Republic of Rwanda

Ministry of Health
P. O. Box 84 Kigali
www.moh.gov.rw

Surgery
C l i n i c a l Tr e a t m e n t G u i d e l i n e s

September 2012

Surgery Clinical Treatment Guidelines 1

 Republic of Rwanda

Ministry of Health
P. O. Box 84 Kigali
www.moh.gov.rw

Surgery
C l i n i c a l Tr e a tment G uidelines

September 2012

Surgery Clinical Treatment Guidelines 3

 Table of Contents

Acronyms...................................................................................................v
Foreword..................................................................................................vii
1. Orthopaedic Surgery.............................................................................1
1.1. Upper Limbs Fractures............................................................................4
1.1.1. Distal Radius & Ulna fractures ...........................................4
1.1.2. Forearm Shaft Fractures.........................................................5
1.1.3. Distal Humerus Fractures.....................................................7
1.1.4. Humeral Shaft Fracture.........................................................9
1.1.5. Fractures of Proximal Humerus...........................................10
1.1.6. Tuberosity Fractures..............................................................10
1.1.7. Clavicle Fractures..................................................................11
1.1.8. Scapula Fractures..................................................................12

1.2. Pelvic and Lower Limb Fractures.........................................................13

1.2.1. Pelvic Ring Disruption.........................................................13
1.2.2. Fractures of the Acetabulum................................................16
1.2.3. Trochanteric Fractures.........................................................18
1.2.4. Femoral Neck Fractures.......................................................19
1.2.5. Femoral Shaft Fractures........................................................20
1.2.6. Distal Femur Fractures.........................................................20
1.2.7. Patellar Injuries......................................................................21
1.2.8. Proximal Tibia Fractures......................................................22
1.2.9. Tibia-Fibula Fractures..........................................................23
1.2.10. Fractures of the Distal end of the Tibia..............................24

1.3. Foot fractures.........................................................................................25

1.3.1. Ankle Fractures.....................................................................25
1.3.2. Calcaneus Fractures..............................................................27
1.3.3. Talus Fractures.......................................................................29
1.3.4. Midfoot Fractures..................................................................31
1.3.5. Fore-Foot Fractures..............................................................31
1.3.6. Fractures of the Phalanges of the Toes...............................32
1.3.7. Fracture of the Sesamoids of the Great Toe.......................32

1.4. Fractures in Children.............................................................................33

1.4.1. Epiphyseal Fracture..............................................................33
1.4.2. Supracondylar Fracture of Humerus..................................33

Surgery Clinical Treatment Guidelines iii

 1.4.3. Radial Neck Fracture............................................................35
1.4.4. Forearm Fracture..................................................................35
1.4.5. Pelvic and Lower Limb Fractures........................................35

1.5. Open Fractures......................................................................................36

1.6. Critical care............................................................................................38
1.6.1. Critical Care Severe Traumatic Brain Injury.....................38
1.6.2. Critical Care of Multiple Injuries........................................41

1.7. Dislocations...........................................................................................43
1.7.1. General Consideration.........................................................43
1.7.2. Acromio-Clavicular Joint Dislocation...............................44
1.7.3. Shoulder Dislocations...........................................................45
1.7.4. Elbow Dislocation.................................................................47
1.7.5. Hip Dislocation.....................................................................48
1.7.6. Traumatic Knee dislocation.................................................50
1.7.7. Patellar Dislocation...............................................................52

1.8. Surgical Infections.................................................................................54

1.8.1. Septic Arthritis......................................................................54
1.8.2. Acute Osteomyelitis..............................................................57
1.8.3. Chronic Osteomyelitis..........................................................60

1.9. Hand Surgery.........................................................................................61

1.9.1. Fracture of Wrist Bones.......................................................61
1.9.2. Fracture of the Scaphoid Bone............................................61
1.9.3. Perilunate Dislocation and Perilunate Fracture
Dislocation.............................................................................63
1.9.4. Other Wrist Bone Fractures.................................................64
1.9.5. Metacarpal Fractures............................................................64
1.9.6. Bennetts and Rolandos Fractures.......................................65
1.9.7. Boxers Fracture.....................................................................66
1.9.8. Fractures of Phalanges..........................................................67
1.9.9. Distal Phalanges and Nail Bed Injuries..............................68
1.9.10. Dislocations of the Hand Joints..........................................69
1.9.11. Burns......................................................................................70
1.9.12. Infections...............................................................................70
1.9.13. Tendon Injuries......................................................................74
1.9.14. Nerve Injuries........................................................................75
1.9.15. Vessel Injuries........................................................................77
1.9.16. Skin Defects...........................................................................78

iv Surgery Clinical Treatment Guidelines

2. Neurosurgery........................................................................................79
2.1. Spinal Cord Injuries..............................................................................79
2.1.1. General Considerations.......................................................79
2.1.2. Spinal Fractures and Dislocation........................................81
2.1.3. Subaxial Spinal Injuries (from C3 C7)............................84
2.1.4. Spinal Cord Injury Without Radiographic Abnormality
(SCIWORA)...........................................................................85
2.1.5. Thoracic Fractures................................................................86
2.1.6. Thoracolumbar Fracture......................................................87
2.1.7. Cauda Equina........................................................................90

2.2. Cerebral Vascular Diseases (Spontaneous Haemorrhage)................91

2.2.1. Intracerebral Hemorrhage...................................................91
2.2.2. Subarachnoid Hemorrhage.................................................93

2.3. CNS Infections and Infestations.........................................................95

2.3.1. Brain Abscess........................................................................95
2.3.2. Cranial Subdural Empyema................................................96
2.3.3. Neuro Cysticercosis..............................................................97

2.4. Hydrocephalus in Children..................................................................98

2.5. Myelomeningocele...............................................................................99
2.6. Head Injury..........................................................................................100
2.6.1. Acute Subdural Hematoma................................................104
2.6.2. Chronic Subdural Hematoma...........................................104
2.6.3. Epidural Hematoma...........................................................105
2.6.4. Intracranial Hematoma.....................................................106

3. Cardio Thoracic Surgery.....................................................................109

3.1 Chest Trauma.......................................................................................109
3.1.1. Simple Rib Fracture.............................................................109
3.1.2. Flail Chest............................................................................110
3.1.3. Pneumothorax....................................................................111
3.1.4. Haemothorax......................................................................112
3.1.5. Cardiac Tamponade............................................................113
3.1.6. Lung Contusion...................................................................113
3.1.7. Ruptured Diaphragm.........................................................114

Surgery Clinical Treatment Guidelines v

 3.2 Lung Conditions.................................................................................115
3.2.1. Empyema Thoracis.............................................................115
3.2.2. Lung Abcess.........................................................................116
3.2.3. Pulmonary Fibrosis and Bronchectasis............................117
3.2.4. Lung Cancer.........................................................................118
3.2.5. Foreign Bodies in the Lung...............................................119
3.3. Mediastinum Masses...........................................................................120
3.4. Congenital Diaphragmatic Hernias..................................................121

4. Abdominal Injuries............................................................................123
4.1. Specific Injuries ...................................................................................125
4.1.1. Splenic Injury.......................................................................125
4.1.2. Hepatic Injury.....................................................................125
4.1.3. Pancreatic Injury.................................................................126
4.1.4. Duodenal Injury..................................................................127
4.1.5. Small Bowel Injury..............................................................127
4.1.6. Colon Injury........................................................................128
4.1.7. Rectal Injury........................................................................128

5. Disorders of Gastro-Intestinal System..............................................129

5.1. Disorders of the Oesophagus..............................................................129
5.1.1. Oesophagial Atresia...........................................................129
5.1.2. Achalasia..............................................................................130
5.1.3. Gastroesophagial Reflux Disease......................................131
5.1.4. Esophageal Cancer..............................................................132
5.1.5. Esophageal Spasm..............................................................133
5.1.6. Perforation of Oesophagus................................................134
5.1.7. Hiatus Hernia......................................................................136

5.2. Acute Abdomen...................................................................................137

5.3. Peritonitis.............................................................................................139
5.4. Intestinal Obstruction........................................................................141
5.4.1. Appendicitis........................................................................144
5.4.2. Appendiceal Mass and Abscess.........................................145
5.4.3. Gall Stones...........................................................................147
5.4.4. Acute Cholecystitis.............................................................148
5.4.5. Jaundice................................................................................149
5.4.6. Gastric Outlet Obstruction................................................151

vi Surgery Clinical Treatment Guidelines

6. Disorders of the Colon and Rectum..................................................153
6.1. Colo-Rectal Cancer.............................................................................153
6.2. Rectal Bleeding....................................................................................154
6.3. Haemorrhoids.....................................................................................155
6.4. Perianal Abscess...................................................................................156
6.5. Fistula in Ano......................................................................................158
6.6. Carcinoma of Anus.............................................................................159
6.7. Acute Pancreatitis...............................................................................160
6.8. Chronic Pancreatitis...........................................................................162

7. Genito-Urinary Disorders..................................................................163
7.1. Traumatic Disorders...........................................................................163
7.1.1. Renal Injuries.......................................................................163
7.1.2. Ureter Injury........................................................................164
7.1.3. Bladder Injury......................................................................165
7.1.4. Urethral Injury.....................................................................166
7.1.5. Testicular Injury...................................................................166

7.2. Non Traumatic Disorders...................................................................167

7.2.1. Urinary Tract Infections (UTI).........................................167
7.2.2. Hematuria............................................................................169

7.3. Testicular and Scrotal Disorders.......................................................170

7.3.1. Testicular Torsion...............................................................170
7.3.2. Fournier Gangrene.............................................................171
7.3.3. Testicular Cancer................................................................172
7.3.4. Hydrocele.............................................................................173
7.3.5. Undescended Testis............................................................174
7.3.6. Varicocele.............................................................................175

7.4. Disorders of the Penis.........................................................................176

7.4.1. Priapism...............................................................................176
7.4.2. Paraphymosis......................................................................177
7.4.3. Phymosis..............................................................................177
7.4.4. Hypospadias........................................................................178
7.4.5. Carcinoma of the Penis......................................................179
7.4.6. Impotence............................................................................180

7.5. Disorders of the Urethra....................................................................182

7.5.1. Urethra Meatal Stenosis.....................................................182

Surgery Clinical Treatment Guidelines vii

 7.6. Disorders of the Prostate....................................................................183
7.6.1. Benign Prostatic Hyperplasia (BPH)...............................183
7.6.2. Prostatic Cancer..................................................................184

7.7. Disorders of the Urinary Bladder.....................................................185

7.7.1. Bladder Calculi/Stones.......................................................185
7.7.2. Bladder Cancer....................................................................186
7.7.3. Cystocele..............................................................................188
7.7.4. Urinary Incontinence.........................................................190

7.8. Disorders of the Kidney and the Ureter.............................................192

7.8.1. Vesico-Ureteric Reflux........................................................192
7.8.2. Calculus................................................................................193
7.8.3. Renal Cell Carcinoma........................................................194
7.8.4. Nephroblastoma or Wilms Tumors..................................194
7.8.5. Pelvi-Ureteric Junctions.....................................................195
7.8.6. Tumors of the Renal Pelvis and Ureter.............................196
7.8.7. Urine Retention...................................................................197
7.8.8. Vesicovaginal Fistula..........................................................198

7.9. Neonatal Obstructive Uropathies......................................................199

7.9.1. Posterior Urethral Valves...................................................199
7.9.2. Urethral Stricture................................................................200

7.10. Non Traumatic Urological Conditions...........................................200

7.10.1. Benign Prostatic Hyperplasia (BPH)...............................200
7.10.2. Adenocarcinoma.................................................................201
7.10.3. Bladder Cancer....................................................................202
7.10.4. Renal Cell Carcinoma........................................................204

8. Burns...................................................................................................207
8.1. Electrical Burns...................................................................................210

9. Bites and Stings of Animals and Insects............................................213

9.1. Animal Bites.........................................................................................213
9.2. Rabies....................................................................................................214
9.3. Snakebites and Venom........................................................................215
9.4. Insect Stings.........................................................................................220
9.5. Spider Bites...........................................................................................222

10. References.........................................................................................223
List of participants.................................................................................227

viii Surgery Clinical Treatment Guidelines

 Acronyms

ABG : Arterial Blood Gas

AO : Arterial Oxygen
ARDS : Acute Respiratory Distress Syndrome
BPH : Benign Prostatic Hyperplasia
CBC : Complete Blood Count
CPK : Creatine Phospho Kinase
CPP : Cerebral Perfusion Pressure
CSF : Cerebral Spinal Fluids
CT : Computed Tomographic
CVP : Central Venous Pressure
DCS : Dynamic Compression Screws
DHS : Dynamic Hip Screw
DRE : Digital Rectal Exam
DRUJ : Distal Radio-Ulna Joint
DRUJ : Distal Radioulnar Joint
DVT : Deep Venous Thrombosis
ECG : Electrocardiogram
ERCP : Endoscopic Retrograde Cholangio- Pancreatography
FBC : Full Blood count
GA : General Anesthesia
GIT : Gastrointestinal Truct
GTN : Glyceryl Trinitrate
HCL : Hydrochloric
ICP : Intra Cranial Pressure
ICU : Intensive Care Unit
IVC : Inferior Vena Cava
IVP : Intra Venous Pressure
LC-DCP : Limited Contact -Dynamic Compression Plate
LISS : Less Invasive Stabilization
LMWH : Low Molecular Weight Heparin
LoC : Level of Consciousness
MIPO : Minimally Invasive Plate Osteosynthesis
MRI : Magnetic Resonance Imaging
NGT : Naso-Gastric Tube
ORIF : Open Reduction and Internal Fixation
PSA : Prostate-Specific Antigen
PT : Prothrombin Time
PTT : Partial Thromboplastin Time

Surgery Clinical Treatment Guidelines ix

PUD : Peptic Ulcer Disease
HCG : Human Chorionic Gonadotropin
TARPO : Retrograde Plate Osteosynthesis
TBSA : Total Burn Surface Area
TIG : Tetanus Immunoglobulin
TRUS : Transrectal ultrasound
TURP : Trans-Urethral resection prostate
UA : Urinary Analysis
US : Ultrasound
VF : Vaginal Fistula
WBC : White Blood cells

x Surgery Clinical Treatment Guidelines

 Foreword

T
he guidelines and protocols presented in this document are designed
to provide a useful resource for healthcare professionals involved in
clinical case management in Rwanda. They were developed by taking
into consideration services provided at different levels within the health
system and the resources available, and are intended to standardize care at
both the secondary and tertiary levels of service delivery across different
socio-economic levels of our society.

The clinical conditions included in this manual were selected based on

facility reports of high volume and high risk conditions treated in each
specialty area. The guidelines were developed through extensive consultative
work sessions, which included health experts and clinicians from different
specialties. The working group brought together current evidence-based
knowledge in an effort to provide the highest quality of healthcare to the
public. It is my strong hope that the use of these guidelines will greatly
contribute to improved the diagnosis, management, and treatment of
patients across Rwanda. And it is my sincere expectation that service
providers will adhere to these guidelines and protocols.

The Ministry of Health is grateful for the efforts of all those who contributed
in various ways to the development, review, and validation of the Clinical
Treatment Guidelines. We would like to thank our colleagues from District,
Referral, and University Teaching Hospitals, and specialized departments
within the Ministry of Health, our development partners, and private health
practitioners. We also thank the Rwanda Professional Societies in their
relevant areas of specialty for their contributions and for their technical
review, which enriched the content of this document, as well as the World
Health Organization (WHO) and the Belgium Technical Cooperation
(BTC) for their support.

We would like to especially thank the United States Agency for International
Development (USAID) for both their financial and technical support
through the Management Sciences for Health (MSH) Integrated Health
System Strengthening Project (IHSSP) and Systems for Improved Access to
Pharmaceuticals and Services (SIAPS).

To end with, we wish to express our sincere gratitude to all those who
continue to contribute to improving the quality of health care of the Rwanda
population.

Dr Agnes Binagwaho
Minister of Health

Surgery Clinical Treatment Guidelines xi

 1. Orthopaedic Surgery

GENERAL OVERVIEW OF FRACTURES

Definition: A fracture is a complete or non-complete disruption of

continuity of the bone tissue. Fractures can be classified as open or
closed fractures, and multi-fragmented or simple and displaced or
undisplaced.

Causes

- High energy trauma

- Motor vehicle accidents
- Sports injuries
- Fall from height
- Low energy trauma
- Simple fall
- Medical conditions

Signs and symptoms

- Pain
- Swelling
- Wounds
- Deformity
- Tenderness
- Inability to move
- Possibility of neurovascular deficit

General Investigations

- Blood tests: Full Blood Count, Blood Group, PT, PTT and
specific tests depending on patient condition and past medical
history
- X-ray
- Ultrasound, CT-Scan, MRI as indicated

General management of fractures

- Assessment consists of four overlapping phases namely:

- Primary survey (ABCDE)
- Resuscitation
- Secondary survey
- Definitive care

Surgery Clinical Treatment Guidelines 1

Chapiter 1: Orthopaedic Surgery

Primary survey (ABCDE) and resuscitation

- This process identifies and treats life-threatening conditions as

per ATLS (Advanced Trauma Life Support) protocols:
Airway maintenance (with cervical spine protection)
The airways should be rapidly assessed for signs of
obstruction, foreign bodies and facial, mandibular, or
tracheal/laryngeal fractures. A chin lift or jaw thrust
manoeuvre should be used to establish an airway
Breathing and ventilation

Any four of the following conditions if present, should be

addressed as an emergency
- Tension pneumothorax
- Flail chest
- Pulmonary contusion
- Open pneumothorax
- Massive hemothorax
- Cardiac temponade
- Circulation (with hemorrhage control), monitor vital signs:
- Blood Pressure
- Pulse Rate
- Heart Rate
- Respiratory Rate
- Oxygen saturation

Secondary survey (history and head-to-toe evaluation)

- Identify life threatening injuries using the Glasgow Coma Scale:
- Alert and oriented
- Vocal stimuli
- Painful stimuli
Unresponsive
- A Glasgow Coma Scale of 8 or less is an indication for the
placement of a definitive airway (e.g. intubation). If patient has
tension pneumothorax, flail chest, pulmonary contusion, open
pneumothorax, massive hemothorax, cardiac temponate must be
addressed as emergencies.
Abdomen (Refer to abdominal trauma management)
Spine (Refer to spine injury management)
Disability: Exposure of the whole body, ensure
environmental safety and avoid hypothermia
Complete examination of skeletal, soft tissue injuries and
distal neurovascular status

2 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Open injuries evaluation

Surgery
Orthopaedic
Definitive care
An open fracture is when disruption of the skin and
underlying soft tissue results in communication between
the fracture and the outside environment.

Severity assessment (Gustilo-Anderson classification)

- Grade I: The wound is less than 1cm long. It is usually a

moderately clean puncture (from inside-out).
- Grade II: The laceration is more than 1 cm long, and there is
no extensive soft-tissue damage. There is a slight or moderate
crushing injury, moderate comminution of the fracture, and
moderate contamination.
- Grade III: These are characterized by extensive damage to soft-
tissues, including muscles, skin, and neurovascular structures,
and a high degree of contamination (Bone is exposed).
III A: Bone is exposed but there is no periosteal stripping
III B: Bone is exposed but there is periosteal stripping
III C: There is association of vascular injury that requires
repair

Management

- Initial management
- Adequate wound care and immobilization
- Drugs therapy (VAT, SAT, analgesics, antibiotics)
- DVT prophylaxis if indicated
- Antibiotic: The choice of antibiotic to be used depends on the
Fracture type and the likely contamination of the fracture site.
- Grade 1: 1st generation cephalosporin
- Grade 2: 1st generation cephalosporin + or an aminoglycoside
depending on the level of wound contamination.
- Grade 3: 1st generation cephalosporin and an aminoglocoside
- All forms of injuries are treated as Grade 3 with addition of
penicillin to cover for staphylococcal infection

Surgical debridement and irrigation

- Surgical debridement should be done in theatre after thorough

washing of the wound
- Debridement has been suggested to be done within 6 hours of injury

Note: For gustillo type III: External fixation is the golden standard
form of fracture fixation and stabilisation

Surgery Clinical Treatment Guidelines 3

Chapiter 1: Orthopaedic Surgery

SPECIFIC FRACTURES

1.1. Upper Limb Fractures

1.1.1. Distal Radius & Ulna Fractures

Fracture Classification

No one fracture classification system is comprehensive in describing

all important variables of distal radius fractures. Based on AO
classification, distal radius fractures are divided into three groups:
- Type A: Extraarticular
- Type B: Partial articular
- Type C: Complete articular

Management
Aim
To achieve anatomical reduction
Anatomical Criteria of reduction: AP and lateral x- ray views
Radial inclination 20-23 degrees,
Volar tilt 11 degrees to 12 degrees
Radial styloid length should be 1,5cm distal to ulnar styloid

Extraarticular nondisplaced fractures

Cast immobilization for 4-6 weeks, followed by
rehabilitation

Extraarticular displaced fractures

Non-operative treatment
Closed reduction and immobilization
Operative treatment is advocated if the reduction cannot
be achieved or maintained by closed means

Means of fracture fixation

- Pins (k-wires)
- Plates and screws
- External fixators

Intraarticular fractures (AO Type B and C)

- The treatment of intraarticular fractures aims at restoring the

congruity of the articular surface which can be done by:
- Closed (pins and cast, external fixators)
- Open means (plates and screws)

4 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
1.1.2. Forearm Shaft Fractures

Surgery
Orthopaedic
Definition: It is a disruption of the bone continuity located between the
distal and proximal epiphysis.

Isolated fracture of the Ulna, itis a disruption of the bone continuity

located between the distal and proximal epiphysis.

Management

- Nondisplaced or minimal displacement:

Long arm cast immobilization for 6 weeks
Cast removal is followed by physiotherapy
The time to union is about 3 months

- Displaced fractures (angulation> 10 degrees or displacement >

50%):
Open reduction and internal fixation with a 3.5 mm plate
Alternative implants: locked nail, flexible nail

- Isolated radial shaft fracture

Management

- Nondisplaced or minimal displacement

Long arm cast immobilization for 6 weeks
Cast removal followed by physiotherapy
The time to union is about 3 months

- Displaced fractures (angulation > 10 degrees or displacement >

50%)
Open reduction and internal fixation with a 3.5 mm plate
Alternative implants: locked nail, flexible nail

- Galeazzi fracture
It is a fracture of the radial diaphysis at the junction of the
middle and distal thirds with disruption of the distal radio-
ulna joint (DRUJ)

Surgery Clinical Treatment Guidelines 5

Chapiter 1: Orthopaedic Surgery

Management

- Open reduction through a Volar Henry approach and internal

fixation with plate fixation
- Distal radioulna joint examination
- DRUJ stable: immobilization in neutral /supination position (6 weeks)
- DRUJ unstable: pinning in a position of stability
- Dislocated and irriducible DRUJ: open stabilization with repair
of associated ligaments
- Monteggia Fracture

It is a fracture of proximal ulna associated with anterior radial head

dislocation

Management

- Children
Closed reduction and immobilization

- Adult
open reduction and internal fixation of the ulna plus closed
reduction of the radial head, followed by immobilization
for 3 weeks

Note:
- If closed reduction is not achievable, open reduction is required.
Attention should be paid to the relationship between the annular
ligament, the lateral epicondyle, and the radial head.
- Entrapment of the soft tissues is the most common reason for
inability to obtain concomitant closed radial head reduction at
the time of open reduction and internal fixation of the ulna.
- Fractures of both the Radius & Ulna, are usually the result
of high-energy injuries. These fractures are usually displaced
because of the force required to produce such an injury

6 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Management

Surgery
Orthopaedic
Undisplaced fracture (VERY RARE)
Immobilization with long arm cast for 6 weeks with early
digital active and passive motion exercises.

Displaced fracture
Open reduction and internal fixation with plate.
(Alternative implants: intramedullary nails, flexible nails,
pins)

Note: Bone grafting can be used for severely comminuted fractures

with significant bone loss.

1.1.3. Distal Humerus Fractures

INTERCONDYLAR FRACTURES

Classification (Rise-borough and Radin)

There are four types namely

- Type I: Undisplaced fracture between the capitellum and
trochlea
- Type II: Separation of the capitellum and trochlea without
appreciable rotation of fragments in the frontal plane
- Type III: Separation of the fragments with rotator deformity
- Type IV: Severe comminution of the articular surface with wide
separation of the humeral condyle

Management
- Type I: Conservative treatment
- Type II &III: Open Reduction and Internal Fixation (ORIF)
- Type IV: Young patients: Bone reconstruction and grafting of
articular defects
- Elderly patients (osteopenic bone): Transolecranon traction or
total elbow arthroplasty

FRACTURE OF THE EPICONDYLES

- Treatment depends on the amount of displacement
If displacement is minimal, then closed reduction is
appropriate
A displaced fracture may require open reduction and screw
fixation

Surgery Clinical Treatment Guidelines 7

Chapiter 1: Orthopaedic Surgery

OLECRANON FRACTURES

Fracture of the olecranon commonly occurs with a direct blow or as an

avulsion injury with triceps contracture.

Management

- None displaced fractures, or fractures with <2 mm displacement:

immobilization with the elbow in 45-90 degrees of flexion for 3
weeks (7-10 days in back slab and 2weeks with a long arm cast).
- Displaced fractures: ORIF
The optimal method for treating this fracture is tension
banding with two longitudinal K-wires placed across the
fracture site and stabilized with a figure-of-8 wire loop
More oblique fractures can be treated with
interfragmentary screws with a neutralization plate
If the articular surface is significantly comminuted, a low-
profile, limited contact compression plate can be applied to
the dorsal surface of the ulna

All these treatments can generally be accompanied with early protected

range-of-motion exercises.

FRACTURE OF THE RADIAL HEAD

Radial head fractures are generally caused by longitudinal loading from
a fall on an outstretched hand; dislocation of the elbow is another cause.

Classification
- Mason proposed a classification scheme for radial head fractures
Type I is a nondisplaced fracture
Type II is a fracture that is displaced usually involving a
single large fragment
Type III is a comminuted fracture
Type IV is a fracture associated with an elbow dislocation

Management

- Type I: Non-operative treatment with early motion

- Type II:
Displacement less than 2 mm step-off : non surgical
treatment
Displacement more than 2mm step-off: ORIF; open
reduction and internal fixation can be performed with pins
or articular screws

8 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
- Type III: Early radial head excision/arthroplasty

Surgery
Orthopaedic
- Type IV: Reduction of elbow dislocation and excision if
comminuted fracture/retain and fix radial head if no comminution

CAPITELLAR FRACTURES

Classification

- Type I: Hahn-SteinthalI: Osteochondral injury or complete fracture

- Type II: Kocher-Lorenz: Articular-cartilage-only injury
- Type III: Hahn-Steinthal II: Comminuted fracture or a fracture
line extending into the trochlea. CT reconstructions are useful to
further delineate the fracture and for surgical planning.

Management

- Open reduction and internal fixation with K-wire or articular screws

1.1.4. Humeral Shaft Fracture

Management

Non-operative methods
Cast immobilization (shoulder spica, U-slab, Sarmiento
cylinder cast etc.) leads to good results with high union rates.
Operative treatment
Special circumstances may merit open reduction and
fixation
Selected segmental fractures
Inadequate closed reduction
Floating elbow
Bilateral humeral fractures
Open fractures
Multiple trauma
Pathologic fractures
Humerus fracture with associated vascular injuries
requiring exploration may benefit from internal fixation

- There are two general forms of internal fixation namely

Compression plate and screw fixation
Intramedullary nailing: especially useful in osteopenic
bone, segmental and external fixator if contaminated open
fractures

Note: Be aware of radial nerve injury

Surgery Clinical Treatment Guidelines 9

Chapiter 1: Orthopaedic Surgery

1.1.5. Fractures of Proximal Humerus

Classification (Duparc and Neer)

Fractures are classified by the number of parts that are displaced more
than 1 cm or angulated more than 45 degrees.
- Two part fractures
Anatomic neck fracture
Tuberosity fracture
Surgical neck fracture

- Three part fractures

- Four part fractures

Management

Non displaced fractures (85%)

Non-operative treatment with an arm sling or shoulder
immobilizer
Early mobilization

Displaced fractures: operative treatment

Two part fractures with anatomic neck fractures:
Young patients: ORIF (pins /screws)
Elderly patients: Hemi-arthroplasty

Note:
- Closed reduction is difficult because of controlling the articular
fragment
- High risk of avascular necrosis of the humeral head

1.1.6. Tuberosity Fractures

GREATER TUBEROSITY
- Attempt closed reduction and immobilization
- If irreducible fracture: ORIF (pins /screws)
- If associated with shoulder dislocation:
Simple reduction of the dislocation may reduce the
tuberosity fracture
If not: ORIF

10 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
LESSER TUBEROSITY

Surgery
Orthopaedic
- If small fragment, closed reduction
- If larger fragments: ORIF

SURGICAL NECK FRACTURE

- Impacted fracture with < 450 angulation: Sling immobilization
plus early mobilization
- Displaced, unstable, or fracture >450 angulation:
Closed Reduction and percutaneous pinning or
intramedullar pinning under fluoroscopic control
If the closed reduction fails: ORIF (plates and screws)

THREE PARTS FRACTURES

- Open reduction and internal fixation (plates and screws)
- Hemiarthroplasty should be considered in the elderly

FOUR PART FRACTURES

- Open reduction and internal fixation
- Hemiarthroplasty in elderly, particularly because the avascular
necrosis rate may be as high as 90% and the bone is usually
osteoporotic
- Repair of any rotator cuff defects is necessary to prevent proximal
migration of the humeral component as well as loss of rotator
cuff power
- Early post-operative rehabilitation

1.1.7. Clavicle Fractures

Classification (Allman)

- Type I: Fracture of the middle third (80%)

- Type II: Fracture of the distal third (15%)
- Type III: Medial clavicle fractures (close to the sternum) (5%)

Management
- Non-operative treatment (arm sling, figure-of-eight brace or
universal shoulder immobilizer)

Surgery Clinical Treatment Guidelines 11

Chapiter 1: Orthopaedic Surgery

Indications of operative treatment (ORIF)

- Clavicle fracture associated with neurovascular injury

- Floating shoulder
- Open fracture
- Bilateral clavicle fractures
- Threatened underlying skin

1.1.8. Scapula Fractures

Classification (AO/OTA)

- Type A: Extraarticular
- Type B: Body of scapula fracture
- Type C: Intraarticular glenoid fracture

Management

Non-operative treatments
Sling use and early range of motion

Operative treatment indication

Displaced intraarticular fracture involving more than 25%
of the articular surface
Scapula neck fracture with greater than 400 angulation or
1cm medial translation
Scapula neck fracture with associated displaced clavicle
fracture
Fracture of the acromion that impinge on the subacromial
space
Fracture of the coronoid process that result in a functional
acromio-clavicular separation
Comminuted fracture of the scapula spine

12 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
1.2. Pelvic and lower limbs fractures

Surgery
Orthopaedic
1.2.1. Pelvic Ring Disruption

Classification (Tile)

Clinical and radiological evaluation of the pelvis based on identification

of the grade of stability or instability, this is the platform for further
decision-making.
- Type A: Stable pelvic ring injury (50-70%)
A1: Avulsion of the innominate bone
A2: Stable iliac wing fracture or stable minimally displaced
ring fractures
A3: Transverse fractures of the sacrum and the coccyx

- Type B: Partially stable (20-30%) rotationally unstable, vertically

stable
B1: Open book injury
B2: The lateral compression injury
B3: Bilateral B injuries

- Type C: Unstable (10-20%) both rotationally and vertically

unstable
C1: Unilateral
C2: Bilateral, one side B one side C
C3: Bilateral C lesions

Surgery Clinical Treatment Guidelines 13

Chapiter 1: Orthopaedic Surgery

Management

After rapid resuscitation, complete assessment of the personality of the

injury including stability of the ring. The decision on whether or not to
operate can be based on the fracture types:

PELVIC RING STABLE (TYPE A OR B)

After rapid resuscitation, assess of personality of injury including stability of the ring

PELVIC RING STABLE (Type A or B)

Minimal displacement significant displacement

Symptomatic treatment Assess type of injury

Open book injury with intact posterior Lateral compression with

ligaments, unilateral (B 1) impaction, in ward rotation or
or bilateral (B3) upward rotation and shortening

Closing reduction by closing the Closed reduction by external rotation

book .
Maintain reduction Maintain reduction

Anterior external fixation or open

Reduction internal fixation with symphyseal plates

Bed rest; symptomatic care Anterior external fixation (polytrauma)

Anterior symphis or anterior open

reduction and internal fixation for
locked symphysis, tilt fracture; etc

14 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
PELVIC RING UNSTABLE (TYPE C)

Surgery
Orthopaedic
Unstable pelvic ring fracture (Type C)

Immediate management (The first day)

Rapid general resuscitation, application of external frame plus skeletal

traction or a pelvic clamp, especially for patients in shock

Early management (The first week)

Reassessment of skeletal injury (special radiographic views, CT)

Symphysis pubis disrupted Pubic rami fractured

Internal fixation of symphysis (dual Assessment of posterior

plates) plus external frame or lesion
internal fixation of posterior lesion

Posterior satisfactory
Position unsatisfactory or
polytrauma or open fracture
Continue external fixation plus
traction

Anterior open reduction Posterior open reduction and

plus internal fixation of
internal fixation
superior pubic rami (for
wide displacement)

Surgery Clinical Treatment Guidelines 15

Chapiter 1: Orthopaedic Surgery

1.2.2. Fractures of the Acetabulum

Classification (Letournel)
- Type A: Partial articular fractures, one column involved
A1: posterior wall fracture
A2: posterior column fracture
A3: anterior wall or anterior column fracture

- Type B : Partial articular fractures (transverse or T type fracture,

both columns involved)
B1: transverse fracture
B2: T-shaped fracture
B3: anterior column plus posterior hemitransverse fracture

- Type C: Complete articular fracture (both column fracture,

floating acetabulum)
C1: Both column fracture, high variety
C2: Both column fracture, low variety
C3: Both column fracture involving the sacro-iliac joint

16 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Management

Surgery
Orthopaedic
The goal of treatment is to attain a spherical congruency between the
femoral head and the weight-bearing acetabular dome, and to maintain
it until bones are healed.

