibiotics
• ICU admission may be necessary depending on GSC

Cranial Epidural empyema

Description: collection of pus between bone and duramater

Causes:
• Hematogenous spread
• Contagious spread
• Direct inoculation

Signs and symptoms

• Swelling on the fore head (Pott’s puffy tumor)
• Non specific signs
• Fever
• Headache
• Nausea
• Lethargy
• Neurological deficit
• Papilloedema
• Seizures

Investigation
• Infection screen
• CT scan with contrast
Complications:
• Seizures

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• Permanent neurological deficit

Management
Management may be medical alone or medical with surgical drainage
Medical management
• Fluid resuscitation
• Anticonvulsants
• Antibiotics
• ICU admission may be necessary depending on GSC

Neuro Cysticercosis

Definition: it is intracranial encasement of larva of T solium, it is the most common parasitic infestation
in CNS

Mode of transmission:
• Water and food contaminated with Eggs
• Fecal oral
• Auto infection

Signs and symptoms

• Seizures
• Signs of Raised ICP
• Focal neurological deficits
• Subcutaneous nodules

Investigations:
• Serology or CSF (Antibody or antigen of Cysticercosis)
• CT scan or MRI

Management:
• Antihelmentic (eg Albendazole 15mg /kg/d PO in divided or single dose for 21 days or
praziquantel)
• Steroids (eg Dexamethasone 2-4 mg PO 8hrly for 2weeks)
• Anticonvulsants (eg phenytoin 15-20mg /kg as a loading dose and maintenance dose of 5mg/
kg/day for 21 days or as long as seizures are present)
• Surgery; excision of the cyst

Indications for surgery

• Large cysts causing mass effect
• Cysts causing abstractive hydrocephalus

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--|Hydrocephalus in Children
Description
It is a condition that results from when normal exit and absorption of cerebral spinal fluid in the
ventricles is impaired. This leads to progressive accumulation of this fluid in ventricles of the brain,
resulting in progressive damage to the developing brain with associated mental retardation and
visual impairment.

Causes
• Congenital abnormality
• Intraventricular hemorrhage
• Infection
• Head trauma
• Brain tumor

Signs and symptoms

• Accelerated head growth
• The baby’s soft spot (anterior fontanelle) is usually full or bulging, or even tense, due to the
increased pressure inside the head
• Sometimes the baby’s eyes will appear to be looking downward all the time (sunset phenomenon),
or may look crossed.

Investigations:
• Serial measurement of head circumference which shows excessive head growth
• Ultrasound study of the brain can be performed
• CT scan of the brain
• MRI of the brain

Complications:
• Permanent blindness
• Permanent psychomotor disability
• Shunt complication (malfunction)
• Infection

Management:
• Ventriculo-peritoneal shunt insertion is the most commonly used
• Endoscopic third ventriculostomy
• Treatment of the cause in case of obstructive hydrocephalus

--|Myelomeningocele
Definition
Congenital defect in vertebral arches with cystic dilatation of meninges and structural or functional
abnormality of spinal cord or cauda equina.

Risk factors:
• Low folate during female reproductive age
• Obesity
• Smoking
• Alcohol use

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• Anticonvulsants
• Febrile illness, heat exposure, hot tub and sauna during first trimester
• Genetic
• Young age

Signs and symptoms

• Non skin covering spinal defect with fluid containing cyst
• Neurological dysfunction below the level of lesion
• Lower limb deformities such as club feet
• Chiari type 2 malformation and hydrocephalus may be associated

Investigation
• Prenatal
o Amniocentesis
o Ultrasound
• Postnatal
o CT scan
o MRI

Management
• Early closure of myelomeningocele defect by a trained surgeon
• Infection prophlaxis with ceftriaxone or cetaxime and gentamycin immediately for 1 week
• Covering of spinal defect with a sterile saline soaked gauze which can be changed as needed
• Monitor head circumference and anterior fontanel for possible development of hydrocephalus

Complications
• Permanent neurological deficit
• Pressure sores
• Urinary tract infection
• Meningitis
• Ventriculitis
• Hydrocephalus

--|Head Injury
General Overview

Definition: Head injury is physical trauma to the head

It is broadly classified into 2 entities;
• Open head trauma in which there is a scalp laceration with underlying skull fracture and
breached duramater (i.e.) brain communication to the outside environment
• Closed head injury - there is no communication with the outside environment.
• It can also be classified by severity into mild, moderate and severe head trauma depending
on the level of consciousness.
Causes
• Motor Vehicle Accidents (MVA)
• Pedestrian Vehicle Accident (PVA)
• Assault injuries
• Fall from heights
• Sports injuries
• Missile injuries e.g. gunshot wounds.
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Signs and symptoms

• Deterioration of level of consciousness (GCS)
• Seizures
• Vomiting
• Headache
• Evidence of skull base fracture such as :
o Racoon eyes (peri-orbital ecchymoses),
o Battles sign which are post auricular ecchymoses,
o CSF rhinorrhoea
o Otorrhoea
o Haemotympanium
• Wounds or hematoma on impact site
• Focal neurological deficit such as hemiplegia

Severity Assesment of Head Trauma

• Divided into 5 categories:
• Minimal: here GCS =15,no Loss of consciousness (LOC)
• Mild: GCS = 14 or GCS = 15 with either brief LOC of < 5 mins, or impaired alertness or
memory.
• Moderate: GCS=9-13 or LOC > 5mins or Focal Neurological Deficit.
• Severe: GCS =5-8
• Critical: GCS = 3-4

Investigation
• RBG, FBC, PT, PTT, Blood Grouping and Cross Matching
• Urea and Electrolytes
• Toxicology screening eg alcohol, illicit drugs screening
• Arterial Blood Gas Levels are very important.
• Skull X- ray to look for fracture
• Brain CT scan

Management
• The Primary goal of therapy is to prevent secondary brain injury that is done by maintaining
adequate perfusion and ventilation.
• After following ATLS guidelines for management of trauma patients, management follows the
severity of the head trauma.

Mild Head Trauma:

• Bed rest with head off bed (HOB) elevated to 30-45 degrees.
• Neuro checks every 2 hrs or 1 hr if more concerned.
• NPO until alert, then clear fluids and advance to other foods as tolerated.
• Isotonic IV fluids mainstay being N/Saline running at usually 100mls/hr
• Mild analgesia: paracetamol PO or PR if NPO.

Moderate Head Trauma:

• As in minor above but always keep NPO in case surgical intervention is needed.
• GCS 9-12 ADMIT to ICU, GCS 13 ADMIT IF CT shows any significant abnormality.
• Patients with normal or near normal CT-Scans should improve within hours. Any that fails to
reach GCS 14-15 with in 12 hrs should have a repeat CT at that time.

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Severe And Critical Head Injury:
These usually have co- systemic injury.
They are admitted to ICU and the first priority is to look for any features of Intra Cranial Hypertension
(IC-HTN) which are:
• Unilateral or bilateral pupillary dilatation
• Asymmetric pupillary reaction to light
• Decerebrate or Decorticate posturing
• Progressive deterioration of neurological sign not attributable to extra cranial factors.
When one or more of these signs is witnessed in evolution, that’s convincing evidence of IC-HTN
These patients have to be:
• Intubated; with a GCS of 8 or less it’s assumed one cannot keep his airway patent. Patients
with severe maxillofacial injury will also need to be given a tracheostomy

• Hyperventilation; only when a patient has CT and clinical features of IC-HTN should they
be hyperventilated, and the PCO2 should be between 30-35 mmHg and should never drop
below 30mmHg - this is a temporalising measure awaiting definitive treatment for the IC-HTN
• Paralysis and Sedation; only when there is evidence of IC-HTN should there be paralysis and
sedation.

• Mannitol ; is given only in cases of:

o Evidence of IC-HTN
o Evidence of mass effect e.g. focal deficits like hemi paresis
o Sudden deterioration prior to CT-Scan
o If a lesion associated with increased ICP is identified e.g. SDH, EDH.
o Asses the salvageability of patients with no evidence of brain stem function (look for
return of brain stem reflexes

It is contraindicated in hypotension (map 70mmhg) but remember that when one is resuscitated and
the BP is acceptable then mannitol can be given.
Mannitol should be used with caution in patients with clotting disorders because it affects coagulation,
and in congestive heart failure patients because it increases intravascular volume before it causes
diuresis

Dose: bolus with 0.25 – 1gm/kg over 20mins.

Remember Steroids (dexamethasone, hydrocortisone) have no place in management of acute head
injury.

Prophylactic Anti-Epileptic Drugs:

Given when there is increased risk of Post Traumatic Seizures namely:
• Acute SDH, epidural and intracerebral haematoma.
• Open depressed skull fractures with parenchymal injury.
• Seizure within the first 24 hrs of injury.
• GCS less than or equal to 10.
• Penetrating Brain injury
• History of significant alcohol intake
• Cortical (hemorrhagic) contusion on CT-Scan.

Preferred drug is PHENYTOIN (EPANEUTIN) loading dose of IV drug 18mg/kg in 200mls of N/Saline
to run within 30mins for the 1st 24 hrs then maintenance of 5mg/kg daily on subsequent days.
Surgery: Is indicated to evacuate any haematomas that are the cause or potential cause of IC-HTN
and is only done when the patient has been stabilized.

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Complications:
• Post-traumatic seizures
• Permanent neurological disability
• Post-traumatic hydrocephalus
• Post-concussion syndrome
• Infection eg Menengitis, brain abscess, chronic osteitis etc
• Chronic traumatic encephalopathy

Subdural hematoma
It is a collection of blood between duramater and arachnoid layer. It is subdivided into acute (<
72hrs) Subacute (between 72hrs and 3 weeks) and Chronic (> 3weeks).
The most commonly seen are acute and chronic subdural hematoma

Acute subdural hematoma

Cause:
• Fall
• Motor vehicle accident
• Assault
• Child abuse (shaken baby syndrome)

Signs and symptoms

• Coma, vomiting
• Brain herniation signs such as dilated ipsilateral pupil
• Hemiparesis

Investigations
• Fundoscopy in case of shaken baby syndrome(Retinal hemorrhage can be evidenced)
• CT scan (to visualize crescentic hematoma and midline shift)

Management
• General management of head injury
• Indications for surgery
o Subdural hematoma thickness greater than 10mm
o Midline shift greater than 5mm as seen on CT scan
o Less of the above but with decreasing of GCS between the time of injury and hospital
by 2 or more points or fixed and dilated pupils and or ICP exceeds 20mmHg

Chronic Subdural Hematoma

Causes:
• Minor head injury or fall often not remembered by patients or relatives

Risk factors:
• Old age
• Alcohol abuse
• Seizures
• Cerebral spinal fluid shunts
• Anticoagulation

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Signs and symptoms
• Headache
• Nausea
• Vomiting
• Hemiparesis
• Language disturbances
• Gait problems
• Transient ischemic attack like symptoms
• Decreased consciousness
• Sphincter disorder
• Bilateral papilloedema on fundscopy

Investigation
• Coagulation screening
• ECG
• CT scan which shows hypo or isodense fluid collection in crescentic shape and midline shift
• MRI

Management
Stabilization of patients according to ACLS protocol
Commonly surgery by a trained surgeon

Epidural Hematoma

Definition
It is a collection of blood between the skull and the duramater and it is caused rupture of artery and
vein in epidural space as a result of a fracture of the skull at the moment of the impact in 60-90%
of cases

Causes
• Motor Vehicle Accidents (MVA)
• Pedestrian Vehicle Accident (PVA)
• Assault injuries
• Fall from heights
• Sports injuries

Signs and symptoms

• Neurological presentations vary according to the size, location and time course of the
hematoma
• Lucid interval is common
• Vomiting
• Hemiparesis
• Brain herniation syndrome

Investigations
• X ray can show the fracture of the skull
• CT scan can show biconvex shaped hematoma adjacent to the skull

Management
• Initial Management according to ATLS
• Epidural hematoma in posterior fossa and temporal region are especially dangerous
• Surgical treatment is commonly indicated to remove hematoma as soon as possible

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Complications
• Permanent neurological deficit
• Prolonged coma leading to pressure sores, DVT, Pulmonary and urinary infection

Intracranial Hematoma

Definition
Traumatic intraparancymal hemorrhage is commonly associated with brain contusion.

Causes
• Motor Vehicle Accidents (MVA)
• Pedestrian Vehicle Accident (PVA)
• Assault injuries
• Fall from heights
• Sports injuries
• Missile injuries

Signs and symptoms

• Focal neurological deficit according to the sites
• Alteration of consciousness
• Seizures
• Vomiting
• Traumatic lesions on site of impact
• Herniation syndrome

Investigations
• X ray shows bone lesion or intracranial foreign bodies in case of penetrating injury
• CT scan is the investigation of choice

Management
• Initial management is according to ATLS protocol
• Surgery is indicated in ;
o Progressive neurological deterioration referable to the TICH, medically refractory
intracranial hypertension or signs of mass effect on CT Scan
o TICH > 50ml
o GCS = 6-8 with frontal or temporal TICH volume > 20ml with midline shift ≥ to 5mm
and/or compressed basal cisterns on CT
Complications
• Post-traumatic seizures
• Permanent neurological disability
• Post-traumatic hydrocephalus
• Prolonged coma leading to pressure sores, DVT, Pulmonary and urinary infection

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Cardio Thoracic Surgical Conditions
--|Chest Trauma
Simple Rib fracture

Definition: Simple rib fracture is a break in continuity of the rib(s)

Causes:
• Pathological
• Trauma to the chest

Signs and symptoms:

• Chest pain
• Difficulty in breathing
• Chest wall wound (bruise, contusion or laceration)
• Shallow and rapid breathing
• Localized tenderness on palpation
• Altered percussion note
• Reduced breath sound on auscultation
Investigations:
• CXR
• CT scan

Management
• Admit the patient
• Analgesics for pain control
• SC Morphine according patient body weight
• NSAIDs (ibuprofen or diclofenac either oral or per rectal)
• Acetaminophens in case of CI to NSAIDS
• Chest physiotherapy

Complication
• Atelectasis
• Pneumonia

Treatment of complications
• Chest physiotherapy and
• Appropriate antibiotics

Flail Chest

Definition
Segmental fracture of rib cage and the segment is detached from the rest of the chest wall that will
result in paradoxical movement of the chest that may lead to respiratory dysfunction. This is a life-
threatening condition

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Causes:
• Trauma to the chest

Signs and Symptoms

• Chest pain
• Difficulty in breathing
• Paradoxical chest movement
• On inspection; bruising, contusion or laceration of the chest wall
• On palpation; localized tenderness
• On auscultation; reduced breath sounds

Investigation
• CXR
• CT scan

Management:
• Admission
• High flow oxygen by mask
• Position patient on the injured side
• Analgesia
• Restricted fluid administration
• Monitor oxygen saturation
• Intubate if patient not responding
• Admit to ICU for mechanical ventilation

Complication
• Associated injuries (lung contusion, hemothorax, Pneumothorax)
• Pneumonia
• Empyema thoracis

Pneumothorax
Definition
Collection of air in pleural cavity. It can be simple or under tension resulting in pressure on the
mediastinum

Causes:
• Chest trauma
• Spontaneous

Signs and Symptoms:

• Tension pneumothorax
o Chest pain
o Bruising, contusion, Laceration of chest wall
o Severe dyspnea
o Cyanosis
o Mental confusion
o Sweating
o Reduced chest movement
o Displacement of the tracheal and apex beat
o Absent breath sounds on affected side

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o Hyperresonance
o Hypotension
o Jugular venous distension

• Simple pneumothorax
o Chest pain
o Shallow respiration
o Bruising, contusion, Laceration of chest wall
o Reduced breath sounds
o Hyperresonance

Investigations
• Clinical diagnosis for tension pneumothorax
• CXR, CT scan for simple pneumothorax

Management
Tension pneumothorax
• Wide bore cannula in the second intercostal space midclavicular line
• High flow oxygen by mask
• Analgesia for pain
• Monitor oxygen saturation
• Chest tube insertion with underwater seal connection
Simple pneumothorax
• High flow oxygen by mask
• Analgesia
• Monitor oxygen saturation
• Chest tube insertion under water seal connection

Complications
• Collapse lung
• Lung contusion
• Pneumonia

Hemothorax

Definition: collection of blood in pleural space

Causes:
• Chest trauma

Signs and symptoms

• Chest pain
• Bruising, contusion, Laceration of chest wall
• Dyspnea
• Sweating
• Hypotension
• Diminished breath sound
• Dullness on percussion

Investigation
• CXR
• CT scan

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Management
• High flow oxygen by mask
• Analgesia
• Chest tube insertion under water seal connection
• May transfuse
• Ideally Thoracotomy may have to be done if initial drainage is more than 1.5 L of blood or
if active drainage is more than 200 ml/ hr. (for 4 consecutive hours); transfer the patient at a
higher level hospital for surgical management)

Cardiac tamponade

Definition
Collection of blood in pericardium causing cardiac dysfunction

Causes:
• Chest trauma

Signs and symptoms

• Chest pain
• Bruising, contusion, Laceration of chest wall
• Congestion of neck veins
• Hypotension
• Severe dyspnea
• Mental confusion
• Distant muffled heart sound
• On ECG there is electrical alternans
• Pulsus paradoxicus
• FAST (focused abdominal sonography in trauma); pericardial effusion

Investigations
• CXR
• CT scan
• ECG

Management
• High flow oxygen
• Analgesia
• Pericardiocentesis (sub xyphoid approach)

Lung contusion

Definition: inflammation of the lung following the chest injury

Causes: chest trauma.

Signs and symptoms:

• Chest pain
• Bruising, contusion, Laceration of chest wall and rib fractures
• Dyspnea
• Reduced breath sound
• Dullness on percussion
• Hemoptysis

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Investigations
• CXR
• CT scan

Management
• High flow oxygen
• Analgesia
• Restricted fluid administration
• Monitor oxygen saturation
• Intubation and mechanical ventilation if not responding to the above
• May require chest drainage if associated pneumothorax and hemothorax.

