Chapter 1.

General Principle of Fracture

1. Fracture: A complete or incomplete break in the continuity of a bone.
2. Multifragmentary fracture: One that has several breaks in the bone, creating more than 2
fragments.
3. Wedge fractures: Either spiral (low energy) or bending (high energy) and allow the proximal & distal
fracture fragments to contact each other.
4. Complex multifragmentary fracture: A segmental fracture or one in which there is no contact
between the proximal and distal fragments without the bone shortening.
5. Simple fracture: Spiral, oblique, or transverse.
6. Factors responsible for fractures:
 Direct violence: Bone and surrounding soft tissues.
Tapping force (oblique fracture), crushing injury (fragmented injury), penetrating direct injury
(high velocity gunshot destroy bone & soft tissues).
 Indirect violence: Less damage to soft and hard tissues.
Muscle pull (avulsion fracture)
 Diseases of bone: Inflammation, tumor/ tumor like disease, osteogenesis imperfect, metabolic
disease (pathological fracture).
 Repeated stresses (fatigue fracture).
Most common in lower extremity: the neck of second/ third metatarsal bone, the shaft of tibia/
fibular, the neck of femur.
7. Classifications from stability:
 Stable: Transverse fracture, greenstick fracture, impacted fracture, epiphyseal fracture.
 Unstable: Spiral fracture, oblique fracture, comminuted fracture, avulsion.
8. Pattern of displacement: Angulation, rotation, lateral side, overlap/shortening, impacting.
9. Mechanism of displacement fragments: Direction of violence, effects of gravity, muscle pull (most
important), improper first aid).
10. Features of fracture:
 Systemic manifestations:
 Primary shock: Neurogenic shock.
 Secondary shock: Hemorrhagia (exclude cerebral injury & respiratory embarrassment).
 Low/slight fever (38°C).
 Increase WBC.
 Increase ESR.
 Local manifestation: Pain, Local swelling, loss/impairment of function, ecchymosis, localized
bone tenderness.
 Specific signs: Deformity, abnormal mobility, crepitus/grating.
 Absence of dysfunction doesn’t preclude fracture is particularly true of: Greenstick fractures,
impacted fractures, fatigue fractures.
10. Treatment of open fracture: Debridement golden time 6-8 hours after injury.
11. Delayed union of fracture: After 8-12 w of fracture, Pain on fracture site, Fracture line can be seen
clearly, Little callus, No osteosclerosis, Has possibility of healing.
12. Non union of fracture:
 No pain but abnormal movement on fragments (false joint/ pseudoarthrosis).
 Atrophic type:
 Sclerosis of bone ends.
 Without callus formation.
 Closed marrow cavity.
 Hyperplasia type: Excess callus formation around fracture site with lucent interval through callus
itself & fragments.
13. Complications of fracture
 Early period: Shock, fat embolism,injury to important organ & tissues, osteofascial compartment
syndrome, infection, thromboembolism, acute respiratory distress syndrome, MODS.
 Later period:
 Systemic complication: Pressure sores, pneumonia, infection of bladder.
 Local complication: Myositis ossificans, post traumatic osteoarthritis, joint stiffness, reflex
sympathetic dystrophy, sudeck atrophy, avascular necrosis of the bone, ischemic contracture
(volkmann’s).
 Delayed union, nonunion, malunion/ angular deformities, shortening, growth arrest, growth
stimulation.
14. Criteria of fracture healing:
 Absence tenderness & axial percussion pain.
 Absence abnormal mobility.
 Visible continued callus has bridged fragments & fracture line indistinct.
 After splints has been removed:
 Arm parallel to ground & hold 1 kg in 3 min.
 Legs walking 30 pace in 3 min.
 Good results shown in fracture site after 2 weeks.
15. Fracture treatment:
 Reduction: Closed/open/mechanical traction with or without manipulation.
 No observe gap/rotation.
 Shortening <1-2 cm in the leg.
 Angulation <15-10.
 Apposition of fragments >1/3 (shaft)/ >3/4 (epiphyseal).
 Immobilization: Wooden splint/ plaster, continuous traction, external fixer, internal fixation
Prevent displacement/ angulation; prevent movement; relief of pain.
 Rehabilitation:
 Active muscular contraction (within 2 weeks injury).
 Active exercises joints of adjacent fracture (2- 8 w after injury).
 Active resistance exercises (after 8 w).
 Physiotherapy.
 Medication.
Chapter 2. Dislocation
1. Classified according to interval from injury to treatment: Fresh <2 weeks; old> 2 weeks.
2. Classified according to capsule opening to the outside: Closed and open.
3. Classified according to degree of dislocation: Complete and incomplete/ subluxation.
4. Classified according to the direction of displacement of the distal extremities after the dislocation:
Anterior, posterior, central, lateral.
5. What will happen after dislocation? Deformity, elastic fixation, cavity of joint vacuity, abnormal
movement.
Shoulder dislocation
6. Anterior shoulder joint dislocation: Subglenoid (very common), Subcoracoid, Subclavicular.
7. Specific signs anterior shoulder joint dislocation:
 Cavity of joint vacuity.
 Square shoulder.
 Deformity.
 Elastic fixation.
 Abnormal movement.
 Dugas sign +: When the elbow close to the chest, the hand can’t touch the opposite shoulder. If
the hand touched the opposite shoulder, the elbow can’t close to the chest.
Treatment: Reduction (Hippocratic technique) & immobilization.
8. Mechanism of posterior dislocation: Fall with elbow extend & forearm supine -> hand touch on the
ground -> violence transmit to elbow & make elbow hyperextension -> olecranon contact n the
olecranon fossa & become pivot point of lever -> coronoid process & olecranon move to behind
humerus.
9. Clinical manifestation & diagnosis:
 History of traction on upper limb.
 Pain in elbow.
 Sign- tenderness on site of radialis head.
 Refuse to grab.
 X-ray.
10. Treatment:
 Manipulative reduction.
 No fixation.
 Prevent strong traction on upper limb.

Chapter 3. Fractures of Upper Limb

Fracture of clavicle
1. Most commonly fractured at the junction of the middle & distal end (weakest point).
2. Displacement of fracture pieces:
 Proximal end of fracture: Superiorly and posteriorlly pulled upward by the traction of SCM.
 Distal end of fracture: Anteriorlly and inferiorly depressed by weight of arm.
3. Etiology:
 Indirect force: Fall on laterally (shoulder touch the ground, force transit to clavicle, oblique
fracture).
 Direct force: transverse/ comminuted fracture.
4. Clinical manifestation:
Compulsive position: Head lean to affected side of the body to relax SCM, the affected limb is lift
with opposite limb in order to against the weight of arm.
5. Treatment:
 Initial: Arm immobilizer not collar & cuff; ice.
 All undisplaced fractures can be treated conservatively: immobilizer sling, discontinued once
pain subsides (3-5w), self administered ROM & straightening.
 Immobilize with figure 8 bandages for 3-6 w.
 Surgery:
 Absolute: Open fracture, skin compromise; progressive neurological deficit.
 Relative: Shortening, displacement/ comminution, non union.
 Plate fixation: Comminution, soft bone/ smokers, less compliant patients.
 Intramedullary screw: 2 part fractures, young patients (girls), avoid above shoulder ROM first
6w.
Fracture of distal radius
6. The fracture of distal radius occurs approximately 3cm proximal to the articular surface of the distal
radius. This area is the intersection of cortical and cancellous bone, for this anatomical factor the
distal radius can be broken easily.
7. Classification:
 Straight type fracture (colles fracture): It happens when wrist extends & forearm pronate and
hand touches the ground.
 Clinical manifestation:
 Pain, swell tenderness, fork shape deformity, rifle bayonet deformity, dysfunction of
wrist joint.
 Distal fracture piece displace radius and dorsal forward.
 X-ray-Distal fracture piece displace radial dorsally.
 Treatment: Manipulative reduction & external fixation; open reduction & internal fixation.
 Flexion type fracture (smith fracture): It happens when wrist flexion & back of hand touches on
the ground.
 Clinical manifestation:
Wrist drop, swell, ecchymosis, dysfunction of wrist joint
X-ray—distal fracture piece displace to ulna & palm forward (reverse Colles fracture)
 Treatment: Manipulative reduction & external fixation
 Articular surface fracture associated with wrist dislocation. (it is the button fracture)
Treatment: manipulative reduction & external fixation; if fracture is unstable, open reduction &
internal fixation can be applied.
Chapter 4. Lower Extremity Fracture (tmbhin bedany femoral neck n intertrochanter fracture)
Fracture of the femoral neck
1. Neck shaft angle 110-140°, Average: 127.
2. Clinical manifestation & diagnosis:
 Middle age & old patients, has history of fall, hip pain, can’t walk.
 Affected limb is external rotation for 45-60 degree:
 Affected limb is short & hip has tenderness.
 Axial direct percussion sign (+).
 Greater trochanter move up sign (+).
 Bryant triangle- patient is dorsal position, Bryant triangle is composed by vertical line that is
per anterior superior iliac crest, horizontal line that is per greater trochanter & line that link
greater trochanter & iliac crest. The bottom line of Bryant triangle shorten while femoral
neck is broken.
 Nelaton line- patient is dorsal position & hip joint is half flexion, in normal people, the
greater trochanter is just on line that link anterior superior iliac spine & ischial tuberosity, it is
superior to the line if the greater trochanter move up.
 Shoemaker line- patient in dorsal position, in normal patient the line that link the greater
trochanter & anterior superior iliac spine has intersection on/ above umbilicus with middle
line, intersection is below umbilicus if the greater trochanter move up.
3. Treatment:
 Conservative treatment: For non displacement & stable fracture, Continue skin traction & wore
shoe that can prevent affected limb rotates for 6-8w.
 Operative treatment: Adduction type fracture & displaced fracture; older than 65 y.o with
subcapital fracture; teenagers; nonunion & femoral head necrosis.
 Closed reduction & internal fixation.
 Open reduction & internal fixation.
 Total hip arthroplasty, older than 65 y.o.
Intertrochanter fracture
4. Clinical manifestation & diagnosis:
 History of trauma, affected hip is pain, dysfunction of affected limb.
 PE:
 External rotation of lower limb, angle of external rotation is 80-90 degree.
 Affected hip is tenderness.
 Swelling.
 Ecchymosis.
 Lower limb shorten.
 Axial direct percussion sign (+).
 X-ray.
5. Treatment: Conservative (stable fracture- skeletal traction), Operation (open reduction & internal
fixation).
Fracture of femoral fracture
6. Proximal 1/3 femur displacement:
 Because of the traction of iliopsoas, gluteus medius, gluteus minimus, hip extortor, the proximal
fracture piece displace to anterior, lateral & supination.
 Distal fracture piece displace to medial & posterior result from traction of adductor & displace
to proximal end because of the traction of quadriceps femoris, tensor fasciae latae & adductor.
7. Medial 1/3 femur fracture displacement: Fracture is lateral angulation because of traction of
adductors.
8. Distal 1/3 femur fracture displacement: Distal fracture piece displace to posterior because of
traction of gastrocnemius & the weight of limb, so the popliteal artery, vein, tibial nerve & common
peroneal nerve are easy to be injured.
9. Clinical manifestation & diagnosis: History of trauma; Thigh swelling & ecchymosis; Angulation &
overlap & rotation deformity; Dysfunction of hip & knee joint; PE (tenderness, abnormal motion,
bony crepitus); X-ray; Distal 1/3 fracture (examined blood circulation, sensation & motion of distal
limb end).
10. Treatment:
 Conservative: Skeletal traction through tibial tubercle/ supracondylar of femur, manipulative
reduction & splint; functional training.
 Younger than 3 years old: Perpendicular suspension skin traction.
 Operation: Failure of conservative treatment, multiple position fractures, associated with blood
vessels & nerves injury, old patient with fracture who is anadvisable to lying in bed for a long
term, malunion with dysfunction/ nonunion of old fracture, open fracture with little/ without
contamination. (Open reduction & internal fixation with compress plate & screw; Open
reduction, interlocking intramedullary nail).
Fracture of patella
11. Clinical manifestation & diagnosis:
 Knee is swelling, ecchymosis, can’t move after trauma.
 PE: Tenderness anterior to patella, fracture end can be touched, floating patella test (+) because
of hematocele.
 X-ray.
12. Treatment: Non operative: nondisplacement fracture, Knee extend & external fixation with plaster
for 4-6w; Operative.
Fracture of the tibia and fibula
13. Anatomy:
 Proximal 1/3 tibia fracture, posterior tibia artery is easy to be injured & result in disturbance of
blood circulation of leg.
 Medial 1/3 fracture, bleeding & severe soft tissue injury result in osteofascial compartment
syndrome, & muscles & nerves would be necrosis, even the leg would be necrosis.
 Distal 1/3 tibia fracture, the rate of nonunion is high.
 Peroneal nerve passed by fibula head & neck, so the fracture of fibular head/ neck is easy to
injury fibular nerve.
14. Treatment:
 Goal of treatment: Correct angulation & rotation displacement, regain the parallel relationship
between knee & ankle articular surface & the length of leg.
 Stable fracture: Manipulative reduction & external fixation with splint or plaster or bony traction.
 Unstable fracture: Skeletal traction & manipulative reduction & splint fixation; open reduction &
internal fixation, extrafixator, plate & screw, interlocking intramedullary nail.
 Fibular fracture without tibia fracture: No treatment or fixation with plaster.
Fracture of ankle
15. Treatment: Regain anatomical structure & stability of ankle. Internal fixation is often needed to
keep reduction. Distal 1/3 fibula & distal tibiofibular joint is key structure for the stability of ankle, so
reduction & fast fixation are needed.

