Short Cases and Skill Lab.

Sessions in Surgery

Tips

Short cases in surgery are the various diagnostic and therapeutic procedures, in the field of surgery, that are
believed by examiners to be mandatory to know about. These are part of surgery exams starting from clinical
year-I all the way to the qualification exam. These moments have proven to be very stressful and unpleasant.
But, that probably wouldn’t be the case with focused preparation. Indubitably, there were many other files that
focus in this very same topic, prior to the golden note. However, most of the previous files just give a highlight
and clearly need some edition. This particular note will use the previous notes as a prototype and add some
other important information. The topics that are discussed are picked based on their importance in the exams,
as evidenced by certain events in the past three consecutive years.

Knowledge is definitely an important attribute to perform well in this exam, but not the only one. As a matter
of fact, the abilities of explaining and interpreting the cases may be more important in some situations. The
examiner’s first request will most likely be for you to explain what you see. The answers for these questions
shouldn’t be the name of the procedure. Instead, explain what you see in a layman’s term.

You should also be calm while interpreting and shouldn’t rush to answer. At times, the questions may not be
quiet straight forward, but usually not above your knowledge. As a result make sure to rely on your reasoning
ability as much as your knowledge. This file will also try to present the content in a way that can prevent losing
face in front of your examiners.

The topics that are covered includes: mass examination (abdominal, neck, thyroid and breast), orthopedic
cases, varicose veins, hemorrhoid, chest tube, urinary catheter, naso-gastric tube, colostomy, tracheostomy, T-
tube, hernia, surgical instruments and common x-ray findings in surgery.

Good luck!

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1
 Mass Examination Varicose Vein Orthopedics cases Hemorrhoid
3 17 22 27

Thoracostomy Urinary Catheter Naso-gastric Tube Colostomy

29 32 34 36

Tracheostomy T-tube Hernia Surgical Instruments

39 41 42 48

X-rays
55

Examination of abdominal mass, neck mass, thyroid gland mass and breast lump are all included under the
topic mass examination. Similarly, there are many cases under the topic orthopedic cases.
c
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2
 Mass Examination
Compiled by: Michael Yeshiwas

Mass examination is one of the most common exam cases in surgery, as reported by many students. From the
experience of these students, the mass can be located at various sites in the body. However, some of the
frequently affected areas of the body, most likely to appear on exams, include the abdomen and the neck.
Masses in other parts of the body are not unheard of in the exams. Luckily, there is a specific sequence of
examination steps that can be applied to all masses despite the site, only with minor alterations.

If this is your short case in the exams, the examiners will first order you to examine the mass, and then to report
your findings. The next step will be coming up with differentials and picking the most likely diagnosis. You may
be asked to defend the final diagnosis based on the site and nature of the mass. This note will try to provide an
examination step and differential diagnosis for masses in certain body parts: particularly abdominal, neck,
thyroid and breast masses.

Steps in examining a mass
Just like in any other physical examination in
medicine, there are four steps in examining a mass:
inspection, palpation, percussion and auscultation.
On inspection: site, size, shape, surface and border
should be assessed. The site should be as specified
as possible, like right upper quadrant abdominal
mass instead of just abdominal mass. The size can
be measured during palpation, but can also be
estimated. The shape may be explained using lay
man terms such as oval/round. The surface can be
explained as smooth or nodular. Finally, state if the
border is regular or irregular. You should
additionally see the area for any change in the skin
including color, visible vasculature and lesions such
as scar, ulceration or discharge. Based on the site of
the lesion, observing the movement of the mass
may be important (movement with swallowing or
protrusion of the tongue for neck mass, movement
with respiration or cough in abdominal mass).
On palpation: tenderness, temperature of the mass,
consistency, pulsation and fixation to the skin are
the parameters to check. You may also objectively
measure the diameters of the mass. The consistency
can be reported as soft, firm (rubbery), hard or
cystic. If the skin can be moved separately from the
mass it is not fixed, but otherwise report it as fixed
to the skin.
Percussion: is used frequently to see if the sound is
dull or resonant. In case of an anterior neck mass
you need to percuss on the sternum as a dull note
suggests a retrosternal extension. Abdominal
masses also frequently give a dull percussion note.
Auscultation: is important to assess for vascularity
of the mass. If a bruit is audible, it suggests a
vascular mass and possibly arising from the
vasculature itself. If you hear a friction rub, it is
suggestive of inflammation (can be infectious or
non-infectious). In case of an abdominal mass, it is
important to hear the bowel sounds, especially in
hernia sites.
Although this steps should be followed in the
examination of any mass, there may be certain
alterations while approaching a mass that is specific
to certain body parts. For instance, the examination

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3
of an abdominal mass may be slightly different from
that of a neck mass.
Summary of mass examination steps:
Inspection: site, size, shape, surface, border, skin
lesion (discoloration, scar, ulcer or discharge),
any visible vasculature, visible pulsation and
movement
Palpation: tenderness, consistency, palpable
pulsation, temperature and fixation
Percussion: dull percussion note
Auscultation: bruit, friction rub, bowel sounds
Examination of an abdominal mass
If you find an abdominal mass, you must examine it
in detail. But unlike masses in many other parts of
the body, you shouldn’t approach it alone, but the
whole abdomen need to be examined. Abdominal
examination also have four steps, like examination
of many other systems but in a different order.
Particularly, auscultation should come before
palpation and percussion as these steps affects the
bowel sound.
For all steps of this examination, the hands of the
patient should be placed on the sides, in order to
relax the abdominal muscles. The exposure should
also be from the xiphisternum to the symphisis
pubis. Ideally, the bladder should be emptied and
per-rectal examination also done at the end. In
surgery, however, the examiners will most probably
be interested in the abdominal mass and per-rectal
examination is not given much attention.
Inspection
The first step in examination of any system is
inspection and to inspect the abdomen the
examiner should stand at the foot of the bed.
While inspecting, you should see the shape of the
abdomen and report it as scaphoid, protuberant or
generalized distention. Report if the flanks are full
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4
as well. You also need to report if the abdomen is
symmetrical or not.
Another condition is to observe if there is any visible
peristalsis. Step ladder type of peristalsis stands for
small bowel obstruction, if it is right to left it is
probably a colonic obstruction and a gastric
peristalsis indicates pyloric stenosis.
Umbilical nodules (Sister Mary Joseph nodules) are
important signs for intra-abdominal malignancies
(colon, stomach or the pancreas). Also report if
there is scar (surgical/trauma) and see hernia sites.
If there is a visible mass, you should also inspect it
alone including site, shape, size, surface, border,
movement with respiration, skin color change,
pulsation, movement with deglutition, movement
with cough, if ulcer or discharge. If mass is not
clearly seen, just say there is fullness.
In males you can also check if the scrotum are empty
as it may rule out undescended testis.
Auscultation
The second step is auscultating for bowel sounds.
The normal range is 4-35 bowel sounds per minute,
although you probably will not spend this much time
to listen to the bowel sounds on the exams. In case
of a mechanical intestinal obstruction, there will be
a hyperactive bowel sound may be heard, although
the intestines may be exhausted at later times and
this may change in to a hypoactive bowel sound.
Diarrheal diseases can also give a hyperactive
bowel. If the bowel sound is decreased you may
suspect a neurologic intestinal obstruction or any of
the conditions that cause peritonitis. However, the
presence of peritonitis can be easily ruled out on the
palpation step. Bowel sounds may also be
exaggerated in a hernia and if the hernia is ischemic
it will rather be depressed.
You should also hear for bruit or friction rubs. The
presence of a friction rub may suggest inflammation
and bruit stands for high vascularity.
August, 2018
Palpation
For the third step, you need to palpate the whole
abdomen but with more of the time spent on the
mass. While palpating, don’t forget to ask the
patient if there is an area of tenderness and start
palpating opposite to that area.
On superficial palpation, you should look for
superficial tenderness, guarding and rigidity.
Abdominal defects, for instance in case of a hernia
can also be seen in this type of palpation. Another
consideration is the presence of abdominal wall
masses such as lipoma, fibroma and neuro-fibroma.
These abdominal wall masses can be distinguished
from intra-abdominal masses by doing the leg
raising or head raising tests, which will contract the
rectus abdominis muscles. The contraction of the
muscles will make these abdominal wall muscles
more prominent.
An enlarged organ or any intraperitoneal mass will
likely give a dull note upon percussion. But a
retroperitoneal mass will rather give a tympanic
note due to the intestinal loops in front of it.
Summary of abdominal examination:
Inspection: shape, symmetry, peristalsis,
pulsation, scar, hernia sites umbilical nodule,
detail of a mass if visible and scrotum in males
Auscultation: bowel sounds, bruit, friction rub
Palpation: tenderness, guarding and rigidity and
if you find a mass: size, shape, consistency,
mobility, palpable pulsation, temperature and
fixation
Percussion: fluid thrill, shifting dullness, percuss
for the liver and the spleen, any other mass
Differentials for abdominal masses

On deep palpation, you must see for deep To come up with differential diagnosis for an
tenderness and the presence of an abdominal mass. abdominal mass, you should think of the structures
If you find a mass, you can do detail examination in located in the particular site of the abdominal mass.
the way outlined on the above part (tenderness, The 8 segments of the abdomen are shown below.
temperature, shape, size, consistency, pulsation,
fixation to skin and mobility with respiration
(fixation and temperature: for superficial masses).

But in abdominal masses you must also state the

line of growth (especially for the spleen) and the
specific site, such as epigastric, right iliac fossa and
so on.

Tips: upper borders are not made out in liver, spleen

and the kidneys (finger insulation impossible) and
the lower borders can’t be outlined in case of pelvic
masses.

Percussion

One of the purposes of doing percussion in an

We can use 8 segments of the abdomen for
abdominal examination is to find out if there is fluid
convenience: 1 & 3: right and left hypochondrium, 4
accumulation, by doing shifting dullness and fluid
& 6: right and left lumbar, 7 & 9: right and left iliac
thrill tests. Shifting dullness is a more specific test as
fossa, 2: epigastrium, 5: umbilicus, 8: hypogastrium.
it is more likely to pick a smaller fluid collection.

