All of Surgery I

Ahmad Salh Soboh
Case 1
35 years old female
Complains of pain in the left upper forearm and difficulty in moving the left elbow joint and
rotator movements of left forearm - 3 month ago.
History: Fall on the hand with the body twisted at the movement of impact 3 month ago.
Treated by native splinting following which patient has difficulty in using the left forearm and
elbow.
Inspection: Attitude of the limb is flexion at the left elbow joint. Deformity noted in the
proximal ulna. Wasting of left forearm muscles. Fullness in the cubital fossa present.
Palpation: Deformity confirmed in proximal 1/3rd of ulna. No abnormal mobility but tenderness
is positive. Anterior angulations present. Radial head is dislocated interiorly.
Movement: Elbow joint is flexed at 40 degrees of flexion. Further flexion up to 60 degree

possible. Pronation and supination - 10 degree from mid prone position each.
Measurement: A shortening of 1 cm. compared to the opposite side. No distal NV deficit. Three
point relationship of bones maintained.
Investigation: X-ray
1. What is the possible diagnosis of this condition?

2. What is the classification of this condition?
3. What kind of treatment types do you know?
4. If surgery needed, what treatment types do you know?
5. What are the complications of this condition?
Ahmad Salh Soboh
1. (Fractures of the Proximal Ulna with Radial Head Dislocation (Monteggia Fracture Dislocation)
2. BADO Classification
→ Type I (anterior dislocation)
→ Type II (posterior dislocation)
→ Type III (lateral dislocation)
→ Type IV (anterior dislocation with radius shaft fracture)
3. →
• Closed reduction:
→ Incomplete fracture with stable length
→ Plastic deformation
→ Greenstick
• Intramedullary pin fixation:

→ Complete fracture with stable length
→ Transverse fracture
→ Short oblique fracture
• Open reduction with plate fixation

→ Complete fracture with unstable length
→ Long oblique fracture
→ Comminuted fracture
4. These injuries require surgery to fix the ulna fracture with plate and screw fixation and
to reduce radial head
5. Nerve injury, ulnar non-union, and compartment syndrome.

Ahmad Salh Soboh
Case 2
27 years old male

Complains of inability to extend his right elbow – 2 months
History: Fall 2 ½ months ago. Direct blow or fall on elbow. Fall on outstretched hand.
Indigenous treatment present.
Inspection: Arm by the side, elbow in flexion, wrist in neutral position. Triceps appears
contracted and wasted.
Palpation of right elbow: Olecranon is irregular, non tender with a transverse gap or step. Both
medial and lateral condyles are normal. Supracondylar ridges are normal. Triceps contracted.
Deformity: fixed flexion deformity 80 degrees.

2. Which fracture type is it from AO classification?
3. What are the treatment objectives of this condition?
4. What kind of treatment would you suggest to do?
1. Non-Union Olecranon
→ 4-6 weeks of Ulna healing (in case Non-union because 2.5 months)
2. AO classification:
A. Extra-articular fractures
B. Partially articular fractures
C. Completely articular fractures
3. Goals of treatment:
A. Restoration of articular surface
B. Restoration elbow motion and prevention of the elbow extensor mechanism
C. Prevention of complication.
4. The ulna has 2 lag screws combined with a classic tension band on the olecranon. /
Plates and Screws
5. →
❑ Implant symptoms
❑ Implant failure
❑ Infection
❑ Pin migration
❑ Ulnar neuritis
❑ Heterotopic ossification
❑ Nonunion
❑ Decreased range of motion
Ahmad Salh Soboh
Case 3
10 years old male

Felt down on his hand, while descending on stairs 2 hours ago.
Examination: Pain, swelling and skin tenting. No distal pulse.
X-ray:

2. What is the classification of this condition?
3. What treatment types do you know?
4. If surgical treatment is indicated which one do you perform?
1. Distal humerus fracture
2. Extra-articular fractures
3. Most are treated with double plating with the plates placed in two different planes…
→ Conservative treatment
• Cast or splint stabilization
• Traction
→ Operative treatment indications:
• Displaced fractures
• Comminuted fracture in young patient
→ Available methods:
• Screws
• Dual plate fixation
• Total elbow arthroplasty
4. In this case we pediatric case so we should to check if there is Comminuted fracture

after that we can perform Double plat fixation
5. →
❑ Non-union
❑ Elbow stiffness
❑ Malunion
❑ Sepsis
❑ Ulna neuritis – avoid over-traction
❑ Post-traumatic arthritis
❑ Failure of fixation
Ahmad Salh Soboh
Case 4
A 40-year-old woman
Comes to the emergency department because she has pain in the right arm two hours after she
fell in her home.
Physical examination shows swelling and deformity of the right arm. The patient is unable to
dorsiflex the wrist.
1. What is this possible diagnosis of this condition?

2. Which type is this condition from AO classification?
4. Which nerve can be involved in this condition?
1. Humerus mid shaft fracture with nerve injury
3. Non operative = closed reduction, casting. operative = intermedullary nailing, external

fixation, plate fixation.
4. Radial nerve.
5. Complications:
❑ Non-union
❑ Malunion
❑ Neurovascular compromise e.g. radial nerve palsy
❑ Iatrogenic shoulder impingement after humeral nailing
❑ Periprosthetic fractures, e.g. after retrograde humeral nailing
Ahmad Salh Soboh
Case 5
40 years old male

Complains of deformity in the right arm - 9 months
History: Fall and sustained closed injury to R upper limb 9 month ago. Indigenous treatment present.
Inspection: Arm is by side of body, elbow in extension, wrist in neutral position. Deformity
present middle 1/3 of humerus. Obvious shortening of R arm present. Wasting of deltoid
muscle on R side present. No evidence of scars, sinuses or mass.
Palpation: No tenderness. Anterior angulations of distal fragment present. Gap palpable on
M/# of humerus. Minimal thickening of humerus at M/3 present. Abnormal mobility present
M/3 of humerus.
Movement: R shoulder - abduction and external rotation restricted. R elbow - flexion, extension
full. R wrist & fingers - full, no radial nerve involvement.

2. What are the risk factors of this condition?
3. Which fracture type is it from AO classification?
5. What complications of surgical treatment do you know of this condition?
1. Non-union fracture shaft of humerus
2. Osteoporosis, obesity, alcohol, smoking.
4. Plate fixation, Intramedullary (IM) nailing
5. Complications of surgical treatment:

❑ Open fractures
❑ Neurovascular injury
❑ Floating/segmental fractures
❑ Associated intra-articular fractures that need treatment
❑ Associated brachial plexus injuries that need treatment
❑ Poly-trauma or bilateral fractures
❑ Pathological fractures
Ahmad Salh Soboh
Case 6
45 years old female

Complains of pain and decrease of ROM in right upper limb.
History: She sustained an injury by falling down on her shoulder, and was brought by
ambulance in ED after 2 hours. Patient is diabetic.
Inspection: Upper limb is by side of body, elbow in flexion, wrist in neutral position, painful at
movement. No obvious deformity or shortening of R hand present. No evidence of scars,
sinuses or mass.
Palpation: Tenderness, abnormal mobility present U/3rd of limb. Distal pulse +. Numbness in
fingers +.
1. What is the most likely diagnosis?