Chapter 5. Spine & Pelvic Fracture

1. Classification of fractures of cervical spine:
 Flexion injuries: excessive flexion injuries, bilateral dislocations, simple compression fracture.
 Vertical compression fracture: Jefferson fracture (fracture of C1 arch), burst fracture.
 Hyperextension injuries: Hangman’s fracture/ traumatic spondylolisthesis of axis, bilateral parts
fractures of C2.
 Hyperextension dislocations.
Classification of fractures of the thoracic and lumbar spine: Simple compression fracture, Stable
burst fracture, Unstable burst fracture, Chance fracture, Flexion distraction injury, Fracture
dislocations.
2. Clinical manifestation & diagnosis:
 History: Violence, pain, motion, sensation.
 Exam:
 Pay attention to another important injuries that can threaten the patient’s life (brain, chest,
abdominal viscera).
 Spinal exam- deformation, tenderness, ecchymosis, hematoma.
 Neurological: sensation & motion of extremities.
 Radiographic: X-ray, CT, MRI.
3. First aid & transport: Rolling, Level support, Fractures of cervical spine- immobilize the neck, cervical
collar, sand bag, head traction.
4. Treatment:
 Conservative:stable fracture without neurological deficit, immobilization, traction, staying in bed
 Operation: unstable fracture, moderate/ severe stenosis of spinal canal, neurological deficit,
Open reduction, decompression, fusion & internal fixation.
Spinal cord injuries
5. Spinal cord injuries: Severe complication of spinal fracture. Fragment of bone protrude into
vertebral canal & can cause spinal cord & caudal equine injuries.
6. Paraplegia: Thoracic or thoraco lumbar spinal cord injuries may result in paralysis of the trunk &
both lower limbs.
7. Quadriplegia: Cervical spinal cord injuries may result in paralysis of the trunk & four limbs.
8. Flaccid paralysis: Occur when spinal cord was suffered from fierce shock. Motor paralysis, sensory &
reflex loss below the level of the affected cord. Recovery begins within 8 hours and recover fully.
9. Cord transaction: Injury is irreparable. Initially, motor paralysis is flaccid because the cord below the
level of injury is in a state of spinal cord shock. After some time, the cord recover from shock & acts
as an independent structure, without any control from higher centres, spasm paralysis & reflex
activity.
10. Clinical manifestation:
 Spinal cord injuries: Spasm paralysis; no sweat of skins below the level of injury, loss
adjustment/ adaptability with air temperature, appear hyperthermy/ hypothermy.
 Conus medullaris injury: Lost function of urination & defecation. Complication: respiratory
failure & respiratory tract infection, urinary tract infection & calculus, bedsore, body
temperature disorder.
11. Therapeutic principle:
 Immobilize the spine.
 Relieve spinal cord edema/ secondary spinal cord injury: Methylprednisolone, 20% mannitol,
hyperbaric oxygen treatment.
 Operation: Relieve spinal cord compression, stable spine, reconstruction of anatomy structure
of the spine.
Fractures of pelvis
12. Clinical manifestation & diagnosis: Severe trauma (road accident, fall); Shock; Swelling, pain,
ecchymosis; Pelvic compression/ separation test; X-ray.
13. Complications: Retroperitoneal hematoma; Organs injury in the pelvic cavity; Bladder, urethra injury;
Rectal injury; Nerve injury (sacrum fracture).
14. Treatment:
 Deal with life threatening injuries:
Shock- blood transfusion
Organs injury in the pelvic cavity- urological surgery
 Treatment of pelvic fracture:
 Conservative treatment- stay in bed 4-6w.
Hammock sling- fracture of pelvic edge, fractures of sacrum & coccyx, isolated pelvic ring
fracture.
 Operation- open reduction & internal fixation/ external fixation.
Severe separation of symphysis pubis, two sites of pelvic ring fractures, acetabulum fracture
accompany femoral head dislocation.

Chapter 6. Hand injury and Peripheral nerve injury

Hand injury
1. Functional position of hand: Wrist in 20-30 degrees of extension & slight ulnar deviation. Fingers in
45 degrees of MCP, 15 degrees of PIP & DIP flexion. Thumbs in 45 degrees of abduction.
2. Hand injury examination which is divided into 5 aspects: skin, tendon, vascular, nerve, bone & joint.
3. Principle of treatment of hand injury: Early debridement, Correct treatment of deep tissue injury,
As far as possible close wound, Correct treatment after operation.
Peripheral nerve injury
4. Muscle strength 6 stages:
 M0- no muscle contraction.
 M1- can feel the muscle contraction, doesn’t produce action.
 M2- can produce action, can’t withstand gravity.
 M3- can withstand gravity, not against a resistance.
 M4- can partially resist resistance.
 M5- normal.
5. Tinel sign: After nerve injury, axonal regeneration is fast than remylelination, then axons exposed,
allergic phenomenon outside tapping can cause pain, radiating pain & a sense of shock. Along the
nerve repair cadre, arrived at front end of neurite regeneration by far the feeling, which is positive,
that reaches the part of nerve regeneration.
6. The lower humerus shaft fracture easily complicated by radial nerve injury, fibular fractures of head
& neck easy injury of common peroneal nerve.

Chapter 7. Compartment syndrome

1. Compartment syndrome: Acute medical condition characterized by raised pressure within a closed
space with irreversible damage to the nerves & muscles containing in the compartment.
2. Tissue threshold to ischemia: Muscle 4 hours, Nerve 8 hours, For viable functional limb the upper
threshold is about 6 hours.
3. Clinical manifestation: Pain (progressive, unbearable, violent), Pulseless, Pallor, Paresthesia,
Paralysis.
4. Treatment:
 Non operative treatment.
 Medicine: Rbanhydration (manico), fluid expansion (dextran 40), improve microcirculation
(salviol).
 Raised affected limb is forbidden.
 Operative treatment.
 Fasciotomy.
 Debride necrotic muscle.

