Answer: Acute subdural haematoma

An acute subdural haematoma (SDH) is a clot of blood that develops between the surface of the brain and the dura mater, the brain’s tough outer covering, usually due to stretching and tearing of veins on the brain’s surface. These veins rupture when a head injury suddenly jolts or shakes the brain.
Traumatic acute SDHs are among the most lethal of all head injuries. Associated with more severe generalized brain injury, they often occur with cerebral contusions.
SDHs are seen in 10 percent to 20 percent of all traumatic brain injury cases and occur in up to 30 percent of fatal injuries.
Diagnosis:

SDHs are best diagnosed by computed tomography (CT) scan. They appear as a dense, crescent-shaped mass over a portion of the brain’s surface.
Most patients with acute SDHs have low Glasgow Coma Scale (GCS) scores on admission to the hospital.

Acute traumatic subdural haematoma often results from falls, violence, or motor vehicle accidents. Suspect acute subdural haematoma whenever the patient has experienced moderately severe to severe blunt head trauma. The clinical presentation depends on the location of the lesion and the rate at which it develops. Often, patients are rendered comatose at the time of the injury. A subset of patients remain conscious; others deteriorate in a delayed fashion as the haematoma expands.
A GCS score less than 15 after blunt head trauma in a patient with no intoxicating substance use (or impaired mental status baseline) warrants consideration of an urgent CT scan. Search for any focal neurologic deficits or signs of increased ICP. Any abnormality of mental status that cannot be explained completely by alcohol intoxication or the presence of another mind-altering substance should increase suspicion of subdural hematoma in the patient with blunt head trauma.

The clinical presentation of a patient with an acute subdural haematoma depends on the size of the hematoma and the degree of any associated parenchymal brain injury. Symptoms associated with acute subdural haematoma include the following:

Headache

Nausea

Confusion

Personality change

Decreased level of consciousness

Speech difficulties

Other change in mental status

Impaired vision or double vision

Weakness

On noncontrast CT scan, an acute subdural haematoma appears as a hyperdense (white), crescent-shaped mass between the inner table of the skull and the surface of the cerebral hemisphere.

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.

A Spigelian hernia (or lateral ventral hernia) is a hernia through the Spigelian fascia, which is the aponeurotic layer between the rectus abdominis muscle medially, and the semilunar line laterally. These are generally interparietal hernias, meaning that they do not lie below the subcutaneous fat but penetrate between the muscles of the abdominal wall; therefore, there is often no notable swelling.

Spigelian hernias are usually small and therefore risk of strangulation is high. Most occur on the right side. (4th–7th decade of life.) Compared to other types of hernias they are rare.

Risk of haematoma (requiring removal) in adults attending accident and emergency units following head injury.

Risk Factor Risk of haematoma
Oriented, no skull fracture 1 in 5983
Not oriented, no skull fracture 1 in 121
Skull fracture, Orientated 1 in 32
Skull fracture, Not orientated 1 in 4

Dermatofibromas may be pigmented and are often larger than they appear. They frequently occur at the sites of previous trauma.

Dermatofibromas are small, noncancerous (benign) skin growths that can develop anywhere on the body but most often appear on the lower legs, upper arms, or upper back. These nodules are common in adults but are rare in children. They can be pink, grey, red, or brown in colour and may change colour over the years. They are firm and often feel like a stone under the skin. When pinched from the sides, the top of the growth may dimple inward. These lesions feel larger than they appear visually.

Dermatofibromas are usually painless, but some people experience tenderness or itching. Most often, a single nodule develops, but some can develop numerous dermatofibromas.

Carbimazole was not found to cause gynaecomastia.