3. What is the choice of treatment for this condition?
4. What is the humerus blood supply?
1. Proximal humerus fracture.
3. Open Reduction Internal Fixation (ORIF)
4. Axillary Artery → Circumflex humeral (ascending, anterior and posterior)
5. Osteonecrosis, nonunion, and malunion of the tuberosities causing rotator cuff

dysfunction
#+ dislocation
Ahmad Salh Soboh
Case 7
42-year-old male
Complaining of fever, chills with swelling, pain, and redness of his left shoulder progressive over
the last 24 hours.
He is now unable to move shoulder due to the pain. He denies any recent trauma or previous
shoulder injury or surgery.
Past Medical History: Type 2 diabetes.
Social History: Smoker.
Review of Systems: As above.
Physical Exam: Temp.= 101.8, BP= 135/88, P= 110, RR= 18. The shoulder has significant swelling
with erythema, warmth and diffuse tenderness with limited ROM.
Shoulder x-rays show an effusion but are negative for fracture.
MRI: see bellow
Laboratory studies show WBC = 18, ESR = 52 CRP = 120. Aspirated joint fluid is cloudy, WBC =
52,000 with, gram stain is positive. Culture is pending.

2. What are the predisposing factors of this condition?
3. What kind of stages of this condition do you know?
4. What are the differential diagnosis of this condition?
1. Septic arthritis of the shoulder
2. Predisposing factors:
❑ Chronic disease
❑ Rheumatoid arthritis
❑ IV drug abuse
❑ Immunosuppressive drug therapy
❑ AIDs.
3. Stages:
A. Acute synovitis with a purulent joint effusion
B. Articular cartilage is attacked by bacterial and cellular enzyme.
C. If infection is not arrested, the cartilage may be completely destroyed
D. Healing then leads to ankylosis
4. Septic arthritis, Rheumatoid arthritis, Tuberculous arthritis, reactive arthritis, drug

induced arthritis, osteomyolytis
5. IV fluid, analgesics, antibiotics, splintage, surgical daring.

Ahmad Salh Soboh
Case 8
30 years old male

Referred to emergency department with pain in right shoulder. Two hours ago felt on the tip of
the right shoulder during hockey game.
Past Medical History: Unremarkable.
Inspection: Visual deformity and swelling around AC joint.
Palpation: Pain, tenderness and deformation around AC joint.
Movement in shoulder joint is restricted due to the pain.
1. What other investigations will you perform?

3. Which type is this condition from classification?
1. Investigations:
• CT scan (best choice, can also determine physeal injury in youngsters)
2. Acromio-Clavicular (AC) joint dislocation
3. Types:
➔ Type 1 – sprained acromio-clavicular ligament
➔ Type 2 – acromio-clavicular joint (ACJ) subluxates
➔ Type 3 – no more contact (CC ligament ruptured)
➔ Type 4 – clavicle driven posteriorly into trapezius
➔ Type 5 – very marked displacement (torn delto-trapezial fascia)
➔ Type 6 – clavicle under acromion, very rarely seen
4. Conservative, Operative, may need distal clavicle excision ± WeaverDunn (modified) by

substitute coraco-acromial (CA) ligament to replace the torn CC ligament
5. Nonunion, skin injury, neurovascular injury, decrease Range of motion

Ahmad Salh Soboh
Case 9
25 years old male

Referred to emergency department with shortness of breath, swallowing difficulties and pain in
sternum. 30 minutes ago felt on the right shoulder during rugby game.
Inspection: Visual deformity and swelling around SC joint.
Palpation: Pain and deformation around SC joint. Palpable sternal corner on ipsilateral side.
Investigation: CT
1. Which soft tissue determines the stability of this joint?

3. Which type of this medical condition is it?
1. Stability determined by strong soft tissue:

capsular ligament, inter-clavicular ligament, costo-clavicular ligament and intra-articular disc
2. Sterno Clavicular (SC) joint dislocation
3. SC joint dislocation types:

• Anterior
• Posterior (much more dangerous)
4. Reduction Manoeuvre:
• Anterior – closed reduction (CR) manoeuvre: direct pressure or try figure-of-
eight strapping
• Posterior – support in between shoulders or seated with
knee of surgeon, then pull shoulders back/in some cases try the use of towel clip.
- Achieve early reduction, ˂ 4 days

- Thoracic surgeon = posterior dislocation
5. Posterior dislocation complications:

❑ Superior vena cava (SVC) laceration
❑ Pneumothorax
❑ Thoracic outlet syndrome
❑ Esophagus rupture ± tracheo-oesophageal (TE) fistula
❑ Death from hemorrhage
Ahmad Salh Soboh
Case 10
20 years old man

Complains of swelling in the upper part of left shoulder 3 months
History: fall on the outstretched hand, direct trauma following which he was unable to raise the
shoulder, indigenous treatment present - native bandages, pain since the fall.
Inspection: Deformity with a mass in the left clavicular region visible at the junction of middle
and outer third, skin over the swelling is normal, no evidence of scar/sinus/no visible
pulsation/no engorged veins
Palpation: No warmth, no tenderness. Hard, irregular mass of size 3X2cm localized in left
clavicular region. Edges not well defined, merges with clavicle. No crepitus or abnormal mobility
in left clavicle.
Movements: abduction 0-110 degree possible. Further abduction painfully restricted though
other movements are normal.
Investigations: X-ray left shoulder with clavicle AP view:
1. What are the risk factors of malunion clavicle fracture?

2. What are the treatment types of malunion clavicle fracture?
3. What are the recovery time of clavicle fracture in adults?
4. If surgical treatment is indicated what is the best choice of malunion clavicle fracture treatment?
5. what is the diagnosis of this condition?
1. Shortness of bone or angulation fracture, DM, smoking.
2. Operative treatment. The only way to prevent a malunion in a dislocated midshaft

clavicle fracture is an open reduction with internal fixation or a percutaneous
procedure. We will discuss the 2 types of fixation that are most commonly used: plate
fixation and intramedullary fixation.
3. Clavicle fractures take the same time to heal with or without surgery. Usually, the
breaks heals in around 6-8 weeks but it is fairly common that it can take up to 3 months.
4. Malunion clavicle fracture

→ A MALUNION occurs when a fractured bone heals in an abnormal position
5. Malunted clavicle fracture

Ahmad Salh Soboh
Case 11
24 years old male

Complains of swelling and pus discharge (rom middle 1/3rd of collar bone-3 months duration with
lever on and off. Old history of trauma of clavicle, 4 months ago treated by native bandages.
Inspection: 1X2 cm swelling in middle 1/3rd / distal 1/3rd junction of clavicle. Sinus draining
purulent foul smelling discharge +
Palpation: Warmth +, tenderness +, sinus adherent to underlying bone, clavicle irregular and
thickened.
Movements: Abduction: 0 – 100o degree beyond which it is restricted. Other movements are
restricted at extremes.
Investigations: Bone resorption with patchy density loss and sclerosis / sequestrum +, pus -
staph aureus grown

3. What kind of phases of this condition do you know?
S. What are the complications of this condition?
1. Osteomyelitis of Clavicle
2. Risk factors are:

