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Reach New Heights Neck Line 1 Reach new heights Neck PB 1 Line 1 Reach new heights Line 1 Neck 2 3 Line 1 ChapterReach new heights4 Neck Anatomy 1. Triangles of the neck The neck has seven triangles anteriorly & two posterior triangles: Take your note Neck Triangle of the neck 1. One submental triangle: between the two anterior bellies of digastric muscle & the body of hyoid bone. 2. Two muscular triangles: between the anterior midline of the neck, superior belly of omohyoid muscle and the lower part of the anterior border of sternomastoid. 3. Two digastric triangles: between the anterior & posterior bellies of the digastric muscle & the lower border of the mandible. 4. Two carotid triangles: between the superior belly of omohyoid muscle, posterior belly of digastric muscle & the upper part of the anterior border of sternomastoid muscle. 5. The two posterior triangles: between posterior border sternomastoid muscle, anterior border of the trapezius muscle & middle 1/3 of clavicle. 2 3 Line 1 Reach new heights Laryngocele Subareolar mastitis It is herniation of the mucosa of the larynx through a weak point, which is the opening in the thyrohyoid membrane that transmits the sup. laryngeal artery & internal laryngeal nerve . Aetiology Pathology Due to increased intraluminal pressure as in glass blowers & trumpet players diverticulum. Clinical picture Trumpet players cyst It is usually unilateral cystic swelling in the carotid A. It is translucent in trans-illumination. It is reducible on compression but Neck reappears when the patient blows his nose with his mouth closed. Thoracic surgery Diffrential diagnosis From other swellings in the carotid triangle. Treatment Surgical excision. Laryngocele Take your note 4 5 Line 1 Reach new heights Clinical picture 1. History of trauma (may be absent) followed by pain which is increased by coughing or deep breathing. 2. Tenderness at the site of fracture. 3. Crepitus is usually present but it is painful & risky to elicit. 4. Picture of complications. Investigation Plain X-ray chest, To confirm diagnosis & detect complications. Treatment Rib fructure X ray I. Treatment of the serious complications: e g. haemothorax has the priority. Neck II. Treatment of the fracture: Take your note The aim is not to fix the fracture but to relieve pain by: Thoracic surgery 1. Strapping: Strap the affected side by adhesive plaster, but this limits the chest movement and predisposes to hypostatic pneumonia due to retained secretions. 2. Intercostal nerve block: Injection of local anaesthetic around the neck of the rib. III. Rehabilitation: By respiratory exercise (inflating balloons) to open collapsed alveoli &coughing to clear airway & get rid of secretions. 2. Flail chest (Stove in chest) Flail chest Multiple ribs (at least four) fractured at two or more points. Note Flail (flāl)… exhibiting abnormal or pathologic mobility 4 5 Line 1 Reach new heights Aetiology Pathology Usually indirect trauma. Pathology The flail segment is free at its both ends, so it moves independent from the chest wall leading to: 1. Paradoxical movement. The affected lung collapses during inspiration & expands slightly during expiration due to the paradoxical movement of the flail Cross ventilation in flail chest segment. 2. Cross ventilation: The air is re-breathed Take your note between the two lungs with hypoxia & retention of CO2 in the blood. 3. Mediastinal Sutter: Thoracic surgery The paradoxical movement of the affected lung leads to oscillation (pendular movement) of the mediastinum from side to side. This movement interferes with venous return and cardiac action. Complications Pathology Like simple isolated fractured rib 1. Hypoxia & hypercapnea (Respiratory failure) 2. Shock due to mediastinal flutter (low venous return). Clinical picture Like isolated rib fracture with marked dyspnea, tachycardia possibly with shock & cyanosis. 6 PB Line 1 ChapterReach new heights1 Hand infection )داحوس( (Whitlows) Whitlows It is one of the commonest infections in the body especially in manual workers Aetiology Causative organisms: Staph aureus in 90% of cases. Route of infection:Through punctures & minor wound, Rarly blood borne infection. Predisposing factors: it is more common in: diabetics & manual workers, housewives Hand & Foot immunocompromized patient. & dish washers. Pathology Types = Classifications: I. Superficial infections: 1. Paronychia. 4. Subungual abscess. 2. Subcuticular abscess. 5. Pulp space infection (felon). 3. Web space infection. 6. Dorsal aspect infection. II. Deep infections: 1. Spaces infections: Thenar & hypothenar space infection. Midpalmar (deep palmar) space infection. Parona space infection. 2. Synovial sheaths infection: Suppurative tenosynovitis of the fingers (intrathecal whitlows). Radial bursitis. Ulnar bursitis. 