Fracture of fumeral neck

Young patient Elderly patient

Stable fracture Unstable fracture

Garden I & II Garden III & IV

Ostesythesis with screws

within 6hrs in any type of
the fracture
Bed ridden Out patient

Osteosythesis with
screws

Necrosis or

Malunion Necrosis or

Malunion

Hip prosthesis or
osteotomy Hip prothesis

Surgery Clinical Treatment Guidelines 17

Chapiter 1: Orthopaedic Surgery

1.2.3. Trochanteric Fractures

ISOLATED LESSER TROCHANTER FRACTURE: (RARE)

A symptomatic non-union may require fragment fixation or excision.

ISOLATED GREATER TROCHANTER FRACTURE

Management
- Displacement less than 1 cm and no tendency toward further
displacement:
Bed rest until acute pain subsides
Activity can increase gradually to protected weight bearing
with crutches
Full weight bearing is permitted as soon as healing is
apparent, usually in 68 weeks
- Displacement greater than 1 cm and increases on adduction of
the thigh: ORIF

INTERTROCHANTERIC FRACTURES
These fractures usually occur along a line between the greater and the
lesser trochanter.

Classification (Boyd & Griffin)

- Type I: A single fracture along the intertrochanteric line
- Type II: Intertronchanteric line fractures with comminution
- Type III: Fracture at the level of the lesser tronchanter with
variable comminution and extension into the subtronchanteric
region (reverse obliquity)
- Type IV: Fracture extending into the proximal femoral shaft

Management
Initial treatment
Skin traction to minimize pain and further displacement

Definitive treatment
Depends upon the general condition of the patient and the
fracture pattern
Operative treatment within 48 hours is preferred
Reduction and internal fixation with sliding hip screw
(DHS, RSP etc.)
The patient can be taken out of bed the next day
Weight bearing with crutches or a walker is begun as soon
as pain allows

18 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
The fracture usually heals in 612 weeks

Surgery
Orthopaedic
Alternatives
Second-generation interlocked nails (PFN, IMHS, Gamma
nails etc.)

SUBTROCHANTERIC FRACTURES
Classification (Russell & Taylor)
- Type IA
Fractures do not involve the piriformis fossa
Lesser trochanter attached to the proximal fragment
- Type IB
Fractures do not involve the piriformis fossa
Lesser trochanter is detached from the proximal fragment
- Type II: Fractures have fracture extension into the piriformis
fossa

Management
- Type I: ORIF with cephalo-medullary nail (gamma nails,
intramedullary hip screws, PFN, Russel-Taylor and Trigen
reconstruction nails etc.)
- Type II: Is best treated with a sliding hip screw or fixed angle plate

1.2.4. Femoral Neck Fractures

Classification (Garden)
- Type 1: Valgus impaction of the femoral head
- Type 2: Complete but non displaced
- Type 3: Complete fracture, displaced less than 50%
- Type 4: Complete fracture displaced greater than 50%
This classification is of prognostic value for the incidence of avascular
necrosis: The higher the Garden number, the higher the incidence

Management
Initial treatment
Traction may offer comfort in some patients but do not
improve overall outcome

Definitive treatment
Internal fixation

Surgery Clinical Treatment Guidelines 19

Chapiter 1: Orthopaedic Surgery

1.2.5. Femoral Shaft Fractures

Classification (Winquist)
- Type 1: Fracture that involves no, or minimal, comminution at
the fracture site, and does not affect stability after intramedullary
nailing
- Type 2: Fracture with comminution leaving at least 50% of the
circumference of the two major fragments intact
- Type 3: Fracture with comminution of 50100% of the
circumference of the major fragments.
- Type 4: Fracture with completely comminuted segmental pattern
with no intrinsic stability

Management
Treatment depends upon the age and medical status of the patient as
well as the site and configuration of the fracture.
Conservative Treatment
Is rarely indicated
Operative Treatment
Interlocking intramedullary nailing is the Golden standard
treatment of femoral shaft fracture
Alternative Treatment
Non locked intramedullary nails (Kuntscher nail, flexible
nails, AO nails etc.), do not provide ideal stable fixation
Plates and screws: require significant soft-tissue dissection
and opening of the fracture hematoma and can be
associated with high rate of infection.
External fixation: remains indicated in some open fractures
and in polytrauma patients

1.2.6. Distal Femur Fractures

These fractures involve the distal metaphysis and epiphysis of the femur.

Classification (AO/OTA)

- Type A: Extraarticular
A1: Simple fracture
A2: Metaphyseal wedge fracture
A3: Metaphyseal complex fracture
- Type B: Unicondylar partial articular
B1: Lateral condylar fracture

20 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
B2: Medial condylar fracture

Surgery
Orthopaedic
B3: Frontal fracture
- Type C : Intercondylar/ bicondylar, complete articular
C1: Articular simple, metaphyseal simple
C2: Articular simple, metaphyseal complex
C3: Multifragmentary articular fracture

Management

EXTRAARTICULAR FRACTURES
Conservative treatment
Skeletal traction treatment is reserved for patients for
whom surgery is not possible due to comorbidities
Operative treatment
Retrograde intramedullary nailing
Plates and screws (blade plates, locking plates, sliding plates)
External fixator (Ilizarov frame etc.)

INTRAARTICULAR FRACTURES
- Maximal functional recovery of the knee joint requires anatomic
reduction of the articular components and restitution of the
mechanical axis
- Undisplaced intaarticular fractures: cast immobilization(6-8 weeks)
- Displaced intraarticular fractures usually require open reduction
and internal fixation with a variety of methods including:
- Dynamic Compression Screws (DCS)
- Plates and screws

1.2.7. Patellar Injuries

TRANSVERSE PATELLAR FRACTURE

Transverse fractures of the patella are the result of indirect force, usually
with the knee in flexion.

Management
Non displaced fractures
Walking cylinder cast or brace for 68 weeks followed by
knee rehabilitation.
Displaced fractures
Open reduction and immobilization by figure-of-eight
tension banding over two longitudinal parallel K-wires.

Surgery Clinical Treatment Guidelines 21

Chapiter 1: Orthopaedic Surgery

If the minor fragment is small (no more than 1 cm in

length) or severely comminuted, it may be excised and
the quadriceps or patellar tendon (depending upon which
pole of the patella is involved) sutured directly to the major
fragment.

COMMINUTED PATELLA FRACTURE

Comminuted fractures of the patella are usually caused by a direct force.

Management
Undisplaced or minimally displaced/ too comminuted to be fixed
Conservative treatment by cylinder cast immobilization for
6-8weeks
Severe displacement
Operative treatment by tension band wiring
Alternative: excision of the patella and repair of the defect
by imbrication of the quadriceps expansion

1.2.8. Proximal Tibia Fractures

TIBIAL PLATEAU FRACTURES

Classification (Schatzker)
- Type I: split fracture of the lateral plateau
- Type II: split-depression of the lateral plateau
- Type III: depression of the lateral plateau
- Type IV: medial plateau fracture
- Type V: bicondylar fracture
- Type VI: plateau fracture with metaphyseal-diaphyseal dissociation

Management
Conservative treatment: Cast immobilization
Articular step-off of 3 mm or less and condylar widening of
5 mm or less can be treated conservatively
Lateral or valgus tilt up to 5 degrees is well tolerated
Operative treatment
Medial plateau fractures with any significant displacement.
Articular step-off >3 mm
Bicondylar fractures with any medial displacement, valgus
tilt >5 degrees or with significant articular step-off

22 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Minimal invasive treatment

Surgery
Orthopaedic
Closed reduction under fluoroscopy plus percutaneous
pinning/screws
Minimally Invasive Plate Osteosynthesis (MIPO) and the
Less Invasive Stabilization Systems (LISS) are used in the
treatment of these injuries

Open reduction: ORIF with plates and screws

External fixation
Monolateral or ring fixator
Hybrid-Ring external fixators

Recommendations
- Bone defects should be grafted
- Early range of motion with weight bearing is allowed at 68
weeks

1.2.9. Tibia-Fibula Fractures

The Tibia has a subcutaneous anteromedial border and is bound to be
associated with significant soft tissue injury.

Classification (Tscherne and Oestern): classified as soft tissue injury

in ascending order of severity
- Grade 0: Soft-tissue damage is absent or negligible.
- Grade 1: There is a superficial abrasion or contusion caused by
fragment pressure from within.
- Grade 2: A deep contaminated abrasion is present associated
with localized skin or muscle contusion from direct trauma.
Impending Compartment Syndrome is included in this category.
- Grade 3: The skin is extensively contused or crushed and
muscular damage may be severe. Also, Compartment Syndrome
and rupture of a major blood vessel may be present.
Isolated Fibula Diaphysis Fractures: The isolated fibular
fracture usually heals independently of the form of treatment.
- Isolated Tibia Diaphyseal Fractures: There is a tendency for the
tibia to displace into varus angulation because of an intact fibula
- Fractures of both the tibia and fibula

Criteria for reduction of a tibial shaft fracture in adults

- Apposition of 50% or more of the diameter of the bone in both
anteroposterior and lateral projections
- Not more than 5 degrees of varus or valgus angulation

Surgery Clinical Treatment Guidelines 23

Chapiter 1: Orthopaedic Surgery

- Not more than 5 degrees of angulation in the anteroposterior

plane
- Not more than 10 degrees of rotation
- Not more than 1 cm of shortening

Management

The goal of treatment is to allow the fracture to heal in an acceptable

position with minimal negative effect on the surrounding tissues or
joints
Undisplaced fractures
Conservative treatment with a long leg cast
Displaced fractures
Reduction in emergency room
If acceptable and stable: long leg non-weightbearing
cast (6-8 weeks). At 6 weeks, some shaft fractures are
stable enough to be put in a short leg weight-bearing cast
(Sarmiento).
If unacceptable or unstable reduction: attempt reduction
under anesthesia
Reduction under anesthesia
If acceptable and stable: long leg non-weightbearing
cast (6-8 weeks). At 6 weeks, some shaft fractures are
stable enough to be put in a short leg weight-bearing cast
(Sarmiento).
If unsuccessful reduction by closed means: operative
treatment
Operative treatment
Intramedullary nailing (best with interlocking devices)
Alternative: plates and screws

1.2.10. Fractures of the Distal end of the Tibia

Also referred to as pilon or plafond fractures, these fractures involve

the distal articular surface of the tibia, the tibiotalar joint and usually
the shaft of the fibula.

Classification (Ruedi and Allgower):

- Type I: non displaced fracture with non significant articular
incongruity
- Type II: articular displacement less than 5mm
- Type III: Displaced and comminuted fracture with significant
articular comminution

24 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Management

Surgery
Orthopaedic
The goal of treatment is to restore an anatomic articular surface. This
can be difficult and sometimes impossible. Bone graft can be added to
metaphyseal defects to support the articular surface
Type I:
Long leg cast and leg elevation
Type II
ORIF of the fibula
ORIF of the tibia. Once soft-tissue swelling subsides,
minimally invasive open reduction and percutaneous
techniques should be attempted.
Type III
ORIF of the fibular fracture to restore length
ORIF of the tibia
Closed reduction and external fixation of the tibia
Combination of ORIF and external fixation of the tibia
- If risk of over swelling
Prevention or treatment of swelling by prolonged leg
elevation
Open surgical treatment should be deferred until the soft
tissue condition improves (7-14 days)
Weight bearing if there is radiologic evidence of bone
healing

1.3. Foot Fractures

1.3.1. Ankle Fractures

Classification (Weber)
- Type A
Avulsion of the fibula to the joint line
Syndesmotic ligament intact
Medial malleolus undamaged or fractured in a shear type
pattern with the fracture line angulating in a proximal-
medial direction from the corner of the morti:
Oblique orOblique or spiral frala beginningfibula
beginning at the level of the joint up to the shaft of the fibula.
The syndesmotic ligament complex can be torn, but the
large interosseous ligament is usually left intact so that no
widening of the distal tibiofibular articulation occurs.

Surgery Clinical Treatment Guidelines 25

Chapiter 1: Orthopaedic Surgery

Medial malleolus intact or sustain a transverse avulsion

fracture. If the medial malleolus is left intact there can be a
tear of the deltoid ligament.
Posterior malleolar avulsion fracture can also occur.
- Type B
Fracture of the fibula proximal to the syndesmotic ligament
complex
Disruption of the syndesmosis
Medial malleolar avulsion fracture or deltoid ligament
rupture
Posterior malleolar avulsion fracture can also occur

Note:
Fracture of the medial malleolus with complete disruption of the
syndesmosis and a proximal fibular shaft fracture (Maisonneuves
fracture) are also considered bimalleolar fractures on a functional
basis.

Management
Principles of initial treatment of ankle fractures
Immediate closed reduction and splinting, with the joint
held in the most normal position possible to prevent
neurovascular compromise of the foot.
An ankle joint should never be left in a dislocated position.
If the fracture is open, the patient should be given
appropriate intravenous antibiotics and taken to the
operating room on an urgent basis for irrigation and
debridement of the wound, fracture site, and ankle joint. The
fracture should also be appropriately stabilized at this time.

Conservative treatment: well-molded short leg cast for 6weeks.

Indications for non operative treatment include

- Non displaced stable fracture patterns with an intact syndesmosis
- Displaced fractures for which stable anatomic reduction is
achieved
- An unstable or multiple trauma patient in whom operative
treatment is contra-indicated due to the conditions of the patient
or the limb
- Operative treatment: ORIF and well-molded short leg cast for
6weeks.

26 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
ORIF is indicated if

Surgery
Orthopaedic
- Failure to achieve or to maintain closed reduction
- Displaced or unstable fractures
- Fractures that requires abnormal foot positioning to maintain
reduction

TRIMALLEOLAR FRACTURES
After the lateral and medial malleolar fractures have been internally
fixed, ligamentotaxis often will anatomically reduce the posterior
malleolar fragment. If this fragment represents less than 25% of the
articular surface of the tibial plafond and there is less that 2 mm of
displacement, internal fixation is not always required.

1.3.2. Calcaneus Fractures

Classification (Essex-Lopresti): Classification based on radiologic

images
- Type I: extraarticular fractures
Anterior process fracture
Tuberosity fracture
Medial process fracture
Sustentacular fracture
Body fracture

- Type II: Intraarticular fractures

Depression type
Tongue type
Comminuted

Classification (Sanders): Classification based upon coronal CT- scan

images
- Type I: All non displaced fractures regardless of the number of
fracture lines
- Type II: Fractures are two-part fractures of the posterior facet
and are divided into A, B, and C based upon the location of the
fracture line
- Type III: Fractures are three-part fractures with a centrally
depressed fragment, also divided into A, B, and C
- Type IV: Fractures are four-part articular fractures with extensive
comminution

Surgery Clinical Treatment Guidelines 27

Chapiter 1: Orthopaedic Surgery

Management

Extraarticular Fractures
Fracture of the Anterior Process
Treatment is by a non-weightbearing short leg cast
in neutral position for 4 weeks
Fracture of the Tuberosity
Isolated fractures of the calcaneal tuberosity are rare.
Horizontal Fracture
If the fragment is big enough, the application of the
skeletal traction can reduce it to the plantar-flexed
foot, and the pin is incorporated in a long leg cast
with the knee flexed at 30 degrees. For smaller
fragments or when closed reduction is unsuccessful,
ORIF with screws, wires or pullout sutures is
indicated.
Vertical Fracture
Because the minor medial fragment normally is
not widely displaced, plaster immobilization is not
required but may reduce pain. Limitation of weight
bearing with crutches is helpful.
Fracture of the Medial Process:
Conservative treatment with a well-molded short leg
walking cast is usually successful
Fracture of the Body
Marked displacement may benefit from closed
reduction to improve heel contour
Fracture of the Sustentaculum
Conservative treatment is usually successful. In the
rare instance of symptomatic non-union, careful
excision is indicated
Intra-articular fractures
Treatment of displaced intraarticular fractures
remains controversial
Some surgeons still advise conservative treatment
Other surgeons advocate early closed manipulation of
displaced intra-articular fractures, to at least partially
restore the external anatomic configuration of the
heel region. Internal fixation with percutaneous pins
(Essex-Lopresti technique) may be performed.

28 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Open reduction and internal fixation with pins,

Surgery
Orthopaedic
screws, or plates, with or without bone grafting, has
gained acceptance. The aim of ORIF is to restore
Bhlers angle and improve heel alignment through
stable fixation.
Some authors advocate primary subtalar arthrodesis
for severely comminuted fractures.

1.3.3. Talus Fractures

Three fifths of the talus is covered with articular cartilage. The blood
supply enters the neck area and is tenuous. Fractures and dislocations
may disrupt this vascularization, causing delayed healing or avascular
necrosis.

FRACTURES OF THE NECK OF THE TALUS

Hawkins classification

- Type 1: Nondisplaced vertical fracture

- Type 2: Displaced fracture of the talar neck with subluxation or
dislocation of the subtalar joint
- Type 3: Displaced fracture of the talar neck with dislocation of
the body of the talus from both the tibiotalar and subtalar joints
- Type 4: Later, a type 4 fracture was described by Canale and Kelly
to include rare variants which are essentially type 3 injuries with
talonavicular subluxation or dislocation.

Management
Type 1
Non-weightbearing below-knee cast for 23 months until
clinical and radiologic signs of healing are present

Type 2
Closed reduction. In about 50% of cases, closed reduction
is unsuccessful and open reduction and internal fixation
with K-wires, pins, or screws is indicated

Types 3 and 4
Closed reduction is almost never successful; ORIF is the
rule.

Surgery Clinical Treatment Guidelines 29

Chapiter 1: Orthopaedic Surgery

FRACTURES OF THE BODY OF THE TALUS

Hawkins classification

- Type 1: Osteochondral fracture

- Type 2: Coronal, sagittal or horizontal fracture
- Type 3: Posterior process fracture
- Type 4: Lateral process fracture
- Type 5: Crush fracture of the body

Management

- Undisplaced and minimally displaced fractures; do conservative

treatment
- Significant displaced fractures:
Closed reduction and short leg cast with foot in plantar
flexion
If closed reduction is not successful then open reduction

OSTEOCHONDRAL FRACTURES OF THE TALAR DOME

Berndt and Harty classification

- Stage 1: Localized compression

- Stage 2: Incomplete separation of the fragment
- Stage 3: Completely detached but non displaced fragment
- Stage 4: Completely detached, displaced fracture

Management
- Stage 1, 2, and 3: Immobilization and restricted weight bearing.
- Stage 4 and failed conservative treatment stage 1,2,3: Reduction
and pinning or fixation with screws and excision with or without
drilling
- Arthroscopic management seems to give as good a result as
arthrotomy, with fewer complications
- Compression fractures of the talar dome are rare injuries. They
cannot be reduced by closed methods. If open reduction, with
or without bone grafting, is elected, prolonged protection from
weight bearing is the best means of preventing collapse of the
healing area.

30 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
1.3.4. Midfoot Fractures

Surgery
Orthopaedic
NAVICULAR FRACTURES

Classification (AO/OTA)
- Type A: Extraarticular
- Type B: Partial articular (talon-navicular joint involved)
- Type C: Articular (talo-navicular & naviculo-cuneiform involved)

Management
- Undisplaced / incomplete fractures: short leg cast (non-weight
bearing for 4-6weeks)
- Displaced /complete fractures: ORIF (lag screws) and short leg
cast (non-weight bearing for 4-6weeks)

CUBOID FRACTURES

Classification (AO/OTA)
- Type A: Extraarticular
- Type B: Partial articular (calcaneo-cuboid or cubo-talsal joints
involved)
- Type C: Articular (calcaneo-cuboid and cubo-talsal joints involved)

Management
- Undisplaced / minimal impacted fractures: short leg cast (non-
weight bearing for 6weeks)
- Displaced : ORIF (K-wire/lag screws) and short leg cast

1.3.5. Fore-foot Fractures

METATARSAL FRACTURES
Metatarsal Shaft Fractures
Undisplaced fractures: short leg walking cast.
Displaced fractures: closed reduction and short leg walking
cast
If significant angulation or intraarticular displacement
persists: ORIF
Metatarsal Neck & Head Fractures
Traction (Chinese finger traps)
Unstable reductions: percutaneous pinning under
fluoroscopic imaging

Surgery Clinical Treatment Guidelines 31

Chapiter 1: Orthopaedic Surgery

If reduction is unacceptable, ORIF with K-wires or plates

and screws
Fracture of the Base of the Fifth Metatarsal
Three distinct patterns occur
Avulsion fracture
Jones fracture
Transverse fracture of the proximal metatarsal diaphysis

Management
- Short leg cast
- In the rare event of a significant displaced intraarticular
component, ORIF may be indicated.

1.3.6. Fractures of the Phalanges of the Toes

Management
- A weight-bearing removable immobilization
- Spiral or oblique fracture of the proximal or middle phalanges of
the lesser toes can be treated adequately by binding the involved
toe to the adjacent uninjured toe (buddy taping)
- Comminuted fractures of the distal phalanx are treated as soft-
tissue injuries

1.3.7. Fracture of the Sesamoids of the Great Toe

Management
- Undisplaced fractures: Hard-soled shoe or metatarsal bar
- Displaced fractures: Immobilization in a walking boot or cast,
with the toe strapped in flexion
- If conservative modalities have been exhausted: THe last resort
treatment is excision
- Treatment of fractures in children: The treatment of the majority
of fractures in children and adolescents will be conservative.
Indications for surgical treatment of fractures in children
include:
Open fractures
Polytrauma
Patients with head injuries
Femoral fractures in adolescents
Femoral neck fractures
Certain types of forearm fractures
Certain types of physeal injuries
Fractures associated with burns

32 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
1.4. Fractures in children

Surgery
Orthopaedic
1.4.1. Epiphyseal Fracture

The cartilage physeal plates are a region of low strength relative to the
surrounding bone and are susceptible to fracture in children.

Classification (Salter-Harris)
- Type I: Transphyseal fracture involving the hypertrophic and
calcified zones
- Type II: Transphyseal fracture that exits the metaphysis
- Type III: Transphyseal fracture that exits the epiphysis
- Type IV: The fracture that traverses the epiphysis and the physis,
exiting the metaphysis
- Type V: Crush injuries to the physis
Treatment
Because physes are near joints and physeal fractures are
common, children may suffer injuries to joint surfaces that
require careful surgical repair and realignment. Thus, open
reduction is more likely in fractures involving physes and
joints than in other pediatric fractures.

1.4.2. Supracondylar Fracture of Humerus

RIGAULT AND LAGRANGE PICTURES/IMAGES

Above is a diagram outlining the Lagrange and Rigault classification.

- StageI: undisplaced fractures, only the anterior cortex is
disrupted;

Surgery Clinical Treatment Guidelines 33

Chapiter 1: Orthopaedic Surgery

- Stage II: fractures involving both corticals, no or little

displacement;
- Stage III: fractures with substantial displacement;
- Stage IV: substantial displacement fractures with no contact
between bone fragments;
- Stage V: metaphyseal-diaphyseal fractures.

Classification (Gartland)

- Extension type
Type I: Non displaced
Type II: Displaced with intact posterior cortex, may be
slightly angulated or rotated
Type III: Complete displacement, posteromedial or
posterolateral

- Flexion type
Type I: Non displaced
Type II: Displaced with intact anterior cortex
Type III: Complete displacement, usually anterolateral

Management (for both Flexion and extension)

- Type I: Immobilization in a long arm cast for 2 to 3 weeks
- Type II: Closed reduction and immobilization
- Type III:
Closed reduction and pinning and immobilization
ORIF
Lateral Condyle Fracture (Jakob):
Stage I: Non displaced fractures with intact articular
surface
Stage II: Complete fracture with moderate
displacement
Stage III: Complete displacement and rotation with
elbow instability

Management
- Stage I: Immobilization for 3 to 4 weeks
- Stage II & III: Closed reduction and immobilization

Note:
If the reduction is unable to be held percuteneous pins / screws may
be placed

34 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
1.4.3. Radial Neck Fracture

Surgery
Orthopaedic
Classification (OBRIEN) based on degree of angulations
- Type I: 00 - 300
- Type II: 300 - 600
- Type III: More than 600

Management
- Type I: Immobilization for 7 to 10 days followed by early range
of motion
- Type II:
Manipulative closed reduction and immobilization for 10
to 14 days.
Manipulative closed reduction and pinning
- Type III: ORIF

1.4.4. Forearm Fracture

In children, most forearm fractures that involve both bones can be
treated successfully by closed reduction and casting. Minor angular
mal-alignment can easily be tolerated if rotational alignment of the
bone end is accurate. Minimal invasive fixation in case of conservative
treatment failure.

METACARPAL & PHALANGEAL FRACTURES

Fractures of the metacarpals and phalanges commonly occur from
crush injuries in children (e.g. catching a hand or finger in a door) and
are generally quite stable because the periosteum remains intact.
Rarely severely angulated or rotationally mal-aligned metacarpals and
phalanges can be managed by immobilization for 23 weeks.

1.4.5. Pelvic and Lower Limbs Fractures

PELVIC FRACTURE
Pelvic fractures in children are usually seen in conjunction with major
blunt trauma. Gross displacement is fairly uncommon and can usually
be treated symptomatically because the intact periosteum stabilizes the
large flat bones.

HIP FRACTURE
As in the adult, the fracture pattern may disrupt the blood supply of the
proximal femoral head and lead to avascular necrosis of the proximal

Surgery Clinical Treatment Guidelines 35

Chapiter 1: Orthopaedic Surgery

femoral epiphysis. Femoral neck fractures in children are generally

treated by reduction and fixation.

FEMORAL SHAFT FRACTURE

Femoral shaft fractures in children involves the subtrochanteric, shaft
and supracondylar region.

Management approach
- Newborn to 2 years: Early spica cast
- From 2 to 10 years of age:
- Early spica cast
- Skin traction (> 2 cm overriding)
- From 10-15 years of age:
- Undisplaced: Conservative treatment
- Displaced: Operative treatment (flexible nails)

TIBIA SHAFT FRACTURE

Most tibial fractures in children can be adequately aligned and
immobilized in above-knee casts. In rare and unstable cases, some
open fractures, or fractures in older children may also require operative
treatment.

ANKLE FRACTURE AND DISTAL TIBIAL FRACTURE

Ankle fractures and distal tibia fractures in younger children are often
either metaphyseal or Salter-Harris type II distal tibial physeal injuries
that heal rapidly (Refer to Salter-Harris classification related treatment).

1.5. Open Fractures

Definition: An Open Fracture is when disruption of the skin and

underlying soft tissue results in communication between the fracture
and the outside environment.

Causes

- Motor vehicle accidents

- Farm accidents
- Sports accidents
- A force large enough to cause a fracture

Signs and symptoms

- Associated with neuro-vascular injury

36 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Diagnosis

Surgery
Orthopaedic
- Clinical examination of the specific fracture should include the
site of the fracture and severity of the fracture.

Investigations
- FBC
- Blood group and cross match
- PT, PTT, U+E
- Swab from the area
- X-ray of the limb (Lateral and AP views)

Severity assessment (Gustilo-Anderson classification)

- Grade I: The wound is less than 1cm long. It is usually a

moderately clean puncture (from inside-out)
- Grade II: The laceration is more than 1 cm long, and there is no
extensive soft-tissue damage
- Grade III: These are characterized by extensive damage to soft-
tissues, including muscles, skin, and neurovascular structures,
and a high degree of contamination

Management
Emergency management
Emergency ATLS resuscitation
Monitor level of consciousness (LOC)
Analgesia preferably an Opoid Analgesic
Antibiotics
Remove gross contamination and apply a moist sterile
dressing e.g. Betadine dressing
Splint the limb
Tetanus Toxoid Prophylaxis
Urgent surgical debridement, washout and stabilization of
the fracture
Call the orthopaedic specialist after stabilizing the patient
and emergency fracture care

Definitive management
Early administration of systemic antibiotics, timely surgical
debridement, skeletal stabilization and delayed wound
closure
Grade 1: 1st generation cephalosporin
Grade 2: 1st generation cephalosporin and/or an
aminoglycoside depending on the level of wound
contamination

Surgery Clinical Treatment Guidelines 37

Chapiter 1: Orthopaedic Surgery

Grade 3: 1st generation cephalosporin and an

aminoglocoside
Consent form must be signed before any procedures
Provide nutritional support to critically ill patients to
promote healing process
Promote patient hygiene to minimize nosocomial
infections
Control of FBC
Maintain analgesic treatment if required
Promote psychology support both patient and family
members to release anxiety
Prevent thrombosis by using anti coagulant drugs such as
lovenox, etc.
Treat all contaminated injuries as grade 3 with addition of
penicillin and amino glucosides
Surgical debridement after thorough washing of the wound
and irrigation
Internal fixation versus external fixation
Thorough debridement and use of biological fracture
fixation techniques
Early soft tissue cover
Internal fixation with plates or intramedullary nails
Follow up is done under the care of the Orthopedic
Surgeon
Physiotherapy and subsequent surgery
Provide rehabilitation
Prevention of bed sores for bedridden patients

1.6. Critical Care

1.6.1. Critical Care Severe Traumatic Brain Injury

Definition: A traumatic brain injury (TBI) is defined as a blow or jolt

to the head or a penetrating head injury that disrupts the function of
the brain. A Concussion, also referred to as a closed head injury is a
type of TBI.

Assessment of brain injury hinges on evaluation of the Glasgow Coma

Score (GCS) and examination of the pupils. Traditionally a GCS of
below 9 is considered to reflect severe brain injury.

Classically, TBI has been divided into two distinct periods: primary
and secondary brain injury. The primary injury is the result of the

38 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
initial, mechanical forces, resulting in shearing and compression of

Surgery
Orthopaedic
neuronal, glial, and vascular tissue. The secondary injury is described
as the consequence of further physiological insults, such as ischaemia,
re-perfusion and hypoxia, to areas at risk in the brain in the period
after the initial injury.

Causes
- Falls
- Motor vehicle crashes
- Assaults

Signs and symptoms

- Headache with or without traumatic wounds
- Subcutaneous hematoma
- Hemoorrhage(Otorrhagia, rhinorrhagia)
- CSF leak(rhinorrhea, otorrhea)
- Seizures
- Pupil dilatation
- Focal deficit(hemiparesis, monoplegia, unilateral mydriasis)
- Lucid interval
- Coma(agitation, confusion or deep coma)
- Skull base fracture (raccoon eyes, battles sign (after 8-12 h), CSF
rhinorrhea/otorrhea, hemotympanum)
- Facial fractures (auscultate the carotids for bruit/possible carotid
dissection)

Investigations
- Head CT-Scan
- Cervical spine x-ray or CT-scan
- Chest x-ray
- Abdominal US
- Transcranian Doppler US
- FBC, coagulation tests, Biochemistry
- Arterial Blood Gas (ABG), central venous blood gas (internal
jugular Saturation venous O2)
- Any other investigation for associated injuries

Complications
- Posttraumatic seizures
- Hydrocephalus
- Deep vein thrombosis
- Spasticity
- GI and GU complications

Surgery Clinical Treatment Guidelines 39

Chapiter 1: Orthopaedic Surgery

- Gait abnormalities
- Autonomic dysfunction syndrome
- Diabetes insipidus
- Brain herniation and death

Management
Treatment of first choice
Early detection and minimization of any secondary insults
Cervical spine stabilization
Avoid moving the patient if at all possible
Secure and preserve the airway
Maintain and support breathing
Intubation and mechanical ventilation
Maintain effective circulation with IV fluids with isotonic
solutions
Maintenance of adequate mean BP in order to sustain an
adequate cerebral perfusion pressure (CPP) ; CPP=MAP-
ICP (targeted CPP:70-110mmhg)
Effective pain relief
Arrest bleeding
Regular evaluation of GCS and pupillary asymmetry and
reaction to light
Ensure Normoxemia, normoglycemia, normo or mild
hypothermia,normonatremia and normocapnia (35-
38mmhg)
Head straight and elevated at 300C
Prevention of seizures with Phenytoin 5mg/kg/24hrs or
Phenobarbital 5mg/kg/24hrs Slow IV

Surgical Treatment
Surgical decompression or craniectomyare indicated in:
Open, depressed skull fracture
Subdural or epidural hematomas
Intraparenchymal hemorrhages or contusions
resulting in significant mass effect or midline shift.
Pre-operation considerations include associated
injuries like intra-abdominal, orthopedic, spinal cord
and other organ trauma

Ventilation & oxygenation may be inadequate

CHOICE OF ANESTHESIA (GA)

Rapid sequence Induction (RSI): Lidocaine IV (1.5
mg/kg) and/or Fentanyl (1-4 mcg/kg) IV, Barbiturates

40 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
(thiopental 3-5mg/kg) or Etomidate 0.3 mg/kg,

Surgery
Orthopaedic
maintenance with Isoflurane or Sevoflurane, muscle
relaxants: Vecuronium 0.1 mg/kg or Pancuronium 0.1
mg/kg or Tracurium 0.5 mg/kg

INTRAOPERATIVE MONITORING
Monitors/Line Placement, standard monitors plus
intra-arterial BP monitor, ideally placed prior to
induction, CVP monitoring, ICP monitor may
be placed by neurosurgeons, Maintain CPP above
70mmHg, avoid increasing ICP, maintain mild
hypothermia, avoid hypoxemia & hypercarbia,
treat anemia, coagulopathy, volume resuscitate with
isotonic, glucose-free solutions or colloids and, blood
or blood products if indicated, avoid hyperglycemia
(keep glucose <150 mg/dL) and hypoglycemia.

MANAGEMENT OF ELEVATED ICP

Hyperventilate to PaCO2 of 25-30 mmHg, Increase
depth of anesthesia with thiopental; avoid high levels
of volatile osmotic dieresis with mannitol 0.25-1
gm/kg IV bolus over 10-20 min or loop diuretics
(furosemide), drain CSF through ventricular
drainage catheter placed by neurosurgeons, maintain
temperature at 33-350 C.

MANAGEMENT OF HYPOTENSION
Use vasopressors (norepinephrine 0.01-0.1 g/kg/min
post-operative period, manage pain, sedation with
midazolam 5-15 mg/hour + Fentanyl 50-150 g/hour
may be required if patient is left intubated.