Ruptured diaphragm

Definition: a tear in the diaphragm which allows protrusion of abdominal organs in the chest
Causes:
• Trauma

Signs and symptoms:

• Asymptomatic
• Abdominal and chest pain
• Dyspnea
• Hypotension
• Decreased breath sound
• Dullness on percussion
• Bowel sound in the chest

Investigations
• CXR
• CT scan

Management
• High flow oxygen
• Analgesia
• Surgical intervention after stabilization

--|Lung conditions
Empyema Thoracis

Definition
Collection of pus in pleural cavity. It can be classified as acute, sub-acute and chronic

Causes
• Partially treated pneumonias
• Neglected pneumonias
• Pulmonary tuberculosis
• Hematogenous spread from distant foci
• Post traumatic chest infections
• Perforated oesophagus
• Local spread from sub-diaphragmatic abscess

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Signs and symptoms

Acute empyema thoracis

• Chest pain
• Fever
• Sweating
• Dyspnea
• Coughing
• Underlying chest infection
• Stony dull percussion sound
• Reduced breath sounds
Sub-acute empyema thoracis
• Chest pain
• Dyspnea
• Cough
• Fever
• Underlying chest infections
• Stony dull percussion note
• Reduced breath sounds
• Reduced chest movement
• Chest deformity

Chronic empyema thoracis

• Chest pain
• Cough
• Dyspnea
• Chest deformity
• Reduced chest movement
• Wasting of the chest muscles
• Stony dull percussion note
• Reduced breath sounds
• Chest wall abscess and sinuses
• Finger clubbing

Investigations
• Sputum exam
• CXR
• CT scan
• Bronchoscopy

Management
Acute empyema thoracis
• Thoracocentesis
• Chest tube drainage
Sub-acute empyema thoracis
• Chest tube drainage
Chronic empyema thoracis
• Chest tube drainage and
• Ideally Decortication, if no required expertise on site, refer to a higher level hospital

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Lung abscess

Definition: presence of pus in the lung parenchyma

Causes:
• Inhalation of food particles
• Virulent pyogenic bacterial like Staph Aureus and Klebsiella in a background of immune
compromise

Signs and Symptoms

• Cough
• High fever
• Dyspnea
• Chest pain
• Halitosis
• Weight loss
• Finger clubbing
• Reduced breath sound
• Crepitations
• Dull percussion note

Investigations
• Sputum examinations
• CXR
• CT scan
• Bronchoscopy

Management
• Apropriate antibiotics (e.g. Clindamycin for 3 up to 6 weeks)
• Chest physiotherapy
• Ideally Surgery, if no required expertise on site, refer to a higher level hospital

Pulmonary fibrosis and bronchiectasis

Definition
Fibrosis of the lung following bacterial infection and/or lung abscess

Causes:
• Post pulmonary TB infection
• Pneumoconiosis
• Fungal infections (aspergillosis)

Signs and symptoms

• Cough
• Chest pain
• Dyspnea
• Loss of weight
• Finger clubbing
• Cyanosis
• Chest deformity

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• Wasting of chest wall muscles

• Dull percussion note
• Crepitations

Investigations
• CXR
• Sputum examination
• CT scan
• Bronchoscopy

Management:
• Treat underlying condition (TB, aspergillosis, …)
• Chest physiotherapy
• Symptomatic treatment
• if no required expertise on site, refer to a higher level hospital

Lung cancer

Definition
Malignant growth of the bronchials or parenchyma of the lung. They are divided into two groups:
central and peripheral cancers. There are two commonest histological subtypes: Small Cell Lung
Cancers and Non-Small Cell Lung Cancers.

Risk Factors:
• Environmental/Chemical/infections: Smoking, radiation therapy, air pollution , radon , metals
(arsenic , chromium and nickel), asbestos , CO
• Genetic: Inherited susceptibility variant for lung cancer have been found.
Prevention: Smoking Cessation
Screening: Annual low dose CT scan for

Common Symptoms:
• Symptoms from local tumor effect: cough, hemoptysis, dyspnea, chest pain, hoarseness
• Symptoms from extrathoracic metastases to supraclavicular lymph nodes, liver, adrenals,
bone, brain
• Symptoms from paraneoplastic syndromes: hypercalcemia symptoms, hyponatremia symptoms,
cushings syndrome symptoms, hypertrophic osteoarthropathy symptoms, dermatomyositis/
polymyositis symptoms, neurologic symptoms, hypercoagulable disorders

Common Signs
• Signs from local tumor effect: airway compromise, hoarseness, superior vena cava syndrome,
pancoast syndrome
• Signs from extrathoracic metastases to supraclavicular lymph nodes, liver, adrenals, bone,
brain
• Signs from paraneoplastic syndromes: hypercalcemia symptoms, hyponatremia symptoms,
cushings syndrome symptoms, hypertrophic osteoarthropathy symptoms, dermatomyositis/
polymyositis symptoms, neurologic symptoms, hypercoagulable disorders

Common Presentations: non resolving pneumonia, cough, hemoptysis, superior vena cava syndrome,
Pancoast syndrome, paraneoplastic syndrome, majority of patients have advanced disease at
presentation.

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Investigations
Laboratory: FBC, LFTs , RFTs , tumor markers
Diagnostic Imaging: CTscan, MRI, PET scan
Diagnostic Procedures:
• Tissue diagnosis with sputum cytology, bronchoscopy, percutaneous fine needle biopsy,
excisional or needle biopsy as appropriate for the patient
• Bronchoscopy to biopsy lung lesion
• Mediastinoscopy to biopsy lymph nodes > 1.0cm short axis on CT scan3 high-risk patients
(>30 pack year smoking history) reduces lung cancer mortality by 20%.

Management
Treatment of lung cancer depends on the stage of the disease. The following are modalities used.
• Radiotherapy
• Chemotherapy
• if no required expertise on site, refer to a higher level hospital

Foreign bodies in the lung

Definition: inhaled or penetrating object in the lung

Signs and symptoms
Inhaled object
• Severe coughing
• Severe dyspnea
• Cyanosis
• Wheezing
• Absent or reduced breath sound
Penetrating objects
• History penetrating trauma
• Cough
• Chest pain
• May be asymptomatic
• Reduced air entrance
• Crepitations
• Dull percussion note

Investigations:
• CXR
• CT scan
• Bronchoscopy

Management
• Inhaled foreign body is an emergency (refer to ENT section).
• For penetrating foreign body
o If symptomatic do thoracotomy and removal
o If asymptomatic, reassure patient and follow up

--|Mediastinum Masses
Definition
Space occupying lesions that may be solid or cystic located in the mediastinum compartment.

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Causes:
In the superior compartmental
• Retrosternal goiter
• Intrathoracic goiter
• Thymoma
• Lymphoma

In the anterial compartment

• Lipoma
• Lymphoma
• Pericardial cyst
• MORGARGNI’S hernias

In the middle compartment

• Aneurysm of the ascending aorta
• Ventricular aneurysm

Posterior compartment
• Neurogenic tumors
• Enteric cysts
• Lymphomas
• Lymphadenopathies
• Bronchogenic tumors
• esophageal tumors

Signs and symptoms

Signs and symptoms will depend on the type of lesion and location in the mediastinal compartments
Investigations
• CXR
• CT scan
• MRI
• Bronchoscopy
• Mediastinoscopy

Management
Management will depend on the type of lesion and mediastinal compartment affected
if no required expertise on site, refer to a higher level hospital

--|Congenital Diaphragmatic hernias

Definition
It is the herniation of abdominal viscera into the chest cavity through a congenital defect of the
diaphragm.
There are two types:
• Posterolateral hernia (Bochdalek hernia)
• Anterior Hernia (Morgagni’s Hernia)

Causes:
• Unknown

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Signs and symptoms
Bochdalek hernia
• They manifest at birth
• Severe dyspnea
• Cyanosis
• Failure to feed
• In drawing of the chest
• Bowel sounds heard in the chest
• Reduced or absent air entrance
• Displacement of the apex beats to the right
Morgagni’s hernia
• It may be asymptomatic
• Symptoms of intestinal obstraction
• Dyspnea
• Recurrent tachycardia

Investigations
• CXR
• Gastrograffin swallow
• Abdominal X ray
• CT scan

Management
• High flow Oxygen by mask
• Intubation and ventilation
• Surgery

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Abdominal Injuries
--|General Overview
Definition: It is an injury to the abdomen, it may be blunt or penetrating and it may involve damage
of abdominal organs

Causes
•Blunt: Road traffic accidents, Falls, Sports injuries
•Penetrating: Stab injuries, Bullet and blast injuries

Clinical features
• Initial abdominal exams are often normal and may be initially asymptomatic
• Pain and tenderness increase and spread from the injury site to the other parts of the abdomen,
frequently the entire abdomen
• The abdomen becomes tender, distended, and rigid
• Bowel sounds disappear
• The patient becomes progressively sicker, develops fever, and usually vomits
• Patient may fall into shock
• Respirations are shallow and rapid because it hurts to breathe deeply
• Abdominal pain is increased by moving, straightening the knees, or taking a deep breath
• The patient frequently prefers to lie quietly on his back or side with the knees flexed

Principles of management of abdominal injuries

•Primary survey and Resuscitation phase: The primary survey should identify immediate life-threatening
injuries. (C-ABCD trauma management approach). The primary survey and resuscitation of the
patient should be done SIMULTANEOUSLY.

C. Ensure the control and stopping of a catastrophic hemorrhage even before airway control.
A. Ensure an adequate airway with cervical spine protection until fractures are excluded
(immobilization). Establish a definitive airway for GCS below 8 or hemodynamically unstable.
B. Ensure adequate breathing and administer O2 support if necessary and assisted ventilation
if required; rule out tension pneumothorax /manage it with needle decompression THEN tube
thoracostomy.
C. Arrest any external bleeding by direct pressure and restore organ circulation by putting
2 large peripheral IV lines and start with a bolus of 2-3L of IV Fluids then maintenance. If
required, administer type specific or O-negative blood if no/inadequate response to fluid
resuscitation. Send blood for type and crossmatch.
D. Disability and Neurological assessment with GCS score for level of consciousness. Treat
hypoxemia and shock, and evaluate intracranial space occupying lesion
E. Expose and undress the patient to evaluate all potential other injuries; and prevent hypothermia
•Secondary survey: Assessment of injury (Detailed history and care full physical examination from
head to toe/front and back, the mnemonics SAMPLE helps in evaluating systematically the patient)
(S-Signs & Symptoms, A-Allergies, M-Medications, P-Past medical Hx, L-Last meal, E-Events &
Exposure)
• Ensure early detection and decision making on Blunt abdominal injuries (Cfr Decision algorithm
below)
• Ensure if abdominal injury is penetrating (Fascia compromise) or blunt (simple/complex wall
laceration but without fascia compromise/opening)
• Ensure absence of peritoneal signs (Generalized peritonitis with high suspicion of hollow viscus

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perforation)
• Ensure hemodynamic stability, rapid clinical deterioration, dropping Hemoglobin, increasing
abdominal distension (hemoperitoneum)
• Treat shock (Cfr chapter on critical care)
• Place Nasogastric tube for drainage and abdominal decompression, and urinary catheterization
for UOP monitoring
• take the sample for FBC, Urea, creatinine, electrolytes, Blood glucose, pregnancy test (if female
childbearing)
• Ensure Oxygen supply
• Adequate pain killers
• Close monitoring of vital signs
• Do e-FAST (extended Focused assessment with sonography for trauma)
• Do trauma work-up as per indication (Formal abdominal US, upright Abdominal xray, Chest xray,
Cervical xray, or if indicated Abdominal CTscan with or without IV contrast). Unstable patients
should not be sent to radiology.
• do all differentials diagnoses, and after workups and clinical exam, confirm/Propose a working
diagnosis
• Discuss the management: conservative/non-operative or Surgery
• If Surgery, Inform theatre team to be ready accordingly, Always inform family members and sign
consent form
• If non-operative management, Adjust the required management, plan serial abdominal
examination, ensure good rehydration and analgesics, admit to the adequate disposition (General
ward or HDU)
• Remember forensic issues (police investigation in case of weapons)

Blunt Abdominal trauma:

• Proceed with exploratory laparotomy if: Generalized peritonitis with high suspicion of visceral
injury, Pneumoperitoneum
• Otherwise, do conservative management; HOWEVER, do close monitoring, serial abdominal
examination, control hemoglobin regularly. Do abdominal CTscan if indicated
• Rule out any distracting injury

Blunt Trauma
Hemodynamically Stable?
no yes

Distending Abdomen? Viscous

No Injury Suspected?
DPL or US
_
yes + CT/US/DPL
+ _

Other
Laparotomy Tests Laparotomy Observe

Figure 8. Management of blunt abdominal trauma

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Penetrating Abdominal trauma:

• All abdominal gunshot wounds require exploratory laparotomy. Tangential wounds that do not
penetrate the peritoneal cavity may be assessed by local wound exploration, CTscan, or DPL, or
explorative laparoscopy if the wound is localized on the anterior abdominal wall.
• Explorative laparotomy is required if: abdominal facia has been compromised, evisceration or
pneumoperitoneum, Signs of visceral injury, shock, hypertension, Upper of lower GI bleeding
• Consider tetanus prophylaxis as indicated

Penetrating Trauma WEAPON

Gun/Missile Knife

Peritoneal Signs Peritoneal Signs

_ Shock +
+ Shock
_

Peritoneal + LAPAROTOMY Site of Injury

Transverse?
? + Abd. Low Chest Back

Laparoscopy +
Explore DPL CT
+
_ _
_
Laparotomy _
Observe
Figure 9. Management of penetrating abdominal trauma.

--|Splenic Injury
Most can be managed non-operatively
• 90% of children
• 60% of adults

Management will depend on scale of splenic injury;

• I: Hematoma or Laceration (10% or 1cm)
• II: Hematoma or Laceration (10-50% or 1-3cm bleeding)
• III: Hematoma or Laceration (Active bleeding with trabecular vessels)
• IV: Hematoma or Laceration (Active Bleeding Intraparenchymal or devascularization)
• V: Shattered or Hilar devascularization

Indications for operation

• Preoperatively, Refer to criteria given above (Abdominal injury)

Operative procedure
• Hemostasis surgical methods (Cauterization, temporary compression, Surgicel,
• Splenorrhaphy

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• Splenectomy (if Hemodynamic instability with splenic injury grade (III-V) However, the current
trend is to conserve the spleen as much as possible)
• Damage control and coming back after 24-48H

--|Hepatic Injury
Management will depend on the liver injury scale;
I: Hematoma or Laceration (<10 cm or 1cm depth)
II: Hematoma or Laceration (10-50% surface or 1-3cm depth)
III: Hematoma or Laceration (Bleeding and expanding or >3cm depth)
IV: Ruptured Hematoma with Active bleeding or Parenchymal disruption (75%)
V: Parenchymal disruption >75% lobe or retrohepatic venous injuries
VI: Hepatic Avulsion
Most can be managed non-operatively (grade I and II)

Indications for operation

• Preoperatively, Refer to criteria given above (Abdominal injury)

Operative procedure
• Grade I and II
o Manual compression
o Suture ligature
o Omental patch
o Closed suction drain
o Argon beam coagulation
o Topic hemostatics

• Grade III, to IV
o Definitive treatment or Damage Control
o Resectional debridement
o Perihepatic packing
o Balloon tamponade
o Foley catheter tamponade

--|Pancreatic Injury
Causes:
• Often from direct blow compressing pancreas against vertebral column
• Often accompanied by duodenal injury

Investigations:
• Serial serum amylase levels
• Very difficult to evaluate, even with CT
• ERCP can be helpful

Complications
• Pancreatic pseudocyst
• Duodenal or pancreatic fistula (treat with somatostatin/surgery)

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Management:
• Isolated injury not involving major duct: observation
• Serious injury: often involves duodenum requiring immediate exploration

--|Duodenal Injury
Duodenum
• Often in unrestrained drivers, handlebar injuries
• Suspect with history, blood in NGT aspirate, or retroperitoneal air
• Difficult to diagnose without CTscan

Operative findings
• Upper retroperitoneal hematoma
• Bile leakage

Operative procedure
• Cattel’s maneuver
• Extended Kocherization, assessment of duodenal injuries
• Pyloric exclusion, gastrostomy, jejunostomy

Diaphragm
• Left Hemidiaphragm more commonly injured
• Elevation on CXR, but may be normal
• Difficult to visualize injuries by other means (including CT, MRI)
• Injuries may be missed for years
Management
• Early: Laparotomy, reduce abdominal contents from chest and diaphragmatic repair
• Late: presents as diaphragmatic hernia. Reduce and repair defect in diaphragm

--|Small Bowel Injury

• Can be from penetration or tearing from compression or deceleration
• Think of injury with “seatbelt sign”
• Complete abdominal examination to rule in generalized peritonitis with suspicion of hollow
viscus perforation

Management:
• Immediate surgery
• Resection of devitalized bowel with primary repair, anastomosis, stoma or closure of both
stamps (Damage control and come back after 24-48h for reevaluation and definitive closure)
• Stop mesenteric hemorrhage
• Peritoneal washout, and abdominal wall closure

--|Colon & Rectal Injury

• Resuscitate the patient
• Rule out other life-threatening injuries
• Colon injuries:

Primary repair, anastomosis, colostomy/ileostomy, or damage control

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Rectal injuries:
Diagnosis: Blood on examination glove, Sigmoidoscopy
Intraperitoneal rectal injuries are treated the same as colon injuries
Extraperitoneal rectal injuries (Repair and diverting stoma, presacral drainage, Place two Penrose
drains, Distal rectal washout
• Peritoneal washout, and abdominal wall closure

--|Abdominal Compartment Syndrome

Abdominal compartment syndrome (ACS) is the increase of intrabdominal pressure affecting the
normal function of the contents of that compartment. It is defined as intraabdominal pressure
(IAP) >20 mm Hg that is associated with new organ dysfunction/failure. Elevated IAP has a direct
effect on nearly every body system, including the pulmonary, cardiovascular, renal, neurologic,
and gastrointestinal ( GI) systems.

Diagnosis
is made by high clinical suspicion and confirmed by elevated IAP. Always have very low threshold
to check bladder pressure or oliguria, with hypotension, and huge abdominal distension with/
without any organ dysfunction.

Management
Consider the management of trauma patient, and explorative laparotomy for abdominal
decompression, critical care assessment and surgery are keys in the management of Abdominal
compartment syndrome.