Drugs frequently causing gynecomastia:
Antiandrogens – Bicalutamide, flutamide, finasteride, dutasteride
Antihypertensive – Spironolactone
Antiretroviral – Protease inhibitors (saquinavir, indinavir, nelfinavir, ritonavir, lopinavir), reverse transcriptase inhibitors (stavudine, zidovudine, lamivudine)
Environmental exposure – Phenothrin (antiparasitic)
Exogenous hormones – Oestrogens, prednisone (male teenagers)
Gastrointestinal drugs – H2 histamine receptor blockers (cimetidine)

Mnemonic for causes of gynaecomastia: METOCLOPRAMIDE

M etoclopramide
E ctopic oestrogen
T rauma skull/tumour breast, testes
O rchitis
C imetidine, Cushings
L iver cirrhosis
O besity
P araplegia
R A
A cromegaly
M ethyldopa
I soniazid
D igoxin
E thionamide

Bronchogenic cysts, although relatively rare, represent the most common cystic lesion of the mediastinum.
Bronchogenic cysts are the result of anomalous development of the ventral foregut; they are usually single but may be multiple and can be filled with fluid or mucus. They have been found all along the tracheoesophageal course, in perihilar or intraparenchymal sites, with a predilection for the area around the carina. Those in the mediastinum frequently attach to but do not communicate with the tracheobronchial tree. Bronchogenic cysts have also been described in more remote locations, including the interatrial septum, neck, abdomen, and retroperitoneal space.
With the advent of improved antenatal diagnosis, many infants are identified before the development of symptoms:
Chest pain and dysphagia are the most common symptoms in adults with bronchogenic cysts.
Recurrent infections may be the clinical presentation in some children
In infants, symptoms are most often produced as a result of airway or oesophageal compression.

Oesophageal duplication cysts are rare inherited lesions usually diagnosed in early childhood. Most of them are found in the mediastinum and manifest themselves as separate masses along or in continuity with the native oesophagus

Klippel-Trenaunay syndrome is a condition that affects the development of blood vessels, soft tissues (such as skin and muscles), and bones. The disorder has three characteristic features: a red birthmark called a port-wine stain, abnormal overgrowth of soft tissues and bones, and vein malformations.

Most people with Klippel-Trenaunay syndrome are born with a port-wine stain. This type of birthmark is caused by swelling of small blood vessels near the surface of the skin. Port-wine stains are typically flat and can vary from pale pink to deep maroon in colour.

Klippel-Trenaunay syndrome is also associated with overgrowth of bones and soft tissues beginning in infancy. Usually this abnormal growth is limited to one limb, most often one leg. However, overgrowth can also affect the arms or, rarely, the torso.

Malformations of veins are the third major feature of Klippel-Trenaunay syndrome. These abnormalities include varicose veins and deep veins in the limbs. Malformations of deep veins increase the risk of a deep vein thrombosis (DVT).

Other complications of Klippel-Trenaunay syndrome can include cellulitis, lymphedema, and internal bleeding from abnormal blood vessels. Less commonly, this condition is also associated with fusion of certain fingers or toes (syndactyly) or the presence of extra digits (polydactyly).

Proctectomy with end stoma is the best operative strategy in severe perianal and/or rectal Crohn’s disease.

Surgical resection of Crohn’s disease does not provide a complete cure but it may produce substantial symptomatic improvement. Indications for surgery include complications such as fistulae, abscess formation, and strictures.

Colonoscopy and a small bowel study (e.g. MR enteroclysis imaging) are used to stage Crohn’s disease to facilitate decision-making regarding surgery.
Complex perianal fistulae are best managed with long-term draining seton sutures. Severe perianal and/or rectal Crohn’s disease usually require proctectomy with formation of end stoma. Ileoanal pouch reconstruction carries a high risk of fistula formation and pouch failure and is, therefore, not recommended. Terminal ileal Crohn’s remains one of the most common form of the disease, and it may be treated with limited ileocaecal resections.

Peptic ulcer disease can involve the stomach or duodenum. Gastric and duodenal ulcers usually cannot be differentiated based on history alone, although some findings may be suggestive. Epigastric pain is the most common symptom of both gastric and duodenal ulcers, characterized by a gnawing or burning sensation and that occurs after meals—classically, shortly after meals with gastric ulcers and 2-3 hours afterward with duodenal ulcers.

Upper gastrointestinal (GI) endoscopy is the preferred diagnostic test in the evaluation of patients with suspected peptic ulcer disease. At endoscopy, gastric ulcers appear as discrete mucosal lesions with a punched-out smooth ulcer base, which often is filled with whitish fibrinoid exudate. Ulcers tend to be solitary and well circumscribed and usually are 0.5-2.5 cm in diameter.
Treatment of peptic ulcers varies depending on the aetiology and clinical presentation. The initial management of a stable patient with dyspepsia differs from the management of an unstable patient with upper gastrointestinal (GI) haemorrhage. In the latter scenario, failure of medical management not uncommonly leads to surgical intervention.