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5
Masses that can arise from the abdominal wall (skin,
muscle or fascia) can be a differential for a mass that
is found on any of the eight segments of the
abdomen. These includes conditions such as lipoma,
fibroma, neuro-fibroma, rhabdo-myosarcoma and
other mass forming conditions in these structures.
Some of the important masses that could appear on
the exams are presented with their sites.
A mass in the right iliac fossa can have many
differentials considering the many structures
around it, including the ovaries, cecum, ileum,
appendix, iliac artery and the psoas muscle.
Differentials for Right iliac fossa masses:
Abdominal wall masses
Females: ovarian cyst, fibroid of the uterus
Abnormal location: undescended testis, kidney
Appendix: appendicular abscess
Ileum and cecum: ileocecal tuberculosis,
carcinoma cecum, intussusception, amoeboma,
actinomycosis
Psoas muscle: ileopsoas abscess
Lymph node: infectious or neoplastic masses
Retro-peritoneum: sarcoma
Vascular: iliac artery aneurysm
There are relatively fewer differentials for an
umbilical mass.
Differentials for umbilical masses:
Lymph nodes: metastastatic (secondary cancer
from other site), lymphoma or tuberculosis of
the para-aortic nodes
Retro-peritoneum: sarcoma
Pancreas: carcinoma of the body
Transverse colon: carcinoma colon
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In the epigastrium, we have structures such as part
of the liver, the stomach, the pancreas and the
aorta. So, you can think of masses that arise from
these structures.
Differentials for epigastric masses:
Abdominal wall masses
Liver: neoplastic (hepatoma), cyst (simple or
hydatid cyst)
Stomach: gastric cancer (a hard irregular mass
that moves with respiration)
Retroperitoneal: diseases of the pancreas
(pseudo-pancreatic cyst, pancreatic cancer),
abdominal aortic aneurism
If the mass arises from the right hypochondrium,
you should think of structures such as the liver, gall
bladder, the colon and the kidneys.
Differentials for right hypochondrium masses:
Abdominal wall masses
Liver: hepatoma, metastasis, polycystic disease
of the liver, hydatid cyst, lymphoma, congenital
riedel lobe
Gall bladder: carcinoma of the bladder, back
pressure in obstructive jaundice, mucocele,
empyema, acute cholecystitis (N.B. mucocele
gives non-tender mass while it is tender in cases
of acute cholecystitis and empyema)
Colon: carcinoma of the hepatic flexure, large
ileocecal tuberculosis
Renal: polycystic kidney, tumors, adrenal mass
Although not as commonly as the abdominal
quadrants that are stated above, you may
encounter masses in other quadrants as well. In
such cases, just think of the structures you find in
that particular area and don’t forget to consider
those masses arising from the abdominal wall.
August, 2018
Cystic masses can be distinguished by palpation. But
at times, the cyst may become tense and as a result
have a firm and possibly even a hard consistency. In
such cases, trans-illumination test can be done in a
dark room.
What can give a cystic mass in the abdomen?
Cystic masses in the abdomen:
Pancreas: pseudo-cyst
Liver: hydatid cyst, simple cyst
Kidney: hydronephrosis
Ovary: ovarian cyst
Gall bladder: mucocele (rare)
Vasculature: abdominal aortic aneurysm
Mesenteric cyst: either a chylolymphatic cyst or
an enterogenous cyst (these cysts move at right
angles to the direction of the mesentery)
Omental cysts (rare)
Examination of a neck mass
If you find a neck mass in the exams, you should
follow the principles used in examination of any
mass (inspection, palpation and auscultation). The
possible exception is the examination of a thyroid
gland mass, which needs a slightly different step in
the physical examination. As a result, examination
of a neck mass and examination of the thyroid gland
are presented independently.
A neck mass in a young child usually represent a
benign condition (congenital or inflammatory). But,
conditions such as lymphoma and neuroblastoma
are still possibilities. In contrary, a case of neck mass
in the elderly (>40 years of age) should always alert
for a potentially malignant pathology, unless proven
otherwise.
To reach at a diagnosis, you will need to acquire
some information on the growth pattern of the
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mass. Take a look at the following scenarios and
think of the possible differentials:
 A mass growing steadily over months or years
with only little change at a time: this stands for
benign conditions such as peripheral nerve
sheath tumors, paragangliomas or benign
tumors of the salivary gland.
 Mass growing at an alarming rate in a short
period of time: this stands for possible
infections or malignant tumors such as rapidly
growing lymphomas.
 A mass that fluctuates over time synching with
upper respiratory infections or other viral
illnesses: this stands for congenital cysts.
Along with the brief history, you should follow the
steps of mass examination, including auscultation
over the mass. Some of the findings you may have
associated with certain pathologies.
 Reactive lymph nodes: discrete, mobile, firm
and may be slightly tender
 Lymph nodes representing metastatic disease:
hard, may be matted and non-tender
 Infected lymph nodes: isolated, asymmetric,
tender, warm, erythematous and they may be
fluctuant masses. Oozing is also possible. In
case of tuberculosis the nodes may also be
matted.
 Cystic congenital masses: soft, ballotable and
mobile masses
 Involvement of the carotid sheath with tumor:
a firm mass on the lateral neck that moves
from side to side but not up and down. Classic
tumors that involves the carotid sheath
include carotid body tumors and vagal
schwannoma.
 Vascular masses: pulsatile quality, may have a
bruit heard on auscultation
 Thyroid masses: a midline neck mass which
elevates with swallowing/drinking
August, 2018
Other sources of information include investigation
modalities, which includes cytology, histology and
imaging studies.
Fine needle aspiration (FNA) will give a cytologic
evidence for malignancies. But we can also get
important information based on the physical
appearance (color) of the aspirated material.
 Purulent: abscess
 Thick (viscous) yellow: mucocele
 Bloody: vascular lesions
 Turbid yellow: brachial cleft cyst
 Serous dark brown: papillary cancer of thyroid
Not unlike abdominal masses, differentials for a
neck mass will also be dependent on the structures
found in the region. For convenience, the possible
causes of mass will be discussed as midline neck
masses and lateral neck masses.
Differentials for midline neck masses:
Ludwig’s angina
Enlarged submental lymph nodes
Pretracheal and prelaryngeal lymph nodes
Sublingual dermoid cyst
Subhyoid dermoid cyst
Thyroglossal cyst
Enlarged isthmus of the thyroid
Retrosternal goiter
Swelling in the suprasternal space of Burns
Ludwig’s angina: inflammation of the floor of the
mouth involving the submandibular and submental
regions resulting in edema. It gives a tense, tender,
brawny, edematous swelling of the submental
region. Halitosis is another character.
Enlarged submental lymph nodes is another
differential and can arise from:
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8
 Tuberculosis: it gives matted, firm nodes and
the upper deep cervical nodes are also
enlarged.
 Non-Hodgkins’s lymphoma: it gives firm and
discrete nodes. Other lymph nodes can also be
involved, namely submandibular, upper deep
cervical, preauricular, postauricular and
occipital nodes. These lymph nodes together
form the external Waldeyer’s ring.
 Metastasis to the submental nodes: it gives a
hard mass which may be fixed. It can be from
carcinoma of tip of the tongue, floor of the
mouth or central portion the lower lip.
Sublingual dermoid cyst: it is a soft, cystic and
fluctuant swelling commonly seen in the young. It is
a result of sequestration of surface ectoderm at the
site of fusion of the two mandibular arches. The
differential diagnosis for this condition are ranula
and thyroglossal cyst. But, ranula is bluish and
positive to transillumination test while a dermoid
cysts is not. Thyroglossal cyst can be differentiated
from sublingual dermoid cyst as it moves upwards
with deglutition.
Subhyoid bursitis: is an oval mass in the transverse
direction, which is located below the hyoid bone
and in front of the thyrohyoid membrane. It is due
to accumulation of inflammatory fluid in the
subhyoid bursa. It is soft, cystic and fluctuant. But
due to the turbidity of the fluid it is transillumination
test negative. Since it is inflammatory, it may be
tender. It moves with deglutition.
Thyroglossal cyst: it is a tubuloembryonic dermoid
cyst that arises from the thyroglossal tract/duct. It
can arise anywhere along this tract:
 Subhyoid (the most common)
 The level of thyroid cartilage (2nd common)
 Suprahyoid
 At the foramen caecum
 The level of cricoid cartilage
 Floor of the mouth
August, 2018
Swelling of the isthmus of the thyroid: can occur
associated with any pathology of the thyroid. But,
solitary nodules and cysts are not uncommon on the
isthmus. Like any benign condition of the thyroid, it
moves upward during deglutition. What
differentiates it from thyroglossal cyst is that it
doesn’t move with protrusion of the tongue.
Pretracheal and prelaryngeal lymph nodes: can
produce a midline nodular swelling when involved
with certain pathologies.
 Acute laryngitis: tender and soft nodes
 Papillary carcinoma of the thyroid: firm and
discrete nodes
 Carcinoma of the larynx: hard nodes
 Tuberculosis: firm, matted nodes
Swellings in suprasternal space of Burns: can be of
different types.
 Lipoma: soft and lobular
 Dermoid cyst: soft, cystic and fluctuant
 Gumma: firm swelling due to syphilis
 Thymic swelling
 Aneurysms: innominate or subclavian arteries
The lateral side of the neck on the other hand is a
quadrilateral spaces divided by the sterno-cleido-
mastoid muscle in to an anterior and posterior
triangles. This is the case both on the right and the
left sides. There are smaller triangles in each
triangle.
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Triangles of the neck:
Anterior triangle
 Submental triangle
 Submandibular (digastric) triangle
 Carotid triangle
 Muscular triangle
Posterior triangle
 Occipital triangle
 Supraclavicular triangle
A swelling from the submandibular triangle can be
secondary to several etiologies.
Submandibular triangle swellings:
 Enlargement of the submandibular lymph
nodes or salivary glands are the most
common causes
 Plunging ranula
 Ludwig’s angina
 Lateral sublingual dermoid cyst
 Tumors of the mandible
Plunging ranula and Ludwig’s angina are not
common causes for submandibular triangle
swelling. But, dermoid cysts and mandibular
tumors are even rarer.
Enlargement of the submandibular salivary glands
can be caused by salivary gland stones, chronic
saialoadenitis (inflammation), salivary gland tumors
and other chronic autoimmune conditions.
Enlargement of the submandibular lymph nodes
can be due to:
 Acute lymphadenitis: painful, tender, soft and
usually due to poor dental hygiene
 Chronic tuberculosis lymphadenitis: firm,
matted nodes
 Secondary from carcinoma of the cheek,
tongue or palate: hard consistency
 Non-Hodgkin’s lymphoma: firm, rubbery
August, 2018
Swelling in the carotid triangle also have certain
important differential diagnosis.
Carotid triangle swellings:
 Brachial cyst
 Enlarged lymph nodes (cold abscess)
 Enlarged thyroid gland
 Aneurism of the carotid artery
 Carotid body tumor
 Laryngocele
 Sternomastoid tumors
 Neurofibroma of the vagus
The rare conditions in this group of differentials
include carotid body tumors, laryngocele and
sternomastoid tumors. Make sure not to
consider these as your primary differentials.
Branchial cysts arise from vestigial remnants of the
2nd branchial arch. Although it is a congenital
condition, most patients are between ages 15 to 25.
It gives a soft, cystic, fluctuant and transillumination
negative mass. The cyst is partially covered by the
sternocleidomastoid muscle. As a result, if you do
stenomastoid contraction test, the swelling
becomes less prominent.
Carotid artery aneurism is mainly due to
atherosclerosis, although other etiologies are also
present. It is mostly found in the elderly and there is
usually a thick walled vessel that stands for
atherosclerosis. The mass is tensely cystic (appears
as if it is firm), fluctuant and transillumination
negative. The characteristic features is that it has an
expansile pulsation and bruit/thrill. The classical
features may be absent if there is thrombosis in
widened part of the vessel.
Carotid body tumor (chemodectoma) is a tumor
that arises from the chemoreceptors that are found
at the bifurcation of the common carotid artery. In
most instances, it is a benign tumor (can also be
malignant) and occurs in middle aged or old
patients. It is a firm to hard mass which is placed
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vertically, typically on the upper part of the anterior
triangle. The surface can be smooth or lobulated,
and the border is round. It is movable side to side
and not vertically. Pulsation can be felt.
Sternomastoid tumors it is due to injury to the
sternomastoid muscle during birth, which will lead
to rupture of few fibers and hematoma. Healing
occurs with fibrosis and this gives firm to hard mass
in the middle of the muscle. The size is usually 1-2
cm and the superior and inferior borders are not
distinct (it is continuous with the muscle). It is
mobile sideways, with tenderness (baby cries). The
term tumor in the name is thus a misnomer. Other
than the fibrosis, there is also a theory that explains
the condition as a congenitally short muscle.
Laryngocele is a result of herniation of the laryngeal
mucosa. A chronic cough may be a risk factor, but
most of the affected people are musician, wind
instrument players and glass blowers. It gives a
smooth, oval, boggy swelling which moves with
swallowing. The swelling becomes more prominent
while coughing and on Valsalva maneuver. It can be
differentiated from other swellings due to its
tympanic note on percussion and its cough impulse
on palpation.
Schwannoma of the vagus is a vertically placed oval
swelling with firm to hard consistency. If you apply
pressure over the mass a dry cough and in some
cases bradycardia may occur.
A pharyngeal pouch is herniation of mucosa of the
pharyngeal wall through the Killian’s dehiscence.
This dehiscence is a potential weak point between
the two parts of the inferior constrictor muscle, the
upper oblique and the lower horizontal fibers.
The posterior triangle can be affected by many
pathologies that results in a swelling. One
interesting fact about the posterior triangle is that it
is the commonest area of lymph node metastasis
from an occult primary tumor. A swelling in this area
can arise from any of the local structures.
August, 2018
The list of the etiologies for a posterior triangle
swelling is given in the next box.
Posterior triangle swellings:
A solid swelling in the posterior triangle can be
due to any of the following
 Lymph node metastasis or lymphoma
 Lymph node tuberculosis
 Lipoma
 Cervical rib
 Pancoast’s tumor
A cystic swelling can be due to
 Lymphangioma
 Hemangioma
 Cold abscess
If the swelling is pulsatile you should consider
aneurysm of one of the two arteries nearby
 Subclavian artery
 Vertebral artery
Examination of the thyroid gland
The thyroid gland is examined in the same basic step
of mass examination. However, there are many
special tests that apply to this mass only.
Inspection
On inspection, you should see the location of the
mass in front of the neck. Its location is usually
stated as between the two sternomastoids
horizontally and from the suprasternal notch to the
thyroid cartilage vertically. The side of the neck
which is dominantly occupied by the mass should
also be mentioned. The size, shape, surface and
borders need to be specified as well. The borders in
most scenarios are round. The surface, on the other
hand, vary greatly and can significantly affect your
differential diagnosis.
 Smooth surface: adenoma, puberty goiter,
pregnancy goiter, Grave’s disease
 Irregular surface: carcinoma of the thyroid
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11
 Nodular: multinodular goiter (if the nodular
surface is very big, it will be called bosselated)
Another consideration on inspection is the
movement of the thyroid. The thyroid gland moves
upward with deglutition (swallowing), which can
differentiate it from many other masses. But there
are other conditions that moves in the same way
and include: subhyoid bursitis, laryngocele,
thyroglossal cyst and enlarged lymph nodes
(particularly the pretracheal and prelaryngeal). In
case you encounter a nodule or cyst in the midline,
you should also see movement with protrusion of
the tongue (suggests thyroglossal cyst).
Pemberton’s test should also be done during
investigation, if you suspect a retrosternal goiter.
You just have to tell your patient to raise the hands
above the head, the arms touching the ears. If there
is a pressure effect on the trachea the superficial
neck veins will be engorged.
Palpation
The first step of palpation is confirming the size,
shape, surface and border. You should also explain
the temperature as warm surface may tell that the
goiter is toxic.
The consistency should also be recorded as it can
help to narrow down your differentials.
 Soft: Grave’s disease, colloid goiter
 Firm: adenoma, multinodular goiter
 Hard: carcinoma of the thyroid or calcific areas
in a multinodular goiter
Movement with deglutition should be confirmed by
holding the thyroid gland. On the way, you should
check for intrinsic mobility of the gland as it may be
severely compromised in carcinoma of the thyroid.
The sternomastoid contraction test and chin test
(neck fixation test) are done in one or both lobe
enlargement, respectively. These tests will tell if the
swelling is located deep to the sternomastoid
muscle.
August, 2018
Sternomastoid contraction test is done by placing
the hand on the side of the chin, on the opposite
side of swelling, and asking the patient to turn
against the resistance. If the swelling becomes
smaller, then we can conclude that the swelling is
deep to the sternomastoid.
The chin test is done when both lobes are enlarged.
You just ask the patient to bend the chin downward
against resistance and looking for decrement in
prominence of the mass.
Kocher’s test is also very important to tell the
involvement of the trachea. This test is done by
applying gentle compression on the lateral lobes. If
there is tracheomalacia secondary to long standing
multinodular goiter or involvement of the trachea
by carcinoma of thyroid this test will give rise to a
stridor. Don’t forget to do this test.
Based on the circumstances, you can also do other
special methods to make a thyroid mass more
prominent.
Special tests
Crile’s method: if there is a doubtful nodule,
keep your hand on the nodule and ask the
patient to swallow. Appreciation of the nodule
will be better.
Lahey’s Method: in order to palpate the right
lobe, push the gland to the right side and feel the
nodules on the posteromedial aspect.
Pizzillo’s method: is for obese, short necked
individuals. The hands are clasped and pressed
against the occiput and the head is extended.
The palpation part is concluded with:
 Tracheal position: it may be pushed to the
opposite side if only one lobe is involved.
 Lymph node palpation: oftentimes papillary
carcinoma of the thyroid significantly involves
the lymph nodes.
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12
 Common carotid artery palpation: in case of a
large multinodular goiter, the common carotid
artery may be pushed laterally from the
anterior to the posterior triangle.
Carcinoma of the thyroid may engulf the
artery and consequently we may loss the
carotid pulse. This is known as ‘Berry sign
positive’.
Percussion
This is done on the sternum, in order to rule out a
retrosternal goiter. Normally, percussion on the
sternum gives a resonant note. But if there is a
retrosternal goiter, the note will be dull.
Auscultation
It should be done on the upper pole of the thyroid.
This is because the superior thyroid artery is a direct
branch of the external carotid and it is found more
superficially.
One of the most important finding in toxic goiter is
a bruit or thrill on auscultation.
Summary of thyroid examination:
Inspection: location, size, shape, surface,
border, movement with swallowing, movement
with protrusion of the tongue and Pemberton’s
test should make the inspection complete
Palpation: the size, shape, surface, border,
temperature, consistency, movement with
deglutition, intrinsic mobility, sternomastod
contraction/chin test, Kocher’s test, special
tests, tracheal position, lymph nodes, carotid
artery pulse
Percussion: on the sternum
Auscultation: on the upper pole of the gland for
bruit/thrill
In practice, a thyroid gland examination is done with
other system examinations: cardiac, neurologic
(deep tendon reflex), musculoskeletal and the eyes.
August, 2018
Differentials for thyroid gland swelling
The differential diagnosis for a thyroid mass is broad
and you can also consider, masses that arise from
other structures (see examination of a neck mass).
In this section, only masses that arise from the
thyroid gland will be considered.
Classification of thyroid gland masses:
Simple goiter
 Puberty goiter
 Colloid goiter, iodine deficiency goiter
 Multinodular goiter
Toxic goiter
 Grave’s disease
 Secondary thyrotoxicosis in multinodular
goiter
 Toxic nodule
Neoplastic goiter
 Benign: follicular adenoma
 Malignant: primary or metastatic
Thyroiditis
 Granulomatous thyroiditis
 Autoimmune thyroiditis
 Riedel’s thyroiditis
Other rare causes
 Acute bacterial thyroiditis
 Thyroid cyst
 Thyroid abscess
 Amyloid goiters
Among all these, the most common are puberty
goiter, multinodular goiter and malignant goiter.
Puberty goiters and pregnancy goiters: are caused
by an increased metabolic demand of the body.
Both are considered as physiologic. However, a
certain proportion may develop a multinodular
goiter. Typically, the stimulation of the gland with
TSH results in diffuse hypertrophy and hyperplasia.
Colloid goiter: occurs due to inadequate intake of
iodine in the meal. If an iodine deficient state
continues for long it will result in accumulation of
colloid material in the gland, resulting in what is
known as colloid (iodine deficiency) goiter. Just like
the physiologic goiters, this type also results in a soft
and smooth thyroid mass.
Multinodular goiter: is the end stage of diffuse
hyperplastic goiter (puberty/pregnancy goiter or
colloid/iodine deficiency goiter). The finding in this
type of goiter is a firm, nodular gland affected on
both the right and left lobes. If you find a hard area,
you should suspect a calcification. A soft area stands
for a necrotized tissue.
Grave’s disease: gives rise to a uniformly enlarged
thyroid gland with smooth surface and soft to firm
consistency. Due to its increased vascularity, the
gland is usually warm to touch and a bruit can be
heard on auscultation. It can also have several
systemic manifestations due to the thyrotoxic state.
Follicular adenoma: is a benign tumor that gives a
solitary nodule which is firm and has a smooth
surface. It is hard to distinguish it from follicular
carcinoma by FNAC. Frozen section biopsy can be
done to tell for sure.
Papillary carcinoma: can present as a solitary
nodule with lymph node involvement.
Follicular carcinoma: is a malignant tumor that
usually arise from a multinodular goiter. It can be
suspected if a multinodular goiter started to show
rapid increment in size, decreased mobility or
became hard.
Anaplastic carcinoma: is characterized with a hard
and irregular mass that grows rapidly.
Solitary nodule: is when a single nodule is palpable
and the rest of the gland is not. Almost any thyroid
swelling can present in this way. The exceptions are
physiologic goiters, colloid goiter and diffuse toxic
goiter. The malignancy potential is high.