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Disorders of Gastro-Intestinal
System
--|Esophageal Atresia
Definition
Congenital disorder with a blind end to the esophagus, at first feed the infant coughs and may
become cyanosed. It may be a fistula to the trachea

Causes:
• Congenital

Signs and symptoms:

Drooling, poor feeding, cyanosis, coughing, gagging, and chocking with attempted feeding
tube is not able to pass all the way to stomach.

Diagnosis:
• Clinical
• Radiological (NGT coiling in the proximal esophagus

Investigations:
• X-ray with contrasts of esophagus shows an air filled pouch and air in the stomach and
intestines
• Inserted feeding tube appear coiled up in the upper esophagus
• Esophagoscopy
• Chest X-ray

Complications:
• Aspiration pneumonia
• Chocking and possible deaths
• Feeding problems
• Reflux after surgery
• Stricture of the esophagus

Management:
• esophageal atresia is considered a surgical emergency
• Rule out any other congenital malformation
• Feeding gastrostomy
• Control of electrolytes imbalance and its replacement accordingly and corrective measures of
dehydration
• Ensure nutritional support
• Good oxygen circulation
• Put the patient in the most comfortable position (elevate the head of bed)
• Antibiotics if pneumonia
• Education to the patient and the family on the management of the gastrotomy tube to avoid
infection
• Transfer to pediatric surgery center

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--|Achalasia
Definition: It is a disorder of the esophagus which affects the ability to move food towards the
stomach. (failure to relax of the lower esophageal sphincter)

Causes:
• A primary neurological disorder of unknown cause
• Failure of the cardiac sphincter to relax
• Faulty peristalsis of the esophagus due to defective parasympathetic innervations
• Cancer of the esophagus in the upper stomach

Signs and symptoms:

• Regurgitation of food
• Chest pain increasing after eating may also be felt in the back, neck and arms
• Cough
• Heart burns
• Unintentional weight loss
• Signs of anemia or malnutrition

Investigations
• esophageal manometry
• Esophagogastroduodenoscopy
• Upper Gastro-intestinal x- ray with barium meal

Complications:
• Regurgitation
• Aspiration pneumonia
• Perforation of esophagus

Management
Management of achalasia aims at reducing pressure at the lower esophageal sphincter
• Medications such as long acting nitrates or calcium channel blockers to relax lower esophagus
sphincter
• Injection with Botulinum toxin to relax sphincter muscles
• Dilatation of esophagus at the location of narrowing done during Esophagogastroduodenoscopy
• Surgery: Esophagomyotomy to decrease pressure in the lower sphincter

--|Gastroesophageal reflux disease

Definition
It is a condition caused by retrograde passage of gastric contents into the esophagus resulting in
inflammation (esophagitis), which manifests as dyspepsia.

Signs and symptoms:

• Retro sternal burning pain radiating to epigastrium
• Regurgitation of acid contents into the mouth ( water brash)
• Back pain (Penetrating ulcer in barrett’s Oesophagus)
• Dysphagia
Odynophagia

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Investigations
o Patients over 45yrs or with suspicious should have investigations for malignancy excluded
as a cause when first presenting with symptoms of GORD
o Barium swallow and meal: sliding hiatus hernia, esophageal ulcer, stricture
o Esophagoscopy: assess the esophagitis, Biopsy for histology, dilate stricture if present
o 24hr pH monitoring: assess degree of reflux

Complications
• Bleeding
• Reflux esophagitis and necrosis
• Ballet’s esophagus
• Benign strictures
• Esophageal adenocarcinoma
• Chronic cough
• Laryngitis
• Pharyngitis

Management:

General
o Lose weight and avoid smoking, coffee and chocolates
o Avoid tight garments and stooping
o Avoid sleeping before 2hrs post prandial

Medications
o Control acid secretion with proton receptor antagonists (e.g. ranitidine), Proton pump
inhibitors(e.g. omeprasol)
o Minimise effects of reflux (give alginic acids e.g. gaviscon)
o Antiacids (e.g. magnesium hydroxide)
o Prokinetic agents (e.g. metoclopramide)

Surgical treatment
o fundoplication is the standard surgical treatment Nissen, Toupet, etc)

--|Esophageal cancer
Definition
It is a malignant tumor of esophagus. The main histological subtypes are : squamous cell carcinoma
(SCC) or adenocarcinoma.

Risk Factors
• Age
• Lifestyle
o SCC: Smoking, Alcohol, Betel nut chewing
o Adenocarcinoma: Obesity, smoking, N-nitroso foods
• Hereditary
• Others:
o SCC: Achalasia, caustic stricture
o Adenocarcinoma: H-pylori infection, Barret’s (GERD) , Zollinger Ellison

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Symptoms
• Regurgitation
• Chest pain unrelated to eating
• Difficulty swallowing solids or liquids
• Heartburn
• Vomiting blood
• Weight loss

Investigations
• Barium swallow
• Esophagogastroduodenoscopy & Biopsy
• CTscan Chest & Abdomen
• Chest MRI or thoracic CT to determine stage of the disease,
• Endoscopic ultrasound and PET (positron emission tomography) scan to determine stage of the
disease (if radical treatment is proposed)
• Stool testing may show blood

Treatment:
• Feeding gastrostomy
• Surgery (Esophageal resection) is the treatment of choice: refer to higher level
• Chemotherapy, radiation or combination of the two
• Endoscopic dilatation of esophagus
• Palliative care
• Ensure enteral feeding and parental treatment support
• Psychological support both to patient and family
• If palliative: Chemotherapy, Eventually endoscopy with esophageal stent

Complications
• Difficulty swallowing
• Severe loss of weight from not eating enough
• Metastasis

--|Esophageal spasm
Definition
Diffuse esophageal spasms are uncoordinated contractions of esophagus resulting from motility
disorders.

Causes:
• not known
• Predisposing factors include: very cold or hot beverages

Signs and symptoms:

• Dysphagia
• Regurgitation
• Substernal midline Chest pain
• Odynophagia

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Diagnosis
• Clinical
• Investigations
o Barium swallow (typical corkscrew esophagus) x-rays
o Esophageal radionuclide transit test (oscillatory or non-clearance pattern)

Management
• Medical
o Botulium toxins
o Long acting nitrites
o Benzodiazepines
o Psychotropic drugs
o Pneumatic dilatation
o Calcium channel blockers

• Surgery
o Considered if medical treatment has failed
o Long esophageal myotomy

--|Perforation of oesophagus
Definition: It is a hole through the esophageal wall.

Causes
• Injury during a medical procedure
• Tumor
• Gastric reflux with ulceration
• Previous surgery on the esophagus
• Swallowing a foreign object or caustic chemicals
• Trauma or injury to the chest and esophagus
• Repetitive vomiting

Symptoms and signs:

• Pain
• Difficulty swallowing
• Chest pain
• Difficulty bleeding
• Tachycardia
• Fever
• Tachypnoea
• Nasal voice (cervical injury)
• Hematemesis (thoracoabdominal segment injury)
• Supraclavicular swelling and crepitus (subcutaneous emphysema)
• Neck pain or stiffness (on perforation of esophagus)
• Respiratory distress (thoracic injuries)

Investigations:
o Chest x-ray may reveal air in the soft tissues of the chest, fluids leaked from esophagus
to the space surrounding lungs or lung collapse
o A chest CT scan may show an abscess in the chest or esophageal cancer
o Endoscopy (incomplete intramural perforations/ Mallory-Weiss syndrome)

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Complications
• Permanent damage to esophagus (narrowing or stricture)
• Abscess formation in and around esophagus
• Infection in and around the lung

Treatment
• Medical:
o Administering fluids
o IV antibiotics to prevent or treat infections
o Draining fluids collected around the lung with a chest tube
o Mediastinoscopy to remove fluids collected in the mediasternum
• Surgery: Surgical emergency, the outcome depends on the time of management, level of
contamination, and comorbidities. Surgery serves to repair the perforation in the middle or
bottom portions of esophagus

--|Hiatus hernia
Definition
It is the protrusion of the upper part of the stomach into the thorax through a tear or weakness in the
diaphragm.

Causes /Risk factors:

• Heavy lifting or bending over,
• Frequent oral hard coffee, hard sneezing,
• Pregnancy and delivery
• Violent vomiting
• Straining with constipations
• Obesity,
• Hereditary, smoking,

Signs and symptoms:

• May be asymptomatic
• Dull pains in the chest,
• Shortness of breath,
• Heart palpitations

Diagnosis : Clinical

Investigations
• Upper GI series,
• Endoscopy
• High resolution manometry

Management:
•General
o Treatment may not be required
o Bed elevation after meals
o Stress reduction technics
o Weight loss if overweight

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•Medical
o Proton pump inhibitors
o H2 receptor blockers
•Surgical
o Hernia reduction and repair
o fundoplication

Complications:
• Gas bloat syndrome,
• Dysphagia,
Dumping syndrome

--|Upper Gastrointestinal bleeding

Definition: It is red blood from mouth originating proximally from ligament of Treitz (Upper GI)
or from anorectal originating distal to ligament of Treitz (Lower GI). it is either through vomiting
blood (hematemesis), coffee ground vomitus or Nasogastric aspirate; or melena, rectorrhagia, or
hematochezia

Causes: Any bleeding from GI tract (traumatic, vascular, malignant, ulcerative)

Signs & Symptoms:

• Hematemesis
• Digested blood
• Melena, Hematochezia
• Dyspepsia, Epigastric pain,
• Heartburn, Diffuse abdominal pain

Investigations: Rapid assessment and resuscitation should precede any diagnostic procedure
• Upper GI Endoscopy (Diagnostic & therapeutic)
• Colonoscopy (if melena)
• FBC, U&E, LFT, RFT, Coagulation profile

Management: Hemodynamic stabilization, Adequate monitoring in ICU/HDU, treat the cause

• Upper GI: Upper GI endoscopy
• Lower GI: anoscopy Rectoscopy, colonoscopy

Surgery may be indicated in refractory bleeding after failure of endoscopy control

--|Acute abdomen
Definition
Acute abdomen is used to describe a group of acute life-threatening intra abdominal conditions
(including pelvis) that require emergency hospital admission and often emergency surgical interventions.
Early recognition, adequate resuscitation and prompt treatment are necessary for recovery of these
patients from potentially fatal conditions.

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Causes
Inflammatory
• Secondary bacterial peritonitis: localized ,generalized
• Primary bacterial peritonitis: generalized
• Tertiary peritonitis: generalized, very poor prognosis
Traumatic
• Injury to solid organs: acute intra abdominal bleeding
• Peritonitis secondary to intestinal injury
Obstructive
• Acute intestinal obstruction(small bowel)
• Chronic intestinal obstruction(colonic)
Vascular
• Mesenteric infarction
• Strangulated external/internal hernia
• Volvulus (small or large intestine)

Clinical signs and symptoms:

• Pain
• Appetite: anorexia, nausea, vomiting, dysphasia, weight loss
• Bowels habits: bloating, diarrhea, constipation, flatulence
• Tenderness
• Rigidity
• Masses
• Altered bowel sounds
• Evidence of malnutrition
• Bleeding
• Jaundice

Abdominal pain from any cause is mediated by either visceral or somatic afferent nerves, and Several
factors can modify expression of pain;
• Age extremes
• Vascular compromise (pain out of proportion)
• Pregnancy
• CNS pathology
• Neutropenia

Diagnosis:
• Clinical presentation
• Investigations
• FBC
• Renal functions tests and electrolytes
• Amylase
• Chest x-ray and abdominal films(erect/supine)
• Blood culture for high fever and pyrexia
• Ultrasound and CT-scan
• Mesenteric angiography
• Laparoscopy/laparotomy

Management:
Acute abdomen requires immediate treatment
• Start large bore IV with either saline or lactated Ringer’s solution
• IV pain medication

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• Nasogastric tube if vomiting or concerned about obstruction

• Foley catheter to follow hydration status and to obtain urinalysis
• Antibiotic administration if suspicious of inflammation or perforation
• Definitive therapy or procedure will vary with diagnosis
• Avoid oral intake
• Oxygen administration if necessary
• Remember to reassess patient on a regular basis.

--|Peritonitis
Definition: Peritonitis is inflammation {irritation} of the peritoneum.

Causes:
• Bacterial peritonitis
o Secondary bacterial peritonitis(from GIT):common
o Primary bacterial peritonitis(streptococcal):rare
o Tertiary bacterial peritonitis(ICU patients): uncommon
• Chemicals
o HCL(early Perforated PUD)
o Extravasation of urine (bladder rupture)
o Bile (leak post cholecystectomy)
o Amylase (pancreatitis)

Spontaneous bacterial peritonitis

• Occurs in immunocompromised patients:
• Cirrhosis, Wilson’s disease, chronic active hepatitis
• Chronic peritoneal dialysis
• Nephrotic syndrome
• Usually Gram – negative organisms
• High risk of septic shock and multiorgan dysfunction syndrome
• Poor prognosis

Clinical signs and Symptoms:

• Systemic features: Illiness, toxicity, pyrexia,tachycardia, rigors (bacteraemia/septicemia)
• Dehydration
• Local symptoms: Pain (localized or generalized) severe, constant, aggravated by movement
• Local signs
• Loss of normal abdominal movement on respiration
• Tenderness, guarding, rigidity, rebound tenderness
• Silent abdomen
• Digital rectal examination may elicit pelvic tenderness, boggy swelling, and cervical tenderness
in female.

Management:
Secondary bacterial peritonitis:
•Immediate treatment: (see treatment of acute abdomen); Ensure adequate IV fluids administration
and electrolyte replacement accordingly
• Control of urinary output
• Antibiotherapy
o If upper gastrointestinal pathology suspected, gram negative aerobe cover( IV
ciprofloxacin, cefotaxime, ceftriaxone, Imipenem)

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o If lower gastrointestinal pathology suspected, gram negative anaerobe cover
(metronidazole)
• Surgical treatment
• Lavage of abdominal cavity with 8 to 10 liters of Normal saline.
• Treat the cause

Primary bacterial peritonitis:

• Haematogenous spread of gram-Positive organisms (S. pneumonia) to peritoneal cavity
• Occurs in children and adult females
• Treatment: antibiotics+/-laparotomy to drain pus
• Prognosis is good

Complications:
• Septic shock
• Hypovolemic shock
• Multiple organ failure

--|Intestinal obstruction
Definition
It is the inability to pass bowel contents distally (partial or complete). Classified into dynamic
(mechanical) and adynamic (paralytic ileus)

Causes:
• Extramural
• Adhesions, bands
• Hernias: internal and external
• Compression by Tumors
• Intramural
• Inflammatory disease: Crohn’s disease
• Tumors: Carcinomas, lymphomas, etc
• Strictures
• Intraluminal
• Feacal impaction
• Swallowed foreign bodies
• Bezoars
• Gallstone

Clinical signs and symptoms:

• Cardinal symptoms of intestinal obstructions:
o Pain
o Vomiting
o Distension
o Absolute constipation
• Signs of dehydration: a dry tongue: sunken eyes and dry inelastic skin may be noted.
• Patient may be rolling about with colic
• Pulse usually elevated
• temperature is usually normal, a raised temperature and a very rapid pulse indicate
strangulation
• Per abdomen, distension and visible peristalsis may be observed.

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• vital to carefully search for presence of a strangulated ex ternal hernia and presence of an
abdominal scar
• Tenderness.
• A mass may be felt (for example in intussusception or cancer of the bowel).
• The bowel sounds are usually accentuated and tinkling (i.e metallic)
• Rectal examination
• May reveal an obstructing mass in the pouch of Douglas
• Feel apex of an intussusceptions
• Faecal impaction or
• An empty rectum in case of sigmoid volvulus
The rule that constipation is present in intestinal obstruction does not apply to Richter’s hernia,
vascular occlusion and Intestinal Obstruction associated with pelvic abscess

Investigations:
• Abdominal series with chest x-ray
• CBC: >20,000 indicates bowel gangrene, abscess, peritonitis >40,000 possible nonocclusive
mesenteric ischemia
• Electrolytes and renal function tests
• Urinalysis
• Lactate (mesenteric ischemia)
• Barium enema : can determine cause and site of LBO
• Sigmoidoscopy: Identification of friable mucosa, Intraluminal lesions, Dead bowel,Diagnostic
and therapeutic for sigmoid volvulus
• Contrast enhanced CT: Delineate partial from complete obstruction

Management:
• Fluid and electrolyte replacement therapy
• Decompression of the bowel with NGT placement
• Well-timed surgical intervention if failure of decompression by NGT
• Avoid oral intake
• Parenteral nutrition through the central line
• Fluid and Electrolytes Replacement Therapy
• Adequate fluid, electrolytes, proteins, and whole blood should be given to stabilize the blood
pressure and pulse as well as to restore warmth, skin colour, turgor, and adequate venous
filling.
• The urinary output and specific gravity should be followed as indicators of extracellular fluid
adequacy
• The amount and type of replacement will vary and should depend on the patient’s condition
as measured by such criteria such as serum chemistry studies, haematocrit, vital signs, and
clinical response to fluid therapy.
Decompression of the bowel
• Distension may be relieved by NGT or surgical decompression.

Operative treatment
• Proper timing of the operation for intestinal obstruction is essential. Surgery is the most
important step, and in case of strangulation or vascular occlusion it is the only effective
treatment.

Surgical procedures
Relief of intestinal obstruction may be divided into five categories:
• Procedures not requiring opening the bowel:- lysis of adhesions, manipulation-reduction of
intussusception, reduction of obstructed hernia.

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• Enterotomy -for removal of obturation obstruction-gallstones, bezoars.
• Resection of obstructing lesion or strangulated bowel with primary anastomosis.
• By- Pass: Anastomosis around an obstruction.
• Formation of a cutaneous stoma proximal to the obstruction-enterostomy, colostomy, cecostomy

Summary of Treatment:
• IV fluid replacement
• Bowel decompression via nasogastric tube
• Broad spectrum antibiotics if signs ischemic bowel
• Adynamic ileus patients: Conservative management: IV fluids, NG tube, bowel rest, pain
management

--|Appendicitis
Definition: It is an inflammation of the appendix

Causes/Predisposing factors:
• No clear cause of appendicitis
• Obstruction of appendiceal lumen
• Inflammation of appendiceal lymphoid tissue (about 60%). This inflammation can be
• Gastroenteritis
• Advanced colonic disease such as crohn’s disease.