Treatment options include empiric antisecretory therapy, empiric triple therapy for H pylori infection, endoscopy followed by appropriate therapy based on findings, and H pylori serology followed by triple therapy for patients who are infected. Breath testing for active H pylori infection may be used.

Microscopic colitis is an inflammation of the large intestine (colon) that causes persistent watery diarrhoea. The disorder gets its name from the fact that it’s necessary to examine the colon tissue under a microscope to identify it, since the tissue may appear normal with a colonoscopy or flexible sigmoidoscopy. It is characterised by normal endoscopic appearances, microscopic features of colonic inflammation and thickening of the sub epithelial collagen layer. Features such as granulomas are absent. It is the normal endoscopic appearance that makes the other options less likely.

The patient has Haemorrhoid Disease
A total of 40% of individuals with haemorrhoids are asymptomatic.
For internal haemorrhoids, bleeding is the most commonly reported symptom. The occurrence of bleeding is usually associated with defecation and almost always painless. The blood is bright red and coats the stool at the end of defection.
Another frequent symptom is the sensation of tissue prolapse. Prolapsed internal haemorrhoids may accompany mild faecal incontinence, mucus discharge, a sensation of perianal fullness, and irritation of perianal skin. Pain is significantly less common with internal haemorrhoids than with external haemorrhoids but can occur in the setting of prolapsed, strangulated internal haemorrhoids that develop gangrenous changes due to the associated ischemia.
In contrast, external haemorrhoids are more likely to be associated with pain, due to activation of perianal innervations associated with thrombosis. Patients typically describe a painful perianal mass that is tender to palpation. This painful mass may be initially increasing in size and severity over time. Bleeding can also occur if ulceration develops from necrosis of the thrombosed haemorrhoid, and this blood tends to be darker and more clotted than the bleeding from the internal disease. Painless external skin tags often result from previous oedematous or thrombosed external haemorrhoids.

Lifestyle and dietary modification are the mainstays of conservative medical treatment of haemorrhoid disease. Specifically, lifestyle modifications should include increasing oral fluid intake, reducing fat consumptions, avoiding straining, and regular exercise. Diet recommendations should include increasing fibre intake, which decreases the shearing action of passing a hard stool.
Most patients with grade I and II and select patients with grade III internal hemorrhoidal disease who fail medical treatment can be effectively treated with office-based procedures.
For internal haemorrhoids, rubber band ligation, sclerotherapy, and infrared coagulation are the most common procedures but there is no consensus on optimal treatment. Overall, the goals of each procedure are to decrease vascularity, reduce redundant tissue, and increase hemorrhoidal rectal wall fixation to minimize prolapse.
Rubber band ligation is the most commonly performed procedure in the office and is indicated for grade II and III internal haemorrhoids.

A patent urachus is one of the spectrum of congenital urachal anomalies. It has occasionally been termed urachal fistula. In an open (or patent) urachus, there is an opening between the bladder and the belly button (navel). The urachus is a tube between the bladder and the belly button that is present before birth. In most cases, it closes along its full length before the baby is born. An open urachus occurs mostly in infants. A patent urachus is often diagnosed in neonates when urine is noted leaking from the umbilicus. The umbilicus may also have an abnormal appearance on physical exam.

A patent urachus predisposes to infection. If the urachal disorder presents with an infection, the infection is treated first. This requires antibiotics, possible admission for intravenous antibiotics, and occasional surgical drainage of any infected cyst or poorly draining cavity. Once the infection is under control, excision of the urachus is usually performed. This can usually be done laparoscopically or with a small incision on the lower abdomen. Patients usually stay in the hospital 1-2 days after the surgery. The urachus can be excised because in normal development it usually obliterates anyway. The umbilicus is not removed.