1.6.2. Critical care of multiple injuries

Definition: Multi-trauma are physical insults or injuries occurring

simultaneously on several parts of the body.
Causes

- Mechanical or kinetic energy- blunt or penetrating injury

- Thermal energy- injury due to heat or cold
- Chemical energy- acid or alkaline exposure
- Radiant energy- exposure to radiation
- Electrical energy- electrocution
- Oxygen deprivation- smoke inhalation or drowning

Surgery Clinical Treatment Guidelines 41

Chapiter 1: Orthopaedic Surgery

Signs and symptoms

- Pain and swelling

- Deformity
- Lesions with bleeding
- Altered mental status or unconsciousness
- Hypotension or shock

Life threatening features include: chest tension pneumothorax, flail

chest, pericardial tamponade, myocardial contusion, open chest wound,
hemothorax, intra-abdominal bleeding, pelvis / femur fracture, spine
fracture / cord injury, head injury (see Severe Head Injury), extremity
fracture / dislocation, HEENT (airway obstruction).

Investigations
- X-rays of the chest, pelvic and C-spine
- Abdominal US
- Head CT-Scan if head Injury
- Body scan
- X-ray of affected limbs
- FBC, Blood group and cross-match, coagulation tests
- Chemistry (electrolytes, transaminases, CPK, Troponin)

Complications
- Haemorrhage infection/ Sepsis
- Multi organ failure
- Deep venous thrombosis
- Fat air embolism

Management
Treatment of first choice
Adult Assessment Procedure focusing on initial C-spine,
ABCD and level of responsiveness (see ATLS)
Spinal immobilization
Airway protection and/or maintenance if appropriate
Assess Vital Signs and GCS

If hypotension
Give IV fluids: Normal saline until you get a mean arterial
pressure > 60 mmHgSplint Suspected fractures consider
pelvic binding/ radiological embolization if available
Control external hemorrhage
Tension Pneumothorax: chest decompression
Laparotomy if abdominal injuries

42 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Head injury protocol (if head injury)

Surgery
Orthopaedic
Blood and/or blood components transfusion if needed

Supportive treatment
Dialysis in case of renal failure
Mechanical ventilation in case of ALI/ARDS
Inotropic drugs like dobutamine 5-20 g/kg/min in case of
cardiogenic shock due to myocardial contusion
NGT for enteral feeding
Prevention of DVT with LMWH e.g. Enoxaparine 40mg
SC/day (starting from day 5 if no contraindications)

1.7. Dislocations

1.7.1. General Consideration

Definition: Complete separation and loss of 2 articulating bone

contact surfaces. A partial or incomplete dislocation is known as a
subluxation.

Causes
- Direct Trauma
High Energy trauma
Road traffic accident
Fall from Heights
Sports injuries
Industrial injuries

Low Energy Trauma

Sports injuries

- Indirect Trauma
Varus, Valgus and rotational stress

Signs and symptoms

- Pain
- Tenderness
- Deformity
- Swelling
- Decreased range of motion
- Shortening
- Effusion

Surgery Clinical Treatment Guidelines 43

Chapiter 1: Orthopaedic Surgery

Investigations
- X-Rays (Lateral view, Anteroposterior View)
- CT Scan
- MRI

1.7.2. Acromio-Clavicular Joint Dislocation

Definition: Classified in 6 different types depending on which
ligaments are sprained or torn.
- Type 1- Sprain of the acromioclavicular ligament
Joint tenderness
Minimal pain with arm motion
No pain in Coraco-Clavicular Interspace
- Type 2- Torn Acromioclaviclar Ligament with sprain Coraco-
Clavicular Ligament
Joint tenderness in both acromioclavicular and
coracoclavicular interspace
Distal clavicle is slightly superior to Acromion and mobile
to palpation
- Type 3 Torn both Acromio clavicular and Coraco-Clavicular
ligament
Acromio clavicular Joint tenderness and coraco clavicular
widening is evident
- Type 4 Type 3 and posterior displacement of the distal Clavicle
into or through the Trapezius
More pain exists than in type 3 and distal clavicle is
displaced posteriorly away from the clavicle.
- Type 5- Type 3 and glossily and severely displaced distal Clavicle
superiorly (radiography demonstrates the Coraco-clavicular
inter-space to be 100% to 300% greater than normal)
Symptoms as in type 3 but this type is typically associated
with tenting of the skin
- Type 6 Dislocated Acromio Clavicular Joint with Clavicle
displaced inferiorly. (shoulder has Flat appearance with a
prominent Acromion)
Shoulder has flat appearance with a prominent Acromion

Note:
Associated clavicle, upper rib fractures and brachial plexus
injuries are due to high energy trauma in this type

44 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Investigations

Surgery
Orthopaedic
- Antero-Posterior x-ray for both shoulders (comparison)
- Stress x-ray of the affected shoulder (holding weight) in case of
doubt

Complications

- Associated fractures (Clavicle, Acromion and Coracoids process)

- Post Traumatic osteoarthritis
- Type 6 could be associated with a pneumothorax
Management

- Type 1: Rest 7-10 Days with an Arm sling (refrain from full
activity for 2 weeks)
- Type 2: Use of Arm sling for 1-2 weeks (refrain from heavy
activity for 6 weeks)
- Type 3: Conservative Treatment (arm sling) or Surgical
Treatment (surgical repair)
- Type 4, Type 5 and Type 6: Open reduction and surgical Repair
of the Coraco-Clavicular Ligament

1.7.3. Shoulder Dislocations

Description

- Most common dislocated joint of the body

- Most shoulder dislocations are anterior
- Posterior dislocations are less frequent and difficult to diagnose
- Inferior and superior dislocations are very rare

Signs and Symptoms

ANTERIOR DISLOCATIONS
- Pain, tenderness and swelling of the affected shoulder
- Arm of the affected shoulder is held in abduction and External
Rotation
- Decreased Range of motion
- Loss of deltoid contour compared with contralateral side
- Prominence of the Acromion and palpable head of the humerus
anteriorly in the Axila

Note:
Careful assessment of the neurovascular status. (Evaluate sensory
and motor function of the musculocutaneous and radial nerves.
Compare distal pulses on both extremities.)

Surgery Clinical Treatment Guidelines 45

Chapiter 1: Orthopaedic Surgery

Investigations

- Antero posterior and lateral x-rays

- CT Scan and MRI (to assess the rotator cuff)

Complications

- Recurrent dislocation
- Soft tissue injuries (rotator cuff injury)
- Vascular Injury- Axillary Artery (Rare: only in elderly patients
with arthrosclerosis)
- Nerve injury especially the Musculocuteneous and Axillary
Nerve
- Osseous lesions
- Post traumatic osteoarthritis

Management
Conservative (closed reduction)
Analgesics and/or Sedation
Always conservative for acute anterior shoulder
dislocations
Arm sling after closed reduction for 2-3 weeks (elderly
patients) and 6 weeks for (young patients)

Surgical
Indication: Chronic dislocation, soft tissue interposition,
fracture dislocation

POSTERIOR DISLOCATION

Signs and symptoms

- Arm of the affected shoulder is held in adduction and internal

rotation
- Pain, tenderness and swelling of the affected shoulder
- Decreased range of motion
- Most commonly missed injury (60-70% are missed)

Investigations

- Antero posterior and lateral x-rays

- CT Scan (to assess the associated fractures: humeral head)

Complications
- Recurrent dislocation
- Nerve Injury especially the Axillary nerve

46 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
- Osseous lesions

Surgery
Orthopaedic
- Post traumatic osteoarthritis

Management
Conservative (Closed reduction)
Analgesics and/or sedation
Always conservative for acute posterior shoulder
dislocations
Arm sling after closed reduction for 2-3 weeks (elderly
patients) and 6 weeks for (young patients)

Surgical
Indication: Chronic dislocation, soft tissue interposition,
fracture dislocation

Recommendations

- Physical therapy under supervision post immobilization removal

- Pre and post reduction: x-Ray and neuro-vascular status
evaluation is mandatory

1.7.4. Elbow Dislocation

Description

- Posterior dislocations account for most elbow dislocations

- Most common in young population

Classification

- Posterior 90% of elbow dislocations

- Anterior
- Lateral
- Medial
- Divergent

POSTERIOR DISLOCATIONS

Signs and Symptoms

- Pain - intense, focused around the elbow joint

- Extremely limited range of motion
- Massive ante-cubital swelling (be aware of compartment
syndrome)
- Elbow is flexed, with an exaggerated prominence of the
olecranon

Surgery Clinical Treatment Guidelines 47

Chapiter 1: Orthopaedic Surgery

Investigations

- X-ray antero- posterior and lateral views

Complications

- Compartment syndrome (Vascular or Neuro: compromise)

- loss of motion (stiffness ) due to long term immobilization
- Instability/ re-dislocation
- Heterotopic ossification

Management

Conservative (Closed reduction):

Analgesics and/or sedation
Always conservative for acute posterior elbow dislocations
Above elbow posterior splint for 3 weeks (young patient)
and up to 10 days (for elderly)

Surgical
Indication: Chronic dislocation, soft tissue and/or bony
entrapment, fracture dislocation, recurrent instability.

Recommendations

- Physical therapy under supervision post immobilization removal

- Pre and post reduction: X-Ray and Neuro-Vascular status
evaluation is mandatory

1.7.5. Hip Dislocation

Description

- Traumatic hip dislocation of the hip joint may occur with or

without fracture of the acetabulum of the proximal end of the
femur. Hip dislocations are classified based on the relationship
of the femur head to the Acetabulum and on whether associated
fractures are present
Causes of hip dislocations

- High energy traffic accidents

- Fall from heights
- Industrial injuries

48 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Investigation

Surgery
Orthopaedic
- X-ray Antero posterior of the pelvis
- Oblique radiographic projections (Judet views)
- CT Scan (Preferably post reduction)
POSTERIOR HIP DISLOCATION
Classification
- Posterior dislocation is the most common and accounts for 90%
of all hip dislocations.
- Classification of Posterior dislocations (Thompson and Epstein
Classification)
Type 1- Simple dislocation with or without any significant
posterior wall fragment
Type 2- Dislocation associated with a single large posterior
wall fragment
Type 3- Dislocation with a comminuted posterior wall fragment
Type 4- Dislocation with fracture of the acetabular floor
Type 5 Dislocation with fracture of the femoral head

Signs and Symptoms

- Severe pain
- Shortening, adduction flexion and internal rotation of the
affected limb
- Decreased motion of the lower extremity on the affected side

Note:
Full trauma survey is critical due to the high energy nature of the
injury.

ANTERIOR HIP DISLOCATION

Classification

Anterior dislocations are not very common

- Type I: superior dislocation including pubic and subspinous
- Type II: inferior dislocation including obturator and perineal

Signs and symptoms

- Severe pain
- Abduction flexion and external rotation of the affected limb
- Decreased motion of the lower extremity on the affected side

Surgery Clinical Treatment Guidelines 49

Chapiter 1: Orthopaedic Surgery

Complications of hip dislocations

- Neurovascular injury
- Thromboembolism
- Avascular osteonecrosis
- Post traumatic osteoarthritis
- Recurrent dislocations
- Heterotopic ossifications

Management of hip dislocations

Reduction should be expedient to decrease the risk of osteonecrosis of

the femoral head.

Conservative treatment
Closed reduction under anesthesia
Skin or skeletal traction (2-3 weeks)

Open reduction
Indications for open reduction
Failure of closed reduction
Non concentric reduction
Fracture of the acetabulum or femur head that
requires either excision or ORIF
Ipsilateral femoral neck fracture

1.7.6. Traumatic Knee Dislocation

Definition: Is the complete displacement of the tibia with respect

to the femur and with disruption of 3 or more of the stabilizing
ligaments.
- Extremely rare but may be limb threatening (associated with
vascular injuries - Popliteal Artery )
- Should be treated as an orthopedic emergency

Causes

- Motor vehicle accidents

- Falls from heights
- Industrial-related accidents
- Sports-related injuries

50 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Signs and Symptoms

Surgery
Orthopaedic
- Severe pain
- Extreme swelling and gross knee derformity with or without
neurovascular compromise

Investigations

- Anteroposterior and lateral x-rays

- MRI

Complications

- Neurovascular
- Ligamentous instability
- Stiffness (due to prolonged immobilization and extend of soft
tissue injury)

Classification

- Anterior: Dislocation is often caused by severe knee

hyperextension
- Posterior: Dislocation occurs with anterior-to-posterior force to
the proximal tibia, such as a dashboard type of injury or a high-
energy fall on a flexed knee
- Lateral: Valgus force with disrupted medial supporting structures
and often with tear of both cruciate ligaments
- Medial: Varus Force with disruption of lateral and post lateral
structures
- Rotational: Varus and Valgus with rotatory component.

Surgery Clinical Treatment Guidelines 51

Chapiter 1: Orthopaedic Surgery

Management

A knee dislocation is a potentially limb threatening condition,

therefore immediate reduction is recommended even before a
radiography evaluation.

Conservative
Immediate closed reduction and immobilization at 20-30o
of flexion for 6 weeks
Range of motion/exercise should be instituted after
adequate soft tissue healing 6-12 weeks

Surgical
Indications
Unsuccessful closed reduction
Open injuries
Vascular injuries
Residual soft tissue interposition

Recommendations

- Acute repair of lateral ligament followed by early functional

bracing is advised (meniscal injuries to be addressed at time of
surgery
- Medial collateral injuries generally heal without surgery
- The role of cruciate reconstruction in the acute setting remains
controversial

1.7.7. Patellar Dislocation

Description: Patella dislocation is more common particularly in

females due to physiologic laxity and in patients with hyper mobility
(athletes)

Causes

- Physiological laxity
- Direct trauma to the patella
- Connective tissue disease (Marfan Syndrome)
- Congenital abnormality of the patella and trochlea
- Hypoplasia of the Vastus Medialis muscle
- Hypertrophy of the lateral retinacular

52 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Signs and symptoms

Surgery
Orthopaedic
- Pain focused around the knee joint
- Inability to flex knee
- Hemarthrosis
- Swelling with tenderness of the knee
- Palpated displaced patella

Investigation

- X-ray of the knee (Anteroposterior and Axial views)

Complications

- Recurrent dislocation
- Re-dislocation
- Patella-femoral Arthritis

Management

Conservative
Closed reduction with cylinder casting for 2- 3 weeks
Isometric quadriceps exercises after removal of the cast

Surgery
Recurrent episodes require operative repair

Surgery Clinical Treatment Guidelines 53

Chapiter 1: Orthopaedic Surgery

1.8. Surgical Infections

1.8.1. Septic Arthritis

Definition: Septic arthritis is the inflammation of a synovial membrane

with purulent effusion into the joint space usually caused by bacteria.
It is a surgical emergency. Typically it affects mono-articular joints.
Commonly affecting the knees, hips and shoulders.

Pathophysiology

- Bacteria can gain entrances to a joint via three routes:

Hematogenous spread
Direct inoculation
Direct extension from an adjacent focus of infection

- Hematogenous infection is the most common type and usually

affects people who have an underlying medical illness
- Predisposing factors include
Immune deficiencies
Chronic disease
Intravenous drug abuse
Local joint trauma
Recent sexual contact (gonococcus sepsis)

Causes

- Staphylococcus Aureus
- Streptococcus
- Gram negative bacteria

Signs and symptoms

- Warm, painful and swollen joint

- Erythema and tenderness
- Limitation of motion
- Pyrexia
- Antalgic posture of the limb

Investigations

- FBC: Often leucocytosis with a left shift

- ESR and CRP
- Blood cultures: 50% positive in S.aureus infection, very poor for
N. gonorrhoea

54 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
- urethral, cervical, pharyngeal and rectal swabs

Surgery
Orthopaedic
- Synovial fluid analysis: gram stain, culture, cell counts, crystal
analysis
- X-ray of the joint
Often normal initially
Soft tissue swelling around the joint, widening of the joint
space, displacement of tissue planes
Bony erosions and joint space narrowing, sclerosis, and
patchy demineralization all in later stages

- Ultrasound of the joint

Complications

- Septicemia
- Dislocations
- Growth plate damage in children
- Osteomyelitis
- Degenerative arthritis
- Avascularis necrosis in hip and shoulder

Surgery Clinical Treatment Guidelines 55

Chapiter 1: Orthopaedic Surgery

Management

SUSPICION OF SEPTIC ARTHRITIS

Needle aspiration, synovial

fluid analysis including
culture, blood cultures and
culture of any possible
remote source of bacteremia

Results consistent Result Inconsistent

with septic Arthritis with septic arthritis

Needle aspiration (Culture),

Analgesics, Intravenous Antibiotics
(Cloxacilline+ 3rd Generation Evaluation for
cephalosporin) and immobilization other types of
inflammatory
arthritis

Symptoms resolve Symptoms do not

in 24-48 hrs resolve in 24-48

Surgical drainage (Arthrotomy)

+ IV antibiotics (dependent on
culture results)

Antibiotics for 4-6

weeks

56 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
1.8.2. Acute Osteomyelitis

Surgery
Orthopaedic
Definition: Osteomyelitis is a bone infection

Cause/Etiology

- Bacterial

Pathogenesis
- Inflammation
Acute inflammatory reaction with vascular bacterial
congestion
Rise in intra-osseous pressure causing intense pain

- Suppuration
At 2-3 days pus forms within the bone and forces its way
down the haversian canals to the surface where it forms a
sub-periosteal abscess
The pus can spread from here back into the bone, into an
adjacent joint or into the soft tissues (where there is an
intra-articular physis)
Vertebral infection can spread through the end plate, disc
and into the next vertebral body

- Necrosis
At 7 days, rising pressure, vascular stasis, infective
thrombosis and periosteal stripping compromise the blood
supply to the bone resulting in bone death resulting in a
sequestrum
New bone formation
At 10-14 days this forms from the deep surface of the
stripped periosteum forming the involucrum

- Resolution
With release of the pressure and appropriate antibiotics
healing can occur
There may be permanent deformity
Unpublished work (quoted in Dee) shows that
experimentally bacteria injected intravenously will settle in
the metaphyses of bone preferentially

Note:
- In 10% of cases there is more than one site of infection

Surgery Clinical Treatment Guidelines 57

Chapiter 1: Orthopaedic Surgery

Signs and Symptoms

- Children (invariably)
Pain, malaise, fever
Limp or not weight bearing

- Infants
Failure to thrive, drowsiness, irritable

- Adults
The most common site is long bones
Local erythema, swelling and tenderness indicates that the
pus has broken through the periosteum

Investigations
- FBC: Often leucocytosis with a left shift
- ESR and CRP
- Blood cultures

58 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
- X-ray of the joint

Surgery
Orthopaedic
Often normal initially
Soft tissue swelling around the joint, widening of the joint
space, displacement of tissue planes
Bony erosions and joint space narrowing, sclerosis, and
patchy demineralization all in later stages

- Ultrasonography

Complications

- Recurrent bone infection

- Pathologic fractures
- Bone destruction
- Chronic osteomyelitis
- Impaired bone growth

Management
Non Operative
ANTIBIOTIC ADMINISTRATION:
It is recommended to start empiric treatment with a
regimen that caters for S.aureus as the culture results
are awaited
Empiric regimen
IV CLOXACILLIN and A 3RD GENERATION
CEPALOSPORIN (e.g. ceftriazone)
OR
IV OXACILLIN can be used in the place of cloxacillin with
the 3rd generation cephalosporin
Culture results to guide definitive antibiotherapy
The change to oral medication will depend on the
clinical response i.e. fevers ceasing and decreasing
CRP and ESR, with the generally accepted course
being of 1week IV treatment then a change to oral
medication
The recommended minimal duration of drug therapy
is 6 weeks

Operative
Periosteal abscess should be managed surgically.

Surgery Clinical Treatment Guidelines 59

Chapiter 1: Orthopaedic Surgery

1.8.3. Chronic Osteomyelitis

Definition: Exogenous or hematogenous infection that has gone

untreated or has failed to respond to treatment.

Signs and symptoms

- Pain
- Swelling/oedema
- Often draining sinus
- Sometimes deformity

Investigations

- FBC
- ESR and CRP
- Blood cultures
- Tissue culture and sensitivity
- X-ray (Anteroposterior and lateral views)
- CT Scan
- MRI
- Scintigraphy

Complications

- Recurrent bone infection

- Pathologic fractures
- Bone destruction
- Impaired bone growth
- Skin neoplasm

Management

- Surgical debridement (Sequestrectomy and curettage)

- Systemic and local antibiotics guided by the results of the
antibiogram
- Analgesics and immobilization
- Dead space management (irrigation, muscle flap, beads or
spacers)
- Amputation
Indication: Association of any of the following
Septicemia
Extreme deformities and Extensive Infection
Severely compromised soft tissue

60 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
1.9. Hand Surgery

Surgery
Orthopaedic
1.9.1. Fracture of Wrist Bones

Description
- Carpal/wrist bones are in 2 rows:
Awrist fractureis a break in one or more of the bones in
thewrist.
The proximal row which is made from radial to ulna sides
of the scaphoid, lunate, triquetrum and pisciform bones.
The distal row which is made from radial to ulna of the
trapezium, trapezoid, capitate and hamate bones.

Causes

- Fall on the outstretched hand and extended wrist

- Motor vehicle accident
- Sports contact injury

1.9.2. Fracture of the Scaphoid Bone

Description: Scaphoid fractures are by far the most common of the

carpal fractures, estimated at 70-79%.

Classification

Herbert classification of scaphoid fractures

- Type A fractures are stable and acute including:
A1: Fracture of the tubercle
A2: Incomplete fractures of the scaphoid waist
- Type B fractures are unstable and include:
B1: Distal oblique fractures
B2: Complete fracture of the waist
B3: Proximal pole fractures
B4: Transscaphoid perilunate fracture dislocation of the
carpus

- Type C fractures are characterized by delayed union.

- Type D fractures are characterized by established non-union
D1: Fibrous union
D2: Pseudarthrosis

Surgery Clinical Treatment Guidelines 61

Chapiter 1: Orthopaedic Surgery

Signs and Symptoms

- Pain and swelling of the radial wrist

- Swelling and pain on palpation of the anatomic snuff box
- Limited range of motion of the wrist
- Radial deviation and flexion of the wrist elicit pain
- Axial load to the first metacarpal elicit pain
- Diminished grip compared to the other hand

Investigations

- Plain x-ray: (Poste-Anterior, true lateral and semi-pronate

oblique)
- CT Scan and MRI: Only for suspected fractures that cant be
found on plain x-ray

Complications

- Bone Necrosis
- Pseudo Arthrosis

Management
Conservative treatment
Short arm casting for 12 weeks
Physiotherapy after removal of casting

Surgical
Open reduction and internal fixation (ORIF) bone
grafting associated with short arm casting for 8 weeks
Physiotherapy after removal of casting

Recommendations

- If patients still feel pain after conservative treatment refer to

Hand or Orthopedic surgery.
- If plain x-ray seems normal despite clinical suspicion of fracture,
repeat x-ray after one week.
- Refer all unsure cases to a Hand or Orthopedic surgeon.

62 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
1.9.3. Perilunate Dislocation and Perilunate Fracture Dislocation

Surgery
Orthopaedic
Definition: Perilunate dislocation and Perilunate fracture dislocation
are injuries that involve traumatic rupture of the Radio-Scaphal Capitate
(RSC) ligament, the scapholunate interosseous and lunotriquetral
interosseous ligament.

Signs and symptoms

- Pain and marked swelling of the wrist

- Wrist is dislocated dorsally and radius is prominent volarly
- Paresthesia in the median nerve territory
- For lunate dislocation the lunate alone is prominent volarly

Investigations

- Plain x-ray: (Poste-Anterior, true lateral and semi-pronate

oblique)
- CT Scan and MRI

Complications

- Median nerve palsy

- Post traumatic athrosis
- Open fracture

Management

- Closed reduction and casting for 8 weeks if reduction is stable

- Unstable Reduction: Closed reduction and percutaneous pin
fixation
- Severe Ligament injuries: Open reduction, Ligament Repair and
Fixation.
- Physiotherapy after removal of casting

Recommendation

- CT scan and/or MRI should be prescribed by the surgeon who is

going to operate.

Surgery Clinical Treatment Guidelines 63

Chapiter 1: Orthopaedic Surgery

1.9.4. Other Wrist Bone Fractures

Description: Commonly associated with above carpal bone fractures.

Signs and symptoms

- Decreased range of motion of the wrist

- Most pain can be radial or ulna depending on the bone involved
- Pain and swelling of the wrist
- Decreased hand grip

Investigations

- Plain x-ray: (Poste-Anterior, true lateral and semi-pronate

oblique)
- CT Scan and MRI

Management
Conservative: Short arm casting for 8 weeks
Surgical: ORIF with short arm casting.
Physiotherapy after removal of casting

1.9.5. Metacarpal Fractures

Description: Metacarpal bones are located between carpal bones and

phalanges. From radial to ulna we have thumb (First) Metacarpal and
second to fifth metacarpal.

- Fractures will be described according to:

Whether closed or open
Finger involved
Site (base, shaft, neck and head)
Type of Fracture (horizontal, oblique, spiral and
comminuted)
Joint involvement

Causes
- Falls
- Blunt injuries
- Penetrating injuries
- Sport contact injuries

64 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Signs and Symptoms

Surgery
Orthopaedic
- Pain
- Swelling of the hand, hematoma and bruising overlying skin
- Decreased range of motion of the fingers
- Shortening of fingers involved
- Rotation of finger
- Angulation

Investigation
- Plain x-ray (Antero-posterial and oblique views)

Management
Conservative
Closed reduction and volar splinting in functional position
for 6 weeks
Physiotherapy after removing the splint

Surgical
Closed reduction and percutaneous pin fixation
Open reduction and internal fixation

Recommendations
- Keep the hand elevated to decrease pain and swelling
- Make sure the finger is not rotated after fixation

1.9.6. Bennetts and Rolandos Fractures

Description

- Bennetts fracture is an intra articular fracture of the base of the

thumb metacarpal characterized by one small ulna fragment.
- Rolandos fracture is a comminuted intra articular fracture of the
base of the thumb metacarpal.

Causes
- Fall with axial loading through the thumb metacarpal
- Direct blow of the thumb metacarpal
- Injury involving forced abduction of the thumb

Signs and symptoms

- Pain and swelling
- Decreased range of motion of the thumb
- Shortening of the thumb
- Dorsal and radial displacement of the metacarpal bone

Surgery Clinical Treatment Guidelines 65

Chapiter 1: Orthopaedic Surgery

Investigations
- Plain x-ray (Antero-posterial and oblique views)

Management
Surgical
If the Bennetts fragment is less than 15-20% of the
articular surface: Closed reduction and percutaneous pin
fixation followed by a thumb spica splint for 4-6 weeks.
Open reduction and internal fixation. (If the Bennetts
fragment is greater than 20% or articular step off after pin
fixation is greater than 1 mm)
For Rolandos fracture: Always do Open reduction and
internal fixation (ORIF)

Recommendations
- Always refer Bennetts or Rolandos fractures to the orthopedic
surgeons after immobilization in a splint.

1.9.7. Boxers Fracture

Description: Fracture of the neck of the fifth metacarpal.

Causes
- Direct blow
- After punching a person or object such as a wall

Signs and symptoms

- Pain and swelling at the base of small finger
- Decreased range of motion
- Deformity over the dorsal aspect of the metacarpal
- Loss of the knuckle definition
- Volar displacement of the head of the metacarpal

Investigation
- Plain x-ray (Antero-posterial and oblique views)

Management
- If angulation is less than 40%: Closed reduction and splint
- If angulation is more than 40% : Closed reduction and
percuteneous pin fixation or open reduction and ORIF (Open
reduction and Internal Fixation)

66 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Recommendation

Surgery
Orthopaedic
- Check for rotation deformity after fixation

1.9.8. Fractures of Phalanges

Proximal and middle phalanges

Definition/Description: Fracture of the bones of the proximal or

middle phalanges of the fingers. Fracture can be extra-articular or
intra-articular

Causes
- Falls
- Direct blows
- Sport contact injuries
- Machinery injuries

Signs and symptoms

- Pain and swelling of the fingers involved
- Decreased range of motion
- Ecchymosis
- Rotation deformity
- Angulation
- Shortening of the fingers

Investigation
- Plain x-ray (AP, lateral and oblique views)

Complication
- Digital neuro-vascular bundle injuries

Management
Conservative (Exra-articular fractures)
Closed reduction,
if stable do buddy strapping for 4 weeks
If reduction not stable then do surgery
Surgical (Unstable Fractures and/or Intra-articular
fractures)
Closed reduction with per-cutaneous pin fixation
Or
Open reduction and internal fixation with plates and
screws

Surgery Clinical Treatment Guidelines 67

Chapiter 1: Orthopaedic Surgery

Recommendation
- Always check sensation and perfusion of the fingers before and
after treatment

1.9.9. Distal Phalanges and Nail Bed Injuries

Description: Distal phalanges fractures are often associated with nail

bed laceration.

Causes
- Crush injuries (from doors mostly in children)
- Work related trauma
- Falls

Signs and symptoms

- Pain and swelling of the fingertip
- Lacerations and/or hematoma of the nail bed
- Deformity of the fingertip

Investigation
- Plain x-ray (AP and lateral views)

Complication
- Traumatic amputation of the fingertip

Management
- If fracture is associated with nail bed laceration, repairing the
laceration will reduce the fracture. Then stabilize with a Zimmer
splint for 4 weeks.
- Otherwise do fixation with an axial per-cutaneous pin if the
distal fragment is big enough.

68 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
1.9.10. Dislocations of the Hand Joints

Surgery
Orthopaedic
Definition: A dislocation is a misalignment of the bones forming a
joint. Metacarpophalangeal joints and interpharlangeal are the most
commonly involved.

Causes
- Falls
- Sport injuries

Signs and symptoms

- Pain and swelling of the joint involved
- Decreased range of motion
- Ecchymosis
- Joint deformity

Investigation
- Plain x-ray (AP, lateral and/or oblique views)

Complication
- Nerve injuries

Management
Conservative
Relocate under nerve block or general anesthesia. If
relocation is difficult under those circumstances do an
open reduction
Splinting in functional position for 4 weeks and then
physiotherapy

Surgical
Sometime the volar plate or tendons can be entrapped into
the joint and that is why it may be impossible to do a closed
reduction.

Recommendation
- Refer to orthopedic surgeon or hand surgeon any dislocation
that cant be relocated conservatively.

Surgery Clinical Treatment Guidelines 69

Chapiter 1: Orthopaedic Surgery

1.9.11. Burns

Wound management of the burned hand follows the general principles

of burn wound management. But there are a few things that are
specific to the hands. For the general principle please refer to the
burns chapter.

- Specifics to hands in acute burn management

Every burned hand must be splinted in a functional
position
Every finger must be dressed separately to avoid synechia
Daily mobilization of fingers
Early skin grafting when required (do not use skin staples
in hands)

- Specifics to hands in post burn reconstruction

When releasing scar contractures, do not use split
thickness skin grafts. Cover defects with full thickness skin
grafts or flaps.
Release scar contractures in stages from proximal to distal.

1.9.12. Infections

PARONYCHIA ABCESS

Definition: It is the infection of the soft tissue fold around the nail. It
is the most common infection of the hand.

Causes
- Splinters
- Manicure instruments
- Nail biting

Signs and symptoms

- Erythema, swelling, and tenderness immediately adjacent to the
nail
- If left untreated the abscess may extend below the nail bed and
track into the pulp

Investigations
- Plain x-ray to exclude bone involvement in late or advanced
presentations
- Microbiology culture and sensitivity of pus and/or necrotic tissue

70 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Complications

Surgery
Orthopaedic
- Pulp abscess
- Bone involvement
- Extensive soft tissue necrosis

Management

Conservative
For early presentations: warm soaks and systemic antibiotics

Surgical
Abscess drainage
Debridement of necrotic tissues
Systemic antibiotics for 6 weeks if the bone is involved

PULP ABSCESS (FELON)

Definition: It is a subcutaneous abscess of the volar aspect of the

fingertip

Causes
- Splinters
- Thorns

Signs and symptoms

- Severe throbbing pain
- Tension
- Swelling of the entire pulp but does not extend proximal to the
distal interphalangeal crease

Investigations
- Plain x-ray to exclude bone involvement
- Microbiology culture and sensitivity of pus and/or necrotic tissue

Complications
- Bone involvement
- Extensive soft tissue necrosis

Management
- Lateral incision and drainage
- Systemic antibiotics

Surgery Clinical Treatment Guidelines 71

Chapiter 1: Orthopaedic Surgery

TENOSYNOVITIS

Definition: It is the infection of the flexor tendon sheath.

Causes
- Wound bite
- Any other penetrating injury

Signs and symptoms

- Semi flexed position of the finger
- Fusiform swelling (Sausage type)
- Excessive tenderness limited to the course of the flexor tendon
sheath
- Excessive pain on passive extension

Investigations
- Plain x-ray to exclude bone involvement
- Microbiology culture and sensitivity of pus and/or necrotic tissue

Complications
- Proximal extension of the infection to the hand and forearm
- Extensive soft tissue destruction
- Bone involvement

Management
- Incision and drainage of the tendon sheath (refer to text books
for description of proper technique)
- Systemic antibiotics

HUMAN BITES (PUNCH BITES)

Definition: It is the infection of the metacarpal phalangeal joint as a

result of an injury by tooth.

Cause
- Human bites

Signs and symptoms

- Excessive tenderness and swelling over the involved knuckle
- Decreased range of motion
- Pus discharge from the wound

72 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Investigations

Surgery
Orthopaedic
- Plain x-ray
- Microbiology culture and sensitivity of pus and/or necrotic tissue

Complications
- Complete destruction of the joint
- Extensive soft tissue destruction

Management
- Opening of the joint and adequate debridement (as many as
required)
- Systemic antibiotics

DEEP SPACE INFECTIONS OF THE HAND

Description: The hand has three anatomically defined potential

spaces and one forearm potential space. These spaces are the thenar,
midpalmar and hypothenar spaces in the hand and Paronas space in
the forearm. A deep seated infection can involve those spaces.

