VARICOSE VEINS

History You are asked to see a 47-year-old hairdresser in the vascular clinic. She has been complaining of pain in the right leg on prolonged standing and has noticed unsightly, distended veins in that leg for the past 2 years. For the past 3 months she has also had itching of the skin just below the knee with a red patch in that area. She is currently on treatment for hypertension with no other past history of note. She has two children. Examination A distended vein can be felt in the medial aspect of the mid-thigh running down to the knee.There are numerous varicosities around and below the knee. There is an erythematous patch of skin approximately 3cm in diameter overlying one of the below-knee varicosities. A thrill is palpable at the sapheno-femoral junction when the patient coughs. Foot pulses are strongly palpable. Questions • What is the most likely diagnosis? • What information would the Trendelenburg test provide? • What is the significance of the erythematous patch of skin? • What imaging studies would you consider? • What are the possible complications if left untreated? ANSWER This patient has varicose veins in the distribution of the long saphenous vein, a common condition that is more common in women. Working as a hairdresser involves prolonged standing, which increases venous hydrostatic pressure leading to distension of the veins and secondary valve incompetence within the superficial venous system. The Trendelenburg test can confirm superficial as opposed to deep-vein incompetence and identify the point of incompetence along the superficial system. The leg is elevated to collapse all the veins and pressure is applied on the long saphenous vein just below the sapheno-femoral junction. The patient then stands up, and if the distal varicosities remain empty the point of reflux from the deep to the superficial system has been identified. If the varicosities fill, then the procedure is repeated, this time applying the pressure at a lower point until the point of reflux is identified. The itching erythematous patch represents varicose eczema and is an indication for operative intervention. Imaging identifies all areas of reflux and obstruction within the superficial and deepvenous system. Duplex ultrasound is now the standard imaging modality for this purpose.Alternatives include contrast varicography/venography and magnetic resonance imaging. Sequelae of varicose veins ! • Pain • Leg swelling • Bleeding • Eczema • Skin ulceration KEY POINTS • Further skin changes may be prevented with surgical correction of the superficial venous reflux disease. • Surgery on the superficial venous system should be avoided in patients with an incompetent deep venous system.

General Medicine • General Surgery

TESTICULAR PAIN

History A 16-year-old boy attends the emergency department complaining of sudden onset of right testicular pain. The pain woke him from his sleep and has persisted over the last 3 h. His mother says that he has vomited once. His previous medical history includes a similar event a year ago, but on that occasion the pain subsided quickly. He is asthmatic and uses a salbutamol inhaler. Examination On examination the left hemi-scrotum feels normal but the right side is acutely swollen and tender on palpation. The testicle is elevated when compared to the other side and has an abnormal horizontal lie. The abdomen is soft and non-tender. His blood pressure is 130/84 mmHg and the pulse rate is 110/min. The cremasteric reflex is absent. Questions • What is the diagnosis? • What should you consider in the differential? • What is the management in this case? INVESTIGATION Urinalysis is clear. ANSWER This boy has testicular torsion until proven otherwise. It is likely that a year ago he had an episode of intermittent torsion with spontaneous detorsion. Testicular torsion is actually torsion of the spermatic cord and not of the testis. This results in irreversible ischaemia to the testicular parenchyma which can occur within 4–6 h of cord torsion. The presentation can vary and includes vague loin or groin pain as well as scrotal signs and symptoms. There may be a history of excessive physical activity or trauma. It is more common between late childhood (post-puberty) and early adulthood. Normally, the tunica vaginalis envelops the body of the testis and only part of the epididymis (which is usually fixed), and the testis is unable to twist. In cases of torsion, there is an abnormal amount of free space between the parietal and visceral layers of the tunica vaginalis which encompasses the testis, epididymis and the cord for a variable distance. This free space allows the now hypermobile testis and epididymis to rise in the scrotum and twist. This accounts for the abnormal horizontal lie of the testis (‘bell clapper deformity’). If the presentation is delayed, an acute hydrocoele may develop making examination difficult, and the scrotum may appear erythematous. Surgical exploration is essential if torsion is considered. Urinalysis is often negative and the diagnosis should be made clinically. Differential Diagnosis • torsion of the appendix testis • torsion of the appendix epididymis • epididymo-orchitis • infected hydrocoele • testicular rupture • strangulated inguinal hernia • a bleed into a tumour In torsion of the appendix testis, the tenderness is usually localized above the upper pole of the testis and may be accompanied by the ‘blue dot’ sign, which represents necrosis in the appendix. Hydrocoeles may be tender if large and will transilluminate. If a patient is suspected of having epididymo-orchitis, the urine should be screened for infection. There may also be a history of urethral discharge or urinary symptoms such as frequency or dysuria KEY POINTS If testicular torsion is suspected, surgical exploration should be carried out as soon as possible. • Irreversible ischaemia of the testis occurs after approximately 6 h.

