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📌Fracture shaft of humerus: It can be long spiral, short oblique, transverse, or comminuted fracture according to the affecting force. Clinical feature: pain, deformity, swelling, ecchymosis, bruises. Check for nerve injury (radial nerve) by active extension of the metacarpo-phalangeal joints. X ray: AP and Lateral views. Treatment: the fractured humerus heal readily, neither reduction nor immobilization are needed, cause the weight of the arm with cast is usually enough to pull the fragment in to alignment. A coaptation splint or hanging cast is used for 2-3 weeks, followed by functional brace for 3-4 weeks. Union rate is 90%. Acceptable alignments are: less than 20 degree anterior angulation, less than 30 degree varus valgus angulation, and less than 3 cm shortening. Operative treatment: ORIF (plate and screw), locked intramedullary nail, or external fixation. Absolute indications: 1)  open fracture       2) vascular injury requiring repair 3) brachial plexus injury     4) ipsilateral forearm fracture (floating elbow) 5) compartment syndrome. Relative indications: 1) bilateral humerus fracture     2) poly trauma or associated lower extremity fracture    3) pathological fracture     4) fracture characteristic ( like distraction at fracture site). Complication: malunion, nonunion, radial nerve injury. #ortho

📌Fracture of proximal humerus: It usually occur after middle age, due to osteoporosis. Mechanism of injury: fall on out stretched arm or direct trauma to the shoulder. Fracture classification: Neer's classification of proximal humerus fracture depends on number of fractured pieces and how much it displaced. He divided proximal humeral fractures in to 4 major pieces: greater  tuberosity, lesser tuberosity, head, and shaft. If one piece is displaced (more than 1 cm or angulated more than 45 degree) it is considered 2 part fracture, if two pieces displaced it is 3 part fracture, if 3 pieces are displaced it is 4 part fracture. if there is dislocation with fracture, it also referred as dislocation with 2 or 3 or 4 parts fracture accordingly. يعني اذا كلهن مكسورات وكاعدات بمكانهن هاي نوع ١ اذا وحده مكسورة ومبتعدة هاي نوع ٢ واذا اثنين مكسورات ومبتعدات هاي نوع ٣ واذا ثلاث قطع مكسورات ومبتعدات هاي نوع ٤ Clinical features: pain, swelling, and decreased movement. There may be bruises or ecchymosis of the chest and arm. Examine for axillary nerve function to exclude injury to it. Imaging:  X ray: true AP view, Scapular Y view, and Axillary lateral view. Sometimes, CT scan is needed. Treatment: Non-operative treatment: by arm sling immobilization for 2-3 weeks followed by progressive rehabilitation. It is indicated for: • minimally displaced surgical neck fracture • greater tuberosity fracture with less than 5 mm displacement • unfit patient for surgery. Operative treatment: it is indicated for displaced 2, 3, 4 parts fractures. Operative treatment include: Close Reduction and Percutaneous Pinning (CRPP), ORIF, Intra Medullary Nailing (IMN), hemiarthroplasy, or total shoulder replacement. Complications: avascular necrosis of the head, nerve injury, malunion, nonunion, rotator cuff injury, joint stiffness (adhesive capsulitis), post-traumatic arthritis, and infection. #ortho

Complication of Acute pancreatitis Systemic:first week 1.CNS :visual disturbance, confusion 2.pulmonary:ARDS 3.CVS:shock ,arrhythmias 4.Hematological: DIC 5.Git :paralytic lieu’s 6.metabolic: glucose and lipid ⬆️ ,Ca🔽 7.other’s:subcutaneous fat necrosis,arthralgia Local complication:usually after first week 1.Acute fluid collection 2.sterile pancreatic Necrosis 3.infection pancreatic necrosis 4.pseudo cyst of pancreas 5.pancreatic ascites 6.plural effusion 7.thrombosis;portal vein ,splenic vein Management of acute pancreatitis: Mile attack of pancreatitis: 1.consecutive approach :IV fluid 2.nil by mouth 3.analgesic ,antiemetic 4.*️antibiotic not indicated until 30% of necrotic pancreatitis prescient ➡️CT Sever attacks of pancreatitis 1.admissions to ICU 2.analgesic .pethidin ,meridin ,no morphine 3.aggressive fluid resuscitation is important: Frequent measures of vital sign ,UOP,CVP 4.nasogastric tube only in pt with vomiting 🤮 5.Supplemental oxygen: serial atrial blood gas analysis 6.*️⃣*️⃣🩸 if gallstone +jaundice +attack of pancreatitis ➡️➡️➡️urgent ERCP should be carried out within 72 hours of the symptoms . #AcutePancreatitis #surgery