Clinical signs and symptoms:

• Peri-umbilical pain shifting to right iliac fossa
• Anorexia
• Abdominal pain
• Nausea with or without vomiting
• Low grade fever
• Mac Burney tenderness
• Rebound tenderness
• Dunphy (increase pain with cough)
• Rovsing ( lower left quadrant palpation inducing right lower quadrant pain)
• Obturator ( Pain on internal rotation of the right hip )
• Ilial psoas ( Pain on extension of the right hip )

Diagnosis
• Clinical diagnosis : Alvarado Score (MANTREL mnemonics)
• Investigations:
o FBC- leucocytosis and left shift
o A WBC greater than 12000 suggests high infectious process (check left shift neutrophils
predominance)
o Urinalysis often reveals minimal white cells, red cells and bacteria
o ß HCG must be checked in female patients
o Plain films- a fecalith is present in less than 15% of cases, free air from perforation Is
seen in 1% of cases
o Ultra sound; most effective in young females of child bearing age in the evaluation of
adnexal diseases which is high on differentials.( sensitivity 75-90%)
o CT scan (sensitivity ranging from 96-100%)
o Radionuclide (sensitivity and specificity >90%)

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Management
The goal of surgical approach to appendicitis is simple-early diagnosis with resection of an acutely
inflamed appendix prior to perforation

Medical treatment:
• Augmentin 1gm x 3/ day/ 5 days if uncomplicated appendicitis .
Alternative:
• Ceftriaxone/2g 24 hourly for 5-7 days (udults), or Cefotaxime 1g/8hourly +
Metronidazole 500mg/8hourly IV
Surgical treatment:
Open or laparoscopic appendicectomy + antibioprophylaxis ceftriaxone 2 gm single dose +
metronidazole 500mg single

--|Appendiceal mass and abscess

Definition
Appendiceal mass is a palpable conglomeration of inflamed tissues, including the appendix and
adjacent viscera.

Causes/Aetiology:
• Idiopathic
• An obstruction (Food waste or fecal stone)
• An infection

Clinical signs and symptoms:

• Aching pain that begins around your navel and often shifts to your lower right abdomen
• Pain that becomes sharper over several hours
• Tenderness that occurs when you apply pressure to your lower right abdomen
• Sharp pain in your lower right abdomen that occurs when the area is pressed on and then the
pressure is quickly released (rebound tenderness)
• Pain that worsens if you cough, walk or make other jarring movements
• Nausea
• Vomiting
• Loss of appetite
• Low-grade fever
• Constipation
• Inability to pass gas
• Abdominal swelling

Diagnosis:
• Clinical
• Investigations
o CT scan of the abdomen and the appendix
The major Complications
• Peritonitis
• Surgical wound infections
• Intra-abdominal abscess
• Fistulas
• Small bowel obstruction (adhesions)
• Paralytic ileus
• Infertility
• Sepsis

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Management:
• Conservative treatment with antibiotics
• Percutaneous drainage of abscess and concomitant IV antibiotics
• Eventually Interval Appendectomy is done 6 weeks to 3 months later

ALGORITHM FOR MANAGEMENT OF APPENDICEAL MASS:

Figure 10. Algorhym of management of ppendiceal mass.

Annals of African Medicine, Vol.7 No.4 2008: 200 - 204

--|Hernia
Definition: Protrusion of body compartment contents through an abnormal or unusual anatomical
opening. There are many types of hernias: Inguinal hernia, umbilical hernia, epigastric hernia,
internal hernia, incisional hernia, abdominal wall hernia, etc.

Causes/risk factors:
• Age
• Obesity
• Heavy lifting
• COPD (Coughing)
• Chronic constipation
• Straining (BPH) for males
• Ascites
• Pregnancy for females
• Peritneal dialysis
• Iatrogenic (incisional)

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Clinical signs and symptoms:

• Protruding soft tissue mass
• Localized pain , tenderness if incarcerated or strangulated
• Associated signs and symptoms related to the incarcerated organ or tissue

Investigations:
• Ultrasound (95-99% sensitive)

Complications:
• Incarceration
• Strangulation
• Necrosis, Sepsis

Management:
• Conservative management for asymptomatic self-reducible small hernias (less than 1cm)
• Surgical technique management depends on the type of Hernia: Hernia repair with or without
Mesh

--|Gallstones
Definition
Gall stones are solid particles that form from bile in the gallbladder. They are of two types; 1)
cholesterol stones (20%) and 2) pigment stones Yellow stones (80%).

Causes/Risk factors:
• Too much cholesterol in the bile
• Excess bilirubin in the bile
• People with liver disease or blood disease
• Poor muscle tone
• Risk factors include, female gender, overweight, losing a lot of weight quickly on a "crash" or
starvation diet, certain medications e.g. birth control pills, cholesterol lowering drugs.

Clinical signs and symptoms:

• Usually asymptomatic (8-15%)
• Biliary colic, nausea and vomiting, approximately 70% will have 1 or more recurrent episodes
of pain within a year of onset of symptoms.

Investigations
• Ultrasound (95-99% sensitive)
• MRCP (92% sensitive)
• CT scan (60% sensitive)
• X ray (15% sensitive)

Complications:
• Severe abdominal pain
• Pancreatitis
• Gallbladder disease
• Infection (Cholecystitis)

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Management
• Symptomatic treatment
• intake of only clear liquids to give the gallbladder a rest
• avoid fatty or greasy meals
• Take acetaminophen (Tylenol, etc.) for pain
• Laparascopic (or open) cholecystectomy should be performed for patients with symptoms

--|Acute cholecystitis
Definition
Prolonged or recurrent cystic duct blockage by a gall stone or biliary stasis can progress total
obstruction

Causes:
• 90-95% of cases are associated with cholelithiasis

symptoms
• Right upper quadrant pain with possible radiation to the right shoulder or back
• Nausea, vomiting
• Fever

Diagnosis:
• Ultra sound (non invasive)
• HIDA is the most sensitive test (Technetium 99m pertechnetate immunodiacetic acid scan)

Treatment
• Medical
• IV fluids
• Ampicilline IV 1 g tid for 7days + Gentamycin IV 160 mg OD for 5days,

Alternative:
• Ceftriaxone IV 1gm bid for 7days
• Pethidine 100mg IV 3-4 times/ per day for analgesia

• Surgical
• Cholecystectomy is a definitive treatment, if performed with in 2-3 days of illness it is better
than delayed chelecystectomy that is performed 6-10 weeks after initial medical treatment
• Laparoscopic cholecystectomy is the procedure of choice

--|Jaundice
Definition
Jaundice is the yellowing of the skin and sclera from accumulation of the pigment bilirubin in the blood
and tissues. The bilirubin level has to exceed 35-40µmol/l before jaundice is clinically apparent.
The three forms of jaundice are; Prehepatic (Hemolytic), Hepatic (hepatocellular) and Posthepatic
(obstructive/surgical jaundice)

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Surgical (Obstructive) Jaundice

Post hepatic conjugated bilirubinemia occurs from anything that blocks release of conjugated bilirubin
from the hepatocytes or prevents its delivery to the duodenum.

Causes:
• Choledocholithiasis
• Periampullary carcinomas
• Portal lymphadenopathy
• Sclerosing cholangitis

Clinical signs and symptoms:

• Frank Jaundice
• Pruritis
• White stool
• Cocacola colored urine

Diagnosis:
• Clinical
• Investigations
• Serum bilirubine:
• Liver function test
• Alkaline phosphatase: very elevated
• ɣ-GT: very elevated
• Transaminase: normal/elevated
• Lactate dehydrogenase: normal/elevated
• Reticulocytes: normal
• Ultrasound
• CT-scan
• PTC
• ERCP

Management:
• Preoperative management: Aims at preventing complications associated with severe cholestasis
such us (infections, Clotting disorders, renal failure, liver failure, fluids and electrolyte
abnormalities)
• Post operative sepsis after biliary tract surgery is common and therefore prophylactic antibiotics
should be given to lower the incidence
• IV fluids should be administered to prevent hepato-renal syndrome
• The most common disorder of coagulation is prolonged PTT (prolonged prothrombin time)
resulting from deficiency of vitamin K dependant factors. Administration of Vit K 10mg IV BID
for at least three days before operation is recommended.

Surgical obstructive jaundice will always be accompanied by dilatation of the biliary tree
• Establishing the cause of the jaundice
• Assessment of the general condition of the patient
• Staging in patients with tumors
• surgical : CBD exploration and adequate release of obstruction (Transfer to General surgery /
Hepatobiliary surgeon)

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--|Gastric outlet obstruction
Definition
Gastric outlet obstruction refers to a condition in which the narrow channel leading from the stomach
into the Pylorus is physically blocked, and, as a result food enters the duodenum slowly or is blocked

Causes:
• Benign
• peptic ulcer disease
• Infection, such as tuberculosis and infiltration diseases such as amyloidosis.
• A rare cause of gastric outlet obstruction is obstruction with gallstone, also termed Bouveret’s
syndrome.
• Malignant
• Tumours of stomach, including adenocarcinoma (and its linitis plastic variant, lymphoma, and
gastrointestinal stromal tumor
• Occasionally, cancers near the pylorus, for example, of pancreas or duodenum

Clinical signs and symptoms:

• Vomiting which typically occurs after meals of undigested food, or bile
• History of peptic ulcers and loss of weight
• Body wasting and dehydration.
• Visible peristalsis may be present
• Succussion splash which is a splash-like sound heard over the stomach in the left upper quadrant
of the abdomen on shaking the patient, with or without the stethoscope

Investiagations
• Esophagogastroduodenoscopy(EGD)
• Abdominal X-ray (Gastric Fluid level)
• Abdominal CT scan with IV and oral contrast

Management:
Depends on the cause, and may include either surgery or medical

• Pharmacological
o In patients with peptic ulcer disease, the oedema will settle with conservative management
with nasogastric suction, replacement of fluids and electrolytes and proton pump inhibitors

• Surgical management
o Antrectomy (which involves anastomosing the duodenum to the distal stomach) or
gastrojejunostomy, Indicated in case of failed medical treatment and recurrent obstruction.

--|Disorders of the Colon and Rectum

Colorectal cancer

Definition
The occurrence of malignant lesions in mucosa on the colon or rectum

Causes/predisposing factors:
• Prior colorectal carcinoma or adenomatous polyps
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• Hereditary polyposis syndrome

• Family history of colorectal carcinoma
• Chronic active ulcerative colitis
• Diet (low in indigestible fibre, high in animal fats)
• Decreased faecal bile salts, selenium deficiency.

Clinical signs and symptoms:

• Anaemia, caecal cancers often present with anaemia
• Colicky abdominal pain
• Alteration in bowel habits (constipation or diarrhea)
• Bleeding or passage of mucus per rectum
• Tenesmus (frequent or continuous desire to defecate)

Investigations
• Digital rectal examination and faecal occult blood
• Full blood count (anaemia)
• Urea and electrolytes (hypokalaemia)
• Liver function test (liver metastasis)
• Abdominopelvic CTscan with iv and oral contraste
• Sigmoidoscopy (Rigid to 30 cm/flexible to 60 cm)
• Double contrast barium enema (apple core lesion, polyp)
• Carcinoembryonic antigen is often raised in advanced disease

Management
• Surgery
• Resection of the tumour with adequate margins to include regional lymph nodes
• Resection possible for liver metastasis if fewer than five are present
• Radiotherapy may be used to shrink rectal cancers pre-operatively or post-operatively or
palliate inoperable rectal cancer
• Adjuvant chemotherapy or to palliate liver metastasis
• Supportive management see management of oesophageal cancer

Rectal bleeding

Definition
The passage of blood from the anus, the blood volume may be small or large, and may be bright red
or dark in colour.

Causes:
• In the small intestines;
• MECKEL diverticulum in young adults
• Intussusceptions in young children (colic abdominal pain, retching, bright red/mucus stool)
• enteritis, Infection, radiation, CROHN’s disease
• Ischemic, severe abdominal pain
• In proximal colon;
• Angiodysplasia, common in elderly Carcinoma of the caecum (causes anaemia rather than frank
rectal bleeding)
• In the colon
• Polyps/carcinomas
• Diverticular disease in elderly
• Ulcerative colitis
• Ischemic colitis in elderly (severe abdominal pain)

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• In the rectum
• Carcinoma (change in bowel habits, associated with mucus, small volumes of blood)
• Proctatis
• Solitary rectal ulcer
• In anus
• Haemorrhoids
• Fissure in ano
• Perianal Crohn’s disease
• Carcinomas in anus

Management
• Treat the cause

Haemorrhoids

Definition: are masses or clumps ("cushions") of tissue within the anal canal that contain blood vessels
and the surrounding, supporting tissue made up of muscle and elastic fibers

Cause:
• Inadequate intake of fibre
• Chronic straining to have a bowel movement (constipation)
• Pregnancy
• Tumors in the pelvis

Signs and symptoms:

Depend on stage and whether internal or external;
• First-degree hemorrhoids: Hemorrhoids that bleed but do not prolapse.
• Second-degree hemorrhoids: Hemorrhoids that prolapse and retract on their own (with or
without bleeding)
• Third-degree hemorrhoids: Hemorrhoids that prolapse but must be pushed back in by a finger
• Fourth-degree hemorrhoids: Hemorrhoids that prolapse and cannot be pushed back in
• Fourth-degree hemorrhoids also include hemorrhoids that are thrombosed (containing blood
clots) or that pull much of the lining of the rectum through the anus
• Anal itchiness(pruritus ani)
• Mass protrusion from the anus and cannot be pushed back inside (incarceration of the hemorrhoid)

Diagnosis:
• Clinical
• Investigations
o Flexible sigmoidoscopy
o Colonoscopy

Complications
• Incarceration of the hemorrhoid
• Thrombosis
• Rectal hemorrhage
• Infection

Management
• Simple: Bulk laxatives and high fiber diet
• Bleeding internal haemorrhoids: injection sclerotherapy, Barron’s band, Cryosurgery
• Prolapsing external haemorrhoids: haemorrhoidectomy

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• Stool softeners and increased drinking of liquids also may be recommended

• Local anesthetics e.g. Benzocaine 5% to 20% (Americaine Hemorrhoidal, Lanacane Maximum
Strength, Medicone);
• Vasoconstrictors e.g. Ephedrine sulfate 0.1% to 1.25% OR Epinephrine 0.005% to 0.01% OR
• Phenylephrine 0.25% (Medicone Suppository, Preparation H, Rectacaine)
• Rectal prolapse: Abdominal rectopexy (rectum is hitched up on to the sacrum)
Perianal hematoma: Incision and drainage, evacuation of the clot

Perianal abscess

Definition
Perianal abscess is a collection of pus in the area of the anus and rectum

Causes/Risk factors:
• Blocked gland in the area
• Infection of an anal fissure
• Sexually transmitted infection
• Inflammatory bowel disease (Crohn's disease and ulcerative colitis)
• Anal sex
• Chemotherapy drugs used to treat cancer
• Diabetes
• Use of medications such as prednisone
• Weakened immune system (such as from HIV/AIDS)

Clinical signs and symptoms:

• Swelling around the anus
• Constant, throbbing pain
• Pain with bowel movements which may be severe
• Constipation
• Discharge of pus from the rectum
• Fatigue and general malaise
• Fever, night sweats and chills
• Lump or nodule, swollen, red, tender at edge of anus
• Painful, hardened tissue on rectal examination
• In infants, the abscess often appears as a swollen, red, tender lump at the edge of the anus. The
infant may be fussy and irritable from discomfort

Investigations
o Proctosigmoidoscopy
o Ultrasound/CT scan/MRI to rule out other diseases

Complications
• Anal fistula
• Body-wide infection (sepsis)
• Continuing pain
• Problem keeps coming back (recurrence)
• Scars
Management
• Incision and drainage of abscess, drained abscesses are usually left open and there are no
stitches
• Antibiotics

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Fistula in ano

Definition: A fistula in ano is a track that develops from the inner lining of the anus through the tissues
that surround the anal canal
Causes:
• Previous anorectal abscess
• Anal canal glands situated at the dentate line
Other causes include trauma, Crohn disease, anal fissures, carcinoma, radiation therapy,
actinomycoses, tuberculosis, and chlamydial infections.

Signs and symptoms

• Perianal discharge
• Pain
• Swelling
• Bleeding
• Skin excoriation
• External opening
• Digital rectal examination may reveal a fibrous tract or cord beneath the skin
• Lateral or posterior indurations suggests deep post anal or ischiorectal extension
• Recurrent episodes of anorectal sepsis
• An abscess develops easily if the external opening on the perianal skin seals itself

Investigation
o Rectoscopy

Complications:
• Incontinence
• Recurrent pain after surgery

Management
•Examen under AnesthesiaLow: Probing and laying open the track ( fistulotomy)
•High: Seton insertion, core removal of the fistula track

Anal fissure

Definition: tear in anal mucosa/anoderm; definition of acute vs chronic: <6 weeks >6-8 weeks. Most
common fissures are posterior. Lateral fissure: is an unusual location for a fissure and should raise
suspicions of possible syphilis, TB, leukemia, cancer, HIV; management should initially be a biopsy

Cause: trauma to the anal canal due to hard stool or diarrhea

Symptoms & Signs: anal pain on defecation and blood on toilet paper, history of constipation
Complications: incontinence

Management:
Acute anal fissure: Fiber, Water, Diet, Stool softener, balking agents, local anaesthetic gels 0.2% GTN
( Glyceryl trinitrate) ointment ; Sitz baths

Chronic anal fissure:

Medical: calcium channel blockers, nitroglycerin, Botox, anal dilation, Sitz baths, topical lidocaine,
steroid injection; Botulinum toxin injection, All of these have lower success rate than surgery but can
consider for patients that are not good surgical candidates

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Surgery: lateral internal sphincterotomy 90% success rate

Examination under anaesthesia and biopsy for atypical/ suspicious abnormal fissures

Anal cancer

Definition: Anal cancer is a disease in which malignant cells form in the tissues of the anus

Risk factors:
• Human papillomavirus (HPV) infection (Mainly serotypes 16 & 18)
• Being over 50 years old,
• History of anal warts
• History of Cervical, vulva or vaginal cancer
• Having many sexual partners
• Having receptive anal intercourse (anal sex)
• Frequent anal redness, swelling, and soreness
• Having anal fistula (abnormal openings)
• Smoking cigarettes.
• Genetic

Signs and Symptoms:

• Bleeding from the anus or rectum.
• Pain or pressure in the area around the anus
• Itching or discharge from the anus
• A lump near the anus
• A change in bowel habits

Investigations:
• Physical Exam:
o DRE and palpation of inguinal lymph nodes
o Pelvic exam for all women with cervical Pap Smear
• Diagnostic imaging:
o Anoscopy: An exam of the anus and lower rectum using an anoscope (a short, lighted
tube)
o Proctoscopy: An exam of the rectum using a proctoscope (short, lighted tube)
o Endo-anal or endorectal ultrasound
o Pelvic MRI
o CT Chest, abdomen and pelvis
• Laboratory: Routine bloodwork, HIV, hepatitis screening
• Biopsy taken for histopathology exams during anoscopy

Management
• Localized/Locally advanced
o Wide excision only considered in Stage 0 and Stage I if negative margins can be
achieved.
o Stage II-III: Concurrent chemoradiotherapy.
--|Acute Pancreatitis
Definition: Pancreatitis is an inflammatory condition of the exocrine pancreas that results from injury
to the acinar cells. It may be acute or chronic.

