Chemotherapy for acute myeloid leukaemia (AML) requires long-term therapy and multiple blood tests. Therefore, an indwelling device, such as Groshong line, is preferable.

Tunnelled lines such as Groshong and Hickman lines are popular devices for patients with long-term therapeutic requirements. These devices are usually inserted, using ultrasound guidance, into the internal jugular vein and then tunnelled under the skin. A cuff of woven material is sited near the end and helps to anchor the device into the tissues. These cuffs require formal dissection to allow the device to be removed.

Answer: Staphylococcus aureus

Mastitis is defined as inflammation of the breast. Although it can occur spontaneously or during lactation, this discussion is limited to mastitis in breastfeeding women, with mastitis defined clinically as localized, painful inflammation of the breast occurring in conjunction with flu-like symptoms (e.g., fever, malaise). Mastitis is especially problematic because it may lead to the discontinuation of breast-feeding, which provides optimal infant nutrition. Mastitis occurs in approximately 10 percent of U.S. mothers who are breastfeeding, and it can lead to the cessation of breastfeeding. The risk of mastitis can be reduced by frequent, complete emptying of the breast and by optimizing breastfeeding technique. Sore nipples can precipitate mastitis. The differential diagnosis of sore nipples includes mechanical irritation from a poor latch or infant mouth anomalies, such as cleft palate or bacterial or yeast infection. The diagnosis of mastitis is usually clinical, with patients presenting with focal tenderness in one breast accompanied by fever and malaise. Treatment includes changing breastfeeding technique, often with the assistance of a lactation consultant. When antibiotics are needed, those effective against Staphylococcus aureus (e.g., dicloxacillin, cephalexin) are preferred. As methicillin-resistant S. aureus becomes more common, it is likely to be a more common cause of mastitis, and antibiotics that are effective against this organism may become preferred. Continued breastfeeding should be encouraged in the presence of mastitis and generally does not pose a risk to the infant. Breast abscess is the most common complication of mastitis. It can be prevented by early treatment of mastitis and continued breastfeeding. Once an abscess occurs, surgical drainage or needle aspiration is needed. Breastfeeding can usually continue in the presence of a treated abscess.

Nasal injuries can be challenging to manage and where there is tissue loss, it can be difficult to primarily close them and obtain a satisfactory aesthetic result. Debridement together with a rotational skin flap would produce the best results.

A rotation flap is a semi-circular skin flap that is rotated into the defect on a fulcrum point. It provides the ability to mobilize large areas of tissue with a wide vascular base for reconstruction. Rotation flaps may be pedicled or free. Pedicled flaps are more reliable but are limited in the range of movement. Free flaps have increased range but carry greater risk of breakdown as they require vascular anastomosis.

Management of Acute Pancreatitis revolves around supportive care, adequate nutrition, and intravenous hydration. The rationale for hydration is based on the need to resolve the hypovolemia that occurs secondary to vomiting, reduced oral intake, third space extravasation, respiratory losses and diaphoresis. Besides, early hydration provides macrocirculatory and microcirculatory support to prevent the cascade of events leading to pancreatic necrosis.
There is a lack of high level evidence to guide the choice of fluid in AP. Crystalloids are recommended by the American Gastroenterological Association, and colloids (packed red blood cells) are considered in cases of low haematocrit (< 25%) and low serum albumin (< 2 g/dL). Among the crystalloids, Ringer's lactate solution is preferred over Normal saline. However, there is an urgent need of studies on this issue.

Ameloblastoma is a rare, benign or cancerous tumour of odontogenic epithelium (ameloblasts, or outside portion, of the teeth during development) much more commonly appearing in the lower jaw than the upper jaw.
Ameloblastomas can be found both in the maxilla and mandible. Although, 80% are situated in the mandible with the posterior ramus area being the most frequent site. The neoplasms are often associated with the presence of unerupted teeth, displacement of adjacent teeth and resorption of roots.

