PAINFUL HANDS

History A 32-year-old woman, who is 36 weeks pregnant, visits her general practitioner complaining of pain affecting both hands. The pain has developed over the last 2 weeks, and is worse at night. She also describes a tingling sensation, particularly in the index and middle fingers. In order to relieve the pain the patient describes shaking her hands to get ‘the circulation going’. There is no history of neck injury, and the pain only radiates as far as her elbows. Examination Examination of the patient’s hands shows no obvious abnormality. The radial pulse and capillary return in both hands are normal. Questions • What test is being demonstrated in figure? • What additional clinical test can be performed to support the diagnosis? • What is the cause of this patient’s problem? • How would it be best managed? ANSWER This woman has carpal tunnel syndrome. The condition is due to compression of the median nerve as it enters the hand through a ‘tunnel’ formed by the flexor retinaculum. Any reduction in this limited space produces pain and tingling along the course of the median nerve. The median nerve has both sensory and motor functions. It provides sensation to the volar aspect of the thumb, index and middle fingers, and half of the ring finger. This gives rise to the tingling sensation affecting only part of the hand. The motor supply is to the ‘LOAF’ muscles i.e. Lateral two Lumbricals, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis. If a patient has severe or long-standing carpal tunnel syndrome then they will complain of weakness and there may be signs of muscle wasting over the thenar eminence. The tests used to support a diagnosis of carpal tunnel syndrome involve trying to further compress the median nerve in order to see if the patient’s symptoms can be reproduced. The test shown infigure is Phalen’s test, which involves placing the wrist in maximal flexion for 1 min. An alternative test is Tinel’s test, in which the examiner taps over the volar aspect of the wrist, in order to see if tingling/paraesthesia is produced in the median nerve distribution. It is important, when examining a patient with suspected carpal tunnel syndrome, to carefully examine their neck, shoulder, and axilla. The symptoms of pain and paraesthesia suggest an entrapment neuropathy, and the source of the neurological compression may be proximal to the carpal tunnel, i.e. cervical disc prolapse, axilla lymph node mass compressing the brachial plexus. Where the diagnosis is uncertain, electrophysiological tests (electromyograms (EMGs)) can be performed to determine whether the median nerve is compressed and at which level. Causes of carpal tunnel syndrome • Idiopathic • Rheumatoid arthritis • Wrist fracture • Hypothyroidism • Pregnancy • Alcoholism • Renal failure Wrist splints may be the most appropriate treatment in this patient, while she is pregnant, as her symptoms are likely to improve after delivery. Alternative treatments include an injection of steroid around the carpal tunnel in order to reduce any swelling and associated inflammation. The definitive treatment is carpal tunnel release, which can be performed either endoscopically or as an open procedure. This patient’s symptoms should improve after delivery of her child. KEY POINTS • EMG studies can be used to confirm the diagnosis of carpal tunnel syndrome.

General Medicine • Orthopedic Surgery + 1 more

DISPROPORTIONATE PAIN

History You are called to the orthopaedic ward to see a 42-year-old man who has been admitted earlier in the day following a motorcycle accident. He sustained a closed tibia and fibular fracture that has been treated in a backslab in anticipation of an operation tomorrow.The nursing staff report that he is complaining of pain despite receiving 20 mg of intravenous morphine. He is otherwise fit and healthy. He smokes 20 cigarettes a day and consumes on average 40 units of alcohol a week. Examination The patient is in obvious discomfort. His blood pressure is 160/90 mmHg and the pulse rate is 100/min. The affected leg is still wrapped in a crepe bandage covering the backslab. The pedal pulses are accessible and are intact. Questions • What diagnosis must you consider? • What bedside tests could be performed to confirm the diagnosis? • What are the initial steps in the management of this condition? ANSWER This patient requires urgent assessment, as he may have developed a compartment syndrome.Within the limbs there are a number of myofascial compartments. These consist of muscles contained within a relatively fixed-volume structure, bounded by fascial layers and bone. After trauma the pressure in the myofascial compartment increases. This pressure may exceed the venous capillary pressure, resulting in a loss of venous outflow from the compartment. The failure to clear metabolites also leads to the accumulation of fluid as a result of osmosis. If left untreated, the pressure will eventually exceed arterial pressure, leading to significant tissue ischaemia. The damage is irreversible after 4–6 h.Tibial fractures are the commonest cause of an acute compartment syndrome, which is thought to complicate up to 20 per cent of these injuries. The clue in this patient is the fact that he is still in significant pain despite intravenous opiate analgesia. The classical description of ‘pain out of proportion to the injury’ may be difficult to determine if the clinician is inexperienced. Passive stretching of the muscles in the affected compartment is a very useful bedside test. In this case, if passive extension of the toes elicits pain, then this would indicate increased pressure in the posterior compartment of the leg. The compartment pressures can also be measured directly using a slit catheter. The limb should be fully exposed, as despite the fact that a backslab is not a completecast, the bandages may still be responsible for causing occlusion. The definitive treatment is a fasciotomy to decompress the relevant myofascial compartments. KEY POINTS • Suspected compartment syndrome should be dealt with promptly to avoid permanent muscle damage