The golden note August, 2018

13
Granulomatous thyroiditis: is due to a viral
infection of the throat. It results in an enlarged,
tender and soft to firm thyroid gland.
Autoimmune thyroiditis (Hashimoto’s thyroiditis):
can give rise to firm to hard thyroid mass that can
involve either a single lobe or the entire gland. The
surface doesn’t show a regular pattern as it is
smooth in certain cases and irregular in others.
Riedel’s thyroiditis: is believed to be a result of
collagen disorders and is characterized by fibrosis. In
general, the extra-thyroidal fibrosis is significantly
greater than the intra-thyroidal fibrosis.
Examination of a breast lump
In most of the cases, breast masses are given as a
long case. But, there are still certain students who
faced this as a short case. Similar to examination of
other masses, here we also have inspection and
palpation. However, there is a small place for
percussion and auscultation.
Inspection
The inspection of the breast should be done in three
positions. These positions have different purposes.
Positions for inspection of the breasts:
 Hands by the side of the patient: most of
the examination is done in this position.
 Hands raised above the head: will make a
Peau-d’orange appearance of the skin
more prominent, if there is any.
 Bending forward: will help to see if a tumor
has involved the chest wall. If the chest
wall is involved, the breast will not fall
forward while bending forward.
All three positions should be utilized in the
examination of the breast.
The first step is seeing if the breasts are
symmetrical. Then comes examination of the nipple,
areola, the skin, a visible lump and the arms for
The golden note
14
edema (lymphatic obstruction). These are done with
the hands by the side of the patient.
The nipple should be inspected first for a discharge,
retraction, destruction.
Retraction is caused by fibrosis of the underlying
tissue. Fibrosis can also alter the level of the nipple,
elevating it. Thus, look for elevation of the nipple to
pick malignancy early.
Differentials for retraction of the nipple:
 Carcinoma of the breast: circumferential
retraction
 Chronic mastitis: periductal mastitis gives a
slit like retraction
 Duct ectasia: slit like retraction
 Congenital
 Chronic diseases (such as TB)
A recent retraction should always alert the
clinician for a possibility of malignancy.
Destruction of the nipple stands for Paget’s disease.
If there is a nipple discharge, you should specify the
color, as it can give a hint for the diagnosis.
Differentials for nipple discharge:
 Serous: fibrocystic disease
 Paste like: duct ectasia
 Greenish: fibrocystic disease, duct ectasia
 Yellowish (pus): breast abscess
 Bloody: duct papilloma, duct carcinoma
 Milky fluid: galactocele, hypothyroidism or
pituitary tumors
You should also see the areola for Peau-d’orange
appearance, which indicate infiltration of the areola
with a tumor. This is due to the lymphedema which
makes the areola thicker and the fixation of the hair
follicles and sweet glands to the tumor which gives
the dots. It appears as an orange’s skin.
The skin overlying the breast tissue should be
inspected for dimpling which stands for tumors. You
should also look for erythema, sinus tract and
August, 2018
discharge. If you see multiple nodules, you should
suspect an advanced disease.
If the lump is visible, you can also look for a detailed
information, including site, size, shape, surface and
border.
Although classically not part of breast examination,
you should look at the arms to rule out lymphedema
due to lymphatic obstruction.
At the end of inspection, inspect the breast on the
other two positions: hand above the head and
bending forward.
Palpation
This is better done by palpating in concentric circles
from the site of the areola to the outside. On
palpation, you should confirm the size, shape,
surface and border of the mass. The consistency
should also be stated. Typically, cancers give rise to
a hard lump, although firm lumps are also possible.
Tenderness is also a significant finding.
The intrinsic mobility of the lump should be
assessed by trying to move it. In the case of cancers,
the mobility is markedly reduced or it may not be
mobile at all. A lump that moves independently
from the breast is most probably fibro-adenoma.
Another consideration is the temperature of the
area around the breast. The skin will be typically
warm in infectious processes and not in cancers.
But, either a rapidly growing tumor or inflammatory
carcinomas can also have this feature.
You should milk on the nipples to see if there is a
discharge. It is better if the patient did this herself.
Finally, the plane of swelling should be outlined to
tell if the mass is fixed to the surrounding structures.
Fixity is a characteristics of malignancy.
 Try to lift the skin: if not possible, the tumor is
fixed to the skin
 Pectoralis major contraction test: is done by
asking the patient to put the hands on the
The golden note
15
flanks and press against the hip. Then try to
move the mass. If the mass is not movable, it
is probably fixed to the pectoralis major.
 Serratus anterior contraction test: is done by
pressing the hand against the wall. The
concept is the same as the previous test. But,
it is only done when the tumor is located in the
outer-inferior quadrant.
After examining the breast in such manner, you
should also search for lymph node enlargement in
the axillary nodes and supraclavicular nodes. These
nodes are:
 Anterior (pectoral) group
 Central group
 Posterior (subscapular) group
 Lateral group
 Apical group: hard to palpate
Summary of breast mass examination:
Inspection: symmetry, nipple, areola, the skin, a
visible lump and the arms (lyomphoedema)
Inspection should be done in the three positions:
 Hands by the side
 Hands above the head
 Bending forward
Palpation: you should assess the size, shape,
surface, border, consistency, tenderness,
intrinsic mobility, temperature, nipple discharge
and fixity (skin and chest wall)
Differentials for masses in the breast
Acute bacterial mastitis
 Cellulitic stage: swollen, tense and tender
breast that is warm to touch
 Abscess stage: soft, cystic and fluctuant mass
and if left untreated ulceration and discharge
on the skin.
 In case of a chronic subareolar abscess, a
partial or slit like retraction of the nipple can
be seen.
August, 2018
  Antibioma: in cases that are treated with Carcinoma of the breast: can rarely present with
antibiotics prior to abscess drainage, this firm blood per nipple, just like duct papilloma. But the
to hard lump can be the result. commonest presentation is breast lump. In 65% of
the cases, it is located in the upper and outer
Phylloides tumor: is a rapidly growing benign tumor
quadrant of the breast. The mass is usually hard and
that usually attains a huge size. On examination, the
irregular but can also be firm. Late features include
skin is starched and shiny with dilated veins over the
fixation to the skin/chest wall, ulceration and Peau
surface. It is warm to touch. The surface of the mass
d’orange appearance.
is bosselated (big nodules) with few cystic areas. You
can tell it apart from malignancy as there is no fixity,
nipple retraction or lymph node involvement.
Tips: when considering differentials for a mass
Intra cystic carcinoma of the breast: is when a located in a certain site of the body, it is better to
rapidly growing tumor undergoes cystic ponder about the structures located in the
degeneration. Other than the cystic lump, features surrounding area. Although masses from metastasis
of malignancy may be present. or ectopic tissues are possible, the regional
structures by themselves provide adequate
Cyclical mastaligia with nodularity (fibroadenosis):
differentials.
causes severe breast pain in the premenstrual
period. It gives multiple, irregular, firm nodularities Structures such as vessels, nerves, skin,
that are tender to touch. For the most part, it occurs subcutaneous tissues, muscles and bones are found
on the upper-outer quadrant, bilaterally. Greenish almost everywhere. Thus, differentials such as
or serous nipple discharge can also be expressed. lipoma, neurofibroma, bone tumor, osteomyelitis,
skin tumors, desmoid tumor… should always be in
Fibro-adenoma: gives a painless, smooth, round
your minds. In most instances, these conditions will
bordered mass with firm to hard consistency. This
not be top on your differentials, however, having
mass is typical due to its free movement in the
something to say is still better. If you do this, you
breast. For this, it is known as breast mouse.
wouldn’t mind if the mass is located in the shoulder,
Duct ectasia (periductal mastitis): is typically rib, legs, hand or anywhere else.
associated with a thick/paste like discharge per
nipple. But it can later give a mass that can be
confused for breast cancer. A long standing,
bilateral slit like retraction of the nipple is the other
feature.

Macrocyst: can be suspected if a single or multiple

smooth and tense cysts are present. Since the cyst
is tense it feels firm on palpation.

Galactocele: is a single subareolar cyst that can give

rise to a hugely enlarged breast. Occasionally, it can
undergo calcification (so harden).

Duct papilloma: is a benign lesion which is usually

single and unilateral. It presents as a small mass
beneath the areola and bloody discharge per nipple.

The golden note August, 2018

16
 Varicose Vein
Compiled by: Metasebia Zewdu

If all the cases in this file are available at your exam station, one of the cases you should know about in detail is
varicose vein. For unknown reason, most examiners really love to ask about varicose vein. It is not unusual to
hear students complaining about encountering this case. In reality, however, it is a fairly easy concept and have
been presented in a way that is easier to understand.

Inorder to understand varicose veins, we need to know the venous drainage of the lower limb first. It is grouped
in to three as superficial venous system, deep venous systems and perforators. The perforators connect the
deep and superficial venous systems.

The superficial venous system is found superficial to Calf pump

the fascia. It drains the skin and subcutaneous tissue
mainly. The best examples are the long and short
saphenous veins.
 Long (great) saphenous vein drains the medial
aspect of the limb. It starts from the dorsal
venous arch and ascends medially upto the
saphenofemoral junction (SF)
 Short (small) saphenous vein drains the lateral
lower limb. Just like the long vein, this one also
starts from the dorsal venous arch. But, it
ascends laterally and drains into the popliteal
vein, which is found behind the knee.
The deep Venous System is found deep to the fascia
and drains the muscles. Classic examples for these
types of veins include popliteal and femoral veins.
Perforators are veins which connect the superficial
veins to the deep system, by perforating the fascia.
There are 3 important groups of perforators, namely
 Thigh perforators (Dodd)
 Knee perforators (Boyd)
 Ankle perforators (Cockett)
Venous drainage from the lower limb is possible due
to the four factors: calf pump, unidirectional pump,
Vis-a-trego and negative intrathoracic pressure.
When the calf muscles contract, the blood in the
deep veins gets squeezed and empties upward to
the heart. The path is, from the popliteal vein to the
femoral, then to the external iliac and then to the
common iliac, finally to the inferior vena cava).
As the muscles relax, the pressure in the deep vein
drops and blood flows from the superficial system
to the deep veins, via perforators. The next muscle
contraction will force this blood towards the heart
and the valves will prevent backflow from the deep
to the superficial veins due to the increased
pressure in the deep veins.
Unidirectional Valves
All 3 systems have valves. The superficial vein valves
and perforator valves prevent backflow from the
deep to the superficial veins. The deep vein valves
prevent backflow from the iliac veins to the deep
system. The comon iliac vein and the inferior vena
cava do not have valves.
Vis-a-trego
This is transmitted pressure from the arteries to the
veins, which helps in draining blood to the heart at
resting position.

The golden note August, 2018

17
Negative intrathoracic pressure
Although the negative pressure from the thorax
appears remote from the lower limb, it actually
assists in its venous drainage.
Basic information
Varicose veins are dilated (>3mm), tortous and
elongated superficial veins of the limb which
develop because of incompetent valves.
Although it occur in the lower limb, most of the
time, it can also be seen in the upper limb, pelvic
plexus and other sites. For instance, varicosity of the
rectal plexus (hemmorhoid), the veins of the
spermatic cord (varicocele), esophageal varices and
ovarian varix are really common.
Varicosity can be primary or secondary. The primary
is due to congenital defect in valves or venous walls
and the secondary is because of aquired conditions.
Risk factors for varicose vein:
Increased intra-abdominal pressure which
causes proximal obstruction to blood flow
 Pregnancy: other than the pressure,
relaxation of venous wall muscle by
progestrone also play a role
 Pelvic tumors
 Ascites
 Abdominla lymphadenopathy
Deep vein thrombosis (DVT) and its risk factors:
oral contraceptive pills, smoking, prolonged
immobilization. Although the thrombosed vein
might recanalize, it can lead to destruction of the
valves.
Congenital connective tissue diseases
Congenital abscence of valves
AV fistula: leads to pulsatile varicosity due to the
high pressure flow
The golden note
18
Clinical manifestation
Varicose vein may be asymptomatic and stay in this
condition for several years. When it is symptomatic,
however, it can present with one or more of the
following:
 Pain: aching or throbbing type which increases
after prolonged standing and gets relieved
when they lie down or elevate their limb.
Unlike pain of peripheral arterial disease (PAD)
which gets worse with exercising, pain of
varicose gets relieved as the patient exercises
or walks. This is because contraction of the calf
muscle will promote drainage.
 Swelling of the lower leg: which increases after
prolonged standing and gets relieved when
they lie down or elevate their limb.
 Dilated vvs on the leg (aesthetical value)
 Complications: such as ulceration, eczema and
bleeding can be the presenting complaint.
Physical examination
Inspection
The inspection should be done on standing position,
with good limb exposure.
 Location: the dilated vein may be found on the
medial or lateral leg, knee or thigh
Medial side: long saphenous veins
Lateral side: short saphenous veins
Saphena Varix: is a single dilated vein at the
Sapheno-femoral junction due to sapheno-
femoral valve incompetence
 Swelling of the limb: if localized, may be due to
the varicose vein. But if the swelling is
generalized, it is due to DVT.
 Complications: ulceration, eczema, scar (prior
ulceration), pigmentation, inflammation of the
veins (phlebitis) and lipodermatosclerosis.
Palpation: you should try to see
 Thickening of the skin
August, 2018
  Redness (thrombophlebitis)
 Temperature (thrombophlebitis, DVT)
 Tenderness (thrombophlebitis, DVT)
 Swelling: compare the size of the two limbs
 Lipodermatosclerosis : is progressive sclerosis
of the skin and subcutaneous tissue because of
tissue death, fibrin deposition and scarring as
a result of repeated inflammation.
 Venous (stasis) ulcer: if present state the site,
size, shape, margin, floor, surrounding skin
change
The inspection and palpation steps are clearly very
important. But, most of the exam questions will
probably focus on the special tests.
Special tests for varicose vein
 Morrisey’s test
 Trendelenburg test
 Multiple tourniquet test
 Modified Perthes test
 Short saphenous vein incompetence test
Morrisey’s Test (Cough impulse test): is done in
standing position. We will put our fingers on the
sapheno-femoral junction and ask the patient to
cough. If we fill a fluid thrill on our fingers it indicates
sapheno-femoral junction incompetence.
Trendelenburg Test: have two tests. Test 1 checks
for sapheno-femoral junction incompetence and
test 2 checks for perforator incompetence.
We ask the patient to lie down then we will elevate
the leg about 30-40° above the level of the heart for
about 2 minutes to empty the veins. We may milk
the leg to aid drainage. Torniquet is applied below
the sapheno-femoral junction (the thumb can also
be used to occlude the junction). Afterwards, we ask
the patient to stand.
The sapheno-femoral junction is found about 3
to 4cm lateral and below the pubic tubercle.
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19
 Trendelenburg Test 1: is done by releasing the
thumb/torniquet immediately. If the varices
fill rapidly from above to downwards,
trendelenburg test 2 is said to be positive. This
indicates sapheno-femoral junction
incompetence.
 Trendelenburg Test 2: is done by keeping the
tourniquet/thumb for about 1 minute. Then
we ask the patient to stand. If there is slow
filling of the long saphenous, trendelenburg
test 2 is said to be positive. This indicates that
perforator incompetence is present.
Multiple tourniquet test: is used to locate the
incompetent perforator, specifically.
We will ask the patient to lie down. Then we will
elevate the limb and milk it. The next step is applying
3-5 tourniquets.
 Just below the sapheno-femoral junction:
occlude the junction
 At the mid thigh: occlude thigh perforators
 Just below the knee: occlude knee perforators
 Palm breadth above the medial malleolus:
occlude ankle perforators
We ask the patient to stand and then look for
apperance of veins
 Between the 1st and 2nd tourniquet: thigh
perforator incompetence
 Between the 2nd and 3rd tourniquet: knee
perforator incompetence
 Between the 3rd and 4th tourniquet: ankle
perforator incompetence
Modified Perthes test: is done to rule out DVT and
there is no need to milk the leg.
The patient is asked to stand and then apply the
tourniquet below the sapheno-femoral junction.
Then ask the patient to walk. Increased prominence
of the varicose with severe crampy calf pain
indicates the presence of deep vein thrombosis.
August, 2018
The original perthes test was done by wrapping the
whole limb with elastic bandage & asking the
patient to walk around. If there is DVT all the blood
getting diverted from the superficial system to the
deep due to the compression effect of the bandage
would cause the deep vvs to dilate & result in severe
cramps. The modified test is better as it has both
subjective (cramp) and objective (dilated veins)
methods of assesing DVT.
Ruling out DVT is very important as its presence of
in a varicose patient is a contraindication for surgical
removal of the varicose veins. This is because, the
deep system is already blocked and the only way
venous blood is draining from the limb is through
the varicosities.
Short Saphenous vein Incompetence Tests: there
are two methods to do this test.
Method 1
We apply a tourniquet at the upper thigh to block
the flow of blood from the long saphenous vein to
the femoral vein. This will inturn divert most of the
blood to the popliteal vein. If there is
saphenopopliteal incompetence, popliteal vein
blood will back flow to the short saphenous vein
causing it to be more prominent.
Method 2:
We will occlude the saphenopopliteal junction
(usually found in the popliteal fossa) and then ask
the patient to stand. Shortly after, we release the
pressure on the saphenopoliteal junction. If there is
rapid filling of veins on the lateral leg, it indicates
saphenopoliteal incompetence.
NB: examination of varicose vein is complete only if
you do abdominal examination. This is because you
may find abdominal masses.
You will be expected to report all your findings for
your examiner. You can use the following step to
report your findings in an organized way.
The golden note
20
Suggestion for the report
 Unilateral or bilateral
 Long or short saphenous vein system
 With/without saphenofemoral or
saphenopopliteal junction incompetence
 With or without perforator incompetence
 Specific perforators affected (if there is
perforator incompetence)
 With or without DVT
 With or without other complications
(eczema, pigmentation, ulcer, phlebitis)
Complications of varicose vein
Complications due to dilated veins
 Hemmorhage: the dilated veins bleed easily
 Thrombophlebitis: occurs after trauma to the
dilated veins, but can occur spontaneously.
Due to the venous hypertension
 Eczema
 Pigmentation: due to extravasation of red
blood cells leading to hemosiderin deposit
 Venous ulcer: because of poor skin nutrition
and repeated excoriation. If longstanding it
may undergo malignant change or cause limb
deformity
 Lipodermatosclerosis
DVT: can develop secondary to the stasis
NB: skin complications usually occur around medial
malleolus. This is because of the blood stasis that is
more pronounced in the area.
Investigations
Base line investigations that are done as a pre-op
assessment should all be done.
 Venogram
 Doppler ultrasound: to check for valvular
incompetence and to rule out DVT
August, 2018
  Duplex ultrasound: very good as it shows the
flow pattern and helps to localize specific
perforator incompetence

