The removal of foreign bodies from the ear is a common procedure in the emergency department.
Abandon attempts to retrieve a foreign body if complications arise. If the object migrates farther into the canal or if bleeding, oedema, or increasing pain develops, consult an ENT specialist. Repeated attempts to remove a foreign body from the ear may result in infection, perforation, or another morbidity.
The presence of a tympanic membrane (TM) perforation, contact of a foreign body with the tympanic membrane, or incomplete visualization of the auditory canal are indications for urgent-emergent ENT consultation for removal by operative microscope and speculum.
Local anaesthesia is invasive and is not generally used for uncomplicated ear foreign body removal because of the complex innervations of the external ear canal.

Answer: Bochdalek hernia

A Bochdalek hernia is one of two forms of a congenital diaphragmatic hernia, the other form being Morgagni hernia. A Bochdalek hernia is a congenital abnormality in which an opening exists in the infant’s diaphragm, allowing normally intra-abdominal organs (particularly the stomach and intestines) to protrude into the thoracic cavity. In the majority of patients, the affected lung will be deformed, and the resulting lung compression can be life-threatening. Bochdalek hernias occur more commonly on the posterior left side (85%, versus right side 15%).

In normal Bochdalek hernia cases, the symptoms are often observable simultaneously with the baby’s birth. A few of the symptoms of a Bochdalek Hernia include difficulty breathing, fast respiration and increased heart rate. Also, if the baby appears to have cyanosis (blue-tinted skin) this can also be a sign. Another way to differentiate a healthy baby from a baby with Bochdalek Hernia, is to look at the chest immediately after birth. If the baby has a Bochdalek Hernia it may appear that one side of the chest cavity is larger than the other and or the abdomen seems to be scaphoid (caved in).

Situs inversus (also called situs transversus or oppositus) is a congenital condition in which the major visceral organs are reversed or mirrored from their normal positions. The normal arrangement of internal organs is known as situs solitus while situs inversus is generally the mirror image of situs solitus. Although cardiac problems are more common than in the general population, most people with situs inversus have no medical symptoms or complications resulting from the condition, and until the advent of modern medicine it was usually undiagnosed. In the absence of congenital heart defects, individuals with situs inversus are homeostatically normal, and can live standard healthy lives, without any complications related to their medical condition. There is a 5–10% prevalence of congenital heart disease in individuals with situs inversus totalis, most commonly transposition of the great vessels. The incidence of congenital heart disease is 95% in situs inversus with levocardia.

Cystic fibrosis is a progressive, genetic disease that causes persistent lung infections and limits the ability to breathe over time. In people with CF, mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene cause the CFTR protein to become dysfunctional. When the protein is not working correctly, it’s unable to help move chloride — a component of salt — to the cell surface. Without the chloride to attract water to the cell surface, the mucus in various organs becomes thick and sticky. In the lungs, the mucus clogs the airways and traps germs, like bacteria, leading to infections, inflammation, respiratory failure, and other complications.

Necrotizing enterocolitis (NEC) is a medical condition where a portion of the bowel dies. It typically occurs in new-borns that are either premature or otherwise unwell. Symptoms may include poor feeding, bloating, decreased activity, blood in the stool, or vomiting of bile.
The exact cause is unclear. Risk factors include congenital heart disease, birth asphyxia, exchange transfusion, and premature rupture of membranes. The underlying mechanism is believed to involve a combination of poor blood flow and infection of the intestines. Diagnosis is based on symptoms and confirmed with medical imaging.

Morgagni hernias are one of the congenital diaphragmatic hernias (CDH), and is characterized by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias are:
-anterior
-more often right-sided (,90%)
-small
-rare (,2% of CDH)
-at low risk of prolapse

Only ,30% of patients are symptomatic. New-borns may present with respiratory distress at birth similar to a Bochdalek hernia. Additionally, recurrent chest infections and gastrointestinal symptoms have been reported in those with previously undiagnosed Morgagni hernia.
The image of the transverse colon is herniated into the thoracic cavity, through a mid line defect and this indicates that it is a Morgagni hernia since the foramen of a Morgagni hernia occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side.