Chapter 8. Infection of bone and joint

1. Clinical feature:
Common sign: Redness, swelling, hotness, pain.
Special sign:
 Sudden releasement sign: Begin with very sharp pain, suddenly released even without any
treatment and usually caused by penetration of abcess.
 Floating patella sign: Caused by synovial fluid (infection), abcess (fracture).
 Immobility: Dysfunction of kinetic system.
 Symptoms:
 Early stage: Severe pain in local region, higher temperature, local limitedly compressed pain,
normally no significant edema or swelling.
 Late stage: Local cutaneous edema, redness sharp compared pain, sign for subperiosteal abcess,
sudden releasement of pain (usually caused by penetration of abcess).
 Systemic or multi-tissue symptom:
 Deep tissue abcess with progressive local redness, hotness or compressed pain.
 Multi joint reactive articular effusion (hydrops).
 Diffuse to whole bone marrow cavity: Whole shaft damage, pathological fracture.
2. Etiology:
 Anatomic reason:
Bone: Abundant blood supply, unidirection blood flow, vessel net in the metaphysic
multidirection diffusion way (diffuse to bone marrow-diffuse to shaft, diffuse to cutaneous
direction-sinus, diffuses to joint-suppurative arthritis).
Joint: Closed environment, no vessel system in intra-articular cavity, more superficial compare
with bone.
 Functional reason: Mobility of bone and joint.
 Pathogenic bacteria reason: High ration of multi-drug resistance.
3. Diagnosis:
 Age and location: For fetal case or children mainly found in distal femur or proximal tibia.
 History: Injury before attack.
 Rapid onset.
 Severe systemic toxic symptoms: Chilling, high fever (39°C).
 Significant toxicaema symptom.
 Lab exam: High count of WBC, high percentage of neutrophile granulocyte higher than 90% has
diagnostic value, blood bacteria culture result or susceptibility testing, local abcess layer
puncture (biopsy).
4. Acute osteomyelitis may lasts for 3-4 weeks with sinus appears, abcess outflow, body temperature
decrease slowly which likely lead to chronic stage.
5. Atypical appearance or mild physical feature can be seen in some low toxicity infected cases, which
are hard to diagnosed.
Tuberculosis bone and joint
6. Clinical features: Pain, swelling, loss of weight; Joint swelling; Decrease ROM; Ankylosis (stiffness);
Deformity.
7. Pathology: Primary complex (in lung or gut), secondary spread, tuberculous granuloma.
8. Diagnosis: Long history, involvement of single joint, marked thickening or synovium, marked muscle
wasting, periarticular osteoporosis, +ve Mantoux test (like PPD test).
9. Investigastion: FBC, ESR; Mantoux: X-ray (soft tissues swelling, periarticular osteoporosis, joint
appear washed out, articular space narrowing); Joint aspiration (AAFB identified in 10-20%); Culture
+ve in 50% of cases.
10. Differential diagnosis: Transient synovitis, monoarticular, hemorrhagic arthiritis, pyogenic arthritis.
11. Treatment: Chemotherapy (isoniazid 8w, ethambutol, rifampicin and isoniazid 6-12m), Rest and
splintage, Operative drainage rarely necessary.
12. Suppurative osteomyelitis: Kind of bacterial inflammation involving bone, periostenum, bone
marrow or joint.
13. Pathway of infection: Hematogenous infection, traumatic infection, creeping infection.
14. Classification: Acute hematogenous osteomyelitis, chronic hematogenous osteomyelitis,
circumscribed bone abscess, sclerosing osteomyelitis, traumatic osteomyelitis.
15. Radiographic of acute suppurative osteomyelitis:
 X-ray: Hard to find small abcess with diameter less than 1 cm.
 CT: Early evidence for subperiosteum abcess.
 ECT: Positive finding 48 hours after attack.
Radiographic feature:
 Soft tissue swelling: In 7-10 days after attach, caused by hyperemia, edema which are not
specific.
 Bony structured destoried: 10 days after attach, local osteoporosis is due to local supply
rebuilding.
 Proliferation or hyperplasma: Single layer, multi layer, wave shape or ray shape. New bone
caused by periostum, called shell or coffin bone.
 Dead bone: Small piece or stick liked bone with high density signal.
 Catastrophic situation: Sinus and outflow of dead bone through sinus.
 CT, MRI.
16. Acute suppurative arthritis: Acute inflammatory articular disease caused by bacteria.
Staphylococcus aureus is the biggets threat. Classification: Hematogenous, traumatic, exotic.
17. Laboratory findings: WBC count (WBC and neutrophils increased), Aspiration (golden standard),
Blood culture (reference for antibio treatment), Imaging studies. (with wide use of anti-bio drug, this
classical changes become rare).
18. Acute hematogenous osteomyelitis : Main cause:Hemolytic staphylococcus aureus Also seen:Group
B Streptococcus. Pathway: Skin/mucosa -> focus of infection -> blood cycle -> metaphysis ->
capillary.
Pathway of abcess:
 During growth period, rich blood supply in metaphysis
 The bending extending capillay lead to net-liked vascular sinus
 Slow blood flow leads to bacteria accumulation ,which causes proliferation of bacteria
 Then abcess.

Chapter 9. Chronic injury of kinetic system

1. Chronic injury of kinetic system: Type of aseptic inflammatory or chronic injury taking place in
kinetic system, caused by longterm ,persisited stress or motion.
2. Etiology: Persisted stress, asepetic inflammtory, failure to compensation.
3. Classification:
 Soft tissue chronic injury: Muscles, tendons, fascia, vessels, ligaments, synovium.
 Skeleton injury.
 Cartilage injury.
 Entrapment syndrome of peripheral nerves: Carpal tunnel syndrome.
4. Clinical features: (mild pain, lesion weakness, aseptic inflammatory).
 Mild to moderate pain: Most are mild pain without evident trauma.
 Continuous “small troubles”: Weakness of lesion area (muscle or tendon).
 Inflammation, but not obvious: Without high fever, severe edema or abcess.
 Local zone not systemic: Over active or over use relate to region of pain.
5. Physical examination:
 Long term pain without trauma.
 Fixed painful zone, when compression.
 No sever sign such as hot, red or swelling can be found.
 Over-use related with focal zone.
 Career.
Special test:
 Mills test – For lateral epicondylitis (tennis elbow).
Elbow held in extension -> one hand to compress lateral condyle -> the other hand to resist
wrist rotation and distal extension -> reproduce pain.
 Finkelstein test – For stenosing tenosynovitis (painful wrist).
Hyperflex the thumb -> trap it in palm with other fingers -> deviates wrist ulnarward -> positive:
compliment for local pain.
 Supraspinatus test – For cuff tear (frozen shoulder).
Extend elbow -> keep the shoulder in abduction position -> examiner give an opposite strength
on distal forearm -> positive: patient can’t resistant the force or gravity and feel painful on
shoulder.
6. Treatment:
 Conservative treatment: Kill triggers factor, immobilization (minimizing vulnerate action of joint
without over loading and chane gesture to distract stress), rehibiliation (physical therapy,
hyperthermia treatment, massage et al).
 Chemical treatment: NSAIDs, adrenocortical (side effect: secondary infection, vessel spasm,
neuritis, tendon rupture, puncture injury, paralysis, necrosis, cushing’s syndrome. Adverse effect:
prednisolone acetate).
 Surgical treatment: Arthrodesis, reconstruction, tenosynovectomy, excision of cyst,
ligamentotomy, correction of deformity.
7. Tennis elbow: Lateral epicondylitis (ECT injury) --- Mill test.
8. Frozen shoulder: Also called as periarthritis shoulder or fifty shoulder. This is a disease of unknown
etiology where the glenohumeral joint becomes painful and stiff because of resilience of the joint
capsule, possibly with adhesions between its folds.
Trigger finger
9. Stenosing flexor tenosynovitis (Trigger finger): One of the most common forms of tendinitis. There
are idiopathic changes in the first annular puller lead to restriction of gliding motion of flexor
tendons and commonly reffered to as trigger digits, snapping of flexor tendon.
10. Clinical diagnosis of trigger dysfunction: Made based on pain or tenderness, crepitance, and locking
focused at the A1 pulley of a specific digit.
11. Treatment:
 Rest and take NSAIDs.
 Injection of corticosteroid into the tendon sheath is a reliable treatment for trigger finger.
 When nonoperative measures fail to relieve triggering, A1 pulley release is appropriate.
12. Clinical feature: 12-14 years male children, pain tenderness, bone protuberance (mass), X-ray local
large fragmentation.
13. Carpal tunnel syndrome: Syndrome characterized by compression of the median nerve as it passes
beneath the flexor retinaculum.
Interverbal disc herniation
14. Cause: Inervertebral disc degeneration, trauma, Inheritance, pregnancy.
15. Disc: Cartilage plate, annulus fibrosus, nucleus.
16. Classification and pathology: Bulge, herniation, prolapse and free disc fragment, schmorl tubercle.
17. Clinical features: Back pain, leg pain (ischiadicus Nerve pain), scliosis, activity limitation, tenderness,
spasm of sacrospinalis muscle, straight leg raising and intensitication, nervous injury, abnormal
sensation, weakness of muscle, reflex abnormality.
18. Treatment of Tendinitis of hand and wrist: Nonoperative management, eliminating activities,
alteration of mechanical factors (splints, rest), NSAIDs, steroid injections, surgical treatment.