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Causes
• Gallstones and alcohol abuse account for 95% of cases of acute pancreatitis
• Idiopatic
• Other causes include Congenital structural abnormalities, Drugs, Viral infections, Hypocalcaemia,
Hypothermia, Hyperlipidemia, Trauma

Signs and symptoms:

• Abdominal pain felt in the upper left side or middle of the abdomen.
• Illness, fever, nausea, vomiting and sweating (acute pancretitis)
• Clay-colored stools, gaseous abdominal fullness, hiccups, jaundice, skin lesions and swollen
abdomen.
• Abdominal tenderness or mass, low blood pressure, rapid heart rate and rapid respiratory
rate are observed on physical examination

Diagnosis:
• Clinical
• Investigations
• Complete blood count
• Increased blood amylase level, increased serum blood lipase level, increased urine amylase
level, comprehensive metabolic panel
• Abdominal ultra sound
• Abdominal CT scan
• Abdominal MRI

Management:
Most pancreatitis is mild and resolves spontaneously.
• Assess disease severity( Imri/Ranson Criteria or APACHEII system)
• Resuscitate the patient if:
• Mild/moderate disease: IV fluids, analgesia, monitor progress with pulse blood pressure and
temperature.
• Severe pancreatitis: full resuscitation in ICU with invasive monitoring
• Avoid oral intake
• Establish the cause: ultrasound to look for gallstones
• Further management. Non proven use for routine nasogastric tube or antibiotics
• Consider vitamin supplement and sedatives, if alcoholism is the cause
• Proven common bile duct stones require urgent ERCP (Endoscopic retrograde
cholangiopancreatography)
• Cholecystectomy should be discussed as early as possible, and CBD exploration might be an
option
• Failure to respond to treatment or uncertain diagnosis warrants abdominal CT- Scan
• Suspected or proven infection of necrotic pancreas requires antibiotics and surgical
debridement

Complications:
• Pancreatic abscess
• Intra-abdominal sepsis
• Necrosis of the transverse column
• Respiratory failure (ARDS) or renal failure(Acute tubular necrosis)
• Pancreatic hemorrhage
• Pancreatic pseudo cyst: may need to be drained internally or externally
• Chronic pancreatitis

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--|Chronic Pancreatitis
Definition: Chronic pancreatitis is inflammation of the pancreas that does not heal or improve, gets
worse over time, and leads to permanent damage

Causes:
• Chronic alcohol abuse
• Repeat episodes of acute pancreatitis
• Damage to the portions of the pancreas that make insulin may lead to diabetes
• Risk factors include Autoimmune, blockage of the pancreatic duct, cystic fibrosis, High levels
of triglycerides in the blood (hypertriglyceridemia), hyperparathyroidism, Use of certain
medications (especially estrogens, corticosteroids, thiazide diuretics, and azathioprine)

Clinical signs and symptoms:

• Intractable abdominal pain
• Evidence of exocrine pancreatic failure(steatorrhoea)
• Evidence of diabetes

Management:
• Medical treatment: Analgesia and exocrine pancreatic enzyme replacement
• Surgical treatment: Drainage of dilated pancreatic duct or excision of the pancreas in some
cases
Splanchnicectomy is performed in intractable pain

--|Breast Management
Definition
Breast diseases can be various with different approaches of management. Benign breast conditions
include abscesses, benign breast masses, trauma. Malignant breast conditions include Inflammatory
breast Cancer, carcinomas, pagets, etc. The approach to breast conditions can be syndromic or
managed case by case.

Signs & Symptoms: Pain, mass, nipple discharge, skin retraction, axillary lymph nodes

Diagnosis : Clinical, radiological and pathology ; coupled to adequate staging (TNM) and hormonal
sensitivity, and immunohistochemistry

Investigations: Breast Ultrasound, Mammography, MRI, FNA, Biopsy (Core needle/open)

Management:
• Treat the cause
o Breast abscess: Incision & Drainage, Antibiotics, analgesics, biopsy if suspicious
malignant presentation or tissues
o Benign breast lump: breast conserving treatment; observation or mass excision, always
involve multidisciplinary teams
o Malignant masses: multidisciplinary team management
• Multidisciplinary approach (Oncologist, general surgeon, Pathology, Radiology, psychology,
radiotherapy, etc)
• Surgery, chemotherapy, radiotherapy, hormonotherapy as indicated (Neoadjuvant or adjuvant)
• Regular follow-up

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--|Neck Mass management
Definition
Neck masses are masses that can appeared to the neck area (3 zones: lateral, posterior, anterior)

Signs & Symptoms

Heat/cold intolerance, tachycardia, palpitations, Pain, mass, SOB, dizziness, dysphagia, trauma,
abscess

Investigations: Ultrasound, CT scan, MRI, hormones testing (Thyroid)

Diagnosis: Clinical, radiological, pathology

Management: Treat the cause

• Thyroid nodule: surgical treatment may be done, but refer to higher hospital level if no surgical
team available. Options may be: Thyroid lobectomy, hemithyroidectomy, or total thyroidectomy
with hormones supplementation
• Some endocrinology conditions may be emergencies (Thyrotoxicosis)
• Multidisciplinary approach (Oncologist, general surgeon, ENT, Maxillofacial, Pathology, Radiology,
psychology, radiotherapy, etc)
• Surgery, chemotherapy, radiotherapy, hormonotherapy as indicated (Neoadjuvant or adjuvant)
• Regular follow-up

--|Varicose veins
Definition: Varicose veins are venous dilatation; mostly localized on the lower limbs

Causes: Persistent Venous insufficiency, peripheral vascular disease, Trauma, Medications, long
standing, pregnancy, Hormonotherapy

Signs & Symptoms: Limb heaviness, Venous dilatation, pain, chronic ulcers

Investigations: Doppler Ultrasound, CT Angiography, MRI

Diagnosis: Clinical, radiological

Management: supportive management

• Elastic compressive stocknet
• Sclerotherapy (Aethoxysclerol 1%)
• Surgery: Venous ablation, Venous stripping
• Life style change, physical exercise
• Regular follow-up

--|Soft tissue masses

Definition: there are variety of soft tissue masses (benign and malignant)

Causes: excessive SUV, sunlight exposure, premalignant conditions

Signs & Symptoms: pain, mass, neurovascular compromise, chronic wound

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Investigations: radiographies, Doppler/Ultrasound, CT scan & Angiography, MRI

Diagnosis: Clinical, radiological, pathology

Management: Treat the cause

• Multidisciplinary approach (Oncologist, general surgeon, Pathology, Radiology, psychology,
radiotherapy, etc)
• Surgery, chemotherapy, radiotherapy, as indicated (Neoadjuvant or adjuvant)
• Regular follow-up

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GENITO-URINARY DISORDERS
--|Traumatic Emergencies
Renal injuries

Causes:
• Blunt trauma (60-90%)
• Penetrating trauma

Signs and symptoms

• Hematuria (>99%)
• Flank tenderness/ecchymosis
• Hemodynamic instability
• Flank pain
• Signs and symptoms of other abdominal injuries present

Investigations
Laboratory:
• FBC
• Renal function tests
• Prothrombine time
• Thromboplastine time
• Blood group and crossmatching
Imaging
• CT scan with contrast Gold standard
• Intravenous pyelography (IVP) when CT scan not available;IVP can be performed on the
table in theater to investigate a retroperitoneal hematoma during emergency laparotomy.
• Ultrasonography can provide useful initial information about abdominal injuries.

Management
The management is based on classification of renal injuries

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Approach Considerations: the contemporary approach to renal trauma is as follows :

1. Operate immediately if the patient has life-threatening bleeding
2. Use ureteral stents for symptomatic or growing urinoma
3. Use angioembolization for non-emergent bleeding or for urgent bleeding if those techniques
are available.
• Grade I to III:
o Conservative management:
o.1. bed rest,
o.2. Analgesics: Paracetamol PO 1gr 8 hourly
o.3. antibiotics: Cefazolin IV 1gr 8 hourly or Cefuroxime PO 500 mg 12 hourly
o.4. serial hematocrits and
o.5. repeat CT at 48 to 72 hours.
• Grade IV : as above but if urinary extravasation: stenting or/and percuteneous drainage of
urinoma.
• GradeV:
œ.1. Management can be conservative,
œ.2. Analgesics: Paracetamol PO/IV 1gr 8 hourly

œ.3. antibiotics: Cefazolin IV 1gr 8 hourly or Cefuroxime PO 500 mg 8

hourly
œ.4. Angiography with selective embolization if available and in stable
patient
œ.5. Surgery if hemodynamic instability, perirenal hematoma >3.5 cm,
intravascular contrast extravasation, medial renal laceration.

Ureteric injuries

Causes:
• Usually iatrogenic following pelvic surgeries.
• Penetrating trauma more common than blunt trauma

Signs and symptoms

Unilateral
• Asymptomatic; secure ligation of the ureter gives silent atrophy of the kidney.
• Pain and Tenderness in the loin.
• Fever, possible with pyonephrosis due to infection of the obstructed urinary system.
• Urinary fistula through the wound.
• Abdominal distension following uroperitoneum.
Bilateral
• Anuria when both ureters are ligated.
• Bilateral loin pain and tenderness
• Fever when pyonephrosis.
• Bilateral hydronephrosis

Investigations:
• Non single test is reliable;
• Ultrasound, may reveal hydronephrosis or free fluid collection.
o CT scan with IV contrasts and delayed images can suggest injury.
o IVP when CT not available
o IV methlylene blue bolus with lasix can be given intraoperatively.

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Management
• If recognized immediately repair then stent the ureter.
• Late diagnosis also need repair but there is high nephrectomy rate .
o Techniques for an abdominal ureteral injury repair
• Mobilization of ureter
• Spatulate
• Tension-free uretero-ureterostomy over a stent.
• Techniques for pelvic ureteral repair
o Psoas hitch
o Boari flap
o Downward nephropexy
o Ureteric reimplantation in the bladder (ureteroneocystostomy)
• Ureteral contusion is managed by a Stenting (bladder can be opened to place the stent
under direct vision or endoscopically).

Bladder injuries

Causes:
• Penetrating or blunt trauma
• Pelvic trauma
• Can be extra or intraperitoneal

Signs and symptoms

• No bladder distension
• Gross hematuria
• Difficult or inability to void
• Suprapubic or abdominal pain or tenderness
• Abdominal distension

Investigation
• FBC
• Renal function test
• Ultrasonography
• Retrograde cystography
• CT scan/IVP

Management
• Indwelling foley catheter (10-14 days) if extraperitioneal ruptures.
• Exploration and repair, if intraperitoneal rupture
• Manage associated injuries if any

Urethral injuries
Urethral injury is common in males than females.

Causes
• Posterior urethra: Pelvic fractures (most commonly associated with bilateral pubic rami-
fractures)
œ.1. Anterior urethra: Direct trauma (straddle injury)

Signs and symptoms:

• Blood at urethral meatus
• Penile hematoma

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• scrotal hematoma
• Penetrating penile injury
• High riding prostate(freely mobile) on DRE
• Inability to urinate/palpable full bladder
• Perineal hematoma
When suspicion of urethral injury, urethral catheterization is contraindicated.

Investigation:
• Retrograde cysto-urethrogram
Management
Management depends on classification

General principles in urethral injury management:

1. urethral contusion (no extravasation): catheter for 10-14 days
2. Minor partial tear (minimal extravasation): bladder drainage for 2-3 weeks
3. Major partial tear or complete urethral transaction
i. Anterior urethra: Repair and bladder drainage for 4-6 weeks
ii. Posterior urethral : Repair and bladder drainage for 9-12 weeks

Urethral trauma management algorithm

Suspicion urethra
injury

Retrograde
urethrocystogram

Extravasati
on No extravasation

Complete Partial Urethral

disruption disruption contusion

Suprapubic
Penetrating Blunt Penetrating cystostomy or
urethral catheter
Cystosto
Primary repair my Primary
repair

Stricture No
stricture

If short(>1 cm) and passable If longer

Endoscopic Delayed
incision urethroplasty

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Testicular injury
• Blunt trauma involves testicular rupture in 50% of cases
• Testicular trauma can affect fertility and endocrine function.

Causes:
• Blunt or penetrating trauma

Clinical Signs and symptoms

• Scrotal pain
• Ecchymosis
• Hematocele
• Scrotal swelling

Investigations
• FBC
• Ultrasonography

Management
• Conservative management with analgesics (Paracetamol 1g 8hourly for 5 days) and scrotal
elevation
• Exploration, if suspicion of testicular rupture
• Repair or partial orchidectomy depending on severity of injury.
• Orchidectomy, if unsalvageable testis.
• Psychological support for patient with severe testicular injury.

Penile injury

• Penile fracture is a rupture or teat of the tunica albuginia of the corpus cavernosum which
occurs when an excessive bending force is applied on an erect penis

Signs and symptoms

1. At the time of injury the patient usually experience a pop or snap of the erect penis followed
by penile pain and detumescence
2. Penile lateral deviation with swelling causing the appearance of “eggplant deformity”.
3. In 10-20% of cases there are associated urethra rupture (associated with urethral bleeding).

Diagnosis
1. Penile fracture is a clinical diagnosis
2. When clinical presentation is unclear surgical exploration is recommended
3. When suspicion of urethral rupture, do a urethrogram or urethroscopy.

Management
Penile fracture is an emergency and requires immediate surgical intervention (repair of the tunica
albuginea).
Associated urethral injury should be repaired immediately as well.

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--|Non-traumatic emergencies
Acute urinary retention

Definition
It is a sudden and painful inability to pass urine voluntarily when the bladder is full

Causes:
• Obstructive
o Benign prostatic hyperplasia
o Cancer of prostate
o Uretheral stricture
o Bladder neck obstruction
o Trauma of the pelvis
o Phimosis
o Pelvic masses and gynecology malignancies
• Infectious and inflammatory
o Acute prostatitis
o Vulvovaginitis
• Neurologic
o Spinal and peripheral nerve injuries
o Spinal compression
o Cerebrovascular disease
o Guillain Barre syndrome
• Diabetes mellitus
• Tumors
• Pharmacologic: Anticholinergics and alphadrainergic agents

Signs and symptoms

• Painfull urge to pass urine
• Dysuria
• Increased frequency
• Uncontrolled dribbling of urine through the urethra

Investigations:
• Blood urea and serum creatinine
• Urinalysis, culture and sensitivity
• Ultrasonography
• CT scan brain, spine, pelvis if suspicion of neurologic lesion
• Plain X-ray

Management:
• Bladder drainage (emergency)
• Aseptic catheterization
• Gradual decompression to prevent rapid decompression syndrome (hematuria, hypotension
or post-obstructive dieresis)
• Antibiotics if infected urine: Nitrofurantoin (100mg, 8 hourly) while waiting for urine culture
and sensitivity.

Complications:
• Chronic urinary retention

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• Chronic renal failure
• Bladder stones
• Infection
• Bladder rupture

Management of Adult Acute Urinary Retention in the Community

Sudden and painful

inability to pass urine
despite the urge

History: age, sex, previous Physical examination (external

urethral pathology, previous genitation, DRE, neurological) and
urinary symptoms, DM basic chemistry and urinalysis

Distended
bladder on
examination

Attempt Urethral Catheterization

by experienced staff (Foley
catheter 16 CH)

Failed catheterization: Successful catheterization: Start

Sonography to rule out alphablockers and Keep catheter for 3
bladder tumor to 7 days and remove it (if BPH)

Place a suprapubic If BPH: if post -void If BPH: if post -void

cystostomy and leave a
residue (PVR)> 300 residue < 300 ml
14CH tube

Refer to urologist Refer to Keep on

for further specialist for medication
management further and moni tor
management PVR

Testicular torsion

Definition
Testicular torsion is the twisting of the spermatic cord, which cuts off the blood supply to the testicle
and surrounding structures within the scrotum. It is the most common cause of acute scrotal pain in boys.

Causes:
• Inadequate connective tissue within the scrotum (Belly-Clapper deformity)
• Trauma to the scrotum, particularly if significant swelling occurs
• Strenuous exercise
• The condition is more common during infancy (first year of life) and at the beginning of
adolescence (13 -18 years).

Signs and symptoms

• Acute scrotal pain

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• Swelling of the scrotum or testis

• High transverse lying testis
• Nausea or vomiting
• Light-headedness
• Testicle lump
• Blood in the semen

Investigations
• The diagnosis is mainly clinical
• Scrotal ultrasound with colour Doppler if available, but should not delay exploration.

Management
• Urgent surgical exploration within 6 hours to save testis.
• Manual detorsion (open book manoeuver) may be tried if theatre not available but
does not replace surgical exploration.
• Reduction and orchidopexy if testis still viable.
• If testis still ischemic after detorsion, wrap it in warm gauzes for 15 -20 minutes.
• Orchiectomy if testis is infarcted.
• Perform contralateral orchidopexy

Complications:
• Loss of testis
• Testicular atrophy (shrink) and need to be surgically removed
• Severe infection of the testicle and scrotum possible if the blood flow is restricted for a
prolonged period
• Risk of infertility (breach of blood-testis-barrier).