Clinical manifestations of congenital diaphragmatic hernia (CDH) include the following:

Early diagnosis – Right-side heart; decreased breath sounds on the affected side; scaphoid abdomen; bowel sounds in the thorax, respiratory distress, and/or cyanosis on auscultation; CDH can often be diagnosed in utero with ultrasonography (US), magnetic resonance imaging (MRI), or both
Late diagnosis – Chest mass on chest radiography, gastric volvulus, splenic volvulus, or large-bowel obstruction
Congenital hernias (neonatal onset) – Respiratory distress and/or cyanosis occurs within the first 24 hours of life; CDH may not be diagnosed for several years if the defect is small enough that it does not cause significant pulmonary dysfunction
Congenital hernias (childhood or adult onset) – Obstructive symptoms from protrusion of the colon, chest pain, tightness or fullness the in chest, sepsis following strangulation or perforation, and many respiratory symptoms occur.

Since the most likely diagnosis is anal fissure, the correct treatment is topical nitrates.

Anal fissures are a common cause of painful, bright red rectal bleeding. Most fissures are idiopathic and present as a painful mucocutaneous defect in the posterior midline (90% cases). Fissures are more likely to be anteriorly located in females, particularly if they are multiparous. Diseases associated with fissure-in-ano include:
1. Crohn’s disease
2. Tuberculosis
3. Internal rectal prolapse

Diagnostic options are as follows:
In most cases, the defect can be visualised as a posterior midline epithelial defect. Where symptoms are highly suggestive of the condition and examination findings are unclear, an examination under anaesthesia may be helpful. Atypical disease presentation should be investigated by colonoscopy and EUA, with biopsies of the area.

For management of anal fissure:
1. Stool softeners are important as hard stools may tear the epithelium and result in recurrent symptoms. The most effective first-line agents are topically applied GTN (0.2%) or Diltiazem (2%) paste.
2. Resistant cases may benefit from injection of botulinum toxin or lateral internal sphincterotomy. Advancement flaps may be used to treat resistant cases.

A cavernous liver haemangioma or hepatic haemangioma is a benign tumour of the liver composed of hepatic endothelial cells. It is the most common liver tumour, and is usually asymptomatic and diagnosed incidentally on radiological imaging. Liver haemangiomas are thought to be congenital in origin. Several subtypes exist, including the giant hepatic haemangioma, which can cause significant complications. This large, atypical haemangioma of the liver may present with abdominal pain or fullness due to haemorrhage, thrombosis or mass effect. It may also lead to left ventricular volume overload and heart failure due to the increase in cardiac output which it causes. Further complications are Kasabach-Merritt syndrome, a form of consumptive coagulopathy due to thrombocytopaenia, and rupture.

As one of the benign neoplasms, the AFP level of hepatic cavernous haemangioma patients is not usually outside the normal range.

Ulcer bleeding stops spontaneously in about 80% of patients. Only a small percentage require specific measures to stop bleeding. surgery remains the most definitive method of controlling ulcer haemorrhage, and is indicated when endoscopic haemostasis fails to control the bleeding, or when rebleeding occurs. The morbidity and mortality of emergency surgery for ulcer bleeding is high. In principle, the operation performed should be the minimum compatible with permanent haemostasis. The choice of operations is determined by the site and size of the ulcer as well as the experience and preference of the surgeon. Most bleeding duodenal ulcers may be managed by underrunning the bleeding vessel together with vagotomy and pyloroplasty.

This individual has acute cholecystitis. This is demonstrated by well-localized pain in the right upper quadrant, usually with rebound and guarding; frequent presence of fever and peritonism. Ultrasonography is the procedure of choice in suspected gallbladder or biliary disease. A bile duct measuring 4mm is usually normal.
Once gallstones become symptomatic, definitive surgical intervention with cholecystectomy is usually indicated (typically, laparoscopic cholecystectomy is the first-line therapy at centres with experience in this procedure).

Open right hemicolectomy (open right colectomy) is a procedure that involves removing the caecum, the ascending colon, the hepatic flexure (where the ascending colon joins the transverse colon), the first third of the transverse colon, and part of the terminal ileum, along with fat and lymph nodes. It is the standard surgical treatment for malignant neoplasms of the right colon; the effectiveness of other techniques are measured by the effectiveness of this technique.

The caecum is a short, pouch-like region of the large intestine between the ascending colon and vermiform appendix. It is located in the lower right quadrant of the abdominal cavity, inferior and lateral to the ileum.

Nasal discharge of clear fluid and a recent head injury makes basal skull fracture the most likely underlying cause for facial nerve palsy.