General Medicine • Orthopedic Surgery

LEFT LOIN PAIN

History A 33-year-old female office worker presents to the emergency department complaining of severe left-sided abdominal pain. The pain woke her in the early hours of the morning and has persisted throughout the day. She is unable to keep still and has vomited bilious material on five occasions. She reports no diarrhoea or rectal bleeding. Previous medical history includes appendicectomy and irritable bowel syndrome. She has had a recent colonoscopy which was normal. She takes mebeverine for irritable bowel syndrome and multivitamin tablets. She smokes 15 cigarettes per day. Examination On examination she has a temperature of 37°C, a blood pressure of 125/88 mmHg and pulse rate of 96/min. There is marked left loin tenderness, but the rest of the abdomen is non-tender. Heart sounds are normal and the chest is clear Questions • What is the likely diagnosis? • What investigation would you like to do to confirm your diagnosis? • What are the indications for admitting this patient? • What is the initial management? ANSWER The combination of left loin pain and microscopic haematuria, in the absence of abdominal peritonism, suggests a diagnosis of renal/ureteric colic. In 10–15 per cent of cases of renal colic, the dipstick will be negative for blood. The differential diagnosis includes pyelonephritis, diverticulitis, bowel obstruction, peptic ulcer disease and gynaecological conditions such as ectopic pregnancy, torted ovarian cyst or tubo-ovarian abscess. In addition to the above, on the right side, appendicitis and biliary colic should also be considered. In an older patient it is important to exclude a ruptured abdominal aortic aneurysm. The pain of renal colic is caused by the distension of the ureter or collecting system from an obstructing calculus. The pain may radiate from loin to groin and to the tip of the penis in males and to the labia in females. Calculi may also irritate the bladder, causing urgency, frequency and strangury. Approximately 90 per cent of urinary tract calculi are radio-opaque and may be seen on a plain kidney, ureter, bladder (KUB) X-ray. The presence of a calculus is often obscured by overlying bowel gas. An intravenous urethrogram (IVU) is used to confirm the diagnosis and the level of the obstruction. Intravenous contrast is administered with repeat KUB X-rays at 5 and 20 min, with a post-micturition film, usually at one hour. A further delayed KUB may be required to detect the level of obstruction if it is not seen on the original X-ray series. An increasingly popular alternative to IVU is a computerized tomography (CT) KUB (performed without contrast), which is more sensitive in detecting all types of urinary tract calculi (with the exception of indinavir stones), with the added benefit of screening for other pathology. Indications for admitting the patient include: • complete obstruction: unilateral/bilateral • pain not controlled with simple analgesia • evidence of sepsis, e.g. pyrexia, raised white cell count or signs and symptoms of septic shock • calculi in a solitary kidney • deranged renal function. The analgesic of choice is rectal diclofenac, although in some cases opiates will be required. Fluids should be given and in cases of suspected infection antibiotics with good gram-negative cover administered. The IVU in Figure is a delayed post-micturition film revealing a standing column of contrast down to the level of the left vesico-ureteric junction, indicating that this is the level of obstruction. KEY POINTS • Haematuria is present in 90 per cent of cases of renal colic. • Approximately 90 per cent of calculi are visible on a plain X-ray.