Management

Conservative treatment: largely focuses on

alterations in life style.

Itincludes avoiding prolonged standing, applying

compressing stockings throughout the day,
exercising the leg by frequent elevation of the leg to
strengthen calf mms, elevating the limb while
sitting/sleeping to facilitate drainage

Indications for conservative management

 Elderly patient
 Patient who is unfit for surgery
 Pregnancy
 Mild varicose vein
 Co-occurring DVT

Injection sclerotherapy:

It involves injection of sclerosant into the vein. This

will illicit inflammation and fibrosis of the vein.
Indications for sclerotherapy

 Small varices below the knee

 Recurrent varices after sugery
 Uncomplicated perforator incompetence
It has higher reccurence rate when compared to
surgery. It may also result in allergy, pigmentation,
DVT, thrombophlebitis and skin necrosis.

Surgery:

Indications for Surgery

 Saphenofemoral junction incompetence

 Saphenopopliteal junction incompetence
There are two operative options:

 Ligation
 Ligation with stripping

The golden note August, 2018

21
 Orthopedic Cases
Compiled by: Metasebia Zewdu

Clearly, orthopedic short cases are some of the most important topics in the exam. But, if your exam station is
Tikur Anbessa, their importance will grow to a whole new level. That being said, it is important to know about
them to a certain acceptable level, regardless of your exam station.

Of all the cases in orthopedics, the most important topic for medical students appears to be the management
of fractures. Consequently, the cases that appear most often in the exams are usually the various techniques of
handling fractures. Another common topic is amputation, particularly the types and indications. This section will
try to provide that much information.

There are generally three basic principles in treating
uncomplicated closed fractures. In sequential order,
these three steps are reduction, immoblization and
rehabilitation.
Reduction: is the process of restoring the fractured
fragments to an acceptable position. In other words,
it means maintaining good apposition (between the
fragments) and acceptable alignment.
It can be done in 3 ways:
 Closed manipulation: without the need for
surgery, it is disimpacting and realigning the
fragments under anesthesia
 Mechanical traction
 Open reduction: requires exposing the bone
surgically and reducing it under direct vision
Immoblization (Stablization)
The methods of stabilisation are:
 Continious traction
 Cast or external splintage splintage
 External fixation
 Internal fixation
 Functional bracing
Traction
Traction is applying continious force to the distal
fracture fragment to create a continious pull in the
long axis of the bone. This will counteract the
muscle pull that tends to displace it. The methods of
traction are traction by gravity, skin traction and
skeletal traction.
Traction by gravity: is used only for upper limb
injury. It uses gravity to counteract muscle pull by
applying an arm sling.

Once we reduce the fracture fragments to their
normal alignment we want to stablise them in their
reduced position to prevent re-displacement. Since
the aim is not to completely immoblize the
fragments, stablisation is a better term. Stablising
the fracture promotes healing, prevent soft tissue
and neurovascular structure damage by the
fragments, decreasing pain.
Skin traction: should be used only in children. The
reason is that we can only apply a maximum of 4-5
Kg weight for the traction. Another use for skin
traction is after surgery, untill you get appropirate
instruments. But, the short coming is that we can’t
use it for long due to the imminent injury to the skin.
Skeletal traction: is when a Pin is inserted to the
distal fragment of the bone to counteract the

The golden note August, 2018

22
muscle pull. Larger weight can be applied. Mostly up
to 1/6th of the body weight is applied. Sometimes,
however, up to 20% of the body weight is used.
Indications for skeletal traction
It is mainly used for long bone fracture and
pelvic fracture that tends to be unstable and re-
displace. The list include:
 Acetabular fracture
 Unstable hip fracture
 Ling bone fracture of the femoral shaft,
tibia and distal humerus
The sites where we can apply the traction are:
 Distal femur
 Proximal tibia
 Distal tibia
 Calcaneus
 Olecranon
NB. At all sites we insert the pin from the medial to
the lateral side, except in proximal tibia. In
proximal tibia, we insert from lateral to medial to
avoid injuring the peroneal nerve, which is found
on the lateral aspect of proximal tibia.
The major complications associated with skeletal
traction are neuro-vascular damage and pin site
infection.
NB. There is no risk of joint stifness as the patient
can move the joint and exercise the muscles.
What would you say if you are asked what you
see? Example for a proximal tibia traction
 There is a pin inserted into the right
proximal tibia. The pin is attached to a
cord passing over a pulley.
 There is this much amount of weight
(example: 6kg) attached to the end of the
cord.
 The skin around the pin does not look
inflamed and there is no discharge.
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23
External Splintage (POP cast)
Most of the time, we use plaster of paris (POP) for
external splintage. But, splints can also be made
from plastics, wires, aluminium strips or other hard
materials like card baord (ካርቶን).
Cremer wires are cheap and easily available wires
which can be used for emergency stabilisation of
fracture. This makes them good alternatives.
POP is a hemi-hydrated calcium sulphate and can be
applied in two ways.
Types of application of POP
Posterior gutter
In this type, the POP is applied only posteriorly
and the rest is covered by banadage. It allows
expansion, thus helping to decrease risk of
compartment syndrome.
Circular cast
In this type, the POP spans the whole
circumference of the limb, making it better at
stablising the fracture fragments. But, it has
higher risk for compartment syndrome.
NB. Inorder to stabilise acute fracture we use
posterior gutter at first. The reason behind this is
that the inflammation will be maximal within 72 hrs
after the fracture and a circular cast causes
compartment syndrome. After about 1 week, we
can change it to circular cast.
Indications for POP
The major indications for the use of POP include:
 First aid treatment of fracture (as a splint)
 Definitive treatment: to hold the fracture
 To correct deformity
 To prevent fracture in high risk patients, a
classic example of which is an old lady with
osteoporosis
August, 2018
How to apply a cast
We put the hemi-hydrated calcium sulphate
preferrably in a cold water to form hydrated calcium
sulphate. We keep it in water until the bubbles
dissappear. This is what we call setting. Then we
apply cotton pads over bony prominences to
prevent pressure sores. The plaster is then applied
and the surgeon will mold it away from bony
prominences. If it is a posterior gutter, we apply
bandages over the anterior part.
Principles of POP application
 The joint above and below the fracture should
be immoblized.
 The plaster and the bandage shouldn’t be too
tight (to avoid compartment syndrome)
 It shouldn’t be too loose either (will be
ineffective in stablising the fracture)
 The cast should be applied in the functional
position of the limb. Otherwise, the joint will
be stiff in abnormal position and the patient
will be permanently deformed.
Complications of POP include:
 Compartment syndrome
 Pressure sore especially on bony prominences
like the patella, heel and elbow
 Stifness of the joints that are immobilized
 Osteoporosis
 Skin abrasion and laceration, especially if we
use electric saw for removal of cast
What would you say if you are asked what you
see? Example for a POP
 There is a POP applied on the right
posterior leg from this point upto this point
(Example: from just above the knee to just
below the ankle)
 It is covered by bandages anteriorly.
 The limb is held in this position (Example:
slightly flexed at the knee joint)
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24
External Fixation
External fixation is the process of stablising the
fractured fragments by attaching it to an external
device (the metal bar) by means of pins inserted into
the proximal and distal fragments of the fracture.
Indications for external fixation
 Open fracture: we can’t use internal
fixation in this type of fracture because of
their high risk of infection
 Emergency stablization of long bone
fracture in polytrauma patient: as a
component of damage control orthopedics
 Periarticular fracture (a fracture involving
the articular surface of the joint)
 Pelvic fracture
 Fracture with bone and soft tissue loss
 Pediatric fracture
 Arthrodesis: after we remove the articular
cartilages, we can hold the two ends of the
bone by external fixator so that they
remain in that position and heal by fibrosis
An external fixator has three parts, i.e. pin, bar and
the clamp.
Pins: are the metals that go through the bone.
Bar: is the metal found externally to which the pins
are attached.
Clamp: can be of 3 types, pin-to-bar (attach the pin
to the bar), pin-to-pin (attach one pin to another)
and bar-to-bar (attach one bar to another bar).
Spanning external fixator
It is when the external fixator crosses a joint. For
example:
 Wrist spanning external fixator
 Knee spanning external fixator
Complications
It will be easier to look at the complications with the
procedure of inserting the fixator.
August, 2018
  As we incise the skin and soft tissue we can
cause a neurovascular damage
 As we drill the bone to insert the pins there
may be heat necrosis of the bone
 If we accidentally damage the cortex on the
other side of the bone it causes Iatrogenic
fracture
 After the external fixator is placed we can have
Pin site infection, Pin loosening (technical
problems), joint stifness (if it is joint spanning)
What would you say if you are asked what you
see? Example for an external fracture
 There are multiple pins going through the
right tibia which are attached to an
external metal bar by clamps.
 The skin over the pin insertion sites does
not look inflamed.
 There is no discharge.
Internal fixation
In this type, metals will be inserted into the bone
operatively. It holds the fractured fragments more
rigidly than external fixation.
Indications for internal fixation
 If closed methods fail
 Fractures that can only be reduced by
operation: since we will open to reduce the
fracture anyway, we can do internal
fixation on the way. It can be used if the
risk of infection is low
 Unstable fracture: such as Mid-shaft
forearm fracture and ankle fracture
 Fracture that unite slowly: such as femoral
neck fracture
 Pathological fractures
 Multiple fractures where early fixation will
decrease the risk of general complication
 Displaced intra articular fracture
Since you can’t possibly see internal fixators with
the naked eye, the likelihood of encountering it is
very low.
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25
But, superficial questions such as the types of
internal fixations may appear. There are four types
of internal fixations.
 Screws
 Wires
 Plate and screws
 Intramedullary nails
Complications: the major complications of internal
fixators include:
 Infection
 Implant failure
 Non-union
 Re-fracture
Amputation
The term amputation stands for the removal of an
extremity or appendage from the body.
Indications for amputation
The indications can be summarized with the
three Ds. These are dead limb, dangerous limb
and damned nuisance.
Dead limb is when the limb is dead and needs to
be removed. It can be due to peripheral vascular
diseases, severe trauma, burn or frostbite.
Peripheral arterial disease alone is responsible
for 90% of all amputations.
Dangerous/deadly limb is when the limb is not
dead but is life-threatening to the patient. This
includes malignant tumors, potentially lethal
sepsis of leg origin (wet gangrene spreading to
the surrounding tissue) and crush injury (can
lead to sever rhabdomyolysis which can cause
acute kidney injury).
Damned Nuisance is when retaining the limb is
worse than having no limb at all. The specific
conditions include severe pain, severe loss of
function (like contracture), gross malformation
and recurrent sepsis.
August, 2018
There are two main types of amputation: major  Ischemia
amputation and distal amputation.  Neuroma: inflammation of the nerve due to
transection during amputation
Major amputation is an amputation above the level
 Infection (osteomtelitis, graft infection)
of the ankle. The specific types include:
 Phantom limb syndrome: Phantom limb is the
 Hip disarticulation: done through the hip joint feeling that the amputated limb is still present.
 Above knee amputation: through the femur Some patients can also have phantom pain
 Knee disarticulation: through the knee joint which is pain at the area of the stump. In most
 Below knee amputation: through the bones of cases it disappears eventually.
the leg (tibia and fibula)  Bone spur formation: is a sharp bone that
develops at the end of the stump which might
Distal (Foot) amputation is an amputation that is at be sometimes painful.
or below the ankle. The specific types include:
Other than the pain, there are few more chronic
 Ankle disarticulation: done through ankle joint complication of amputation. These are ulceration,
 Mid and hind foot amputation flexion contracture, re-amputation, osteoporosis
 Trans metatarsal amputation: done through and pathological fracture.
the metatarsals
 Isolated digit amputation: is amputation of a Ulceration can be due to either Ischemia or infection
single digit (in case of isolated digit gangrene of the stump.
with good blood supply to surrounding tissue)
Flexion contracture: is a stiff and deformed joint
Complications: can be divided as early and late. which usually occurs in old amputees or in those
who recieved inadequate postop pain management.
Early complications
Re-amputation is a possibility, especially in diabetic
 Bleeding
patients and in distal amputations.
 Hematoma
 Infection: the risk is higher for the above knee Osteoporosis and pathological fracture occur if the
amputations due to the contamination with amputated bone is bearing very little weight.
urine and feaces
 Breakdown of skin flap
 Medical complications such as myocardial
infarction, arrythmia, heart failure, pulmonary
thrombo-embolism and atelectasis
The commonest indication is PAD and its risk
factors are smoking, diabetes, cardiovascular
diseases. This conditions put the patient at a
higher risk of developing cardiopulmonary
complications, post surgery.