Facial palsy is a neurological condition in which function of the facial nerve (cranial nerve VII) is partially or completely lost. It is often idiopathic (Bell’s palsy) but in some cases, specific causes such as trauma (e.g. temporal bone fracture), infections, or metabolic disorders can be identified. Two major types are distinguished:

1. Central facial palsy—lesion occurs between cortex and nuclei in the brainstem
2. Peripheral facial palsy—lesion occurs between nuclei in the brainstem and peripheral organs

Diagnosis can usually be made clinically while patient’s history often helps in evaluating the underlying aetiology.
Patients with basal skull fracture following head injury (as in this case) exhibit Battle’s sign on examination. It is an indication of fracture of middle cranial fossa of the skull and consists of bruising over the mastoid process as a result of extravasation of blood along the path of the posterior auricular artery. Clinical presence of CSF leak further supports the diagnosis.

Assessment options for basal skull fracture include CT and MRI scan. Idiopathic facial nerve palsy is treated with oral glucocorticoids and, in severe cases, with antivirals. Treatment of the other types depends on the underlying cause. Prophylactic antibiotics are given in cases of CSF leak.

Mirizzi’s syndrome is a rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common hepatic duct, resulting in obstruction and jaundice. The obstructive jaundice can be caused by direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis (inflammation).

Type I – No fistula present

Type IA – Presence of the cystic duct
Type IB – Obliteration of the cystic duct

Types II–IV – Fistula present

Type II – Defect smaller than 33% of the CHD diameter
Type III – Defect 33–66% of the CHD diameter
Type IV – Defect larger than 66% of the CHD diameter

Simple cholecystectomy is suitable for type I patients. This patient has type I because no fistula is present.

Answer: Fitz Hugh Curtis syndrome

Fitz-Hugh-Curtis syndrome is a rare disorder that occurs almost exclusively in women. It is characterized by inflammation of the membrane lining the stomach (peritoneum) and the tissues surrounding the liver (perihepatitis). The muscle that separates the stomach and the chest (diaphragm), which plays an essential role in breathing, may also be affected. Common symptoms include severe pain in the upper right area (quadrant) of the abdomen, fever, chills, headaches, and a general feeling of poor health (malaise). Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease (PID), a general term for infection of the upper genital tract in women. Infection is most often caused by Neisseria gonorrhoeae and Chlamydia trachomatis.

Fitz-Hugh-Curtis syndrome is characterized by the onset of sudden, severe pain in the upper right area of the abdomen. Pain may spread to additional areas including the right shoulder and the inside of the right arm. Movement often increases pain. The upper right area may be extremely tender.

Additional symptoms may occur in some cases including fever, chills, night sweats, vomiting and nausea. Some affected individuals may develop headaches, hiccupping, and a general feeling of poor health (malaise).

Some affected individuals may have symptoms associated with pelvic inflammatory disease including fever, vaginal discharge, and lower abdominal pain. Lower abdominal pain may precede, follow, or occur simultaneously with upper abdominal pain.

Most cases of Fitz-Hugh-Curtis syndrome are caused by infection with the bacterium Chlamydia trachomatis, which causes Chlamydia or the organism Neisseria gonorrhoeae, which causes gonorrhoea. Chlamydia and gonorrhoea are common sexually transmitted diseases (STDs). Researchers believe that more cases of Fitz-Hugh-Curtis syndrome are caused by infection with Chlamydia trachomatis than with Neisseria gonorrhoeae.

The exact process by which such infections cause Fitz-Hugh-Curtis syndrome (pathogenesis) is not completely understood. Some researchers believe that it occurs because of infection of the liver and surrounding tissue, which may result from bacteria traveling from the pelvis directly to the liver or via the bloodstream or lymphatic system. Fitz-Hugh-Curtis syndrome is characterized by the developed of string-like, fibrous scar tissue (adhesions) between the liver and the abdominal wall or the diaphragm.

Laparoscopy is the gold standard for diagnosing FHCS and PID. In the setting of PID, laparoscopy can show oedema with exudates on tubal surfaces, ectopic pregnancy, or tubo-ovarian abscess. FHCS can be diagnosed directly via visualization of adhesions between the diaphragm and liver or liver and the anterior abdominal wall.

Hypertension in a young patient without any obvious cause should be investigated.