Chapter 10. Tumor Bone

1. Surgery grade:
 G grading: G0 benign, G1 low potential malignancy; juxtacortical osteosarcoma, G2 malignancy
osteosarcoma; synovial sarcoma.
 T surgical site: T0 tumor is enwrapped with fibrous cyst or reactive bong, T1 tumor is in the
muscular septa or membrane or fascia, T2 exceed the muscular septa or membrane or fascia.
 M lymphatic metastasis or distant metastasis: M0 no local and distant metastasis, M1 distant
metastasis.
2. Symptoms:
 No symptoms.
 Fever.
 Pain:
 Constant deep, aching pain.
 Pain that persists at night and is unrelieved by rest: Suggestive of malignancy.
 Mild, dull, aching pain that suddenly becomes severe following minimal or no trauma:
Suggests a pathologic fracture.
 Signs:
 Swelling: For malignant tumors, the margins of the swelling are not well-defined.
 Mass:
 For malignant tumors, the margins of the mass are not well-defined.
 If the mass is painful and attached to bone: Malignant.
 If the mass is attached to bone but painless: Benign (unless it is a soft tissue tumor).
 High skin temperature.
 Superficial vein is engorge (prominent).
 Tenderness.
 Impairment of joint function: especially if the tumor is near a joint. Nearby nerves may be
compressed.
 The signs of compression:
Spinal cord -- Paralysis.
Peripheral nerve -- Sensation and motion.
Artery --Ischemic.
Vein -- Stagnant blood.
 Cachexia: Weight loss, anemia.
3. Imaging
 X-ray:
 Bone formation tumor: Ractive bone, neoplastic bone.
 Codman triangle: New bone formation under the corners of the raised periosteum. It is
often a pseudotriangle on radiographic findings with ossification on the original bone and
one additional side of the triangle which forms a two sided triangle with one open side.
 Sunburst (sun-ray) appearance: Type of periosteal reaction giving the appearance of a
sunburst secondary to an aggressive periostitis.
 Onion: Skin appearance.
 Osteolysis tumor: Destruction of bone.
 CT.
 MRI: For marrow lesions, primary tumors of soft tissue, and soft tissue extensions of osseous
tumors.
 Nuclide bone scan: For detecting distant osseous metastases and periosteal involvement of
contiguous soft tissue tumors.
Lab exam:
 Erythrocyte sedimentation rate (ESR): Most frequently elevated in metastatic and small round-
cell tumors, such as Ewing sarcoma.
 Alkaline phosphatase (ALP): Usually elevated when bone is being broken down and remodeled.
 Electrophoreses of Serum and urine (useful if myeloma is suspected).
 Biopsy to confirm diagnosis.
4. Treatment:
 Operation:
 Curetage + graft: Indication for endogenous benign tumors.
 Resection + graft: Indication for exogenous benign tumors.
 Limb saving surgery: Low malignant tumors, early diagnosed malignant tumors
Regular chemotherapy or/and radiotherapy + resection + graft and reconstruction or + joint
replacement.
 Amputation: Advanced disease, aiming at pain-relief and a better life. The safe margin of
amputation is 10cm away from tumor to avoid stump recurrence.
 Chemotherapy, Radiotherapy, Immunotherapy, Chinese medicine.
Benign
5. Solitary bone cyst: Common lesion of the immature skeleton characterized by an intramedullary
fluid- filled cavity that forms in the metaphysis, juxtaposed to or near the physis.
Symptoms & signs: Most lesions are asymptomatic, but patients may present with pain, swelling,
and deformity following pathological fracture.
X-ray: The lesion presents as a geographic intramedullary lucency. The cortex is often markedly
thinned and the bone contour frequently expanded.
6. Osteoid osteoma clinical features:
 Children and adolescents (5-25 age) are most frequently affected, which may exist for many
years without change.
 Common region of lesion: The femur and tibia. In the spine, the lesion often causes a painful
scoliosis.
 Painful lesions in which the pain is described as deep, boring, constant, nocturnal, and
frequently relieved by aspirin or other non steroidal anti-inflammatory drugs.
 No sign, or tenderness, swelling.
Radiographic:
 X-ray: Lesion is an area of very dense bone surrounding a central lucent area or nidus that is less
than 1.5 cm in diameter.
 CT: If reactive bone obscures nidus on plain radiographs, CT scan may be necessary to disclose it.
Treatment: Take medicine, Operation (curettage): If the agents do not provide pain relief, complete
excision of the nidus along with the sclerotic bone should be applied.
7. Osteochondroma: One of the most common bone neoplasm. It is a cartilage-capped projection of
bone from the metaphysis of a long bone near the growth plate. Any bone preformed in cartilage
can be affected. Treatment: Asymptomatic lesions: Observation; Symptomatic exostosis: Resection.
Clinical features:
 Mass: Lesion is a hard, immovable, smooth mass that is firmly fixed to bone without tenderness
unless it has been traumatized.
 Dysfunction of nerve and joint: Nerve is compressed and the joint is blocked by mass.
 X-ray: Appearance is peduncu-lated bony protuberance from the metaphysis of a long bone that
points away from the nearby joint.
8. Enchondromas clinical features:
 Region of lesion: Hands and feet (Arise within the medullary cavity of bone, most frequently in
the small tubular bones of the hands and feet).
 Asymptomatic (unless complicated by a pathologic fracture).
 Pain: Dull aching pain.
 X-ray: Osteolytic radiographic.
Treatment:
 Observation: Radiographs at 3 to 4month intervals for asymptomatic lesions. If no growth is
noted during first or two years, patient need return only if pain develops in the area. Painful
lesions without cortical erosion should also be followed.
 Operation: Curettage and removal of the tissue filling the cyst, including the lining.
9. Giant cells tumor: Osteolysis tumor with variable growth potential originate from cancellous bone,
it is potential malignancy or malignancy. Most common in adults. It is consist of giant cell (osteoclast)
& usually occur in matrix cell and lower end of the femur, upper end of the tibia, lower end of the
radius, upper end of the humerus.
Clinical features:
 Pain: Vague pain.
 Swelling.
 Tenderness on firm palpation.
 Pathological fracture.
 X-ray: Destruction of the bone substance, with expansion of cortex; Soap-bubble appearance;
Grow eccentrically; Extend as far as the the articular end of the bone.
Treatment:
 Excision part and whole bone such as clavicle or fibula.
 Curettage followed by packing bone graft such as femur.
 Arthroplasty.
 Amputation.
 Radiotherapy may induce malignant.
10. Fibrous dysplasia: Normal bone is replaced by fibrous tissue. Mass of fibrous tissue growth inside
bone and erodes cortices of bone from medullary cavity. Tx: Curetage + graft + fixation (fracture).
Clinical features:
 Most common sites include the ribs, proximal end of femur, and tibia.
 Pain swelling, deformity.
 X-ray:
 Appears as a geographic, intramedullary lesion with a ground glass appearance.
 The density of the lesions varies with the amount of immature bone: produced, Cortical
thinning and expansion of the bone contour is common.
 Calcification. Extensive involvement of the bone can lead to significant deformities, such as
shepherd's crook deformity of the proximal femur.
Malignant
11. Osteosarcoma- Predominantly a tumour of adolescence. The most common site is the lower end of
the femur, the upper end of the tibia, and the upper end of humerus. It begins in the metaphysis.
Clinical features: Pain, Swelling, Superficial vein is engorge (prominent), Tenderness, Overlying skin
is warmer than normal because of the vascularity of the tumor, Skin appears stretched and shiny.
X-ray:
 Show irregular destruction of the metaphysis. Later the cortex appears to have been burst open
at one or more place.
 There is usually evidence of new bone formation under the corners of the raised periosteum
(Codman’s triangle).
 Sun ray appearance.
 Profuse formation of new bone.
 Pulmonary metastases.
Treatment:
 Chemotherapy before surgical treatment: Control recurrence and distal metastatic.
 Limb-saving surgery: For low malignant tumors, early diagnosed malignant tumors.
Regular chemotherapy or/and radiotherapy + resection + graft and reconstruction or + joint
replacement.
 Amputation: for advanced disease. The safe margin of amputation is 10cm away from tumor to
avoid stump recurrence.
12. Ewing sarcoma: Cancerous tumor that grows in the bones or in the tissue around bones (soft tissue).
It can spread to the lungs, bones and bone marrow. It originates from protocell.
Clinical features: Pain, Low-grade fever, Swelling, Tenderness, Warm skin, WBC, ESR heighten.
X-ray: Appearance of mottled bone destruction and reactive "onionskin" periosteal bone formation
Treatment: Chemotherapy, surgery, radiotherapy.
13. Metastatic bone tumor clinical features: Severe pain, Primary disease, Loss weight, anemia,
Laboratary test, X-ray, Nuclide bone scan.
Treatment:
 Manage the primary tumor: Chemotherapy, radiotherapy, operation.
 Metastatic lesion treatment: Fixation of fracture, amputation.
 Symptom treatment: Relieve pain.

Chapter 11. Chest injury

1. Characteristics of pleural cavity:
 Pleural cavity integrity.
 Persistent negativity of intrapleural pressure.
Inspiratory phase: -8~-10cmH2O
Expiratory phase: -3~-5cmH2O
2. 3 pressure changes: Atmospheric, intrapleural, intrapulmonary pressure.
3. Manifestation of thoracic trauma:
 Symptoms:
 Chest pain.
 Respiratory distress of varying degrees.
 Circulatory insufficiency of varying degrees.
 Blood tinged sputum, hemoptysis, bloody frothy sputum.
 Signs:
 Laceration of chest wall.
 Chest wall deformity.
 Local tenderness, bony crepitus, referred pain on pressing chest wall- signs of rib fractures.
 Paradoxical respiratory movement.
 Subcutaneous emphysema.
 Signs of blood or air collection in chest cavity- hemothorax or pneumothorax.
 Signs of blood in pericardiac sac- hemopericardium.
4. Diagnosis: History, Clinical manifestation, thoracentesis or pericardiocentesis, Chest x-ray.
5. Treatment:
 Restoration of chest wall integrity: Restoration and reestablishment of intrathoracic negative
pressure.
 Respiratory support: Keeping respiratory tract patent, Restoration of respiratory function.
 Circulatory support: Combating shock treatment.
 Exploratory thoracotomy: Intrathoracic bleeding or injury of visceral organs.
 Prevention of complicating infection: Encouraging cough and expectoration and the use of
antibiotics.
6. Indication of exploratory thoracotomy:
 Continuing intrathoracic bleeding.
 Extensive laceration of lung, rupture of bronchus or perforation of esophagus.
 Injury of heart and great vessels.
 Thoracoabdominal injury.
 Intrathoracic foreign body retention
Rib Fracture
7. Classification according to whether the skin of chest wall is perforated: Closed and open type.
Classification according to the number and sites of rib fracture: Single and multiple.
8. Paradoxical respiratory movement: Opposite to the direction of chest wall movement of normal
respiration, the malacic (softened) part of flail chest wall moves inward during phase of inspiration
and outward during phase of expiration.
9. What is the mechanism of mediastinal flutter occurring with paradoxical respiratory movement
after multiple ribs fracture at multiple sites?
Normally intrapleural pressures on both sides are equal both during inspiratory or expiratory phases
and mediastinum is stable without swinging. Inbalance of intrapleural pressures and pressure
gradient between two sides during respiration causes mediastinal flutter after paradoxical
respiratory movement of chest wall.
10. Clinical manifestations:
 Symptoms:
Localized pain + Respiratory distress of
(specific) varying degree