General Medicine • Pathology + 1 more

SUDDEN CALF PAIN

History A 31-year-old man attends the emergency department complaining of pain affecting his left calf. He was playing squash when he suddenly felt as though he had been hit on the back of the ankle. A loud snapping sound accompanied the pain. Examination Examination of the left foot and ankle reveals no obvious deformity. There is tenderness over the calf and posterior aspect of the ankle. There is a full passive range of movement of the foot, ankle and knee joints. There are normal foot pulses, and neurological examination is unremarkable. Questions • What clinical test is being demonstrated on a normal leg in Figure? • What is the likely diagnosis in this patient? • What investigation can be performed if the diagnosis is in question? ANSWER The clinical test that is being demonstrated is the ‘Simmonds test’. It describes the absence of ankle plantar flexion when the calf is compressed. This picture demonstrates normal plantar flexion with calf compression on the right leg. Failure of plantar flexion indicates that the patient has ruptured their Achilles tendon. The history of sudden pain affecting the calf during sporting activity is typical. Other examination findings may include a palpable gap in the Achilles tendon and an inability to actively plantar flex the ankle (i.e. the patient is unable to stand on ‘tip toes’). The latter feature may be misleading, as the deep flexors of the foot can compensate for this movement. An ultrasound scan can confirm a gap in the Achilles tendon when the diagnosis is in doubt. Serial ultrasound scans can also be used to assess healing of the tendon. There is debate as to the best way to treat this injury. Non-surgical management involves immobilizing the leg in a plaster of Paris cast, with the foot initially in full plantar flexion. While this avoids the risks of surgery, it delays functional rehabilitation and results in a greater risk of the tendon re-rupturing. The tendon can be repaired surgically, which is thought to result in a stronger tendon repair. This may be more appropriate for patients who require a greater level of sporting activity. KEY POINTS • Ultrasound can be used to detect damage to the Achilles tendon. • Simmonds test is diagnostic of an Achilles tendon rupture.