A pheochromocytoma is a catecholamine-secreting tumour typically located in the adrenal medulla. Pheochromocytomas are usually benign (∼ 90% of cases) but may also be malignant. Classic clinical features are due to excess sympathetic nervous system stimulation and involve episodic blood pressure crises with paroxysmal headaches, diaphoresis, heart palpitations, and pallor. However, a pheochromocytoma may also present asymptomatically or with persistent hypertension. Elevated catecholamine metabolites in the plasma or urine confirm the diagnosis, while imaging studies in patients with positive biochemistry are used to determine the location of the tumour. Surgical resection is the treatment of choice, but is only carried out once alpha blockade with phenoxybenzamine has become effective.

Pheochromocytoma is said to follow a 10% rule:

,10% are extra-adrenal
,10% are bilateral
,10% are malignant
,10% are found in children
,10% are familial
,10% are not associated with hypertension
,10% contain calcification

Answer: Ganglion

A ganglion cyst is a fluid-filled swelling that usually develops near a joint or tendon. The cyst can range from the size of a pea to the size of a golf ball. Ganglion cysts look and feel like a smooth lump under the skin.

They’re made up of a thick, jelly-like fluid called synovial fluid, which surrounds joints and tendons to lubricate and cushion them during movement.

Ganglions can occur alongside any joint in the body, but are most common on the wrists (particularly the back of the wrist), hands and fingers.

Ganglions are harmless, but can sometimes be painful. If they do not cause any pain or discomfort, they can be left alone and may disappear without treatment, although this can take a number of years.

It’s not clear why ganglions form. They seem to happen when the synovial fluid that surrounds a joint or tendon leaks out and collects in a sac.
They are most common in younger people between the ages of 15 and 40 years, and women are more likely to be affected than men. These cysts are also common among gymnasts, who repeatedly apply stress to the wrist.

Answer: MAG 3 renogram

This is the agent of choice due to a high extraction rate, which may be necessary for an obstructed system. Diuretic (furosemide) renogram is performed to evaluate between obstructive vs. nonobstructive hydronephrosis. The non-obstructive hydronephrosis will demonstrate excretion (downward slope on renogram) after administration of diuretic from the collecting system. Whereas mechanical obstructive hydronephrosis will show no downward slope on renogram, with retained tracer in the collecting system.

Pelviureteric junction (PUJ) obstruction/stenosis can be one of the causes of an obstructive uropathy. It can be congenital or acquired with a congenital PUJ obstruction being one of the most common causes of antenatal hydronephrosis. This is defined as an obstruction of the flow of urine from the renal pelvis to the proximal ureter.
Many cases are asymptomatic and identified incidentally when the renal tract is imaged for other reasons. When symptomatic, symptoms include recurrent urinary tract infections, stone formation and even a palpable flank mass. They are also at high risk of renal injury even by minor trauma.

Symptom: Classically intermittent pain after drinking large volumes of fluid or fluids with a diuretic effect is described, due to the reduced outflow from the renal pelvis into the ureter.

Tc-99m DMSA (dimercaptosuccinic acid) is a technetium radiopharmaceutical used in renal imaging to evaluate renal structure and morphology, particularly in paediatric imaging for detection of scarring and pyelonephritis. DMSA is an ideal agent for the assessment of renal cortex as it binds to the sulfhydryl groups in proximal tubules at the renal cortex with longer retention than other agents. This results in higher concentration and hence much higher resolution with pinhole SPECT imaging. Also, it allows better assessment of differential renal function. It is a static scan as opposed to dynamic DTPA or MAG3 scans.

In patients with liver tumours, it is crucial to detect and stage the tumours at an early stage (to select patients who will benefit from curative liver resection, and avoid unnecessary surgery). Therefore, an optimal preoperative evaluation of the liver is necessary, and a contrast-enhanced MRI is widely considered the state-of-the-art method. Liver MRI without contrast administration is appropriate for cholelithiasis but not sufficient for most liver tumour diagnoses.

Answer: Spondylolisthesis

Spondylolisthesis is a condition in which a bone (vertebra) in the spine moves forward out of the proper position onto the bone below it.

Causes
In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum (pelvis) area. It is often due to a birth defect in that area of the spine or sudden injury (acute trauma).

In adults, the most common cause is abnormal wear on the cartilage and bones, such as arthritis. The condition mostly affects people over 50 years old. It is more common in women than in men.

Bone disease and fractures can also cause spondylolisthesis. Certain sports activities, such as gymnastics, weightlifting, and football, greatly stress the bones in the lower back. They also require that the athlete constantly overstretch (hyperextend) the spine. This can lead to a stress fracture on one or both sides of the vertebra. A stress fracture can cause a spinal bone to become weak and shift out of place.

