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🛑Supracondylar fracture: مهم جدا بالطوارئ وامتحانات الاوسكي one of commonest fractures in children. The distal fragment may displaced posteriorly (95%), or anteriorly. ⁉️Mechanism of injury: posterior displacement is due to fall on outstretched hand with extended elbow. The distal fragment is displaced backward and rotated medially. The distal end of proximal fragment may injure the anterior soft tissue and brachial artery. Anterior displacement is caused by fall on the elbow. ⛔️Classification: Type I: undisplaced # Type II: angulated # with the posterior cortex still in continuity. Type IIA: less severe injury, and distal fragment is only angulated. Type IIB: severe injury, with distal fragment angulated and rotated. Type III: completely displaced fracture. 🩺Clinical feature: pain, swelling, deformity (S shape deformity). Check for distal pulse, capillary refilling, nerve injury, and for compartment syndrome (passive extension of flexed fingers should be free of pain). 💡X ray: AP view: show distal fragment displaced and tilted side way and rotated medially. Measure Baumann's angle (normally it is less than 80 degree), if it is more than 80 degree it indicate medial angulation (varus angulation). Lateral view: it show 1) displaced fat pad due to haematoma and it looks like triangular lucency along posterior distal humerus and olecranon fossa. 2)anterior humeral line normally pass through the capitulum, if not it indicate type 2 fracture. 💊Treatment: Type I (undisplaced #): back slab with elbow 90 degree flexion for 3 weeks with neutral rotation of the elbow, then start gentle movement and physiotherapy. Type IIA: closed reduction under anesthesia, check reduction by X ray, then apply back slab (or fix by K wires) for 3 weeks followed gentle movement and physiotherapy. Type IIB: and III: fracture reduction (closed or opened reduction) under anesthesia as soon as possible with K wire fixation for 3 weeks, followed by gentle movement and physiotherapy. 🧨Complication: Early: vascular injury (brachial artery), nerve injury (ulnar n., median n., anterior interosseous n., radial n.) Late complication: malunion (varus deformity- cubitus varus- may need corrective osteotomy), elbow stiffness. In some cases of supracondylar fracture, vascular injury may be caused by immediate and severe injury (rare), or by forearm oedema and development of compartment syndrome (more common). If the patient complain from undue pain plus one of the following signs: 1- pain on passive stretching of the fingers            2- tense and tender forearm            3- absent pulses            4- blunted sensation            5- reduced capillary return Then you should do: 1- extend the flexed elbow 2- remove all tight bandage and dressing 3- reduce the fracture (if not reduced yet) Then recheck the circulation and check the above signs. If there is no improvement do Doppler study or angiography, and accordingly, the brachial artery may need exploration and repair or grafting, with fasciotomy of the forearm.

🛑Elbow dislocation: it is fairly common, and 90% of the cases are posterior dislocation. ⁉️Mechanism of injury: Posterior dislocation is caused by fall on outstretched hand with extended elbow. In simple dislocation, there is only capsule and ligament disruption, so the reduction would be stable and recurrence is unlikely. In complex dislocation, there is ligament injury associated with fracture radial head, coronoid fracture, or olecranon process. Here the reduction is unstable and liable for recurrence. 🩺Clinical feature: pain, swelling, and deformity. Examine the hand to exclude nerve or vascular injury. 💡X ray: AP, and Lateral. Sometimes, CT is needed for complex dislocation and fracture. 💊Treatment: the patient is relaxed under sedation or anesthesia. Pull the forearm with elbow in slight flexion. With one hand correct sideway displacement, then the elbow is further flexed while the olecranon process pushed forward with the thumb, then full flexion can achieved after elbow reduction. Test for stability after reduction. Confirm the reduction by X ray, and use arm sling for 1-2 weeks then start gentle physiotherapy. Complex elbow fracture need operative treatment by ORIF of fractures, with ligaments repair. 🧨Complications: Early: vascular injury, nerve injury (median n.,) Late:  joint stiffness, heterotopic ossification, recurrent dislocation.