Orthopedic Surgery • Foot & Ankle Orthopaedics + 2 more

EPIGASTRIC PAIN AND VOMITING

History A 50-year-old man presents to the emergency department with vomiting and epigastric pain which radiates through to the back. The pain was of gradual onset, coming on over the last 2 days. He denies any previous episodes. He is not on any regular medication, but admits to drinking in excess of eight cans of lager a day. He is a heavy smoker, but denies any recreational drug use. He is homeless and relates his heavy drinking to depression. Examination The patient is sweaty and agitated. He says he is unable to lie flat for the examination and vomits persistently. His blood pressure is 150/80 mmHg and he has a pulse rate of 120/min. Palpation of his abdomen reveals tenderness in the epigastrium. The abdomen is not distended and he has normal bowel sounds. Rectal examination is unremarkable. Questions • What is the most likely diagnosis? • Which important differential diagnosis should be excluded? • How will you grade the severity of the condition? • What are its causes? • What are the other causes of the elevated serum marker of this condition? • How will you manage the condition? • Give four potential complications. ANSWER The most obvious abnormal result is the raised amylase, giving a diagnosis of acute pancreatitis. The history and macrocytosis would suggest this is of alcoholic aetiology, but it is important to ultrasound the abdomen to exclude gallstones as the cause. The pain is typically severe and radiates through to the back, due to the retroperitoneal position of the pancreas. Vomiting is also a common feature, as a result of gastric stasis caused by the local inflammation. The severity of the attack has no relation to the rise in serum amylase. Twenty per cent of cases of pancreatitis have a normal serum amylase, particularly when there is an alcoholic aetiology. It is important to exclude a perforated peptic ulcer in this patient. This should be done with an erect chest X-ray, which would show free subphrenic air in 90 per cent of cases. The serum amylase can be elevated in a patient with gastric perforation due to the systemic absorption of pancreatic enzymes from the abdominal cavity. An amylase rise of over 1000 IU/dL, however, is usually diagnostic of acute pancreatitis. Ranson’s criteria are used to grade the severity of alcoholic pancreatitis, but it takes 48 h before the score can be used. Each fulfilled criterion scores a point and the total indicates the severity. • On admission: • age 55 years • white cell count 16
109 L • LDH 600 IU/L • AST 120 IU/L • glucose 10 mmol/L • fluid sequestration 6 L • Within 48 h: • haematocrit fall 10 per cent • urea rise 0.9 mmol/L • calcium 2mmol/L • partial pressure of oxygen (pO2) 60 mmH Estimates on mortality are based on the number of points scored: 0–2  2 per cent; 3–4  15 per cent; 5–6  40 per cent; 7  100 per cent. Causes of acute pancreatitis • Common (80 per cent): gallstones, alcohol • Rare (20 per cent): idiopathic, infection (mumps, coxsackie B virus), iatrogenic (endoscopic retrograde cholangiopancreatography [ERCP]), trauma, ampullary or pancreatic tumours, drugs (salicylates, azathioprine, cimetidine), pancreatic structural anomalies (pancreatic divisum), metabolic (hypertriglyceridaemia, raised Ca2), hypothermia Causes of hyperamylasaemia: • Perforated peptic ulcer • Mesenteric infarction • Cholecystitis • Generalized peritonitis • Intestinal obstruction • Ruptured ectopic pregnancy • Diabetic ketoacidosis • Liver failure • Bowel perforation • Renal failure • Ruptured abdominal aortic aneurysm The aim of treatment is to halt the progression of local inflammation into systemic inflammation, which can result in multi-organ failure. Patients will often require nursing on a highdependency or intensive care unit. They require prompt fluid resuscitation, a urinary catheter and central venous pressure monitoring. Early enteral feeding is advocated by some specialists. If there is evidence of sepsis, the patient should receive broad-spectrum antibiotics. An ultrasound may demonstrate the presence of gallstones, biliary obstruction or a pseudocyst. Computerized tomography is used to confirm the diagnosis a few days after the onset of the symptoms, and can be used to assess for pancreatic necrosis.

General Medicine • Gastroenterology + 1 more

SWELLING IN THE NECK

History A 45-year-old woman is referred to the general surgical outpatients after her general practitioner (GP) noticed a swelling in the neck. On questioning, the patient reports losing about a stone in weight over the preceding 3 months, despite having an increased appetite. She also complains that she always feels hot and has to sleep on top of the bed covers at night. Her bowel motions have been loose. Examination The patient is thin, irritable and has a noticeable fine resting tremor. Her peripheries feel warm and she has a resting heart rate of 110/min, with a blood pressure of 150/90 mmHg. On examination of the neck, there is a smooth moderate enlargement of the thyroid gland, which moves on swallowing. There is protrusion of the eyes with lid retraction.Her visual acuity and eye movements are normal. There is no associated lymphadenopathy. Questions • What are the causes of a goitre? • What is the likely diagnosis in this patient? • What are the options for treatment? ANSWER A goitre is an enlargement of the thyroid gland. It can be diffuse or multinodular in origin. This patient has hyperthyroidism secondary to Graves’ disease. The TSH levels are suppressed and there are increased levels of free T3 and T4. Graves’ disease most commonly develops in women aged between 30 and 50 years and is caused by circulating stimulating antibodies to the thyroid receptors (LATS). Patients often present with many symptoms including palpitations, anxiety, thirst, sweating, weight loss, heat intolerance and increased bowel frequency. Enhanced activity of the adrenergic system also leads to agitation and restlessness. Approximately 25–30 per cent of patients with Graves’ disease have clinical evidence of ophthalmopathy. This almost only occurs in Graves’ disease (very rarely found in hypothyroidism) and is also due to autoantibody damage leading to swelling of the orbital fat and connective tissue. Low titres of microsomal and thyroglobulin antibodies are also often present in patients with Graves’ disease. Many patients are now treated with radio-iodine therapy. Antithyroid medication, carbimazole or propylthiouracil, are used to establish control of hyperthyroidism and act by inhibiting thyroid hormone production. Beta-blockers may also be used initially to control symptoms. Surgery is indicated in patients with a large goitre, in patients with recurring disease and in patients unable to have radio-iodine therapy (patients planning pregnancy). There is a surgical risk of damage to the recurrent laryngeal nerve (1 per cent), hypocalcaemia (1 per cent) and hypothyroidism (10 per cent). • Diffuse: • physiological: puberty/pregnancy • autoimmune: Graves’ disease/Hashimoto’s thyroiditis • inflammatory: De Quervain’s (acute) thyroiditis/Riedel’s (chronic) thyroiditis • iodine deficiency: colloid/simple • goitrogens: carbimazole/propylthiouracil • lymphoma • Multinodular/solitary nodule: • multinodular goitre • cysts • tumours: adenomas/carcinoma • miscellaneous: sarcoidosis/tuberculosis KEY POINTS: Graves’ disease is caused by antibodies to the thyroid receptors. Up to 30 per cent of patients with Graves’ disease have eye signs.