General Medicine • Nephrology + 1 more

DIFFICULTY PASSING URINE

History An 81-year-old man presents to the emergency department complaining of difficulty in passing urine. On questioning, he reports a worsening urinary stream over the last 6 months, together with increased nocturia. There is a recent history of bedwetting. He has no pain. He opens his bowels 3–4 times a week and his last bowel motion was 2 days ago. He is on insulin for type 1 diabetes. He also takes aspirin 75 mg od and simvastatin 20 mg od. He lives alone and mobilizes well with a walking stick. He is a non-smoker and has the occasional whisky at night to help him sleep. Examination On examination of the abdomen, there is a palpable suprapubic mass, which is nontender and dull to percussion. The rest of the abdomen and genitalia are unremarkable. Digital rectal examination reveals an enlarged smooth-feeling prostate gland. Questions • What is the diagnosis? • Why does he recently complain of bedwetting? • How should this patient be managed? • What features on digital rectal examination would make you suspicious of prostate cancer? ANSWER This patient has chronic urinary retention secondary to an enlarged prostate. Acute and chronic retention are usually differentiated by the presence or absence of pain. Acute retention is painful, unlike chronic retention, when the bladder accommodates the increase in volume over time. A recent history of bedwetting is associated with a picture of chronic retention with overflow incontinence which usually occurs at night. A urethral catheter should be inserted and the colour of the urine and residual volume noted and recorded in the notes. In cases of chronic retention the residual is often high (2 L). The urine output should be monitored, as the patient may develop a diuresis. If the urine output is greater than 250 mL/h, intravenous fluid replacement in the form of 0.9 per cent normal saline is necessary to avoid hypovolaemia. The urine should be dipstick tested and sent for microscopy and culture. If positive for infection, antibiotics should be started. His renal function needs to be monitored to assess a response to treatment, and if not improving early consultation with the renal physicians is recommended. Constipation or urinary tract infection can compound the problem and they need to be treated accordingly. Often the patient has a history of lower urinary tract symptoms,which in this case are both obstructive and irritative in nature. A digital rectal examination should be performed for patients in retention, noting the following points: • external appearance of the anal orifice • rectal masses • consistency of the prostate • presence of a median sulcus • presence of nodules within the prostate • fixity of the prostate gland • estimated size of the prostate gland • anal tone. Features that suggest carcinoma of the prostate include hard gland, loss of normal contour(craggy prostate), loss of the midline sulcus, palpable nodule and a fixed gland. In cases of benign prostatic hyperplasia, the prostate feels enlarged and smooth as in this case. KEY POINTS • Acute retention is differentiated from chronic retention by the presence of pain. • Precipitating factors, e.g. constipation, urinary tract infection, excessive alcohol, need to be screened for in the history