Late complications

Chronic pain at amputation stump is one of the most

important late complications and it can be a result
of one of the following:
The golden note August, 2018
26
 Basics of Hemorrhoid
For a reason that you can easily guess, hemorrhoid has not been commonly seen in the past few years. However,
there is still a remote chance of facing this case in the examinations. Considering this fact, only an optimal detail
of the most important concepts will be included in this section of the note.
Other common names for hemorrhoid include
pile and lump.
There are many definitions that are used to define a
hemorrhoid. Many people commonly define it as a
dilated or enlarged veins in the lower rectum or
anus.
But, the appropriate definition will need an
understanding about the anal cushions. The anal
cushions are specialized and highly vascularized
discrete masses of thick submucosa. Its contents are
blood vessels, smooth muscle, elastic tissue and
connective tissue. The cushions are located at the
left lateral (3 o’clock), right anterior (11 o’clock) and
right posterior (7 o’clock) parts of the anal canal.
With this much understanding of the anal cushions,
we can give a more sensible definition for
hemorrhoid. It is just a condition associated with
downward sliding of the anal cushions. The cause
remains unknown but it may be due to downward
sliding of the anal cushions associated with gravity,
straining and irregular bowel habits.
The peak age of occurrence is 45-65 years and it also
tends to be increasingly seen pregnancy. However,
hemorrhoids that develop during pregnancy are
most of the time temporary.
Hemorrhoids can be totally asymptomatic. It usually
become symptomatic if there is a cancer of the
rectum (compress the superior rectal vessel),
pregnancy and straining (as in urethral stricture).
The golden note
27
Compiled by: Michael Yeshiwas
There are two types of hemorrhoids:
Internal hemorrhoid: can be defined as a dilatation
of the internal venous plexus in an enlarged and
displaced anal cushion. It is located proximal to the
dentate line. The characteristic feature is a painless
bright red bleeding or prolapse associated with
defecation. A pain in an internal hemorrhoid
indicates a serious condition, such as thrombosis.
Although the most popular findings in hemorrhoid
are bleeding and prolapse, a discharge is also a
common features.
Etiology of internal hemorrhoids
 Hereditary: runs in families
 Morphology: we have two legs and this
predispose us to hemorrhoid. There is a
very low incidence in quadrupeds.
 Anatomical: since the veins in the area
doesn’t have valves, the tributaries of the
superior rectal vessels are unsupported.
 Exacerbating factors: such as straining
during constipation or diarrhea
Other risk factors include
 Pregnancy
 Heavy lifting
 Sitting or standing for long
During the physical examination, you may find signs
of anemia with other regional signs.
August, 2018
On inspection, you may see redundant skin folds or
skin tags. In the case of internal hemorrhoid, if you
ask the patient to strain, there may be prolapse.
Digital rectal examination should be done. However,
internal hemorrhoids can’t be felt on palpation
unless they are thrombosed.
Proctoscopy and sigmoidoscopy are superior to any
other investigation modality as they allow a direct
visualization of the bulge. Additionally, they can be
used to rule out other pathologies like cancer.
Internal hemorrhoids can be catagorized in to four
grades. Bleeding and discharge can occur in any of
the grades and hence not part of the grading.
Grade 1
Bulge in to the lumen, doesn’t protrude.
Treatment: only dietary modification
Grade 2
Protrudes during bowel movement, but will be
reduced spontaneously.
Treatment: rubber band ligation
Grade 3
Protrudes, but will not be spontaneously reduced.
It will require manual replacement.
Treatment: surgical hemorrhoidectomy, rubber
band ligation
Grade 4
Permanently prolapsed and irreducible, despite
attempts to manually reduce it.
Treatment: surgical hemorrhoidectomy
Strangulation: urgent hemorrhoidectomy
Dietary modifications should be a component of the
management of all grades of hemorrhoid. Its effect
are not acute but prevent exacerbation and
recurrence after the definitive treatment. The
dietary modification revolves around an increased
intake of fibers (bran, psyllium) and water.
Rubber band ligation is another effective technique.
Hemorrhoidectomy on the other hand, should be
done with specific indications.
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28
Indications for hemorrhoidectomy
 Severely prolapsed hemorrhoid that needs
annual replacement
 Failure to improve after several non-
operatve treatments
 Hemorrhoid complicated by associated
pathologies: ulcerations, fissure, fistula,
large hypertrophied anal papilla or
extensive skin tag
For exam purposes: other treatment options include
sclerotherapy and laser therapy.
External hemorrhoid: is found distal to the dentate
line. The main complaints associated with external
hemorrhoid are swelling, discomfort and difficult
hygiene. If there is severe pain, the only explanation
is thrombosis (by leading to necrosis).
A thrombosed external hemorrhoid is also known as
a perianal hematoma. It presents with a sudden
onset as a painful, tender and tense swelling. The
treatment of choice is excision with local anesthesia.
However, if the hemorrhoid is occurring anteriorly
or posteriorly, we generally follow conservative
management. This is because surgeries done in
these types can cause anal fissure.
Complications of hemorrhoids
 Hemorrhage
 Strangulation/gangrene
 Thrombosis
 Ulceration
 Fibrosis
 Suppuration
 Pylephlebitis
August, 2018
 Tube Thoracostomy
Compiled by: Nahom Gashaye

A tube thoracostomy is a flexible tube that is inserted through the chest wall into the pleural space. The use of
this tube ranges from draining fluid and air to instillation of medications. It can be alternatively called by its
popular name, chest tube. If you hear of an intercostal catheter, it is still a substitute name for thoracostomy.

Although the concepts about chest tube are fairly easy to understand, it is by far the most common short case
in surgery exams. As a result, it is a wise approach to give emphasis to every little detail.

Parts of a chest tube
In general, a chest tube has two parts: the tube and
the drainage system.
The tube is usually made from a silicon or PVC. It
comes in different sizes from 6 to 40 French size as
measured by the external diameter. A French size
(Fr) is simply the diameter in milli-meters multiplied
by 3. For example, 18Fr means 6mm.
The choice of the size depends on the age of the
patient as well as the problem under consideration.
Choices of the tube size
Based on age
 Children: 6Fr-26Fr
 Adults: 20Fr-40Fr
Based on the problem
The other part is the chest drainage system. In a
resource scarce setting such as ours, it is just a bottle
with two openings on top. The first opening is the
one that is connected to tube to receive fluid or gas
from the pleural space. The second opening is made
to let the gas out of the bottle.
The bottle should contain a normal saline or distilled
water and the tube should be immersed in 2-3cm
depth of the water.
In the best setups, the chest drainage system will
have three chambers:
 Chamber 1: collection of the drained fluid
 Chamber 2: a water seal that functions as a
valve that allows gas to escape but not return
 Chamber 3: suction control chamber, which
sets the negative pressure that allows the
system to drain the gas or fluid

 Trauma: 36Fr Insertion of a chest tube

 Hemothorax: 32Fr
 Pneumothorax: 24Fr or smaller
A conventional tube has multiple fenestrations in
the part that will reside in the pleural cavity. You
may also see a line along the length extending up
until the first drainage hole. This line is radio-opaque
and its purpose is the verification of correct
placement by an x-ray.
There are two techniques for the insertion:
 Blunt dissection
 Selderger technique
During insertion, you should always follow aseptic
technique. Since it is a surgical procedure, you will
also need a drape. The incision should be done

The golden note August, 2018

29
above the ribs in order to avoid damage to the
neurovascular structures.
For pneumothorax, you incise on the 2nd intercostal
space at the mid-clavicular line. A small sized tube is
used as it is adequate to drain air.
For fluids, the tube should be inserted between the
4th and 5th intercostal space along the anterior
axillary line (triangle of safety). The triangle of safety
is made by:
 Medially: lateral border of the pectoralis major
muscle
 Laterally: mid axillary line
 Inferiorly: the nipple line
Why is the safety triangle the safest?
 The least risk for organ injury
 The least risk for neurovascular damage
 The least muscle bulk
When you insert a chest tube, you should make sure
that all the fenestrae are inside the pleural space.
The insertion should also be gentle.
Indications and contra-indications
There are certain indications for the insertion of a
chest tube, including:
Indications for chest tube insertion
 Empyema
 Chylothorax
 Hemothorax
 Pneumothorax
 Hemo-pneumothorax
 Malignant pleural effusion
 Following thoracic or upper abdominal
surgery
 Pleurodesis: is an artificial obliteration of
the pleural space that is done by creating
an inflammatory environment.
The purpose of pleurodesis is to prevent fluid or gas
from continually building up. Chest tube is inserted
The golden note
30
for instillation of the chemicals that are responsible
for the inflammation. The best examples are talc
and tetracycline.
Although not as many as the indications, there are
also contra-indications for chest tube insertion.
Contra-indications for chest tube insertion
 If the patient has a coagulopathy or is on
anticoagulant medications
 Skin infection over the insertion sites
 Pleural effusion due to liver failure
 Adhesion of the pleural space
 Diaphragmatic hernia
Chest tube care
These are things that should be done to sustain the
functionality of the chest tube and avoid problems.
Aseptic technique: should be followed during the
insertion and throughout the time the tube is going
to stay in the pleural space.
Limiting Initial drainage: the initial drainage should
not be more than 1000ml. If it is above 1 litter, it can
lead to re-expansion edema.
Prevent air entry: under saline sealed bottle
Functionality: of the tube should be checked from
time to time. It can be easily checked by asking the
patient to cough. If the fluid in the tube oscillates
with the cough, you can say that it is functional.
A non-functional tube (non-oscillation) can be a
result of:
 Clogged tube
 Misplaced tube
 Malposition
 Kinked tube
 Full bottle
Transportation: when transportation is needed, you
should clump the tube.
August, 2018
Position: the bottle should be below the level of the Complications of chest tube
chest. An ideal position for our practice is under the
The complications that are most often associated
bed. It should also be un-disturbed (static).
with a chest tube are:
Change the bottle: when it becomes full or you can
 Malposition
also change it every 6 hours.
 Infection
Removal of a chest tube  Subcutaneous emphysema
 Re-expansion pulmonary edema
Before removing a chest tube, you will need a strong
 Organ damage (broncho-pleural fistula can be
justification, which can be clinical or radiologic.
suspected if there is continuous bubbling in
Justifications for chest tube removal the underwater seal system)

 The Symptoms need to resolve or in other
words an acceptable clinical improvement
 Control x-ray should show lung expansion
 The drainage should be serous and less
than 50ml/24 hours (in some books this
amount may be as much as 100-150ml). If
there is blood, pus or chyle, you shouldn’t
remove.
 For pneumothorax, there should not be
bubbling in the underwater seal system
 Clump for 24 hours before removal:
dyspnea shouldn’t reappear
There is a certain accepted step for removal of the
tube. In chronological order:
 Clump the tube
 Disconnect from the water seal
 Remove the stich
 Mobilize gently
 Remove the tube rapidly at the end of
expiration
 Cover the wound area with pressure bandage
for 5-7 days.
What would you say if you are asked what you
see? Example for a chest tube
 I see a tube inserted in a chest of a
man/woman at the 5th intercostal space
along the anterior axillary line
 There is oscillation in the tube
 It is draining a ______ fluid in to a bottle
(serous, whitish, bloody or yellowish can
all substitute the space)
 There is large/small amount of fluid in the
bottle
 You can state if the patient appears to be
in a respiratory distress or not
What would you say if you are asked what it is?
There is a simple phrase for that:
Chest tube with under-water seal system

Why do we remove the tube at the end of

expiration? This is because the intrathoracic
pressure will be relatively more positive during the
end of expiration. This means, the entrance of air in
to the pleural space will be largely prevented.

The golden note August, 2018

31
 Urinary Catheter
Compiled by: Michael Yeshiwas

Urethral catheterization will probably be one of the procedures you will be doing most often in your clinical
career. As a result of this and other exam related reasons, knowing about this particular case shouldn’t be
considered optional. Luckily, understanding this topic is not hard at all.

A catheter can be easily defined as a tube that is inserted into the bladder through the urethra to allow the
urine in the bladder to drain out.
Types and size of catheters
There are many types of catheters, particularly four
in number. These are:
 Condom (external) catheter: for males only
 Straight catheter
 Suprapubic catheter
 Foley catheter (indwelling catheter)
The only important difference between straight
catheter and foley catheter is that the foley has a
balloon which helps in keeping the tube in the
bladder.
The foley catheter can also be cathegorized as 1 way
foley, 2 way foley and 3 way foley. The 3 way foley
is named as such, because it has a 3rd additional
port. This additional port is meant to allow the
instillation of medications, hemostasis and lavage.
The size of the catheter depends on the age:
 For children we use less than 10Fr
 For adults it can be 16 or 18Fr
Indication
The indications for catheterization can be diagnostic
as well as therapeutic.
The diagnostic indications include:
 Monitor urine output
 Measurement of post-void residual volume
 Investigation (urinalysis)
 Contrast administration
The therapeutic indications include:
 Urinary retention
 Urinary incontinence
 Neurogenic bladder
 Irrigation of the bladder
 To instill chemotherapy
 Bypass an obstruction (suprapubic)
 Hematuria with clot
 For immobilized or unconscious patients
 Pre-surgery, peri-surgery and post-surgery
Modes of insertion
The mode of insertion can be
 Suprapubic: with an incision on the supapubic
region (surgical)
 Clean intermittent self-catheterization
 Urethral: is the most common mode and it can
be indwelling or intermittent
Indwelling urethral catheters are most commonly
used in the hospital setting for short-term bladder
drainage (<3 weeks). They are also used for the
management of patients with chronic urinary
retention who are refractory to, or not candidates
for, other interventions.
Intermittent catheterization is an alternative to
indwelling catheterization. It is the removal of the
catheter immediately after bladder decompression,
with re-catheterization on a scheduled basis. When
intermittent catheterization is used, it must be

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32
performed at regular intervals to prevent bladder Other classifications of catheter as
over distention.
 Based on the site: suprapubic or transurethral
Complication  Based on duration: intermittent or indwelling
The major complications associated with urethral  Based on the catheter type: straight, coude’ or
catheterization are: foley catheter
 Infection
Intermittent catheters are usually straight and
 Injury to the urethra
indwelling catheters are usually foley.
 Stricture
 Bladder perforation Insertion of transurethral catheter
 Bladder fistula
The sequential steps are:
 Reduced functional capacity of the bladder
 Assess indications and contraindications
Catheter Care
 Informed consent
The cares that should be followed are:
 Preparation: select the size of catheter (start
 The drainage bag should be lower than the
with 16 in adults),other materials prepared
person's bladder
 Expose and clean the area in a circular fashion
 Empty the bag when full
from center to periphery (start from the glans
 Prevent kinking and coiling
penis, then to the shaft)
 The catheter strap (adhesion tape) need to be
 4-5ml of lidocaine combined with KY-jelly is
loosely connected to the persons' body
injected through the urethra. For females, you
 Assess comfort of the patient
don’t need to combine the two. Just inject the
 Record characteristics and amount of urine
lidocaine in to the perineum and put the jelly
 Closed system-bed ridden
on your hand to apply it to the catheter tip.
 Link system-ambulatory
 Hold the penis with the non-dominant hand
Contraindications and straighten the shaft upward. If the person
is uncircumcised, you need to retract the
Despite its many complications, there are only few
prepuce. Then insert the catheter up to the
contraindications for urethral catheterization.
end. For females, you can stop when you get
These are urethral trauma and urethral stricture. urine. You can also estimate the length of the
Urethral trauma is an absolute contraindication for urethra in females (4cm).
insertion of a foley catheter.  Once you are sure that the catheter is in the
bladder, inflate the balloon preferably with
Urethral stricture is a relative contraindication as
10ml of distilled water. If you don’t have it you
the tube can’t pass through. In fact, the inability of
can use normal saline. After you inflate the
the catheter to pass through the urethra can very
balloon, you can pull the tube a little, just to
much help in the diagnosis of urethral stricture.
secure.
Additional  If you fail to pass the catheter due to
resistance, you can retry one or two times with
Coude’ catheter: has a relatively strong and more
the same size of catheter. If it still fails, change
curved end which follows the curvature of an
the size depending on the indication. If it is
enlarged prostate. So it is preferable for patients
urethral stricture, use smaller catheter and if it
with BPH (benign prostatic hyperplasia).
is BPH larger sized or coude’ catheter.

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33
 NG-Tube
Compiled by: Michael Yeshiwas

Writing about the extensive importance of a naso-gastric tube is just stating the obvious. The fact that NG tube
insertion can be a lifesaving procedure is a simple statement that can be supportive for the previous statement.
Thus, the frequent appearance of this case in the exams can be justified without much trouble. Not unlike many
of the previous topics, this one is very easy to understand.

If you are asked to define what an NG tube insertion is, don’t make your answer complex. Just define it in simple
words. A good example would be: insertion of a plastic tube through the nose, past the throat in to the stomach.