Causes
- Penetrating injuries
- Retained foreign bodies

Signs and Symptoms

- Excessive pain
- Tension and swelling of the hand
- Decreased range of motion

Investigations
- FBC
- MCS (Microbiology culture and sensitivity) of pus and/or
necrotic tissue
- US
- X-ray

Complications
- Extension of the infection into the forearm
- Extensive soft tissue destruction
- Frozen hand

Surgery Clinical Treatment Guidelines 73

Chapiter 1: Orthopaedic Surgery

Management
- Adequate incision and drainage plus debridement of necrotic
tissue
- Systemic antibiotics
- Splinting
- Early mobilization

1.9.13. Tendon Injuries

Definition: A tendon is a fibrous structure that connects a muscle to a

bone. A tendon injury is the laceration of a tendon.

Causes
- Penetrating injuries
- Traumatic forced extensions
- Pathologic ruptures
- (Note): Flexor and Extensor tendon injuries will be discussed
seperately

Types

:
FLEXOR TENDON INJURIES Laceration or rupture of tendons that
flex the wrists and fingers

EXTENSOR TENDON INJURIES: Laceration or rupture of tendons

that extend the wrists and fingers

Signs and symptoms

General
Pain
Swelling
Tenderness
Look for loss of sensation to exclude associated nerve
injury
Check for perfusion to exclude associated arterial injuries

Specific in flexor Tendor Injuries

Loss of active flexion of the wrist or fingers
The finger involved is in extension compared to the other
fingers
Presence of laceration on the volar aspect of the forearm,
wrist, hand or fingers

74 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
Specific in Extensor Tendor Injuries

Surgery
Orthopaedic
Loss of active extension of the wrist or fingers
Presence of laceration on the dorsal aspect of the forearm,
wrist, hand or fingers

Investigations
- Plain x-ray to exclude associated fractures
- FBC

Management
- Before transferring the patient to a hand or orthopedic surgeon
do the following:
Saline wash of the wound
Removal of foreign bodies
Dress the wound and put the hand in a volar splint

- Exploration of the laceration and repair ruptured tendons

- Postoperative hand protocol for flexor tendon injuries

Complications
- Arterial injuries
- Nerve injuries
- Infections
- Rupture of repaired tendon
- Adhesions
- Late flexion deformity

1.9.14. Nerve Injuries

Definition: Rupture or contusion of nerves.

Causes
- Penetrating injuries
- Compression neuropathies

Signs and symptoms

(Will depend on which nerves are involved and at which level it is
injured)
- Numbness
- Pain
- Weakness
- Twitching
- Sensitivity

Surgery Clinical Treatment Guidelines 75

Chapiter 1: Orthopaedic Surgery

- Paralysis
- High radial palsy: loss of extension of wrist and fingers
- Low radial palsy: extension of wrist is preserved
- High median palsy:
Paralysis of long flexors of the thumb, index and middle
finger
Loss of thumb opposition
Paralysis of pronator teres

- Low median palsy:

Power loss of thumb opposition
Loss of skin sensation to the palmar surfaces of the thumb,
index and middle finger

- Low ulna palsy:

Paralysis of most intrinsic muscles of the hand causing:
Loss of adduction and abduction of fingers
Loss of precision movement of fingers
Loss of sensation to ring and little fingers
Clawing deformity

- High ulna palsy: It is similar to low ulna palsy except that there is
no clawing deformity

Investigations
- FBC
- Plain x-ray
- EMG (Electromyography)

Management
- For non penetrating injuries, follow up patients for 3 months to
rule out neuropraxia which will recover spontaneously.
- For penetrating injuries, if nerve injury is suspected, refer the
patient to a unit that can explore the wound and repair damages.

Complications
- Associated arterial injuries
- Paralysis
- Neuromas
- Hyper or hyposensitivity

76 Surgery Clinical Treatment Guidelines

 Chapiter 1: Orthopaedic Surgery

1
1.9.15. Vessel Injuries

Surgery
Orthopaedic
Definition: Laceration to the arterial supply of the hand or fingers.

Causes
- Penetrating injuries
- Fractures

Signs and symptoms

- Profuse bleeding
- Pain
- Compartment syndrome
- Sluggish capillary filling
- Cold hand
- Loss of sensation (associated nerve injury)

Investigations
- FBC
- Plain x-ray

Management
- What to do in case of profuse arterial bleeding:
Follow ATLS protocol
Elevate the hand
Put a tourniquet proximal to the laceration
Explore the wound or put a compressive dressing just on
the spot that is bleeding just enough to control bleeding
Remove the tourniquet
Take the patient to theater for selective ligation of the
artery or its repair
If Compartment Syndrome is suspected, do compartment
release with appropriate fasciotomy.

Complications
- Associated nerve injuries
- Compartment Syndrome
- Loss of hand or finger (Gangrene)

Surgery Clinical Treatment Guidelines 77

Chapiter 1: Orthopaedic Surgery

1.9.16. Skin defects

Definition: Loss of skin tissue.

Causes
- Burn
- Trauma
- Tumor excisions
- Debridement

Signs and symptoms

- Assess the size of the defect
- Assess the depth of the defect
- Assess whether underlying vital structures are exposed or
involved

Management
- If the wound can be closed without compromising the function
of the hand or the anatomy of the hand, do a primary closure
- If a primary closure is not feasible and there is no underlying
vital structures exposed, do a skin graft
- If underlying structures are exposed, cover with a flap
- If underlying structures are involved, repair them and cover with
a flap

Complications
- Scar contractures
- Damage of vital structures

78 Surgery Clinical Treatment Guidelines

 2. Neurosurgery

2.1. Spinal Cord Injuries

2.1.1. General Considerations

2
Definition: physical trauma to the spinal cord from craniocervical

Neurosurgery
junction to the sacrococcygeal region. It may be complete or partial.

Complete: There is no neurological function below the level of the

lesion.

Partial: There is preservation of some neurological function which

may be motor, sensory or both.

Cervical cord injuries are divided into two namely high cervical and
low cervical injuries.

High cervical injuries are from C3 and above and are associated with
high mortality rates due to the phrenic nerve being cut off (C3, 4 and 5
that results in respiratory failure)

Low cervical injuries are from C5 and below

Spinal shock is the transient loss of neurological function and evidence

is flaccid paralysis and areflexia that may last up to 2 weeks

Causes
- Trauma
- Tumors
- Infections
- Vascular conditions

Signs and symptoms

Complete
High cervical injury; most of the patients will die at the
scene of the accident because of respiratory failure
Gasping for air
Urinary retention
Reduced GIT function

Surgery Clinical Treatment Guidelines 79

Chapiter 2: Neurosurgery

Low cervical injury

Low BP due to sympathetic cut off
Abdominal breathing
May have upper limb function e.g. injury at C7 will
be able to lift arms
Extremities are warmer than usual with dilated
vessels

Partial
Partial Cord injuries are composed of the following
syndromes
Central Cord Syndrome: greater motor deficit in
upper limbs than lower limbs
Brown Sequard (Cord hemisection) Syndrome:
motor paralysis and loss of proprioception and
vibratory sense ipslateral to the lesion with loss of
pain and temperature sensation contralateral to the
lesion 1 or 2 segments below
Anterior Cord Syndrome: loss of motor function
with preservation of proprioception and vibratory
sensation
Posterior Cord Syndrome: loss of proprioception
and vibratory sensation with preservation of motor
function

Investigations
- FBC, CRP and ESR etc. when suspecting infection
- X-rays and CT scan may show the bony cause of spinal cord
injury
- Myelography with or without CT scan, indicated for people that
have contra indication for MRI
- Investigation of choice is MRI

Management
- For spinal trauma manage according to ATLS (Adult Trauma Life
Support)
- Put cervical collar
- Hard board for thoracic and lumber suspected injuries (Prevent
pressure sores)
- For blunt trauma give Methyl prednisolone 30mg/kg IV for
30min and rest for 30min give 5mg/kg/hr 23 hours for those
seen within first 5 hours of injury and for 48 hours for those seen
between 5 - 8 hours of injury
- After making diagnosis treat accordingly

80 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

- Patients should have immediate decompression where there

is cord compression by a neuro surgeon or any other trained
surgeon in doing the procedure

Complications
- Pressure sores
- Respiratory Tract Infections 2
- Urinary Tract Infections

Neurosurgery
- DVT
- Pulmonary embolus

Recommendation
- Complications are best managed by anticipatory preventive
measures.

2.1.2. Spinal Fractures and Dislocation

Definition: Refers to disruption of vertebra column caused by physical

trauma. Fractures may be stable or unstable. Stable fractures are those
with minimal or no risk of neurological damage whereas unstable
fractures are those with a high likelihood of neurological damage
coupled with slight movement.

Causes
- Motor accidents
- Fall from height
- Sports injuries
- Projectiles

Specific types of fractures

- C1 - Jefferson
- C2 - Odontoid fractures (Types 1,2and 3)
- Hangermans fractures
- Subaxial spinal injuries
Single facet dislocation
Bifacet dislocation

- Thoracic
Upper
Middle
Thoraco lumber

Surgery Clinical Treatment Guidelines 81

Chapiter 2: Neurosurgery

- Lumber
Wedge compression fractures
Burst fractures
Fracture dislocations
Seatbelt fractures

C1 Fractures

There are three types of C1 fractures, types I to III, the most common
is type II (Jefferson)

C1 - JEFFERSON

Definition: It is a burst fracture of C1 ring; at 2 or more points on C1

ring

Cause
- Loading force directly over the head (in neutral position)

Signs and symptoms

- History suggestive
- Neck pain
- Neurological deficits are rare

Investigations
- X-ray of C spine
- C T scan (best choice)
- MRI

Management
- Analgesia
- Hard collar or SOMI brace (Sternal Occipital Mandibular
immobilization)
- Surgical intervention indicated when there is disruption of
transverse ligament

C2 - FRACTURES

ODONTOID FRACTURES
- Type 1: fracture through the tip
- Type 2: fracture through the base of odontoid
- Type 3: involves both odontoid and body of C2

82 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

Causes
- Motor accidents
- Fall from height
- Sports injuries
- Projectiles

Signs and symptoms 2

- High posterior cervical pain sometimes radiating to occipital region

Neurosurgery
- Paraspinal muscle spasm
- Reduced range of motion of the neck
- Tenderness to palpation over the upper cervical spine
- Tendency to support the head with the hands
- Paraesthesias in upper limbs

Investigations
- C x-ray with open mouth views
- CT scan

Management
- Type1: The most common is immobilization with SOMI brace
or hard collar. Sometimes needs surgery because of associated
ligamentous injury
- Type 2: If there is displacement of more than 4mm surgery is
needed
- Type 3: Treated by immobilization with SOMI brace or hard
collar for 6 -12 weeks

HANGERMANS FRACTURES
Description: Bilateral fracture through the pars interarticularis with
traumatic sublaxation on C2 and C3, most of them are stable with no
neurological deficits. It has three types which are: type1, type2, type 3
(Levine classification), type 1 is stable; types 2 and 3 are unstable.

Causes
- Motor accidents
- Fall from height
- Sports injuries
- Projectiles

Signs and symptoms

- Neurotically intact if any they are minor
- Neck pain
- Commonly associated with head and cervical injuries

Surgery Clinical Treatment Guidelines 83

Chapiter 2: Neurosurgery

Investigations
- X-rays
- CT scan with CTA (CT angiography)
- MRI/MRA (MR angiography)

Management
- SOMI brace or hard collar for 8- 14 weeks
- For Type 2 may require closed reduction with external
immobilization
- Type 3 requires ORIF

2.1.3. Subaxial Spinal Injuries (from C3 C7)

Types
- Unifacet sublaxation (Jumped facet)
- Bifacet sublaxation

UNIFACET SUBLAXATION

Description: Commonly associated with less neurological deficit, the

affected facet has its capsule disrupted.

Cause
- Flexion and rotation of the neck

Signs and symptoms

- Neck pain
- Neurological deficit

Investigations
- C spine x-rays
AP view spinous process above sublaxation they rotate to
the same side of the jumped facet
Lateral view shows bow tie sign (visualization of left and
right facet joint instead of usual superimposed position
Oblique view may demonstrate jumped facet blocking
neuro foramen

- CT scan shows naked facet sign (reversed Hamburg sign)

- MRI to rule out disc prolapsed

84 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

Management
- Initial treatment may be open or closed reduction.

BIFACET SUBLAXATION

Descriptions: Occurs with disruption of ligaments of apophysial

joints, ligamentum flavum, longitudinal and interspinous ligaments 2
and annulus, most common at C5/ C6 or C6/C7, associated with 65-

Neurosurgery
87% complete quadriplegia.

Causes: Hyperflexion of the neck.

Signs and symptoms

- Associated with 65- 87% complete quadriplegia
- 15-25% may have incomplete quadriplegia

Investigations
- C spine x-ray (lateral view show a vertebral body over the
adjacent one)
- CT scan
- MRI to rule out prolapsed disc

Management
- Closed reduction by putting patient on prolonged tongs traction
- ORIF

2.1.4. Spinal Cord Injury Without Radiographic Abnormality

(SCIWORA)

Description: It happens in a subgroup of children with neurological

deficits, but radiographic investigations show no abnormality (both
static and dynamic). This is attributed to normally increased elasticity
of the spinous ligaments and intervertabral soft tissue in young
population.

Causes
- Motor accidents
- Fall from height
- Sports injuries
- Projectiles

Surgery Clinical Treatment Guidelines 85

Chapiter 2: Neurosurgery

Signs and symptoms

- Gasping for air
- Urinary retention
- Reduced GIT function
- Low BP due to sympathetic cut off
- Abdominal breathing
- May have upper limb function e.g. injury at C7 will be able to lift
arms
- Extremities are warmer than usual with dilated vessels

Investigation
- MRI is the investigation of choice

Management
- Commonly supportive
- Surgical intervention has shown no improved outcome

2.1.5. Thoracic Fractures

Description: The thoracic canal is smaller compared to other spinal

regions making it more vulnerable to even small compressive lesions.
Having a ribcage makes it more rigid and less susceptible to unstable
fractures. It is commonly associated with chest injuries.

Causes
- Motor accidents
- Fall from height
- Sports injuries
- Projectiles

Signs and symptoms

- Bruising around the area
- Tenderness on affected area
- Bump along the spine
- Partial or complete paraplegia
- Bladder and bowel dysfunction

Investigations
- Thoracic x-rays
- CT thoracic spine
- MRI

86 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

Management
- Initial assessment and management according to ATLS
- Definitive treatment in specialized centres

2.1.6. Thoracolumbar Fracture

2
Description: Thoracolumber fructure is a transition zone between the

Neurosurgery
rigid thoracic spine and mobile lumbar spine. It is between T10 to L2.
This is among the most commonly susceptible regions to fractures.

Common Types of fractures

- Compression fractures
- Burst fractures
- Seat belt fractures
- Fracture dislocation

COMPRESSION FRACTURES

Definition: Its a wedge compression of the anterior part of the vertebral

body.

Cause
- Flexion injury to thoraco lumbar region

Signs and symptoms

- Bruising around the area
- Tenderness on affected area
- Bump along the spine

Investigations
- Plain thoracolumbar x-rays ( AP &Lateral Views)
- CT Scan

Management

Indications for surgery

Wedge pointing
Excessive Kyphosis
When there are 2 or more contiguous fractures
If there is any neurological deficit
Progressive kyphosis

Surgery Clinical Treatment Guidelines 87

Chapiter 2: Neurosurgery

Recommendations
- Bed rest
- Analgesia
- TLSO ( Thoracolumbar sacral orthosis)

BURST FRACTURES

Description: There is a pure axial loading force leading to compression

of the vertebral body.

Causes
- Motor accidents
- Fall from height
- Sports injuries
- Projectiles

Signs and symptoms

Will depend on patency of the spinal canal

- Severe pain
- Tenderness to palpation
- Bruising
- May or may not have neurological deficit ( 50 % of patients will
remember some form of neurological dysfunction, that subside
during transfer to hospital)

Investigations
- X-rays
Lateral x-rays show; cortical fracture of posterior VB
retropulsion of bone fragments into canal
AP View show increase in interpeducular distance,
laminae fractures, spraying of facet joints

- CT scan
- MRI

Management
- Manage according to ATLS protocol
- Specialized surgical intervention

88 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

SEATBELT FRACTURES

Definition: Its a flexion injury sustained on a fulcrum which may be

bony, ligamentous or both. It has four subtypes, type I is called a chance
fracture (purely through bone).

Causes
2
- Motor accidents

Neurosurgery
- Seatbelt injuries
- Fall from height
- Sports injuries
- Projectiles

Signs and Symptoms

- Severe pain
- Tenderness to palpation
- Seatbelt bruising
- Abdominal injuries
- May or may not have neurological deficit

Investigations
- X-rays
- CT scan
- MRI

Management
- Manage according to ATLS
- TLSO in extension for patients with no neurological deficit
- Specialized surgical intervention

FRACTURE DISLOCATION

Description: It is due to failure of the three columns due to compression,

tension, rotation or shear leading to sublaxation or dislocation. It is the
worst type of a thoracolumbar fracture.

Causes
- Fall from height
- Motor accidents
- Sports injuries
- Projectiles

Surgery Clinical Treatment Guidelines 89

Chapiter 2: Neurosurgery

Signs and symptoms

- Severe pain
- Tenderness to palpation
- May have abdominal injuries
- Neurological deficit

Investigations

- X-rays
- CT scan
- MRI

Management

- Manage according to ATLS

- Specialized surgical intervention

2.1.7. Cauda Equina

Definition: It is a clinical condition arising from dysfunction of

multiple lumbar and sacral nerve roots compression within lumbar
spinal canal. Usually due to compression of cauda equina.

Causes

- Massive herniated lumber disc

- Tumors
- Free fat graft following discectomy
- Trauma
- Spinal epidural hematoma
- Infection e.g. epidural abscess, septic thrombophlebitis
- Neuropathy (inflammatory or ischemic)
- Enkylosing spondolytis

Signs and symptoms

- Sphincter disturbance
- Saddle anesthesia
- Significant motor weakness (usually involves more than a single
nerve root if not treated may progress to paraplegia)
- Bilateral absence of Achilles reflex
- Low back pain and/or Sciatica usually bilateral
- Sexual dysfunction

90 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

Investigations

- Infection screening
- X-ray
- CT scan
- MRI

Management 2
- Surgical intervention in specialized centers in case of

Neurosurgery
compression, which must be performed within 24 hours
- Conservative management in case of inflammatory and ischemic
neuropathies

Complications
- Paraplegia
- Persistent sphincter dysfunction
- Pressure sores
- Urinary infection
- DVT

2.2. Cerebral Vascular Diseases (Spontaneous

Haemorrhage)

Intracranial hemorrhage may be subdural, subarachnoid and

intracerebral (intra parancyma). Subdural hemorrhage is discussed
under traumatic causes of intracranial hemorrhages.

2.2.1. Intracerebral Hemorrhage

Definition: It is a hemorrhage within the brain parenchyma, commonly

referred to as hypertensive hemorrhage, it is the second most common
form of strokes (15-30%) but most deadly. Occurs at common sites for
hypertensive bleeds (putaminal, thalamic, cerebellar and lobar).

Risk Factors
- Age ( > 55yrs)
- Gender common in females
- Previous stroke
- Alcohol consumption
- Drug abuse
- Cigarette smoking
- Liver dysfunction

Surgery Clinical Treatment Guidelines 91

Chapiter 2: Neurosurgery

Causes
- Chronic poorly treated hypertension
- Amyloid angiopathy
- Ischaemic transformation
- Rupture of an aneurysm
- AVM (arterio Venous malformation)
- Coagulopathies
- Tumors
- Idiopathic

Signs and symptoms

- Headache of sudden on set
- Gradual neurological deterioration (consciousness, slurred
speech, extremity weakness)

Causes
- Hypertension
- Trauma

Investigations
- Coagulation screen (LFTs, PI/PTT or INR etc)
- RFTs
- Glycemia
- ECG
- CT scan without contrast
- CT angiography in suscipicious cases ( AVM, aneurysm)
- MRI (Not necessary in acute phase)

Management
- Manage according to ACLS (Advanced Cardiac Life Support)
- Manage specific to cause:
Anuarysm (see Sub Arachnoid haemorrhage (SAH))
AVM; do clipping or embolization or both

- Control hypertension by 20% of initial systolic pressure

- Admit comatose patients to ICU ( GCS = 9 < from 13-10 to
HDU)
- Control and maintain Euglycemia, Euvolaemia
- Normal temperature
- Anticonvulsants
- Medical Control of intracranial hypertension

92 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

Guidelines for considering surgery versus medical management

Non surgical
Minimally symptomatic lesions ( GSC >10)
Situations with little chance of good outcome such as poor
prognostic factors such as: renal failure, heart failure, poor
neurological dysfunction etc. 2
Severe coagulopathies

Neurosurgery
Basal ganglia or thalamic hemorrhage

Surgical
Lesion with marked mass effect, oedema, midline shift
Lesions where symptoms appear to be due to increases ICP
Volume of hematoma (Types minor < or = 10mls,
moderate 10-30mls, severe > 30mls) surgery is indicated
for moderate volumes
Cerebellar hematomas surgery is indicated for hematomas
> or = 3cm in widest diameter
Failure of medical management
Rapid deterioration regardless of hematoma location and size
Favorable location e.g. lobar, cerebellar, external capsule
and non dominant hemisphere
Age less than 50yrs
Early intervention (less than 24 hours)

2.2.2. Subarachnoid Hemorrhage

Description: It occurs as a result of bleeding from aneurismal rapture

in 5% from perimesencephalic.

Causes/Risk factors
- Hypertension
- Smoking
- Excessive alcohol consumption

Signs and Symptoms

- Sudden onset of headaches (described as the worst headache of
my life)
- Nausea and vomiting
- Photophobia
- Neurological dysfunctions
- Seizures

Surgery Clinical Treatment Guidelines 93

Chapiter 2: Neurosurgery

Investigations
- Coagulopathy screen
- CT Scan without contrast
- CTA

Management
Management is based on grade of patient

PATIENT GRADING (WFNS SAH grading)

Grade GCS Focal neurological deficit

I 15 Absent

II 13-14 Absent
III 13-14 Present
IV 7-12 Present or absent
V <7 Present or absent

General measures
Fluids additional 3l to the usual maintenance
Adequate analgesia
Elevate head to 300
Quiet rooms and dim light
Anticonvulsants
Stool softeners
Nimodipine 60mg Per Os every 4 hours for 21days or
when aneurysm is clipped
Aneurysm clipping or coiling (specific measure)

Complications
- Vasospasms occurs between day 3 14
- Treated with hydration and Nimodipine
Hydrocephalus which can occur immediately or after

94 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

2.3. CNS Infections and Infestations

2.3.1. Brain Abscess

Definition: Is a pus containing cavity in brain, it goes through stages.

Causes 2
- Hematogenous spread

Neurosurgery
- Contagious spread

Signs and symptoms

- Direct inoculation
- Non specific signs
- Fever
- Headache
- Nausea
- Lethargy
- Neurological deficit
Papilloedema
Seizures

Investigations
- Infection screen
- CT scan with contrast

Complications
- Seizures
- Permanent neurological deficit

Management
Management may be medical alone or medical with surgical drainage/
surgical excision

Medical management
Fluid resuscitation
Anticonvulsants
Antibiotics

Note:
ICU admission may be necessary depending on GSC

Surgery Clinical Treatment Guidelines 95

Chapiter 2: Neurosurgery

2.3.2. Cranial Subdural Empyema

Definition/Description

SUBDURAL EMPYEMA: A collection of pus in subdural space.

CRANIAL EPIDURAL EMPYEMA: A collection of pus between bone

and duramater

Causes
- Hematogenous spread
- Contagious spread
- Direct inoculation

Signs and symptoms

- Swelling on the fore head (Potts puffy tumor)
- Non specific signs
- Fever
- Headache
- Nausea
- Lethargy
- Neurological deficit
- Papilloedema
- Seizures

Investigations
- Infection screen
- CT scan with contrast

Complications
- Seizures
- Permanent neurological deficit

Management

Management may be medical alone or medical with surgical drainage

Medical management
Fluid resuscitation
Anticonvulsants
Antibiotics
ICU admission may be necessary depending on GSC

96 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

2.3.3. Neuro Cysticercosis

Definition: it is intracranial encasement of larva of T solium, it is the

most common parasitic infestation in CNS.

Mode of transmission
2
- Water and food contaminated with eggs

Neurosurgery
- Fecal oral
- Auto infection

Signs and symptoms

- Seizures
Signs of Raised ICP
Focal neurological deficits
Subcutaneous nodules

Investigations

- Serology or CSF (Antibody or antigen of Cysticercosis)

- CT scan or MRI

Management

- Antihelmentic (e.g. Albendazole 15mg /kg/d PO in divided or

single dose for 21 days or praziquantel )
- Steroids (e.g. Dexamethasone 2-4 mg PO every 8 hours for
2weeks)
- Anticonvulsants (e.g. Phenytoin 15-20mg /kg as a loading dose
and maintenance dose of 5mg/kg/day for 21 days or as long as
seizures are present)
- Surgery; excision of the cyst

Indications for surgery

- Large cysts causing mass effect

- Cysts causing abstractive hydrocephalus

Surgery Clinical Treatment Guidelines 97

Chapiter 2: Neurosurgery

2.4. Hydrocephalus in Children

Description: It is a condition that results when normal exit and

absorption of cerebral spinal fluid in the ventricles are impaired. This
leads to progressive accumulation of this fluid in the ventricles of the
brain, resulting in progressive damage to the developing brain with
associated mental retardation and visual impairment.

Causes
- Congenital abnormality
- Intraventricular hemorrhage
- Infection
- Head trauma
- Brain tumor

Signs and symptoms

- Accelerated head growth

- The babys soft spot (anterior fontanelle) is usually full or bulging,
or even tense, due to the increased pressure inside the head.
- Sometimes the babys eyes will appear to be looking downward
all the time (sunset phenomenon), or may look crossed.

Investigations

- Serial measurement of head circumference which shows

excessive head growth
- Ultrasound study of the brain can be performed
- CT scan of the brain
- MRI of the brain

Complications

- Permanent blindness
- Permanent psychomotor disability
- Shunt complication (malfunction)
- Infection

Management

- Ventriculo-peritoneal shunt insertion is the most commonly

used
- Endoscopic third ventriculostomy
- Treatment of the cause in case of obstructive hydrocephalus

98 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

2.5. Myelomeningocele
Definition: Congenital defect in vertebral arches with cystic dilatation
of meninges and structural or functional abnormality of spinal cord or
cauda equina.

Risk factors
2
- Low folate during female reproductive age

Neurosurgery
- Obesity
- Smoking
- Alcohol use
- Anticonvulsants
- Febrile illness, heat exposure, hot tub and sauna during first
trimester
- Genetic
- Young age

Signs and symptoms

- Non skin covering spinal defect with fluid containing cyst
- Neurological dysfunction below the level of lesion
- Lower limb deformities such as club feet
- Chiari type 2 malformation and hydrocephalus may be
associated

Investigations

Prenatal
Amniocentesis
Ultrasound

Postnatal
CT scan
MRI

Management
- Early closure of myelomeningocele defect by a trained surgeon
- Infection prophlaxis with ceftriaxone or cetaxime and
gentamycin immediately for 1 week
- Covering of spinal defect with a sterile saline soaked gauze which
can be changed as needed
- Monitor head circumference and anterior fontanel for possible
development of hydrocephalus

Surgery Clinical Treatment Guidelines 99

Chapiter 2: Neurosurgery

Complications
- Permanent neurological deficit
- Pressure sores
- Urinary tract infection
- Meningitis
- Ventriculitis
- Hydrocephalus

2.6. Head Injury

Definition: Head injury is physical trauma to the head. It is broadly

classified into 2 entities:
- Open head trauma in which there is a scalp laceration with
underlying skull fracture and breached Dura Mater (i.e. brain
communication to the outside environment).
- Closed head injury there is no communication with the outside
environment.

It can also be classified by severity into mild, moderate and sever head
trauma depending on the level of consciousness.

Causes
- Motor Vehicle Accidents (MVA)
- Pedestrian Vehicle Accident (PVA)
- Assault injuries
- Fall from heights
- Sports injuries
- Missile injuries e.g. gunshot wounds

Signs and symptoms

- Deterioration of level of consciousness (GCS)
- Seizures
- Vomiting
- Headache
- Evidence of skull base fracture such as :
Racoon eyes (peri-orbital ecchymoses)
Battles sign which are post auricular ecchymoses
CSF rhinorrhoea
Otorrhoea
Haemotympanium

- Wounds or hematoma on impact site

- Focal neurological deficit such as hemiplegia

100 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

SEVERITY ASSESMENT OF HEAD TRAUMA

- Divided into 5 categories:
- Minimal : here GCS =15,no Loss of consciousness (LOC)
- Mild: GCS = 14 or GCS = 15 with either brief LOC of < 5
minutes, or impaired alertness or memory
- Moderate: GCS=9-13 or LOC > 5minutes or Focal Neurological
Deficit
- Severe : GCS =5-8 2
- Critical : GCS = 3-4

Neurosurgery
Investigations
- RBG, FBC, PT, PTT, Blood Grouping and Cross Matching
- Urea and Electrolytes
- Toxicology screening e.g. alcohol, illicit drugs screening
- Arterial Blood Gas Levels are very important
- Skull x- ray to look for fracture
- Brain CT scan

Management
- The Primary goal of therapy is to prevent secondary brain
injury which is done by maintaining adequate perfusion and
ventilation.
- After following ATLS guidelines for management of trauma
patients, management follows the severity of the head trauma.
- Mild head trauma
Bed rest with head off bed (HoB) elevated to 30-45 degrees
Neuro checks every 2 hours or every hour if more
concerned
NPO until alert, then clear fluids and advance to other
foods as tolerated
Isotonic IV fluids mainstay being N/Saline running at
usually 100mls/hr
Mild analgesia: paracetamol PO or PR if NPO

- Moderate head trauma

As in minor above but always keep NPO in case surgical
intervention is needed
GCS 9-12 ADMIT to ICU, GCS 13 ADMIT IF CT shows
any significant abnormality
Patients with normal or near normal CT-Scans should
improve within hours. Any that fails to reach GCS 14-15
with in 12 hours should have the CT repeated at that time.

Surgery Clinical Treatment Guidelines 101

Chapiter 2: Neurosurgery

SEVERE AND CRITICAL HEAD INJURY

These are usually co- systemic injuries. They are admitted to ICU
and the first priority is to look for any features of Intra-Cranial
Hypertension (IC-HTN) which are:
- Unilateral or bilateral pupillary dilatation
- Asymmetric pupillary reaction to light
- Decerebrate or decorticate posturing
- Progressive deterioration of neurological sign not attributable to
extra cranial factors

When one or more of these signs is witnessed in evolution, thats

convincing evidence of IC-HTN

These patients have to be:

- INTUBATED - with a GCS of 8 or less its assumed one
cannot keep the patients airway patent. Patients with severe
maxillofacial injury will also need to be given a tracheostomy.

- HYPERVENTILATION - only when a patient has CT and

clinical features of IC-HTN should they be hyperventilated, and
the PCO2 should be between 30-35 mmHg and should never
drop below 30mmHg - this is a temporary measure awaiting
definitive treatment for the IC-HTN

- PARALYSIS AND SEDATION - only when there is evidence of

IC-HTN should there be paralysis and sedation

- MANNITOL - is given only in cases of:

Evidence of IC-HTN
Evidence of mass effect e.g. focal deficits like hemi paresis
Sudden deterioration prior to CT-Scan
If a lesion associated with increased ICP is identified e.g.
SDH, EDH
Assess the recovery ability of patients with no evidence of
brain stem function (look for return of brain stem reflexes)

It is contraindicated in hypotension (map 70mmhg) but remember

that when one is resuscitated and the BP is acceptable then mannitol
can be given.

Mannitol should be used with caution in patients with clotting

disorders because it affects coagulation, and in congestive heart failure
patients it increases intravascular volume before it causes diuresis.

102 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

DOSE: bolus with 0.25 1gm/kg over 20mins.

Remember steroids (dexamethasone, hydrocortisone) have no place in
management of acute head injury.

- PROPHYLACTIC ANTI-EPILEPTIC DRUGS:

Given when there is increased risk of Post Traumatic Seizures
namely:
2
Acute SDH, epidural and intracerebral haematoma
Open depressed skull fractures with parenchymal injury

Neurosurgery
Seizure within the first 24 hours of injury
GCS less than or equal to 10
Penetrating brain injury
History of significant alcohol intake
Cortical (hemorrhagic) contusion on CT-Scan

Preferred drug is PHENYTOIN (EPANEUTIN) loading dose of IV

drug 18mg/kg in 200mls of N/Saline to run within 30mins for the 1st
24 hrs then maintenance of 5mg/kg daily on subsequent days.

- SURGERY: Is indicated to evacuate any haematomas that are the

cause or potential cause of IC-HTN and is only done when the
patient has been stabilized.

Complications
- Post-traumatic seizures
- Permanent neurological disability
- Post-traumatic hydrocephalus
- Post-Concussion Syndrome
- Infection e.g. Meningitis, brain abscess, chronic osteitis etc.
- Chronic traumatic encephalopathy
- Subdural hematoma
- It is a collection of blood between the Dura Mater and arachnoid
layer. It is subdivided into acute (< 72hours) Subacute (between
72 hours and 3 weeks) and Chronic ( > 3weeks).
- The most commonly seen are acute and chronic subdural
hematoma

Surgery Clinical Treatment Guidelines 103

Chapiter 2: Neurosurgery

2.6.1. Acute Subdural Hematoma

Causes
- Fall
- Motor vehicle accident
- Assault
- Child abuse (Shaken Baby Syndrome)

Signs and symptoms

- Coma, vomiting
- Brain herniation signs such as dilated ipsilateral pupil
- Hemiparesis

Investigations
- Fundoscopy in case of Shaken Baby Syndrome (retinal
hemorrhage can be evidenced)
- CT scan (to visualize crescentic hematoma and midline shift)

Management
- General management of head injury
- Indications for surgery
Subdural hematoma thickness greater than 10mm
Midline shift greater than 5mm as seen on CT scan
Less of the above but with decreasing of GCS between the
time of injury and hospital by 2 or more points or fixed and
dilated pupils and or ICP exceeds 20mmHg

2.6.2. Chronic Subdural Hematoma

Cause
- Minor head injury or fall often not remembered by patients or
relatives.

