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Line 1 Neck

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Neck Anatomy

1.

The neck has seven triangles anteriorly & two posterior triangles: Take your note Neck

Triangle of the neck

1. One : between the two anterior bellies of & the body of . 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 . 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 muscle & middle 1/3 of .

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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 .

Treatment

Surgical excision.

Laryngocele Take your note

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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

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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

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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

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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.

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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

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11 Line 1 Reach new heights Mutapie Small Oval Smooth (sulphar Cystine A.A) containing green light Yellow on light Soft greasey(bee wax) Amorphus Radio opaque sulphar it’s to due content cystine stone Usually multiple Usually Small Oval faceted or Smooth acid pure Uric brown to Yellow Hard Amorphus is acid stone Uric &urate translucent radio opaque are Uric acid & urate acid & urate Uric stones Urology Hand & Foot Single or multiple or Single Large or staghorn Oval Smooth or Ca phosphate phosphate tripple Ditry white Chalky&friable Laminated Radio opaqe Phosphate stone Phosphate : Usually single Usually Moderate Irregular Spikey Ca oxalate bl.) to (due Dark Hard Amorphus Radio opaque Oxalate stone Oxalate Pathology Number Size Shape Surface Composition Color Consitancy Cut section X-ray Types of renal stone renal of Types 10

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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 ). 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 (20-70 mi) are given IV. Then serial X ray films are taken after 5,10, IS 45 &minutes and after voiding of urine (post- voiding film):  The first film(s) for nephrogram Zone of pressure may be created around the of the patient using two tennis balls and a binder to retain the dye in the kidney for somewhile.  The film taken after 45 min is called descending cystogram. Which normally shows the bladder, distended with the dye after evacuation of both ureters.  Post voiding film is taken to delect residual urine after evacuation and ensure complete evacuation of the bladder. Disadvantages:  Hypersensitivity reaction to the contrast  Nephrotoxicity of the contrast IVU shouldn’t be used when S.cr is > 2.5 mg%.  lt is time consuming in emergency conditions e g. trauma.  kidney may not secrete the dye because of malfunction or spasm of renal artery due to pain. 12

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