Increased respiratory
Scared for pain -> tract secretion
 Signs:
 Local tenderness or deformity at site of rib fracture + Bony crepitus + Referred tenderness on
anteroposterior compression of chest wall (+).
 Paradoxical respiratory movement.
 X-ray.
11. Treatment:
 Relief of pain: Analgesic drug, immobilization of chest wall, intercostal nerve block.
 Prevention of complication: Encourage cough and expectoration, prevention of atelectasis of
lung, and pneumonia, antibiotics.
12. Treatment of paradoxical respiratory movement:
 Pressure bandaging of chest wall.
 Traction fixation of chest wall: For more extensive flail chest or if pressure bandage fails to be
effective.
 Surgical fixation of chest wall at the site of rib fracture: In cases needing exploratory
thoracotomy or open rib fracture needing debridement and suture.
 Internal fixation with the use of respirator for assist respiration: An intratracheal intubation or a
tracheotomy, usually for 2-3 weeks.
Traumatic pneumothorax
13. Traumatic pneumothorax: The collection of air in pleural cavity caused by trauma, e.g. laceration of
lung, rupture of bronchus or perforating wound of chest wall.
14. Closed pneumothorax: Often in closed chest injury/chest wall injury.
Pathophysiology: Partial lung collapse and Effect to respiratory or circulatory function is limited.
Clinical manifestation:
 Chest pain, chest oppression sensation + some shortness of breath.
 Signs of air collection in chest cavity: Deviation of trachea toward normal side, tympanitic sound
on chest percussion, respiratory sound diminished or abolished on injured side.
 X-ray examination: Collection of air in chest cavity + lung collapse or compression.
Treatment:
 < 30%: No particular treatment, can absorb itself 1-2 weeks.
 30-50% lung collapse: Thoracentesis with aspiration of air or closed chest drainage for early lung
expansion.
 Antibiotics.
15. Tension pneumothorax: Often seen in lung laceration.
Characteristics: One way leakage and rapid accumulation of air resulting in rapid rise in
intrapleural pressure mach higher than the atmospheric pressure (positive intrapleural) pressure.
Clinical manifestation:
 Extreme respiratory difficulty, acute respiratory failure or asphyxia (excessive perspiration
irritability, exhaustion, cyanosis). Circulatory failure or shock.
 Signs of collection of air in chest cavity, subcutaneous emphysema or mediastinal emphysema.
 Not suitable to move the patient for further X-ray examination.
Treatment: Emergency management - Immediate thoracentesis to withdraw air for decompression
of tension pneumothorax.
16. Open pneumothorax- Often seen in firing weapon/ shell fragment.
Characteristics: Air coming in and out the chest cavity through the opening of open chest wound.
Pathophysiology:
 Loss of intrapleural negative pressure.
 Mediastinal flutter: Intrapleural pressure is greater on injured side than it is on normal side and
the pressure difference is even greater in inspiration than it is in expiration results in
mediastinum moves more toward normal side in expiration than it is in inspiration.
Clinical manifestations:
 Respiratory functional impairment: Respiratory distress, circulatory functional impairment or
even shock.
 Signs of collection of air in the chest.
 Chest wall open wound: Wheezing.
Treatment:
 Urgent closure of wound to convert an open pneumothorax into a closed pneumothorax with
any dressing available.
 Beware of a concomitant large chest wall defect and a resultant flail chest wall.
 Beware of sudden change of open pneumothorax into a tension pneumothorax.
 Correction of shock, debridement and suture of chest wall open wound, and closed chest
drainage.
 Exploratory thoracotomy as indicated.
 Prevention of infection.
Traumatic hemothorax
17. Source of hemorrhage:
 Bleeding from laceration of lung. Bleeding usually stops spontaneously because of low
pulmonary arterial pressure.
 Bleeding from intercostal or chest wall blood vessels. Does not stop easily because of higher
systemic arterial pressure.
 Bleeding from heart and great vessels. Bleeding is excessive and rapidly cause shock or death of
the patient.
18. Pathophysiology:
 Loss of blood volume: Signs of internal bleeding (rapid and feeble pulse, blood pressure lowering,
increased respiratory rate etc, signs of hypovolemic shock.)
 Blood collection in chest: Causing lung compression and mediastinal shift → impaired
respiratory and circulatory functions.
19. Method of judging whether there is active bleeding:
 Increasing pulse rate and progressive lowering of blood pressure.
 No rise or stability of blood pressure after blood or fluid replacement.
 Continuing lowering of blood HB and RBC level.
 Increasing shadow of hemothorax on successive chest films.
 Amount of chest drainage each hour >200ml in 3 successive hours, or amount of chest drainage >
1000ml observed in a short period of time (< 6 hours).
20. Treatment:
 Non progressive hemothorax:
 Spontaneous absorption and clearance if the amount is small.
 Removal of hemothorax by thoracentesis or chest drainage.
 Prevention of infection.
 Progressive hemothorax:
 Replacement of blood volume.
 Exploratory thoracotomy as needed control of bleeding and evacuation of hemothorax.
 Clotted hemothorax: Remove clotting.
 Organized hemothorax: Operative decortication of the lung to be performed 4-6 weeks after
injury to remove the fibrous layer for reexpansion of lung and recovery of pulmonary function.
21. How to diagnose infected clotted pneumothorax?
 Toxic symptoms of infection: high fever, chill, leucocytosis.
 Cell count of pleural fluid - RBC: WBC ratio is <100:1.
 Bacteria found on smear or culture (+) of pleural fluid.
Hemopericardium
22. Hemopericardium: The bleeding and collection of blood in pericardiac sac after thoracic trauma.
Mostly are seen in penetrating wounds of the chest with sharp things.
23. Pathophysiology: Collection of blood in pericardiac sac leads to increased intrapericardiac pressure
and cardiac tamponade causing decreased venous return and cardiac output, then increased venous
pressure and decreased cardiac output. The patient will suffer from acute circulatory collapse. Acute
cardiac tamponade may occur even after 100~200ml blood collection or occasionally even after
50ml blood collection.
24. Clinical manifestations & diagnosis:
 Beck’s triad: Venous pressure ↑ (>15cmH2O); Arterial pressure ↓; Feeble, pulse and distant
heart sound.
 Diagnostic point: Location of opened chest wound + venous pressure ↑, arterial pressure ↓ and
pulse pressure ↓ + clinical feature of circulatory failure.
25. Treatment:
 Urgent pericardiocentesis if cardiac tamponade is suspected to relieve intrapericardiac pressure
& for temporary decompression before emergency surgery is undertaken.
 Surgical repair of cardiac wound.
26. Traumatic asphyxia: It is often resulted from sudden severe compression injury of the chest with
reflex closure of glottis. As a result, there is sudden rise of intrathoracic pressure and retrograde
reflux of venous toward head, neck and shoulders. Such refluxed blood under high pressure then
causes rupture of capillaries and extravaration into the tissue of head, neck and shoulder regions.
Treatment: Management of bleeding according to its site and severity and Oxygen inhalation.
27. Blast injury of the lung: As result of sudden explosion, blast pressure transmitted through air or
water medium causes sudden enormous blast to the chest wall and concomitant further pressure
wave transmitted through the glottis and trachea in reaching bronchioles and alveoli. This sudden
pressure increase in bronchioles and alveoli causes sudden rise of intrapulmonary pressure and
rupture of bronchioles and alveoli.
Treatment: Steroids + oxygen inhalation; Intermittent positive pressure breathing (IPPB) with a
respirator in serious cases.

