A great video shows and simply illustrates minimally invasive trigger finger release surgery performed by Dr. Stephen L Helgemo. In-office procedure done with local anesthesia and an extremely high success rate.

How to differentiate clinically between LTB (croup) and epiglottitis

Which of the following best differentiates, by history, LTB (croup) from epiglottitis?
  • (A) Temperature
  • (B) Presence of inspiratory stridor
  • (C) Length of time from onset to defining symptom
  • (D) Lung field auscultation
  • (E) Presence or absence of dyspnea

The answer is C.
Croup, laryngeotrachiobronchitis, a viral illness with subglottic involvement, typically exhibits the symptoms of inspiratory stridor only after 12 to 24 hours of coryza, typical of a viral “cold.” Epiglottitis, which is a much more serious condition, begins suddenly. Epiglottitis is caused by bacterial infection with supraglottic involvement, classically by H.influenzae but also by S.aureus and Corynebacterium diphtheriae.

Although epiglottitis is characterized more by high fever than is croup, this appears to be a weak factor on which to base a preliminary diagnosis. Whereas croup virtually always includes a cough, epiglottitis rarely
does so. Epiglottitis typically includes dysphagia while croup does not. The child with croup is comfortable in all positions, whereas the patient with epiglottitis will be sitting forward with the mouth open. Both conditions are characterized by inspiratory dyspnea. Croup is benign and epiglottitis is potentially critical.

Sesamoid bones, Functions and mechanism of action.

The sesamoid bone is a small rounded bone embedded within a tendon that usually passes over a joint (Sesamoid bones are the bones not connected to any other bone).The largest sesamoid bobe is the patella.
Latin........."ossa sesamoidea"

Sesamoid bones functions probably are to modify pressure, to diminish friction, and occasionally to alter the direction of a muscle pull.Sesamoid bones also prevent the tendon from flattening into the joint as tension increases and therefore also maintain a more consistent moment arm through a variety of possible tendon loads.
Sesamoid bones can be found in the knee, hand and foot...
Sesamoid bones at the distal end of the first metatarsal bone of the foot.
Sesamoids act like pulleys. They provide a smooth surface over which the tendons slide, so they increase the ability of the tendons to transmit muscle forces. The sesamoids in the forefoot also assist with weightbearing and help elevate the bones of the big toe.

Associated conditions result in intestinal intussusception in children

An 8 year old boy is seen in the emergency room secondary to abdominal pain. Further evaluation confirms the presence of intussusception. The most likely precipitating cause for this intussusception is :
  • A) colon polyp
  • B) Meckel's diverticulum
  • C) lymphoma
  • D) parasite infection
  • E) foreign body
The answer is C.
Intussusception is the most common cause of intestinal obstruction in the first 2 years of life. It is more common in males than in females. In most cases (85%) the cause is not apparent. Associated conditions that can result in intussusception include :
-polyps, Meckel's diverticulum, Henoch–Schonlein purpura, lymphoma, lipoma, parasites, foreign bodies, and viral enteritis with hypertrophy of Peyer patches.

Intussusception of the small intestine occurs in patients with celiac disease and cystic fibrosis—related to the bulk of stool in the terminal ileum. Henoch–Schonlein purpura may also cause isolated small-bowel intussusception. In children older than 6 years, lymphoma is the most common cause. Intermittent small-bowel intussusception is a rare cause of recurrent abdominal pain.

Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:616–617

Burns Injury and Burns Degrees

example of 2nd dgree burn

A burn is a part of traumatology that is caused by heat, radiation, chemicals or electricity. Burns affect usually the skin (epidermis and dermis).Affection of deeper tissues, such as muscle, bone, and blood vessels may be fatal

1-Outer skin layer
2-Middle skin layer
3-Deep skin layer
4-First degree burn
5-Second degree burn
6-Third degree burn

Burns can be classified by depth of injury into :
1st degrre burn
1- 1st Degree Burns ;the least severe of commonly seen burn injuries, just affects the epidermal layer and appears as dry area of redness "erythema" with pain and tingling sensation.
1st degree burn usullay has no complication and healed in about 1 week.

2- 2nd Degree Burns ; this type of burn affects tha dermis layer and may be subdivided into superficial partial thickness and deep partial thickness.
These second-degree burns are characterized by extreme pain and appears as wet, red, swollen and blistered areas. healing time 2-3 weeks and complications like Local infection/cellulitis, Scarring, Contractures may be seen.

3- 3rd Degree Burns ;affect the whole thickness of the skin and should be treated in a hospital setting, Symptoms may include:

*dry and leathery skin
*black, white, brown, or yellow skin
*lack of pain because nerve endings have been destroyed

4- 4th Degree Burns ;are life threatening injury where the burn Extends through skin, subcutaneous tissue and into underlying muscle and bone, the affect limb usually amputated.

Treating pressure ulcers

The case shown here in this picture was noted associated with an 89-year-old debilitated nursing home resident. He has no evidence of bacteremia or osteomyelitis. Which of the following is an acceptable treatment?