➔ Recent trauma
➔ Diabetes
➔ Hemodialysis
➔ IV drug abuse
➔ People who had splenectomy.
3. Acute osteomyelitis presents within 2 weeks after disease onset, subacute osteomyelitis
within one to several months, and chronic osteomyelitis after a few months.
4. Treatment:
➔ Medical: Infection must be diagnosed early. Intravenous antibiotics (usually
oxacillin or cloxacillin 8–16 g adult) started soon after obtaining specimen for
culture. Monitor temperature, swelling, pain, WBC, and joint mobility.
➔ Surgical: Open drainage of abscess if antibiotics fail or signs of abscess appear.
After surgical drainage, wound is left open to heal by secondary intention.
5. Complications:
• Chronic OM
• Bone abscess (pocket of pus)
• Bone necrosis (bone death)
• Spread of infection to the
→ - joint-septic arthritis
→ other bones - metastatic osteomyelitis
• Inflammation of soft tissue (cellulitis)
• Growth disturbance -> if physis is damaged- leads to shortening, deformity
• Sepsis
Ahmad Salh Soboh
Case 12
50 years old female

Complains of deformity and pain in right hip joint. She was brought by ambulance after high
speed motor vehicle collision.
Inspection: No wounds/scars around right hip joint
Palpation: Right hip joint is tender, visual deformity is presented.
Movement: Knee flexed, Hip in adduction and internally rotated.

2. Which type is it?
4. What other investigations you can suggest?
5. Which complications of this condition do you know?
1. Hip Dislocation
2. Common types of hip dislocation:

➔ Posterior–overall most common
➔ Anterior, e.g. after anterolateral approach of total hip replacement (THR)
➔ Inferior–rare
➔ Obturator–rare
➔ Central–usually associated with some types of acetabular fracture
3. Reduction of the hip under anesthesia (surgery required if the hip cannot be reduce).
4. CT in all cases after reduction
5. Complications:
• Sciatic nerve injury.
• Medial femoral circumflex artery injury.
• Osteonecrosis of the femoral head.
◦ Hip in abduction and external rotation (ER) in anterior dislocation

◦ Hip in adduction and internal rotation (IR) in posterior dislocation
Ahmad Salh Soboh
Case 13
29 years old male

Complains of pain in right hip for past 4 month. History of difficulty in walking and squatting for
the past 4 month. Road traffic accident 4 months ago. The patient was riding a bullock cart
which was hit by a bus. He sustained injury in right hip. He underwent native bandaging 5
times.
Examination: Palpation – head of femur palpable at the inferior aspect below the pelvic
tubercle.
No tenderness. Transmitted movement positive.
Movement: Flexion – 10-90 degree, Abduction – 10-45 degree, Ext. rotation – jog of movement.
Measurement 3cm lengthening +.
X-ray:

4. If surgical treatment is indicated which one do you know?
1. Unreduced anterior dislocation of hip.
2. Femoral Head Avascular Necrosis, Femoral Neck Fracture, Femur Injuries and Fractures,
Hip Fracture
3. Closed reduction - allis/bigelow/stimson methods.
4. Surgical - Open reduction and internal fixation (ORIF). → but increases the risk of
osteonecrosis
5. Complications:
❑ Femoral head fracture
❑ Transchondral fracture –excision/ORIF
❑ Indentation fracture more common, superior, no specific treatment, prognostic
implications
❑ Osteonecrosis
Hip in abduction and external rotation (ER) in anterior dislocation

Hip in adduction and internal rotation (IR) in posterior dislocation
Ahmad Salh Soboh
Case 14
A 32-year-old female
Was brought to ED after few hours from accident. She has been bucked off of her horse. She
felt down on lateral side.
Physical examination shows tenderness all over the pelvic, especially when attempt to
compress or distract the pelvis. Bleeding in external meatus.
X-ray:

2. Which classification of this condition do you know?
1. Pelvic fracture
2. Type Ai: stable post arch intact, type Bii: partially stable (incomplete disruption of post
arch), type Ciii (unstable).
3. Treatment types:
• (APC) <2.5 cm bed rest + posterior sling.
• (APC) >2.5 cm surgery (close reduction +External fixation), lateral compression
(reduction + external fixation)
• AP III +VC - most dangerous - reduction + external fixation or plate and screws.
4. Open fracture treated by external fixation.
5. Complications:
❑ Sciatic nerve injury.
❑ Urogenital problem like stricture, incontinence and impotence.
❑ Persistent sacroiliac pain due to unstable pelvis.
Ahmad Salh Soboh
Case 15
15 years old male

Complains of pain right hip and limp right lower limb – 4 weeks. History of trivial fall.
General examination: Patient obese, secondary sexual characters not well developed.
Right lower limb: Attitude is extension at the hip, extension at knee, neutral at ankle and
externally rotated. Right lower limb appears shortened. Wasting of thigh and calf muscles. No
exaggerated lumbar lordosis. No scar or sinuses seen.
Palpation: No exaggerated lumbar lordosis. No warmth. Trochanter is elevated, not thickened.
No mass palpable. No fixed deformities.
Movements: Flexion – 0-120 degree, Extension 0-15 degree, Abduction 0-10 degree,
Adduction 0-35 degree, External rotation 0-30 degree, Internal rotation 0-5 degree
Measurements: There is an apparent shortening of 1cm and a 1,5 cm true shortening in the
right lower limb confined to the supra-trochanteric region. Special tests – Trendelenberg +.
X-ray pelvis with both hips – AP and frog leg view slip + - right femoral epiphysis.

1. Slipped capital femoral epiphysis
2. Inflammatory condition, rheumatic fever, septic arthritis.
3. change in apposition ( mild, moderate, sever), slip angle, true lateral projection (mild,
moderate, severe).
4. ORIF, percutaneous and open in situ pinning, osteotomy, epiphysiodesis.
5. Osteonecrosis, chondrolysis, osteoarthritis.

Ahmad Salh Soboh
Case 16
7 years old female
Complaints: Patient’s parents C/o “the girl walks with limp of the right lower limb” for the past
6 months. The limp started insidiously. No history of trauma. Pain 6 months ago, but now there
is no pain.
Inspection of right hip and lower limb: Attitude is extension at the hip, extension at knee,
neutral at ankle and mild external rotation. Right lower limb appears shortened. Wasting of
thigh and calf muscles +, no exaggerated lumbar lordosis, no scars or sinuses seen.
Palpation: No exaggerated lumbar lordosis. No warmth. Trochanter is elevated, thickened. No
mass palpable, no fixed deformities, no distal NV deficit.
Measurements: There is an apparent shortening of 1 cm and 1,5 cm true shortening in the right
lower limb.
X-ray:

1. Legg-Calvé-Perthes Disease
2. Sickle cell disease, dysplasia, hypothyroidism, Gaucher disease.
3. Classifications:
• Waldenström
• Lateral Pillar (Herring ) Classification
• Catterall Classification
• Salter-Thompson classification
• Stulberg classification
4. Non operative (observation, decrease activity, physical therapy or surgical (

femoral/pelvic osteotomy).
5. lose of motion (affected leg), degenerative bone disease.