Symptoms include a slow-growing, painless swelling leading to facial deformity. As the swelling gets progressively larger it can impinge on other structures resulting in loose teeth and malocclusion. Bone can also be perforated leading to soft tissue involvement.

The lesion has a tendency to expand the bony cortices because of the slow growth rate of the lesion allows time for the periosteum to develop a thin shell of bone ahead of the expanding lesion. This shell of bone cracks when palpated. This phenomenon is referred to as Egg Shell Cracking or crepitus, an important diagnostic feature.

Maxillary ameloblastomas can be dangerous and even lethal. Due to thin bone and weak barriers, the neoplasm can extend into the sinonasal passages, pterygomaxillary fossa and eventually into the cranium and brain. Rare orbital invasion of the neoplasm has also been reported.

The latissimus dorsi myocutaneous flap (LDMF) is one of the most reliable and versatile flaps used in reconstructive surgery. It is known for its use in chest wall and postmastectomy reconstruction and has also been used effectively for coverage of large soft tissue defects in the head and neck, either as a pedicled flap or as a microvascular free flap.

The latissimus dorsi may be transferred as a myofascial flap, a myocutaneous flap, or as a composite osteomyocutaneous flap when harvested with underlying serratus anterior muscle and rib. For even greater reconstructive flexibility, the latissimus can be harvested for free tissue transfer in combination with any or all of the other flaps based on the subscapular vessels (the so-called subscapular compound flap or “mega-flap”), including serratus anterior, scapular, and parascapular flaps

Absence of comorbidities and a small procedure with no likelihood of systemic compromise will equate to an ASA score of 1.

The ASA physical status classification system is a system for assessing the fitness of patients before surgery. It has six grades, as described below:

ASA 1: No physiological, biochemical, or psychiatric disturbance. The surgical pathology is localised and has not invoked systemic disturbance.

ASA 2: Mild or moderate systemic disruption caused either by the surgical disease process or through an underlying pre-existing disease.

ASA 3: Severe systemic disruption, not life-threatening, caused either by the surgical pathology or a pre-existing disease.

ASA 4: Patient has severe systemic disease that is a constant threat to life.

ASA 5: Patient is moribund and will not survive without surgery.

ASA 6: A brain-dead patient whose organs are being removed with the intention of transplanting them into another patient.

This patient has aphonia due to bilateral damage to the recurrent laryngeal nerve. Bilateral recurrent laryngeal nerve (RLN) injury is rare for benign thyroid lesions (0.2%). After extubation-stridor, respiratory distress, aphonia occurs due to the closure of the glottic aperture necessitating immediate intervention and emergency intubation or tracheostomy. Intra-operative identification and preservation of the RLN minimizes the risk of injury.
The recurrent laryngeal nerves control all intrinsic muscles of the larynx except for the cricothyroid muscle. These muscles act to open, close, and adjust the tension of the vocal cords, and include the posterior cricoarytenoid muscles, the only muscle to open the vocal cords. The nerves supply muscles on the same side of the body, with the exception of the interarytenoid muscle, which is innervated from both sides.

The nerves also carry sensory information from the mucous membranes of the larynx below the lower surface of the vocal fold, as well as sensory, secretory and motor fibres to the cervical segments of the oesophagus and the trachea.

Answer: Thoracotomy in theatre

A high CVP of 13 indicates cardiac tamponade. Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. The condition is a medical emergency, the complications of which include pulmonary oedema, shock, and death.
A pericardiotomy via a thoracotomy is mandatory for lifesaving cardiac decompression in acute traumatic cardiac tamponade in cases of ineffective drainage due to clot formation within the pericardial space. Wherever possible a patient needing surgery for penetrating chest trauma should be moved to an operating theatre where optimal surgical expertise and facilities are available.