General Medicine • General Surgery + 1 more

HEADACHE, LETHARGY AND BLURRED VISION

History A 76-year-old man presents to his general practitioner (GP) with a 2-day history of headache and blurred vision. He describes general lethargy and muscle aching over the last 3–4 days.On further questioning, he reports that when brushing his hair he experiences pain on the same side of his forehead as the headache. His GP has recently started a statin for raised cholesterol and he takes bendroflumethiazide 2.5 mg once daily for hypertension. Examination His general examination is unremarkable, blood pressure 136/86 mmHg and pulse 78/min. Questions • What is the likely diagnosis? • What should the initial management involve? ANSWER The most likely diagnosis is temporal arteritis. This condition predominantly affects the elderly population. Temporal arteritis is usually a clinical diagnosis, which is suggested by its unilateral features (bilateral presentation is rare), typically of pain affecting the temporal region, and can be associated visual disturbance. Palpation of the affected artery may reveal tenderness, warmth, and pulselessness. The inflamed artery may be dilated and thickened,allowing the vessel to be rolled between the fingers and skull. Jaw claudication may occurwhen the patient is chewing or talking and is seen in approximately 65 per cent of patientswith temporal arteritis. Constitutional symptoms include anorexia, weight loss, fever, sweats and malaise. The ESR is characteristically over 100 mm/h. The importance of making the diagnosis is that without high-dose oral steroids the patient can permanently lose vision on the affected side. Oral steroid treatment usually results in an improvement in symptoms within 48h, and such a response further supports the diagnosis. The length of the treatment course is 12–18 months. To confirm the diagnosis, a temporal artery biopsy can be performed. This should ideally be performed within 2 weeks of commencing treatment. It is important to note that a negative biopsy does not rule out the presence of temporal arteritis as the areas of inflammation affecting the temporal artery may not be uniform and can skip regions. KEY POINTS: • The importance of making the diagnosis is that without high-dose oral steroids the patient can permanently lose vision on the affected side.