Ahmad Salh Soboh
Case 17
10 years old female

Complains of pain, swelling and restriction of movement in her right knee joint.
History: Felt down from a horse. Knee swelled immediately. Patient was unable to bear weight.
Her pain score is 10/10.
Examination: Knee is swelled, warm and difficult to move due to pain.
X-ray:

1. Growth Plate Injuries (Metaphysis, physis, and epiphysis fractures.)
2. Salter-Harris classifications:
A. Salter-Harris I - fractures traverse the physis.
B. Salter-Harris II - fractures split through the physis and the metaphysis.
C. Salter-Harris III - fractures involve the physis and then extend through the
epiphysis and into the joint.
D. Salter-Harris IV - fractures involve the metaphysis, physis, and epiphysis.
E. Salter-Harris V - fractures are compression or crush injuries to the physis itself.
3. Slater-Harris (I, II, III) → closed reduction and casting or splinting.

Slater-Harris (IV, V) → open reduction and internal fixation
4. Open reduction and internal fixation because is Type IV of Slater-Harris
5. Growth deformity, malunion, angular deformity.

Ahmad Salh Soboh
Case 18
12 years old female

Complains of pain, swelling and restriction of movement in her right knee joint.
History: She was brought by ambulance in ED after felt down from a bike. Knee swelled
immediately. Patient was unable to bear weight. Her pain score is 10/10.
Examination: Knee is swelled, warm and difficult to move due to pain.
X-ray:

1. Distal Femoral Physeal Fractures
2. Salter-Harris classifications:
A. Salter-Harris I - fractures traverse the physis.
B. Salter-Harris II - fractures split through the physis and the metaphysis.
C. Salter-Harris III - fractures involve the physis and then extend through the
epiphysis and into the joint.
D. Salter-Harris IV - fractures involve the metaphysis, physis, and epiphysis.
E. Salter-Harris V - fractures are compression or crush injuries to the physis itself.
3. Slater-Harris (I, II, III) → closed reduction and casting or splinting.

Slater-Harris (IV, V) → open reduction and internal fixation
4. Closed reduction and percutaneous fixation followed by casting.
5. limp length discrepancy, angular deformity, and septic arthritis.

Ahmad Salh Soboh
Case 19
9 years old male

Was brought to ED with pain and deformity in his lower limb.
History: He sustained injury by falling down while skiing. He was unable to stand on his lower
limb.
Examination: Swelling, deformity and pain in mid 3rd of femur. No distal NV compromise.
X-ray:

2. What are the acceptable alignments of this condition?
4. If surgical treatment is indicated which one do you perform?
1. Fractured femur shaft
2. Acceptable alignment in children

< 10 years > 10 years
Varus / Valgus < 15 ͦ 5 – 10 ͦ
Anterior / Posterior < 20 ͦ < 10 ͦ
Malrotation 25 – 30 ͦ 25 – 30 ͦ
3. casting or splinting, Intramedullary (IM) nailing, open reduction and internal fixation
4. Flexible nail: 6 to near 12, mid-shaft transverse especially good ± occasional case of
proximal and distal third
5. Angular deformity, rotational deformity, delayed union.

Ahmad Salh Soboh
Case 20
45 years old female

Complains of deformity in the right lower limb.
History: She sustained an injury in the MVA and was brought by ambulance in ED after 3 hours.
Inspection: Lower limb is in neutral position, swelled, painful at movement. Deformity present
middle 1/3 of femur. Obvious shortening of R leg present. No evidence of scars, sinuses or mass.
Palpation: Tenderness. Anterior angulations of distal fragment present. Abnormal mobility
present M/3 of femur. No NV problem.

4. What are the goals of the treatment?
1. Fracture of shaft of femur
2. Sample fracture 32-A2 Oblique displaced.
3. Intramedullary (IM) nailing, External fixation, open redaction internal fixation.
4. Goals of the treatment:

➔ Restoration of alignment of the lower limb, restoration of proper rotation, and
prevention of shortening
➔ Early weight-bearing
➔ Early pain relief by fixation with adequate rigidity
➔ Early return to normal function
5. Shock, sciatic nerve injury, DVT, infection.

Ahmad Salh Soboh
Case 21
81-year-old thin white female

Presents to the ER via ambulance complaining of severe left groin pain after slipping and falling
onto her left hip at home. She attempted to get up with assistance but was unable to bear
weight on her left leg.
Physical Exam: Bruising over the left trochanter and the left leg in slight external rotation. She
can flex the ankle and foot but passive rotation of the left hip is painful. Sensation is intact,
good pulses and capillary refill.

2. What are the predisposing factors of this condition?
3. Which type is it from Garden’s classification?
1. Femoral neck fractures
2. Trauma, age, gender, osteoporosis, alcohol, loss of bone length.
3. Garden’s classification:
❑ Type 1 = incomplete fracture
❑ Type 2 = complete fracture, not displaced
❑ Type 3 = complete fracture with displacement, posterior retinaculum of
Weitbrecht still intact: thus can be treated with CR and IR
❑ Type 4 = completely displaced fracture and complete loss of continuity
4. Hip replacement (elderly) ,internal fixation (young).
5. Complications:
❑ AVN
❑ Non-union
❑ Malunion
❑ Periprosthetic fractures
Ahmad Salh Soboh
Case 22
18 year old male
Complains of pain, swelling and discharge from a sinus on left thigh for past 8 months
History: Apparently normal till 8 months back. Developed recurrent episodes of fever with
swelling, acute pain over left thigh associated with severe pain on weight bearing and walking.
Took native treatment in the form of bandages. During one of the episodes, swelling developed
over the lateral aspect of left thigh, which broke to discharge pus after which the pain
decreased. From then on he has recurrent episodes of pain and discharge of pus from the sinus.
Inspection: Gross wasting of the left thigh, 2 sinuses on middle 3rd of lateral aspect with bluish
borders with active pus discharge +, no limb length discrepancy.
Palpation: Left thigh warmth. Deep tenderness. Sinus fixed to underlying bone. Puckering + on
flexion of left thigh.
Left hip and knee movements are restricted.
X-ray: Diffuse sclerosis of left femur middle 31rd+, Sequestrum+, deformed cortex +

3. What kind of phases of this condition do you know?
a. What kind of treatment types do you know?
1. Osteomyelitis of femur
2. Risk factors are:

➔ Recent trauma
➔ Diabetes
➔ Hemodialysis
➔ IV drug abuse
➔ People who had splenectomy.
3. Acute osteomyelitis presents within 2 weeks after disease onset, subacute osteomyelitis
within one to several months, and chronic osteomyelitis after a few months.
4. Treatment:
➔ Medical: Infection must be diagnosed early. Intravenous antibiotics (usually
oxacillin or cloxacillin 8–16 g adult) started soon after obtaining specimen for
culture. Monitor temperature, swelling, pain, WBC, and joint mobility.
➔ Surgical: Open drainage of abscess if antibiotics fail or signs of abscess appear.
After surgical drainage, wound is left open to heal by secondary intention.
5. Complications:
• Chronic OM
• Bone abscess (pocket of pus)
• Bone necrosis (bone death)
• Spread of infection to the
→ - joint-septic arthritis
→ other bones - metastatic osteomyelitis
• Inflammation of soft tissue (cellulitis)
• Growth disturbance -> if physis is damaged- leads to shortening, deformity
• Sepsis
Ahmad Salh Soboh
Case 23
18 years old male

Complains of right knee pain, swelling, and decreased ROM after having his knee slammed in a
car door 5 weeks prior to presentation
History: At the time of injury, the patient seen in hospital where X-rays were negative, and the
patient has told that he has a contusion of the knee. Denies locking of the knee, but gives a
history of “giving way” of the knee. No significant past medical history.
Inspection: Mild swelling and effusion of right knee
Palpation and movement: No medial or lateral joint line tenderness. No tenderness around
collateral ligaments. ROM is 30-90 degrees. There is no instability to varus or vagus stressing at
0 degrees. McMurray's test is negative. Lachman test show and increase in laxity compared to
the contralateral side. Anterior drawer test is also positive. Posterior drawer is negative.
Investigation:
1. What is the possible diagnosis?