General Surgery • Urology/Genito-Urinary Surgery + 2 more

RENAL MASS

History A 61-year-old male presented to his general practitioner (GP) complaining of intermittent left-sided loin pain for 2 months. An ultrasound scan of the urinary tract was organized,which showed a large central mass in the left kidney. His previous medical history included a recent diagnosis of hypertension, hypothyroidism and non-insulin-dependent diabetes mellitus. He currently takes thyroxine 100 µg od, bendrofluazide 2.5 mg od and metformin 850 mg bd. He lives alone and drinks 5–10 units of alcohol per week. He is a lifelong smoker. Examination His temperature is 37°C, his blood pressure is 165/99mmHg and his pulse is 84/min. Heart sounds are normal and his chest is clear. He has a soft non-tender abdomen with no palpable masses. A left sided varicocoele is present. Digital rectal examination is unremarkable. Questions • What investigation is now required? • Can you explain why the patient may have a varicocoele? • Do you know of a genetic condition that may predispose individuals to renal cell carcinoma? • Why may the patient be hypertensive? Ultrasound of the urinary tract: there is a solid central mass measuring 3.6 cm in the left kidney. The right kidney appears normal. There is no evidence of pelvi-calyceal dilatation or calculi on either side. The bladder was not filled and was therefore difficult to examine. ANSWER The patient has been found to have a renal mass on ultrasound scan. The most likely diagnosis is renal cell carcinoma and the patient now requires a contrast computerized tomography (CT) scan of the abdomen and pelvis to confirm the diagnosis and to stage his disease. A chest X-ray should also be organized to screen for chest metastases (if a CT of the chest is not performed at the same time of his staging). Approximately one-quarter to one-third of patients with renal cell carcinomas have metastases at presentation.The venous drainage from the testes (pampiniform plexus) is into the gonadal (testicular) veins. On the left, the gonadal vein drains into the left renal vein and on the right the vein drains directly into the inferior vena cava. Tumours extending into the left renal vein will obstruct the venous drainage from the left testicle, leading to a left-sided varicocoele. The commonest genetic abnormality associated with renal cell carcinoma is von Hippel–Lindau syndrome. This is an autosomal dominant disease characterized by phaeochromocytoma, pancreatic and renal cysts, cerebellar haemangioblastoma and the development of renal cell carcinoma which is often bilateral. Lifelong follow-up is required and nephronsparing surgery employed in view of the recurrent nature of the disease. Other non-genetic aetiological factors associated with renal cell carcinoma include: • smoking • anatomical: horseshoe kidney; polycystic disease; cystic disease of dialysis • hypertension • obesity • environmental: cadmium, asbestos exposure, phenacitin (analgesic) • low social class. The classic presenting triad of loin pain, a mass and haematuria only occurs in about 10 per cent of patients. More commonly one of these features appears in isolation. Other presentations include left-sided varicocoele (5 per cent) and paraneoplastic syndromes Paraneoplastic syndromes ! • Endocrine (ectopic hormone production): • erythropoietin: polycythaemia • renin: hypertension • insulin: hypoglycaemia • adrenocorticotrophic hormone (ACTH): Cushing’s synd parathyroid hormone: hypercalcaemia • gonadotrophins: gynaecomastia, amenorrhea, reduced libido, baldness • Haematological: anaemia • Metabolic: pyrexia KEY POINTS • The classic presenting triad of loin pain, a mass and haematuria only occurs in a small proportion of patients. • Patients may present with a paraneoplastic syndrome

General Surgery • Oncology + 1 more

Wound dehisence

A 56-year old Caucasian male presented with a recurrent basal cell carcinoma of his scalp. The lesion was incompletely removed by a general practitioner six years previously, and subsequently excised by a dermatologist twice – but recurred again. Although basal cell carcinoma may be considered a very “innocent type of cancer” because it rarely metastasizes, it is notorious for recurring locally. The patient was then referred to a plastic and reconstructive surgeon who booked the patient for a more radical excision of the 10 x 12 mm lesion. A couple of days later the lesion was removed under sedation in O.T with about 1 cm clean margins making the defect about 2 x 3 cm. The adjacent tissue was undermined for a reasonable distance and closed primarily with 3-0 monofilament resorbable suture material. The wound was initially treated with a topical antibiotic ointment and dressed – but later allowed to dry. Initially, the healing progressed according to plan – but about seven days post-operatively, one of the sutures snapped. The patient reported that: “it sounded like a guitar string snapping in his skull – ZINGGGG.” On inspection, the wound started to open up and dehisced quite severely. It was decided to allow the wound to granulate and thus heal by secondary intention. Complications are unpleasant to anyone involved in this kind of a situation, but specifically so to the practitioner and the patient. However, as you may notice, it is not always a train smash. In this case, the wound eventually healed rather nicely with an acceptable aesthetic result. In the imagines, you will note that the red color marking the dehisced wound fades almost entirely in time as the final stages of wound healing occur and scar maturation progresses. Discussion The surgeon opted for a primary closure but may have considered using: A free skin graft – In my opinion, this would have given a much worse aesthetic outcome. But if the defect was anything more substantial, the surgeon may have had to use this option. Should this procedure be selected, the donor site should be kept in mind since it becomes a secondary surgical site with all the possibilities of complications developing. A local pedicled scalp flap – This may have been a better choice because the defect margins could be increased. This option minimizes the tension on the wound margin since it “spreads” the wound defect more evenly over a larger area. Alternative suture materials and techniques – The surgeon could have undermined the wound edges even more and then used a deep layer of resorbable and non-resorbable sutures on the surface for the final closure. This choice gives the surgeon control over the length of time to keep the suture in place. Vertical and/or horizontal mattress suture may have been a better suturing method to use as it would have added a bit more “hold” to the wound closure. Retrospective wisdom is valuable because it allows for evaluation of choices made – what worked, what didn’t, and what could have been done differently. In my opinion, the surgeon achieved an acceptable and reasonable functional and cosmetic result. https://www.theapprenticedoctor.com/13-reasons-for-wound-dehiscence/