Management of Acute Scrotum in the Community

Acute scrotal pain and

swelling

Sudden and short

Longduration,
durationlower
lower duration onset
Long
urinary tractsymptoms
symptoms especially in adolescent
urina ry tract with no urinary
symptoms

Echo -doppler (if

Surgical exploration
possible)

Absent or decreased
arterial flow in the testis Increased or normal
or doubt or no doppler blood flow
available

Surgical exploration Conservative treatment

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Renal and Ureteric colic

Definition:
Sudden and severe flank pain (often recurrent) due to an obstructing stone in the ureter
causing the dilatation of upper urinary tract.

Causes
Renal and ureteric colics are most of the time caused by renal stones that are descending into the
ureter. These stones are in most cases calcium-oxalate calculi associated with increased calcium,
oxalates level in the urine. There are other common types of stones as well: struvites (magnesium
ammonium phosphate), uric acid, cystine.

History
Patients may report a sudden and severe colicky flank pain irradiating to the groin, the testicle or labia
major; several patients have prior history of stone disease and therefore have been experiencing
similar episodes. Complaints of persistent dull pain in the costo-vertebral angle often points to the
existing kidney stones; often patients report history of urinary tract infection and hematuria, nausea
and vomiting. The absence of gastrointestinal and gynecology symptoms may rule out differentials
such as acute appendicitis or ruptured ectopic pregnancy, etc.

Physical examination
Often examination is difficult as the patient is restless and does not hold in one position; between
attacks the abdomen may be palpated and found soft with no signs of peritoneal irritation; depending
on the location there may be some moderate tenderness in the upper quadrant (stone blocked in the
pyeloureteric junction), right iliac fossa (stone blocked at the iliac crossing) or the lateral suprapubic
region (stone blocked in the ureterovesical junction). Presence of fever may signal a complicated stone
with acute pyelonephritis.

Diagnosis
• Urine microscopy and culture may show microscopic hematuria and pyuria if existing infection
• Abdomen sonography may demonstrate ipsilateral hydronephrosis or stone (s) in the
pyelocaliceal system
• Non-Contrast CT scan of the abdomen is generally the gold standard imaging modality to
confirm the presence of radio-opaque calculi
• KUB or Plain X-Ray of the abdomen may also confirm the diagnosis
• Blood Urea Nitrogen and serum creatine assesses the renal function

Management
• Analgesia: if oral route possible try NSAIDs:ibuprofen PO 400mg bd; add parenteral opiods
such as morphine 10 mg every 4 hours (if necessary).
• IV fluids
• The patient should be transferred for further management after pain control
• Alphablockers such as tamsulosin capsules 0.4 mg orally if stone burden less than 5 mm.
• If suspicion of pyelonephritis, add empirical antibiotherapy targeting Enterobacteriaceae
(mostly E. Coli, Klebsiella species, Pseudomonas species…): Nitrofurantoin PO 100mg tid (First
line); Cefuroxime IV 750 mg every 8 hours) and adjust after culture and sensitivity results are
available.
• If stone is over 5 mm diameter or if hydronephrosis, a ureteric stent or nephrostomy may be
placed in emergency.
• Definitive treatment will depend upon position and size of the stone and technology available:
percutaneous laser/ultrasonic/pneumatic lithotripsy, ureteroscopic laser lithotripsy, external
shock-wave lithotripsy (ESWL).

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Management of a suspicion of ureteric colic

Dalziel PJ, Noble VE. Bedside ultrasound and the assessment of renal colic: a review. Emergency
Medicine Journal 2013;30:3-8.

Gross hematuria

Causes/ risk factors:

• Pseudohematuria: menses, dyes (beets, rhodamine B in drinks, candy and juices),
hemoglobin (hemolytic anemia), myoglobin (rhabdomyolysis), porphyria, laxatives
(phenolphthalein)
• Based on source of bleeding: pre-renal, anticoagulants, coagulation defects, sickle cell
disease, leukemia
• Renal: renal tumors, infections, trauma

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• Ureter:stone, tumour, trauma
• Bladder: infections, tumour, stone, trauma
• Urethra: infections, stone, tumour, urethral stricture, trauma

Diagnosis:
• History: flank pain, irritative or obstructive symptoms, recent UTI, STDs, TB exposure,
pelvic, irradiation, bleeding diathesis, smoking, drugs (NSAIDs, anticoagulants),
diabetes, sickle cell anemia, polycystic kidney disease, urinary tract calculi
• Physical exam:
œ.2. abdominal exam - abdominal masses (including renal or bladder) or
tenderness
œ.3. GU exam - DRE for prostate, external genitalia in males
Investigations:
• FBC (rule out anemia, leukocytosis)
• chemistry: electrolytes, creatinine, BUN
• urinalysis: culture and sensitivity and cytology
• ultrasound
• CT with contrast
• Cystoscopy
• intravenous pyelogram (IVP)

Management
• Irrigation with normal saline to remove clots
• Cystoscopy and stop bleeding
• Continuous irrigation
• Refer to specialized center for further management depending on causes (TURBT, TURP,
Cystectomy)

Fournier’s gangrene

Definition: it is a necrotizing fasciitis of the genitalia and perineum. It affects mostly males than
females.

Causes/risk factors:
• Uretheral stricture
• Perirectal abcesses
• Poor perineal hygiene
• Diabetes
• HIV
• Other immunocompromising conditions.

Signs and symptoms

• Fever
• Perineal and scrotal pain
• Cellulitis
• Necrosis of the scrotum
• Crepitus

Investigations:
• FBC
• HIV test
• Glycemia
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• Urinalysis
• Pus culture for sensitivity

Management
• Prompt debridement of nonviable tissues with subsequent relook debridements as
necessary.
• Broad spectrum antibiotics (Ciprofloxacin IV 400 mg BID+ Metronidazole IV 500 mg
TID + Clindamycin IV 300 mg TID) ; adjust as soon as the culture results are available.
• Suprapubic cystostomy if urethral stricture
• Colostomy , if there is damage to the external anal sphincter
• Glucemia control and adequate nutrition are necessary to facilitate wound healing
• Refer to specialized center for reconstruction when the wound is clean

Priapism

Definition
Priapism is a persistent erection for greater than 4 hours unrelated to sexual stimulation. It can be low
flow (ischemic) or high flow (non-ischemic).

Causes/risk factors:
• Most priapiasms are idiopathic
• Sickle cell disease
• Medication (e.g. antidepressant anti psychosis_chlorpromazine, ..)
• Pelvic tumors
• Malignancies (leukemia)
• Spine cord injury
• Penile injections for erectile dysfunction
• Cocaine abuse
• Total perenteral nutrition
• Pelvic trauma

Signs and symptoms

• Persistent erection
• Tenderness of the penis
• Rigid cavernous bodies with flaccid glans
•

Investigation:
• FBC
• Blood gases
• Peripheral blood film
• Abdominal ultrasound

Additional investigations (Color Doppler ultrasound, Angiography) may be needed to establish the
diagnosis.

Management
• Low flow priapism:
o Medical management if Priapism resulted from sickle cell disease and leukemia
• hydration,
• oxygenation

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• alkalinisation
• Transfusions or exchange transfusions should be considered
o Surgical management:
• Irrigation and aspiration of corpora cavernosa with intracavernosal
injection of phenylephrine (use a mixture of phenylephrine 1ml:1000
mcg and dilute it with an additional 9 ml of normal saline. Inject 0.3-
0.5 ml into the corpora cavernosa, waiting 10-15 minutes between
injections).
• If phenylephrine is not available, epinephrine can be used.
• Distal shunt
• Proximal shunt if distal shunt fails
• High flow priapism
o Selective angio-embolisation
o Fistula surgical ligation if embolisation fails

Paraphimosis

Definition: It is the retraction of foreskin behind the corona of the glans penis reducing a tonic effect.

Causes:
• Trauma
• Iatrogenic

Signs and symptoms

• Oedema of the foreskin and glans penis
• Pain
• Foreskin ulceration

Management
• Reduction under local anesthesia
o Puncture then squeeze the oedematous foreskin
o If not successful, do a dorsal slit.
• Delayed Circumcision after oedema subsided

--|Urinary Tract Infections

Definition
It is a significant bacteriuria of the urinary system (colony count of greater than 100000 organisms
per milliliter). It may affect upper urinary tract (pyelonephritis, renal abscess) or lower urinary tract
(cystitis, urethritis), or both.

Cause/Risk factors:
• Urinary tract obstruction
• Instrumentation (e.g in-dwelling catheter)
• Neurogenic bladder
• Urolithiasis
• Diabetes mellitus
• Vesico-ureteric reflux
• Immunosuppression
• Pregnancy

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Signs and symptoms

• Upper UTI
o Fever
o Chills/rigors
o Flank pain
o Malaise
o Anorexia
o Costovertebral angle and abdominal tenderness
• Lower UTI
o Dysuria
o Frequency
o Urgency
o Suprapubic pain
o Hematuria
o Scrotal pain(epididymo-orchitis) or perineal pain(prostatitis)

Investigations:
• Upper urinary tract infection
o FBC
o Urinalysis
o Renal function tests
o Electrolytes
o Renal ultrasound
o Intravenous urogram
o CT scan
o Isotope scan
• Lower urinary tract infections
o FBC
o Urinalysis
o Cystoscopy (if hematuria or obstruction)
o Ultrasound,
o CT IVU (intravenous urography)

Management
• If upper UTI:
o Treat underlying causes ( e.g relieve obstruction)
o Appropriate antibiotic therapy. Use Nitrofurantoin PO 100 mg TID as first choice if
no fever. If septic use Cephalexin IV 500 mg 6 hourly for 7 days.
o Adjust antibiotherapy after culture results.
o If abcess it should be drained.
• If Cystitis and uncomplicated lower UTI:
o Treat underlying causes( e.g relieve obstruction)
o Managed with oral antibiotics: First choice is Nitrofurantoin PO 100 mg 12 hourly for
5 days, second choice is Cefuroxime 500 mg 12 hourly for 5 days)
o Adjust antibiotherapy as per culture results.
o Encourage high fluid intake
• If there is poor response treatment, consider unusual UTI;
o Tuberculosis (sterile pyuria)
o Candiduria
o Schistosomiasis
o N.gonorrhea
o Chlamydia trachomatis

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Complications:
• Bacteremia and septic shock
• Chronic pyelonephritis leading to chronic kidney disease
• Xanthogranulomatous pyelonephritis
• Renal and perinephric abcesses
• Emphysematous nephritis

--|Benign Prostatic Hyperplasia (BPH)

Definition
An increase in size of the inner zone of the prostate gland. It is a disease of the aged men.

Causes:
• Not known
• Predisposing factors are age, normally functioning testes, race, geographical location, sexual
behavior, diet, alcohol, tobacco (no evidence that they play a part).

Signs and symptoms:

• Urinary frequency - The need to urinate frequently during the day or night (nocturia), usually
voiding only small amounts of urine with each episode
• Urinary urgency - The sudden, urgent need to urinate, owing to the sensation of imminent loss
of urine without control
• Hesitancy - Difficulty initiating the urinary stream; interrupted, weak stream
• Incomplete bladder emptying - The feeling of persistent residual urine, regardless of the
frequency of urination
• Straining - The need strain or push (Valsalva maneuver) to initiate and maintain urination in
order to more fully evacuate the bladder
• Decreased force of stream - The subjective loss of force of the urinary stream over time
• Dribbling - The loss of small amounts of urine due to a poor urinary stream
A sexual history is important, as epidemiologic studies have identified LUTS as an independent risk
factor for erectile dysfunction and ejaculatory dysfunction.

Physical examination
Conduct a focused physical examination to assess the suprapubic area for signs of bladder distention
and a neurological examination for sensory and motor deficits.
The digital rectal examination (DRE) is an integral part of the evaluation in men with presumed BPH.
During this portion of the examination, prostate size and contour can be assessed, nodules can be
evaluated, and areas suggestive of malignancy can be detected.
Decreased anal sphincter tone or the lack of a bulbocavernosus muscle reflex may indicate an
underlying neurological disorder.

Investigation

Urinalysis and Urine Culture

Examine the urine using dipstick methods and/or via centrifuged sediment evaluation to assess for the
presence of blood, leukocytes, bacteria, protein, or glucose.
A urine culture may be useful to exclude infectious causes of irritative voiding. It is usually performed
if the initial urinalysis findings indicate an abnormality.

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Prostate-Specific Antigen
Although BPH does not cause prostate cancer, men at risk for BPH are also at risk for prostate cancer
and should be screened accordingly. Screening for prostate cancer remains controversial and should
done after an informed discussion between the physician and patient.
A physician should discuss the risks and benefits of PSA screening with the patient. Notably, men with
larger prostates may have slightly higher PSA levels.

Electrolytes, BUN, and Creatinine

These evaluations are useful screening tools for chronic renal insufficiency in patients who have high
post-void residual (PVR) urine volumes. A routine serum creatinine measurement is not indicated in the
initial evaluation of men with lower urinary tract symptoms (LUTS) secondary to BPH. 1

Ultrasonography
Ultrasonography (abdominal, renal, transrectal) are useful for helping determine bladder and
prostate size and the degree of hydronephrosis (if any) in patients with urinary retention or signs of
renal insufficiency.
Transrectal ultrasonography (TRUS) of the prostate is recommended in selected patients, to determine
the dimensions and volume of the prostate gland.

Imaging of the upper tracts is indicated in patients who present with any of the following:
• Concomitant hematuria
• A history of urolithiasis
• An elevated creatinine level
• High PVR volume
• History of upper urinary tract infection
Other imaging studies, such as CT scanning and MRI, have no role in the evaluation and treatment of
uncomplicated BPH.

Differential Diagnosis
• Bladder Cancer
• Bladder Stones
• Bladder Trauma
• Interstitial Cystitis
• Neurogenic Bladder
• Prostatitis
• Radiation Cystitis
• Urethral Strictures in Males
• Urinary Tract Infection (UTI) in Males

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Management:

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IPSS

Approach Considerations
Therapeutic options for benign prostatic hyperplasia (BPH) include the following:
• Watchful waiting for patients with mild symptoms.
• Drug therapy for patients with moderate to severe symproms:
o Alpha-blockers (Tamsulosin 0.4 mg OD) alone,
o 5-alpha-reductase inhibitors(Dutasteride 0.5 mg OD, Finasteride 5 mg OD)
o Combined therapy
• Surgical management:
o Open simple prostatectomy
o Minimally invasive procedures (TURP, Traansurethral needle ablation, Transurethral
incision of prostate, Laser vaporisation, Laser enucleation, Urolift)

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--|Urethral Stricture
Definition
It is a narrowing of the urethra lumen

Causes
• Congenital
• Failure of normal canalization
• Trauma
• Urethral instrumentation (mostcommon, at fossa navicularis)
• External trauma
• Sexually transmitted infections especially Chlamydia/Gonorrhea
• Long-term indwelling catheter
• Balanitis xerotica obliterans (Linchens sclerosus)

Signs and symptoms:

• Decreased flow/amount of urinary stream
• Sense of incomplete voiding
• Double stream (Intermittency)
• Post-void dribbling
• History of recurrent UTI (urethritis, prostatitis, and epididymo-orchitis).

Investigations:
• Dynamic urodynamics: flow rates < 10 mL/s (normal = 20 mL/s)
• Urine culture
• Urethrogram, VCUG(voiding cysto-urethrography ) will demonstrate location of stricture.
• Urethroscopy

Management
• urethral dilatation
o Temporarily increases lumen size by breaking up scar tissue
o healing will reform scar tissue and recreate stricture
o not usually curative
• Internal urethrotomy (IU)
o Endoscopically incise stricture without skin incision
• Only single and short (< 1 cm) bulbar urethra strictures respond well
• Cure rate 50-80% with single treatment, < 50% with repeated courses

Open surgical reconstruction;

o Complete stricture excision for all, then (dependent on location and size of stricture):
• Membranous urethra – end-to-end anastomosis
• Bulbar urethra < 2 cm – end-to-end anastomosis
• Bulbar urethra > 2 cm or penile urethra:Substitution urethroplasty using
various grafts. The most commonly used is the buccal mucosa.

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--|Common Congenital Urological Disorders

Ureteropelvic Junction Obstruction (UPJO)

Definition: blockage of the ureter where it meets the renal pelvis

Causes:
- Congenital from either abnormalities of the muscles itself or crossing vessels

Signs and symptoms:

- Abdominal mass in the new born
- Flank pain and infection in later life

Investigations:
- Ultrasound
- CT Urography
- Diuretic renal scan

Management
- Pyeloplasty (Anderson- Hayne)

Posterior Urethra Valves (PUV)

Definition: obstructive urethral lesions usually diagnosed in male newborns and infants. They are thin
membranous folds located in the prostatic urethra. It is the most common cause of lower urinary tract
obstruction in newborn and infants.

Cause and risk factors:

• Congenital

Signs and symptoms

• .
• Urinary retention
• Weak stream
• Dysuria( infection)
• Able to pass catheter without difficulty
• May present late if incomplete valves

Investigations
• Urinalysis
• Ultrasound scan
• Voiding cysto-urethrogram (dilatation of the urethra above the valves)

Management:
• Detect and treat early to avoid renal failure
• Vesicostomy
• Transurethral resection and/or furguration of valves

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Vesico-ureteric reflux

Definition
It is a congenital condition from the ureteral bud coming off too close to the urogenital sinus on
the mesonephric duct which result in short intravesical length (intramural) of ureter. Urine travels
retrograde from the bladder into the ureter and often into the kidney.

Signs and symptoms:

• Fever
• Evaluate
o Any child with febrile urinary infection
o Any boy with urinary infection
o Any girl with recurrent UTI

Investigations:
• Ultrasonography
• Voiding cystourethrogram
• Hereditary, be suspicious in siblings and screen with imaging studies

Management
• Low grade reflux,
o Conservative treatment with observation and antibioprophylaxis (Nitrofurantoin 1-2
mg/kg/day in children > 3 months and Amoxicillin 5 mg/kg/day in children < 3months)
o Close follow up
o Treat voiding dysfunction
• High grade reflux
o Surgical intervention with ureteral re-implantation

Undescended testis

Definition: interruption of the normal descent of the testis into the scrotum

Causes/risk factors:
• Low birth weight
• Premature birth
• Family history of undescended testicles or other problems of genital development
• Conditions of the fetus that can restrict growth, such as Down syndrome or an abdominal wall
defect
• Alcohol use by the mother during pregnancy
• Cigarette smoking by the mother or exposure to second hand smoke
• Parents' exposure to some pesticides

Signs and symptoms

• Absence of testis in the scrotum
• Palpable mass in the inguinal canal
• Difficult or impossible to palpate the testis(abdominal testis or congenital absence of the
testis)

Investigation:
• The diagnosis is mainly clinical
• Ultrasound or MRI may be used to localize the testis but have low sensitivity.