2. What additional clinical tests do you know for this condition?
3. What are possible differential diagnosis of this condition?
5. If surgical treatment is indicated which methods are used?
1. ACL Tear
2. Lachman Test, Anterior Drawer Test, Pivot Shift Test and Radiograph (Arthrogram and
MRI)
3. Meniscal tear, articular cartillage damage, collateral ligaments damage, MCL damage
4. Treatment
• Immediately after injury - R.I.C.E (Rest Ice Compression Elevation)
• Non surgical treatment
- Exercise (after swelling decreases and weight-bearing progresses)
- Braces
• Surgical treatment: replace torn ACL ligament by a graft (Autograft:
patellar/hamstring/quadriceps tendon. or allograft) arthroscopic repair.
5. Arthroscopic repair using autograft / allograft

Ahmad Salh Soboh
Case 24
18 years old male

Presented with left knee pain after sustaining an injury while playing football, three month
prior to this visit. His left knee was in hyper flexed position when it was twisted. Felt a 'pop'
associated with pain on the medial aspect of his knee. Had minimal knee swelling which had
resolved, but his pain persisted.
Inspection: No swelling/effusion. No scars/sinuses/wasting of muscles
Palpation: Minimal effusion, medial joint line tenderness, catchy pain as his knee was brought
into extension from hyper flexed position. There was a negative Lachman test. No instability of
varus or valgus stress. Full ROM of his left knee.

3. What are the possible treatment methods of this condition?
4. In which areas is possible to heal the meniscus tear?
5. What kind of clinical tests do you know to detect menisceal injury?
1. Knee instability - Meniscal tear.
2. Popliteal vessels damage, nerve damage, ACL tear, Tibia fracture.
3. Non operative: physical therapy, NASIDs, cortisone injection - Surgery: 1)Meniscectomy,

2)Meniscal Repair, 3) Meniscal Transplantation
4. Red zone: this the area of the meniscus that's has some blood supply, which aid healing.
5. • Thessaly test, • McMurrny test, • Apley’s Grinding test and Radiographs (MRI)
Ahmad Salh Soboh
Case 25
A 63-year-old man
Referred to the office by his primary care provider because he has pain in the right knee that
has been worsening over the past two years. He usually plays tennis several times per week,
but recently the pain has made it difficult for him to continue this routine.
Conservative treatment measures such as courses of nonsteroidal anti-inflammatory drugs and
injections of cortisone have failed to relieve the patient's pain.
Current physical examination of the right knee shows moderate effusion and tenderness along
the medial joint line. Result of McMurray test is positive.
Weight-bearing x-ray studies of the right knee show no narrowing of the joint spaces.
Investigation : MRI of the knee shows

4. If surgical treatment is indicated which is the most appropriate management?
1. Knee cartilage injury
2. Medial meniscus (abnormal grade 2).
3. Non operative treatment ( immediate obstinea from weight bearing, rest, Ice, compression
dressiry, NSAIDs) or operative ( meniscectomy).
4. Meniscal transplantation (allograft meniscus).
5. blood vessels injury, never damage, infection

Ahmad Salh Soboh
Case 26
15 years old male

Complains of pain in left knee for the past 1 month. Pain increases on running, climbing down
the stairs, the boy is athlete by profession. No history of injury.
Inspection: Attitude - hip neutral, knee neutral, ankle neutral. Mild swelling infra patellar
region, signs of inflammation me be/may not be present.
Palpation: Swelling in tibial tuberosity region, tenderness is positive in tibial tuberosity.
Movement: flexion 0-135 degree, no extensor lag. No distal NV deficits.

2. What is the classification of this diagnosis?
A. What kind of treatment types do you know?
1. Osgood-Schlatter Disease
2. Classification:
• Type I, where the tibial tubercle is prominent and irregular
• Type lI, where there is additional small fragments of bone adjacent to the anterior and
superior aspects
• Type III, where the tubercle is normal, but there is free bone particles in similar
distributio
3. Complications: pain of anterior tibial tubercle worse with jumping or running, warmth,
erythema skin.
4. Treatment: its Self-limited condition

• Basic management is conservative.
– Conservative management does not mean that you “do nothing.”
• Decreased Activity
– Not, NO ACTIVITY!
– Recommend that they decrease their activities to the point where pain is
improved and then begin adding back in activity as it is tolerated.
– Cross training may help (ex, swimming)
• Ice
– I usually tell them to pretend like they are Michael Jordan and need to ice down
their knees.
– Good trick is to fill small paper cups with water and freeze them. Then they can
peel the paper and then use that to apply directly over the tibial tubercle.
• NSAIDs
• Physical Therapy
5. Osteomyelitis, slipped capital femur epiphysis, fracture in tibial.

Ahmad Salh Soboh
Case 27
50 years old female

Complains of pain, swelling and decreased ROM in her left lower leg.
History: She twisted her ankle while getting out from bus and was brought by ambulance after
3 hours in ED.
Examination: Her ankle is swelled, tenderness around joint +, decreased ROM in the joint.
Patient is not able to weight bear.
Investigation: X-ray, CT scan

4. What are the goals of the treatment?
1. Pilon fracture.
2. Type B2 (Split depression)
3. long leg cast for 6 week, brace, ROM exercises.
4. GOALS OF TREATMENT
❑ To obtain an anatomical articular reduction
❑ Restore axial alignment
❑ Maintain joint stability
❑ Achieve fracture union
❑ Regain functional and pain-free weight bearing and motion
❑ Avoiding infections and wound complications
5. Complications:
❑ Skin necrosis
❑ Infection-osteomyelitis
❑ Traumatic arthritis
❑ Nonunion or delayed union
❑ Ankle joint stiffness
Ahmad Salh Soboh
Case 28
46 years old male

Complains of difficulty in running and in descending stairs while using left foot past week.
History: Apparently normal 1 week back. Gives a history of sudden painful snap of the left heel
1 week back, while at work. The pain subsided following which the patient noticed a small
swelling in the back of left heel associated with difficulty in the running and descending stairs
using left foot.
Inspection: No wounds/scars in left heel/foot
Palpation: Gap felt in the Achilles tendon, 4cm above it's insertion. Non-tender. Tip-toe test
positive. Thompson test is positive.
Movement: Left ankle: PF - 20 degree, DF - 20 degree.
Right ankle: PF - 40 degree, DF - 20 degree
1. What investigations would you perform?