This is likely a case of epididymo-orchitis which usually occurs due to infection with gonorrhoea or chlamydia in this age group (<35 years). Epididymo-orchitis is an acute inflammation of the epididymis and often involves the testis. It is usually caused by bacterial infection which spreads from the urethra or bladder. Amiodarone is a recognised non-infective cause of epididymitis, which resolves on stopping the drug. On examination, tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion where pain usually affects the entire testis.

Pelvic fractures may cause laceration of the urethra. Urinary retention, blood at the urethral meatus, and a high-riding prostate on digital rectal examination are the typical features of urethral injury.

Up to 10% of male pelvic fractures are associated with urethral or bladder injuries. Urethral injury occurs mainly in males. It has two types.
1.Bulbar rupture:
a. most common
b. mostly associated with straddle-type injury, e.g. from bicycles
c. presentation with a triad of urinary retention, perineal haematoma, and blood at the meatus

2. Membranous rupture:
a. can be extra- or intraperitoneal
b. occurs commonly due to pelvic fracture
c. symptomology may include penile or perineal oedema/haematoma
d. prostate displaced upwards (high-riding prostate)

Ascending urethrogram is carried out in patients of suspected urethral injury. Suprapubic catheter is surgically placed and is indicated in:
1. External genitalia injuries (i.e. the penis and the scrotum)
2. Injury to the urethra caused by penetration, blunt trauma, continence- or sexual pleasure–enhancing devices, and mutilation.

Medial extension of an appendicectomy incision carries a risk of injury to the inferior epigastric artery which can bleed briskly. It is best managed by ligation.

Bleeding is a complication encountered in all branches of surgery. The decision as to how best to manage the bleed, depends upon its site, vessel, and circumstances.

1. Superficial dermal bleeding:
This will usually cease spontaneously. If not, then direct use of a monopolar or a bipolar cautery device will usually control the situation. Scalp wounds are a notable exception and bleeding from them may be brisk. In this situation, use of a mattress suture as a wound closure method will usually address the problem.

2. Superficial arterial bleeding:
If the vessel can be safely identified in superficial arterial bleeding, then the easiest method is to apply a haemostatic clip and ligate the vessel.

3. Major arterial bleeding:
If the vessel can be clearly identified and is accessible, then it may be possible to apply a clip and ligate the vessel. If the vessel is located in a pool of blood, then blind application of haemostatic clips is highly dangerous and may result in collateral injury. In this situation, evacuating the clot and packing the area is often safer. The pack can then be carefully removed when the required instruments are available. Some vessels may retract and bleeding may then be controlled by dissection of surrounding structures or underrunning the bleeding point.

4. Major venous bleeding:
The safest initial course of action is to apply digital pressure to the bleeding point. To control the bleeding, thereafter, the surgeon will need a working suction device. Divided veins may require ligation.

5. Bleeding from raw surfaces:
This may be mixed bleeding and can be troublesome. Spray diathermy and argon plasma coagulation are both useful agents. Certain topical haemostatic agents, such as surgicel, are useful in encouraging clot formation and may be used in conjunction with, or instead of, the above agents.

Answer: Bradycardia

Prolonged bed rest and immobilization inevitably lead to complications. Such complications are much easier to prevent than to treat. Musculoskeletal complications include loss of muscle strength and endurance, contractures and soft tissue changes, disuse osteoporosis, and degenerative joint disease. Cardiovascular complications include an increased heart rate (tachycardia), decreased cardiac reserve, orthostatic hypotension, and venous thromboembolism.

Epirubicin is an anthracycline; intercalates between DNA base pairs and triggers cleavage by topoisomerase II, which results in cytocidal activity.
Inhibits DNA helicase and generates cytotoxic free radicals.