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Management
• Exploration and orchidopexy
• It testis palpable: inguinal approach orchidopexy
• If testis not palpable: laparoscopic exploration and 1 or 2 stages orchidopexy is the gold
standard.

Hypospadias

Definition: a condition where the urethral orifice opens in abnormal position on the ventral surface
of the penis or scrotum

Causes /risk factors:

• Use of maternal estrogen or progesterone during pregnancy
• Hereditary

Signs and symptoms:

• Difficulty directing the urinary stream and stream spraying
• Penile chordee (ventral curvature)
• Having to sit down to urinate
• Malformed foreskin that makes the penis look "hooded" (dorsal hood)

Investigations:
• The diagnosis is mainly clinical
• Karyotype if perineal hypospadias associated with bilateral non palpable gonads.

Complications:
• Difficulty with toilet training
• Problems with sexual intercourse in adulthood with infertility
• Urethral strictures and fistulas may form throughout life

Management:
• Infants with hypospadias should not be circumcised
• For distal hypospadias (e.g glandular hypospadias) require no treatment
• Surgical management:
o Orthoplasty
o Urethroplasty
o Glansplasty
o
o The repair may require multiple surgeries

Recommendations:
• Surgery is usually done before the child starts school
• Surgery can be done as young as 4 months old, better before the child is 18 months old

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--|Urological Malignancies
Kidney cancers

* Renal cell carcinoma

Occurs in young adults

Signs and symptoms

• A triad of pain hematuria and frank mass
• Weight loss
• Fever,
• Erythrocytosis
• Eight sided varicocele which occurs sudden
• Hypertension
• Paraneoplastic syndromes(hypercalcemia, hypertension, polycythemia and stauffer’s
syndrome)

Complications:
• RCC can extend into renal vein, up the IVC (inferior vena cava) and into the atrium

Management
• Surgery:
o Partial nephrectomy, if small peripheral lesions < 3 mm
o Radical nephrectomy ( Gerota’s fascia and regional lymphnodes)
• Renal artery embolisation( may stop hematuria)
• Chemotherapy (10% response rate)
• Hormonal therapy (5% response rate)
• Immunotherapy
• Palliation
• Isolated lung metastases should also be removed surgically

* Nephroblastoma or WILMS TUMORS

Definition
It is the most common solid renal tumor of childhood, accounting for roughly 5% of childhood
cancers. It is an embryonic tumor arising from nephrogenic tissue.

Signs and symptoms:

• An abdominal mass(incidental)
• Abdominal pain
• Fever/ convulsions
• Cough
• Anorexia
• Nausea and vomiting
• Hematuria (in about 20% of cases)
• High blood pressure in 25 – 60%
• Coagulopathy can occur in 10%

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Investigations
• FBC
• Renal function test
• Liver function test
• Ultrasound
• CT scan or MRI
• Chest x-ray
• Plain abdominal x ray
• IVP

Management
• If unilateral tumours:
o chemotherapy: Adriamycin, vincristine or doxorubicine for 52 weeks followed
by
o Radical nephrectomy
• If bilateral tumours:
o Partial nephrectomy + chemotherapy
o Radiotherapy

* Tumors of the renal pelvis and the ureter

They are relatively rare. They account for approximately 10% of all renal tumors and approximately
5% of all urotherial tumors.

Causes/risk factors:
• Tobacco smoking
• Drinking coffee (observed for people who take > 7cups of coffee/day)
• Analgesic abuse
• Chronic infections, irritations
• Hereditary

Signs and symptoms:

• Painless intermittent hematuria
• Clot colic
• Loin pain
• Anorexia
• Dysuria
• Weight loss
• abdominal mass palpable in 5%

Investigation:
• Urine cytology
• IVU
• Ultrasonography
• Retrograde ureterography
• Antigrade pylography
• CT scan
• Chest x ray
• Cystoscopy
• Ureteroscopy
Management:

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• Nephro-ureterectomy and partial cystectomy.

• Chemotherapy in case of metastases
• Refer to specialized center

Bladder cancer

Definition
Bladder cancer is a cancer that starts in the bladder; 90% is transitional cell carcinoma,
5-7% is squamous cell carcinoma, and 1-2% is adenocarcinoma /Urachal carcinoma.

Classification of bladder cancers:

I. Papillary tumors: have a wart-like appearance and are attached to a stalk
II. Non-papillary (sessile): tumors are much less common, but more invasive and have a
worse outcome

Signs and symptoms:

- Painless gross haematuria is the commonest presentation
- Microscopic heamaturia
- Irritative voiding symptoms

Causes/Risk factors:
- Cigarette smoking
- Age
- Drugs (Cyclophosphamide, Phenacetin)
- Chemical exposure at work – carcinogens (dye workers, rubber workers, aluminum
workers, leather workers, truck drivers, and pesticide applicators)
- Radiation treatment
- Chronic bladder infections

Investigations:
- Urine cytology
- Cystoscopy
- Upper tract/abdominal/pelvic evaluation with CT scan or intravenous pyelography (IVP)
- TURBT for tissue diagnosis ( Histopathological analysis)
If tests confirm bladder cancer, staging is done to see if the cancer has spread. Staging helps
guide future treatment and follow-up and gives idea on patient prognosis.

Management
Treatment depends on the stage of the cancer, the severity of disease symptoms and performance
status.
Stage 0 and I treatments:
• TURBT
• Intravesical chemotherapy or immunotherapy
• Radiotherapy +/- chemotherapy

Stage II and III treatments:

• Radical cystectomy
• Partial cystectomy in selected cases
• Neo-adjuvant chemotherapy
• Concurrent chemoradiation
Most patients with stage IV tumors cannot be cured and surgery is not appropriate. In these patients,
palliative chemotherapy is often considered.

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Prostatic cancer

Adenocarcinoma is the most common type (greater than 90%). It primarily develops in peripheral
zone of the prostate gland

Causes/Risk factors:
• Age
• Family history
• Smoking

Symptoms and Signs

• Localized disease: Vast majority -presents with an abnormal digital rectal examination or PSA
screening
• Locally advanced disease: Lower urinary symptoms – hesitancy, weak stream, frequency,
nocturia, incomplete bladder emptying.
• Metastatic disease: Constitutional symptoms, bony pain

Investigations:
• History and Physical examination including DRE
• Laboratory: PSA, CBC, Calcium profile, creatinine, ALP and LFTs
• Transrectal biopsy: Typically, 10-12 cores
• Radiology: CT chest/abdomen/pelvis
• If symptoms or signs of cord compression: MRI whole spine.

Management
• Localized /locally advanced Prostate Cancer: Based on the risk stratification, the following
treatment options can be utilized either as a single modality or in combination.
1. Watchful waiting
2. Active Surveillance
3. Radical prostatectomy
4. External Beam Radiotherapy (EBRT)
5. Androgen deprivation therapy (ADT)

• Metastatic Prostate Cancer

• ADT
• Combined chemohormonal therapy (ADT +Docetaxel)
• ADT + Abiraterone

Penile cancer

The majority of penis malignancies are squamous cell carcinomas

Causes and risk factors:

• Human papillovirus (HPV) and balanitis xerotica obliterans infection
• Smoking
• Phimosis
• UV light
• Immunosuppression
• Poor hygiene related to non-circumcision and STDs

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Signs and symptoms:

• Redness
• Irritation
• Sore on the penis
• Indurations or erythema
• Ulceration
• Small nodule, or an exophytic growth

Diagnosis
• Biopsy for histopathological confirmation

Management
Primary lesion:
• Circumcision: lesion localized to the prepuce
• Radiotherapy: glans alone affected and tumor ≤ 1cm
• Glans resurfacing
• Partial amputation/penectomyif shaft of the penis is involved
• Total amputationif extensive involvement of the shaft
• Antibiotics for 6 weeks before evaluating the inguinal nodes
Inguinal lymph nodes:
• Careful follow up if Impalpable nodes
• Radical dissection if palpable mobile nodes persisting 3 months after initial treatment
• Fixed inguinal lymph node: Chemotherapy or concurrent chemoradiation.

Testicular cancer

Definition: Testicular cancer is the malignant lesion of the testis

Risk factors:
• Cryptorchidism
• Germ Cell Neoplasia in situ
• Hypospadias
• Contralateral testicular cancer
• HIV infections

Signs and symptoms

• Painless swelling of the testis
• Vague testicular discomfort
• Dull ache in lower abdomen
• Back pain
• Rarely, evidence of metastatic disease or gynecomastia
• Hard irregular non tender testicular mass

Investigations:
• Laboratory: FBC, LFTs , RFTs , Blood for tumor markers, AFP and beta -HCG , LDH
• Imaging: Scrotal ultrasound , Chest X-Ray to assess lungs and mediastinum, CT scan of the
chest and abdomen to detect lymph nodes
• Diagnostic Procedures: Radical inguinal orchidectomy

Management
• Testicular biopsy should not be done except in selected cases (bilateral involvement and
single testis)

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• Inguinal radical orchidectomy
• Further treatments depend on histology and staging

If Seminoma:
- Stage I and II: Radical orchiectomy followed by either observation, chemotherapy or
radiotherapy.
- Stage III: Chemotherapy (bleomycin, cisplatin and etoposide)

If non seminoma germ cell:

- Stage I: Orchiectomy + Retroperitoneal lymph node dissection (RPLND).
- stage II: Orchiectomy followed by RPLND +/- chemotherapy
- stage III: Chemotherapy

--|Urinary Stones
Kidney/Ureter stones

Calcium stones (Ca oxalate, Ca phosphate) are the most common types in 70% of the cases.

Causes:
• Renal infections
• Inadequate urinary drainage and urinary stasis
• Prolonged immobilization
• Decreased urinary citrate
• Dietetic( deficiency of vitamin A)
• Altered urinary solutes and colloids
• Hyperparathyroidism

Signs and symptoms

• Asymptomatic (non-obstructive renal stones)
• Flank pain (colicky radiating to the lateral abdomen forproximal ureteral stones or pain that
irradiate into the groin and genitals fordistal ureteral stones)
• Microscopic or gross hematuria
• Obstructive pyelonephritis with signs of sepsis)

Investigations:
• Kidney/Ureter(KUB) X-ray
• Abdominal ultrasound
• Non contrast CT scan of the abdomen

Management
• Extracorporeal shock wave lithotripsy( ESWL) if non obstructive renal stones less than 2.5 cm
• Percutaneous nephrolithotomy(PCNL), if large renal stone
• Ureteroscopic lithrotripsy
• Cystoscopy with stent placement

Bladder stones/calculi

Definition: Bladder calculi/stones are hard build-ups of minerals that form in the urinary bladder

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Causes:
• Calculi from the kidney
• Bladder outflow obstruction
• Presence of foreign bodies( e.g. urethral catheter)
• Neuropathic bladders
• Bladder diverticulum
• Enlarged prostate
• Urinary tract infection

Signs and symptoms:

• Abdominal pain, pressure
• Pain, discomfort in the penis
• Dysuria with frequent urge to urinate
• Abnormally colored or dark-colored urine
• Frequency
• Hematuria
• Nocturia
• Hesitancy
• Weak stream
• Sadden cessation of flow with pain in the perineum and tip of the penis
• Urinary incontinence may also be associated with bladder stones
• Rectal examination may reveal an enlarged prostate

Investigations
• Urinalysis may show blood in the urine, crystals, or an infection
• Urinary culture (clean catch) may reveal infection
• IVP
• Ultrasound
• Bladder or pelvic x-ray may show stones
• Cystoscopy can reveal a stone in the bladder

Complications:
• Acute bilateral obstructive uropathy
• Bladder cancer in severe, long-term cases
• Chronic bladder dysfunction (incontinence or urinary retention)
• Obstruction of the urethra
• Recurrence of stones
• Reflux nephropathy
• Urinary tract infection

Management
• Drinking 6 - 8 glasses of water or more per day to increase urinary output may help the
stones pass
• Remove stones that do not pass on their own using a cystoscope and graspers
• Treat causes of bladder outlet obstruction
• Transurethral resection of the prostate (TURP) with stone removal
• Medications are rarely used to dissolve the stones.
• Removal of the stones (endoscopically/open surgery_ cystolithotomy for very large stones)

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--|Other Common urological conditions
Impotence

Definition: persistent inability to obtain and sustain an erection sufficient for sexual intercourse

Causes
• Psychologenic (80%)
• Neurological causes (spinal cord lesions, myelodisplasia, multiple sclerosis, Tabes dorsalis,
peripheral neuropathies)
• Diabetes mellitus
• Endocrine (Hypogonadotrophic hypogonadism, klinefelter’s syndrome or surgical orchidectomy)
• Low testosterone levels (prolactin producing tumors)
• Vascular (Atherosclerosis)
• Trauma (perineal, posterior urethra, pelvic fracture leading to arterial injury, uraemic chronic
dialysis
• Iatrogenic (Radical prostatectomy, cystoprostatectomy, neurological surgical procedures,
transurethral endoscopic procedures, Pelvic irradiation procedures)
• Medications (centrally acting agents, anticholinergic agents (antidepressant), anti-androgenic
agents (digoxin), hyperprolactinemic agent (cimetidine), sympatholitic agent(methyldopa).

Diagnosis
• Detailed history
• Physical examination
o Length, plaques and deformity of the corporal bodies of penis
o Presence or absence of testis
o Size and consistency of the penis
o Gynecomastia( endrogene deficiency)
o Neurological assessment
o Sensory function of the penis and perineal skin
o Bulbocavernosus reflex to evaluate the sacral reflexes

Investigations
• Nocturnal penile tumescence (change in penis size during sleep)
• Dynamic infusion cavernosometry and cavernosonography (to assess venous/corporal leak)
• Check for systemic disease (FBC, random blood sugar, lipid profile)

Management
• Psychological: treated by trained psychotherapist or sex therapist
• Medical therapy:
o Sildenafil(viagra), tadalafil(cialis)
o Apomorphine(uprima)
o Intracorporal administration of vasoactive substances (papaverine hydrochloride
alone or associated with vasodilator like phentolamine, or prostaglandin E1)
o Androgen replacement therapy with testosterone
o Vacuum suction devices
- Surgical therapy:
o Penile prostheses
o Vascular surgical techniques like micro surgical anastomosis of inferior epigastric
artery to the dorsal penile artery.

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Vesicovaginal fistulas

Causes
• Obstetric: The usual cause is protracted or neglected labor
• Gynecological: Total hysterectomy and anterior colporrhaphy
• Radiotherapy: Direct neoplastic infiltration
• Exceptionally: carcinoma of the cervix invading the bladder.

Signs and symptoms:

• Leakage of urine from the vagina
• Excoriation of the vulva.
• Vaginal examination may reveal a localized thickening on its anterior wall or in the vault.
• On speculum: urine escaping from an opening in the anterior vaginal wall.

Investigation:
• The three-swab test
• Cystoscopy
• Bilateral retrograde cysto-urethrography
• IVP

Management:
• Conservative management: bladder drainage
• Surgical repair;
o Low fistula (subtrigonal): transvaginal repair.
• High fistulae (supratrigonal): suprapubic approach
A postoperative urethral catheter should be left in situ for at least 10 days

Incontinence

Definition: involuntary loss of urine

Table 2: Classification

Classification of incontinence according to anatomical abnormality

Signs and
Class Sub- class Causes/risk factors
symptoms
Urethral incompetence
Urethral Incontinence less common in men Involuntary
abnormalities after prostatectomy or pelvic urine loss
fracture
Urethral Inhibited detrusor contractions by: Frequency and
Bladder
incontinence neuropathic(detrusor hyperreflexia) urgency (urge
abnormality
non neuropathic(detrusor instability incontinence)
Non urinary
impaired mobility
abnormalities(in
Impaired mental function
elderly patients)
Non urethral Fistula
incontinence Ureteral ectopia

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Classification of incontinence according to clinical presentation
Ref.
Stress
Ref. anatomical classification anatomical
incontinence
classification
Ref.
Urge
Ref. anatomical classification anatomical
incontinence
classification
Nocturnal
enuresis: bed Day time voiding abnormalities
wetting in older such as frequency and urgency
children
Constant urine Urinary fistula
wetness Ectopic ureter

Diagnosis:
• Detailed history
• Poor flow, Hesitancy,
• Post micturation dribble (outflow obstruction),
• Dysuria (infection)
• Hematuria (possibility of tumor)
• Sexual function (males), bowel function(both sex) point toward neurological cause
• Mobility and mental status
• Past or present illness (diabetes, surgery e.g Abdominal Perineal Resection, hysterectomy)
• DRE for the prostate in male
• DVE for female for cystoureterocele
• Neurological assessment

Investigations
o Urine microscopy and culture
o UltrasonographyUrodynamics
o Cystoscopy

Management
• If urge incontinence
o Treat the underlying cause (Overactive bladder, small capacity bladder)
o Pharmaceutical therapy: Anticholinegic (Oxybutynin PO 5 mg BD) ,

• If minor stress incontinence:

• Pelvic flow exercise
• Estrogen therapy
• s If major stress incontinence:
o Surgical treatment for female:
o Laparoscopic or retropubic uretropexy
o Anterior colporrhaphy
o Surgical treatment for male:
o Artificial urinary sphincter
o Urinary diversion (if medical treatment fails)
• If nocturnal enuresis:
o Bladder training during the day gradually increasing interval between voiding
o Voiding before going to bed
o Enuresis alarm at night
o Drugs: imipramine, ,oxybutynin, desmopressin

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Cystocele

Definition
is a protrusion of the bladder into the vagina due to defects in pelvic support.
Causes:
• Muscle straining during delivery
• Heavy lifting or repeated straining during bowel movements
• Oestrogen deficiency due to aging

Signs and symptoms:

• Urine leakage
• Incomplete emptying of the bladder.
• Frequency,
• Nocturia,
• Stress incontinence
• Bulging in the vagina

Investigations
• Urinalysis
• Ultrasonography

Management
• Mesh sling technique
• Transobturator tape (TOT)
• Transvaginal tape (TVT)
• Anterior colporrhaphy

Hydrocele

Definition: Hydrocele is the collection of fluid within tunica vaginalis. It can be communicating or non-
communicating.