Symptoms
Symptoms of spondylolisthesis may vary from mild to severe. A person with spondylolisthesis may have no symptoms. Children may not show symptoms until they’re 18 years old.

The condition can lead to increased lordosis (also called swayback). In later stages, it may result in kyphosis (round back) as the upper spine falls off the lower spine.

Symptoms may include any of the following:

Lower back pain
Muscle tightness (tight hamstring muscle)
Pain, numbness, or tingling in the thighs and buttocks
Stiffness
Tenderness in the area of the vertebra that is out of place
Weakness in the legs

Ankylosing spondylitis (AS) is a type of arthritis in which there is a long-term inflammation of the joints of the spine.[2] Typically the joints where the spine joins the pelvis are also affected. Occasionally other joints such as the shoulders or hips are involved. Eye and bowel problems may also occur. Back pain is a characteristic symptom of AS, and it often comes and goes. Stiffness of the affected joints generally worsens over time.

Although the cause of ankylosing spondylitis is unknown, it is believed to involve a combination of genetic and environmental factors. More than 90% of those affected in the UK have a specific human leukocyte antigen known as the HLA-B27 antigen. The underlying mechanism is believed to be autoimmune or autoinflammatory. Diagnosis is typically based on the symptoms with support from medical imaging and blood tests. AS is a type of seronegative spondyloarthropathy, meaning that tests show no presence of rheumatoid factor (RF) antibodies. It is also within a broader category known as axial spondylarthritis.

The signs and symptoms of ankylosing spondylitis often appear gradually, with peak onset being between 20 and 30 years of age. Initial symptoms are usually a chronic dull pain in the lower back or gluteal region combined with stiffness of the lower back. Individuals often experience pain and stiffness that awakens them in the early morning hours.

As the disease progresses, loss of spinal mobility and chest expansion, with a limitation of anterior flexion, lateral flexion, and extension of the lumbar spine, are seen. Systemic features are common, with weight loss, fever, or fatigue often present. Pain is often severe at rest but may improve with physical activity, but inflammation and pain to varying degrees may recur regardless of rest and movement.

The preauricular sinus is a benign congenital malformation of the preauricular soft tissues. Mostly it is noted during routine ear, nose and throat examination, though can present as an infected and discharging sinus. Preauricular sinus is more often unilateral, only occasionally are bilateral forms inherited. The right side is more often involved and females more than males. Most sinuses are clinically silent, eventual, however not rare, appearance of symptoms is related to an infectious process. Erythema, swelling, pain and discharge are familiar signs and symptoms of infection. The most common pathogens causing infection are Staphylococcal species and, less frequently Proteus, Streptococcus and Peptococcus species.

Courses of treatment typically include the following:
– Draining the pus occasionally as it can build up a strong odour
– Antibiotics when infection occurs.
– Surgical excision is indicated with recurrent fistula infections, preferably after significant healing of the infection.
In case of a persistent infection, infection drainage is performed during the excision operation. The operation is generally performed by an appropriately trained specialist surgeon e.g. a otolaryngologist or a specialist General Surgeon.
The fistula can be excised as a cosmetic operation even though no infection appeared. The procedure is considered an elective operation in the absence of any associated complications.

An inguinal hernia is a common condition requiring surgical repair in the paediatric age group.
The infant or child with an inguinal hernia generally presents with an obvious bulge at the internal or external ring or within the scrotum. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls.
The swelling may or may not be associated with any pain or discomfort. More commonly, no pain is associated with a simple inguinal hernia in an infant. The parents may perceive the bulge as being painful when, in truth, it causes no discomfort to the patient.
The bulge commonly occurs after crying or straining and often resolves during the night while the baby is sleeping.
Indirect hernias are more common on the right side because of delayed descent of the right testicle. Hernias are present on the right side in 60% of patients, on the left is 30%, and bilaterally in 10% of patients.
Physical examination of a child with an inguinal hernia typically reveals a palpable smooth mass originating from the external ring lateral to the pubic tubercle. The mass may only be noticeable after coughing or performing a Valsalva manoeuvre, and it should be reduced easily. Occasionally, the examining physician may feel the loops of intestine within the hernia sac. In girls, feeling the ovary in the hernia sac is not unusual; it is not infrequently confused with a lymph node in the groin region. In boys, palpation of both testicles is important to rule out an undescended or retractile testicle.
In boys, differentiating between a hernia and a hydrocele is not always easy. Transillumination has been advocated as a means of distinguishing between the presence of a sac filled with fluid in the scrotum (hydrocele) and the presence of bowel in the scrotal sac. However, in cases of inguinal hernia incarceration, transillumination may not be beneficial because any viscera that is distended and fluid-filled in the scrotum of a young infant may also transilluminate. A rectal examination may be helpful if intestine can be felt descending through the internal ring.
A femoral hernia can be very difficult to differentiate from an indirect inguinal hernia. Its location is below the inguinal canal, through the femoral canal. The differentiation is often made only at the time of operative repair, once the anatomy and relationship to the inguinal ligament are clearly visualized. The signs and symptoms for femoral hernias are essentially the same as those described for indirect inguinal hernias.