Contraindications:
– Severe hypersensitivity to drug, other anthracyclines, or anthracenediones
– Baseline ANC<1500/mm³
– Cardiomyopathy and/or heart failure, recent MI, or severe arrhythmias
– Severe myocardial insufficiency
– Cumulative dose achieved in previous anthracycline treatment
– Severe persistent drug-induced myelosuppression
– Severe hepatic impairment (Child-Pugh Class C or serum bilirubin level greater than 5 mg/dL)

Using fluids to correct hypovolaemia is a dynamic process that requires ongoing evaluation of clinical and haemodynamic indices. Thus, the use of the fluid challenge provides a successful method of adjusting the fluid volume to the patient’s need.

The fluid challenge is a method of safely restoring circulating volume according to physiological need rather than using fixed haemodynamic end-points. The fluid is given in small aliquots to produce a known increment in circulating volume with an assessment of the dynamic haemodynamic response to each aliquot. No fixed haemodynamic end-point is assumed and the technique provides a diagnostic test of hypovolaemia (via an appropriate positive response of the circulation to fluid) and a method of titrating the optimal dose of fluid to the individual’s requirement.
The response of SV and/or CVP (or PAWP) should be monitored during a fluid challenge. The basis of the fluid challenge is to achieve a known increase in intravascular volume by rapid infusion of a bolus of colloid fluid (200 ml).
In the inadequately filled left ventricle, a fluid challenge will increase SV. Failure to increase SV with a fluid challenge may indicate a circulation that is unresponsive to fluid or an inadequate challenge.

Answer: Admit the child to the high dependency unit for close monitoring.

Grade 3: This mid-stage rupture is a tear more than 3 cm deep. It can also involve the splenic artery or a hematoma that covers over half of the surface area. A grade 3 rupture can also mean that a hematoma is present in the organ tissue that is greater than 5 cm or expanding.
The trend in management of splenic injury continues to favour nonoperative or conservative management.
Most haemodynamically stable injuries can be managed non-operatively (especially Grades I to III).

Pyrexia is a very common post operative finding and can most likely result from an infection. However, it is highly unlikely to occur as a result of ileus. Anastomotic leaks are uncommon after right sided colonic surgery. In this scenario atelectasis would be the most likely underlying cause, as open extended right hemicolectomies will necessitate a long midline incision.

Burn depth is classified as first, second, third, or fourth degree, as follows:
First-degree burns are usually red, dry, and painful. Burns initially termed first-degree are often actually superficial second-degree burns, with sloughing occurring the next day.
Second-degree burns are often red, wet, and very painful. Their depth, ability to heal, and propensity to form hypertrophic scars vary enormously.
Third-degree burns are generally leathery in consistency, dry, insensate, and waxy. These wounds will not heal, except by contraction and limited epithelial migration, with resulting hypertrophic and unstable cover. Burn blisters can overlie both second- and third-degree burns. The management of burn blisters remains controversial, yet intact blisters help greatly with pain control. Debride blisters if infection occurs.
Fourth-degree burns involve underlying subcutaneous tissue, tendon, or bone. Usually, even an experienced examiner has difficulty accurately determining burn depth during an early examination. As a general rule, burn depth is underestimated upon initial examination.

The management plan for patients with large burns that require inpatient care is usually determined by the physiology of the burn injury.
Hospitalization is divided into 4 general phases, including (1) initial evaluation and resuscitation, (2) initial wound excision and biologic closure, (3) definitive wound closure, and (4) rehabilitation and reconstruction.

Early excision and closure of full-thickness wounds change the natural history of burn injury, avoiding the otherwise common occurrence of wound sepsis. Wound size is the most important factor in determining the need for early operation