2. What is the possible diagnosis?
3. How do you perform the Thompson test?
4. What are the treatment types on this condition?
1. X-ray, ultrasound, MRI.
2. Achilles tendon rupture
3. By squeezing the calf to identify the present of a complete rupture.
4. Surgical (open-repair, percutaneous technique)/ non surgical (resting the tendon with
ice and avoid stiffens of ankle).
5. deep infection, skin necrosis, fistula, recurrent rapture.

Ahmad Salh Soboh
Case 29
26 years old female athlete

Complains of stabbing pain in the bottom of her feet. The pain is usually the worst in the first
few steps after awaking. The pain usually worse after exercise.
Examination: There is a pain on medial process of the calcaneal tuberosity.
Investigations: MRI

4. If surgical treatment is indicated what will you perform?
1. Plantar Fasciitis
2. Risk Factors:
❑ Age: most common between the ages of 40-60.
❑ Gender: Woman
❑ Obesity
❑ Running in hard surfaces
3. Rest, ice packsm foot water modification, weight reduction, NSAIDs.
4. Operative planted fascia release.
5. Heel hypoesthesia ( decrease normal sensation), sepsis, bone necrosis, scar.

Ahmad Salh Soboh
Case 30
58-year-old male
Brought to the ER by private car after sustaining a rattlesnake bite to his left lower lateral leg
while out hiking approximately 2 hours ago.
The patient is complaining of 10/10 pain in his left foot and calf, worse with even minimal ROM
of the left foot. He denies any other trauma, no falls.
Physical Exam: The lower left leg is pale, swollen and firm below the knee, cool to the touch and
without palpable dorsalis pedis or posterior tibial pulses.
1. Which diagnostic tools will you use?

3. Which types of this condition do you know?
4. What kind of treatment of this condition do you know?
1. X-ray, MRI, CT, US.
2. Rattlesnake bite and compartment syndrome
3. Acute ( follows traumatic ) , chronic (exercise or work).
4. Cast care management (split, elevate, IV infusion). or surgery (fasciotomy - skin grafting).
5. Motor deficits, infection with potential amputation, acute renal failure, respiratory
distress syndrome.
Ahmad Salh Soboh
Case 31
25 years old male
Complains of pain in his back 6 months.
Pain increases with activity and at night. Relieved by taking analgesic (aspirin).
Swelling – not seeing
No constitutional symptoms. No history of a trauma, no history of similar condition in the body.
Palpation – tenderness +
No warmth/signs of inflammation.
Movement in spine is full and free. No distal NV deficit.
Investigation – CT of spine: zone of bony sclerosis surrounding a radiolucent nidus of (<1cm)
with variable degree of mineralization.

2. What is the most appropriate treatment for this condition?
3. What is the prognosis of this condition?
4. What are the differential diagnoses of this condition?
5. What is the etiology of this condition?
1. Osteoid Osteoma of spine
2. Aspirin and NSAIDs or Operative (resection of lesion or radiofrequency ablation of lesion)
3. Outcomes good with treatment

→ most cases of scoliosis due to osteoid osteoma will resolve after resection
4. Osteomyelitis, osteoblastoma, stress fracture, cortical desmoid
5. Osteoid osteomas or osteoblastomas are not known.

Ahmad Salh Soboh
Case 32
30 years old male

Complains of inability to use lower limbs following a fall into dry well – 1 week back.
History: Apparently normal 1 week back. Fell into a dry well 1 week back, while at work and
sustained injury to back. Complains of pain in back and inability to use bilateral lower limbs
since then. Associated with constipation and difficulty in micturition. No H/o past medical
illness.
Patient is conscious and oriented.
Inspection: On examining the back, gibbus + at T11, T12, L1 region. Grade 1 sacral sore +
Palpation: Tenderness + T11, T12, L1 region
Investigation: X-ray, MRI, CT

1. Spine fracture (thoracic, lumbar)
2. Anterior, Middle, and posterior columns
3. Non operative: bed rest (avoid flexion, rotation) , bracing (6-8). and rehabilitation
4. Operative: posterior anterior fixation (aim to neural compression, stabilization, solid fusion).
5. Swelling, tenderness bleeding, neurovascular defect, brown syndrome.

Ahmad Salh Soboh
Case 33
73 years old woman

She had a fractured femur neck for that she had a surgery ORIF screws and plates were fixed.
After 8 months she had returned to us complaining dull and constant pain in hip region and she
was not able to walk. she uses a stuck to walk around
1. Diagnosis (Avascular necrosis/ Osteonecrosis)
2. Investigation: MRI, Bone scan (DEXA)
3. Hip Replacement
4. Open reduction and internal fixation (ORIF)

→ in younger patients
→ all displaced fractures
Hip arthroplasty
→ in older patients
→ when surgery is contraindicated
5. And were the doctor right for their first treatment

→ yes, may be the patient has chance to improve.
Ahmad Salh Soboh
Urology
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Gastroenterology
Colon
Types of colectomy
Terminology of types of colorectal resections:

1. A→C Ileocecectomy; 10 cm of terminal ileum+cecum+appendix
2. A + B→D Ascending colectomy; 10 cm of terminal ileum+cecum+appendix+ Ascending colon
3. A + B→F Right hemicolectomy; 10 cm of terminal ileum+cecum+appendix+ Ascending colon+
Proximal 1/3 of Transverse Colon
4. A + B→G Extended right hemicolectomy; 10 cm of terminal ileum+cecum+appendix+ Ascending
colon+ 2/3 of Transverse Colon.
5. E + F→G + H Transverse colectomy; Transverse Colon.
6. G→I Left hemicolectomy; Distal 1/3 of Transverse Colon + Descending Colon
7. F→I Extended left hemicolectomy; Distal 2/3 of Transverse Colon + Descending Colon
8. J + K Sigmoid colectomy; Sigmoid colon
9. A + B→J Subtotal colectomy; 10 cm of terminal ileum+cecum+appendix+ Ascending colon
+Transverse Colon + Descending Colon.
10. A + B→K Total colectomy; 10 cm of terminal ileum+cecum+appendix+ Ascending colon +Transverse
Colon + Descending Colon + Sigmoid colon.
11. A + B→L Total proctocolectomy. 10 cm of terminal ileum+cecum+appendix+ Ascending colon
+Transverse Colon + Descending Colon + Sigmoid colon+ rectum.
12. Hartmann’s Procedure a type of colectomy that removes part of the colon and sometimes rectum
(proctosigmoidectomy).
13. Quenu-Miles procedure = Abdominoperineal Resection. P.1189
An abdominoperineal resection (APR) involves removal of the entire rectum, anal canal, and
anus with construction of a permanent colostomy from the descending or sigmoid colon.
Fistula In Ano
is a tunnel that develops between the inside of the anus and the outside skin around the anus.
Ahmad Salh Soboh
Anal fissure P.1225
A fissure in ano is a tear in the anoderm distal to the dentate line. The pathophysiology of anal
fissure is thought to be related to trauma from either the passage of hard stool or prolonged
diarrhea. A tear in the anoderm causes spasm of the internal anal sphincter, which results in
pain, increased tearing, and decreased blood supply to the anoderm. This cycle of pain, spasm,
and ischemia contributes to development of a poorly healing wound that becomes a chronic
fissure. The vast majority of anal fissures occur in the posterior midline. Ten percent to 15%
occur in the anterior midline. Less than 1% of fissures occur off midline.
Symptoms and Findings. Anal fissure is extremely common. Characteristic symptoms include
tearing pain with defecation and hematochezia (usually described as blood on the toilet paper).
Patients may also complain of a sensation of intense and painful anal spasm lasting for several
hours after a bowel movement.
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Hernia:
Direct hernia (different between direct and indirect)