3. Bone & joint infections: Osteomyelitis. III. Unclassified infections:e.g. Infected wounds, & bites, pilonidal sinuses of burbars. PB 7 Line 1 Reach new heights General rules in diagnosis & management of hand infection 1. Antibiotic (penicillinase resistant) must be given, once Hand infection suspected. 2. No surgical intervention before adequate localization & exact location of pus. 3. Don’t wait for fluctuation in palmar aspect infection Take your note as the thick skin & tough fascial septa delay fluctuation & increase tension (risky). The first sleepless night due to pain is an indication for immediate operation. 4. Edema of the dorsum of the hand is marked even in palmar infection. So, don’t incise in the in dorsum except after exclusion of palmar infection. 5. Adequate anaesthesia is essential either general anaesthesia (better) or regional nerve block. Ring anaesthesia may be used in finger infection but adrenaline must not be used 10 avoid ischaemia & gangrene of the finger. 6. Tourniquet may be used to have a bloodless field. Hand & Foot 7. lncisions should be done: Over the maximum point of tenderness tested by a probe. Never crossing the skin creases. Respecting important structures e.g. vessels & nerves. 8. Drainage is secured by trimming the wound edge or by soft Position of immobilization drain. Tough drains may press over vessels & nerves. Packs are contraindicated. 9. Immobilization & elevation are important to relieve pain & oedema & help healing. Immobilization is done in Ideal position of immobilization: the fingers are flexed 90° at metacarpophalangeal joints and minimally flexed at the interphalangeal joints. The thumb is adducted & the wrist is dorsiflexed. This position avoids or minimizes stiffness. 10. Early postoperative physiotherapy is essential. 8 9 Line 1 Reach new heights First Superficial infections A Paronychia Paronychia Infection under the nail fold. Anatomy of the nail Aetiology Usually after removal of hang-nail or careless nail paring. Clinical picture Drainage of paronychia It is the commonest form of hand infection. Red tender swelling of the side of the nail fold which may extend to the other side (run around ) & may Hand & Foot extend under the nail —> subonychia. Paronychia & run around Treatment Take your note Drainage of pus by Hilton’s method. If a pocket is present under the comer of the nail fold a triangular area of the nail fold is excised. In subungual abscess, part or the whole nail is excised. Note Chronic paronychia: is a more insidious infection of the nail fold in house wives & dishwashers. Fungi e.g. monilia are the commonest organism. So antifungal agents both orally & locally give good result beside keeping the fingers as dry as possible. 8 9 Line 1 Reach new heights Second Deep infections 1. Volar spaces infection Anatomy of spaces Thenar Mid palmar Parona Anteriorly palmar fascia Ulnar bursa Flexor tendons Pronator adductor pollicis Metacarpal quadratus Posteriorly muscle. bones muscle Intermediate thenar muscle Laterally septa Urology Intermediate Hypothenar Hand & Foot Medially septa. space Infection Thenar Mid palmar Parona Trauma, Pinprick, ulnar infection or from Aetiology tenosynovitis bursitis ulnar or radial palmar space bursitis Edema of the Edema of the Swelling to the dorsum, preserved dorsum, obliterate forearm from the C/P cup of hand the cup of the original hand hand infection 10 11 10 Line 1 Pathology Types of renal stone: Uric acid & urate Oxalate stone Phosphate stone cystine stone stones Number Usually single Single or multiple Usually multiple Mutapie Size Moderate Large or staghorn Small Small Shape Irregular Oval Oval or faceted Oval Surface Spikey Smooth Smooth Smooth Ca phosphate or Cystine (sulphar Composition Ca oxalate Uric acid pure tripple phosphate containing A.A) Color Dark (due to bl.) Ditry white Yellow to brown Yellow light green Soft on light Consitancy Hard Chalky&friable Hard greasey(bee wax) Reach newheights Cut section Amorphus Laminated Amorphus Amorphus Uric acid stone is Radio opaque X-ray Radio opaque Radio opaqe translucent &urate due to it’s sulphar are radio opaque content 11 HandUrology & Foot Line 1 Reach new heights Investigation I. Laboratory investigations: 1. Urine analysis for crystals, pus cells &pH. 2. Kidney function test. II. Imaging studies: Take your note 1. U/S: Detection of stone &more importantly backpressure changes of PC system. 2. Plain X ray: More than 95% of urinary stones are radio opaque (DD from radio-opaque shadow in the hypochondrium). 3. Intravenous urography (IVU): it is mandatory to: Detect radiotransluccnl stone ” filling defects” Detect backpressure changes. Detect distal obstruction or predisposing factors. Note Technique: Urology 1-2 amp of urogniphin
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