Chapter 12. Surgery for lung cancer

1. TNM staging of lung cancer:
 T - Primary Tumor: TX T0 TIS T1 T2 T3 T4
TX -- Tumor proven by the presence of malignant cells
TO -- No evidence of primary tumor
Tis -- Carcinoma in situ
 N - Nodal Involvement: N0 N1 N2 N3
N0 -- no regional metastasis in regional Lymph nodes.
N1 -- metastasis in ipsilateral peribronchial and/or perihilar lymph nodes and intrapulmonary
nodes, including involvement by direct extension
N2 -- metastasis in ipsilateral mediastinal and/or subcarinal lymph nodes
N3 -- metastasis in contralateral hilar/mediastinal/scalene/supraclavicular lymph node(s) or
metastasis in ipsilateral scalene/supraclavicular lymph node
 M - Distant Metastasis: M0 M1
M1a -- lung cancer with contralateral pulmonary nodules or malignant pleural effusion/nodules
M1b -- lung cancer with distant metastasis e.g. brain, bone, live or adrenal gland.
 Stage 1a: T1 M0 N0
 Stage 1b: T2 M0 N0
 Stage 2a: T1 N1 M0
 Stage 2b: T2 N1 M0; T3 N0 M0
 Stage 3a: T3 N1 M0; T1 N2 M0; T2 N2 M0; T3 N2 M0
 Stage 3b: T4 Any N M0; Any T N3 M0
 Stage 4: distant metastasis
2. Lung cancer: It results from uncontrolled growth of malignant cells in one or both lungs and tracheo-
bronchial tree, which arises from protective or ciliated cells in the bronchial epithelium. This disease
often begins as a result of repeated carcinogenic irritation causing increased rates of cell replication,
as a result proliferation of abnormal cells leads to hyperplasia, dysplasia or carcinoma in situ.
3. Signs and symptoms: Cough, Hemoptysis, Chest pain or shoulder pain, Shortness of breath,
wheezing, Repeated pneumonia or bronchitis, Swelling and effusion, Loss of appetite or weight loss,
Bone and joint pain, Hoarseness, SVC syndrome, Finger clubbing.
4. Lung cancer type: Non small cell lung cancer & small cell lung cancer.
NSCLC type: adenocarcinoma, squamous cell carcinoma, large cell carcinoma.
5. Diagnostic techniques: Chest X-Ray films, CT, Bronchoscopy (FOB), Cytology examination (sputum,
pleural effusion), Transthoracic needle aspiration (TTNA), MRI, PET, Isotope scan (lung, bone),
Ultrasound scan (liver, kidney), Mediastinoscopy (used to examine lymph nodes in a patient with
lung cancer, for disease staging purposes), Thoracoscopy/VATS (minimally invasive way of accessing
the chest through small incision(s) to diagnose and treat lung cancer).
6. Treatment:
Stage Description Treatment Options

Stage I a/b Tumor of any size is found only in the lung Surgery

Stage II a/b Tumor has spread to lymph nodes Surgery

associated with the lung
Stage III a Tumor has spread to the lymph nodes in Chemotherapy followed by
the tracheal area, including chest wall and radiation or surgery
diaphragm
Stage III b Tumor has spread to the lymph nodes on Combination of chemotherapy
the opposite lung or in the neck and radiation
Stage IV Tumor has spread beyond the chest Chemotherapy and/or palliative
(maintenance) care
 Surgery:
 Wedge resection: Used when the cancerous growth is located in the outer sections of the
lung, and when a lobectomy cannot be performed, in order to spare lung tissue and function.
 Segmentectomy.
 Lobectomy: Removal of a lobe, is the preferred procedure when a cancerous tumor involves
a single lobe of the lung.
 Sleeve Lobectomy and/or Sleeve resection.
 Pneumonectomy: When a lobectomy cannot be performed for the total removal of a
bronchial cancer. A pneumonectomy is the total removal of one lung. A right
pneumonectomy means that the right lung is surgically removed.
 Lymph node dissection.
 Chemotherapy, biotherapy, and radiation therapy.
 Neoadjuvant chemotherapy, Immunotherapy and gene therapy, Molecular Targeted Therapy,
Traditional Chinese medicine.
Chapter 13. Empyema
1. Empyema- Pleural infection and pleural space suppurative fluid collection, characterized by
presence of pus or microorganism in pleural fluid most often is caused by Staphylo-coccus aureus.
2. Pathway of pathogen into pleural cavity:
 Direct invasion- Pneumonia, lung abcess
 Lymphatic drainage- Liver abscess, subphrenic abscess
 Blood stream- Septicemia, sepsis
3. Pathology:
 Phase 1- Exudative/ acute (1-3 days)
 Fluid is thin and lungs are readily re-expandable.
 Gram stain and culture is negative for micro-organism.
 Phase 2- Fibrinopurulent/ transient stage
 Large number of poly-morphonuclear leukocytes and fibrin accumulate in the effusion. With
continued accumulation of neutro-phils and fibrin, effusion becomes purulent.
 Pleural fluid pH and glucose level fall while LDH rises.
 Gram stain and culture reports show microorganism.
 Phase 3- Organizing/ chronic (after 14 days)
 Fibro-blasts grow into exudates on both the visceral and parietal pleural surfaces, producing
an inelastic membrane "the peel".
 Can lead to drug resistance.
 Trapped lung- A thickened pleural peel can restrict lung movement.
Acute empyema
4. Common symptoms:
 Chills, fever, dyspnea, chest pain or referred pain, night sweat, malaise, cough and increased
sputum production.
 Auscultation- Rales, decreased breath sounds, possibly a pleural rub.
 Dullness to percussion.
 Focal chest wall heat, erythema, swelling, splinting of the chest or a preference to lie on the
affected side may be noticed.
 Deviation of trachea.
Lab exam: Leukocytosis with poly-morphonuclear cells predominance; Lower hemoglobin, low
serum albumin and abnormal liver function test.
5. Diagnosis:
 Patient is usually "toxic".
 ± productive cough and chest pain.
 Chest X-ray and CT scan may show features suggestive of a pleural effusion.
 Ultrasound to confirm presence of fluid in pleural space.
 Confirmation of the diagnosis can be obtained by aspirating pus.
6. Treatment:
 3 core principle:
 Prompt initiation of appropriate antibiotics according to the drug sensitivity of pathogen.
 The complete evacuation of suppurative pleural fluid.
 The preservation or restoration of lung expansion.
 Antimicrobial treatment: Cefuroxime (Zinacef), Clindamycin (Cleocin).
 Closed tube thoracostomy: Patients with pleural effusion or frank pus on thoracentesis.
 Chest tube insertion drainage (most important).
 Video assisted thoracic surgery.
Chronic empyema
7. Causes:
 Failure to institute early aggressive treatment of acute empyema leads to chronicity.
 Inappropriate drainage.
 Neglected foreign body.
 Coexistance of bronchopleural fistula or esophageal fistula.
 Specific microorganism infection such as tuberculosis, fungus.
8. Clinical manifestations & diagnosis:
 Chronic “toxic” symptoms: persistent low fever, loss of appetite, weakness, anemia, low serum
albumin.
 Respiratory symptoms: shortness of breath, cough, purulent sputum.
 Bronchopleural fistula symptoms.
 X-ray: Loss of volume in the left hemithorax, pleural effusion, air fluid level, consolidated lung,
raised left hemidiaphragm, crowding of the ribs of the left hemithorax compared to the right
 CT- appears well defined, smooth, round or elliptical.
9. Treatment:
 3 core principles:
 Improve the patient’s general conditions, to correct chronic toxic symptoms and malnutrition.
 Eliminate the primary chronic causes and to obliterate purulent space.
 Restore lung expansion and pulmonary function.
 Improvement of chest drainage.
 Decortication.
 Thoracoplasty.
 Pleura-lung resection (pleura-lobectomy or pleura-neumonectomy).
10. Complication of empyema: Scoliosis, mild pleural thickening and mild restrictive defect.

Chapter 14. Primary Mediastinal Tumor (tmbhin characteristic location n neurogenic tumors)
1. Primary mediastinal tumor: Arises from the mediastinal structures. Mediastinal tumors are a
heterogenous group of neoplasms. 60%--neurogenic tumors, thymomas, and benign cyst; 30%--
lymphoma, teratoma; 10%--others. Overall it is rare.
2. Neurofibroma: Usually in posterior mediastinum, asymptomatic, in young adults & may be multiple
(benign).
3. Schwannoma: Most common mediastinal neurogenic tumor (benign), also called neurilemoma &
usually in posterior mediastinum, asymptomatic, in young adults. It may present with symptoms of
esophageal or nerve root compression.
4. Teratomas: Usually contain tissue derived from at least 2 of 3 germ cell layers - endoderm,
mesoderm, ectoderm. Encapsulated mass by the presence of cyst and solid area. In anterosuperior
mediastinum, usually children or young adults (mean age 20 years).
5. The four most common anterior and superior mediastinal tumors are thymomas, teratomas,
lymphomas, and enlarged or ectopic thyroid tissue. These are often referred to as the "4 T's"
(Thymoma, Teratoma, Terrible lymphoma, and Thyroid).
6. Clinical manifestations:
 Cough, hemoptysis, shortness of breath, wheezing.
 Chest pain, hoarseness, loss weight, dysphagia.
 SVC syndrome.
 Horner’s syndrome- Partial Ptosis, Anhydrosis, Myosis, Enophthalmos.
 Paraplegia: When the level of compression occurs below the first thoracic spinal nerve.
7. Diagnosis: History + PE, X-ray, CT/ CT guided needle biopsy, MRI, Ultrasound, Thyroid iodine scan,
Cervical lymph node biopsy, Mediastinoscopy and bronchoscopy, Angiography.
8. Treatment: Surgery - For all primary mediastinal tumor except lymphomas (radiation therapy);
Radiation/ chemotherapy.