Insertion  Get a glass of water and put the tip in water: if

The insertion is not very difficult. But you should
have a justifiable indication and no contraindication.
 Explain the procedure, benefits and risks for
the patient
 Examine the nostril for septal deviation and
ask the patient to occlude each nostril and
breath through the other (patency)
 Pick the appropriate French size as calculated
by the formula 16+(age/2)
 High fowler’s position: the upper part of the
body makes 60-90o with the lower part (sitting
straight)
 Anesthetize: use viscous lidocaine and ask the
patient to sniff and swallow
 Measure from to the tip of the nose to the ear
and then the xiphisternum (if infants up to the
umbilicus instead of the xiphisternum)
 Lubricate the tip and insert the measured
length of the tube
 Check for correct placement
The placement of the tube can be checked by four
methods. These methods are:
 Aspiration of gastric content
 Introducing air in to the stomach by a syringe
and auscultating over the epigastrium
there are bubbles then it is incorrectly placed
in the lungs
 Radiography: confirmation by chest x-ray
The confirmation of placement may be an easy
process, but should never be neglected. This is
because the airway will be involved if misplaced.
Indications
The indications for NG tube insertion can be either
diagnostic or therapeutic.
Diagnostic indications
 Upper gastro-intestinal bleeding: to see
the presence and measure the volume
 Aspiration of gastric content for diagnostic
investigations
 To administer radiologic contrast to the GI
 Identification of chest and abdomen
through chest radiography
Therapeutic indications
 Gastric decompression
 For feeding
 Administration of medications
 Fluid and electrolyte therapy
 Stomach lavage (bowel irrigation)

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34
Contraindications

There are several contraindications and you should

actively search for them before inserting the tube.
The most important contraindications are:

 Basal skull fracture: for fear of intracranial

placement of the tube
 Recent nasal, esophageal or gastric surgery
 Mid-face trauma
 Obstructed airway
 History of acid/caustic ingestion
 Esophageal stricture
 Relative contraindications include esophageal
varices and coagulation problems

Complications and care

There are serious complications associated with NG

tube insertion. Some of them are encountered while
inserting the tube and the others occur after a while.

Complications of NG tube insertion

 Malposition (naso-tracheal intubation)

 Esophageal perforation
 Esophagitis
 Sinusitis
 Pulmonary aspiration
 GI bleeding
 Intracranial placement of the tube

The care for an NG tube is not complex, but should

be taken seriously.

The first care is keeping the tube out of the patient’s

vision after securing it. Many clinicians bind the tube
on the nose, but this should not be done. The cheeks
can be considered as a better alternative.

The other care is meeting and maintaining the

patient’s comfort needs. Just understand that
having a tube inside the nose is no picnic.

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35
 Colostomy
Compiled by: Obsine Abate

One thing that is for sure is that there will be a patient with colostomy in every exam station. For this reason,
not reading about it can be equated with self-harm.

Colostomies are some of the most widely performed major surgical procedures all over the world. The reason
for the operation, however, vary from one country to the other. In our setup, the most common indication for
colostomy is sigmoid volvulus. In some other countries, it can be colorectal carcinoma or another indications.

A stoma is an artificial opening of an internal organ on the surface of the body. Other than colostomy, there are
also other stomas such as ileostomy, cecostomy, gastrostomy, tracheostomy, thoracostomy and cystostomy.
Ostomy is the process of bringing opening of an internal organ to the outside surface of the body.

Colostomy: is an iatrogenic fistula between the
colon and the skin: colo-cutaneous fistula.
It is used in situations where decompression or
diversion of feces is needed, or access to the
bowel lumen is needed.
Types of colostomy
Colostomy can be divided in to many types, based
on different criteria.
Based on the duration, it can be temporary or
permanent.
A permanent colostomy is the one which will never
be closed. An end colostomy (Hartmann procedure)
is the only option.
Indications for permanent colostomy
 After abdomino-perineal resection (APR)
as in colorectal cancer
 Rectal excision (rectal cancer)
 Anal ring incontinence
 Gangrenous sigmoid
 Rectovaginal/vesical fistula
 Hirschsprung disease
The temporary colostomy on the other hand will be
reversed after the goals are achieved. Loop, double
barrel and end colostomies are the types most often
done as temporary colostomy.
A temporary colostomy can be diverting or
exteriorization in type.
Diverting colostomy: colostomy of unaffected colon
to allow proper healing of colon after manipulation.
Exteriorization colostomy: the plan is not diversion
of fecal matter. But the injured part will be kept
externally after closure. When it heals properly, it
will be restored back.
Based on the surgical construction, it can be
Loop colostomy: both the proximal and distal
segments are parts of the colostomy and there is an
intact posterior wall between them. Because of this
intact wall, some feces can pass to the distal
segment. One of the opening is made to expel the
feces and the other to drain the naturally occurring
mucous. It may look like one large opening. It is most
often used in penetrating abdominal trauma,
descending colon diverticula, peri-anal injury and
Hirschsprung disease (congenital megacolon).

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36
Double barrel colostomy: both proximal and distal
segments are involved in the colostomy, but they
don’t have posterior connection. So, two distinct
stomas are formed.
Spectacle colostomy: both segments are involved
and there is an intact skin between the two
openings. Similar to the double barrel, there are two
distinct stomas in this type.
End colostomy: only the proximal segment is on the
colostomy site. It is used when a total diversion of
fecal matter is needed.
Based on the involved bowel segment it can be:
 Descending colostomy: is the most frequently
performed colostomy and is done in last 1/3rd
of the colon. The opening is found at the lower
left part of the abdomen.
End and double barrel colostomies are the
commonly performed types in this site. The
waste is firmer and less watery.
 Transverse colostomy: is done in the
transverse colon and the opening is found in
the middle of the abdomen, slightly to the
right side.
Loop and double barrel colostomies are the
commonly performed types in this site. The
waste is loose and watery.
 Ascending colostomy: is the least common of
the three. It is done at the very start of the
colon, so it is located at the right lower
abdomen.
The waste is very loose and contain digestive
enzymes, predisposing to skin irritation.
Based on the function it can be classified as:
 Diversion colostomy: is to divert the waste, so
that a distal anastomosis will have time to heal
 Decompression colostomy: is to relieve the
bowel from a fecal load
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37
Colostomy bag (stoma appliance)
It is a disposable adhesive bag that is used to
collect the feces from the stoma. There are two
types of colostomy bag
 One piece appliance: when changing the
bag, the skin protective barrier is removed
 Two piece appliance: the adhesive bag
need not be removed with the bag
Indications
There are several indications to do a colostomy, as
presented in the box.
Indications for colostomy
 Distal obstruction secondary to carcinoma,
diverticulum and sigmoid volvulus (the
major reason in Ethiopia)
 Trauma: penetrating injury, to prevent
fecal peritonitis (especially left sided)
 Fistulas: Perianal, vesicocolic, rectovesical,
rectovaginal, colovaginal
 Congenital problems such as imperforate
anus and Hirschsprung’s disease
 Inflammatory Bowel disease: ulcerative
colitis and Crohns disease
 Gangrenous sigmoid volvulus
Complications
The complications of colostomy can be divided in to
two as early or late complications.
The early complications include:
 Bleeding
 Necrosis of the distal end
Late complications are:
 Prolapse
 Retraction
 Colostomy hernia (parastomal hernia)
 Colostomy diarrhea (acute gastroenteritis)
 Fecal impaction
August, 2018
  Infection
 Excoriation (irritation) of the skin: more
common and pronounced for proximal bowel
due to the bile and digestive enzymes
 Psychological problems: depression

Colostomy Closure

Colostomies are closed in 6-12 weeks. A late

closure is difficult due to adhesion.
Ilestomy

Ileostomy is similar to colostomy in many ways. But

it is different in that it is made in the ileum and few
other parameters.

Similar to colostomy, ileostomy can be temporary or

permanent.

Loop ileostomy is the choice if it is meant to be

temporary. This is meant to protect anastomosis.

A permanent ileostomy may be needed after a total

proctocolectomy is done. In this case an end
ileostomy will be done.

Ileostomies are elevated from the skin and are

usually located on the right side.

The complications of ileostomy are almost identical

to colostomy with only few differences. These are:

 Parastomal hernia is less common with

ileostomy compared to colostomy
 Skin irritation is more in ileostomy
 Dehydration with fluid and electrolyte
imbalance is more common in ileostomy,
because it bypasses the fluid absorbing
capability of the colon

Ascending colon, ileum Transverse, descending

and sigmoid

>500ml per day <500ml per day

Irritation (enzymes) No irritation

Liquid feces Well-formed stool

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38
 Tracheostomy
Tracheostomy can be defined as making an incision on the anterior neck and opening a direct airway through
an incision in the trachea. It is not a very complicated procedure, although it is mostly done in the operation
room under general anesthesia. In reality, it can be done just with a local injection of lidocaine+vasoconstrictor.
Types of tracheostomy
A tracheostomy can be a metal tracheostomy or a
plastic (PVC) tracheostomy.
The metal tracheostomy is permanent. It has two
lumen and if it is obstructed, you can take out the
inner tube. However, it easily get distorted.
The PVC tracheostomy have cuffs in most instances,
which can be inflated by air to prevent aspiration.
But, the cuff can cause pressure necrosis of the
tracheal wall and lead to tracheo-esophageal fistula.
Parts of a tracheostomy
 Flange: it is secured with tracheostomy ties
to stabilize the tracheostomy
 Outer cannula: connected to the flange
 Inner cannula: removable for cleaning
(metal)
 Obturator: a plastic guide with a smooth
rounded tip, that is used to guide the outer
cannula during insertion
 Cuff: a soft balloon around the end of the
outer cannula, that can be inflated to allow
for mechanical ventilation (plastic)
Indications
The most popular indication for tracheostomy is
upper airway obstruction, which can be functional
or mechanical.
Functional: tetanus, GBS or polio (bulbar type)
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39
Compiled by: Veronica Zinabu
Mechanical: can be intraluminal, intramural or
extramural.
 Intraluminal: dentures (especially among the
elderly), food, coin, tongue (if trauma),
hematoma or secretions
 Intramural: benign or malignant
Benign: inflammation (anaphylaxis), infectious
(croup, epiglottis, HPV), trauma (including
burn), benign neoplasms (laryngeal papilloma,
adenoma, lipoma, hemangioma), congenital
(webs, atresia)
Malignant: laryngeal or esophageal cancer,
Kaposi sarcoma
 Extramural: lymphoma, submandibular
abscess, thyroid tumors, hematoma or
angioedema
Other indications include:
 To wean off mechanical ventilators (reduce
dead space 10-50%). Remember that the dead
space is normally 150ml.
 Failed orotracheal or nasotracheal intubation
 If longstanding intubation is needed
Complications and care
There are many complications associated with
tracheostomy. The complications can be immediate,
early or late.
In all cases, preventing the complications is a lot
better than treating it.
August, 2018
Immediate complications
 Bleeding
 Perforation of posterior part of trachea
 Injury to para tracheal structures (recurrent
laryngeal nerve, great vessels, esophagus)
 Puemothorax or Pneumomediastinum in cases
of misplacement
Early complications
 Blockage (secretions, foreign body): in order to
prevent this complication, you should apply
suction every 15 min for the first 48 hours
 Hematoma
 Dislodgment: can be prevented by fixing it to
the skin by silk
 Wound infection
 Pneumonia
Late complications
 Tracheoesophageal fistula
 Laryngeal (tracheal) stenosis
 Tracheomalecia (poorly fitting tube)
The care for a tracheostomy should consider that
these patients are at high risk for airway obstruction
and infections along with other complications. As a
result, a skilled and timely nursing care is necessary.
The things you should keep in mind are:
 Suctioning
 Hygiene
 Preventing dislodgement
 Changing tube every 30 days
 Humidify air and mucolytic (in Ethiopia: saline)
Contraindications
Contraindication for tracheostomy
 Uncorrectable bleeding diathesis
 Gross distortion of neck due to hematoma
 Infections in the soft tissue of the neck
 Cervical spine instability
 Obese and short necked patient
 Age less than 15 years (questionable)
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40
Steps before tracheostomy insertion
Reading this part is relatively optional. But knowing
the steps will not hurt.
Endotracheal tube is a better alternative for short
Tracheostomy insertion
 Is there a justifiable indication? Is there
any contraindication? You need to answer
both questions.
 Prophylactic antibiotics specific for skin
flora should be given 30-60 minutes prior
to incising the skin
 Shoulder elevated with head extension
(unless there is cervical trauma)
 Skin from below the chin up to the clavicle
should be prepared with antiseptics
 Drape is put on place
 Local anesthesia+vasoconstrictor injected
to infiltrate the skin and deeper tissues
 Then you can start the incision
term intubation. This is because surgery is not
needed and there is no stoma site complications.
But for long term intubation, tracheostomy is more
preferable due to the following reasons.
 Speech is possible
 Mobility
 Ease of suctioning
 Patient will be more comfortable
August, 2018
 T-tube
Compiled by: Michael Yeshiwas

There is nothing much to say about T-tube. It was named as such due to its shape. If you get to face this case in
the exams, one important fact to remember is that most of the patients that have a T-tube insertion are post-
operative patients for obstructive jaundice. But, obstructive jaundice is not the only indication.

A T-tube is a tubular structure that is inserted to the supra-duodenal portion of the common bile duct (CBD), to
drain the bile and other secretions.

Indications Removal

There are certain indications for T-tube insertion Removal of the T-tube is often done after 8-10 days
that are mandatory to know about. of the insertion. But, the external drainage of the
Morrison’s pouch should be kept for 3-5 days after
Indications for T-tube insertion
the T-tube removal.
 Choledochotomy drainage for edematous
The T-tube, however, can’t be removed just because
sphincter (obstructive jaundice)
it has been 8, 9 or 10 days after the insertion. There
 Common bile duct stone
are four criteria that should be fulfilled first.
 After biliary tree manipulation
 Injury to the common bile duct The four criteria for T-tube removal
 For cholangiography
 The drainage bile looks normal
Procedure  Draining amount becomes small enough
T-tube should be inserted to the supra-duodenal  There should be no sign/symptom such as
portion of the common bile duct. pain, fever and jaundice after clumping the
tube for 24 hours
The incision on the common bile duct should be
 T-tube cholangiography shows clear flow
vertical. After the incision, the stone is removed
to the duodenum
followed by T-tube insertion. The duct is then closed
N.B. If you find a residual stone on cholangiography,
around the tube.
you have to keep the tube for 6 weeks. After 6
The long segment will be drawn externally in the weeks, you can perform percutaneous removal of
right upper quadrant and will be connected to a the stone.
plastic bag, to be placed under the bed. It also
Most of the complications that are associated with
important to concomitantly drain the Morrison’s
T-tube insertion are similar to those of any other
pouch, also known as the sub-hepatic space.
surgery: infection, bleeding…
Afterwards, you should regularly check for the
condition of the patient as well as the character of
the draining fluid (color, amount and consistency).

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41
 Hernia
Compiled by: Rabia Ahmed

Similar to varicose vein, hernia is one of the examiner’s favorite cases. This is especially true for inguinal hernia.
For the exams, it is important to know the definition as well as common areas of hernia, but necessary to know
about inguinal hernias in detail.

Among all cases of groin hernias, 96% is constituted by inguinal hernia while the rest is contributed by femoral
hernia. In this section both will be discussed.

Hernia is simply protrusion of a viscus through a weak point in the body. There are different types of hernias
based on the site of occurrence. Just for instance we have hiatal hernia, epigastric hernia, umblical hernia,
incisional hernia, spegelian hernia and incisional hernia.

Causes of hernia There are also other risk factors such as previous
surgery, which will weaken the enclosing structure.
The major causes, especially for inguinal hernia
Causes of hernia Complications

A hernia located at any site can present with certain

 Congenital
complications as presented in the following box.
A persistent processus vaginalis sac is chief
cause of indirect inguinal hernia Complications of hernia
 Collagen fiber disorders
 Irreducibility: due to adhesions formed
 Congenital: Prune-belly disorder
between omentum, sac and the contents.
 Acquired collagen deficiency: smoking
 Obstructed hernia: is an irreducible hernia
 Obesity
with obstruction to the lumen of the gut.
 Chronic causes of increased intra-
 Strangulated hernia: is an obstructed
abdominal pressure such as:
hernia with impairement of blood supply
 Chronic cough
to the intestine.
 Chronic constipation
 Incarcerated hernia: is when the hernia
 Straining at micturition
can’t be pushed back in and is trapped in
 Ascites
the abdominal wall, due to obstruction by
 Weakness of conjoined tendon/rupture of
focal inflammation.
a few fibers
 Inflamed hernia: occurs when the
 Lifting heavy weight
contents of hernia get inflamed. Examples
 Post-appendectomy (injury to ilioinguinal
include an appendicitis or a Meckel's
nerve)
diverticulitis occurring in hernial sac.
 Chronic debilitating disease causing
transversalis fascia weakness in the Irreducible, obstructed and strangulated hernias
Hesselbach's area. have close relations to one another.