Omphalitis is an infection of the umbilicus and/or surrounding tissues, occurring primarily in the neonatal period. Omphalitis is primarily a disease of the neonate and is characterized by tenderness, erythema, and induration of the umbilicus and surrounding tissues. Early on, patients may only have superficial cellulitis but, if untreated, this can progress to involve the entire abdominal wall. Patients may also have purulent drainage or be bleeding from the umbilical cord stump. Foul-smelling drainage should raise the suspicion of anaerobic infection.

Patent vitellointestinal or persistent omphalomesenteric duct is a very unusual congenital anomaly which occurs in 2% of population related with the embryonic yolk stalk. A persistent vitellointestinal duct can induce abdominal pain, bowel obstruction, intestinal haemorrhage and umbilical sinus, fistula or hernia which commonly occurs in children.

An umbilical granuloma is a moist, red lump of tissue that can form on a baby’s navel (belly button). It can be seen in the first few weeks of life, after the umbilical cord has dried and fallen off. It’s usually a minor problem that looks worse than it is. An umbilical granuloma does not cause pain. It may ooze a small amount of fluid that can make the skin around it red and irritated.

Answer: Undertake an open inguinal herniotomy

Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structure, such as bowel or omentum, protrudes through a defect in the abdominal wall. Inguinal hernias do not spontaneously heal and must be surgically repaired because of the ever-present risk of incarceration. Generally, a surgical consultation should be made at the time of diagnosis, and repair (on an elective basis) should be performed very soon after the diagnosis is confirmed.

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.

Open herniotomy is its standard treatment against which all alternative modalities of treatment are evaluated. It is credited with being easy to perform, having a high success rate, and low rate of complications.
The use of prosthetic mesh in these patients is rare, however not uncalled for. Laparoscopic inguinal herniotomy is significantly associated with longer operative time for unilateral cases and a reduction in metachronous hernia development when compared to open inguinal herniotomy. There was a trend towards higher recurrence rate for laparoscopic repairs and shorter operative time for bilateral cases. A well conducted randomized controlled trial is warranted to compare both approaches.

The history of bloodstained vaginal discharge and lower abdominal tenderness makes ectopic pregnancy a strong possibility. Therefore, a pregnancy test (for beta hCG) and abdominal and pelvic USS should be performed. If the beta HCG is high, that is an indication for intrauterine pregnancy. If it is not, then an ectopic pregnancy is likely, and surgery should be considered.

Generally, the differential diagnosis of right iliac fossa (RIF) pain includes:
1. Appendicitis
2. Crohn’s disease
3. Mesenteric adenitis
4. Diverticulitis
5. Meckel’s diverticulitis
6. Perforated peptic ulcer
7. Incarcerated right inguinal or femoral hernia
8. Bowel perforation secondary to caecal or colon carcinoma
9. Gynaecological causes—pelvic inflammatory disease/salpingitis/pelvic abscess/ectopic pregnancy/ovarian torsion/threatened or complete abortion
10. Urological causes—ureteric colic/urinary tract infection/Testicular torsion
11. Other causes—tuberculosis/typhoid/ infection with herpes zoster

Answer: Cystine stone

Cystinuria is a genetic cause of kidney stones with an average prevalence of 1 in 7000 births. Cystine stones are found in 1 to 2 percent of stone formers, although they represent a higher percentage of stones in children (approximately 5 percent). Cystinuria is an inherited disorder. Inherited means it is passed down from parents to children through a defect in a specific gene. In order to have cystinuria, a person must inherit the gene from both parents.
Cystine is a homodimer of the amino acid cysteine. Patients with cystinuria have impairment of renal cystine transport, with decreased proximal tubular reabsorption of filtered cystine resulting in increased urinary cystine excretion and cystine nephrolithiasis. The cystine transporter also promotes the reabsorption of dibasic amino acids, including ornithine, arginine, and lysine, but these compounds are soluble so that an increase in their urinary excretion does not lead to stones. Intestinal cystine transport is also diminished, but the result is of uncertain clinical significance.