Cardiology • General Medicine + 2 more

Devil’s Horn Sign

A 22 year-old male injured his right hand as shown in the image below: Describe and interpret the clinical image. Description: Both hands are making the ‘devil’s horn’ sign well known to heavy metal aficionados. The finger positions are slightly different on the right hand compared with the left. The middle and ring fingers are not as completely flexed at the metacarpophalangeal joints and the little finger is not completely extended. There is an open wound on the dorsum of the right hand overlying the proximal 5th metacarpal, with a white structure protruding from, or visible within, the wound. There are other superficial wounds overlying the metacarpophalangeal joints and phalanges on the dorsum of the middle, ring and little ringers of the right hand. Interpretation: The findings are consistent with a ZONE 6 extensor tendon injury of the right hand, affecting extensor digiti minimi. The white structure seen within the wound is the transected tendon. What are the zones of the hand? Bamboozler Answer These zones are worth knowing as the anatomic location of extensor tendon injuries influences treatment. Zone 6 extensor tendon injuries may occur with seemingly trivial skin wounds as the tendons are very superficial in this region. Any wound in Zone 6 involves a tendon injury until proven otherwise! Hand Extensor Zones Why are these injuries potentially difficult to detect clinically? Bamboozler Answer It is easy when the severed tendon is on view! Always move the nearby joints through full range of motion when assessing a wound to ensure tendon injuries aren’t missed. Depending on the position of the hand at the time of injury, the site of tendon injury may be distant from the wound at the time of examination. Extensor tendons of the 2nd to 5th digits of hand are connected by the juncturae tendini (fibrous bands passing obliquely between the diverging tendons of the extensor digitorum and extensor digiti minimi on the dorsum of the hand) near the metacarpophalangeal joints, as shown below. Extensor tendon injuries proximal to these connections can be missed because the affected digit can still be extended (with less strength) by the action of the adjacent extensor tendon transmitting force through the juncturae tendini. To detect functional impairment from these injuries test active extension of the affected digit with the other digits flexed at the metacarpophalangeal joints. For the little finger, and presumably the index finger too, this can also be done by performing the ‘devil’s horn’ sign! The full story of the patient in the photo is enlightening in this respect: Whilst partying with some friends he fell over in some sand, cutting his right hand on some buried glass. He washed the wound out and wasn’t too worried about the injury – even though the severed tendon was visible – because his hand seemed to work just fine. It was only later, when he turned up the Metal on the stereo, that he attempted the ‘Devil’s Horn’ sign and realized that his little finger didn’t extend properly… hand-extensors-gray How is this injury managed? Management overview: Exclude/ treat other injuries (e.g. secondary survey; x-ray to rule out fractures and radio-opaque foreign bodies) Analgesia Update tetanus immunization if appropriate Consider antibiotics (unproven, but often given if contaminated, delayed presentation or admission for delayed closure) Clean, explore and irrigate the wound Zone 6 extensor tendon injuries can usually be repaired by a figure-of-eight stitch (or similar technique) using 4-0 non-absorbable sutures and a straight needle. Following repair the hand should be splinted with the wrist at 30 degrees extension and the MCPJs in neutral position. Roberts and Hedges suggest a dorsal slab with malleable metal and foam extension to splint the affected finger. Early follow up with a hand specialist should be arranged (e.g <1 week) Can definitive treatment occur in the ED? Extensor tendon ruptures may be repaired in the ED in specific circumstances (mostly from Trott, 2005): if the injury is between the distal wrist and the metacarpophalangeal joints (zone VI) if the skin and tendon wounds are sharp and not heavily macerated or contaminated if the injury is less than 8 hours old if the two ends of the tendon are easily visualized if appropriate instruments are available to minimize trauma to the tissues if a doctor/ surgeon is available with the appropriate training and experience if the patient is cooperative and will comply with follow-up care if in accordance with local standards of practice In our case, the injury was about 20 hours old so the patient was admitted for IV antibiotics pending further wound washout and tendon repair by an orthopedic surgeon in an operating theatre. To read from source, click on the link below : https://litfl.com/devils-horn-sign/