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42
  Irreducible: irreducibility
 Obstructed: irreducibility + obstruction
 Strangulated: irreducibility + obstruction +
ischemia
The clinical features however differ from one
another.
 Irreducible: dull aching pain
 Obstructed: severe colicky abdominal pain,
abdominal distension, vomiting and step
ladder peristalsis
 Strangulated: sudden, severe and prolonged
pain with some features of shock
Investigations
You may do baseline investigations and those that
are important for pre-op preparation. But, in most
scenarios a diagnostic investigation is not needed
for hernias. The diagnosis should be clinical.
If you are asked to mention at least one
investigation, then it should be ultrasound, as it may
be confirmatory in early cases.
Anatomy
A fair understanding of the anatomy of the inguinal
region is essential before approaching a case of
inguinal hernia.
Inguinal ligament: is the ligamentous portion of the
external oblique aponeurosis which folds inwards
and extends from anterior superior iliac spine to the
pubic tubercle.
The deep ring: is a 'U' shaped defect in the fascia
transversalis which forms the posterior wall of the
inguinal canal. It lies 1.25 cm above the midpoint of
the inguinal ligament.
The external (superficial) ring: is a triangular defect
in external oblique aponeurosis. It is bounded by the
lateral and medial crura formed by the external
oblique aponeurosis and the base of the triangle is
formed by the pubic crest.
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43
Inguinal canal: is a 4 cm canal extending from the
deep inguinal ring to the superficial inguinal ring.
Boundaries of the inguinal canal
 Anteriorly: external oblique aponeurosis
and a few fibers of the conjoined muscle
(especially of internal oblique) laterally
 Superiorly: arched fibers of the conjoined
muscle
 Inferiorly: inguinal ligament and the
lacunar ligament on the medial side
(Gimbernat's ligament).
 Posteriorly: fascia transversalis and the
conjoined tendon medially.
The inguinal canal is strong in the lateral part
anteriorly and the medial part posteriorly.
Contents of inguinal canal
 Ilioinguinal nerve
 Genital branch of genito-femoral nerve
 Spermatic cord in males
 Round ligament in females
 Vestigeal remnant of processus vaginalis sac
Inguinal defense mechanisms: these are factors
that protect against the development of hernia.
 Obliquity of inguinal canal (straight in children)
 During straining or coughing, the conjoined
tendon contracts. Since this structure forms
the anterior, superior as well as the posterior
boundaries, it closes the inguinal canal
(shutter or sphincter-like effect).
 Increased intra-abdominal pressure produces
plugging effect at the external ring. The deep
ring is pulled upwards and laterally because it
is adherent to the posterior surface of
transversalis muscle. This occludes the ring
and prevents herniation (ball-valve effect).
This anatomy is important to understand the types
of inguinal hernias as well as the structures involved
in the hernia.
August, 2018
Types of inguinal hernia  Inferiorly: Inguinal ligament

Inguinal hernia can be either indirect or direct. Coverings of the direct inguinal hernia from
outside to inside:
Indirect inguinal hernia
Indirect inguinal hernia is a herniation of abdominal  Skin
contents through the deep ring into the inguinal  Two layers of superficial fascia
canal. It is the most common type of hernia in the  External oblique aponeurosis
human body.  Conjoined tendon
Indirect hernia occurs due to persistent processus  Fascia transversalis
vaginalis sac. The preformed sac passes through the  Peritoneum
deep ring, traverses the inguinal canal and may
Some of the differences between direct and indirect
extend into the scrotum through the external ring.
inguinal hernia are listed below.
As it comes into the inguinal canal, it is invested by
the following coverings 3 fascia: Direct Indirect
External spermatic fascia derived from external
oblique aponeurosis Commonly elderly Any age group

Cremasteric fascia drived from internal oblique Weak posterior wall Preformed sac

Internal spermatic fascia from fascia transversalis Pops out on standing Doesn’t pop out

Coverings of the indirect inguinal hernia from Usually bilateral Only 30% are bilateral
outside to inside:
Complication: rarely Complication: common
 Skin
Comes through the Comes through the
 The two layers of superficial fascia: Fatty
Hesselbach’s triangle deep ring
(Camper’s) and membranous (Scarpa's)
fascia Clinical features
 External spermatic fascia
History
 Cremasteric muscle and fascia
 Internal spermatic fascia The complaint can be a swelling in the inguinal
region which is gradually increasing in size.
 Extraperitoneal fat
 Peritoneum At the start, the swelling disappears on lying down
and increases on straining or walking. Later it cannot
Direct inguinal hernia be reduced (due to adhesions).
Unlike the inguinal hernia which have a congenital Since the omentum is attached to the stomach
basis, the direct inguinal hernia is always acquired. above and supplied by T-10, the pain is referred to
It occurs through Hesselbach 's triangle, a weakness the umbilical region.
in the posterior wall of the inguinal canal on the Sudden, severe pain in the hernia, vomiting and
transversalis fascia. irreducibility indicates obstructed hernia.
Its boundaries are: History of chronic cough, constipation, difficulty in
 Medially: the lateral border of the rectus passing urine should be asked. If present, it may
abdominis suggest the cause of hernia and the cause itself may
 Laterally: Inferior epigastric artery need treatment. History of surgery (appendectomy)
is also important.

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44
Physical Examination
Inspection: should be done in the standing position
and both sides should be checked.
 Location, size, shape and border
 Ask the patient to cough: expansile impulse
 Peristalsis: indicates an enterocoele.
 Surgical scar: recurrent hernia
 Ragged scar: infection
If the hernia pops out as soon as the patient stands,
it indicates a direct hernia.
Palpation
It should confirm your findings on inspection part as
well as search for other findings
 Size
 Shape
 Border
 Consistency: typically soft, but an omentocele
may be firm or granular
 Ask the patient to cough: feel the expansile
impulse at the root of scrotum
 Try to get above the swelling
 Reducibility
 Special tests
Try to get above the swelling in the standing
position. This is simply trying to palpate the
spermatic cord at the root of the scrotum. In case of
a complete indirect hernia, the spermatic cord is
covered by the sac antero-laterally, thus can’t be
palpated as a naked structure. When this happen,
we say that getting above the mass is not possible.
Check reducibility: ask the patient to lie down and
see if the swelling becomes smaller or disappears. If
it is reducible, it rules out hydrocele (non-reducible).
Omentocoele is initially easily reducible. But later, it
becomes difficult due to adhesions.
 If it is difficult to reduce, ask the patient to
reduce it
 Taxis method: flex and medially rotate the hip
and try to reduce it
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45
 If the swelling is not reduced after all these we
will call it an irreducible hernia.
Special tests for inguinal hernias
 External ring invagination test
 Internal (deep) ring occlusion test
 Leg raising and neck raising test
 Zieman’s (three fingers) method
External ring invagination test
At the root of the scrotum, skin is gathered and
lifted up with the little finger. It is then invaginated
into the external ring. On asking the patient to
cough, the impulse touches the pulp of the finger in
direct hernia and the tip in indirect hernia.
Internal (deep) ring occlusion test
This test can be done with the patient standing or in
supine position.
First, reduce the swelling. Then locate the deep ring
above the midpoint between anterior superior iliac
spine and symphysis pubis. Occlude the deep ring
with the thumb and ask the patient to cough.
 If impulse and the swelling are seen, it is a
direct hernia because it occurs in the
Hesselbach 's triangle (medial to deep ring).
 If the swelling is not seen, it is an indirect
hernia.
Leg raising test or head raising test
Weakness of the oblique muscles is manifested by
Malgaigne's bulging above the medial half of
inguinal ligament. It is an absolute indication for
hernioplasty.
Zieman's (three fingers) method
Keep index finger at the deep ring, middle finger on
the posterior wall (above and lateral to the external
ring) and the ring finger at femoral ring. Now ask the
patient to cough. Depending upon the type of
hernia, impulse is felt. It is not necessary to perform
this test in incomplete or complete indirect hernias.
After performing the special tests, you should also
do abdominal and respiratory examinations. This
may pick abdominal masses or respiratory diseases.
August, 2018
You must also look for phimosis/stricture urethra.
Young patients having urinary complaints with
hernia may be suffering from stricture urethra. Lift
the scrotum and feel for any strictures in the bulbar
urethra. Then retract the prepuce (if uncircumcised)
and rule out phimosis.
In reality, the examiners don’t expect you to do
abdominal and respiratory examinations. But, they
may ask you which system’s examination you will do
if you are given the chance.
Treatment
Herniotomy, herniorrhaphy and hernioplasty are
the three "key" operations for inguinal hernia.
Complications of hernia surgery
 Injury to the iliac vessels
 Injury to the urinary bladder
 Pain
 Bleeding
 Urinary retention (more in males)
 Abdominal distension
 Seroma due to inflammatory response to
mesh or suture materials
 Wound infection
 Inguinodynia: mainly because of injury to
the following nerves
Iliohypogastric
Ilioinguinal
Genital branch of genitofemoral nerve
 Testicular atropy: due to injury to the
testicular artery which is not noticed
during surgery
Femoral hernia
Femoral hernia is the herniation of intra-abdominal
contents through the femoral canal.
Women are more often involved, as compared to
men with a 2:1 ratio. This ratio (and the risk) is
doubled in parous women.
Commonly the hernia is unilateral, the right side
being affected more often than the left side. It is
bilateral in about 15-20% of the patients.
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Anatomy
The femoral canal extends from the femoral ring to
the saphenous ring. It is 2.5cm below and lateral to
the pubic tubercle. It is the innermost compartment
of femoral sheath.
It is similar to a truncated cone, the narrow end
being the femoral ring.
Contents of the femoral canal
 Fat
 Fascia
 Lymphatics: lymph node of Cloquet
 Femoral vein: in middle compartment of
the femoral sheath
 Femoral artery: in lateral compartment of
femoral sheath
 Femoral nerve: is outside of the femoral
sheath
 Femoral sheath: has anterior and posterior
layers
 Anterior layer: is the continuation of
fascia transversalis
 Posterior layer: is the continuation of
fascia iliaca
Boundaries of femoral ring
 Anteriorly: the inguinal ligament
 Posteriorly: ligament of Cooper and
iliopectineal ligament.
 Medial: lacunar ligament (Gimbemat's
ligament)
 Lateral: thin septum which separates the
femoral canal from femoral vein (silver fascia)
Clinical features
Females in the age group 20-40 years are commonly
affected by femoral hernias.
The right side is more commonly affected, because
of the dominant nature of right side of the body.
Typically, the swelling is below and lateral to the
pubic tubercle, unlike the inguinal hernia, which is
above and medial to pubic tubercle.
At the start, there is a small swelling below the
inguinal ligament, which goes unnoticed very often.
Reducibility may be present.
August, 2018
But, many of them (30-80%) present to the hospital
with strangulation.
Expansile impulse is often not present because of
the fact that the femoral canal is narrow.
Gaur sign: is the dilatation of the superficial
epigastric/circumflex iliac veins due to compression.
Treatment
Femoral hernia can be treated with
 Low operation of Lockwood
 Inguinal operation

If you have the time, it is better to read the

management of inguinal and femoral hernias in
detail. The details doesn’t frequently appear on the
exams, but who knows what your luck holds.

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47
 Surgical Instruments
Compiled by: Minale Menberu

Thinking of surgery without the instruments is similar to thinking of walking without the legs. Even this can’t
stress the importance of the instruments. As the surgeon can’t perform a surgery without the blade, forceps
and other instruments, you also can’t possibly be confident about the viva exam without studying this topic.

This section will try to cover the major surgical instruments that are being used in Tikur Anbessa and other
hospitals that we are attaching in.

Surgical instruments are precisely designed and manufactured tools which are made resistant to bodily
secretions, physical and chemical effects, cleaning agent and sterilizations for the purpose of surgical operation.
They can be used once (disposable) or many times (non-disposable). They are made from high quality stainless
steel, chromium or vanadium alloy for serving the required purpose.

Functional classification of surgical instruments arresting bleeding from arteries, capillaries and
veins until you ligate or coagulate.
 Cutting and dissecting
 Grasping and holding
 Clamping and occluding
 Suturing and stapling
 Exposing and retracting
 Viewing
 Suctioning
 Dilating and probing
 Measuring
 Micro-instrument
 Powdered instrument
Three versions of this forceps can be seen: mosquito
Forceps
forceps, curved artery forceps and straight artery
1. Artery forceps forceps.
There are many types of forceps that have different Mosquito forceps is a smaller version, which is used
structure and functions. It may be important to see for repairing of harelip, cleft palate and other plastic
the first picture for the anatomy as it may help to surgery operation.
understand the differences between different
Straight artery forceps is straight and used for
forceps.
holding stay sutures.
It has two ratchet and two blade with uniform
serrations. This is an artery forceps. It is used for

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48
Curved artery forceps: is a commonly used artery 3. Kocher’s forceps
forceps for controlling bleeding in many tissue.
This is similar to an
Notice the curve on the end on the next picture.
artery forceps except
that it has sharp tooth
at tip. Because of the
sharp tooth, it has a
better grip of tough
structures. It can be curved or straight. Look at the
tip on the picture.

4. Sinus forceps

Picture of a sinus forceps

A sinus forceps is like an artery forceps, but has no

ratchet and serrations are confined to tips. It is used
for holding the wall of an abscess cavity and biopsy.

In Hilton method of abscess drainage, an incision is

made and sinus forceps is inserted and is opened in
Pictures of mosquito forceps, curved artery forceps all direction so that it will break loculi of an abscess.
and straight artery forceps, respectively
5. Sponge forceps (swab holding forceps)
2. Allis forceps
It has ratchet and two
long blades with
rounded serrations on
its operating end. It is
used to hold swab
(gauze pieces) for
antiseptic preparation.
It can also be used as
Picture of Allis forceps blunt dissector with
swab at depth.
Allis forceps has a ratchet and triangular expansion
at the tip where serrations are present. It is used for
holding tough structure like aponeruosis and fascia.

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6. Babcock’s forceps 8. Magill forceps

Picture of Babcock’s forceps

Picture of Magill forceps: used for the removal of
This forceps has a ratchet and a triangular expansion airway foreign bodies
with fenestration at the operating end. It does not
have teeth. It is used to hold intestine, thyroid gland, Scissors
mesoappendix, uterine tube and other structures, 1. Mayo’s (tissue) scissor
during operations.

6. Pickup (Adson’s) forceps

It can be toothed or non-toothed and is used to pick

individual layers of structures.

Picture of Mayo’s scissor

Picture of non-toothed Adson’s forceps
It does not have ratchet and the operating end is
sharp. It is used to dissect tissue plane during
operation.

Picture of toothed Adson’s forceps: used to pick
tough structures like skin and fascia
7. Cheatles forceps
2. Straight scissor
Similar to the Mayo’s, straight scissors has no
ratchet and the blade is straight with sharp edge. It
is used to cut sutures and knots.

It is a long instrument having a curved shaft. The Both Mayo’s and straight scissors can be easily
handle has no lock. Kept dipped in antiseptic distinguished from most of the forceps.
solution and used to pick up sterilized materials such
as sponge and gauze pieces.