Ingunal femoral hernia
Groin hernia =
Direct inguinal -indirect-femoral
Hernia treatment types:

Treatment :
Herniotomy = opening the transversalis fascia -hernia sac isolation -cremastric division
Herniorrhaphy = marcy repair and mc vay cooper ligament repair -bassini repair
Hernioplasty = plug and patch repair - tension free repair
Laparoscopic = TAPP and TEP
Diaphragmatic Herniation
•Type I – Sliding
–Herniation of Cardia
•Type II – Rolling (paraesophageal)
–Herniation of Fundus
•Type III – Combined
(paraesophageal)
– Herniation of both
•Type IV
–Herniation of additional organ
(colon mostly)
Bassini repair:
The Bassini repair was an historic advancement in operative technique. Its current use is
limited, as modern techniques reduce recurrence. The original repair includes dissection of the
spermatic cord, dissection of the hernia sac with high ligation, and extensive reconstruction of
the floor of the inguinal canal. After exposing the inguinal floor, the transversalis fascia is
incised from the pubic tubercle to the internal inguinal ring. Preperitoneal fat is bluntly
dissected from the upper margin of the posterior side of the transversalis fascia to permit
adequate tissue mobilization. A triple-layer repair is then performed. The internal oblique,
transversus abdominis, and transversalis fascia are fixed to the shelving edge of the inguinal
ligament and pubic periosteum with interrupted sutures. The lateral aspect of the repair
reinforces the medial border of the internal inguinal ring.
The technique involves suturing the transversalis fascia and conjoint tendon to the inguinal
ligament behind the spermatic cord, and is frequently coupled with a Tanner slide (vertical
relaxing incision in the anterior rectus sheath) in order to prevent tension.
Shouldice Repair
The Shouldice repair recapitulates principles of the Bassini repair, and its distribution of tension
over several tissue layers results in lower recurrence rates. During dissection of the cord, the
genital branch of the genitofemoral nerve is routinely divided, resulting in ipsilateral loss of
sensation to the scrotum in men or the mons pubis and labium majus in women. With the
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posterior inguinal floor exposed, an incision in the transversalis fascia is made between the
pubic tubercle and internal ring. Care is taken to avoid injury to preperitoneal structures, which
are bluntly dissected to mobilize the upper and lower fascial flaps. At the pubic tubercle, the
iliopubic tract is sutured to the lateral edge of the rectus sheath using a synthetic,
nonabsorbable, monofilament suture. This continuous suture progresses laterally,
approximating the edge of the inferior transversalis flap to the posterior aspect of the superior
flap. At the internal inguinal ring, the suture continues back in the medial direction,
approximating the edge of the superior transversalis fascia flap to the shelving edge of the
inguinal ligament. At the pubic tubercle, this suture is tied to the tail of the original stitch. The
next suture begins at the internal inguinal ring, and it continues medially, apposing the
aponeuroses of the internal oblique and transversus abdominis to the external oblique
aponeurotic fibers. At the pubic tubercle, the suture doubles back through the same structures
laterally toward the tightened internal ring.
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Esophagus Disorders:
Achalasia:
Symptoms:
• Dysphagia for both solids and liquids.
• Regurgitation of food.
DIAGNOSIS:
• Chest x-ray (CXR)
• Barium swallow will reveal the characteristic distal bird’s beak sign
Treatment:
Medical management:
→Drugs that relax the LES—nitrates, calciumchannel blockers, and antispasmodics
Surgical management:
• Esophagomyotomy (Heller’s myotomy) with or without fundoplication is the treatment
of choice for achalasia.
→ Fundoplication surgery wraps the upper stomach around the lower esophagus.
• Endoscopic dilatation: Has a lower success rate and a higher complication rate. It
involves inserting a balloon or progressively larger-sized dilators through the narrowed
lumen, which causes tearing of the esophageal smooth muscle and decreases the
competency of the LES.
Zenker’s Diverticulum
Symptoms:
• Dysphagia
• Halitosis
• Choking
• Weight loss
DIAGNOSIS:
→ A BARIUM SWALLOW will reveal the presence of all types of diverticula.
#Endoscopy is difficult and potentially dangerous due to the risk of perforation
through the diverticulum.
Treatment:
• Cervical pharyngocricoesophageal myotomy (incising the cricopharyngeus) and is done
in all cases needing operative intervention.
• Diverticulopexy (suturing the diverticulum in the inverted position to the prevertebral
fascia) is added to myotomy for larger diverticula.
• Diverticulectomy (endoscopic stapling of the diverticulum), along with myotomy, is
performed for the largest diverticulae.
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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Symptoms:
Heartburn
nausea, vomiting
hoarseness.
Mallory-Weiss Syndrome
It is massive upper gastrointestinal hemorrhage caused by a tear through the mucosa of the
distal esophagus or gastroesophageal junction.
Symptoms:
Hematemesis
DIAGNOSIS:
Upper endoscopy is diagnostic.
Treatment:
• Endoscopic injection of epinephrine may be therapeutic if bleeding does not stop
spontaneously.
• Only occasionally will surgery be required to stop blood loss. The procedure consists of
laparotomy and high gastrotomy with oversewing of the linear tear.
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Pancreatitis
Acute Pancreatitis Chronic Pancreatitis

Symptoms: • Epigastric pain radiating to the back • Epigastric and/or back pain.
• Nausea • Malabsorption/malnutrition
• Vomiting • Steatorrhea – fat-soluble vitamin
deficiency.
• Type 1 diabetes mellitus
• Polyuria.
Diagnosis: • Abdominal x-ray: Sentinel loop sign • History.
and colon cutoff sign. • Fecal fat analysis.
• Ultrasound: May demonstrate • X-ray (kidneys, ureters, bladder):
pseudocysts, phlegmon, abscesses Pancreatic calcifications.
or cholelithiasis. • ERCP: Chain-of-lakes pattern—ductal
• Computed tomographic (CT) scan: irregularities with dilation and stenosis.
Diagnostic test of choice (90% • CT: Pseudocysts (see Figure 14-3) (use
sensitive and 100% specific). ultrasound for follow-up of pseudocysts).
Demonstrates pseudocysts, Gland enlargement/atrophy,
phlegmon, abscesses or pancreatic calcifications, masses also seen on CT.
necrosis (see Figure 14-2).
Lab Elevated lipase Amylase and lipase may present with normal
Elevated amylase (3 times) rang
Includes control of abdominal pain, endocrine

and exocrine insufficiency (insulin and
pancreatic enzyme therapy).
Surgical: • Infected necrosis of pancreas.
• Correction of associated biliary tract
disease: Gallstone pancreatitis
should be treated with early interval
cholecystectomy only after acute
pancreatic inflammation has
resolved. Acutely, ERCP with
endoscopic sphincterotomy may be
used to relieve biliary obstruction.
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Gastrinoma = Zollinger-Ellison syndrome
→ Second most frequent islet cell tumor
Symptoms:
• Signs of peptic ulcer disease (especially in patients with recurrent or unusually located
ulcers).
• Epigastric pain most prominent after eating.
• Profuse watery diarrhea.
Diagnosis:
• Fasting serum gastrin level > 500 pg/mL
• Ulcers in unusual locations (e.g., third part of duodenum or jejunum) is highly suggestive.
• Octreotide scan to localize tumor.
Treatment:
• Proton pump inhibitor to alleviate symptoms.
• Surgical resection (curative or debulking).
• Chemotherapy.
Portal hypertension
→ Esophageal Varices
Treatment:
Splenorenal (Warren shunt): Connects the splenic vein to the left
renal vein. Used for patients with esophageal varices and a history of
bleeding.
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HCC presents all