Medications
See the list below:
– Silver sulfadiazine – Broad antibacterial spectrum; painless application
– Aqueous 0.5% silver nitrate – Broad-spectrum coverage, including fungi; leeches electrolytes
– Mafenide acetate – Broad antibacterial spectrum; penetrates eschar best
– Petrolatum – Bland and nontoxic
– Various debriding enzymes – Useful in selected partial-thickness wounds
– Various antibiotic ointments – Useful in many superficial partial-thickness wounds
Membranes
See the list below:
– Porcine xenograft – Adheres to wound coagulum and provides excellent pain control
– Split-thickness allograft – Vascularizes and provides durable temporary closure of wounds
– Various hydrocolloid dressings – Provide vapour and bacteria barrier while absorbing wound exudate
– Various impregnated gauzes – Provide vapour and bacteria barrier while allowing drainage
– Various semipermeable membranes – Provide vapour and bacteria barrier
– Acticoat (Westhaim Biomedical, Saskatchewan, Canada) – Nonadherent wound dressing that delivers a low concentration of silver for antisepsis
– Biobrane (Dow-Hickman, Sugarland, Tex) – Synthetic bilaminate that facilitates fibrovascular tissue growth into the inner layer and provides temporary vapour and bacteria barrier
– Transcyte (Smith and Nephew, Largo, Fla) – Synthetic bilaminate that facilitates fibrovascular tissue growth into the inner layer populated with allogenic fibroblasts and overlying layer that provides temporary vapour and bacteria barrier
– AlloDerm R – Consists of cell-free allogenic human dermis; requires an immediate thin overlying autograft
– Integra R – Provides scaffold for neodermis; requires delayed thin autograft

Answer: Myofibroblasts

Fibroblasts are a type of cell which have mesenchymal origin and can exhibit either non-contractile or highly contractile phenotype. Under normal conditions, fibroblasts function to maintain tissue homeostasis by regulating the turnover of extracellular matrix (ECM). When tissues are injured, however, fibroblasts around the injured region differentiate into myofibroblasts, a type of highly contractile cells that produce abundant ECM proteins. While the mechanisms of wound healing are not completely understood, it has become clear that both fibroblasts and myofibroblasts play a critical role in the wound healing process. Specifically, the traction forces of fibroblasts and coordinated contraction of myofibroblasts are believed to be responsible for wound contraction and closure. However, excessive myofibroblast activity, accompanied by elevated levels of mechanical stress in the healing region, often causes scar tissue formation, and in the worst case, contracture of tissues (e.g. Dupuytren’s contracture), leading to local immobilization and loss of function.

Hartmann’s solution is the preferred fluid among the listed options.

In UK, Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP) and The National Institute for Health and Care Excellence (NICE) guidelines were devised to try and develop a consensus on how to administer intravenous fluids (IV) postoperatively. A decade ago, it was a commonly held belief that little harm would occur as a result of excessive administration of normal saline, and many oliguric postoperative patients received enormous quantities of IV fluids. As a result, they developed hyperchloraemic acidosis. With greater understanding of this potential complication, the use of electrolyte-balanced solutions (Hartmann’s or Ringer Lactate solution) is now favoured over normal saline.

The guidelines further include:
1. Fluids given should be documented clearly.
2. Assess the patient’s fluid status when they leave the theatre.
3. If the patient is haemodynamically stable and euvolaemic, aim to restart oral fluid intake as soon as possible.
4. If the patient is oedematous, hypovolaemia if present should be treated first. This should then be followed by a negative balance of sodium and water, monitored closely.
5. Solutions such as Dextran 70 should be cautiously used in patients with sepsis as there is a risk of developing acute renal injury.

A pressure of 10 mmHg should be set on the gas insufflation system.

Laparoscopic surgery may be performed in a number of body cavities. In some areas, irrigation solutions are preferred. In the abdomen, however, insufflation with carbon dioxide gas is commonly used. The amount of gas delivered is adjusted to maintain a constant intra-abdominal pressure of 12–15 mmHg. Excessive intra-abdominal pressure may reduce venous return and lead to hypotension. Too little insufflation will risk obscuring the surgical view.

Aortic injuries not resulting in immediate death may be due to a contained haematoma. Clinical signs are subtle, and diagnosis may not be apparent on clinical examination. Without prompt treatment, the haematoma usually bursts and the patient dies.