Causes:
• congenital
• Idiopathic
• Secondary (intrascrotal pathology such us tumour, torsion, trauma or infection)

Signs and symptoms:

• Fluctuant
• Trans-illuminate
• Swelling
• Non tender

Investigations:
• Ultrasound
• Urinalysis
• FBC

Management
• Surgery
o Hydrocelectomy
o Herniotomy in communicating hydrocele

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Varicocele

Definition: is dilatation and tortuous veins within the pampiniform plexus of scrotal veins

Cause and risk factors:

• Valvular incompetency or absence of the valves at the termination of the left testicular vein
• Venous occlusion by renal or retroperitoneal tumors

Signs and symptoms:

• Common on the left side
• Dragging-like or aching pain within the scrotum
• Feeling of heaviness in the testicle
• Atrophy of the testicle
• Visible or palpable enlarged vein
• Likened to feeling a bag of worms

Investigations:
• Color Doppler ultrasonography

Management:
• Medical therapy: no effective medical treatment have been identified
• Embolization (first choice treatment)
• Varicocelectomy: either laparoscopic approach, inguinal approach, subinguinal approach or
scrotal approach).

Phimosis

Definition: Is tightness of the foreskin of such a degree as to prevent retraction

Causes:
• Congenital
• Secondary to infection

Signs and symptoms

• Ballooning of the foreskin during micturation
• Failure of retraction
• Small contracted orifice

Management
• Circumcision

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BURNS
Definition
Burns are the skin and tissue damage caused by exposure to or contact with extremes temperatures,
electrical current or a chemical agent or radiation.

Causes
• Thermal causes; Hot or cold exposure or contact with objects or liquids
• Chemical or caustic substances
• Electrical current

Symptoms and signs

• Pain when superficial
• Painless when very deep
• Discolored skin (Black, Red when superficial, white when very deep)
• Blisters (superficial burns)
• Moist, wet wound in skin
• Smell of burnt flesh
• Loss of skin

Assessment of burns
• Primary survey: ABC’s (As in all traumatic patients approach)
o Stop the burning process
o A: Airway:Check for erythyma and oedema of airway, to anticipate possible need for
early intubation
o B: Breathing (beware of inhalation, CO intoxication and rapid airway compromise)
o C: Circulation ( 2 large bores peripheral IV access, Fluid replacement)
o D: Disability (GCS, Compartment syndrome)
o E: Exposure ( % burn)

Note: Nasotracheal or endotracheal intubation is indicated especially if patient has severe

increasing hoarseness, difficulty swallowing secretions, or increased respiratory rate
with history of inhalation injury.
•Secondary survey
o Coincident trauma diagnosed and treated
o Burns are further characterized by estimating Extent of Burn depth
•First–degree
o Superficial (sunburn)
o Erythema, pain, absence of blisters
o Consists of epidermal damage alone
• Second-degree
o Entire epidermal layer
o Part of underlying dermis
o Mottled and red, painful, swelling and blisters
•Third-degree (Full thickness)
o Injury/Destruction of all epidermal and dermal elements
o Burn into subcutaneous fat or deeper
o Skin is charred and leathery (woody)
o Pearly-white sheen / waxy
o Generally NOT painful (nerve endings are dead)

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•Fourth-degree
o Full-thickness
o Extending into muscle, tendons or bones
o Typically involves appendage
o Black and dry
o NOT painful

•Use rule of nine to estimate the extent of burn (TBSA: Total burn surface area)

Management
Use Parkland formula for fluid replacement: % (TBSA burned) x (Weight in kg) x (4 ml lactated
Ringer’s/kg;
• Administer the first half of the volume in the first 8 hrs, then Administer the second half of the
volume in the following 16 hrs
• The timing starts when the burn occurred (Not when the patient arrived in the treatment
facility)
• MeasureINPUT and urine OUTPUT (output of 0.5 ml/kg/hr in adults and 1 cc/kg/hr in children
• Use Lactated Ringer’s solution
• Endpoints for Fluid Resuscitation
o Hourly Urine Output
o Heart Rate, Blood Pressure
o Acid-Base Status
o Filling Pressure (CVP, PAWP)

Burn Wound Treatment:

• Clean the burn area with normal saline for clean wounds, and hypertonic solution for infected
wounds
• debridement of devitalized tissue and debris
• Apply topical antibacterial agent
o Bacitracin ointment on Face / ears
o Silver sulfadiazine on the body
o Ensure aseptic procedures
• Escharotomy: when pulse less extremity with a circumferential burn
• Ensure effective pain management
• Provide tetanus prophylaxis to all burn patients. If without current tetanus immunization,
Requires tetanus immune globulin (TIG)
• Give antibiotic for infected wounds: IV cloxacilline 100mg/kg in children and 3gm in adults
(in three divided doses perday, 5-7days)

--|Electrical Burns
Definition: electrical burns are body injuries caused by the electrical current itself. The current
generates intense heat along its path through the body, which can lead to severe muscle, nerve and
blood vessel damage.

Causes:
• Lightning strikes and generated electrical power
• Exposure to electrical flow

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Signs and symptoms:

• Cardiac or respiratory arrest
• Intracranial hemorrhage and Coma
• Blunt trauma
• Severe burns

Diagnosis:
• Clinical
• Investigations
o CBC – Hemoglobin, hematocrit, white blood cell count
o Electrolytes – Sodium, potassium, chloride, carbon dioxide, blood urea nitrogen, glucose
o Urinalysis – Specific gravity, pH, hematuria, and urine myoglobin if urinalysis is positive
for hemoglobin
o A baseline assessment of muscle damage is established with Total CPK (followed byCPK
isoenzymes if total CPK is elevated)
o Urine myoglobin (followed by serum myoglobin if urine myoglobin is present) Creatinine
– High risk of rhabdomyolysis/myoglobinuria and creatine kinase (CK) levels
o Serum myoglobin – If urine is positive for myoglobin, a serum level should be obtained
o Arterial blood gas – To be obtained for patients needing ventilatory support, or those
with severe rhabdomyolysis who require urine alkalinization therapy
o Chest radiography
o CT scan of the head and spine
o MRI of the head and spine

Complications:
• Peripheral nerve injury
• Vascular damage
• Acute pulmonary complications
• Abdominal complications
• Bone lesions
• Multiple organ injuries

Management:
It is important to establish the type of exposure (high or low voltage), duration of contact, and falls
or other trauma.
• Hydration is the key to reducing the morbidity of electrical injuries
• Osmotic diuretic if muscle damage is significant
• Initial IVF resuscitation is with LR, up to 10cc/kg/hr
• Mannitol or furosemide to the fluid regimen of patients with elevated CPK and/or
myoglobinemia

NB: These drugs provide diuresis for the toxic myoglobin, which can help prevent acute tubal necrosis
and renal failure secondary to myoglobinuria

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Bites and Stings of Animals and
Insects
--|Animal Bites
Definition
Animal bites are wounds inflicted on the body due to animals sinking teeth into one’s body
Animal bites and scratches, even when they are minor, can become infected and spread bacteria
to other parts of the body.
Whether the bite is from a family pet or an animal in the wild, scratches and bites can carry
disease. Other animals can transmit rabies and tetanus.

Table 3. Animal bites.

Evaluation and Disposition of Post-exposure Prophylaxis

Animal Type
Animal Recommendations
Should not begin prophylaxis,
10 days observation, unless
Healthy and available
animal develops symptoms of
rabies
Dogs and cats
Immediate vaccination
Rabid or suspected rabid
(consider also tetanus toxoids)
Unknown (escaped) Consult public health officials
Regarded as rabid unless
Skunks, raccoons, bats, geographic area is known
foxes, and most other to be free of rabies or until Immediate vaccination
carnivores; woodchucks animal proven negative by
laboratory tests
Consult public health officials;
bites of squirrels, hamsters,
Livestock, rodents, and guinea pigs, gerbils, chipmunks,
lagomorphs (rabbits Consider individually rats, mice, other rodents,
and hares) rabbits, and hares almost
never require ant-rabies
treatment

--|Rabies
Definition: Rabies is a deadly viral infection that is mainly spread by infected animals

Causes:
Rabies is spread by infected saliva that enters the body through animal bite or broken skin
Animals known to spread rabies are;
• Dogs
• Bats
• Raccoons
• Foxes
• Skunks
The average incubation period is 3 - 7 weeks

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Clinical signs and symptoms:

• Paresthesia
• Headache
• Stiff neck
• Lethargy
• Pulmonary symptoms
• Maniacal behaviour
• Muscle spasm of throat with dysphasia
• Convulsion →coma →paralysis →death

Diagnosis:
• Clinical presentation of the patient and animal that inflicted the bite
• Investigations:
o immunofluorescence is used to look at the brain tissue after an animal is dead
o Pieces of skin and saliva analysis for presence of rabies

Complications:
• Coma and death
• Allergic reaction to the rabies vaccine (rare)

Management
• Local care
o Thorough irrigation
o Cleansing with soap solution
• Debridement of bite site
• human rabies immunoglobulin (HRIG), given the day the bite occurred
• Antibiotics in case of infection
• Rabies Vaccination in 5 days over 28 days:
o Rabies vaccine adsorbed (RVA) (Imovax)
o Human diploid cell rabies vaccine (HDCV)
o Either administered with HRIG (Imogan rabies)
o Vaccine administered intramuscularly in deltoid area for adult and anterolateral aspect
of thigh for children

Recommendations:
• Most of the time, stitches should not be used for animal bite wounds
• Immunization and treatment for possible rabies are recommended for at least up to 14 days
after exposure or a bite

--|Snakebites and venom

Definition:
Poisonous snakes inject venom using modified salivary glands

The venom apparatus

Venomous snakes of medical importance have a pair of enlarged teeth, the fangs, at the front of
their upper jaw.

These fangs contain a venom channel (like a hypodermic needle) or groove, along which venom can
be introduced deep into the tissues of their natural prey.

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If a human is bitten, venom is usually injected subcutaneously or intramuscularly. Spitting cobras can
squeeze the venom out of the tips of their fangs producing a fine spray directed towards the eyes of
an aggressor:

Causes:
• crotalidae or pit vipers snakes
• Coral snakes of the elapidae family
• Snakes with elliptical pupil
• Snakes with single row of sub caudal plates

Signs and symptoms:

• Eyes (Spitting cobras and ringhals can eject their venom quite accurately into the eyes of the
victims, resulting in direct eye pain and damage
• Swelling and tissue damage
• Suddenly develop breathing difficulty and go into shock
• Local effects (swollen, bleeding, blister and gangrene)
• Nervous system effects (vision problems, speaking and breathing trouble, and numbness close
to or distant to the bite site, and death without treatment)
• Muscle death (muscle necrosis, rhabdomyolysis, kidney failure)

Diagnosis
- History and clinical presentation

Clinical signs and symptoms:

• Hypotension
• Weakness
• Nausea/vomiting
• Pain, swelling, tenderness and ecchymosis at site of bite
• Paresthesia and muscle fasciculations
• Defect in blood coagulation
• Pulmonary edema

Grade Signs and Symptoms

0 – No envenomation Fang marks, min pain, small edema and erythema

I – Minimal Fang marks, mod to severe pain, surrounding edema

Envenomation and erythema
II – Moderate Fang marks, severe pain, edema, erythema, possible
Envenomation systemic involvement (nausea, vomiting, shock)
III – Severe Fang marks, large surrounding edema and erythema
Envenomation with generalized petechiae and ecchymosis
IV – Very severe Systemic effect present. Symptoms may include renal
Envenomation failure, coma, death
Table 4. Grading of envenomation

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Complications of snake bites

• The injection of even highly purified serum carries a risk of untoward reactions. The commonest
is serum sickness which may occur about ten days after the injection but sometimes sooner. It is
characterized by itching rashes and sometimes a rise in temperature and joint pains. Proper
treatment (antihistaminics, steroids) should alleviate the symptoms.

• A rare but far more serious complication is an acute serum reaction (anaphylaxis) with a
sudden drop in blood pressure and collapse within a few minutes. The risk of this type of
reaction in a healthy person is very slight but those with an allergic disposition, in particular a
history of asthma or infantile eczema, should not receive serum unless it is absolutely necessary
and then only with the greatest caution. Treatment for this condition includes the injection of
adrenalin

Management of snake bites

• Application of a tourniquet, incision and suction are appropriate if done within one hour from
time of bite
• Antivenon (crotalidae polyvalent immune)
• The dose of ant-venom serum required depends on the amount of venom injected by the
snake, not on the size or mass of the victim, and should not be reduced in the case of children
• The initial doze should be large; at least contents of 20 ml, but the condition of the patient
may demand the injection of up to 4 or 5 times as much
• When given intravenously, the venom serum should be at room temperature, and the injection
given very slowly, with the patient recumbent during injection, and at least one hour afterwards
• IVF required to replace the decreased extra cellular fluid volume resulting from edema
formation
• Fascial planes may become tense with obstruction of venoms and later arterial flow, requiring
fasciotomy
• Vit K may be required to correct bleeding and clotting abnormalities
• Tetanus toxoid administered and antibiotic recommended to prevent secondary infection

Recommendations
• When serum treatment, although not imminently urgent, may become necessary, a trial dose
of 0,1 mL of serum diluted 1:10 in sterile saline or water could be injected under the skin. If
there is no untoward reaction within half an hour, 0,2 mL of undiluted serum could be given in
the same way, to be followed, if necessary, by the full dose if no reaction occurs to this trial
dose
• Where possible, whenever serum is to be injected, the patient should be kept under observation
for at least 30 minutes after the injection, and adrenalin and corticosteroid kept in readiness
for emergency use.

--|Insect stings
Definition
A sting is usually from an attack by a venomous insect such as a bee or wasp, which uses this
as a defense mechanism by injecting toxic and painful venom through its stinger.
Insect bites and stings can be simply divided into 2 groups: venomous and non-venomous.
Whereas non-venomous insect bites pierce the skin to feed on your blood. This usually results
in intense itching.

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Table 5. Causes of insect bites and stings

Venomous (stingers) Non-venomous (biters)

Fire ants Bed bugs
Yellow jackets Fleas
Hornets Ticks
Wasps Lice
Bees Scabies
Caterpillars & moths
Mosquitoes

Signs and Symptoms

• Localized pain
• Petechial hemorrhages
• Swelling of skin and mucus membrane
• Generalized erythema
• Abdominal cramps
• Pulmonary and cerebral edema
• Blurred vision
• Vascular collapse
• Death results from combination of shock,
• respiratory failure and CNS changes
• Most death from insect sting occur within 15 to 30 minutes
• Early application of a tourniquet may prevent rapid spread of venom
• Emergency kit containing epinephrine commercially available

Spider bites

Definition: spider bite is the puncture wound produced by the bite of a spider

Signs and symptoms

Generalized muscle spasm is the most prominent physical finding
• Priapism and ejaculation (have been reported)
• Severe bite results in necrosis and sloughing of skin with residual ulcer formation
• Pathophysiology of bite: intravascular coagulation →formation of micro thrombi →
capillary occlusion → hemorrhage → necrosis
• Fever, nausea, vomiting, headache, weakness, arthralgia, malaise, petechiae
• Hemolysis and thrombocytopenia responsible for death

Treatment
• Narcotics for pain
• Muscle relaxant for relief of spasm
• Calcium gluconate relieves most symptoms
Note: Most patients recover within 24 hrs

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The list of contributors

Ministry of Health and Stakeholders
Names Institution
1 Dr Corneille NTIHABOSE MOH
2 Dr Parfait UWALIRAYE MOH
3 Dr Nathalie UMUTONI MOH
4 Dr MUVUNYI Zuberi MOH
5 Theobald HABIYAREMYE MOH
6 Eliezer NSENGIYUMVA MOH
7 Dr Felix SAYINZOGA RBC
8 Dr Francois UWINKINDI RBC
9 Dr Evariste NTAGANDA RBC
10 Dr Jean Louis MANGARA RBC
11 Marc HAGENIMANA RBC
12 Frederic MUHOZA RFDA
13 Dr Lysette UMUTESI RSSB
14 Alexis RULISA RSSB
15 Esperance MUKARUSINE RSSB
16 Dr Emmanuel SABAYESU MMI
17 Diane MUTONI RMS
18 Jean Bernard MUNYANGANZO RMS
19 Julie KIMONYO NCNM
20 Prof. Annette UWINEZA RMDC
21 Jean Damascene GASHEREBUKA RAHP
22 Prof. Emile RWAMASIRABO Consultant
22 Dr Raymond MUGANGA Consultant
23 Dr Richard BUTARE Consultant
24 Prof. Charlotte M. BAVUMA RCP
25 Stella Matutina TUYISENGE WHO
26 Dr William NIRINGIYIMANA RHIA
27 Patrick RUGAMBYA MPC
28 Eugene R. Abinene USAID
29 Theogene NDAYAMBAJE RFDA
30 Jean D’Amour URAMUTSE NUDOR
31 Ines MUSABYEMARIYA FHI
32 Dr Georges RUZIGANA RSOG

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174 TREATMENT GUIDELINES

Surgery

No Names Specialty

1 Prof. Nkusi Agabe Emmy Surgery

2 Phn Damaris Uwase Pharmacy

3 Dr Albert Nzayisenga Surgery
4 Dr. Butare Richard Expert
5 Phn. Hitayezu Felix Pharmacy
6 Prof. Emile Rwamasirabo Lead Expert
7 Dr. Raymond Muganga Expert
8 Phn Twambanze Marie Françoise Pharmacy
9 Dr. Byiringiro Fidele Surgery
10 Phn.Thadee Nzahumunyurwa Pharmacy
11 Phn Dieudonné Akimaniduhaye Pharmacy
12 Dr Lam D. RUTI Surgery
13 Dr. Rubagumya Fidel Oncology
14 Dr. Umurangwa Florence Surgery
15 Dr. Nzeyimana Innocent Surgery

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