Clinical features: Acute pancreatitis 1.upper abdominal pain :sudden onset ,sever,referred to back *️⃣pain may reduced by leaning forward 2.vomiting (not contain 🩸) 🍺 alcoholic 3.high fever 🤒 4.tachypnea ,cyanosis 🧞‍♂️ 5.Abdominal ex;: Tenderness Rebound tenderness Garding& rigidity Abdominal distention *️⃣Ascites may present *️⃣Mild jaundice due to ➡️cholonhitis *️⃣Grey turner sign ;blush discoloration around umbilicus *️⃣Gullen s sign ;blush discoloration in the flank *️⃣paralytic ileus common 6.lung :pleural effusion,consolidation,features of ARDS 7.CNS:mild psychotic ,coma Fluid &metabolic abnormalities in acute pancreatitis 💧;: 1.Hypovolemia 2.albumin 🔽 3.Ca🔽 4.insulin🔽 5.Na🔽 6.Cl🔽 7.thrombin 🔽 ,prolonged Pt ,later DIC 8.bilirubin ⬆️,WBC⬆️,Triglycerides ⬆️ #AcutePancreatitis #surgery

#AcutePancreatitis Inflammation of the parenchyma of the pancreas. ◦ Categorized as : ◦ 1.mile :interstitial edema of the gland &minimal organ dysfunction ◦ 2.sever:pancreatic necrosis &SSIR &Multi organ failure 😞. ◦ ◦ (possible cause of acute pancreatitis) 1.gallstones 2.post ERCP 3.Alcoholism’s 25% 5.Abdominal truma 6.surgery of upper git ,CVS,biliary 7.Ampullary tumor 8.Hyperparathyrodisim 9.Ca ⬆️ 10.Autoimmune pancreatitis 11.Hereditary pancreatitis 12.viral infection:mump, coxsaka viral B 13.idiopathic 14.Malnutrition 15.sacrobite, pancreatic division 16.drugs : Corticosteroids,azithromycin Thiazide,estrogen, Valporic acid ,Asparginase DDX of acute pancreatitis: 1.Mi 2.rupture aortic aneurysms 3.perforated due 4.cholecystitis 5.mesenteric lymphadenitis 6.intestinal obstruction 7.ectopic pregnancy 8.salphangitis 9.DKA Investigations:; 1.serum amylase :dose-not exclude pancreatitis 2.serum lipase : more specific than serum amylase 3.serum Trypsin or Trypsinogen :;reveal severity of acute pancreatitis 4.CRP:more than 150 mg /l 5: other :LFT Blood urea &serum creatinine Blood glucose 🔼 Serum Ca🔽 Alternation of Po2&PCo2 CBC,gamatocrit,platelet count,coagulation profile 6.peritoneal tap fluid :show high amylase &protein level ➡️very useful method 7:imaging 1.Plain x ray of the abdomen; Colon cut sign & renal halo sign Chest x ray :pleural effusion &ARDS 2.US :not established the diagnosis 3.Ct scan ; *️⃣ *️⃣If there is any doubt about the diagnosis *️⃣in pt with acute pancreatitis to distinguish interstitial from necrotizing pancreatitis 5:MRI same like CT 6:EUS :MRCP; to detect stone in CBD in gallstone pancreatitis 7:ERCP : to identification and removal of stone in the CBD in gallstones pancreatitis. #AcutePancreatitis #surgery ......follow

💢Management of fulminant Ulcerative colitis •✅Admit to hospital for intensive therapy and monitoring •✅Give IV fluids and correct electrolyte imbalance •✅Consider transfusion if haemoglobin is < 100 g/L (< 10 g/dL) •✅Give IV methylprednisolone (60 mg daily) or hydrocortisone (400 mg daily) •✅Give antibiotics until enteric infection is excluded •✅Arrange nutritional support •✅Give subcutaneous low-molecular-weight heparin for prophylaxis of venous thromboembolism •✅Avoid opiates and antidiarrhoeal agents •✅Consider infliximab (5 mg/kg) or ciclosporin (2 mg/kg) in stable patients not responding to 3–5 days of glucocorticoids