General Surgery • Plastic & Reconstructive Surgery + 1 more

A PAINFUL AND SWOLLEN KNEE

History A 63-year-old man with insulin-dependent diabetes mellitus attends the emergency department complaining of pain affecting his right knee. There is no history of significant trauma.On further questioning he had noticed that while gardening a few days previously he sustained a small graze to the skin in that area. Examination On examination he is febrile, (temperature 37.8°C), his blood pressure is 160/86 mmHg and his pulse rate is 96/min. Examination of his right knee reveals a red swollen joint that is tender. Attempting to move his knee both actively and passively results in severe pain. There is no abnormality to be found examining his right ankle or hip. Questions • What is the likely diagnosis? • What should the initial management involve? ANSWER This man has a septic arthritis of the right knee. The localized redness and swelling can be associated with any inflammatory monoarthritis, but a septic arthritis is an important differential diagnosis suggested here by the history, examination findings and blood tests. Septic arthritis can affect any joint. The most commonly affected joint is the knee (50 per cent of cases), followed by the hip (20 per cent), shoulder (8 per cent), ankle (7 per cent) and wrist (7 per cent). Staphylococcus aureus is the cause in the vast majority of cases of acute bacterial arthritis in adults. Streptococcal species, such as Streptococcus viridans, Streptococcus pneumoniae, and group B streptococci, account for 20 per cent of cases. Aerobic gram-negative rods are involved in 20–25 per cent of cases. Organisms may invade the joint by direct inoculation, spread from adjacent infected tissue, or via the bloodstream, which is the most common route. Following the initial stabilization of the patient (they may be unwell with signs of septic shock), the joint should be aspirated. The aspirated fluid should be sent to the laboratory for microscopy to look for pus cells and evidence of bacterial infection. The fluid should also be examined with polarizing microscopy to look for the presence of crystals. This is to exclude the differential diagnosis of crystal arthropathy (gout or pseudo-gout). Blood tests can be useful as they suggest the presence of infection (raised WCC and inflammatory markers). In addition, blood cultures should be sent as they may isolate a causative organism. Treatment of a septic joint should be prompt and effective. The joint should undergo a thorough washout followed by immobilization. High-dose empirical antibiotics should be administered intravenously until cultures and sensitivities are available. The major consequence of bacterial infection is damage to articular cartilage. This may be the result of the infective organism’s pathological properties or the host’s own immune response. Delay in the diagnosis and treatment will result in a poorly functioning joint. KEY POINT • Staphylococcus aureus is the most common causative organism. • Prompt treatment is required to prevent permanent damage to the joint

General Medicine • Orthopedic Surgery + 1 more

A FALL ONTO THE OUTSTRETCHED HAND

History A 76-year-old woman is brought to the emergency department having fallen on the ice. She remembers slipping over and stretching out her right hand in order to ‘save her fall’. She describes significant pain around her right wrist. Fortunately, her only other injury is a minor graze on her forehead. She says she has previously had a heart attack in her 60s. She takes atenolol, ramipril, simvastatin and aspirin. She also has a history of essential hypertension and she had a hysterectomy for menorrhagia when she was 40 years old. She is the sole carer for her husband who suffered a stoke 2 years ago and is bed-bound. She is anxious to get back home to look after him. Examination Her vital observations are stable. She has an obvious deformity of her right wrist. There is already bruising evident. There is no distal neurovascular deficit. Anterior-posterior and lateral X-rays of her wrist have been performed and are shown in the figure. Questions • What injury has this woman sustained? • How should it be managed? • Are there any other considerations before this woman is sent home? ANSWER This woman has sustained a Colles’ fracture. This term is often applied to any distal radial fracture. The correct definition of this injury comes from Abraham Colles in 1814, who originally described a low-energy extra-articular fracture of the distal radius occurring in elderly individuals. The typical mechanism of injury has been given in this scenario, which is a fall on the outstretched hand resulting in forced extension at the wrist. The distal fragment is dorsally angulated and displaced, giving a ‘dinner-fork deformity’ appearance It is important as with all injuries to assess the distal neurovascular status. In this injury it is not uncommon to develop symptoms associated with compression of the median nerve. A Colles’ fracture can usually be managed by closed reduction and immobilization. A number of techniques have been described. Adequate analgesia can be provided locally with lidocaine injected into the fracture site, a so-called haematoma block, or regional anaesthesia is used. The latter is thought to provide better pain control as well as allowing more accurate fracture reduction and a better functional outcome. To achieve fracture reduction the distal fragment is further dorsally angulated in order to disengage it from the fracture site. Longitudinal traction is then applied while trying to manipulate that fragment in a distal and volar direction, thereby restoring the normal position and length to the radius. A backslab is applied with the wrist held in slight flexion and ulnar deviation. X-rays should be performed to check that there has been an adequate fracture reduction. The patient should be brought back to the fracture clinic in a few days in order to complete the cast and check that the fracture has not slipped out of position. This case also illustrates the secondary consequences of significantly injuring a limb. It is unlikely that this woman will be able to cope at home, looking after her incapacitated husband. Most hospitals and general practitioners have access to a ‘rapid response team’, which is ideally suited to provide extra community-based social, nursing and physiotherapy support on a short-term basis. KEY POINT • In all fractures the distal neurological and vascular status should be assessed.