Portal hypertension
Appendicitis
Liver abscess
Rectum cancer
Cholysitis
Splenic rupture
Cholecystitis
Stages of cell carcinoma
Peptic Ulcer
Melena
Vesicular bleeding (esophagus)
Zollinger-Ellison Syndrome
Patient had cholecystectomy 2 years ago , RUQ pain and jaundice and rigor attack what’s the
diagnosis?
1-HCC presentation , staging , treatment

2-colectomy types , hartmann precedure
3-fistula ano
4-laparoscopic hernia
1:presentation : Weight loss.

- Abdominal pain.
- Right upper quadrant mass, fever, rupture, ascites (sometimes).
Physical examination finding may include: jaundice, ascites, hepatomegaly, alcoholic stigmata,
asterixis, pedal edema, caput medusae.
staging : classified into three stages (I: not advanced; II: moderately advanced; III: very
advanced
2: -Total colectomy involves removing the entire colon.
-Partial colectomy involves removing part of the colon and may also be called subtotal
colectomy.
-Hemicolectomy involves removing the right or left portion of the colon.
-Proctocolectomy involves removing both the colon and rectum.
Hartmann's procedure is a type of colectomy that removes part of the colon and sometimes
rectum
3:fistula Ano : tunnel that develops between the inside of the anus and the outside skin around
the anus.
• Symptoms :
• skin irritation around the anus.
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• a constant, throbbing pain that may be worse when you sit down, move around,
poo or cough.
• smelly discharge from near your anus.
• passing pus or blood when you poo.
• swelling and redness around your anus and a high temperature if you also have
an abscess.
Treatment: fistulotomy
4: performed with general anesthesia and requires use of a breathing tube. Three half-inch or
smaller incisions are made in the lower part of the abdomen. In laparoscopic hernia repair, a
camera called a laparoscope is inserted into the abdomen to visualize the hernia defect on a
monitor.
Tipp + tapp

Anal fissures:
Zolinger syndrome /
Acute pancreatitis /
HCC stages treatments /
Gallstones /
Spleen rupture : presention treatment /
Esophagus
Fundoplication types /
Rectal cancer stages treatments complications 4 procedures upper lower interior resection —-
Quen wiles procedure /
HCC treatment :
Liver transplant/resection / radifrequency ablation-microwave-ethanol ablation / TACE/TARE
Fundoplication
: create new anti reflux valve - only fungus should be used
Nissen = 360 around lower esophagus for 4-5cm
Toupet =270 gastric fundoplication around distal 4cm of esophagus
Dor = 180 partial fundoplication
Colorectal cancer
Staging : TNM
T= primary tumor
N= regional lymph nodes
M= distant metastasis
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Anal fissure
= tear in anal causing pain with defecation
Treatment : if acute (6 weeks ) no treatment just high fiber and fluid it will resolve
If symp persist : nitroglycerin ( causes relaxation of internal and external sphincters ) +
botulinum toxin (treat muscle spasm ) + anasthetic cream +BP medications
If chronic: lateral internal sphincterotomy (LIS), which involves cutting a small portion of the
anal sphincter muscle to reduce spasm and pain, and promote healing.
He had cholecystectomy 2 years ago , RUQ pain and jaundice and rigor attack what’s the
diagnosis?
1-HCC presentation , staging , treatment

2-colectomy types , hartmann precedure
3-fistula ano
4-laparoscopic hernia
Qunu miles : abdominoperineal resection of the rectum
Intussusception is a serious condition in which part of the intestine slides into an adjacent part
of the intestine
laproscopic hernia→ tep and tapp
Markes Meckel’s Diverticulum → Diverticulitis

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Ahmad Salh Soboh

Movement: Elbow joint is flexed at 40 degrees of flexion. Further flexion up to 60 degree

1. What is the possible diagnosis of this condition?

• Intramedullary pin fixation:

• Open reduction with plate fixation

5. Nerve injury, ulnar non-union, and compartment syndrome.

27 years old male

1. What is the possible diagnosis of this condition?

10 years old male

1. What is the possible diagnosis of this condition?

1. Distal humerus fracture

4. In this case we pediatric case so we should to check if there is Comminuted fracture

1. What is this possible diagnosis of this condition?

1. Humerus mid shaft fracture with nerve injury

3. Non operative = closed reduction, casting. operative = intermedullary nailing, external

40 years old male

1. What is the possible diagnosis of this condition?

1. Non-union fracture shaft of humerus

2. Osteoporosis, obesity, alcohol, smoking.

4. Plate fixation, Intramedullary (IM) nailing

5. Complications of surgical treatment:

45 years old female

1. What is the most likely diagnosis?

1. Proximal humerus fracture.

3. Open Reduction Internal Fixation (ORIF)

4. Axillary Artery → Circumflex humeral (ascending, anterior and posterior)

5. Osteonecrosis, nonunion, and malunion of the tuberosities causing rotator cuff

1. What is this possible diagnosis of this condition?

1. Septic arthritis of the shoulder

4. Septic arthritis, Rheumatoid arthritis, Tuberculous arthritis, reactive arthritis, drug

5. IV fluid, analgesics, antibiotics, splintage, surgical daring.

30 years old male

1. What other investigations will you perform?

2. Acromio-Clavicular (AC) joint dislocation

4. Conservative, Operative, may need distal clavicle excision ± WeaverDunn (modified) by

5. Nonunion, skin injury, neurovascular injury, decrease Range of motion

25 years old male

1. Which soft tissue determines the stability of this joint?

1. Stability determined by strong soft tissue:

2. Sterno Clavicular (SC) joint dislocation

3. SC joint dislocation types:

- Achieve early reduction, ˂ 4 days

5. Posterior dislocation complications:

20 years old man

1. What are the risk factors of malunion clavicle fracture?

1. Shortness of bone or angulation fracture, DM, smoking.

2. Operative treatment. The only way to prevent a malunion in a dislocated midshaft

4. Malunion clavicle fracture

5. Malunted clavicle fracture

24 years old male

1. What is the possible diagnosis of this condition?

2. Risk factors are:

50 years old female

1. What is the possible diagnosis of this condition?

2. Common types of hip dislocation:

4. CT in all cases after reduction

◦ Hip in abduction and external rotation (ER) in anterior dislocation

29 years old male

1. What is the possible diagnosis of this condition?

1. Unreduced anterior dislocation of hip.

3. Closed reduction - allis/bigelow/stimson methods.

Hip in abduction and external rotation (ER) in anterior dislocation

1. What is the possible diagnosis of this condition?