Cystinuria only causes symptoms if you have a stone. Kidney stones can be as small as a grain of sand. Others can become as large as a pebble or even a golf ball. Symptoms may include:

Pain while urinating
Blood in the urine
Sharp pain in the side or the back (almost always on one side)
Pain near the groin, pelvis, or abdomen
Nausea and vomiting

Struvite stones are a type of hard mineral deposit that can form in your kidneys. Stones form when minerals like calcium and phosphate crystallize inside your kidneys and stick together. Struvite is a mineral that’s produced by bacteria in your urinary tract. Bacteria in your urinary tract produce struvite when they break down the waste product urea into ammonia. For struvite to be produced, your urine needs to be alkaline. Having a urinary tract infection can make your urine alkaline. Struvite stones often form in women who have a urinary tract infection.

Calcium oxalate stones are the most common type of kidney stone. Kidney stones are solid masses that form in the kidney when there are high levels of calcium, oxalate, cystine, or phosphate and too little liquid. There are different types of kidney stones. Your healthcare provider can test your stones to find what type you have. Calcium oxalate stones are caused by too much oxalate in the urine.

What is oxalate and how does it form stones?
Oxalate is a natural substance found in many foods. Your body uses food for energy. After your body uses what it needs, waste products travel through the bloodstream to the kidneys and are removed through urine. Urine has various wastes in it. If there is too much waste in too little liquid, crystals can begin to form. These crystals may stick together and form a solid mass (a kidney stone). Oxalate is one type of substance that can form crystals in the urine. This can happen if there is too much oxalate, too little liquid, and the oxalate “sticks” to calcium while urine is being made by the kidneys.

Uric acid stones are the most common cause of radiolucent kidney stones in children. Several products of purine metabolism are relatively insoluble and can precipitate when urinary pH is low. These include 2- or 8-dihydroxyadenine, adenine, xanthine, and uric acid. The crystals of uric acid may initiate calcium oxalate precipitation in metastable urine concentrates.
Uric acid stones form when the levels of uric acid in the urine is too high, and/or the urine is too acidic (pH level below 5.5) on a regular basis. High acidity in urine is linked to the following causes:
Uric acid can result from a diet high in purines, which are found especially in animal proteins such as beef, poultry, pork, eggs, and fish. The highest levels of purines are found in organ meats, such as liver and fish. Eating large amounts of animal proteins can cause uric acid to build up in the urine. The uric acid can settle and form a stone by itself or in combination with calcium. It is important to note that a person’s diet alone is not the cause of uric acid stones. Other people might eat the same diet and not have any problems because they are not prone to developing uric acid stones.
There is an increased risk of uric acid stones in those who are obese or diabetic.
Patients on chemotherapy are prone to developing uric acid stones.

Only cystine stone is inherited.

Fractures of the distal tibia and fibula may result in loss of stability of the ankle joint. They may present as a fracture only, fracture and ligamentous injury, multiple fractures or a fracture dislocation.

Isolated fibular fractures at the level of the syndesmosis (Weber B) without associated medial injury should be placed in a short leg backslab (ankle at plantargrade) and remain NWB (non-weight bearing).

With medial malleolus fractures care should be taken to rule out any other fracture or injury around the ankle. The entire length of the fibula should be palpated and x-rayed to rule out any Maisonneuve type injuries. Any other fracture, ligament injury or talar shift indicate the fracture is likely to be unstable and should be reviewed by orthopaedics.

If medial malleolar injury is truly isolated then a short leg backslab (below knee plaster cast) should be applied and the patient is to remain NWB until orthopaedic review.

Answer: Spina bifida occulta

Spina Bifida Occulta is the mildest type of spina bifida. It is sometimes called “hidden” spina bifida. With it, there is a small gap in the spine, but no opening or sac on the back. The spinal cord and the nerves usually are normal. Many times, Spina Bifida Occulta is not discovered until late childhood or adulthood. This type of spina bifida usually does not cause any disabilities.

Eighty percent of those with a spinal cord problem will have skin over the defect with:
a hairy patch
a fatty lump
a haemangioma—a red or purple spot made up of blood vessels
a dark spot or a birthmark—these are red and don’t include blue-black marks, called “Mongolian spots”
a skin tract (tunnel) or sinus—this can look like a deep dimple, especially if it’s too high (higher than the top of the buttocks crease), or if its bottom can’t be seen
a hypopigmented spot—an area with less skin colour.