Chapter 15. Esophageal cancer

1. Growth type pathology: Fungating-type, Ulcerating-type, Infiltrating-type, Constricting-type.
2. Staging:
 T categories:
 TX: The primary tumor can't be assessed.
 T0: No evidence of a primary tumor.
 Tis: Only in the epithelium (carcinoma in situ).
 T1: Growing into tissue under epithelium: lamina propria, muscularis mucosa, or submucosa.
 T2: Growing into the thick muscle layer (muscularis propria).
 T3: Growing into the outer layer of the esophagus (the adventitia).
 T4: Growing into nearby structures.
 N categories:
 NX: Nearby lymph nodes can't be assessed.
 N0: No nearby lymph nodes involved.
 N1: Spread to 1 or 2 nearby lymph nodes.
 N2: Spread to 3 to 6 nearby lymph nodes.
 N3: Spread to 7 or more nearby lymph nodes.
 M categories:
 M0: The cancer has not spread (metastasized) to distant organs or lymph nodes.
 M1: The cancer has spread to distant lymph nodes and/or other organs.
3. Clinical manifestations:
 Early symptoms: Catching sensation, Foreign body sensation, Retention sensation, Substernal
dull pain.
 Progressive dysphagia: Malnutrition become thin, skinniness, slim down.
 Symptoms of carcinoma invasion of adjacent organs: Aorta (Massive hematemesis, fatal
hemorrhage), Trachea (Tracheoesophageal fistula), RLN (Hoarseness of voice).
 Symptoms of metastasis: Pain at multiple sites.
 Physical signs: Sign for metastasis- enlarged supraclavicular LN, hepatomegaly, ascitis, or pleural
effusion; Dehydration, emaciation or cachexia.
4. Diagnosis:
 Exfoliative cytologic.
 Esophagoscopy or fibrogastroscopy.
 X-ray examination: Barium swallowing.
Signs of early carcinoma of esophagus: 3 local signs and 1 small niche.
 Local mucosal signs mucosal thickening, tortuosity, irregularity or interruption of mucosal
folds.
 Local sign of stiffening of esophageal wall.
 Local sign of small filling defect: 0.5cm-2cm.
 Small niche: 0.2cm-0.4cm
Advanced signs: Lumen narrowing, Lumen obstruction, Lumen enlargement, Mucosal
destruction and filling defect, Wall rigidity and decreased motility, Soft tissue shadow.
 CT and MRI.
 Endoscopic ultrasound examination (EUS).
 Radioactive isotopic examination.
 ECT or PET.
5. Differential diagnosis: Achalasia & caustic stricture.
6. Treatment:
 Surgery: Radical excision of carcinoma, Extensive regional lymph node excision, Esophageal
reconstruction, Esophagogastric short circuiting anastomosis, Intraluminal intubation,
Intraluminal stent, Gastrostomy
 Radiotherapy.
 Chemotherapy.
 Immunotherapy.
 TCM.
7. Why do we make the esophageal substitution after esophagectomy?
 Excision of esophageal carcinoma should include at least 5cm of adjacent esophagus on both
cutting ends.
 Segmental distribution of esophageal blood supply.
 Predominant longitudinal muscle of esophagus that tends to retract after cutting across.
8. Organs that may be used for esophageal substitution (in the order of their clinical application
nowadays): Stomach, colon, jejunum.
Chapter 17. Cardiacsurgery
1. Classification:
 Congenital: Cyanosis and Non cyanosis (L—R shunt ASD, VSD, PDA); no shunt PS.
 Acquired: Rheumatic valve disease, constrictive pericardiotis, coronary heart disease.
2. Purpose of cardiac surgery: Restore myocardial contractility and correct hemodynamic disorder.
PDA (Patent Ductus Arteriosus)
3. PDA: Congenital heart diseases, occurs soon after birth. Abnormal blood flow occurs between two
of the major arteries connected to the heart (between aorta & pulmonary artery).
4. Pathophysiology:
Pulmonary circulation PH -> Eisenmenger
Aorta pulmonary.A.
Shunt
L ventricle output -> L ventricle enlarged -> L V failure

Artery perfusion development affected

5. Operation indication: All indicated; optimal age 4-16 age.
Contraindication: Eisenmenger.
Operation methods:
 Ligation: L thoracotomy -> Dissection of ductus -> ligation of ductus
 Division + suture.
 Suturing through PA under CPB.
 Rranscatheter closure of PDA.

Chapter 18. Urogenital disease

1. Irritation sign of bladder:
 Frequency.
 Urgency: Strong and sudden desire to urinate.
 Odynuria: Urethral pain, during/ after excreting urine. Characteristic of the pain: like burning,
stinging, cutting or unexplainable discomfort.
2. Classification of urinary incontinence: True incontinence, Stress incontinence, Overflowing
incontinence, Urge incontinence.
Common causes Bladder Normal urination
storage func
True  Injury of spinchter
 Neurogenic disease
Stress Common in multiparous women Normal +
Overflowing Chronic urinary retention due to various causes >normal +
Urge  Strong stimulus <normal Neither exist nor
 Motor neurons damage disappear
3. Diagnosis of hematuria & pyuria?
 Hematuria: Increased RBC in the urine.
Gross hematuria > 1ml blood /1000ml urine; microscopic hematuria RBC >3/HP.
 Pyuria: WBC > 5 / HP, suggests urinary tract infection.
4. Urinary three cups test: Suggest source situation of hematuria/ pyuria
 First cup: initial 10—15ml urine.
 Third cup: last 10ml urine.
 Second cup: middle part of urine.
5. Diagnosis of oligouria and anuria: Oliguria < 400ml/24h. Anuria < 100ml/24h. Causes: Urinary tract
obstruction, renal failure.
6. Symptoms in relations to diseases:
 Total hematuria without pain, especially old people-tumor.
 Hematuria with dysuria-infection.
 Hematuria with kidney pain-urinary calculi.
 Intense radiating pain with interruption of urinary stream-bladder calculi.
 Old man with difficulty of urination-BP

Chapter 19. Hydronephrosis

1. Hydronephrosis: Physical result of whatever disease is keeping urine from draining out of the kidney,
ureter, and bladder. Develops when the pelvis and calyces of kidney become distended because
urine is unable to drain from the kidney down the ureters into the bladder.
2. Symptoms & signs:
 Symptoms of urethral stricture or urethral or renal stone (Severe flank pain/ pain in the side
/back pain /urinary tract infection/ hematuria/ fever ).
 Nausea, vomiting, loss of weight and strength, and pallor.
 PE- Enlarged kidney by palpation/ percussion.
Lab exam:
 Hemanalysis: WBC maybe increase in the acute stage of infection.
 Urinalysis.
 Urine culture.
 Blood chemistry- urea creatinine ratio above the normal.
 Ultrasound.
 X-ray: KUB (enlargement of renal shadows; stones/ tumor), IVU, Retrograde urograms, CT.
 Isotope scan.
 Endoscopy.
3. Complications: Infection, Renal failure, Pyonephrosis.
4. Treatment:
 The goal of treatment is to relieve or reduce the blockage- catheter; Draining the bladder or
relieving pressure through percutaneous nephrostomy tubes.
 Antibiotics- Urinary tract infection.
 Surgery- Repair the underlying cause of the obstruction.
Chapter 20. Benign Prostatic Hyperplasia
1. BPH: Lower urinary tract symptoms (frequency, urgency, odynuria, dysuria) caused by enlarged
prostate. BPH always occur in transition zone of the prostate.
2. Clinical manifestations:
 Irritation symptoms: Nocturia, frequency, urgency, urgent incontinence.
 Obstruction sx: Hesitancy, exertion, intermittency, urinary retention, overflow incontinence.
3. Complications: Infection, Bladder calculus, Hematuria, Hydronephrosis, Chronic renal failure,
Inguinal hernia & Anal prolapsed.
4. Pathophysiology:
 Mechanical obstruction: The urethra is compressed by the enlarged prostate, so the resistances
of urination increase.
 Dynamic obstruction: The contractions of the muscle fibers in the enlarged prostate enhance
the resistance.
 Secondary dysfunction of bladder: Detrusor muscle of the bladder gets thicker and overactive.
The decompensation of the bladder will lead to urinary retention or even overflow incontinence.
5. Diagnosis:
 Typical manifestation: Dysuria.
 Digital rectal examination (DRE): Enlarged, central sulcus, become shallow, pliable.
 Flow rate of the urination: Qmax<15ml/s.
 Dynamics of urination.
 IVU, CT, Cystoscopy.
 IPSS & QoL.
6. Differential diagnosis: Pca, Neurogenic bladder, Bladder neck cancer, Urethral stenosis, Urethral
stone.
7. Surgery: Open operation (prostate enucleation) & TURP (Transurethral Resection of Prostate) gold
standard.
Indication:
 Severe symptoms frustrating the patients.
 Severe complications: Cystic calculus, hematuria, renal failure.
 Volume of residual urine ≥ 60 ml.
 Qmax < 15 ml/s.
 Acute urinary retention.
8. Contraindication: Complicated with acute prostatitis, Severe urinary tract infection, Dysfunction of
blood clotting system, Dysfunction of significant organs, Debilitation of the detrusor muscle,
Relatively younger patient (<50).
9. Treatment:
 Watchful waiting: For mild symptoms.
 Medication: For middle symptom or with contraindication of surgery.
 Alpha blocker: To block alpha-receptor on muscle fiber and target on dynamic obstruction.
 5-alpha reductases inhibitor: To inhibit the activation of testosterone and gradually inhibit
the hyperplasia.
Chapter 21. Urolithiasis
1. Diagnosis:
 Symptoms and signs: Asymptomatic, lumbago, nausea & vomiting, hematuria, percussion pain.
 Lab test: Urinalysis, hematuria.
 Ultrasound.
 Radiologic investigations.

2. Etiology:
 Mechanism of stone formation: Nucleation theory, Crystal inhibitor theory, Anderson-Carr-
Randall theory.
 Local factors: Obstruction, infection, foreign body (center stone).
 Systematic factors:
 Metabolic disorder: Hyperparathyroidism, hypercalciuria (calcium calculi), hyperoxaluria,
hyperuricosuria (uric acid stones).
 Malnutrition.
 Environmental factors: Geography, climate, high mineral in water.
 Others:
 Drugs: cortical hormone, vit C, Vit D
 Milk: San Lu (Melamine).
 Food: Spinach.
3. Pathophysiology: Obstruction, infection, injury, canceration.
4. Treatment principles of bilateral upper tract urinary stone:
 When ureteral stone on one side and renal stone on the other side, the ureter stone should be
dealt with firstly.
 When bilateral ureter stones, one which is suffered from obstruction more serious should be
dealt with.
 When bilateral renal stones, the simple and safe side should be dealt with firstly.
 When stone lead to anuria, we should relief obstruction as fast as we can.