Risk factors
- Old age
- Alcohol abuse
- Seizures
- Cerebral spinal fluid shunts
- Anticoagulation

104 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

Signs and symptoms

- Headache
- Nausea
- Vomiting
- Hemiparesis
- Language disturbances
- Gait problems 2
- Transient ischemic attack like symptoms

Neurosurgery
- Decreased consciousness
- Sphincter disorder
- Bilateral papilloedema on fundscopy

Investigations
- Coagulation screening
- ECG
- CT scan which shows hypo or isodense fluid collection in
crescentic shape and midline shift
- MRI

Management
- Stabilization of patients according to ACLS protocol
- Surgery by a trained surgeon

2.6.3. Epidural Hematoma

Definition: It is the collection of blood between the skull and the Dura
Mater caused by a rupture of artery and vein in epidural space, as a
result of a fracture of the skull at the moment of the impact in 60-90%
of cases.

Causes
- Motor Vehicle Accidents (MVA)
- Pedestrian Vehicle Accident (PVA)
- Assault injuries
- Fall from heights
- Sports injuries

Signs and symptoms

- Neurological presentation varies according to the size, location
and time course of the hematoma
- Lucid interval is common
- Vomiting
- Hemiparesis
- Brain Herniation Syndrome

Surgery Clinical Treatment Guidelines 105

Chapiter 2: Neurosurgery

Investigations
- X-ray can show the fracture of the skull
- CT scan can show biconvex shaped hematoma adjacent to the
skull

Management
- Initial management according to ATLS
- Epidural hematoma in posterior fossa and temporal region are
especially dangerous
- Surgical treatment is commonly indicated to remove hematoma
as soon as possible

Complications
- Permanent neurological deficit
- Prolonged coma leading to pressure sores, DVT, pulmonary and
urinary infection

2.6.4. Intracranial Hematoma

Definition: Traumatic intraparancymal hemorrhage is commonly

associated with brain contusion.

Causes
- Motor Vehicle Accidents (MVA)
- Pedestrian Vehicle Accident (PVA)
- Assault injuries
- Fall from heights
- Sports injuries
- Missile injuries

Signs and symptoms

- Focal neurological deficit according to the sites
- Alteration of consciousness
- Seizures
- Vomiting
- Traumatic lesions on site of impact
- Herniation Syndrome

Investigations
- X-ray shows bone lesion or intracranial foreign bodies in case of
penetrating injury
- CT scan is the investigation of choice

106 Surgery Clinical Treatment Guidelines

 Chapiter 2: Neurosurgery

Management
- Initial management is according to ATLS protocol
- Surgery is indicated in:
Progressive neurological deterioration referable to the
TICH, medically refractory intracranial hypertension or
signs of mass effect on CT Scan
TICH > 50ml 2
GCS = 6-8 with frontal or temporal TICH volume > 20ml

Neurosurgery
with midline shift to 5mm and/or compressed basal
cisterns on CT

Complications
- Post-traumatic seizures
- Permanent neurological disability
- Post-traumatic hydrocephalus
- Prolonged coma leading to pressure sores, DVT, pulmonary and
urinary infection

Surgery Clinical Treatment Guidelines 107

 3. Cardio Thoracic Surgery

3.1. Chest Trauma

3.1.1. Simple Rib Fracture

Definition: Simple rib fracture is a break in continuity of the rib(s).

Causes
- Pathological
- Injury to the chest

Signs and symptoms

3
- Chest pain

Surgery
Cardio Thoracic
- Difficulty breathing
- Chest wall wound (bruise, contusion or laceration)
- Shallow and rapid breathing
- Localized tenderness on palpation
- Altered percussion note
- Reduced breath sound on auscultation

Investigations
- CXR
- CT scan and MRI

Management
- Admit the patient
- Analgesics for pain control
local infiltration using 2% lignocain)
SC morphine according to patient body weight
NSAID (ibuprofen or diclofenac either oral or per rectal)

- Chest physiotherapy

Complications
- Atelectasis
- Pneumonia

Surgery Clinical Treatment Guidelines 109

Chapiter 3: Cardio Thoracic Surgery

3.1.2. Flail Chest

Definition: Segmental fracture of rib(s) resulting in paradoxical

movement of the chest that may lead to respiratory dysfunction.

Cause
- Trauma to the chest

Signs and Symptoms

- Chest pain
- Difficulty in breathing
- Paradoxical chest movement
- On inspection - bruising, contusion or laceration of the chest
wall
- On palpation - localized tenderness
- On auscultation - reduced breath sounds

Investigations
- CXR
- CT scan and MRI

Management
- Admission
- High flow oxygen by mask
- Position patient on the injured side
- Analgesia
- Restricted fluid administration
- Monitor oxygen saturation
- Intubate if patient not responding
- Admit to ICU for mechanical ventilation

Complications
- Associated injuries (lung contusion, haemothorax,
pneumothorax and pericardial tamponade)
- Pneumonia
- Empyema thorasis

110 Surgery Clinical Treatment Guidelines

 Chapiter 3: Cardio Thoracic Surgery

3.1.3. Pneumothorax

Definition: Collection of air in pleural cavity which can be either

simple or under tension resulting in pressure on the mediastinum.

Causes
- Chest trauma
- Spontaneous

Signs and Symptoms

Tension pneumothorax
Chest pain
Bruising, contusion, laceration of chest wall
Severe dyspnea 3
Cyanosis

Surgery
Cardio Thoracic
Mental confusion
Sweating
Reduced chest movement
Displacement of the tracheal and apex beat
Absent breath sounds on affected side
Hyperresonance
Hypotension
Jugular venous distension

Simple pneumothorax
Chest pain
Shallow respiration
Bruising, contusion, laceration of chest wall
Reduced breath sounds
Heperresonance

Investigations
- Clinical diagnosis for tension pneumothorax
- CXR, CT scan for simple pneumothorax

Management

Tension pneumothorax
Wide bore cannula in the second intercostals space mid-
clavicular line
High flow oxygen by mask
Analgesia for pain
Monitor oxygen saturation
Chest tube insertion with underwater seal connection

Surgery Clinical Treatment Guidelines 111

Chapiter 3: Cardio Thoracic Surgery

Simple pneumothorax
High flow oxygen by mask
Analgesia
Monitor oxygen saturation
Chest tube insertion under water seal connection

Complications
- Collapse lung
- Lung contusion
- Pneumonia

3.1.4. Haemothorax

Definition: The collection of blood in pleural space.

Cause
- Chest trauma

Signs and symptoms

- Chest pain
- Bruising, contusion, laceration of chest wall
- Dyspnea
- Sweating
- Hypotension
- Diminished breath sound
- Dull percussion note

Investigations
- CXR
- CT scan

Management
- High flow oxygen by mask
- Analgesia
- Chest tube insertion under water seal connection
- May transfuse
- Thoracotomy may have to be done if initial drainage is more than
1.5 L of blood or if active drainage is more than 200 ml/ hour

112 Surgery Clinical Treatment Guidelines

 Chapiter 3: Cardio Thoracic Surgery

3.1.5. Cardiac Tamponade

Definition: The collection of blood in pericardium causing cardiac

dysfunction.

Cause
- Chest trauma

Signs and symptoms

- Chest pain
- Bruising, contusion, laceration of chest wall
- Congestion of neck veins
- Hypotension
- Severe dyspnea
- Mental confusion 3
- Distant muffled heart sound

Surgery
Cardio Thoracic
- On ECG there is electrical alternans
- Pulsus paradoxicus
- FAST (focused abdominal sonography in trauma); pericardial
effusion
Investigations
- CXR
- CT scan
- ECG

Management
- High flow oxygen
- Analgesia
- Pericardiocentesis (sub xyphoid approach)

3.1.6. Lung Contusion

Definition: The inflammation of the lung following a chest injury.

Cause: Chest trauma

Signs and symptoms

- Chest pain
- Bruising, contusion, laceration of chest wall and rib fractures
- Dyspnea
- Reduced breath sound
- Dull percussion note
- Hemoptysis

Surgery Clinical Treatment Guidelines 113

Chapiter 3: Cardio Thoracic Surgery

Investigations
- CXR
- CT scan

Management
- High flow oxygen
- Analgesia
- Restricted fluid administration
- Monitor oxygen saturation
- Intubation and mechanical ventilation if not responding to the
above
- May require chest drainage if associated pneumothorax and
haemothorax.

3.1.7. Ruptured Diaphragm

Definition: A tear in the diaphragm which allows protrusion of

abdominal organs in the chest.

Cause
- Trauma

Signs and symptoms

- Assymptomatic
- Abdominal and chest pain
- Dyspnea
- Hypotension
- Decreased breath sound
- Dull percussion note
- Bowel sound in the chest

Investigations
- CXR
- CT scan

Management
- High flow oxygen
- Analgesia
- Surgical intervention after stabilization

114 Surgery Clinical Treatment Guidelines

 Chapiter 3: Cardio Thoracic Surgery

3.2. Lung Conditions

3.2.1. Empyema Thoracis

Definition: The collection of pus in the pleural cavity. It can be

classified as acute, sub-acute and chronic.
Causes
- Partilly treated pneumonias
- Neglected pneumonias
- Pulmonary tuberculosis
- Hematogenous spread from distant foci
- Post traumatic chest infections
- Perforated oesophagus
- Local spread from sub-diaphragmatic abscess 3

Surgery
Cardio Thoracic
Signs and symptoms

Acute empyema thoracis

Chest pain
Fever
Sweating
Dyspnea
Coughing
Underlying chest infection
Stony dull percussion note
Reduced breath sounds

Sub-acute empyema thoracis

Chest pain
Dyspnea
Cough
Fever
Underlying chest infections
Stony dull percussion note
Reduced breath sounds
Reduced chest movement
Chest deformity

Chronic empyema thoracis

Chest pain
Cough
Dyspnea
Chest deformity
Reduced chest movement

Surgery Clinical Treatment Guidelines 115

Chapiter 3: Cardio Thoracic Surgery

Wasting of the chest muscles

Stony dull percussion note
Reduced breath sounds
Chest wall abscess and sinuses
Finger clubbing

Investigations
- Sputum exam
- CXR
- CT scan
- Bronchoscopy

Management

Acute empyema thoracis

Thoracocentesis
Chest tube drainage

Sub-acute empyema thoracis

Chest tube drainage

Chronic empyema thoracis

Chest tube drainage and
Decortication

3.2.2. Lung Abscess

Definition: Is the presence of pus in the lung parenchyma.

Causes
- Inhalation of food particles
- Virulant pyogenic bacterials like S.Aureus and Klebsiella in a
background of immune compromise

Signs and Symptoms

- Cough
- High fever
- Dyspnea
- Chest pain
- Halitosis
- Weight loss
- Finger clubbing
- Reduced breath sound
- Crepitations
- Dull percussion note

116 Surgery Clinical Treatment Guidelines

 Chapiter 3: Cardio Thoracic Surgery

Investigations
- Sputum examinations
- CXR
- CT scan
- Bronchoscopy

Management
- Apropriate antibiotics (e.g. Clindamycin for 3 to 6 weeks)
- Chest physiotherapy
- Surgery(lobectomy)

3.2.3. Pulmonary Fibrosis and Bronchectasis

Definition: Fibrosis of the lung following bacterial infection and/or

lung abscess. 3

Surgery
Cardio Thoracic
Causes
- Post pulmonary TB infection
- Pneumoconiosis
- Fungal infections ( e.g. aspergilosis)

Signs and symptoms

- Cough
- Chest pain
- Dyspnea
- Loss of weight
- Finger clubbing
- Cyanosis
- Chest deformity
- Wasting of chest wall muscles
- Dull percussion note
- Crepitations

Investigations
- CXR
- Sputum examination
- CT scan
- Bronchoscopy

Management
- Treat underlying condition (TB, aspergilosis)
- Chest physiotherapy
- Symptomatic treatment
- Lobectomy or pneumonectomy

Surgery Clinical Treatment Guidelines 117

Chapiter 3: Cardio Thoracic Surgery

3.2.4. Lung Cancer

Definition: Malignant growth of the bronchials or parenchyma of the

lung. They are divided into two groups namely; central and peripheral
cancers.

Causes
- Unknown
- Predisposing factors include:
Smoking
Exposure to dusts from industrial pollution

Signs and symptoms

- Central tumors
Cough
Chest pain
Hemoptysis
Wheezing
Dyspnea
Finger clubbing
Loss of weight (not very common)
Dull percussion note
Crepitations on auscultation
Reduced breath sound
Metastases to other organs
Paraneoplastic syndromes

- Peripheral tumors
Cough
Chest pain
Pleural effusion
Dyspnea
Finger clubbing
Crepitations on ausculatation
Reduced air entrance
Metastases to other organs
Paraneoplastic syndromes

Investigations
- CXR
- Chest and brain CT scan
- Bronchoscopy and biopsy

118 Surgery Clinical Treatment Guidelines

 Chapiter 3: Cardio Thoracic Surgery

- Mediastinoscopy
- Pleural effusion aspiration for cytology
- Pleural biopsy

Management
- Radiotherapy
- Chemotherapy
- Surgery

3.2.5. Foreign Bodies in the Lung

Definition: Inhaled or penetrating object in the lung.

Signs and symptoms

3
- Inhaled object

Surgery
Cardio Thoracic
Severe coughing
Severe dyspnea
Cynosis
Wheezing
Absent or reduced breath sound

- Penetrating objects
History penetrating trauma
Cough
Chest pain
Maybe assymptomatic
Reduced air entrance
Crepitations
Dull percussion note

Investigations
- CXR
- CT scan
- Bronchoscopy

Management
- Inhaled foreign body is an emergency (refer to ENT section)
- For penetrating foreign body
If symptomatic do thoracothomy and removal
If assymptomatic, reassure patient and follow up

Surgery Clinical Treatment Guidelines 119

Chapiter 3: Cardio Thoracic Surgery

3.3. Mediastinum Masses

Definition: Space occupying lesions that may be solid or cystic located

in the mediastinum compartment.

Causes

- In the superior compartment

Retrosternal goiter
Intrathoracic goiter
Thymoma
Lymphoma

- In the anterial compartment

Lipoma
Lymphoma
Pericardial cyst
MORGARGNIS hernias

- In the middle compartment

Aneurysm of the ascending aorta
Ventricular aneurysm

- Posterior compartment
Neurogenic tumors
Enteric cysts
Lymphomas
Lymphadenopathies
Bronchogenic tumors
Oesophagial tumors

Signs and symptoms

- Signs and symptoms will depend on the type of lesion and

location in the mediastinal compartments.

Investigations

- CXR
- CT scan
- MRI
- Bronchoscopy
- Mediastinoscopy

120 Surgery Clinical Treatment Guidelines

 Chapiter 3: Cardio Thoracic Surgery

Management
- Management will depend on the type of lesion and mediastinal
compartment affected.

Note:
For more information refer to relevant textbooks (Short Practice of
Surgeryby Bailey and Love and Principles of Surgery by Schwartz)

3.4. Congenital Diaphragmatic Hernias

Definition: Is the herniation of abdominal viscera into the chest cavity

through a congenital defect of the diaphragm. 3

Surgery
Cardio Thoracic
- There are two types
Postero- lateral hernia (Bochdalek Hernia)
Anterior Hernia (Morgagns Hernia)

Cause
- Unknown

Signs and symptoms

- Bochdalek Hernia
They manifest at birth
Severe dyspnea
Cyanosis
Failure to feed
In drawing of the chest
Bowel sounds heard in the chest
Reduced or absent air entrance
Displacement of the apex beats to the right

- Morgagnis Hernia
It may be assymptomatic
Symptoms of intestinal obstraction
Dyspnea
Recurrent tachycardia

Surgery Clinical Treatment Guidelines 121

Chapiter 3: Cardio Thoracic Surgery

Investigations
- CXR
- Gastrografin swallow
- Abdominal x-ray
- CT scan

Management
- High flow oxygen by mask
- Intubation and ventilation
- Surgery

122 Surgery Clinical Treatment Guidelines

 4. Abdominal Injuries

Definition: It is an injury to the abdomen, it may be blunt or penetrating

and it may involve damage of abdominal organs.

Causes
- Blunt: road traffic accidents, falls, sports injuries
- Penetrating: stab injuries, bullet and blast injuries

Clinical features
- Initial abdominal exams are often normal and may be initially
assymptomatic
- Pain and tenderness increase and spread from the injury site to
the other parts of the abdomen, frequently the entire abdomen
- The abdomen becomes tender, distended, and rigid
- Bowel sounds disappear
- The patient becomes progressively sicker, develops fever, and
usually vomits
- Patient may fall into shock
- Respirations are shallow and rapid because it hurts to breathe 4
deeply
Injuries
Abdominal
- Abdominal pain is increased by moving, straightening the knees,
or taking a deep breath
- The patient frequently prefers to lie quietly on his back or side
with the knees flexed

Management Principles of abdominal injuries

- Primary survey: The initial management of all trauma patients
is to ensure an adequate air way, arrest any bleeding and restore
organ circulation (ABCD evaluation)
- Secondary survey: Assessment of injury (detailed history and
careful physical examination)
- Ensure early detection and decision-making on blunt abdominal
injuries
- Place nasogastric tube for drainage
- Place the IV line with big calibre, administrate crystalloids/
colloids and take the sample for FBC
- Ensure oxygen supply
- closely monitor vital signs
- Inform theatre team to be ready accordingly

Surgery Clinical Treatment Guidelines 123

Chapiter 4: Abdominal Injuries

- Always inform family members and sign consent form

- Remember forensic issues (police investigation in case of
weapons)

Blunt Trauma
Hemodynamically Stable?
no yes
Distending Abdomen? Viscous
No Injury Suspected?
DPL or US
_ CT/US/DPL
yes +
+ _

Other
Laparotomy Tests Laparotomy Observe

Penetrating Trauma WEAPON

Gun/Missile Knife

Peritoneal Signs Peritoneal Signs

_ +
Shock + Shock
_
Peritoneal + LAPAROTOMY Site of Injury
Transverse?
? + Abd. Low Chest Back

Laparoscopy +
Explore DPL CT
+
_ _
_ _
Laparotomy
Observe

124 Surgery Clinical Treatment Guidelines

 Chapiter 4: Abdominal Injuries

4.1. Specific Injuries

4.1.1. Splenic Injury

Most can be managed non-operatively

90% of children
60% of adults

Management will depend on scale of splenic injury

- I: Hematoma or laceration (10% or 1cm)

- II: Hematoma or laceration (10-50% or 1-3cm bleeding)
- III: Hematoma or laceration (active bleeding with trabecular
vessels)
- IV: Hematoma or laceration (active bleeding intraparenchymal
or devascularization
- V: Shattered or Hilar devascularization

INDICATIONS FOR OPERATION

- Hemodynamic instability (III-V)
- Acute abdomen
4
OPERATIVE PROCEDURE
Injuries
Abdominal
- Splenorrhaphy
- Splenectomy (NGT in post-op is recommended to avoid any
distension)

4.1.2. Hepatic Injury

Management will depend on liver injury scale

- I: Hematoma or laceration (<10 cm or 1cm depth)

- II: Hematoma or laceration (10-50% surface or 1-3cm depth)
- III: Hematoma or Laceration (bleeding and expanding or >3cm
depth)
- IV: Ruptured Haematoma with active bleeding or Parenchymal
disruption (75%)
- V: Parenchymal disruption >75% lobe or retrohepatic venous
injuries
- VI: Hepatic Avulsion
- Most can be managed non-operatively (grade I and II)

Surgery Clinical Treatment Guidelines 125

Chapiter 4: Abdominal Injuries

INDICATIONS FOR OPERATION

- Hemodynamic instability
- Acute abdomen

OPERATIVE PROCEDURE
Grade I and II
Manual compression
Suture ligature
Omental patch
Closed suction drain
Argon beam coagulation
Topic haemostatics

Grade III to IV
Definitive treatment or damage control
Resectional debridment
Perihepatic packing
Baloon tamponade
Foley catheter tamponade

4.1.3. Pancreatic Injury

Causes

- Often from direct blow compressing pancreas against vertebral

column
- Often accompanied by duodenal injury

Investigations

- Serial serum amylase levels

- Very difficult to evaluate, even with CT
- ERCP can be helpful

Complications

- Pancreatic pseudocyst
- Duodenal or pancreatic fistula (treat with somatostatin/surgery)

Management

- Isolated injury not involving major duct: observation

- Serious injury: often involves duodenum requiring immediate
exploration

126 Surgery Clinical Treatment Guidelines

 Chapiter 4: Abdominal Injuries

4.1.4. Duodenal Injury

DUODENUM
- Often in unrestrained drivers, handlebar injuries
- Suspect with history, blood in NGT aspirate, or retroperitoneal
air
- Difficult to diagnose without CT scan

OPERATIVE FINDINGS
- Upper retroperitoneal hematoma
- Bile leakage

OPERATIVE PROCEDURE
- Cattels maneuver
- Pyoric exclusion, gastrostomy, jejunostomy

DIAPHRAGM
- Left hemidiaphragm more commonly injured
- Elevation on chest x-ray, but may be normal
- Difficult to visualize injuries by other means (including CT, MRI)
- Injuries may be missed for years
4
Management

Injuries
Abdominal
- Early: laparatomy, reduce abdominal contents from chest and
repair
- Late: present as diaphragmatic hernia. Reduce and repair defect
in diaphragm

4.1.5. Small bowel Injury

- Can be from penetration or tearing from compression or

deceleration
- Think of injury with seatbelt sign
- DPL good at detection transluminal injuries, but small bowel
bleed minimal, may be negative
- F.A.S.T. and CT not good for small bowel

Management

- Immediate surgery
- Resection of devitalized bowel with primary anastomosis
- Stop mesenteric haemorrhage
- Peritoneal lavage

Surgery Clinical Treatment Guidelines 127

Chapiter 4: Abdominal Injuries

4.1.6. Colon Injury

- Immediate surgery
- Primary closure and proximal defunctioning colostomy/
ileostomy
- Peritoneal lavage
- Excision and exteriorization of two ends with re-anastomosis at
3months

4.1.7. Rectal Injury

- Most often penetrating

- Can occur with pelvic function

Diagnosis

- Blood on examination glove

- Sigmoidoscopy

Management

- Primary repair
- +/- colostomy
- +/- pre-sacral drainage

128 Surgery Clinical Treatment Guidelines

5. Disorders of Gastro-Intestinal System

5.1. Disorders of the Oesophagus

5.1.1. Oesophagial Atresia

Definition: Congenital disorder with a blind end to the oesophagus,

at first feed the infant coughs and may become cyanosed. It may be a
fistula to the trachea.

Cause

- Congenital

Signs and symptoms

- Drooling, poor feeding, cyanosis, coughing, gagging, and
chocking with attempted feeding tube is not able to pass all the
way to stomach.

Diagnosis

- Clinical

Investigations

- X-ray with contrasts of oesophagus shows an air filled pouch and

air in the stomach and intestines
- Inserted feeding tube appear coiled up in the upper oesophagus
- Oesophagocopy 5
- Chest x-ray
System
Gastro-Intestinal
Disorders of

Complications

- Aspiration pneumonia
- Chocking and possible death
- Feeding problems
- Reflux after surgery
- Stricture of the oesophagus

Management

- Oesophagial atresia is considered a surgical emergency

- Feeding gastrostomy

Surgery Clinical Treatment Guidelines 129

Chapiter 5: Disorders of Gastro-Intestinal System

- Control of electrolytes imbalance replace accordingly with

corrective measures of dehydration
- Ensure nutritional support
- Good oxygen circulation
- Put the patient in the most comfortable position
- Education to the patient and the family on the management of
the gastrotomy tube to avoid infection

5.1.2. Achalasia

Definition: It is a disorder of the oesophagus which affects the ability to

move food towards the stomach.

Causes

- A primary neurological disorder of unknown cause

- Failure of the cardiac sphincter to relax
- Faulty peristalsis of the oesophagus due to defective
parasympathetic innervations
- Cancer of the oesophagus in the upper stomach

Signs and symptoms

- Regurgitation of food
- Chest pain increasing after eating may also be felt in the back,
neck and arms
- Cough
- Heart burn
- Unintentional weight loss
- Signs of anaemia or malnutrition

Investigations

- Oesophagium manometry
- Esophagogastroduodenoscopy
- Upper Gastro-intestinal x-ray with barium meal

Complications

- Regurgitation
- Aspiration pneumonia
- Perforation of esophagus

130 Surgery Clinical Treatment Guidelines

 Chapiter 5: Disorders of Gastro-Intestinal System

Management

- Management of achalasia aims at reducing pressure at the lower

esophageal sphincter
Injection with Botulinum toxin to relax sphincter muscles
Medication such as long acting nitrates or calcium channel
blockers to relax lower esophagus sphincter
Surgery: Esophago myotomy to decrease pressure in the
lower sphincter
Dilatation of esophagus at the location of narrowing done
during Esophagogastroduodenoscopy

5.1.3. Gastroesophagial Reflux Disease

Definition: It is a condition caused by retrograde passage of gastric

contents into the esophagus resulting in inflammation (oesophagitis),
which manifests as dyspepsia.

Signs and symptoms

- Retro sternal burning pain radiating to epigastrium

- Regurgitation of acid contents into the mouth (water brash)
- Back pain (penetrating ulcer in Barretts oesophagus)
- Dysphagia
- Odynophagia

Investigations

- Patients over 45 years old or patients suspected of having a

gastroesophagial reflux disease should be investigated, for
malignancy to be excluded as a cause when symptoms of GORD
5
are first presented.
System
Gastro-Intestinal
Disorders of

- Barium swallow and meal: sliding hiatus hernia, esophageal

ulcer, stricture
- Esophagoscopy: assess the esophagitis, biopsy for histology, dilate
stricture if present
- 24 hours pH monitoring: assess degree of reflux

Complications

- Bleeding
- Reflux oesophagitis and necrosis
- Ballets oesophagus
- Benign strictures
- Oesophagioadenocarcinoma

Surgery Clinical Treatment Guidelines 131

Chapiter 5: Disorders of Gastro-Intestinal System

- Chronic cough
- Laryngitis
- Pharyngitis

Management

General
Lose weight and avoid smoking, coffee and chocolates
Avoid tight garments and stooping
Avoid sleeping before 2 hours post prandial

Medication
Control acid secretion with proton receptor antagonists
(e.g. ranitidine), proton pump inhibitors (e.g. omeprasol),
Dose:
Minimize effects of reflux (give alginic acids e.g. gaviscon),
Dose:
Antacids (e.g. magnesium hydroxide), Dose:
Prokinetic agents (e.g. metoclopramide), Dose:

Surgical treatment
Nissen fundoplication is the standard surgical treatment
Vagotomy as an obsolete treatment

5.1.4. Esophageal Cancer

Definition: It is a malignant tumour of the oesophagus, which may be

squamous cell carcinoma or adenocarcinoma.

Causes

- Commonly occurs in men over 50 years old

- Smoking
- Alcohol consumption
- Risk factors include male gender, obesity and smoking

Symptoms

- Regurgitation
- Chest pain unrelated to eating
- Difficulty swallowing solids or liquids
- Heartburn
- Vomiting blood
- Weight loss

132 Surgery Clinical Treatment Guidelines

 Chapiter 5: Disorders of Gastro-Intestinal System

Investigations

- Barium swallow
- Chest MRI or thoracic CT to determine stage of the disease
- Endoscopic ultrasound to determine stage of the disease
- Esophagogastroduodenoscopy and biopsy
- PET (positron emission tomography) scan
- Stool testing may show blood

Management

- Surgery is the treatment of choice

Minimally invasive oesophagectomy

- Chemotherapy, radiation or combination of the two

- Endoscopic dilatation of oesophagus
- Photodynamic therapy
- Palliative care
- Ensure enteral feeding and parental treatment support
- Psychological support both to patient and family

Complications

- Difficulty swallowing
- Severe weight loss from not eating enough
- Metastasis of tumour to other areas

5.1.5. Esophageal Spasm

Definition: Diffuse oesophagal sphasms are uncoordinated

contractions of oesophagus resulting from motility disorders. 5
System
Gastro-Intestinal
Disorders of

Causes

- Not known
- Predisposing factors include: very cold or hot beverages

Signs and symptoms

- Dysphagia
- Regurgitation
- Substernal midline chest pain
- Odynophagia

Surgery Clinical Treatment Guidelines 133

Chapiter 5: Disorders of Gastro-Intestinal System

Diagnosis

- Clinical
- Investigations:
Barium swallow (typical corkscrew oesophagus) x-rays
Oesophageal radionuclide transit test (oscillatory or non
clearance pattern)

Management

Medical
Botulium toxins
Long acting nitrites
Benzodiazepines
Psychotropic drugs
Pneumatic dilatation
Calcium channel blockers

Surgery
Considered if medical treatment has failed
Long oesophageal myotomy

5.1.6. Perforation of oesophagus

Definition: It is a hole through which the contents of oesophagus can

pass into the mediasternum, the surrounding area in the chest.

Causes

- Injury during a medical procedure

- Tumour
- Gastric reflux with ulceration
- Previous surgery on the oesophagus
- Swallowing a foreign object or caustic chemicals
- Trauma or injury to the chest and oesophagus
- Violent vomiting

Symptoms and signs

- Pain
- Difficulty swallowing
- Chest pain
- Difficulty bleeding
- Tachycardia
- Fever

134 Surgery Clinical Treatment Guidelines

 Chapiter 5: Disorders of Gastro-Intestinal System

- Tachypnoea
- Nasal voice (cervical injury)
- Haematamesis (thoracoabdominal segment injury)
- Supraclavicular swelling and crepitus (subcutenias emphizema)
- Neck pain or stiffness (on perforation of oesophagus)
- Respiratory distress (thoracic injuries)

Investigations

- Chest x-ray may reveal air in the soft tissues of the chest, fluids
leaked from oesophagus to the space surrounding lungs or lung
collapse
- A chest CT scan may show an abscess in the chest or oesophageal
cancer
- Endoscopy (incomplete intramural perforations/ Mallory-Weiss
Syndrome)

Complications

- Permanent damage to oesophagus (narrowing or stricture)

- Abscess formation in and around oesophagus
- Infection in and around the lung

Management

Medical
Administering fluids
IV antibiotics to prevent or treat infections
Draining fluids collected around the lung with a chest tube
Mediasternoscopy to remove fluids collected in the
mediasternum 5
System
Gastro-Intestinal
Disorders of

Surgery: To repair perforation in the middle or bottom portions of

oesophagus

Surgery Clinical Treatment Guidelines 135

Chapiter 5: Disorders of Gastro-Intestinal System

5.1.7. Hiatus Hernia

Definition: It is the protrusion of the upper part of the stomach into the
thorax through a tear or weakness in the diaphragm.

Causes / Risk factors

- Heavy lifting or bending over

- Frequent oral hard coffee, hard sneezing
- Pregnancy and delivery
- Violent vomiting
- Straining with constipation
- Obesity
- Hereditary smoking

Signs and symptoms

- May be assymptomatic
- Dull pains in the chest
- Shortness of breath
- Heart palpitations

Diagnosis

- Clinical
- Investigations
Upper GI series,
Endoscopy
High resolution manometry

Management

General
Treatment may not be required
Bed elevation after meals
Stress reduction techniques
Weight loss if overweight

Medical
Proton pump inhibitors
H2 receptor blockers

Surgical
Nissens fundoplication

136 Surgery Clinical Treatment Guidelines

 Chapiter 5: Disorders of Gastro-Intestinal System

Complications

- Oesophageal cancer
- Gasbloat Syndrome
- Dysphagia
- Dumping Syndrome
- Achalasia

5.2. Acute Abdomen

Definition: Acute abdomen is used to describe a group of acute

life-threatening intra abdominal conditions (including pelvis) that
require emergency hospital admission and often emergency surgical
intervention. Early recognition, adequate resuscitation and prompt
treatment are necessary for recovery of these patients from potentially
fatal conditions.

Causes

Inflammatory
Secondary bacterial peritonitis: localized, generalized
Primary bacterial peritonitis: generalized
Tertiary peritonitis: generalized, very poor prognosis

Traumatic
Injury to solid organs: acute intra abdominal bleeding
Peritonitis secondary to intestinal injury

Obstructive
Acute intestinal obstruction (small bowel) 5
Chronic intestinal obstruction (colonic)
System
Gastro-Intestinal
Disorders of

Vascular
Mesenteric infarction
Strangulated external/internal hernia
Volvulus (small or large intestine)

Signs and symptoms

- Pain
- Appetite: anorexia, nausea, vomiting, dysphasia, weight loss
- Bowels habits: bloating, diarrhea, constipation, flatulence
- Tenderness
- Rigidity

Surgery Clinical Treatment Guidelines 137

Chapiter 5: Disorders of Gastro-Intestinal System

- Masses
- Altered bowel sounds
- Evidence of malnutrition
- Bleeding
- Jaundice

Abdominal pain from any cause is mediated by either visceral or

somatic afferent nerves, and several factors can modify expression of
pain:
- Age extremes
- Vascular compromise (pain out of proportion)
- Pregnancy
- CNS pathology
- Neutropenia

Diagnosis

- Clinical presentation
- Investigations
Haemogramme
Renal function tests and electrolytes
Amylase
Chest x-ray and abdominal films (erect/supine)
Blood culture for high fever and pyrexia
Ultrasound and CT-scan
DPL
Mesenteric angiography
Laparoscopy/laparotomy

Management

- Acute abdomen requires immediate treatment

Start large bore IV with either saline or lactated ringers
solution
IV pain medication
Nasogastric tube if vomiting or concerned about
obstruction
Foley catheter to follow hydration status and to obtain
urinalysis
Antibiotic administration if suspicious of inflammation or
perforation
Definitive therapy or procedure will vary with diagnosis
Avoid oral intake
Oxygen administration if necessary
Remember to reassess patient on a regular basis

138 Surgery Clinical Treatment Guidelines

 Chapiter 5: Disorders of Gastro-Intestinal System

5.3. Peritonitis

Definition: Peritonitis is inflammation (irritation) of the peritoneum.