Myelocele is herniation of spinal cord tissue through a defect in a region of the vertebral column. The protrusion of the tissue is flush with the level of the skin surface. In myelocele, the spinal cord is exposed so that nerve tissue lies exposed on the surface of the back without even a covering of skin or of the meninges, the membranous tissue surrounding the brain and spinal cord.

Answer: Transposition of the great arteries

Transposition of the great arteries (TGA) is the most common cyanotic congenital heart lesion that presents in neonates. The hallmark of transposition of the great arteries is ventriculoarterial discordance, in which the aorta arises from the morphologic right ventricle and the pulmonary artery arises from the morphologic left ventricle.

Infants with transposition of the great arteries (TGA) are usually born at term, with cyanosis apparent within hours of birth.

The clinical course and manifestations depend on the extent of intercirculatory mixing and the presence of associated anatomic lesions. Note the following:

Transposition of the great arteries with intact ventricular septum: Prominent and progressive cyanosis within the first 24 hours of life is the usual finding in infants if no significant mixing at the atrial level is evident.

Transposition of the great arteries with large ventricular septal defect: Infants may not initially manifest symptoms of heart disease, although mild cyanosis (particularly when crying) is often noted. Signs of congestive heart failure (tachypnoea, tachycardia, diaphoresis, and failure to gain weight) may become evident over the first 3-6 weeks as pulmonary blood flow increases.

Transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction: Infants often present with extreme cyanosis at birth, proportional to the degree of left ventricular (pulmonary) outflow tract obstruction. The clinical history may be similar to that of an infant with tetralogy of Fallot.

Transposition of the great arteries with ventricular septal defect and pulmonary vascular obstructive disease: Progressively advancing pulmonary vascular obstructive disease can prevent this rare subgroup of patients from developing symptoms of congestive heart failure, despite a large ventricular septal defect. Most often, patients present with progressive cyanosis, despite an early successful palliative procedure.

An anal fistula is an abnormal tract between the anal canal and the skin around the anus.
Anal fistulas can be classified according to their relationship with the external sphincter. A fistula may be complex, with several openings onto the perianal skin. Intersphincteric fistulas are the most common type and cross only the internal anal sphincter. Trans-sphincteric fistulas pass through both the internal and external sphincters.

The aim is to drain the infected material and encourage healing.
For simple intersphincteric and low trans-sphincteric anal fistulas, the most common treatment is a fistulotomy or laying open of the fistula tract.
For high and complex (deeper) fistulas that involve more muscle, with a high risk of faecal incontinence or recurrence, surgery aims to treat the fistula and preserve sphincter-muscle function. Techniques include a 1‑stage or 2‑stage seton (suture material or rubber sling) either alone or in combination with fistulotomy, ligation of an intersphincteric fistula tract, creating a mucosal advancement flap, injecting glue or paste, or inserting a fistula plug .

The Frykman classification of distal radial fractures is based on the AP appearance and encompasses the eponymous entities of Colles fracture, Smith fracture, Barton fracture, chauffeur fracture.

Colles fractures are very common extra-articular fractures of the distal radius that occur as the result of a fall onto an outstretched hand. They consist of a fracture of the distal radial metaphyseal region with dorsal angulation and impaction, but without the involvement of the articular surface.
Colles fractures are the most common type of distal radial fracture and are seen in all adult age groups and demographics. They are particularly common in patients with osteoporosis, and as such, they are most frequently seen in elderly women.

Smith fractures, also known as Goyrand fractures in the French literature 3, are fractures of the distal radius with associated volar angulation of the distal fracture fragment(s). Classically, these fractures are extra-articular transverse fractures and can be thought of like a reverse Colles fracture.
The term is sometimes used to describe intra-articular fractures with volar displacement (reverse Barton fracture) or juxta-articular fractures

Barton fractures are fractures of the distal radius. It is also sometimes termed the dorsal type Barton fracture to distinguish it from the volar type or reverse Barton fracture.
Barton fractures extend through the dorsal aspect to the articular surface but not to the volar aspect. Therefore, it is similar to a Colles fracture. There is usually associated with dorsal subluxation/dislocation of the radiocarpal joint.

Chauffeur fractures (also known as Hutchinson fractures or backfire fractures) are intra-articular fractures of the radial styloid process. The radial styloid is within the fracture fragment, although the fragment can vary markedly in size.