Orthopedic Surgery • Hand Surgery + 1 more

ASSESSMENT OF AN ANKLE INJURY

History A 17-year-old boy is brought to the emergency department by his father, having fallen off his skateboard earlier on in the afternoon. He is complaining of ankle swelling and pain, and has been unable to fully weight-bear on his right leg. He is otherwise fit and healthy. He last ate a sandwich 7 h ago. Examination He has been assessed by the casualty officer, who reports that he warranted an X-ray based on the Ottawa rules. Questions • What are the Ottawa rules? • What does the X-ray show? • What is the initial management? An X-ray is taken and is shown in Figure. ANSWER The Ottawa rules have been developed to help clinicians make a decision as to whether an ankle (or mid-foot) injury warrants radiographic assessment: • bone tenderness at the posterior edge or distal 6 cm or tip of the medial or lateral malleolus. • bone tenderness at the base of the fifth metatarsal (for foot injuries) • bone tenderness at the navicular bone (for foot injuries) • unable both to weight-bear immediately after injury and walk four steps in the emergency department. All suspected bony injuries should have X-rays taken in at least two different planes (normally anterior-posterior and lateral), to show whether there is a fracture. For the assessment of ankle injuries, mortise and lateral X-rays are taken. In this case the patient has sustained a fracture of the medial malleolus. The initial principles of management of any closed fracture are the same. Having made the diagnosis of an ankle fracture, the fracture should be stabilized. Usually this involves applying a ‘backslab’ (a plaster of Paris cast that is a half-completed cylinder, which will mean that any resultant swelling is not restricted). It is important that the patient is provided with adequate analgesia; the act of stabilizing the fracture will reduce the fracture movement and so help with pain control. Stabilization will also allow the ankle and leg to be elevated to reduce the swelling. The next stages in the management are reduction of the fracture, and fixation. In this case the ankle will need operative fixation; this can potentially be performed quickly as the patient has fasted for over 6 h. However, if the ankle is too swollen and there is concern that the soft tissues will be compromised by the operation, then this will mean a delay by a matter of days. KEY POINTS • The Ottawa rules can be used to determine if radiographical assessment of the ankle injury is required.