Assessment of severity in Ulcerative colitis

⁉️Shoulder dislocation: The shoulder is the most commonly dislocated joint due to: • Shallow glenoid socket • Extra-ordinary range of movement • Some underlying condition like ligamentous laxity, or glenoid dysplasia. Shoulder dislocation is either anterior, posterior, or inferior. Anterior shoulder dislocation: usually due to fall on the hand. 🩺Clinical features: the patient has severe pain, supporting the arm with opposite hand, the lateral outline is flattened, there is bulge felt below the clavicle in thin person. 💡Imaging study: AP X ray view show overlapping shadow of the glenoid fossa and humeral head which is lying below and medial to the socket. Scapular Y view will show the humeral head out of the glenoid and displaced anteriorly. 💊Treatment: closed reduction done under sedation or general anesthesia. There are several ways of closed reduction. In Hippocratic method, do gentle increase in traction on the abducted arm and shoulder while the assistant apply counter traction to the body. Kocher's method; the elbow is bent to 90° and held close to the body; no traction should be applied. The arm is slowly rotated 75 degrees laterally, then the point of the elbow is lifted forwards, and finally the arm is rotated medially. In Stimson's method, the patient sleep prone with the arm hanging over the side of the bed, the dislocation may reduced after 15-20 minutes. 📍X ray is taken after reduction to confirm reduction and to exclude associated fracture. then the arm is rested in a sling for 3 weeks for those who are less than 30 years of age ( who are prone for recurrence) and for only one week for those who are over 30 years. Complications: early: • Rotator cuff tear, • Vascular injury, • Nerve injury (axillary nerve, median nerve, radial nerve, musculo-skeletal nerve), • Fracture dislocation of the proximal humerus         Late complications:   • Shoulder stiffness, • recurrent dislocation, • unreduced dislocation. Posterior shoulder dislocation: Rare (less than 2% of all shoulder dislocations), and commonly missed in diagnosis. It is due to fit or convulsion, electrical shock, or due to fall on flexed adducted arm, or direct blow to the front of the shoulder. 🩺Clinical features: the arm is held in internal rotation, and the front of the shoulder looks flat with prominent coracoid. 💡X ray: in AP view, the humeral head looks abnormal (like electrical light bulb) and stand away from the glenoid fossa (empty glenoid sign). Scapular Y view and lateral axillary view will show the dislocation clearly. 💊Treatment: acute reduction done under anesthesia with direct pull on the arm on adduction position for few minutes to disengage the humeral head, then the arm laterally rotated and the humeral head pushed forward.  After reduction use arm sling for 3 weeks (airplane type of splint). Complications: • missed unreduced dislocation: it may need open reduction for young patients, or leave it and encourage movement in elderly patient. • Recurrent dislocation #ortho

⁉️Acromio-clavicular joint (ACJ) injury: It is caused by direct blow to the shoulder or fall on the shoulder. The stability of the ACJ is by the acromio-clavicular ligament and the coraco-clavicular ligaments (main stabilizers), joint capsule, and surrounding muscles (deltoid and trapezoid m.). 🩺Clinical features: pain, tenderness, and abnormal contour of the shoulder. 💡Imaging study: AP view for both shoulder joints, axillary lateral view, cephalic tilt view. 🔢Classification: the injury is graded according to the type of ligament injury and amount of displacement. In type 1, there is acute sprain in acromio-clavicular ligament. In type 2, AC ligament is torn. In type 3, the AC ligament and coraco-clavicular (CC) ligaments are torn. In type 4 the AC and CC ligaments are torn with the clavicle displaced posteriorly, in type 5 the clavicle displaced superiorly, and in type 6, the clavicle displaced inferiorly.   💊Treatment: NON-OPERATIVE TREATMENT: indicated for type I, II, and most of type III injury. The patient advised for rest, ice, and arm sling for 3 weeks. OPERATIVE TREATMENT: for type IV, V, VI, and some of type III injuries.  It is done by ORIF with or without reconstruction of coraco-clavicular ligament. #ortho

⁉️Fracture of the scapula: it is uncommon fracture, due to high energy injury. It can be associated with other injuries, like rib fracture, clavicle fracture, spine injury, brachial plexus injury, pulmonary injury, pneumothorax, head injury, and vascular injury. Fracture classification is based on the location of the fracture; it include coracoid fracture, acromion fracture, glenoid fracture, scapular neck fracture, and scapular body fracture. Each of these fractures has its own classification.   💡Imaging study: • X ray: AP view, scapular Y view, axillary lateral view • CT scan       💊Treatment: NON-OPERATIVE TREATMENT: by arm sling for 2-3 weeks followed by early movement. It is indicated for vast majority of scapular fracture with minimal displacement. OPERATIVE TREATMENT: BY Open Reduction and Internal Fixation (ORIF). It is indicated for: • Gleno-humeral instability • Displaced scapular neck fracture • Open fracture • displaced coracoid fracture • Floating shoulder (scapular neck fracture with fracture clavicle or acromio-clavicular ligament). #ortho

💠Meconium-stained liquor💠 🌀Meconium is made up of water, bile pigment, mucus, and amniotic fluid debris. Detection in amniotic fluid causes anxiety as it is associated with i perinatal morbidity and mortality; it may be aspirated by fetus. • Meconium-stained amniotic fluid (MSAF) is rare in preterm infants (<5%) and is associated with infection and chorioamnionitis. • Incidence of MSAF gradually increases from 36 to 42wks. 🛑 Passage of meconium signifies the maturation of central nervous and gastrointestinal systems. 🛑 Sometimes hypoxia causes peristalsis of the bowel and relaxation of anal sphincters resulting in MSAF. #obstetrics #pediatrics

Anaphylactic reaction management