Traumatic aortic disruption, or aortic transection, is typically the result of a blunt aortic injury in the context of rapid deceleration. This condition is commonly fatal as blood in the aorta is under great pressure and can quickly escape the vessel through a tear, resulting in rapid haemorrhagic shock and death. A temporary haematoma may prevent the immediate death. Injury to the aorta during a sudden deceleration commonly originates near the terminal section of the aortic arch, also known as the isthmus. This portion lies just distal to the take-off of the left subclavian artery at the intersection of the mobile and fixed portions of the aorta. As many as 80% of the patients with aortic transection die at the scene before reaching a trauma centre for treatment.

A widened mediastinum may be seen on the X-ray of a person with aortic rupture. Other findings on CXR may include:
1. Deviation of trachea/oesophagus to the right
2. Depression of left main stem bronchus
3. Widened paratracheal stripe/paraspinal interfaces
4. Obliteration of space between aorta and pulmonary artery
5. Rib fracture/left haemothorax

Diagnosis can be made by angiography, usually CT aortogram.

Treatment options include repair or replacement. The patient should, ideally, undergo endovascular repair.

Open haemorrhoidectomy is traditionally viewed as a painful procedure. Most operations are performed under general or regional anaesthesia. Following excisional haemorrhoidectomy, severe pain is not unusual, a well placed caudal anaesthetic will counter this. A pudendal nerve block is an alternative but is less effective than a caudal.

A surgical drain is a tube used to remove pus, blood or other fluids from a wound. They are commonly placed by surgeons or interventional radiologists. Suction is applied through the drain to generate a vacuum and draw fluids into a bottle. Following breast surgery, it is standard practice to use a Redivac type system that is made of polypropylene.

Answer: Flail chest injury

Flail chest is a life-threatening medical condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall. Two of the symptoms of flail chest are chest pain and shortness of breath.

It occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently. The number of ribs that must be broken varies by differing definitions: some sources say at least two adjacent ribs are broken in at least two places, some require three or more ribs in two or more places. The flail segment moves in the opposite direction to the rest of the chest wall: because of the ambient pressure in comparison to the pressure inside the lungs, it goes in while the rest of the chest is moving out, and vice versa. This so-called paradoxical breathing is painful and increases the work involved in breathing.

Flail chest is usually accompanied by a pulmonary contusion, a bruise of the lung tissue that can interfere with blood oxygenation. Often, it is the contusion, not the flail segment, that is the main cause of respiratory problems in people with both injuries.

Surgery to fix the fractures appears to result in better outcomes.

Sjogren syndrome (SS) is a long-term autoimmune disease that affects the body’s moisture-producing glands. Primary symptoms are a dry mouth and dry eyes. Other symptoms can include dry skin, vaginal dryness, a chronic cough, numbness in the arms and legs, feeling tired, muscle and joint pains, and thyroid problems. Those affected are at an increased risk (5%) of lymphoma. It primarily affects women in their peri and post-menopausal years of life.

Since TPN solutions irritate the veins, they are best administered via a central line. The femoral route has a higher incidence of line-associated sepsis and is, thus, best avoided in this setting.

The National Institute for Health and Care Excellence (NICE) has laid down guidelines for identifying patients as malnourished or at risk of malnourishment, in order to start oral, enteral, or parenteral nutrition support, alone or in combination.

Following patients are identified as malnourished:
1. BMI <18.5 kg/m2
2. Unintentional weight loss of >10% within the last 3–6 months
3. BMI <20 kg/m2 and unintentional weight loss of >5% within the last 3–6 months

Following patients are at risk of malnutrition:
1. Eaten nothing or little for >5 days and/or likely to eat little or nothing for the next 5 days or longer
2. Poor absorptive capacity and/or
3. High nutrient loss and/or
4. High metabolic rate

Considering the method of parenteral nutrition:
1. For feeding <14 days, consider feeding via a peripheral venous catheter
2. For feeding >30 days, use a tunnelled subclavian line,
continuous administration in severely unwell patients
3. If feed needed for >2 weeks, consider changing from continuous to cyclical feeding
4. Do not give >50% of daily regime to unwell patients in the first 24–48 hours
5. In surgical patients, if malnourished with unsafe swallow or a non-functional GI tract or perforation, consider perioperative parenteral feeding.