General Medicine • Orthopedic Surgery

ABDOMINAL DISTENSION AND PAIN

History A 70-year-old man has been sent to the emergency department from a nursing home, complaining of intermittent sharp abdominal pain. He has not opened his bowels for 5 days. He suffered a major stroke in the past and requires constant nursing care. He has a history of chronic constipation. Previous medical history includes chronic obstructive airways disease for which he is on regular inhalers. He is allergic to penicillin and is an ex-smoker. Examination His blood pressure is 110/74mmHg and the pulse rate is 112/min. His temperature is 37.8°C. There is gross abdominal distension with tenderness, most marked on the left-hand side. The abdomen is resonant to percussion and digital rectal examination reveals an empty rectum. There is a soft systolic murmur and mild scattered inspiratory wheeze on auscultation of the chest. INVESTIGATIONS Questions • What does the abdominal X-ray show? • What other radiological investigation could be employed if the diagnosis was in doubt? • How should the patient be managed? • What is the explanation for the pathology? ANSWER The X-ray shows a sigmoid volvulus. The sigmoid colon is grossly dilated and has an inverted U-tube shape. The involved bowel wall is usually oedematous and can form a dense central white line on the radiograph. On either side, the dilated loops of apposed bowel give the characteristic ‘coffee bean’ sign. X-ray appearances are diagnostic in 70 per cent of patients. If there is doubt about the diagnosis, a water-soluble contrast may be helpful in showing a classical ‘bird’s beak’ appearance representing the tapered lumen of the colon. The flatus tube is left in situ for approximately 48 h and is often only a temporary measure. Colonoscopy can be used to decompress the bowel and may resolve the volvulus. Urgent laparotomy will be required if decompression is not possible or in cases of suspected gangrene/perforation (fever, leucocytosis, peritonism, free air under the diaphragm on erect chest radiography). The patient’s fitness for surgery, prognosis and quality of life should be considered before proceeding to laparotomy. It may be appropriate to use only conservative treatments in some patients. Sigmoid volvulus is predisposed to by a long, narrow mesocolon, chronic constipation or a high-roughage diet. The rotation of the gut can lead to obstruction and intestinal ischaemia. The sigmoid is the commonest part of the colon for this to occur, although the caecum and splenic flexure are other potential sites. Treatment of sigmoid volvulus ! • Keep patient nil by mouth • Intravenous access and fluids • Fluid balance monitoring • Routine bloods and crossmatch • Erect chest X-ray/abdominal X-ray • Decompression with rigid sigmoidoscopy and insertion of a flatus tube once the diagnosis is confirmed on abdominal X ray.

General Surgery • Surgical Gastroenterology + 1 more

ABDOMINAL TRAUMA

History You are called urgently to the resuscitation room for a trauma call. An 18-year-old girl has fallen from her horse. During her descent the horse kicked her, and she is now complaining of generalized abdominal pain and left shoulder-tip pain. Examination She is talking and examination of her chest is normal. The oxygen saturations are 100 per cent on 24 per cent oxygen. Initially, her pulse rate is 110/min with a blood pressure of 84/60 mmHg. She is slightly drowsy and her Glasgow Coma Score (GCS) is 14. On examination of the abdomen, there is an abrasion on the left side beneath the costal margin with tenderness in the left upper quadrant. There is no evidence of any other injuries and the urinalysis is clear. The patient is given 2 L of intravenous fluids and the blood pressure improves to 130/90 mmHg. As the patient has now become stable, a computerized tomography scan (CT) of the chest and abdomen is obtained. Questions • What does the CT show? • Are there any alternative investigations to CT? • What special requirements may this patient have postoperatively? ANSWER The patient has sustained a tear to the splenic capsule causing intraperitoneal bleeding. The CT shows the fractured spleen with surrounding haematoma. The shoulder-tip pain described is known as Kehr’s sign, and is indicative of blood in the peritoneal cavity causing diaphragmatic irritation. Unstable patients suspected of splenic injury and intra-abdominal haemorrhage should undergo exploratory laparotomy and splenic repair or removal. Blunt trauma, with evidence of haemodynamic instability which is unresponsive to fluid challenge, should be considered to be a life-threatening solid organ (splenic) injury. Those patients who respond to an initial fluid bolus, only to deteriorate again with a drop in blood pressure and increasing tachycardia, are also likely to have a solid organ injury with ongoing haemorrhage. Transfer to the CT scanner can be extremely dangerous for an unstable patient. Focused abdominal sonographic technique (FAST) is helpful in diagnosing the presence or absence of blood in the peritoneal cavity. Diagnostic peritoneal lavage may be a valuable adjunct if time permits and multiple other injuries are present. In a haemodynamically stable trauma patient, CT scanning provides an ideal non-invasive method for evaluating the spleen. The decision for operative intervention is determined by the grade of the injury and the patient’s current or pre-existing medical conditions. If possible, it is preferable to repair minor tears of the spleen. Those patients who undergo splenectomy have a lifetime risk of septicaemia and should receive immunizations against pneumococcus, haemophilus and meningococcus KEY POINTS • Whenever possible the spleen should be conserved. • Patients require lifelong prophylactic antibiotics after splenectomy.

Emergency Medicine • General Surgery + 2 more