Causes

- Bacterial peritonitis
Secondary bacterial peritonitis (from GIT): common
Primary bacterial peritonitis (streptococcal): rare
Tertiary bacterial peritonitis (ICU patients): uncommon

- Chemicals
HCL (early Perforated PUD)
Extravasation of urine (bladder rupture)
Bile (leak post cholecystectomy)
Amylase (pancreatitis)

SPONTANEOUS BACTERIAL PERITONITIS

- Occurs in immunocompromised patients

- Cirrhosis, Wilsons Disease, chronic active hepatitis
- Chronic peritoneal dialysis
- Nephrotic Syndrome
- Usually Gram negative organisms
- High risk of septic shock and Multi-organ Dysfunction
Syndrome
- Poor prognosis

Signs and symptoms

- Systemic features: illness, toxicity, pyrexia, tachycardia, rigors 5

(bacteraemia/septicemia)
System
Gastro-Intestinal
Disorders of

- Dehydration
- Local symptoms: pain (localized or generalized) severe, constant,
aggravated by movement
- Local signs
- Loss of normal abdominal movement on respiration
- Tenderness, guarding, rigidity, rebound tenderness
- Silent abdomen
- Digital rectal examination may elicit pelvic tenderness, boggy
swelling, and cervical tenderness in females

Surgery Clinical Treatment Guidelines 139

Chapiter 5: Disorders of Gastro-Intestinal System

Management

Secondary bacterial peritonitis

Immediate treatment: (see treatment of acute abdomen);
ensure large quantities of IV fluids administration and
electrolyte replacement accordingly
Control of urinary output
Antibiotherapy:
If upper gastrointestinal pathology suspected, gram
negative aerobe cover( IV ciprofloxacin, cefotaxime,
ceftriaxone, imipenem)
If lower gastrointestinal pathology suspected, gram
negative anaerobe cover (metronidazole)
Surgical treatment:
Lavage of abdominal cavity with 8 to 10 liters of normal
saline
Treat the cause

Primary bacterial peritonitis

Haematogenous spread of gram-positive organisms (S.
pneumonia) to peritoneal cavity
Occurs in children and adult females
Treatement :antibiotics+/-laparotomy to drain pus
Prognosis is good

Complications

- Septic shock
- Hypovolemic shock
- Multiple organ failure

140 Surgery Clinical Treatment Guidelines

 Chapiter 5: Disorders of Gastro-Intestinal System

5.4. Intestinal Obstruction

Definition: It is the inability to pass bowel contents distally (partial

or complete). Classified into dynamic (mechanical) and adynamic
(paralytic ileus).

Causes

- Extramural
- Adhesions, bands
- Hernias: internal and external
- Compression by Tumors
- Intramural
- Inflammatory disease: Crohns disease
- Tumors: carcinomas, lymphomas, etc.
- Strictures
- Intraluminal
- Feacal impaction
- Swallowed foreign bodies
- Bezoars
- Gallstone

Signs and symptoms

Cardinal symptoms of intestinal obstructions

Pain
Vomiting
Distension
Absolute constipation
5
- Signs of dehydration: a dry tongue: sunken eyes and dry inelastic
System
Gastro-Intestinal
Disorders of

skin may be noted

- Patient may be rolling about with colic
- Pulse usually elevated
- Temperature is usually normal,a raised temperature and a very
rapid pulse indicative of strangulation
- Per abdomen, distension and visible peristalsis may be observed
- Vital to carefully search for presence of a strangulated external
hernia and presence of an abdominal scar
- Tenderness
- A mass may be felt (for example in intussusceptions or cancer of
the bowel)
- The bowel sounds are usually accentuated and tinkling (i.e.
metallic)

Surgery Clinical Treatment Guidelines 141

Chapiter 5: Disorders of Gastro-Intestinal System

- Rectal examination
- May reveal an obstructing mass in the pouch of Douglas
- Feel apex of an intussusceptions
- Faecal impaction or an empty rectum (in case of sigmoid
volvulus)
The rule that constipation is present in intestinal obstruction does not
apply to Richters Hernia, vascular occlusion and intestinal obstruction
associated with pelvic abscess.

Investigations

- Abdominal series with chest x-ray

- CBC: >20,000 indicates bowel gangrene, abscess, peritonitis
>40,000 possible nonocclusive mesenteric ischemia
- Electrolytes and renal function tests
- Urinalysis
- Lactate (mesenteric ischemia)
- Barium enema: can determine cause and site of LBO
- Sigmoidoscopy:
- Identification of friable mucosa
- Intraluminal lesions
- Dead bowel
- Diagnostic and therapeutic for sigmoid volvulus
- Contrast enhanced CT: delineate partial from complete
obstruction

Management

- Fluid and electrolyte replacement therapy

- Decompression of the bowel
- Well-timed surgical intervention
- Avoid oral intake
- NG tube for drainage
- Parenteral nutrition through the central line
- Fluid and Electrolytes Replacement Therapy
- Adequate fluid, electrolytes, proteins, and whole blood should
be given to stabilize the Blood Pressure and pulse as well as to
restore warmth, skin colour, turgor, and adequate venous filling
- The urinary output and specific gravity should be followed as
indicators of extracellular fluid adequacy
- The amount and type of replacement will vary and should
depend on the patients condition as measured by criteria such
as serum chemistry studies, haematocrit, vital signs, and clinical
response to fluid therapy

142 Surgery Clinical Treatment Guidelines

 Chapiter 5: Disorders of Gastro-Intestinal System

- Decompression of the bowel

Distension may be relieved by intestinal intubation or
surgical decompression.

- Operative treatment
Proper timing of the operation for intestinal obstruction is
essential. Surgery is the most important step, and in case of
strangulation or vascular occlusion it is the only effective
treatment. Surgical procedures for the relief of intestinal
obstruction may be divided into five categories.

- Surgical procedures
Relief of intestinal obstruction may be divided into five
categories
Procedures not requiring opening the bowel-
lysis of adhesions, manipulation-reduction of
intussusceptions, reduction of obstructed hernia.
Enterotomy - for removal of obturation obstruction-
gallstones, bezoars.
Resection of obstructing lesion or strangulated bowel
with primary anastomosis.
By-pass: anastomosis around an obstruction.
Formation of a cutaneous stoma proximal to the
obstruction- catheter enterostomy, caecostomy.

Summary of treatment
IV fluid replacement
Bowel decompression via nasogastric tube
Broad spectrum antibiotics preoperatively for mechanical
obstructions 5
Adynamic ileus patients: conservative management - IV
System
Gastro-Intestinal
Disorders of

fluids, NG tube, bowel rest, pain management

Surgery Clinical Treatment Guidelines 143

Chapiter 5: Disorders of Gastro-Intestinal System

5.4.1. Appendicitis

Definition: It is an inflammation of the appendix.

Causes/Predisposing factors

- No clear cause of appendicitis

- Obstruction of appendiceal lumen
- Inflammation of appendiceal lymphoid tissue (about 60%). This
inflammation can be
- Gastroenteritis
- Advanced colonic disease such as Crohns Disease.

Signs and symptoms

- Peri-umbilical pain shifting to right iliac fossa

- Anorexia
- Abdominal pain
- Nausea with or without vomiting
- Low grade fever
- Mac Burney tenderness
- Rebound tenderness
- Dunphy (increase pain with cough)
- Rovsing (lower left quadrant palpation inducing right lower
quadrant pain)
- Obturator (pain on internal rotation of the right hip)
- Ilial psoas (pain on extension of the right hip)

Investigations

- FBC- leucocytosis and left shift

- A WBC greater than 20000 suggests a perforation
- Urinalysis often reveals minimal white cells, red cells and
bacteria
- HCG must be checked in female patients
- Plain films- a fecalith is present in less than 15% of cases, free air
from perforation is seen in 1% of cases
- Ultra sound; most effective in young females of child bearing
age in the evaluation of adnexal diseases which is high on
differentials. (Sensitivity 75-90%)
- CT scan (sensitivity ranging from 96-100%)
- Radionuclide (sensitivity and specificity >90%)

144 Surgery Clinical Treatment Guidelines

 Chapiter 5: Disorders of Gastro-Intestinal System

Management

The goal of surgical approach to appendicitis is simple-early diagnosis

with resection of an acutely inflamed appendix prior to perforation,
with a minimum of negative appendectomies.

Medical treatment
Augmentin 1gm x 3/ day/ 5 days if uncomplicated
appendicitis

Alternative
Ceftriaxone/2g 24 hourly for 5-7 days (adults), or
Cefotaxime 1g/ every 8 hours + Metronidazole 500mg/every
8 hours IV

Surgical treatment
Open or laparoscopic appendicectomy and
antibioprophylaxis ceftriaxone 2 gm single dose +
metronidazole 500mg single

5.4.2. Appendiceal Mass and Abscess

Definition: Appendiceal mass is a palpable conglomeration of inflamed

tissue, including the appendix and adjacent viscera.

Causes/Aetiology

- Idiopathic
- An obstruction (food waste or fecal stone)
- An infection
5
Signs and symptoms
System
Gastro-Intestinal
Disorders of

- Aching pain that begins around your navel and often shifts to
your lower right abdomen
- Pain that becomes sharper over several hours
- Tenderness that occurs when you apply pressure to your lower
right abdomen
- Sharp pain in your lower right abdomen that occurs when the
area is pressed on and then the pressure is quickly released
(rebound tenderness)
- Pain that worsens if you cough, walk or make other jarring
movements
- Nausea
- Vomiting

Surgery Clinical Treatment Guidelines 145

Chapiter 5: Disorders of Gastro-Intestinal System

- Loss of appetite
- Low-grade fever
- Constipation
- Inability to pass gas
- Abdominal swelling

Diagnosis

- Clinical
- Investigation
CT scan of the abdomen and the appendix

The major complications

- Peritonitis
- Surgical wound infections
- Intra-abdominal abscess
- Fistulas
- Small bowel obstruction (adhesions)
- Paralytic ileus
- Infertility
- Sepsis

Management

- Conservative treatment with antibiotics (Ochsner Method)

- Percuteneous drainage of abscess and concomitant IV antibiotics
- Appendectomy is done later, 6 weeks to 3 months

146 Surgery Clinical Treatment Guidelines

 Chapiter 5: Disorders of Gastro-Intestinal System

Algorithm for management of appendiceal mass

Figure 1. Algorithm for management of appendiceal mass

Appendiceal Mass

Initial conservative management

Abscess formation Persistent mass/pain

Resolved Drainage of Abscess Further assessment and

investigations

Interval Appendicectomy

Resolved Persistent
Mass or pain

Laparotomy

Annals of African Medicine, Vol.7 No.4 2008: 200 - 204

5.4.3. Gall Stones

Definition: Gall stones are solid particles that form from bile in the
gallbladder. They are of two types namely (1) cholesterol stones (20%)
and (2) pigment stones yellow stones (80%).

Causes/Risk factors

- Too much cholesterol in the bile

- Excess bilirubin in the bile 5
- People with liver disease or blood disease
System
Gastro-Intestinal
Disorders of

- Poor muscle tone

- Risk factors include, female gender, overweight, losing a lot of
weight quickly on a crash or starvation diet, certain medication
e.g. birth control pills, cholesterol lowering drugs

Signs and symptoms

- Usually assymptomatic (8-15%)

- Biliary colic, nausea and vomiting, approximately 70% will have
1 or more recurrent episodes of pain within a year of onset of
symptoms.

Surgery Clinical Treatment Guidelines 147

Chapiter 5: Disorders of Gastro-Intestinal System

Investigations

- Ultrasound (95-99% sensitive)

- MRCP (92% sensitive)
- CT scan (60% sensitive)
- X-ray (15% sensitive)

Complications

- Severe abdominal pain

- Pancreatitis
- Gallbladder disease
- Infection (Cholecystitis)

Management

- Symptomatic treatment
- Intake of only clear liquids to give the gallbladder a rest
- Avoid fatty or greasy meals
- Take acetaminophen (Tylenol, etc.) for pain
- Laparascopic cholecystectomy should be performed for patients
with symptoms

5.4.4. Acute Cholecystitis

Definition: Prolonged or recurrent cystic duct blockage by a gall stone

or biliary stasis that can progress to total obstruction.

Cause

- 90-95% of cases are associated with cholelithiasis.

Symptoms

- Right upper quadrant pain with possible radiation to the right

shoulder or back
- Nausea, vomiting
- Fever

Investigations

- Ultra sound (non invasive)

- HIDA is the most sensitive test (Technetium 99m pertechnetate
immunodiacetic acid scan)

148 Surgery Clinical Treatment Guidelines

 Chapiter 5: Disorders of Gastro-Intestinal System

Management

Medical
IV fluids
Ampicilline IV 1 g tid for 7days + Gentamycin IV 160 mg
OD for 5days

Alternative
Ceftriaxone IV 1gm bid for 7days
Pethidine 100mg IV 3-4 times/ per day for analgesia

Surgical
Cholecystectomy is a definitive treatment, if performed
with in 2-3 days of illness it is better than delayed
chelecystectomy that is performed 6-10 weeks after initial
medical treatment
Laparoscopic cholecystectomy is the procedure of choice

5.4.5. Jaundice

Definition: Jaundice is the yellowing of the skin and sclera from

accumulation of the pigment bilirubin in the blood and tissue. The
bilirubin level has to exceed 35-40mol/l before jaundice is clinically
apparent. The three forms of jaundice are: Prehepatic (Hemolytic),
Hepatic (hepatocellular) and Posthepatic (obstructive/surgical jaundice).

Surgical (Obstructive) Jaundice

Post hepatic conjugated bilirubinemia occurs from
anything that blocks release of conjugated bilirubin from
the hepatocytes or prevents its delivery to the duodenum. 5
System
Gastro-Intestinal
Disorders of

Causes

- Choledocholithiasis
- Periampullary carcinomas
- Portal lymphadenopathy
- Sclerosing cholangitis

Signs and symptoms

- Frank Jaundice
- Pruritis
- White stool
- Coca-cola coloured urine

Surgery Clinical Treatment Guidelines 149

Chapiter 5: Disorders of Gastro-Intestinal System

Investigations

- Serum bilirubine
- Liver function test
- Alkaline phosphatase: elevated
- -GT: elevated
- Transaminase: normal/elevated
- Lactate dehydrogenase: normal/elevated
- Reticulocytes: normal
- Ultrasound
- CT-scan
- PTC
- ERCP

Management

- Preoperative management: Aims at preventing complications

associated with severe cholestasis such us (infections, clotting
disorders, renal failure, liver failure, fluids and electrolyte
abnormalities)

Surgical
Surgical obstructive jaundice will always be accompanied
by dilatation of the biliary tree
Establishing the cause of the jaundice
Assessment of the general condition of the patient
Staging in patients with tumours
Surgical (endoscopic, radiological)

Post operative sepsis after biliary tract surgery is common

and therefore prophylactic antibiotics should be given to
lower the incidence
IV fluids should be administered to prevent hepato-renal
syndrome
The most common disorder of coagulation is prolonged
PTT (prolonged prothrombin time) resulting from
deficiency of vitamin K dependant factors. Administration
of Vit K 10mg IV BID for at least three days before
operation is recommended

150 Surgery Clinical Treatment Guidelines

 Chapiter 5: Disorders of Gastro-Intestinal System

5.4.6. Gastric Outlet Obstruction

Definition: Gastric outlet obstruction refers to a condition in which the

narrow channel leading from the stomach into the Pylorus is physically
blocked and as a result food enters the duodenum slowly or is blocked.

Causes

- Benign
Peptic ulcer disease
Infection, such as tuberculosis and infiltration diseases
such as amyloidosis.
A rare cause of gastric outlet obstruction is obstruction
with gallstone, also termed Bouverets Syndrome.

- Malignant
Tumours of stomach, including adenocarcinoma( and
its linitis plastic variant, lymphoma, and gastrointestinal
stromal tumour
Occasionally, cancers near the pylorus, for example, of
pancreas or duodenum.

Signs and symptoms

- Vomiting which typically occurs after meals of undigested food

- Devoid of any bile
- History of peptic ulcers and loss of weight
- Body wasting and dehydration
- Visible peristalsis may be present
- Succussion splash which is a splash-like sound heard over the
stomach in the left upper quadrant of the abdomen on shaking 5
the patient, with or without the stethoscope
System
Gastro-Intestinal
Disorders of

Investigations

- Esophagogastroduodenoscopy(EGD)
- Abdominal x-ray (Gastric Fluid level)
- Abdominal CT scan

Surgery Clinical Treatment Guidelines 151

Chapiter 5: Disorders of Gastro-Intestinal System

Management

Depends on the cause, and may include either surgery or medical

treatment

Pharmacological
In patients with peptic ulcer disease, the oedema will settle
with conservative management with nasogastric suction,
replacement of fluids and electrolytes and proton pump
inhibitors

Surgical
Antrectomy (which involves anastomosing the duodenum
to the distal stomach) or gastrojejunostomy, indicated in
cases of failed medical treatment and recurrent obstruction

152 Surgery Clinical Treatment Guidelines

 6. Disorders of the Colon and Rectum

6.1. Colo-Rectal Cancer

Definition: The occurrence of malignant lesions in mucosa on the

colon or rectum.

Causes/predisposing factors

- Prior colorectal carcinoma or adenomatous polyps

- Hereditary Polyposis Syndrome
- Family history of colorectal carcinoma
- Chronic active ulcerative colitis
- Diet (low in indigestible fibre, high in animal fats)
- Decreased fecal bile salts, selenium deficiency

Signs and symptoms

- Anemia, ceacal cancers often present with anemia

- Colicky abdominal pain
- Alteration in bowel habits (constipation or diarrhea)
- Bleeding or passage of mucus per rectum
- Tenesmus (frequent or continuous desire to defecate)

Investigations

- Digital rectal examination and fecal occult blood

- Full Blood Count (anemia)
- Urea and electrolytes (hypokalaemia)
- Liver function test (liver metastasis)
- Sigmoidoscopy (Rigid to 30 cm/flexible to 60 cm)
- Double contrast barium enema (apple core lesion, polyp)
- Carcinoembryonic antigen is often raised in advanced disease

Management

Surgery
Resection of the tumour with adequate margins to include 6
regional lymphnodes
Colon and Rectum
Disorders of the

Resection possible for liver metastasis if fewer than five are

present
Radiotherapy may be used to shrink rectal cancers pre-
operatively or palliate inoperable rectal cancer

Surgery Clinical Treatment Guidelines 153

Chapiter 6: Disorders of the Colon and Rectum

Adjuvant chemotherapy (5-fluorouracile +/- levamisole) to

reduce risks of systemic recurrence (DUKE classification C
and some DUKEs B) or to palliate liver metastasis
Supportive management (see management of oesophageal
cancer)

6.2. Rectal bleeding

Definition: The passage of blood from the anus, the blood volume may
be small or large, and may be bright red or dark in colour.

Causes

- In the small intestines

MECKEL diverticulum in young adults
Intussusceptions in young children (colic abdominal pain,
retching, bright red/mucus stool)
Interitis, infection, radiation, Crohns disease
Ischemic, severe abdominal pain
- In proximal colon
Angiodysplasia, common in elderly carcinoma of the
caecum (causes anaemia rather than frank rectal bleeding)
- In the colon
Polyps/carcinomas
Diverticular disease in the elderly
Ulcerative colitis
Ischemic colitis in elderly (severe abdominal pain)
- In the rectum
Carcinoma (change in bowel habits, associated with mucus,
small volumes of blood)
Proctatis
Solitary rectal ulcer
- In anus
Haemorrhoids
Fissure in ano
Perianal Crohns disease
Carcinomas in anus

Management

- Treat the cause

154 Surgery Clinical Treatment Guidelines

 Chapiter 6: Disorders of the Colon and Rectum

6.3. Haemorrhoids

Definition: Are masses or clumps (cushions) of tissue within the

anal canal that contain blood vessels and the surrounding, supporting
tissue made up of muscle and elastic fibers.

Causes

- Inadequate intake of fibre

- Chronic straining to have a bowel movement (constipation)
- Pregnancy
- Tumours in the pelvis

Signs and symptoms

- Depends on stage and whether internal or external

First-degree hemorrhoids: bleed but do not prolapse.
Second-degree hemorrhoids: prolapse and retract on their
own (with or without bleeding)
Third-degree hemorrhoids: prolapses but must be pushed
back in by a finger
Fourth-degree hemorrhoids: prolapses and cannot be
pushed back in. It also includes hemorrhoids that are
thrombosed (containing blood clots) or that pull much of
the lining of the rectum through the anus
Anal itchiness (pruritus ani)
Mass protrusion from the anus that cannot be pushed back
inside (incarceration of the hemorrhoid)

Investigations

- Flexible sigmoidoscopy
- Colonoscopy

Complications

- Incarceration of the hemorrhoid

- Thrombosis
- Rectal hemorrhage 6
- Infection
Colon and Rectum
Disorders of the

Surgery Clinical Treatment Guidelines 155

Chapiter 6: Disorders of the Colon and Rectum

Management

- Simple: bulk laxatives and high fibre diet

- Bleeding internal haemorrhoids: injection sclerotherapy, Barrons
band, cryosurgery
- Prolapsing external haemorrhoids: haemorrhoidectomy
- Stool softeners and increased drinking of liquids can be
recommended
- Local anaesthetics e.g. Benzocaine 5% to 20% (Americaine
Hemorrhoidal, Lanacane Maximum Strength, Medicone)
- Vasoconstrictors e.g. Ephedrine sulfate 0.1% to 1.25% OR
Epinephrine 0.005% to 0.01% Or
- Phenylephrine 0.25% (Medicone Suppository, Preparation H,
Rectacaine)
- Rectal prolapsis: Abdominal rectopexy (rectum is hitched up on
to the sacrum)

Perianal hematoma: evacuation of the clot

Anal fissure:
- First line treatment: stool softeners / balking agents, local
anaesthetic gels 0.2% GTN ( Glyceryl trinitrate) ointment
- Second line treatment:
Botulinum toxin injection, lateral internal sphincterotomy
Examination under anaesthesia and biopsy for atypical/
suspicious abnormal fissures

6.4. Perianal Abscess

Definition: Perianal abscess is a collection of pus in the area of the
anus and rectum.

Causes/Risk factors

- Blocked gland in the area

- Infection of an anal fissure
- Sexually transmitted infection
- Inflammatory bowel disease (Crohns disease and ulcerative
colitis)
- Anal sex
- Chemotherapy drugs used to treat cancer
- Diabetes
- Use of medication such as prednisone
- Weakened immune system (such as from HIV/AIDS)

156 Surgery Clinical Treatment Guidelines

 Chapiter 6: Disorders of the Colon and Rectum

Signs and symptoms

- Swelling around the anus

- Constant, throbbing pain
- Pain with bowel movement which may be severe
- Constipation
- Discharge of pus from the rectum
- Fatigue and general malaise
- Fever, night sweats and chills
- Lump or nodule, swollen, red, tender at edge of anus
- Painful, hardened tissue on rectal examination
- In infants, the abscess often appears as a swollen, red, tender
lump at the edge of the anus. The infant may be fussy and
irritable from discomfort

Investigations

- Proctosigmoidoscopy
- Ultrasound/CT scan/MRI to rule out other diseases

Complications

- Anal fistula
- Body-wide infection (sepsis)
- Continuing pain
- Problem keeps coming back (recurrence)
- Scars

Management

- Incision and drainage of abscess, drained abscesses are usually

left open and there are no stitches
- Antibiotics

6
Colon and Rectum
Disorders of the

Surgery Clinical Treatment Guidelines 157

Chapiter 6: Disorders of the Colon and Rectum

6.5. Fistula in Ano

Definition: A fistula in ano is a track that develops from the inner

lining of the anus through the tissues that surround the anal canal.

Causes

- Previous anorectal abscess

- Anal canal glands situated at the dentate line
- Other causes include trauma, Crohn disease, anal fissures,
carcinoma, radiation therapy, actinomycoses, tuberculosis, and
chlamydial infections

Signs and symptoms

- Perianal discharge
- Pain
- Swelling
- Bleeding
- Skin excoriation
- External opening
- Digital rectal examination may reveal a fibrous tract or cord
beneath the skin
- Lateral or posterior indurations suggests deep post anal or
ischiorectal extension
- Recurrent episodes of anorectal sepsis
- An abscess develops easily if the external opening on the perianal
skin seals itself

Investigation

- Rectoscopy

Complications

- Incontinence
- Recurrent pain after surgery

Management

- Low: Probing and laying open the track (fistulotomy)

- High: Seton insertion, core removal of the fistula track

158 Surgery Clinical Treatment Guidelines

 Chapiter 6: Disorders of the Colon and Rectum

6.6. Carcinoma of Anus

Definition: Anal cancer is a disease in which malignant cells form in

the tissues of the anus.

Staging process

- CT scan (CAT scan)

- Chest X-ray: An x-ray of the organs and bones inside the chest
- Endo-anal or endorectal ultrasound

Causes/Risk factors

- Human papillomavirus (HPV) infection

- Risk factors include:
Being over 50 years old, being infected with human
papilloma virus (HPV)
Having many sexual partners
Having receptive anal intercourse (anal sex)
Frequent anal redness, swelling, and soreness
Having anal fistula (abnormal openings)
Smoking cigarettes

Signs and Symptoms

- Bleeding from the anus or rectum

- Pain or pressure in the area around the anus
- Itching or discharge from the anus
- A lump near the anus
- A change in bowel habits

Investigations

- Anoscopy: An exam of the anus and lower rectum using an

anoscope (a short, lighted tube)
- Proctoscopy: An exam of the rectum using a proctoscope (short,
lighted tube)
- Endo-anal or endorectal ultrasound
- Biopsy taken for histopathology exams during anoscopy 6
Colon and Rectum
Disorders of the

Management

- Radiation therapy: uses high-energy x-rays or other types of

radiation to kill cancer cells
- Chemotherapy: uses drugs to stop the growth of cancer cells

Surgery Clinical Treatment Guidelines 159

Chapiter 6: Disorders of the Colon and Rectum

- Surgery
Local resection
Abdominoperineal resection
- Combined local radiotherapy and chemotherapy: This displaced
the traditional abdominoperineal resection

6.7. Acute Pancreatitis

Definition: Pancreatitis is an inflammatory condition of the exocrine

pancreas that results from injury to the acinar cells. It may be acute or
chronic.

Causes

- Gallstones and alcohol abuse account for 95% of cases of acute

pancreatitis
- Idiopatic
- Other causes include congenital structural abnormalities, drugs,
viral infections, hypocalcaemia, hypothermia, hyperlipidemia,
trauma

Signs and symptoms

- Abdominal pain felt in the upper left side or middle of the

abdomen
- Illness, fever, nausea, vomiting and sweating (acute pancretitis)
- Clay-colored stools, gaseous abdominal fullness, hiccups,
jaundice, skin lesions and swollen abdomen
- Abdominal tenderness or mass, low Blood Pressure, rapid
heart rate and rapid Respiratory Rate are observed on physical
examination

Investigations

- Complete Blood Count

- Increased blood amylase level, increased serum blood lipase
level, increased urine amylase level, comprehensive metabolic
panel
- Abdominal ultra sound
- Abdominal CT scan
- Abdominal MRI

160 Surgery Clinical Treatment Guidelines

 Chapiter 6: Disorders of the Colon and Rectum

Management

Most pancreatitis is mild and resolves spontaneously.

- Assess disease severity (Imri / Ranson Criteria or APACHEII
system)
- Resuscitate the patient if:
Mild/moderate disease: IV fluids, analgesia, monitor
progress with pulse Blood Pressure and temperature.
Severe pancreatitis: full resuscitation in ICU with invasive
monitoring
Avoid oral intake

- Establish the cause: ultrasound to look for gallstones

- Further management: Non proven use for routine nasogastric
tube or antibiotics
- Consider vitamin supplement and sedatives, if alcoholism is the
cause
- Proven common bile duct stones require urgent ERCP
(Endoscopic retrograde cholangiopancreatography)
- Failure to respond to treatment or uncertain diagnosis warrants
abdominal CT- Scan
- Suspected or proven infection of necrotic pancreas requires
antibiotics and surgical debridement

Complications

- Pancreatic abscess
- Intra-abdominal sepsis
- Necrosis of the transverse column
- Respiratory failure (ARDS) or renal failure (Acute tubular
necrosis)
- Pancreatic hemorrhage
- Pancreatic pseudo cyst: may need to be drained internally or
externally
- Chronic pancreatitis

6
Colon and Rectum
Disorders of the

Surgery Clinical Treatment Guidelines 161

Chapiter 6: Disorders of the Colon and Rectum

6.8. Chronic Pancreatitis

Definition: Chronic pancreatitis is inflammation of the pancreas

that does not heal or improve, gets worse over time, and leads to
permanent damage.

Causes

- Chronic alcohol abuse

- Repeat episodes of acute pancreatitis
- Damage to the portions of the pancreas that make insulin may
lead to diabetes
- Risk factors include autoimmune, blockage of the pancreatic
duct, cystic fibrosis, high levels of triglycerides in the blood
(hypertriglyceridemia), hyperparathyroidism, use of certain
medication (especially estrogens, corticosteroids, thiazide
diuretics, and azathioprine)

Signs and symptoms

- Intractable abdominal pain

- Evidence of exocrine pancreatic failure (steatorrhoea)
- Evidence of diabetes

Management

Medical
Analgesia
Exocrine pancreatic enzyme replacement

Surgical
Drainage of dilated pancreatic duct or excision of the
pancreas in some cases
Splanchanicectomy is performed in intractable pain

162 Surgery Clinical Treatment Guidelines

 7

Disorders
Genito-Urinary
7. Genito-Urinary Disorders

7.1. Traumatic Disorders

7.1.1. Renal Injuries

Causes

- Blunt trauma (60-90%)

- Penetrating trauma

Signs and symptoms

- Hematuria(>99%)
- Flank tenderness / ecchymosis
- Hemodynamic instability
- Flank pain
- Signs and symptoms of other abdominal injuries are present

Investigations

- FBC
- Renal function tests
- Ultrasonography
- Prothrombine time
- Thromboplastine time
- IVP (visualization or non-vis)
- CT scan with contrast

Management

The management is based on classification of renal injuries.

- Grade I to III
Manage conservatively with bed rest, antibiotics, serial
hematocrits and a repeat CT between 48 and 72 hours
Urinary extravasation requires stent

- Grade IV to V
Requires surgical exploration, nephrectomy done after
confirming a functioning contralateral kidney

Surgery Clinical Treatment Guidelines 163

Chapiter 7: Genito-Urinary Disorders

7.1.2. Ureter Injury

Causes

- Usually iatrogenic
- Penetrating trauma more common than blunt trauma

Signs and symptoms

- Unilateral
- Assymptomatic, secure ligation of the ureter gives silent atrophy
of the kidney
- Tenderness in the loin
- Fever, possible with pyonephrosis due to infection of the
obstructed system
- Urinary fistula through the wound
- Abdominal distension following uroperitoneum
- Bilateral
- Ligation of both ureters gives anuria
- No passage of ureteric catheter
- Bilateral hydronephrosis

Investigations

- Non single test is reliable:

Pre-operation CT scan with IV contrasts and delayed
images can suggest injury
IV methlylene blue bolus with lasix can be given in
operation room

Management

- If recognized immediately repair with stenting

- If late diagnosis: repair but high nephrectomy rate (30%)
Techniques for an abdominal ureteral injury repair
Spatulate
Stent
Tension free uretero-ureterostomy
Techniques for pelvic ureteral repair
Psoas hitch
Downward nephropexy
Reimplantation in the bladder
- Management of the ureteral contusion by a stent (a bladder
can be opened to place the stent under direct vision or
endoscopically)

164 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

7
- Delayed diagnosis (less than 5 days) consider repair

Disorders
Genito-Urinary
- If greater than 5 days, control urinary extarvasation with ureteral
stent, urinary diversion and urinoma drainage

7.1.3. Bladder Injury

Causes

- Penetrating or blunt trauma

- Pelvic trauma

Signs and symptoms

- No bladder distension
- Gross hematuria
- Difficult or inability to void
- Suprapubic or abdominal pain or tenderness
- Abdominal distension
- Delayed presentation associated with intoxication due to uric
acid accumulation

Investigations

- FBC
- Renal function test
- Ultrasonography
- CT scan
- Retrograde cystography
- Intravenous urography

Management

- Indwelling foley catheter (10-14 days), if extraperitioneal

ruptures
- Eploration and repair, if intraperitoneal rupture
- Manage associated injuries if any

Surgery Clinical Treatment Guidelines 165

Chapiter 7: Genito-Urinary Disorders

7.1.4. Urethral Injury

90% of urethral injuries are at the posterior urethra

Causes

- Posterior urethra: Pelvic fractures (most commonly associated

with bilateral pubic rami-fracures)
- Anterior urethra: Direct trauma

Signs and symptoms

- Blood at urethral meatus

- High riding prostate (freely mobile) on DRE
- Inability to urinate/palpable full bladder
- Perineal hematoma

Investigation

- Retrograde urethrogram

Management

- Primary endoscopic realignment if posterior urethral injury

- Supra-pubic cystostomy and urethroplasty at 4 weeks to 3
months
- Open anastomotic repair if anterior urethra

Complications

- Impotence
- Incontinence
- Strictures

7.1.5. Testicular Injury

Blunt trauma involves testicular rupture in 50% of cases.

Cause

- Blunt or penetrating trauma

166 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
Signs and symptoms

- Scrotal pain
- Ecchymosis
- Hematocele
- Swelling of testis

Investigations

- FBC
- Ultrasonography

Management

- Conservative management with analgesics (paracetamol 1g every

8 hours for 5 days) and scrotal elevation
- Exploration, if tender scrotum/suspicion of testicular rupture
- Orchidectomy, if delayed exploration of a significant testicular
injury
- Psychologic support treatment for patient with severe testicular
injury

7.2. Non Traumatic Disorders

7.2.1. Urinary Tract Infections (UTI)

Definition: Is a significant bacteriuria of the urinary system (colony

count of greater than 100000 organisms per milliliter). It may affect
upper urinary tract (pyelonephritis, renal abscess) or lower urinary
tract (cystitis, urethritis), or both.