Pyogenic granuloma is a vascular lesion that occurs on both mucosa and skin, and appears as an overgrowth of tissue due to irritation, physical trauma, or hormonal factors. It is often found to involve the gums, the skin and nasal septum, and has also been found far from the head such as in the thigh. Contact bleeding and ulceration are common.

One of the less common but more challenging issues is ulceration of the skin or pyoderma gangrenosum (PG). Although PG was initially thought to be associated with Crohn’s or inflammatory bowel disease, it is now also known to be associated with malignancies, blood dyscrasias, diabetes, and hepatitis. Pyoderma has been described in several forms, but the ulcerative presentation usually occurs on the abdomen, perineum, and lower extremities. The lesions begin as discrete pustules that erupt and coalesce into a classic painful ulcer with a violaceous border and undermined edge. Multiple lesions are common.
PG is a significant complication associated with prolonged pain and increased morbidity.
As its aetiology and pathophysiology are poorly understood, multiple treatments have been employed. These include multiple topical therapies and corticosteroids given topically, intralesionally, or orally. Cyclosporin has also been tried, but Fauld and associates noted weak evidence for its use in pyoderma gangrenosum.
Peristomal pyoderma presents challenges to successful pouching. The size of the ulceration and its proximity to the stoma affects the seal of the appliance to the skin. The goal for management is to promote healing while maintaining adequate wear time of the pouch. The painful nature of PG ulcerations influences the options for topical care. Small ulcerations can usually be treated with stoma powder or antimicrobial powder covered by a piece of hydrocolloid. A foam dressing over the ulceration is helpful if the ulcer is particularly moist. Silver dressings in sheet form or calcium alginates have also been effective. The goal of topical therapy is to use a modality that can absorb the moisture and allow for appliance adhesion.

Hyperacute rejection occurs almost immediately following organ implantation and necessitates immediate explant of the organ. Hyperacute rejection is uncommon with pre-transplantation cross-matches and screening. Hyperacute rejection (HAR) of the kidney was first recognized 20 years ago in cases of donor-recipient incompatibility for the major blood group and tissue antigen systems. Classic pathological changes described include early accumulation of PMNs in glomeruli and peritubular capillaries, progressive glomerular thrombosis, tubular necrosis, and eventual cortical necrosis. Reaction of host humoral antibodies with antigens on donor cells serves as one trigger of the clotting mechanism, which then proceeds in a nonspecific fashion.

Antigen systems other than the ABO groups that contribute to HAR reactions are leukocyte antigens, endothelial and monocyte antigens, and B cell antigens. It is also documented that glomerular thrombosis identical to HAR may occur secondary to endothelial damage after pulsatile perfusion. However, in such cases no specific deposition of immunoglobulins and complement is detected.

Ileal resection may lead to bile acid malabsorption and an altered biliary lipid composition. A “bile acid deficiency” in the enterohepatic circulation with a relative excess of cholesterol and cholesterol supersaturated bile might ensue, causing cholesterol gallstone formation.

In patients with Crohn’s disease involving the small
intestine, the prevalence of gall-bladder stones is higher
than that in the general population. One hypothesis
for this increased risk is that bile acid malabsorption,
secondary to impaired active bile acid transport as a
consequence of ileal disease/resection, leads to a
reduction in the total bile acid pool size and an increase
in biliary cholesterol saturation. In patients with
ulcerative or Crohn’s colitis, or who have undergone
colectomy, the bile acid malabsorption is less than that
in those with ileal dysfunction or resection, but the risk
of gallstone formation is still increased, allegedly by the
same mechanism.

As the stone is smaller in size, there is a strong likelihood (75%) of it to be passed spontaneously. Furthermore, distally sited stones are more likely to pass spontaneously than proximally sited ones. Hence, it should be arranged to review the patient in two weeks with a KUB X-ray.

Urolithiasis affects up to 15% of the population worldwide. The development of sudden-onset, colicky loin to groin pain is a classical feature in the history. It is nearly always associated with haematuria that is either micro- or macroscopic. The most sensitive and specific diagnostic test is helical, non-contrast CT scanning.