Hashimoto thyroiditis is part of the spectrum of autoimmune thyroid diseases (AITDs) and is characterized by the destruction of thyroid cells by various cell- and antibody-mediated immune processes.
The thyroid gland may become firm, large, and lobulated in Hashimoto’s thyroiditis, but changes in the thyroid can also be nonpalpable. Enlargement of the thyroid is due to lymphocytic infiltration and fibrosis, rather than tissue hypertrophy.

Laboratory studies and potential results for patients with suspected Hashimoto thyroiditis include the following:
– Serum thyroid-stimulating hormone (TSH) levels: Sensitive test of thyroid function; levels are invariably raised in hypothyroidism due to Hashimoto thyroiditis and in primary hypothyroidism from any cause
– Free T4 levels: Needed to correctly interpret the TSH in some clinical settings; low total T4 or free T4 level in the presence of an elevated TSH level further confirms diagnosis of primary hypothyroidism
– T3 levels: Low T3 level and high reverse T3 level may aid in the diagnosis of nonthyroidal illness

Thyroid autoantibodies: Presence of typically anti-TPO (anti-thyroid peroxidase) and anti-Tg (anti-thyroglobulin) antibodies delineates the cause of hypothyroidism as Hashimoto thyroiditis or its variant; however, 10-15% of patients with Hashimoto thyroiditis may be antibody negative.
While their role in the initial destruction of the follicles is unclear, antibodies against thyroid peroxidase (TPO) (also called TPOAb) or thyroglobulin are relevant, as they serve as markers for detecting the disease and its severity. They are hypothesized to be the secondary products of the T cell mediated destruction of the gland.

Initially, all tibial shaft fractures should be stabilized with a long posterior splint with the knee in 10-15° of flexion and the ankle flexed at 90°
Closed fractures with minimal displacement or stable reduction may be treated nonoperatively with a long leg cast, but cast application should be delayed for 3-5 days to allow early swelling to diminish. The cast should extend from the midthigh to the metatarsal heads, with the ankle at 90° of flexion and the knee extended. The cast increases tibial stability and can decrease pain and swelling.
Despite proper casting techniques and adequate follow-up, not all nonoperatively treated tibial shaft fractures heal successfully.
Operative fixation is required when fractures are unstable. Surgical options include plating, external fixation, intramedullary nailing, and, in some cases, amputation.
Intramedullary nailing with locking screws (see the image below) has become the treatment of choice for most tibial shaft fractures. The prevalence of non-union and malunion is greatly decreased in comparison with the other methods of fixation. Patients are also able to return to low-impact activities much sooner than they can with the other treatments.

Acute renal artery thrombosis is a devastating complication of renal transplantation that can result in graft loss if not detected early. Surgical and technical errors are the major cause of renal artery thrombosis. Renal artery thrombosis usually presents with sudden onset oliguria or anuria accompanied by pain and tenderness over the graft site. Patients may develop thrombocytopenia due to platelet aggregation at the thrombosis site. The imaging modality of choice for diagnosis of renal artery thrombosis is colour Doppler sonography. Conventional, computed tomography (CT) and magnetic resonance (MR) angiography may also be used to confirm the presence of renal artery thrombosis. Although there are reports of successful resolution of post-transplant acute renal artery thrombosis with endovascular and surgical modalities such as percutaneous thrombus aspiration, intra-arterial injection of fibrinolytic agents and surgical thrombectomy, renal artery thrombosis usually results in ischemic necrosis and graft loss.