Orthopedic Surgery • General Medicine

FALLS IN THE ELDERLY

History A 78-year-old woman is brought in to the emergency department following a fall at home.She is complaining of severe pain affecting her left leg and groin, and has been unable to get up since the fall. On further questioning, the patient has been treated with steroids for polymyalgia rheumatica for the last 12 months and had sustained an injury of the right hip 5 years ago. Her only other medication is ramipril for essential hypertension. She lives independently in a three-bedroom, two-storey house and was widowed 4 years ago. She has a supportive son who normally visits her once a week. Examination The patient is now comfortable having been given intravenous morphine sulphate. Her left leg appears shorter than her right one and is externally rotated. She is unable to actively lift her leg, and any attempt to passively move it results in pain. Her pedal foot pulses and sensation are intact. Questions • What investigation is depicted in figure, and what does it show? • What other relevant history would you wish to elicit? • What would be the further management in this patient? • Why is the social history particularly important in this patient? ANSWER This woman has sustained a (intracapsular) sub-capital neck of femur fracture. The X-ray also demonstrates a hip prosthesis on the right side, after a previous similar injury .Fractured neck of the femur is a relatively common injury following a fall in the elderly population. The rate of hip fracture doubles every decade from the age of 50 years. There is a female preponderance of three to one. This woman is at particularly high risk because of her long-term steroid use. It is now a British National Formulary (BNF) recommendation that patients on long-term steroids should have concomitant treatment for the prevention of osteoporosis. There are two different types of fractured neck of femur, intracapsular and extracapsular.Displaced fractures that are intracapsular disrupt the intra-osseous blood supply; the remaining blood supply comes from the retinacular vessels and from the artery of the ligamentum teres. This is usually not adequate to provide enough nutrition to allow fracture healing, leading to avascular necrosis of the femoral head. In this situation the fracture is not amenable to fixation; instead the head and proximal femoral neck are removed and replaced by a hemi-arthroplasty. Fractures that are extracapsular do not compromise the blood supply to the femoral head, so can be treated by fixation, i.e. a dynamic hip screw. Irrespective of the fracture type, the initial management remains the same. It involves providing adequate analgesia, usually in the form of intravenous morphine. Intravenous fluid resuscitation is essential as these patients may well have been incapacitated for some time and will have sustained blood loss secondary to the fracture. Since these patients are likely to require an operation, they need a complete work-up for theatre. This will include blood tests (renal function, full blood count and group and save) and electrocardiogram and a chest X-ray if clinically indicated. As part of the initial assessment it is important to take a comprehensive history, concentrating on of the mechanism of injury. It is incorrect to assume that all falls are mechanical; it is not uncommon to find the cause of the fall is actually due to a urinary or chest infection or even a silent myocardial infarction. The patient’s social history is also very important. The input of physiotherapists and occupational therapists is essential to ensure an adequate social care package is in place for discharge. KEY POINTS • Femoral neck fractures are classified as either intracapsular or extracapsular. • Methods of surgical treatment depend on which type of fracture has been sustained

Orthopedic Surgery • Joint Preservation + 2 more

RIGHT SHOULDER INJURY

History A 23-year-old woman is brought to the emergency department having fallen over while on a dry ski slope. She is holding her right arm and is very reluctant to move her shoulder. She has previously had an appendicectomy and is known to have had mild attacks of asthma. She takes salbutamol and beclometasone regularly, and she is allergic to penicillin. She lives with her parents and works in the computer industry. Examination Her shoulder shows an obvious deformity and looks ‘squared off’, the arm is held in slight abduction and is externally rotated. Both active and passive movement of the shoulder cause pain. The radial pulse and capillary refill are normal. Questions • What is the diagnosis? • What are the other essential examination findings that have not been commented on? • How should this injury be managed? ANSWER This patient has sustained an anterior dislocation of her right shoulder. Shoulder dislocations are the commonest joint dislocation, accounting for nearly half of all dislocations. The glenohumeral joint is a multi-axial ‘ball and socket’ joint and can, therefore, dislocate in any direction. However, in the majority of cases (90–98 per cent) the dislocation is anterior. Posterior dislocation is much less common and is typically secondary to either an epileptic fit or electric shock. In order to confirm the diagnosis, radiographic assessment should be performed. The commonly used views are the anterior-posterior view in combination with either an axillary or scapular view. The important point is to examine the joint with two different views. The axillary view has the advantage of showing the glenoid cavity, which may pick up any associated fracture. An assessment of both the distal vascular and neurological function must be made in any patient with a severe limb injury. The close relationship of the shoulder joint to the brachial plexus makes a nerve injury more likely. At particular risk are the radial and axillary nerves. The incidence of axillary nerve neuropraxias following anterior shoulder dislocation is quoted at up to 10 per cent. The axillary nerve supplies sensation to the lateral aspect of the upper arm, the ‘regimental badge area’.The majority of anterior shoulder dislocations can be replaced by closed reduction. The key to successful reduction is to ensure adequate analgesia. This will relax the shoulder musculature that is typically in spasm resisting any joint movement. After successful reduction, the patient should be able to touch the contralateral shoulder tip. The shoulder should be supported in a sling, with radiological confirmation of the reduction. KEY POINTS • A full neurological examination must be performed prior to reduction of any dislocated joint. • The X-ray should be carefully examined for associated fractures. • Adequate analgesia is crucial during reduction of the dislocation.

Orthopedic Surgery • Joint Preservation + 1 more