عام سعيد عليكم ياربي💚 وانشاء الله تتحقق كل امنياتكم وسلامة الجميع 🙏💚

⁉️Fracture of the olecranon: Mechanism of injury: either due to direct fall on elbow (cause comminuted fracture), or fall onto hand with triceps contraction (causing transverse fracture). The fracture can classified in to comminuted fracture (either undisplaced or displaced), and transverse fracture (either undisplaced or displaced). 🩺Clinical feature: In comminuted fracture, there is pain and bruises over the elbow and the patient may be able to extend the elbow against gravity (intact triceps). In displaced transverse fracture, there is gap, and the patient can not extend the elbow against gravity. 💡X ray: AP and Lateral views are recommended.  Some times CT is helpful for comminuted fractures 💊Treatment: Undisplaced transverse fracture or comminuted fracture with intact triceps : do pop cast in 60 degree flexion for 2-3 weeks followed by active gentle movement. Displaced comminuted fracture: need operative fixation by plate and screws. For displaced transverse fracture: ORIF by tension band and wires. Complications: symptomatic hard ware, joint stiffness, nonunion, post traumatic arthritis, nerve injury. #ortho

⁉️Fracture head of the radius: common in adult, (rare in children). Mechanism of injury: fall on outstretched hand with extended elbow and forearm pronated. 🩺Clinical feature: there is tenderness on pressure over the radial head, and pain on pronation and supination of flexed forearm. Some times this fracture is missed. 💡X ray: AP view, Lateral view, and some times oblique view for the radial head. Take X ray for the wrist joint to exclude distal radio-ulnar joint injury (damage to the interosseous membrane).   CT scan can be useful for comminuted radial head fracture. The radial head fracture classified to:  Type I: undisplaced vertical split in the head. Type II: displaced single fragment from the head. Type III: comminuted fracture of the head. Type IV: for radial head fracture with elbow dislocation. 💊Treatment: type I:  arm sling for 3 weeks then start active movement and physiotherapy. Type II fracture: reduction and fixation by headless screw. Type III fracture: do open reduction and fixation, or excision with metal spacer replacement Complication: joint stiffness, myositis ossificans, and recurrent instability. #ortho

#internal_medicine #respiratory

🔴Digoxin toxicity 🔴 Digoxin is the only cardiac glycoside commonly used for medicinal purposes. It has a narrow therapeutic index and toxicity is common. 🟢Clinical manifestation: We should first Determine if toxicity is acute or chronic by identifying if the patient normally takes digoxin therapeutically or if the patient ingested someone else's prescription. Critical clinical manifestations of toxicity are usually cardiac in both acute and chronic but may include gastrointestinal and neurologic signs. 🔸The cardiac manifestations of cardiac glycoside toxicity can include virtually any type of arrhythmia with the exception of rapidly conducted atrial arrhythmias 🔸With an acute ingestion, the patient may remain asymptomatic for several hours then develop significant gastrointestinal symptoms, such as anorexia, nausea, vomiting, and abdominal pain. 🔸Neurologic manifestations such as confusion and weakness, independent of hemodynamic parameters, are common and often develop later upon distribution of the drug into the central nervous system. 🔸 Chronic toxicity is often more difficult to diagnose, as symptom onset tends to be more insidious and may occur over a period ranging from days to months. Gastrointestinal symptoms, such as anorexia, nausea, and vomiting, can occur but may be less pronounced. Neurologic manifestations, such as lethargy, fatigue, delirium, confusion, disorientation, and weakness, may be prominent in chronic toxicity. 🔸 Visual changes associated with cardiac glycoside toxicity are varied and may include alterations in color vision (chromatopsia), diplopia, photophobia, decreased visual acuity, photopsia, scotomas, or blindness. Chromatopsia, specifically xanthopsia (objects appear yellow), is classically associated with cardiac glycoside toxicity but is frequently absent and not necessary for diagnosis. 🟢 Ix: 🔹 serum digoxin level (6 hours after ingestion). 🔹 serum k (hyperkalemia is an important marker of acute cardiac glycoside toxicity, and a predictor of mortality). 🔹 creatinine and BUN (Renal dysfunction is commonly encountered in the setting of chronic digoxin toxicity and is often what precipitates the rise in the digoxin concentration). 🔹 Glucose level to rule out hypoglycemia 🔹 acetaminophen and salcylate level to rule out other toxicity. 🔹 serial ECG( Premature ventricular contractions are the most common rhythm disturbance caused by digoxin toxicity. Others include bradycardia, atrial tachyarrhythmias with AV block, ventricular bigeminy, junctional rhythms, various degrees of AV nodal blockade, ventricular tachycardia, and ventricular fibrillation. Bidirectional ventricular tachycardia, while not pathognomonic for digoxin toxicity, is encountered in rare instances; digoxin is one of only a few xenobiotics known to produce this arrhythmia) 🟢Tx: 🔘Assess airway, breathing, and circulation; stabilize as necessary 🔘Place the patient on continuous cardiac and pulse oximetry monitors 🔘Establish intravenous (IV) access 🔘 digoxin-specific antibody (Fab) fragments. 🔘 if Fab fragments are not immediately available, symptomatic bradycardia or bradyarrhythmia can be treated with atropine (0.5 mg IV in adults; 0.02 mg/kg IV in children, minimum dose 0.1 mg) and hypotension with IV boluses of isotonic crystalloid. 🔘 administration of activated charcoal (AC) or cholestyramine for gastrointestinal decontamination should be viewed as adjunctive and not primary therapy in patients with digoxin poisoning. #internal_medicine #cardio