The diagnosis for this case is acute haemolytic transfusion reaction, due to ABO incompatibility. Haemolysis of the transfused cells can cause loin pain, shock, and hemoglobinemia, which may subsequently lead to disseminated intravascular coagulation. A direct Coombs test should confirm haemolysis. Other tests include unconjugated bilirubin, haptoglobin, serum and urine free haemoglobin.

Delayed haemolytic reactions, however, are normally associated with antibodies to the Rh system and occur 5–10 days after transfusion.

Acute transfusion reactions present during or within 24 hours of a blood transfusion. The most frequent clinical features are fever, chills, pruritus, or urticaria, which typically resolve, promptly, without specific treatment or complications. Other signs occurring in temporal relationship with a blood transfusion such as severe dyspnoea, pyrexia, or loss of consciousness may be the first indication of a more severe, potentially fatal reaction. Transfusion reactions may be immune-mediated or non-immune-mediated.

Answer: Myoglobin

When muscle is damaged, a protein called myoglobin is released into the bloodstream. It is then filtered out of the body by the kidneys. Myoglobin breaks down into substances that can damage kidney cells.
Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells.

Compartment syndrome can be either acute or chronic.

Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury. Without treatment, it can lead to permanent muscle damage.

Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion. Compartments are groupings of muscles, nerves, and blood vessels in your arms and legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily.
Compartment syndrome develops when swelling or bleeding occurs within a compartment. Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged.

In acute compartment syndrome, unless the pressure is relieved quickly, permanent disability and tissue death may result. This does not usually happen in chronic (exertional) compartment syndrome.

Compartment syndrome most often occurs in the anterior (front) compartment of the lower leg (calf). It can also occur in other compartments in the leg, as well as in the arms, hands, feet, and buttocks.

Acute compartment syndrome usually develops after a severe injury, such as a car accident or a broken bone. Rarely, it develops after a relatively minor injury.

Conditions that may bring on acute compartment syndrome include:

A fracture.
A badly bruised muscle. This type of injury can occur when a motorcycle falls on the leg of the rider, or a football player is hit in the leg with another player’s helmet.
Re-established blood flow after blocked circulation. This may occur after a surgeon repairs a damaged blood vessel that has been blocked for several hours. A blood vessel can also be blocked during sleep. Lying for too long in a position that blocks a blood vessel, then moving or waking up can cause this condition. Most healthy people will naturally move when blood flow to a limb is blocked during sleep. The development of compartment syndrome in this manner usually occurs in people who are neurologically compromised. This can happen after severe intoxication with alcohol or other drugs.
Crush injuries.
Anabolic steroid use. Taking steroids is a possible factor in compartment syndrome.
Constricting bandages. Casts and tight bandages may lead to compartment syndrome. If symptoms of compartment syndrome develop, remove or loosen any constricting bandages.

Streptococci may be divided into alpha and beta haemolytic types

Alpha haemolytic streptococci

The most important alpha haemolytic streptococcus is Streptococcus pneumoniae (pneumococcus). Pneumococcus is a common cause of pneumonia, meningitis and otitis media. Another clinical example is Streptococcus viridans

Beta haemolytic streptococci

These can be subdivided into group A and B

Group A

most important organism is Streptococcus pyogenes
responsible for erysipelas, impetigo, cellulitis, type 2 necrotizing fasciitis and pharyngitis/tonsillitis
immunological reactions can cause rheumatic fever or post-streptococcal glomerulonephritis
erythrogenic toxins cause scarlet fever

Group B

Streptococcus agalactiae may lead to neonatal meningitis and septicaemia