Cause/Risk factors

- Urinary tract obstruction

- Instrumentation (e.g. in dwelling catheter)
- Neurogenic bladder
- Diabetis mellitus
- Vesico-ureteric reflux
- Immunosuppression
- Pregnancy

Surgery Clinical Treatment Guidelines 167

Chapiter 7: Genito-Urinary Disorders

Signs and symptoms

- Upper UTI
- Fever
- Chills/rigors
- Flank pain
- Malaise
- Anorexia
- Costovertebral angle and abdominal tenderness
- Lower UTI
- Dysuria
- Frequency
- Urgency
- Suprapubic pain
- Hematuria
- Scrotal pain (epididymo-orchitis) or perineal pain (prostatitis)

Investigations

- Upper urinary tract infection

- FBC
- Urinalysis
- Renal function tests
- Electrolytes
- Renal ultrasound
- Intravenous urogram
- CT scan
- Isotope scan
- Lower urinary tract infections
- FBC
- Urinalysis
- Cystoscopy(if hematuria or obstruction)
- Ultrasound,IVU(intravenous urography)

Complications

- Bacteremia and septic shock

- Chronic and xanthogranulomatous pyelonephritis
- Renal and perinephric abcesses

168 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
Management

- If Upper UTI, epididymo-orchitis and prostatitis

Treat underlying causes (e.g. relieve obstruction)
Intravenous appropriate antibiotic therapy. Agents
commonly used are gentamycin160 mg OD /5 days,
cefotaxime 1g TDS/ 7 days for adult or 50to 100mg/kg/day
divided in 3 doses in children or ceftriaxone 1-2 gr OD/ 7
days for adult or 50mg/kg/day in one dose

- If Cystitis and uncomplicated lower UTI:

Treat underlying causes (e.g. relieve obstruction)
Managed with oral antibiotics: amoxicilline 500mg
TDS/7 days, nitrofurantoine 100mg, 2 tabs BID/10 days,
cephalosporine( cefuroxime 500 mg BID/ 5-10 days)
Encourage high fluid intake
Drainage either radiologically or surgically, if abcess

- If there is poor response to treatment, consider unusual UTI

Tuberculosis (sterile pyuria)
Candiduria
Schistosomiasis
N.gonorrhea
Chlamydia trachomatis

7.2.2. Hematuria

Causes/ risk factors

- Pseudohematuria: menses, dyes (beets, rhodamine B in drinks,

candy and juices), hemoglobin (hemolytic anemia), myoglobin
(rhabdomyolysis), porphyria, laxatives (phenolphthalein).
- Based on source of bleeding: pre-renal, anticoagulants,
coagulation defects, sickle cell disease, leukemia.
- Renal: renal tumours, infections, trauma, ureter, stone, tumour
- Bladder: infections, tumour, stone, Polyps, Urethra: infections,
stone, tumour, urethral stricture

Diagnosis

- History: flank pain, irritative or obstructive symptoms, recent

UTI, STDs, TB exposure, pelvic, irradiation, bleeding diathesis,
smoking, drugs (NSAIDs, anticoagulants), diabetes, sickle cell
anemia, polycystic kidney disease, urinary tract calculi

Surgery Clinical Treatment Guidelines 169

Chapiter 7: Genito-Urinary Disorders

- Physical exam
Abdominal exam - abdominal masses (including renal or
bladder) or tenderness
GU exam - DRE for prostate, external genitalia in males

Investigations

- FBC (rule out anemia, leukocytosis)

- Chemistry: electrolytes, creatinine, BUN
- Urinalysis: culture and sensitivity and cytology
- Ultrasound
- CT with contrast
- Cystoscopy
- Intravenous pyelogram (IVP)

Management

- Irrigation with normal saline to remove clots

- Cystoscopy and stop bleeding
- Intravesical instillation of 1% silver nitrate solution
- Intravesical instillation of 1-4% formalin (need general
anesthesia)
- Embolization or ligation of iliac arteries
- Partial or total cystectomy

7.3. Testicular and Scrotal Disorders

7.3.1. Testicular Torsion

Definition: Testicular torsion is the twisting of the spermatic cord,

which cuts off the blood supply to the testicles and surrounding
structures within the scrotum. It is the most common cause of acute
scrotal pain in boys.

Causes

- Inadequate connective tissue within the scrotum

- Trauma to the scrotum, particularly if significant swelling occurs
- Strenuous exercise
- The condition is more common during infancy (first year of life)
and at the beginning of adolescence (puberty)

170 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
Signs and symptoms

- Acute scrotal pain

- Swelling of the scrotum or testis
- High transverse lying testis
- Nausea or vomiting
- Light-headedness
- Testicle lump
- Blood in the semen

Investigations

- Scrotal ultrasound with colour Doppler

- Nuclear scintigraphy

Complications

- Testicular atrophy (shrink) and need to be surgically removed

- Severe infection of the testicle and scrotum possible if the blood
flow is restricted for a prolonged period

Management

- Take immediately to surgery within 6 hours to save testis

- Reduction and orchidopexy if testis still viable
- Orchiectomy if testis are infarcted
- Contralateral orchidopexy

7.3.2. Fournier Gangrene

Definition: It is a necrotizing fasciitis of the male genitalia and

perineum.

Causes/risk factors

- Uretheral stricture
- Perirectal abcesses
- Poor perineal hygiene
- Diabetes
- HIV
- Immunocompromised states

Surgery Clinical Treatment Guidelines 171

Chapiter 7: Genito-Urinary Disorders

Signs and symptoms

- Fever
- Perineal and scrotal pain
- Cellulitis
- Necrosis of the scrotum
- Flanking skin
- Crepitus

Investigations

- FBC
- HIV test
- Glycemia
- Pus culture for sensitivity

Management

- Prompt debridement of nonviable tissues

- Broad spectrum antibiotics (Ceftriaxone1-2gr BID or
cefotaxime1-2gr TDS + metronidazole 500 mg TDS 5-10 days)
- Colostomy, if there is damage to the external anal sphincter
- Glucose control and adequate nutrition are necessary to facilitate
wound healing

7.3.3. Testicular Cancer

Definition: Testicular cancer is the malignant lesion of the testis.

Causes/risk factors

- Cryptorchidism
- Risk is unaffected by orchidopexy
- Higher incidence in the whites

Signs and symptoms

- Painless swelling of the testis

- Vague testicular discomfort
- Rarely, evidence of metastatic disease or gynecomastia
- Hard irregular non tender testicular mass

172 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
Investigations

- Blood for tumor markers, AFP and HCG

- Scrotal ultrasound
- Chest x-ray to assess lungs and mediastinum
- CT scan of the chest and abdomen to detect lymphnodes
- Laparoscopy (retroperitonoscopy)

Management

- Orchidectomy (groin incision) and histological diagnosis

- Further treatments depend on histology and staging
- If seminoma
Stage I and II: radiotherapy to the abdominal nodes
Stage III: chemotherapy( bleomycin, cisplatine and
etoposide)

- If non seminoma germ cell

Stage I: RPLND
stage II: Chemotherapy + RPLND
stage III: Chemotherapy

7.3.4. Hydrocele

Definition: Hydrocele is the collection of fluid within tunica vaginalis.

Causes

- Congenital
- Idiopathic
- Secondary (intrascrotal pathology such us tumour, torsion,
trauma or infection)

Signs and symptoms

- Fluctuant
- Trans-illuminate
- Swelling
- Non tender

Investigations

- Ultrasound
- Urinalysis
- FBC

Surgery Clinical Treatment Guidelines 173

Chapiter 7: Genito-Urinary Disorders

Management

- Surgery
- Lords procedure in adults
- Herniotomy in children

7.3.5. Undescended Testis

Definition: Interruption of the normal descent of the testis into the

scrotum

Causes/risk factors

- Prematurity

Signs and symptoms

- Absence of testis in the scrotum

- Palpable mass in the inguinal canal
- Difficult or impossible to palpate the testis (abdominal testis or
congenital absence of the testis

Investigations

- Hormonal dosage (chorionic gonadotropin levels)

- Spermogram
- Ultrasound
- Laparoscopy

Management

- Unilateral undescended testis: surgical repositioning

(orchidopexy) before two years of age
- Bilateral undescended testis
- Chorionic gonadotropine
- Operative correction (failure of descent after one month of
therapy)
- Prostheses (testicular agenesis)

174 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
7.3.6. Varicocele

Definition: Is dilatation and tortuous veins within the pampiniform

plexus of scrotal veins.

Cause and risk factors

- Valvular incompetency or absence of the valves at the

termination of the left testicular vein
- Venous occlusion by renal or retroperitoneal tumors

Signs and symptoms

- Common on the left side

- Dragging-like or aching pain within the scrotum
- Feeling of heaviness in the testicle
- Atrophy of the testicle
- Visible or palpable enlarged vein
- Likened to feeling a bag of worms

Investigation

- Color Doppler ultrasonography

Management

- Medical therapy: no effective medical treatment have been

identified
- Embolization (first choice treatment)
- Gonadal vein ligation (inguinal canal or low tie/ retro
peritoneum or high tie)

Surgery Clinical Treatment Guidelines 175

Chapiter 7: Genito-Urinary Disorders

7.4. Disorders of the Penis

7.4.1. Priapism

Definition: Is a persistent erection for greater than 4 hours unrelated

to sexual stimulation. It can be low flow (ischemic) or high flow
(traumatic).

Causes/risk factors

- Most priapiasms are idiopathic

- Sickle cell disease
- Medication (e.g. antidepressant anti psychosis chlorpromazine)
- Pelvic tumors
- Malignancies (leukemia)
- Spine cord injury
- Penile injections for erectile dysfunctions
- Cocaine abuse
- Total perenteral nutrition

Signs and symptoms

- Persistent erection
- Tenderness of the penis
- Cavernous bodies rigid while the glans will be flaccid

Investigations

- Blood analysis (gases, cell count and morphology)

- Abdominal ultrasound
- Color Doppler ultrasound
- Angiography

Management

- Low flow priapism: medical management if Priapism results from

sickle cell disease and leukemia
hydration
oxygenation
alkalinisation
Transfusions or exchange transfusions should be
considered
Irrigation of corpora cavernosa (phenylephedrine 5 mg in
500 ml of Normal saline) when diagnosed before 36 hours

176 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

7
Distal shunt (winter shunt)

Disorders
Genito-Urinary
Proximal shunt if distal shunt fails

- High flow priapism

Selective embolization
Fistula surgical ligation if embolization fails

7.4.2. Paraphymosis

Definition: Is the retraction of foreskin behind the corona of the glans

penis reducing a tonic effect.

Causes

- Trauma
- Latrogenic

Signs and symptoms

- Oedema of the fore skin and glans penis

- Pain
- Fore skin ulceration

Management

- Reduction under anesthesia

- Operation (circumcision)

7.4.3. Phymosis

Definition: Is tightness of the fore skin of such a degree as to prevent

retraction.

Causes

- Congenital
- Secondary to infection

Signs and symptoms

- Ballooning of the fore skin micturation

- Failure of retraction
- Small contracted orifice

Management

- Circumcision

Surgery Clinical Treatment Guidelines 177

Chapiter 7: Genito-Urinary Disorders

7.4.4. Hypospadias

Definition: A condition where the urethral orifice opens in abnormal

position on the ventral surface of the penis or scrotum.

Causes /risk factors

- Use of maternal estrogen or progesterone during pregnancy

- Hereditary

Signs and symptoms

- Difficulty directing the urinary stream and stream spraying

- Chordee
- Males with this condition often have a downward curve (ventral
curvature or chordee) of the penis during an erection
- Abnormal spraying of urine
- Having to sit down to urinate
- Malformed foreskin that makes the penis look hooded

Investigations

- A physical examination can diagnose this condition

- A buccal smear and karyotyping
- Urethroscopy
- cystoscopy
- Excretory urography

Complications

- Difficulty with toilet training

- Problems with sexual intercourse in adulthood
- Urethral strictures and fistulas may form throughout the boys
life

Management

- Infants with hypospadias should not be circumcised

- For a Minor degree of hypospadias (e.g. glandular hypospadias)
require no treatment

Surgical management
During the surgery, the penis is straightened and the
hypospadias is corrected using tissue grafts from the
foreskin. The repair may require multiple surgeries

178 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
Relief of the chordee
Urethral reconstruction
In some cases, more surgery is needed to correct fistulas or
a return of the abnormal penis curve

Recommendations

- Surgery is usually done before the child starts school

- Surgery can be done as young as 4 months old, better before the
child is 18 months old

7.4.5. Carcinoma of the Penis

The majority of penis malignancies are squamous cell carcinomas.

Causes and risk factors

- Oriental origin
- Age
- Human papillovirus (HPV) and balanitis xerotica obliteran
infection
- Smoking
- Smegma and phymosis
- Treatment of psoriasis with UV light
- AIDS
- Poor hygiene related to non circumcision and STDs

Signs and symptoms

- Redness
- Irritation
- Sore on the penis
- Indurations or erythema
- Ulceration
- Small nodule, or an exophytic growth

Diagnosis

- Biopsy for histopathology tests

Management

Primary lesion
Circumcision: lesion localized to the prepuce
Radiotherapy: glans alone affected and tumor 1cm

Surgery Clinical Treatment Guidelines 179

Chapiter 7: Genito-Urinary Disorders

Partial amputation: shaft of the penis is involved

Total amputation: extensive involvement of the shaft
Antibiotics for 6 weeks before evaluating the inguinal
nodes

Inguinal lymph nodes

Careful follow up if impalpable nodes
Radical dissection if palpable mobile nodes persisting 3
months after initial treatment
Fixed inguinal lymph node: chemotherapy with
bleomycine, cisplatin and methotrexate

7.4.6. Impotence

Definition: Persistent inability to obtain and sustain an erection

sufficient for sexual intercourse.

Causes

- Psychological
- Neurological causes (spinal cord lesions, myelodisplasia,
multiple sclerosis, tabes dorsalis,peripheral neuropathies)
- Diabetes mellitus
- Endocrine (hypogonadotrophic hypogonadism Klinefelters
Syndrome or surgical orchidectomy)
- Low testosterone levels (prolactin producing tumors)
- Vascular(atherosclerosis)
- Trauma (perineal, posterior urethra, pelvic fracture leading to
arterial injury, uraemicchronic dialysis
- Iatrogenic (radical prostatectomy, cystoprostatectomy,
neurological surgical procedures,transurethral endoscopic
procedures, pelvic irradiation procedures)
- Medication (centrally acting agents, anticholinergic
agents (antidepressant), anti-androgenic agents (digoxin),
hyperprolactinemic agent (cimetidine), sympatholitic agent
(methyl dopa)

Diagnosis

- Detailed history
- Physical examination
- Length, plaques and deformity of the corporal bodies of penis
- Presence or absence of testis
- Size and consistency of the penis

180 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

7
-

Disorders
Genito-Urinary
Gynecomastia (endrogene deficiency)
- Neurological assessment
- Sensory function of the penis and perineal skin
- Bulbo cavernosus reflexe to evaluate the sacral reflexes

Investigations

- Nocturnal penile turnescence (change in penis size during sleep)

- Dynamic infusion cavernosometry and cavernosonography (to
assess venous/corporal leak)

Management

Psychological
Treated by trained psychotherapist or sex therapist

Medical therapy
Sildenafil(viagra), tadalafil (cialis)
Apomorphine (uprima)
Intracorporal administration of vasoactive substances
(papaverine hydrochloride alone or associated with
vasodilator like phentolamine, or prostaglandin E1)
Androgen replacement therapy with testosterone
Vacuum suction devices

Surgical therapy
Penile prostheses
Vascular surgical techniques like micro surgical
anastomosis of inferior epigastric artery to the dorsal
penile artery

Surgery Clinical Treatment Guidelines 181

Chapiter 7: Genito-Urinary Disorders

7.5. Disorders of the Urethra

7.5.1. Urethra Meatal Stenosis

Definition: Is a narrowing of the opening of the urethra, the tube

through which urine leaves the body.

Causes

- Congenital
- Failure of normal canalization
- Treat at time of endoscopy with dilatation, internal urethrotomy
- Trauma
- Instrumentation (most common, at fossa navicularis)
- External trauma
- Urethral trauma with stricture formation
- Infection
- Common with gonorrhea in the past (not common now)
- Long-term indwelling catheter
- Balanitis xerotica obliterans - causes meatal stenosis

Signs and symptoms

- Decreased force/amount of urinary stream

- Spraying
- Double stream
- Post-void dribbling
- Related infections: recurrent UTI, secondary prostatitis /
epididymitis

Investigations

- Dynamic: flow rates < 10 mL/s (normal = 20 mL/s)

- urine culture
- urethrogram, VCUG (voiding cysto urethrography ) will
demonstrate location
- urethroscopy

Management

- Uurethral dilatation
- Temporarily increases lumen size by breaking up scar tissue
- Healing will reform scar tissue and recreate stricture
- Not usually curative

182 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
- Internal urethrotomy (IU)
- Endoscopically incise stricture without skin incision
Only single and short (< 1 cm), bulbar urethra strictures
respond
Cure rate 50-80% with single treatment, < 50% with
repeated courses

- Open surgical reconstruction

Complete stricture excision for all, then (dependent on
location and size of stricture):
Membranous urethra end-to-end anastomosis
Bulbar urethra < 2 cm end-to-end anastomosis
Bulbar urethra > 2 cm or penile urethra 1)
vascularized flap of local genital skin or 2) free graft
(penile shaft skin or buccal mucosa) preferred

7.6. Disorders of the Prostate

7.6.1. Benign Prostatic Hyperplasia (BPH)

Definition: An increase in size of the inner zone of the prostate

gland. It is a disease common in elderly men. BPH never progresses to
carcinoma.

Causes

- Not known
- Predisposing factors are age, normally functioning testes, race,
geographical location, sexual behavior, diet, alcohol, tobacco (no
evidence that they play a part).

Signs and symptoms

- Nocturia
- Urgency and frequency
- Weak stream and hesitancy
- Acute urinary retention
- Urinary tract infections
- Renal failure
- Urinary stones
- Haematuria

Surgery Clinical Treatment Guidelines 183

Chapiter 7: Genito-Urinary Disorders

Management

- Medical therapy (Alpha Blockers and androgen suppression)

- Minimally invasive surgery (Trans urethral microwave
thermotherapy, transurethral needle ablation)
- Surgery (TURP (trans-urethral resection prostate), open surgery)

7.6.2. Prostatic Cancer

Adenocarcinoma is the most common type (greater than 90%). It

primarily develops in the peripheral portion of the prostate gland.

Causes/Risk factors

- Age
- Family history

Investigations

- PSA is used in conjunction with DRE to help provide early

detection of the disease
- PSA is also used to detect biochemical disease recurrence
following treatment
- Patient with an elevated PSA and/or abnormal DRE are
recommended to undergo TRUS guided biopsy
- Metastatic work up should be performed in selected patient
based on clinical picture ( work up usually comprises bone scan
and CT against MRI)

Management

- Brachytherapy, external beam radiation therapy or radical

retropubic prostatectomy
- At the time of prostatectomy, a pelvic lymphadenectomy is
performed first.
- Systemic therapy (androgen deprivation therapy and hormonal
therapy) in patients with significant comorbidities and/or more
extensive diseases.

184 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
7.7. Disorders of the Urinary Bladder

7.7.1. Bladder Calculi/stones

Definition: Bladder calculi/stones are hard buildups of minerals that

form in the urinary bladder.

Causes

- Calculi from the kidney

- Bladder outflow obstruction
- Presence of foreign bodies ( e.g. urethral catheter)
- Neuropathic bladders
- Bladder diverticulum
- Enlarged prostate
- Urinary tract infection

Signs and symptoms

- Abdominal pain, pressure

- Pain, discomfort in the penis
- Dysuria with frequent urge to urinate
- Abnormally colored or dark-colored urine
- Frequency
- Hematuria
- Nocturia
- Hesitancy
- Weak stream
- Sadden cessation of flow with pain in the perineum and tip of the
penis
- Urinary incontinence may also be associated with bladder stones
- Rectal examination may reveal an enlarged prostate

Investigations

- Urinalysis may show blood in the urine, crystals, or an infection

- Urinary culture (clean catch) may reveal infection
- IVU
- Ultrasound
- Bladder or pelvic x-ray may show stones
- Cystoscopy can reveal a stone in the bladder

Surgery Clinical Treatment Guidelines 185

Chapiter 7: Genito-Urinary Disorders

Complications

- Acute bilateral obstructive uropathy

- Bladder cancer in severe, long-term cases
- Chronic bladder dysfunction (incontinence or urinary retention)
- Obstruction of the urethra
- Recurrence of stones
- Reflux nephropathy
- Urinary tract infection

Management

- Drinking 6 - 8 glasses of water or more per day to increase

urinary output may help the stones pass
- Remove stones that do not pass on their own using a cystoscope
(a small tube that passes through the urethra to the bladder)
- Treated causes of bladder stones e.g. benign prostatic hyperplasia,
bladder outlet obstruction
- Transurethral resection of the prostate (TURP) with stone
removal
- Medication is rarely used to dissolve the stones
- Removal of the stones (endoscopially / open surgery)
cystolithotomy for very large stones

7.7.2. Bladder Cancer

Definition: Bladder cancer is a cancer that starts in the bladder; 90%

is transitional cell carcinoma, 5-7% is squamous cell carcinoma, and
1-2% is adenocarcinoma/urachal carcinoma.

Classification of bladder cancers

I. Papillary tumors: have a wart-like appearance and are attached to

a stalk
II. Nonpapillary (sessile): tumors are much less common, but more
invasive and have a worse outcome

Signs and symptoms

- Painless
- Gross haematuria is the commonest presentation
- Microscopic heamaturia
- Irritative voiding symptoms

186 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
Causes/Risk factors

- Cigarette smoking
- Age
- Cyclophosphamide
- Phenacetin
- Chemical exposure at work carcinogens (dye workers, rubber
workers, aluminum workers, leather workers, truck drivers, and
pesticide applicators)
- Chemotherapy
- Radiation treatment
- Bladder infection

Diagnosis

- Clinical
- Investigations
- Urine cytology
- Cystoscopy
- Upper tract/abdominal/pelvic evaluation with CT scan or
intravenous pyelography (IVP)
- TURBT for tissue diagnosis (Histopathological analysis)

Note:
If tests confirm bladder cancer, staging is done to see if the cancer
has spread. Staging helps guide future treatment and follow-up
and gives idea on patient prognosis.

The TNM (Tumor, Nodes, Metastasis) staging system of bladder

cancer:
- Stage 0 - Noninvasive tumours that are only in the bladder lining
- Stage I - Tumour goes through the bladder lining, but does not
reach the muscle layer of the bladder
- Stage II - Tumour goes into the muscle layer of the bladder
- Stage III - Tumour goes past the muscle layer into tissue
surrounding the bladder
- Stage IV - Tumour has spread to neighboring lymph nodes or to
distant sites (metastatic disease)

Management

- Treatment depends on the stage of the cancer, the severity of

disease symptoms and overall health

Surgery Clinical Treatment Guidelines 187

Chapiter 7: Genito-Urinary Disorders

- Stage 0 and I treatments

Surgery to remove the tumor without removing the rest of
the bladder
Chemotherapy or immunotherapy directly into the bladder

- Stage II and III treatments

Surgery to remove the entire bladder (radical cystectomy)
Surgery to remove only part of the bladder, followed by
radiation and chemotherapy
Chemotherapy to shrink the tumor before surgery
A combination of chemotherapy and radiation (in patients
who choose not to have surgery or who cannot have
surgery)

Most patients with stage IV tumors cannot be cured and surgery is not
appropriate. In these patients, chemotherapy is often considered.

Treatment Summary

- Superficial bladder cancer and carcinoma in situ (Intravesical

chemotherapy with mitomycin C, intravesical immunotherapy
with BCG)
- Perform radical cystectomy with urinary diversion; for BCG
failure in carcinoma in situ, for muscle invasive disease
- Neo adjuvant chemotherapy to down stage tumours for
unresectable to resectable
- Chemotherapy for advanced disease

7.7.3. Cystocele

Definition: Is a medical condition that occurs when the tough fibrous

wall between a womans bladder and her vagina is torn by childbirth,
allowing the bladder to herniate into the vagina.

Causes

- Muscle straining during delivery

- Heavy lifting or repeated straining during bowel movements
- Oestrogen deficiency due to old age

188 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
Signs and symptoms

- Urine leakage
- Incomplete emptying of the bladder
- Bladder emptying impaired
- Frequency
- Nocturia
- Stress incontinence
- Relaxation of the anterior vaginal wall and descent of the urethra
and bladder when the patient strains to void

Investigations

- Urinalysis
- Ultrasonography

Management

- Mesh sling technique

- Transobturator tape (TOT)
- Transvaginal tape (TVT)
- Anterior colporrhaphy

Surgery Clinical Treatment Guidelines 189

Chapiter 7: Genito-Urinary Disorders

7.7.4. Urinary Incontinence

Definition: Is the involuntary loss of urine

Classification

Classification of incontinence according to anatomical abnormality

Class Sub- class Causes/risk factors Signs and
symptoms
Urethral Urethral Involuntary
abnormalities incompetence urine loss
Incontinence less
common in men
Urethral after prostatectomy
incontinence or pelvic fracture
Bladder Inhibited detrusor Frequency and
abnormality contractions by: urgency (urge
Neuropathic incontinence)
(detrusor
hyperreflexia)
non neuropathic
(detrusor instability
Non urinary impaired mobility
abnormalities(in Impaired mental
elderly patients) function
Non urethral Fistula
incontinence Ureteral ectopia
Classification of incontinence according to clinical presentation
Stress Ref. anatomical Ref. anatomical
incontinence classification classification
Urge Ref. anatomical Ref. anatomical
incontinence classification classification
Nocturnal Day time voiding
enuresis: bed abnormalities such
wetting in as frequency and
older children urgency

Constant Urinary fistula

urine wetness Ectopic ureter

190 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
Diagnosis

- Detailed history
- Poor flow, hesitancy
- Post micturation dribble (outflow obstruction)
- Dysuria (infection)
- Hematuria (possibility of tumour)
- Sexual function (males), bowel function (both sex) point toward
neurological cause
- Mobility and mental status (incontinence in elderly)
- Past or present illness (diabetes, surgery e.g. abdominal perineal
resection, hysterectomy DRE for the prostate in male
- DVE for female for cystoureterocele
- Neurological assessment

Investigations

- RFT
- Urine microscopy and culture
- IVU
- Urodynamics
- Cystometry
- Cystoscopy
- Cystogram

Management

- If urge incontinency
Treat the underlying cause
Pharmaceutical therapy: anticholinegic and/or smooth
muscle relaxant (oxybutynin, emepronium carageenate,
flavoxate hydrochloride) associated with bladder exercise
- Surgical therapy
Cystoscopy and bladder distention
Partial bladder denervation by subtrigonal phenol injection
or pre sacral neurectomy
Augmentation cystoplasty (bladder enlargement) or
substitution cystoplasty(bladder substitution)
Urinary diversion (ileal conduit)
- If stress minor incontinence
Pelvic flow exercise
Estrogen therapy
Sympathomimetics (ephedrine or alpha adrenergic agonist
e.g. phenylpropanolamine)

Surgery Clinical Treatment Guidelines 191

Chapiter 7: Genito-Urinary Disorders

- If stress major incontinence

Surgical treatment for female
Endoscopic or retropubic uretropexy
Vaginal repair ( anterior colporrhaphy)
Artificial urinary sphincter

Surgical treatment for male

Artificial urinary sphincter
Urinary diversion (if medical treatment fails)

- If nocturnal enuresis
Bladder training during the day gradually increasing
interval between voiding
Voiding last thing at night
Lift the child before bed
Enuresis alarm
Drugs: imipramne (tofranil), propantheline,oxybutynin,
desmopressin
Augmentation cystoplasty (if failure of medical treatment)

7.8. Disorders of the Kidney and the Ureter

7.8.1. Vesico-Ureteric Reflux

Definition: A congenital condition from the ureteral bud coming

off too close to the urogenital sinus on the mesonephric duct which
result in short intravesical length (intramural) of ureter. Urine travels
retrograde from the bladder into the ureter and often into the kidney.

Signs and symptoms

- Evaluate
- Any child with febrile urinary infection
- Any boy with urinary infection
- Any girl with recurrent UTI

Investigations

- Ultrasonography
- Voiding cystourethrogram
- Hereditary, be suspicious in siblings and screen with imaging
studies

192 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
Management

- Low grade reflux

- Conservative treatment with observation and antibioprophylaxis
- Close follow up
- Treat voiding dysfunction
- High grade reflux
- Surgical intervention with ureteral re-implantation

7.8.2. Calculus

Calcium stones (Ca oxalate, Ca phosphate) are the most common

types in 70% of the cases.

Causes

- Renal infections
- Inadequate urinary drainage and urinary stasis
- Prolonged immobilization
- Decreased urinary citrate
- Dietetic (deficiency of vitamin A)
- Altered urinary solutes and colloids
- Hyperparathyroidism

Signs and symptoms

- Assymptomatic (non obstructive renal stones)

- Flank pain (colicky radiating to the lateral abdomen- proximal
ureteral stones or pain that irradiate into the groin and genitals-
distal ureteral stones)
- Microscopic or gross hematuria
- Obstructive pyelonephritis (signs of sepsis)

Investigations

- Kidney/Ureter x-ray
- Bladder x-ray
- Abdominal ultrasound

Management

- Extracorporeal shock wave lithotripsy (ESWL) if non obstructive

renal stones less than 2.5 cm
- Percutaneous nephrolithotomy (PCNL), if large renal stone
- Percutaneous removal if Staghorn calculi
- Cystoscopy with stent placement

Surgery Clinical Treatment Guidelines 193

Chapiter 7: Genito-Urinary Disorders

7.8.3. Renal Cell Carcinoma

Occurs in young adults

Signs and symptoms

- A triad of pain hematuria and frank mass

- Weight loss
- Fever
- Erythrocytosis
- Left sided varicocele
- Hypertension
- Paraneoplastic syndromes (hypercalcemia, hypertension,
polycythemia and Stauffers Syndrome)

Complications

- RCC can extend into renal vein, up the IVC (inferior vena cava)
and into the atrium.

Management

Palliation
Renal artery embolisation (may stop hematuria)
Chemotherapy (10% response rate)
Hormonal therapy (5% response rate)
Immunotherapy (under review)

Surgery
Partial nephrectomy, if small peripheral lesions
Radical nephrectomy (Gerotas fascia and regional
lymphnodes)
Isolated lung metastases should also be removed surgically

7.8.4. Nephroblastoma or WILMS TUMOURS

Definition: It is the most common solid renal tumour in childhood,

accounting for roughly 5% of childhood cancers. It is an embryonic
tumour arising from nephrogenic tissue.

Signs and symptoms

- An abdominal mass (incidental)

- Abdominal pain and distention

194 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
- Fever/ convulsions
- Cough
- Anorexia
- Nausea and vomiting
- Hematuria (in about 20% of cases)
- High Blood Pressure in 25 60%
- Coagulopathy can occur in 10%

Investigations

- FBC
- Renal function test
- Liver function test
- An Ultrasound
- CT scan or MRI
- Chest x-ray
- Plain abdominal x-ray
- IVP
- Surgical biopsy

Management

- If unilateral tumours
chemotherapy: Adriamycin, vincristine or doxorubicine for
52 weeks followed by
nephrectomy

- If bilateral tumours
Partial nephrectomy and chemotherapy
Radiotherapy

7.8.5. Pelvi-Ureteric Junctions

Definition: Blockage of the ureter where it meets the renal pelvis.

Cause

- Congenital from either abnormalities of the muscles itself or

crossing vessels.

Signs and symptoms

- Abdominal mass in the new born

- Flank pain and infection in later life

Surgery Clinical Treatment Guidelines 195

Chapiter 7: Genito-Urinary Disorders

Investigations

- Ultrasound
- Diuretic renal scan

Management

- Pyeloplasty (Anderson- Hayne)

7.8.6. Tumours of the Renal Pelvis and Ureter

They are relatively rare. They account for approximately 10% of all
renal tumours and approximately 5% of all urotherial tumours.

Causes/risk factors

- Tobacco smoking
- Drinking coffee (observed for people who take > 7cups of coffee/
day)
- Analgesic abuse
- Chronic infections, irritations
- Hereditary

Signs and symptoms

- Painless intermittent hematuria

- Clot colic
- Loin pain
- Anorexia
- Dysuria
- Weight loss
- Abdominal mass palpable in 5%

Investigations

- Urine cytology
- IVU
- Ultrasonography
- Retrograde ureterography
- Antigrade pylography
- CT scan
- Chest x-ray
- Cystoscopy
- Ureteroscopy

196 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
Management

- Nephro ureterectomy and partial cystectomy

- Chemotherapy in case of lymphnode metastases

7.8.7. Urine Retention

Definition: It is a sudden and painful inability to pass urine

voluntarily when the bladder is full (acute UR) or painless retention
with sometimes overflow incontinence (Chronic UR).

Causes

- Obstructive
- Benign prostatic hyperplasia
- Cancer of prostate
- Uretheral stricture
- Bladder neck obstruction
- Trauma of the pelvis
- Phymosis
- Pelvic masses and gynecology malignancies
- Infectious and inflammatory
- Acute prostatitis
- Vulvovaginitis
- Neurologic
- Spinal and peripheral nerve injuries
- Spinal compression
- Cerebrovascular disease
- Guillain Barre Syndrome
- Diabetes mellitus
- Tumours
- Pharmacologic
- Anticholinergics and alphadrainergic agents

Signs and symptoms

- Painful urge to pass urine

- Dysuria
- Increased frequency
- Uncontrolled dribbling of urine through the urethra

Investigations

- Blood urea and serum creatinine

- Urinalysis, culture and sensitivity

Surgery Clinical Treatment Guidelines 197

Chapiter 7: Genito-Urinary Disorders

- Ultrasonography
- CT scan brain, spine, pelvis if suspicion of neurologic lesion
- Plain x-ray

Management

- Bladder drainage (emergency)

- Aseptic catheterization
- IV fluid replacement if rapid decompression syndrome
(hematuria, hypotension or post-obstructive dieresis)
- Antibiotics if infected urine: fluoroquinolones (ciprofloxacine)
and wait for urine culture and sensitivity

Complication

- Chronic renal failure

7.8.8. Vesicovaginal Fistula

Causes

- Obstetric: The usual cause is protracted or neglected labor

- Gynecological: The operation chiefly causing this complication
are total hysterectomy and anterior colporrhaphy
- Radiotherapy: Direct neoplastic infiltration
- Exceptionally: Carcinoma of the cervix ulcerates through the
anterior fornix to implicate the bladder

Signs and symptoms

- Leakage of urine from the vagina

- Excoriation of the vulva
- Vaginal examination may reveal a localized thickening on its
anterior wall or in the vault
- On speculum: urine escaping from an opening in the anterior
vaginal wall

Investigations

- The three-swab test

- Cystoscopy
- Bilateral retrograde ureterography
- IVU

198 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
Management

- Conservative management: Bladder drainage

- Surgical repair
- Low fistula (subtrigonal): Transvaginal repair. A urethral catheter
should be left in situ for at least 10 days
- High fistula (supratrigonal): Suprapubic approach

7.9. Neonatal Obstructive Uropathies

7.9.1. Posterior Urethral Valves

Definition: Obstructive urethral lesions usually diagnosed in male

newborns and infants. They are thin membranous folds located in the
prostatic urethra.