#internal_medicine #cardio

#urology

⁉️Fracture of the Capitulum: rare fracture. Mechanism of injury: fall on outstretched arm with extended elbow. 💡X ray: AP view, Lateral view. On the lateral view the capitulum or part of it is fractured and in front of the lower humerus, and the radial head is no longer pointing to the capitulum. CT scan: some times is recommended for better understanding of fracture nature 💊Treatment: Undisplaced fracture is treated by simple splint for 2-3 weeks. Displaced fracture (more than 2 mm) need operative reduction and fixation by pin or screw, followed by early movement and rehabilitation (after 2-3 weeks). Small fragment fracture can be excised followed by early movement. #ortho

#Rheumatology

🔴“ De winter syndrome “ 🔴 🔸The de Winter ECG pattern is an anterior STEMI equivalent that presents without obvious ST segment elevation. We know that (PCI) is the preferred treatment for patients with ST-segment elevation myocardial infarction but a significant number of patients with large acute myocardial infarction, caused by occlusion of an epicardial coronary artery, do not show ST-elevation on the electrocardiogram. Other ECG abnormalities may be present, the so called STEMI-equivalents which shows : 🔸junctional upsloping ST-segment depression. 🔸 tall symmetrical T-waves in the precordial leads. 🔸often in combination with slight ST-elevation in lead AVR. And these changes has been associated with proximal occlusion of the left anterior descending coronary artery”LAD”. ⚠️Recognition of this ECG pattern by ambulance staff, emergency physicians and interventional cardiologists envolved in STEMI networks, is important to ensure timely reperfusion therapy in these patients with PCI as soon as possible without any delay or waiting for MI changes. #medicine #internal_medicine

⁉️Fractures of distal humerus in adults: They are usually caused by high energy trauma, and may associated with nerve or vascular injury. These fracture can be divided in to extra-articular supracondylar fracture, intra-articular unicondylar fracture, and bicondylar  fracture with varying degree of comminution. Supracondylar fracture in adult is rare and unstable which need operative reduction and fixation, usually by plate and screws. Intra-articular fractures are caused by severe trauma, associated with soft tissue injury, and careful assessment for nerve and vascular injuries is needed. 💡Imaging study: X ray (AP and Lateral views) and CT scan are needed to assess the fracture and comminution. 💊Treatment: undisplaced fracture can be treated by back slab with frequent checking by X ray to exclude redispalcement, then to start early mobilization after 3 weeks to prevent elbow stiffness. Displaced fractures والي هو عادة يكون هيج are best treated by ORIF with plates and screws. Alternative methods are elbow replacement (for comminuted fracture in elderly patient), bag of bone technique (comminuted fracture with no surgical facilities of fixation), and skeletal traction. Complications: vascular injury, nerve injury, elbow joint stiffness, and hetero-topic ossification.   #ortho