Management options for urolithiasis are:
1. Most renal stones measuring <5mm in maximum diameter typically pass within four weeks of onset of symptoms. More intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal developmental abnormality such as horseshoe kidney, and previous renal transplant.
2. Ureteric obstruction due to stones together with infection is a surgical emergency and the system must be decompressed. Options include nephrostomy tube placement, insertion of ureteric catheters, and ureteric stent placement.
3. In the non-emergency setting, the preferred options for treatment include extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy, ureteroscopy, and open surgery (selected cases). Minimally invasive options are the most popular first-line treatment.

Renal vein thrombosis (RVT) is the formation of a clot in the vein that drains blood from the kidneys, ultimately leading to a reduction in the drainage of one or both kidneys and the possible migration of the clot to other parts of the body.

Venous thrombosis is a rare occurrence, occurring in 0.5% of kidney transplants. With aggressive treatment,
i.e. thrombectomy, the chances of success are very poor, but treatment is successful in rare cases. More often, patients are treated with transplantectomy.

The left side is preferred for live donor transplants due to longer renal vein while right side has been associated with renal vein thrombosis and shorter vessels.

With the iliac artery anatomically located lateral to iliac vein, one would need a longer vein in the graft to enable the graft placement in the iliac fossa, its final location. Most renal transplant surgeons would intuitively prefer to implant a graft harvested from the left side. The right kidney has a simpler anatomy for retrieval, with no adrenal or lumbar veins to tackle. However, a long artery and short vein make this kidney’s anatomy skewed for grafting. Studies on cadavers have shown significantly shorter right renal vein length (average 13.7%) on the right side. With its weak posterior wall, there is an added risk of tear of the right renal vein if there is tension during anastomosis. Overzealous manoeuvres and stretching of a short vein during retrieval, or handling during allografting may also risk intimal damage, a possible aetiology for some early reports of right grafts lost to renal vein thrombosis following laparoscopic harvest.

Recommendations:
• On the right, lengthen the renal vein with the infra renal vena cava in order to avoid an anastomosis
under tension.
• Carry out a large venous anastomosis; at declamping, if the renal vein is tight, re-do the venous anastomosis.

The Galeazzi fracture is a fracture of the middle to distal one-third of the radius associated with dislocation or subluxation of the distal radioulnar joint. It presents with pain, swelling and deformity. Physical examination reveals point tenderness over the fracture site. Isolated fracture of radius is rare and there usually is an associated injury.

Other fractures:
– Colles’ fracture (dinner fork deformity): fall onto extended outstretched hand. Classical Colles’ fractures have 3 features:
1. Transverse fracture of the radius
2. 1 inch proximal to the radio-carpal joint
3. Dorsal displacement and angulation

– Smith’s fracture (reverse Colles’ fracture): volar angulation of distal radius fragment (Garden spade deformity). Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed

– Bennett’s fracture: Intra-articular fracture of the first carpometacarpal joint. Impact on flexed metacarpal, caused by fist fights

– Monteggia’s fracture: dislocation of the proximal radioulnar joint in association with an ulna fracture. Caused by a fall on outstretched hand with forced pronation.

– Pott’s fracture: Bimalleolar ankle fracture from forced foot eversion

– Barton’s fracture: Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation from a fall onto extended and pronated wrist

– Holstein Lewis Fracture: fracture of the distal third of the humerus resulting in entrapment of the radial nerve.

A history of weight loss and intermittent diarrhoea makes inflammatory bowel disease (IBD) the most likely diagnosis. Conditions such as appendicitis and infections have a much shorter history. Although Meckel’s diverticulum can bleed and cause inflammation, it seldom causes marked weight loss. Irritable bowel syndrome (IBS) presents with alternating episodes of constipation and diarrhoea along with abdominal pain, bloating, and gas.

The treatment approach primarily depends on the histopathologic classification and the disease stage and involves a combination of surgical management, radiation therapy, and systemic therapy. Surgical management is either breast-conserving therapy (BCT) or mastectomy. Systemic therapy has significantly improved in recent years with the development of hormone therapy (tamoxifen) and targeted therapy (trastuzumab). The most important prognostic factors are lymph node status, tumour size, patient’s age, and tumour receptor status (hormone receptors and HER2).