Cause and Risk factors

- Congenital

Signs and symptoms

- Assymptomatic till adolescence or childhood in incomplete

valves
- Urinary retention
- Weak stream
- Dysuria (infection)
- Able to pass catheter without difficulty

Investigations

- Urinalysis
- Ultrasound scan
- Voiding cyctogram (dilatation of the urethra above the valves)

Management

- Detect and treat early to avoid renal failure

- Suprapubic catheter
- Transurethral resection

Surgery Clinical Treatment Guidelines 199

Chapiter 7: Genito-Urinary Disorders

7.9.2. Urethral Stricture

Definition: Congenital narrowing of the urethra

Cause

- Duplication of the urethra.

Signs and symptoms

- Rare and delayed till adolescence

- Indistinguishable from a stricture due to unrecognized urethra
infection in childhood

Investigations

- Urinalysis
- RFT
- FBC
- Ultrasonography
- Urethrogram
- IVU

Management

- Treatment infections
- Dilatation
- Optical urethrotomy

7.10. Non traumatic Urological Conditions

7.10.1. Benign Prostatic Hyperplasia (BPH)

Definition: Is a pathologic disorder that develops in response to the

action of dihydrotestosterone on the aging prostate and to changes
in stromal and epithelial cells in this exocrine gland. BPH never
progresses to carcinoma.

Causes

- Idiopathic
- Predisposing factors: age, normally functioning testes, sexual
behavior, diet, alcohol, tobacco (no evidence that they play a
part)

200 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
Signs and symptoms

- Nocturia
- Urinary urgency and frequency
- Acute urinary retention
- Urinary tract infections
- Renal failure
- Urinary stones
- Haematuria

Management

Conservative management
Medical therapy
Alpha Blockers: e.g.
Androgen suppression: e.g.

Surgery
Trans urethral microwave thermotherapy
Transurethral needle ablation
Trans-urethral Resection prostate (TURP)
Open surgery: Prostatectomy

7.10.2. Adenocarcinoma

Definition: Adenocarcinoma is a cancer originating in glandular

epithelial tissue. Epithelial tissue includes, but is not limited to, skin,
glands and a variety of other tissue that lines the cavities and organs of
the body.

Causes/Risk factors

- Age: is the most powerful risk factor

- Family history: first degree relative with the disease implies a
twofold increased risk

Investigations

- PSA is used in conjunction with DRE to enable early detection of

the disease and detect biochemical disease recurrence following
treatment
- Patient with an elevated PSA and/or abnormal DRE are
recommended to undergo TRUS guided biopsy

Surgery Clinical Treatment Guidelines 201

Chapiter 7: Genito-Urinary Disorders

- Metastatic work up in selected patient based on clinical picture

CT scan of the Bones
MRI of the bones

Management

- Brachytherapy, external beam radiation therapy or radical

retropubic prostatectomy for patients with localized prostate cancer
- Definitive therapy for patients expected for greater than 10 year
survival
- At the time of prostatectomy, a pelvic lymphadenectomy is
performed first
- Consider systemic therapy (androgen deprivation therapy and
hormonal therapy) for patients with significant co-morbidities
and/or more extensive diseases

7.10.3. Bladder Cancer

Definition: Bladder cancer is a cancer that starts in the bladder. It is

of two forms, transitional cell carcinoma (> 90%) and squamous cell
carcinoma (5-7%).

Causes/Risk factors

- Cigarette smoking
- Chemical exposure at work (carcinogens - dye workers, rubber
workers, aluminum workers, leather workers, truck drivers, and
pesticide applicators)
- Chemotherapy (e.g. cyclophosphamide)
- Radiation treatment
- Chronic bladder infection or irritation (e.g. schistosomiasis)

Signs and symptoms

- Gross painless haematuria (most common)

- Microscopic heamaturia
- Irritative urine voiding symptoms
- Bone pain or tenderness

Investigations

- Urinalysis
- Cystoscopy
- Intravenous pyelography ( IVP)
- TURBT for tissue diagnosis (Histopathhnological analysis)

202 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
- Intravenous pyelogram - IVP
- CT scan of the upper urinary tract Pelvic CT scan

The TNM (Tumor, Nodes, Metastasis) staging system of bladder

cancer
- Stage 0 - Noninvasive tumours that are only in the bladder lining
- Stage I - Tumour goes through the bladder lining, but does not
reach the muscle layer of the bladder
- Stage II - Tumour goes into the muscle layer of the bladder
- Stage III - Tumour goes past the muscle layer into tissue
surrounding the bladder
- Stage IV - Tumour has spread to neighboring lymph nodes or to
distant sites (metastatic disease)

Complications

- Anemia
- Hydronephrosis
- Urinary incontinence

Management

Treatment depends on the stage of the cancer, severity of symptoms,

and overall health of the patient.

Treatment for Stage 0 and 1

Surgery to remove the tumour without removing the rest of
the bladder
Chemotherapy or immunotherapy directly into the
bladder

Treatment of stage II and III

Chemotherapy to shrink the tumour before surgery
Radical cystectomy
Surgery to remove only part of the bladder, followed by
radiation and chemotherapy
A combination of chemotherapy and radiation (in patients
who choose not to have surgery or who cannot have
surgery)

Note:
Most patients with stage IV tumours cannot be cured and surgery
is not appropriate. In these patients, chemotherapy is often
considered

Surgery Clinical Treatment Guidelines 203

Chapiter 7: Genito-Urinary Disorders

Treatment summary

- Intravesical chemotherapy with mitomycin C or intravesical

immunotherapy with BCG): for patients with superficial bladder
cancer and carcinoma in situ
- Radical cystectomy with urinary diversion: for BCG failure in
carcinoma in situ with muscle invasive disease
- Neo adjuvant chemotherapy: to down stage tumours for
unresectable to resectable
- Chemotherapy for advanced disease

7.10.4. Renal Cell Carcinoma

Definition: Renal cell carcinoma is a type of kidney cancer that starts

in the lining of the kidney tubules. It occurs in young adults (40-60
years of age).

Causes/Risk factors

- The exact cause is unknown

- Dialysis treatment
- Family history of the disease
- High Blood Pressure
- Horseshoe kidney
- Polycystic kidney disease
- Smoking
- Von Hippel-Lindau disease

Signs and symptoms

- Classic presentation: A triad of pain hematuria and frank mass

- Other presentations: Includes weight loss, fever, erythrocytosis,
left sided varicocele and hypertension
- Paraneoplastic syndromes in 20% of patients (hypercalcemia,
hypertension, polycythemia and Stauffers Syndrome
- Non metastatic hepatic dysfunction
- Mass or swelling of the abdomen

Investigations

- Chest x-ray and CT scan

- Abdominal CT scan
- Abdominal MRI
- Bone scan
- PET scan

204 Surgery Clinical Treatment Guidelines

 Chapiter 7: Genito-Urinary Disorders

Disorders
Genito-Urinary
Management

- Radical nephrectomy include Gerotas fascia and regional

lymphnodes
- Isolated lung or liver metastasis resection
- Partial nephrectomy (reserved for small peripheral lesions or in
patient with solitary kidneys or bilateral tumours)

Note:
RCC can extend into renal vein, up the IVC and into the atrium

Surgery Clinical Treatment Guidelines 205

 8. Burns

Definition: Burns are skin and tissue damage caused by exposure to or

contact with temperature extremes, electrical current, a chemical agent
or radiation. 8

Burns
Causes

- Thermal causes; hot or cold exposure or contact with objects or

liquids
- Chemical or caustic substances
- Electrical current

Symptoms and signs

- Pain when superficial

- Painless when very deep
- Discolored skin (black, red when superficial, white when very
deep
- Blisters (superficial burns)
- Moist, wet wound in skin
- Smell of burnt flesh
- Loss of skin

Assessment of burns

- Primary survey: ABCs

Stop the burning process
Airway Check for erythyma and oedema of airway, to
anticipate possible need for early intubation
Breathing (Beware of inhalation and rapid airway
compromise)
Circulation (Good IV access fluid replacement)
Disability (GCS, Compartment Syndrome)
Exposure (% burn)

Note:
Nasotracheal or endotracheal intubation is indicated especially if
patient has a severe increase in hoarseness, difficulty swallowing
secretions, or increased respiratory rate with history of inhalation
injury.

Surgery Clinical Treatment Guidelines 207

Chapiter 8: Burns

- Secondary survey
Coincident trauma diagnosed and treated
Burns are further characterized by estimating extent of
burn depth

- Firstdegree
Superficial (sunburn)
Erythema, pain, absence of blisters
Consists of epidermal damage alone

- Second-degree
Entire epidermal layer
Part of underlying dermis
Mottled and red, painful, swelling and blisters

- Third-degree (Full thickness)

Injury/destruction of all epidermal and dermal elements
Burn into subcutaneous fat or deeper
Skin is charred and leathery (woody)
Pearly-white sheen / waxy
Generally NOT painful (nerve endings are dead)

- Fourth-degree
Full-thickness
Extending into muscle, tendons or bones
Typically involves appendage
Black and dry
NOT painful

- Use rule of nine to estimate the extent of burn

Management

Use Parkland formula for fluid replacement: % TBSA burned) x

(Weight in kg) x (4 ml lactated Ringers/kg:
- Administer the first half of the volume in the first 8 hrs, then
administer the second half of the volume in the following 16 hrs
- The timing starts when the burn occurred and not when the
patient arrived in the treatment facility
- Measure URINE INPUT and OUTPUT (output of 0.5 ml/kg/hr
in adults and 1 cc/kg/hr in children)
- Use Lactated Ringers solution

208 Surgery Clinical Treatment Guidelines

 Chapiter 8: Burns

- Endpoints for Fluid Resuscitation

Hourly Urine Output
Heart Rate, Blood Pressure
Acid-Base Status
Filling Pressure (CVP, PAWP)

Burn Wound Treatment 8

- Clean the burn area with mild normal saline for clean wounds,

Burns
and hypertonic solution for infected wounds
- debridement of devitalized tissue and debris
- Apply topical antibacterial agent:
Bacitracin ointment on face / ears
Silver sulfadiazine on the body
Ensure aseptic procedures

- Escharotomy: when pulse less extremity with a circumferential

burn
- Ensure effective pain management
- Provide tetanus prophylaxis to all burn patients. If without
current tetanus immunization, requires tetanus immune globulin
(TIG)
- Give antibiotic for infected wounds: IV cloxacilline 100mg/kg
in children and 3gm in adults (in three divided doses per day,
5-7days)

Surgery Clinical Treatment Guidelines 209

Chapiter 8: Burns

8.1. Electrical Burns

Definition: Electrical burns are body injuries caused by electrical

current itself. The current generates intense heat along its path through
the body, which can lead to severe muscle, nerve and blood vessel
damage.

Causes

- Lightning strikes and generated electrical power

- Exposure to electrical flow

Signs and symptoms

- Cardiac and respiratory arrest

- Intracranial hemorrhage and coma
- Blunt trauma
- Severe burns

Investigations

- CBC Hemoglobin, hematocrit, white blood cell count

- Electrolytes Sodium, potassium, chloride, carbon dioxide,
blood urea nitrogen, glucose
- Urinalysis Specific gravity, pH, hematuria, and urine
myoglobin if urinalysis is positive for hemoglobin
- A baseline assessment of muscle damage is established with Total
CPK (followed by
- CPK isoenzymes (if total CPK is elevated)
- Urine myoglobin (followed by serum myoglobin if urine
myoglobin is present) Creatinine High risk of rhabdomyolysis/
myoglobinuria and creatine kinase (CK) levels
- Serum myoglobin If urine is positive for myoglobin, a serum
level should be obtained
- Arterial blood gas To be obtained for patients needing
ventilatory support, or those with severe rhabdomyolysis who
require urine alkalinization therapy
- Chest radiography
- CT scan of the head and spine
- MRI of the head and spine

210 Surgery Clinical Treatment Guidelines

 Chapiter 8: Burns

Complications

- Peripheral nerve injury

- Vascular damage
- Acute pulmonary complications
- Abdominal complications
- Bone lesions
- Multiple organ injuries 8

Burns
Management

- It is important to establish the type of exposure (high or low

voltage), duration of contact, and falls or other trauma.
Hydration is the key to reducing the morbidity of electrical
injuries
Osmotic diuretic if muscle damage is significant
Initial IVF resuscitation is with LR, up to 10cc/kg/hr
Mannitol or furosemide to the fluid regimen of patients
with elevated CPK and/or myoglobinemia

Note:
These drugs provide diuresis for the toxic myoglobin, which can
help prevent acute tubal necrosis and renal failure secondary to
myoglobinuria.

Surgery Clinical Treatment Guidelines 211

 9. Bites and Stings of Animals
and Insects

9.1. Animal Bites

Definition: Animal bites are wounds inflicted on the body due to

animals sinking teeth into ones body. Animal bites and scratches, even
when they are minor can become infected and spread bacteria to other
parts of the body. Whether the bite is from a family pet or an animal
in the wild, scratches and bites can carry disease. Some animals can
transmit rabies and tetanus.

Animal Type Evaluation and Post-exposure 9

Disposition of Prophylaxis

Animals and insects

Bites and Stings of
Animal Recommendations
Dogs and cats Healthy and available Should not begin
prophylaxis, 10 days
observation, unless
animal develops
symptoms of rabies
Rabid or suspected Immediate
rabid vaccination (consider
also tetanus toxoids)
Unknown (escaped) Consult public health
officials

Skunks, Regarded as rabid Immediate

raccoons, bats, unless geographic area vaccination
foxes, and is known to be free of
most other rabies or until animal
carnivores; proven negative by
woodchucks laboratory tests
Livestock, Consider individually Consult public health
rodents, and officials; bites of
lagomorphs squirrels, hamsters,
(rabbits and guinea pigs, gerbils,
hares) chipmunks, rats,
mice, other rodents,
rabbits, and hares
almost never require
anti-rabies treatment

Surgery Clinical Treatment Guidelines 213

Chapiter 9: Bites and Stings of Animals and Insects

9.2. Rabies

Definition: Rabies is a deadly viral infection that is mainly spread by

infected animals.

Causes

Rabies is spread by infected saliva that enters the body through animal
bite or broken skin

Animals known to spread rabies are:

- Dogs
- Bats
- Raccoons
- Foxes
- Skunks

The average incubation period is 3 - 7 weeks

Signs and symptoms

- Paresthesia
- Headache
- Stiff neck
- Lethargy
- Pulmonary symptoms
- Maniacal behaviour
- Muscle spasm of throat with dysphasia
- Convulsion coma paralysis death

Investigations

- immunofluorescence is used to look at the brain tissue after an

animal is dead
- Pieces of skin and saliva analysis for presence of rabies

Complications

- Coma and death

- Allergic reaction to the rabies vaccine (rare)

214 Surgery Clinical Treatment Guidelines

 Chapiter 9: Bites and Stings of Animals and Insects

Management

- Local care
Thorough irrigation
Cleansing with soap solution

- Debridement bite site

- Human Rabies Immunoglobulin (HRIG), given the day the bite
occurred
- Antibiotics in case of infection
- Rabies Vaccination in 5 days over 28 days
Rabies vaccine adsorbed (RVA) (Imovax)
Human diploid cell rabies vaccine (HDCV)
Either administered with HRIG (Imogan rabies)
Vaccine administered intramuscularly in deltoid area for 9
adult and anterolateral aspect of thigh for children

Animals and insects

Bites and Stings of
Recommendations

- Most of the time, stitches should not be used for animal bite
wounds
- Immunization and treatment for possible rabies are
recommended for at least up to 14 days after exposure or a bite

9.3. Snakebites and Venom

Definition: Poisonous snakes inject venom using modified salivary

glands

The venom apparatus

Venomous snakes of medical importance have a pair of enlarged teeth,

the fangs, at the front of their upper jaw. These fangs contain a venom
channel (like a hypodermic needle) or groove along which venom can
be introduced deep intp the tissue of their natural prey. If a human is
bitten, venom is usually injected subcutaneously or intramuscularly.
Spitting cobras can squeeze the venom out of the tips of their fangs,
producing a fine spray directed toward the eyes of an aggressor.

Causes

- Crotalidae or pit vipers snakes

- Coral snakes of the elapidae family
- Snakes with elliptical pupil
- Snakes with single row of sub caudal plates

Surgery Clinical Treatment Guidelines 215

Chapiter 9: Bites and Stings of Animals and Insects

Signs and symptoms

- Eyes (spitting cobras and ringhals can eject their venom quite
accurately into the eyes of the victims, resulting in direct eye pain
and damage)
- Swelling and tissue damage
- Suddenly develop breathing difficulty and go into shock
- Local effects (swollen, bleeding, blister and gangrene)
- Nervous system effects (vision problems, speaking and breathing
trouble, and numbness close to or distant to the bite site, and
death without treatment)
- Muscle death (muscle necrosis, rhabdomyolysis, kidney failure)

Diagnosis

- History and clinical presentation

Signs and symptoms

- Hypotension
- Weakness
- Nausea/vomiting
- Pain, swelling, tenderness and ecchymosis at site of bite
- Paresthesia and muscle fasciculations
- Defect in blood coagulation
- Pulmonary edema

Grading of envenomation
Grade Signs and Symptoms
0 No envenomation Fang marks, minimal pain, small edema and
erythema

I Minimal Fang marks, moderate to severe pain,

Envenomation surrounding edema and erythema

II Moderate Fang marks, severe pain, edema, erythema,

Envenomation possible systemic involvement (nausea,
vomiting, shock)
III Severe Fang marks, large surrounding edema and
Envenomation erythema with generalized petechiae and
ecchymosis
IV Very severe Systemic effect present. Symptoms may
Envenomation include renal failure, coma and death

216 Surgery Clinical Treatment Guidelines

 Chapiter 9: Bites and Stings of Animals and Insects

Complications of snake bites

- The injection of even highly purified serum carries a risk of

untoward reactions. The most common is serum sickness which
may occur about ten days after the injection but sometimes
sooner. It is characterized by itching rashes and sometimes
a rise in temperature and joint pains. Proper treatment
(antihistaminics, steroids) should alleviate the symptoms.
- A rare but far more serious complication is an acute serum
reaction (anaphylaxis) with a sudden drop in Blood Pressure and
collapse within a few minutes. The risk of this type of reaction
in a healthy person is very slight but those with an allergic
disposition, in particular a history of asthma or infantile eczema,
should not receive serum unless it is absolutely necessary and
then only with the greatest caution. Treatment for this condition 9
includes the injection of adrenalin.

Animals and insects

Bites and Stings of
Management of snake bites

- Application of a tourniquet, incision and suction are appropriate

if done within one hour from time of bite
- Antivenon (crotalidae polyvalent immune)
- The dose of anti-venom serum required depends on the amount
of venom injected by the snake, not on the size or mass of the
victim, and should not be reduced in the case of children
- The initial doze should be large; at least contents of 20 ml, but the
condition of the patient may demand the injection of up to 4 or 5
times as much
- When given intravenously, the venom serum should be at room
temperature, and the injection given very slowly, with the patient
recumbent during injection, and at least one hour afterwards
- IVF required to replace the decreased extra cellular fluid volume
resulting from edema formation
- Fascial planes may become tense with obstruction of venom and
later arterial flow, requiring fasciotomy
- Vit K may be required to correct bleeding and clotting
abnormalities
- Tetanus toxoid administered and antibiotics recommended to
prevent secondary infection

Surgery Clinical Treatment Guidelines 217

Chapiter 9: Bites and Stings of Animals and Insects

Recommendations

- Serum treatment, although not imminently urgent, may become

necessary, a trial dose of 0,1 mL of serum diluted 1:10 in sterile
saline or water could be injected under the skin. If there is no
untoward reaction within 30 minutes, 0,2 mL of undiluted serum
could be given in the same way, to be followed, if necessary, by
the full dose if no reaction occurs to this trial dose
- Where possible, whenever serum is to be injected, the patient
should be kept under observation for at least 30 minutes after the
injection, and adrenalin and corticosteroid kept in readiness for
emergency use

218 Surgery Clinical Treatment Guidelines

 Chapiter 9: Bites and Stings of Animals and Insects

Summarized chart for management of snakebites

Venom type Cytotoxic Neurotoxic Mixed cytotoxic and Haemotoxic

neurotoxic

Puff adder, Gaboon Rinkhals, berg adder,

adder, spitting cobras Peringueys adder,
(Mozambique, black Black and green Boomslang, vine snake
mamba, non-spitting desert mountain
Snake species necked, black, zebra), adder, garter snakes, (eastern and savanna)
Stiletto snakes, night cobras (snouted, Cape,
Forest, Anchietas shieldnose
adders, horned and snake
many horned adders,
lowland swamp viper.

Painful progressive
Progressive
Dominant clinical swelling (PPS)
Weakness (PW)
Presentation of Bleeding may occur Combined PPS
PPS occurs in no-spitting Bleeding (B)
victim in puff adder bites And PW
cobra bites
(thrombocytopenia)
and Gaboon adder bites
9

Animals and insects

Bites and Stings of
(consumption coagulopathy)

* Suction. Non-spitting cobras:

pressure immobilisation No specific first aid
Do not apply a See PPS and
First aid or arterial tourniquet. PW column measures
tourniquet! Mambas: arterial tourniquet.
Protect the airway. Artificial
respiration may be
necessary

Hospitalisation Take the patient to Take the patient to Take the patient to Take the patient
hospital hospital hospital to hospital

Intravenous fluids Protect the airway. Blood or blood

Supportive treatment See cytotoxic and
Elevate bitten limb Oxygen by mask or component therapy
neurotoxic
Analgesia ventilation.

Antivenom may be
Puff adder, spitting Boomslang
necessary for threat All species Rinkhals
cobras, Gaboon
to limb or life adder
See Algorithm 3

Antivenom type Boomslang

Polyvalent Polyvalent Polyvalent monospecific

Suggested dose 80 ml (40 200 ml)

50ml : puff adder and Small doses may lead 50 ml 10 20 ml
by intravenous spitting cobras
injection to a recurrence of
200ml : Gaboon adder symptoms.

Percentage bites in
which antivenom is < 10% 50 70% < 10% 80 -100%
indicated

Surgery Clinical Treatment Guidelines 219

Chapiter 9: Bites and Stings of Animals and Insects

9.4. Insect Stings

Definition: A sting is usually from an attack by a venomous insect

such as a bee or wasp, which uses this as a defence mechanism by
injecting toxic and painful venom through its stinger. Insect bites
and stings can be divided into 2 groups namely: venomous and non-
venomous. Non-venomous insect bites pierce the skin to feed on
blood, this usually results in intense itching.

Causes of insect bites and stings

Venomous (stingers) Non-venomous (biters)
Fire ants Bed bugs

Yellow jackets Fleas

Hornets Ticks
Wasps Lice
Bees Scabies
Caterpillars and moths
Mosquitoes

Signs and Symptoms

- Localized pain
- Petechial hemorrhages
- Swelling of skin and mucus membrane
- Generalized erythema
- Abdominal cramps
- Pulmonary and cerebral edema
- Blurred vision
- Vascular collapse
- Death results from combination of shock
- Respiratory failure and CNS changes
- Most death from insect stings occur within 15 to 30 minutes
- Early application of a tourniquet may prevent rapid spread of
venom
- Emergency kit containing epinephrine commercially available

220 Surgery Clinical Treatment Guidelines

 Chapiter 9: Bites and Stings of Animals and Insects

9.5. Spider Bites

Definition: Spider bite is the puncture wound produced by the bite of

a spider.

Signs and symptoms

Generalized muscle spasm is the most prominent physical finding.

- Priapism and ejaculation (have been reported)
- Severe bite results in necrosis and sloughing of skin with residual
ulcer formation
- Pathophysiology of bite: intravascular coagulation formation of
micro thrombi capillary occlusion hemorrhage necrosis
- Fever, nausea, vomiting, headache, weakness, arthralgia, malaise,
petechiae 9
- Hemolysis and thrombocytopenia responsible for death

Animals and insects

Bites and Stings of
Treatment

- Narcotics for pain

- Muscle relaxant for relief of spasm
- Calcium gluconate relieves most symptoms

Note:
Most patients recover within 24 hours

Surgery Clinical Treatment Guidelines 221

 Chapiter 10: References

10. References

1. Ashford RU, Mehta JA, Cripps R. Delayed presentation is no

barrier to satisfactory outcome in the management of open
fractures. Injury: 2004; 35:411-416.
2. Barbara A Latenser, MD Critical Care of the Burn Patient: The
First 48 Hours, Crit Care Med. 2009;37(10):2819-2826
3. Blaylock R. Epidemiology of snakebite in Eshowe, KwaZulu-Natal,
South Africa. Toxicon 2004 ; 43 (2): 159 66
4. Blaylock RS. Antibiotic use and infection in snakebite victims. S
Afr Med J 1999; 89 (8): 874 6
5. AO principles of fracture management (2007) Editors-in-Chief T.
P. Redi W. Murphy. Editors C. L. Colton A. Fernandez DellOca J.
F. Kellam U. Holz.
6. Blaylock RSM. Acute adverse reactions to South African
manufactured snakebite antivenom. Current Allergy & Clinical
Immunology 2002: 15 : 107 13
7. Blaylock RSM. Antibacterial properties of KwaZulu Natal snake
10
venoms. Toxicon 2000; 68:1529 34

References
8. Blaylock RSM. Normal oral bacterial flora from some Southern
African snakes. Ondestepoort Journal of Veterninary Research 2001;
68: 175 82
9. S. Terry Canale (1998): Campbells Operative Orthopaedics, 9th
Edition
10. Chaaralambour CP, Siddique et al. Early versus Delayed Surgical
Treatment of open Tibial Fractures; effects on the rate of infection
and need of secondary surgical procedures to promote bone
union. Injury 2005; 36:656-661.
11. Chitra S. Mani and Dennis L. Murray. Rabies. Pediatr. Rev., Apr
2006; 27: 129 - 136.
12. Coetzer PWW, Tilbury CR. The epidemiology of snakebite in
Northern Natal. S Afr Med J 1982; 62: 206 12.
13. Current orthopaedics 4th Edition (2006) Harry B. Skinner,
MD, PhD is Professor and Chairman of the Department of
Orthopaedic Surgery at the University of California, Irvine
14. Edwards IR, Fleming JBM, James MFM. Management of a Gaboon
viper bite : a case report. Cent Afr J Med 1979; 25: 217 21

Surgery Clinical Treatment Guidelines 223

Chapiter 10: References

15. Evans EI, Purnell OJ, Robinett PW, et al: Fluid and electrolyte
requirements in severe burns. Ann Surg 1952; 135:804815
16. Fractures of the Pelvis and Acetabulum 2nd Edition Marvin
TileBaltimore, Williams and Wilkins, 1995.
17. Gross T et al.: Multiple-trauma management: standardized
evaluation of the subjective experience of involved team members.
European Journal of Anaesthesiology (2005), 22: 754-761
18. Henley MB, Chapman JR, Agel J et al.Treatment of Type 1, 11A,
111B open fractures of Tibial Shaft a Prospective comparison of
interlocking intramedullary nails and half-pin external fixators.
Journal of Orthopedic Trauma 1998; 12:1-7.
19. Herndon DN (Ed): Total Burn Care. Philadelphia, Elsevier
Saunders, 2007
20. Jane Curtis. Insect Sting Anaphylaxis. Pediatr. Rev., Aug 2000; 21: 256.
21. KanuOkike, BA and Timothy Bhattacharyya MD, Trends in
Management of Open Fractures, A Critical Analysis. The American
Journal of Bone and Joint Surgery 2006; 88:2739 2748.
22. Kauvar D, Lefering R &Wade C (2006) Impact of Hemorrhage
on Trauma Outcome: An Overview of Epidemiology, Clinical
Presentations and Therapeutic Considerations, 60 (6): S3-S11
23. Malasit P, Warrell DA, Chanthavanich P, Viravan C,
Mongkolsapaya J, Singhthong B, Supich C. Prediction, prevention,
and mechanism of early (anaphylactic) antivenom reactions in
victims of snake bites. Br Med J 1986 292: 17 20
24. McNally SL, Reitz CJ. Victims of snakebite: A 5-year study at
Shongwe Hospital, Kangwane, 1978 1982. S Afr Med J 1987; 72:
855 60
25. Moppett IK: Traumatic brain injury: assessment, resuscitation and
early management. BJA (2007) 99 (1): 18-31.
26. Muller GJ. Black and brown widow spider bites in South Africa. S
Afr Med J 1993; 83: 399 -405
27. Muller GJ. Scorpionism in South Africa. S Afr Med J 1993; 83: 405
11Bergman NJ. Scorpion sting in Zimbabwe. S Afr Med J 1997;
87: 163 7
28. Patzakis MJ, Bains et al. Prospective, randomized, double blind
study comparing single agent antibiotic therapy ciprofloxacin to
combination antibiotic therapy in management of open fracture
wounds. Journal of Orthopedic Trauma 2000;14:529-533.

224 Surgery Clinical Treatment Guidelines

 Chapiter 10: References

29. Phillip L. Rice et al. Emergency care of moderate and severe

thermal burns in adults ; UpToDate, May 2011
30. Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the
United States: Emergency Department Visits, Hospitalizations,
and Deaths. Atlanta, Ga: Centers for Disease Control and
Prevention; Jan 2006
31. Scharf GM, du Plessis HJC. Guidelines for the management of puff
adder bites. Trauma Emerg Med 1993; 948 52
32. The acute abdomen Dr. Ed. Snyder, Drmelanie Walker
Huntington MemorialPAEDIATRIC EMERGENCIES, Hospital
Medicine (2004) vol 65
33. The South African institute for medical research Serum and vaccine
department, RIETFONTEIN
34. Tilbury, CR. Observations on the bite of the Mozambique spitting
cobra (Najamossambicamossambica). S Afr Med J 1982; 61: 308
13s; 1996
35. Wilkinson D. Retrospective analysis of snakebite at a rural hospital
in Zululand. S Afr Med J 1994; 84 (12): 844 7
36. Vons C., Barry C., Maitre S et al.: Amoxycillin plus clavulanic
10
acid versus appendicectomy for treatment of acute uncomplicated
appendicitis: an open-label, non-inferiority, randomized
References
controlled trial. Lancet2011,377:1573-79
37. Operative Treatment of Femoral Neck Fractures in Patients Between
the Ages of Fifteen and Fifty Years; George J. Haidukewych, MD1;
Walter S. Rothwell, PA-C2; David J. Jacofsky, MD2; Michael E.
Torchia, MD2; Daniel J. Berry, MD2
37. Turgut AT, Bhatt S, Dogra VS. Acute Painful Scrotum. Ultrasound
Clinics. Jan 2008; 3(1). [PubMed]
38. Ringdahl E. Testicular Torsion. Am Fam Physician. Nov 2006; 74
(10): 1739-43. [PubMed]
39. Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa:
Saunders Elsevier; 2007.
40. Ho K-LV, Segura JW. Lower urinary tract calculi. In: Wein AJ,
ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders
Elsevier; 2007: chap 84.

Surgery Clinical Treatment Guidelines 225

Chapiter 10: References

41. Rupprecht CE, Briggs D, Brown CM, et al. Centers for Disease
Control and Prevention (CDC). Use of a reduced (4-dose) vaccine
schedule for postexposure prophylaxis to prevent human rabies:
recommendations of the advisory committee on immunization
practices. MMWR Recomm Rep. 2010 Mar 19;59(RR-2):1-9.
Erratum in: MMWR Recomm Rep. 2010 Apr 30; 59(16):493.
[PubMed]
42. Bassin SL, Rupprecht CE, Bleck TP. Rhabdoviruses. In: Mandell
GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious
Diseases. 7th ed. Philadelphia, Pa: Elsevier Churchill Livingstone;
2009: chap 163.
43. Handbook of Neurosurgery, Seventh Edition by Mark S.
Greenberg (2010)
44. Principles of Neurosurgery, Second Edition by Setti S. Rengachary
(2004)

226 Surgery Clinical Treatment Guidelines

 List of participants

No Last name First name Position

1 MUGENZI Savio Dominique Orthopedic-Surgeon

2 MUNEZA Severien Neurosurgeon
3 NTAKIYIRUTA Georges Surgeon
4 REGINALD Morcels Surgeon
5 RWAMASIRABO Emile Surgeon (Urology)
6 BITEGA Jean paul Orthopedic-Surgeon
7 MUKIMBIRI Edmond Orthopedic-Surgeon
8 NKUSI Emmanuel Neurosurgeon
9 NSENGIYUNZA Emmanuel Orthopedic-Surgeon
10 NYANGEZI Bonanne Surgeon (Urology)
11 UWAMAHORO Florence Post Graduate (Urology )

12 MUKAMA Deogratius Medical Officer

13 KAYIBANDA Emmanuel Surgeon
14 FURAHA Charles Plastic Surgeon
15 MUKISA Didas Thoracic Surgeon
16 NZEYIMANA Bonaventure Public Health Facilities
Expert
17 ATWINE Joy QI Advisor
18 BUTARE Richard QI Advisor
19 MANZI Emmanuel QI Advisor
20 AHABWE Moses Technical Advisor
21 MUNYAMPUNDU Horatius QI Advisor

Surgery Clinical Treatment Guidelines 227

230 Surgery Clinical Treatment Guidelines