  • A) application of povidone-iodine gauze two times per day
  • B) application of hydrogen peroxide 3 times per day
  • C) systemic antibiotics for 7 to 10 days
  • D) keeping the area clean and dry until granulation tissue forms
  • E) surgical debridement

 The answer is E. (Surgical débridement)
When treating this pressure ulcer, it is important to maintain a moist environment while keeping the surrounding skin dry. This can be accomplished by loosely packing the ulcer with saline-moistened gauze. Topical antimicrobials such as silver sulfadiazine cream may be helpful in ulcers that appear infected. Topical antiseptics such as povidone-iodine or hydrogen peroxide should be not be used in the treatment of pressure ulcers. Systemic antibiotics should be reserved for serious infections (e.g., bacteremia, osteomyelitis). A 2-week trial of topical antimicrobials may be considered for ulcers that do not appear infected but are not improving. Although most patients are successfully managed without surgery, procedures may be appropriate in patients whose quality of life would be markedly improved by rapid wound closure. Stage 3 and 4 ulcers with necrotic tissue should be débrided. Ulcers with minimal exudate that are not infected can be covered with an occlusive dressing to promote autolytic débridement. Ulcers with thick exudate, slough, or loose necrotic tissue should undergo mechanical débridement. Options include wet-to-dry dressings, hydrotherapy, wound irrigation, and scrubbing the wound with gauze. Ulcers with evidence of cellulitis or deep infection should undergo sharp débridement with a scalpel or scissors. Ulcers with a thick eschar or extensive necrotic tissue should undergo sharp débridement as well. However, a thick, dry eschar covering a heel ulcer should generally be left intact. Patients without access to surgical inter-ventions (such as in a long-term care setting) or those who may not be acceptable surgery candidates can be treated with enzymatic débriding agents. Wound débridement should stop once necrotic tissue has been removed and granulation tissue is present.

Illustration of Lumbar Hernia

Lumbar hernia "hernia in the lumbar region" or may be called Bleichner's Hernia is quite uncommon as compared to other ventral abdominal wall hernias, 1.5% of all abdominal hernias. note that 25% of all lumbar hernias have a traumatic etiology.
These occur more commonly in males and are twice as common on the left than the right side. Patients are usually between 50 to 70 years old. These hernias can occur anywhere within the lumbar region but are more common through the superior lumbar triangle (of Grynfeltt-Lesshaft)

So, Lumbar hernia has 2 anatomical types:
1-Petit's hernia: a hernia through Petit's triangle (inferior lumbar triangle). It is named after French surgeon Jean Louis Petit (1674–1750).
2-Grynfeltt's hernia: a hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle). It is named after physician Joseph Grynfeltt (1840–1913).

**Patients with lumbar hernia are usually asymptomatic but may complain of backache, flank pain or a dragging sensation. These hernias have a natural history of a gradual increase in size over time.

Left lumbar hernia .

The differential considerations :
At this stage include the differential considerations includes lipoma, soft tissue tumors, hematoma or abscess.

Illustrated Cephalohematoma Vs Caput succedaneum

Cephalohematoma is a collection of blood under the periosteum of a skull bone "very tough tissue covering that encapsulates bones"
Because of its location, it is impossible for cephalohematoma to cross suture lines. If more than one bone is affected, there will be a separation between the two areas at the suture line as seen in this photo at the left where  the sagittal suture separates the bilateral parietal cephalohematomas.

Unlike cephalohematoma; A caput succedaneum is caused by the mechanical trauma of the initial portion of scalp pushing through a narrowed cervix. The swelling may be on any portion of the scalp, may cross the midline (as opposed to a cephalhematoma), and may be discolored because of slight bleeding in the area. There may also be molding of the head, which is common in association with a caput succedaneum.
A cephalohematoma in a 1-week-old newborn with a right parietal bump by vacuum extractor . A plain skull X-ray lateral view revealing the linear skull fracture on the right parietal area .

Appearance of Sunset sign in infant eyes

 The sclera are visible between the upper eyelid and the iris,Sunsetting sign is seen usually in hydrocephalus due to loss of upward conjugate gaze caused by raised intracranial pressure (ICP)

The setting-sun phenomenon is an ophthalmologic sign in young children resulting from upward-gaze paresis. In this condition, the eyes appear driven downward, the sclera may be seen between the upper eyelid and the iris, and part of the lower pupil may be covered by the lower eyelid. Pathogenesis of this sign is not well understood, but it seems to be related to aqueductal distention with compression of periaqueductal structures secondary to increased intracranial pressure.
However, it can also be transiently elicited in healthy infants up to 7 months of age by changes of position or removal of light (benign setting-sun phenomenon). The benign form might represent immaturity of the reflex systems controlling eye movements.

When persistent, this sign is one of the most frequent markers of elevated intracranial pressure, appearing in 40% of children with hydrocephalus (whatever the cause of Hydrocephalus as obstructive, communicating, Dandy-Walker anomaly/syndrome) and in 13% of patients with ventriculoperitoneal shunt dysfunction. It is an earlier sign of hydrocephalus than enlarged head circumference, full fontanelle, separation of sutures, irritability or vomiting. Consequently, this sign is a valuable early warning of an entity requiring prompt neuroimaging and urgent surgical intervention.

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