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50
Retractors
1. Morris retractor
This is a long instrument with an operating end. It is
useful to retract the abdominal wall, after you open
the peritoneum.
2. Czerny (superficial) retractor
This is a doubled hook
retractor on one side and
single blade on the other
side. It is most commonly
used for
Appendectomy
Herniorrhaphy
Thyroidectomy
3. Langenbeck retractor
This retractor has a similar use as
that of Czerny retractor.
But unlike the Czerny, which has
hooks, the Langenbeck only has a
blade.
4. Transverse retractors
Transverse retractor West retractor
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Transverse retractor is self-retaining retractor used
for intermediate type of operation such as
herinorraphy, groin dissection for femoral vein and
femoral emolectomy. It retracts skin and
subcutaneous tissue.
West retractor is similar to the traverse retractor,
but is ideal in minor procedure under anesthesia
without assistant. These procedures includes lymph
node biopsy and temporal artery biopsy.
There is also another transverse retractor named
mastoid retractor which has similar structure with
slightly different use.
5. Deaver retractor
It has long blade with a curved operating end. It is
used to retract deep abdominal or chest incisions. It
is available in different size.
6. Other hand held retractors
Picture of Senn retractor
Picture of Volkmann retractor
Picture of Army-Navy retractor
August, 2018
Towel clip

Instrument which has a Yankauer suction

ratchet and sharp operating
end. It is used to hold
towels in place. Frazier suction

Scalpel with blade

Popularly called surgeon’s Electro-coagulating system

knife, it comes in various
size.
Mono-polar electro-
It is used to incise skin and subcutaneous tissue.
coagulating system:
Needle holder this is what we have
in our country
This is a long instrument
with ratchet.

It has two blade with central The Bipolar electro-

indentations and crossed coagulating system:
serration which makes it observe that there are
unique from straight artery two tips
forceps.

Suturing needles
Curette
The suturing needle can be either traumatic or
atraumatic.

Traumatic needles
Volkmann curette These are needles that have an eye at the point of
attachment to the string. Trauma is due to the eyes.
See the eyes on the picture of round needles, below.

Suction

Suction machine can have

different appearance.
Round body needle is an eye needle used for
suturing soft tissues, muscles, tendons, vessels,
intestine and few other structures.

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52
 Cutting needles on the
other hand are slim and
used suturing tough
structures such as the skin.
Reverse cutting needles are
another group of needles.
These are used for suturing
muco-periosteum. The eye
of this type of needle is
wider than the body,
increasing the trauma.
Atraumatic needles
These are needles that doesn’t have an eye. The
suture is instead attached to the needle by a process
known as swaging. Due to this, the trauma to the
tissue is minimal.
This type of needles are
used mainly to suture
vessels and repair a small
tear in the bowel.
Chromic catgut (21 days catgut)
Is prepared by mixing plain catgut with chromic
salts. It is biologically absorbable monofilament, but
can wait for 15-25 days. It is used in intestinal
anastomosis, closure of urinary bladder, closure of
common bile duct, gastrojejunostomy and other
procedures.
2. Vicryl (polyglactin)
This is a copolymers of glycoside and lactide. It is
absorbed by hydrolysis. It is now replacing chromic
catgut due to its strength, reliability, use in infection
and better tissue reaction. It is used for surgeries
such as intestinal anastomosis and bile duct
surgeries.
3. Dexon (polyglycolic acid)
It is a synthetic absorbable, braided suture that is
used like vicryl.
4. PDS (polydioxanone)
Its use is similar to vicryl. It is financially costly. It is
distinguished by its creamy color.
Non-absorbable suture materials

1. Prolene

Suture materials This is a polypropylene. It is monofilament, artificial

Suture materials can be absorbable or non-
absorbable.
Absorbable suture materials
1. Catgut
The word catgut comes from KIT-GUT (violin
strings). It is prepared from the sub mucosa of a
sheep intestine. It is a biologically absorbable
monofilament. It can be plain or chromic cargut.
Plain catgut (7 days catgut)
Their use is minimal due to the short duration
before it is absorbed (7-10 days). It is used to put fat
stitches (subcutaneous fat).
and uncoated. Its use is in suturing abdominal
closure and repairs of hernia.
2. Suture pack
It is a polyamide and can be either multi-filament or
mono-filament. It is black in color, braided and
uncoated. Its use is similar to that of prolene’s.
3. Mersilk
This is a braided silk. It is black in color and is used in
ligating bleeding points or anastomosis.
4. Black silk
This is biological and prepared from the cocoon of
silkworm larvae. It is braided, multifilament and

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53
coated with wax to reduce capillary action. Tissue
reaction is more common since it is biological and
contains foreign protein. Since it is widely available
and cheap it is used in most scenarios.

5. Cotton

Cotton suture is white in color and is multifilament.

Although the price is low the infection rate is high,
discouraging the use.

Widely used sutures in Ethiopia

 Vicryl
 Catgut
 Silk
The size of the suture is dependent on the type of
surgery under consideration.

 Ophthalmologic: very small diameter

 General surgery: larger diameter
 Orthopedics: largest diameter

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54
 Common X-rays in Surgery
Compiled by: Yasmin Abdulsemed and Zelalem Girma

X-ray is an integral part of the viva examination in the clinical year II exam as well as the qualification exam. On top of
that, examiners may occasionally ask you about x-rays on long or short case exams. As a result, it is preferable to know,
at least about the most common x-ray findings of certain important surgical conditions.

In this section of the note, x-rays of various body parts, particularly the chest, biliary tree, the urinary tract, the
esophagus and the stomach are presented along with the most important information.

The first thing you should know about x-rays is the densities: white (metallic), less white (bone), light gray (soft tissue),
dark (gas) and less dark (fat). Knowing this will help you to identify certain body parts with much ease.

When you are asked to read an x-ray, you should try to report the patient’s information, the type of the x-ray and
everything you see, normal or abnormal. A good example is chest x-ray reading.

Comments on chest x-ray

 Patient ID (name, sex, age)

 Quality of image
 Projection (AP, PA or lateral view)
PA is the most common (scapula is laterally displaced, gastric bubbles are seen, because it is taken in erect
position). In an AP x-ray, the cardiac shadow is magnified.
 Penetration: can tell by looking at the retrocardic vertebra. It is good penetration if the intervertebral disc is
visible (up to T4). An over penetrated film will be dark and if under penetrated, white.
 Rotation: clavicle in relation to the spinous process (1mm is acceptable)
 Inspiratory or expiratory film: at least 6 anterior or 8 posterior ribs should pass through the diaphragm
 Bone (any lesion or fracture), soft tissue (for emphysema or swelling)
 Trachea: should be central or only slightly deviated to the right at the thoracic inlet.
 Cardiac shadow: cardiothoracic ratio should be measured (max cardiac diameter: max inner thoracic diameter).
A cardio-thoracic ratio of > 60% indicates cardiomegaly. Cardiac border is also another consideration.
 Pulmonary artery and vein
 Lung hilum: left hilum is higher than the right
 Lung parenchyma
 Pleura: costophrenic and cardiophrenic angle
 Diaphragm: have smooth outline. If there is hiatal hernia, there may be discontinuity. A diaphragmatic height of
< 1.5 cm indicates hyperinflation of the lung or diaphragmatic paralysis.
 Obvious lesion in the abdomen

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55
Chest X-ray

X-ray of the most important chest conditions that we are expected to know are hemothorax and pneumothorax. But,
don’t forget to look for conditions such as flail chest, which is fracture of at least 2 adjacent ribs in at least 2 places.
You should also pick a chest tube, if it was inserted. You can follow the chest tube from outside to inside and see its
end lying in the pleural space.

If you see a total haziness of the lung field on chest x-ray of a patient with hemothorax, the possibilities are

 Massive fluid (hemothorax) in the pleural, leading to collapse of the lung

 X-ray taken in the supine position, which will distribute the fluid throughout the pleura

Important information

 If there is air or fluid in the pleural space, the visceral pleura can be clearly seen lying on the lung
 If the broncho-vascular markings (air-bronchogram) can’t be seen, either the lung is collapsed due to conditions
such as pneumothorax or the lung is not there at all (pneumectomy)
 Costophrenic angle obliteration may not be seen until the volume reaches 150-200 ml. As a result, an early x-ray
of a hemothorax may have normal findings

Tension pneumothorax

 Increased radiolucency (darken)

 No broncho-vascular markings
 Depressed or flattened diaphragm
 Mediastinum displaced to the opposite side
 Widening of intercostal spaces
 White line of visceral pleura parallel to chest wall (Do
not confuse the line with skin fold or with scapula)
 If any doubt, take CXR in inspiratory phase
 There may be associated rib fractures
 On exam: outline the lung on the affected side

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 Pleural effusion Massive hemothorax of the right lung

 Obliteration of costophrenic angle Small hemothorax may appear massive, if

 Meniscus sign the x-ray was taken in the supine position

Hemopneumothorax Lung abscess

You see the features of both hemothorax  Air-fluid levels

and pneumothorax

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 Empyema on lateral chest x-ray Right upper lobe mass of the lung

Cannon ball appearance Pneumonectomy on the left lung

 Sign of pulmonary metastasis

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58
Barium studies

These studies are used to see what is going in the bile. This tests can be applicable for pathologies of almost the whole
length of the gastrointestinal tract from the esophagus to the large intestines.

 Esophagus: barium swallow

 Stomach: barium meal
 Small intestine: barium follow-through
 Large intestine: barium enema

Esophageal cancer Achalasia cardia

 Irregular mucosal outline  Smooth mucosal outline
 Abrupt narrowing  Gradual tapering
 Minimal dilatation proximal to the  Significant dilatation proximal to the
obstruction obstruction, no shouldering
 Shouldering effect  Birds beak appearance

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 Caustic ingestion Diffuse esophageal spasm

 Long segment affected  Corkscrew appearance

 No proximal dilatation
 Usually multiple strictures

Mid-esophageal stricture in a patient with Barium meal of sliding hiatus hernia with a
Barrett’s esophagus narrowing of sphincter and diaphragmatic
crura, clearly shown

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 Para-esophageal hernia Duodenal ulcer
 Gastro-esophageal junction is just
above the diaphragm
 The fundus is alongside the
esophagus, compressing the lumen

Benign gastric ulcer Filling defect in the stomach

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 Intussusception of the ileum Barium enema showing diverticular disease
of the sigmoid
 Claw sign: is when the barium is seen
as a claw in the negative shadow of  ‘Saw-teeth’ and diverticula
the intussusception

Intestinal obstruction

The presentation of small bowel and large bowel obstruction is different. Similarly, the x-ray features are also distinct
from each other.

Small bowel obstruction

 Dilated small bowel (>3cm)

 Multiple air fluid level (the number
of the air-fluid level is directly related
to the degree of obstruction)
 Valvulae conniventes (in jejunum):
regularly spaced mucosal folds which
completely pass across the width of
the bowel
 Absent rectal air shadow
 Stepladder pattern (on the right
picture)

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 Large bowel obstruction (particularly sigmoid volvulus)
 Massive abdominal colon with air in the rectum
 Fewer air fluid levels (usually not more than 2)
 The two limbs are seen diagonally across the
abdomen from right to left
 Haustra marking (except in cecum): irregularly
spaced, don’t cross the whole diameter of the
bowel (unlike the valvulae conniventes) and don’t
have indentations placed opposite to each other
 Signs in sigmoid volvulus (coffee bean sign and
omega sign)

Signs in sigmoid volvulus

 Coffee bean (kidney shaped)

 Omega sign

Perforated viscus
The classic x-ray feature of a perforated viscus is collection of free gas under the right dome of the diaphragm.

Another fonding may be ground glass appearance, indicating significant fluid in the peritoneal cavity.

Causes of viscus perforation

 Peptic ulcer disease

 Enteric ulcer
 Meckel’s diverticulum
 Malignant ulcers (colonic, gastric)
 Tuberculous ulcer (ileum)
 Abdominal stab

Surgery is also another cause of air under

the right diaphragm: laparotomy and tubal
insufation test done for tubal patency

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Esophageal foreign body

In the esophagus, a swallowed coin is usually seen on the wider part on AP/PA x-rays. In the trachea, it is most probably,
the side of the coin will be seen in AP/PA.

The biliary tree

Plain radiograph showing radio-opaque

stones in the gall bladder.

Rarely, the center of a stone may contain

radiolucent gas in a triradiate or biradiate
fissure, and this gives rise to characteristic
dark shapes on a radiograph: the ‘Mercedes-
Benz’ or ‘seagull’ sign

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 Porcelain (calcified) gall bladder Gas in the gall bladder

Caused by Clostridium perfringens

ERCP: stone obstructing the common bile ERCP: partial occlusion of the bile duct by
duct a malignant stricture

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 Trans-hepatic cholangiogram (PTC) showing Peroperative cholangiography showing a
stricture of the common hepatic duct normal duct (contrast passes to duodenum
without hindrance.

Dilated biliary system with multiple stones

in the common bile duct and reflux of
contrast into the pancreatic duct

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66
Urologic x-rays (KUB or IVP)
Aim of ordering these investigations

 To locate the stones exactly in relation to kidney and ureter (90% stones are radiopaque)
 To assess renal function
 To detect any pathology of kidneys, ureters and bladder
 To study any anatomical variations of the renal system
 PUJ Patency (may be obstructed because of stone, tumor or congenital causes of PUJ obstruction)

Normal intravenous urogram showing the Cystogram showing a left inguinal hernia
outline of both kidneys with the collecting containing the bladder
system and upper ureters highlighted by the
contrast medium

Radiograph showing a left-sided, pigtail

Retrograde ureterogram demonstrating the nephrostomy tube draining a kidney

collecting system. The radiolucent filling obstruction by a ureteric calculus, seen at

defect in the renal pelvis is caused by a uric the level of L3–4. A J-stent is in the right
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acid note
calculus ureter, which has been cleared ofAugust,
stones2018
67
 Urogram: horse shoe kidney Urogram: left kidney with double pelvis

Retrograde uretrogram: double ureter on Retrograde uretropyelogram showing a

the left side hydronephrosis:

 Greatly enlarged renal pelvis

 Dilated, ‘clubbed’ calyces

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 Plain abdominal radiograph: Stone in the right renal pelvis

 Complete stag-horn calculi

Radiography showing a vesical calculus (no Retrograde cystography of tuberculosis

contrast was added) cystitis: an exceedingly contracted
(‘thimble’) urinary bladder

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Orthopedic x-rays

The most important orthopedic case is fracture. A fracture means a disruption in all or part of the cortex of a bone.
When reading a musculo-skeletal x-ray, you should at least follow the ABCS step:

 Alignment and number of bones

 Bone density (cortex and medulla)
 Cartilage and
 Soft tissue

How to described fractures

 By the direction of fracture line: transverse, Diagonal (oblique), Longitudinal or Spiral

 By the relationship of the distal fracture fragment in relation to the proximal: Displacement, Angulation,
Shortening, Rotation or Impaction
 By the number of fracture fragments: Simple or comminuted
 By the relationship of the fracture to the atmosphere: Closed or Open (compound)

Remember rules of two

 Two views: AP and LATERAL

 Two joints: joints above and below the fracture
 Two limbs: in children for comparison of the growth plates
 Two injuries: severe forces often causes injuries (> 1 level)
 Two occasions

Gustillo Anderson classification of open fractures

Grade 1: skin opening of 1cm or less, minimal muscle contusion, usually inside out mechanism

Grade 2: skin laceration 1-10cm, extensive soft tissue damage

Grade 3

 Grade 3a: extensive soft tissue laceration (>10cm) but adequate bone coverage
 Grade 3b: extensive soft tissue injury with periosteal stripping requiring flap advancement or free flap
 Grade 3c: vascular injury requiring repair

Dislocation: is a complete displacement of the articular surface of joint (Joints are no longer in contact). Recurrent
dislocation is repeated dislocation of a joint usually due to damage to the ligaments and joint margin.

Subluxation is an incomplete displacement of the articular surface of the joint.

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 Comminuted Fracture

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 Internal fixation: Internal fixation: Internal fixation:

Plate and screws Intra-medullary nailing Wires

Internal fixation:
Shoulder dislocation
Interfragmentary screws

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 Editors References
Metasebia Zewdu Bailey and Love’s Short practice of Surgery, 25th Edition
Michael Yeshiwas Manipal Manual of Surgery
Minale Menberu Previous short case notes
Nahom Gashaye Lecture slides of surgery and radiology
Obsine Abate Up to Date
Rabia Ahmed
Veronica Zinabu
Yasmin Abdulsemed
Good Luck!
Zelalem Girma

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