Chapter 22. Renal cell carcinoma

1. Lab findings: Hematuria, Anemia unrelated to blood loss.
Imaging studies:
 Abdominal plain film: Calcified renal mass.
 IV urogram: Calcification within the mass, Increased tissue density, Irregularity of the margin,
Invasion of the collecting system (displacement or distortion of renal calyces by mass; Invasion
of calices by tumor resulting in filling defect).
 Ultrasound: Define mass/ vena caval tumor thrombus.
 CT, MRI, Angiography.
 Isotope bone scanning.
 Needle aspiration: Only intermediate case.
2. Differential diagnosis: Benign renal tumors, renal pelvic cancer, angiomyolipoma.
3. Renal cell carcinoma: It is the most common type of kidney cancer in adults. The cancerous cells are
found in the lining of very small tubes (tubules) in the kidney. It usually presents with hematuria,
flank pain, or flank mass.
4. Complications: Acute flank pain, varicocele, pathologic fractures, brain metastases.
5. Treatment:
 Surgery:
 Radical nephrectomy- Resection of kidney, perirenal fat, and ipsilateral adrenal gland. For
stages I, II & IIIa.
 Partial nephrectomy- Resection of portion of one kidney, Polar tumor, tumor size<4cm,
bilateral RCC, solitary kidney.
 Immunotherapy: Combined interleukin-2(IL-2) and interferon α.
 Chemotherapy.
 Sorafenib (Nexavar): Inhibit tumor cell proliferation.
6. Common sites of metastases include lung, liver, bone, and brain.
7. Which of the following can occur as a paraneoplastic manifestation of renal cell carcinoma? Hepatic
dysfunction.
8. Which of the following about renal cell carcinoma (adenocarcinoma of the kidney) is correct? It
usually presents with hematuria, pain and abdominal mass.
9. A healthy appearing, 8-year-old boy is evaluated for an abdominal mass, felt by his mother, what is
the most likely diagnosis? Wilm’s tumour.

Chapter 23. Bladder tumor

Pathology
1. Tumor type: Transitional cell carcinoma, squamous cell carcinoma, adenocarcinoma.
Patterns of tumor growth: Papillary, sessile, infiltrating, nodular, mixed, and flat intraepithelial
growth (carcinoma-in-situ).
2. Tumor grade: Grade I well differentiated (~10% invasive), Grade II moderately differentiated (~50%
invasive), Grade III poorly differentiated (>80% invasive).
3. Tumor staging: Tis Carcinoma-in-situ, Ta Noninvasive papillary carcinoma, T1 Tumor invades
submucosa/lamina propria, T2a Tumor invades superficial muscle, T2b Tumor invades deep muscle,
T3 Tumor invades perivesical tissue, T4 Tumor invades adjacent organs.
4. Patterns of spread:
 Direct extension: Malignant transitional epithelial cells extend beneath the basal lamina into the
connective tissue of the lamina propria and, subsequently, into muscularis propria and
perivesical fat.
 Lymphatic spread: Pelvic lymph nodes.
 Vascular spread.
 Implantation: Implantation in abdominal wounds, denuded urothelium, resected prostatic fossa,
or traumatized urethra.
5. Signs & symptoms: Painless hematuria, urinary frequency, urgency, dysuria.
6. Diagnosis: History, PE, Lab test (Urinalysis and culture), Conventional microscopy cytology, Flow
cytometry (FCM), X-ray, Cytoscopy, Biopsy, CT, MRI.
7. Treatment:
 Superficial bladder cancer (Ta,T1,Tis):
 Transurethral resection.
 Intravesical chemotherapy or immunotherapy (BCG).
 Cystoscopic surveillance.
 Intravesical chemotherapy- Bacillus Calmette Guerin (BCG), Mitomycin C 50%.
Indications: Rapid tumor recurrence, multicentricity, higher grade or invasion of the lamina
propria, presence of CIS.
 Invasive bladder cancer (T2-T4):
 Partial cyctectomy: Solitary, inflitrating tumors localized along the posterior lateral wall or
dome of the bladder.
 Radical cystectomy:
Muscle-invasive bladder cancer T2-T4a, N0-NX, M0
High-risk superficial tumours (T1G3, BCG-resistant Tis)
Extensive papillary disease
Urinary diversion after radical cystectomy
Prostate cancer
8. Pathology: Adenocarcinoma.
9. Clinical findings:
 Symptoms:
 Early stage: Asymptomatic.
 Locally advanced/metastatic disease: Obstructive or irritative voiding complaints, bone pain,
paresthesias and weakness of lower extremities.
 Signs: Digital rectal examination-induration.
 Tumor markers: Prostate Specific Antigen (PSA).
 < 4 ng/ml normal.
 4 ~ 10 ng/ml Grey Zone.
 > 10 ng/ml highly suspect of PCa.
 Imaging: USG (hypoechoic lesion), Transrectal ultrasonography (TRUS), CT, MRI, Bone scan.
 Prostate biopsy- golden standard.
10. Treatment:
 Localized disease:
 Watchful waiting, older patients with small, well-differentiated cancer.
 Radical prostatectomy, patients with a life expectency > 10 years.
 Radiation.
 Locally advanced/metastatic diseases:
 Endocrine therapy-androgen blockade: Orchiectomy, antiandrogen agent, LHRH agonist.
 Radiation.
 Chemotherapy.
11. Gleason system: Well differentiated- poor differentiated
• Small uniform glands.
• More space between glands.
• Infiltration of cells from glands at margin.
• Irregular masses of cells with few glands.
• Lack of glands, sheet of cells.
12. Prostate cancer occurs most commonly in which zone of the prostate? Peripheral zone.
13. Appropriate treatment for a superficial bladder cancer is___? Endoscopic resection and fulguration.
14. Initial therapy for metastatic prostate cancer is___? Bilateral orchiectomyendoscopic resection and
fulguration.
15. General examination from his urologist is noncontributory. A rectal examination reveals
hemorrhoids and a left-sided irregular mass in the prostate. Following normal blood tests, he should
have which of the following? Biopsy of the nodule.
16. Because of positive biopsy findings and negative workup, he undergoes a radical prostatectomy. The
pathology report reveals Gleason score 9/10 and involvement of several pelvic lymph nodes. Which
is the most likely site for prostatic cancer metastasis? Bone.
17. A 79-year-old man is examined for severe pain in the iliac crest. Metastatic disease from prostatic
cancer is confirmed. What is the treatment offered initially to most patients with metastatic
prostatic cancer? Luteinizing releasing hormone (LRH) agonist (Leuprolide).
18. During a workup for infertility, a 34-year-old man is noted to have a solid tumor in the anterior
aspect of his right testis. What is the most likely diagnosis? Cancer of the testis.
19. Which is the most important in the diagnosis of prostate cancer? Prostate Biopsy.
20. The most common form of testicular tumour in infants and children is: Yolk sac tumor.
21. Which is the most common symptom of bladder cancer? Hematuria.

Chapter 24. Urinary Trauma (tambahin table anterior vs posterior)

Kidney Trauma
1. Treatment:
 Emergency: Resuscitation, Treatment of shock and hemorrhage, Evaluation associated injuries.
 Non operative treatment:
 Bed rest for 2~4 weeks.
 Watchful waiting: Vital signs, blood, urine.
 Hydration and nutrition.
 Antibiotics for prevent infection.
 Symptomatic therapy: Analgesic, sedative, hemostasis.
 Operation.
2. Clinical findings:
 Symptoms:
 Pain may be localized to one flank area or over the abdomen associated to injury
 Microscopic or gross hematuria following trauma to the abdomen or flank
 Fever: infection.
  Signs:
 Shock or signs of a large loss of blood from heavy retroperitoneal bleeding may be noted.
 Palpable mass may represent a large retroperitoneal hematoma or urinary extravasation.
 Diffuse abdominal tenderness.
 Lower ribs fracture.
Lab findings:
 Red blood cells in urine: hematuria.
 Hematocrit may be normal initially, but a drop may be found with time past.
 Hematocrit dropping represents persistent retroperitoneal bleeding and development of a large
retroperitoneal hematoma.
3. Pathology:
 Renal contusion: Subcapsular hematoma, Superficial cortical lacerations.
 Partial lacerations: Injuries extend to renal capsule or collecting system, Perirenal hematoma,
Hematuria.
 Deep lacerations: Injuries extend both renal capsule and collecting system, Extravasation of
urine into perirenal space, Large retroperitoneal hematoma.
 Vascular injury.
4. Male, 35ys old, complained of dysuria and hematuria after a car accident, X-ray showed severe
pelve fracture, the mostlikely sites of injury is: membranous urethra.
5. Which item of the following is not an emergency exploration indication for patients with renal
injurys: complicated by rib fracture.
6. Of the following conditions, which is not considered a urological emergency? Orchitis.
7. An otherwise healthy, 30-year-old man is brought to the emergency department after being thrown
off the back of a motorcycle. During the assessment, blood is noted at the urethral meatus. Which of
the following statement is TRUE? A fracture of the pubic ramus is usually associated with posterior
urethral injury.
8. Which of the following is not considered a principle of treatment of bladder rupture: Immediate
exploratory laparotomy is necessary.
9. Which of the following is an absolute indication for surgical treatment of a renal injury? Expanding
perirenal hematoma.
10. A 42-year-old woman involved in a traffic accident presents to the emergency room complaining of
flank pain and gross hematuria, she is hemodynamically stable. The next step in management is:
Computed axial tomography (CAT) scan with the useof intravenous contrast.
11. Which is the most helpful for the diagnosis of bladder rupture: cystography.
12. Which is the most direct and effective means of staging renal injuries? CT scan.
13. Which of the following is the most common type of bladder rupture and often occur with pelvic
fractures? extraperitoneal bladder rupture.
14. Which is the most common urogenital trauma: Urethral trauma.
15. Which part of male urethra is likely to be injured in straddle injure? Anterior Urethra.
Chapter 25. Genitourinary Tuberculosis
1. Pathological renal tuberculosis: No clinical symptoms, Change only in capillary vessel of renal cortex,
Tubercle bacilli in urine, Self-healing, Only the few turned to clinical renal tuberculosis.
2. Diagnosis:
 Symptoms: Most are vesical in-origin: burning, frequency & nocturia, hematuria.
 Signs: External genitalia.
 Thickened, nontender epididymis.
 Chronic scrotal draining sinus.
 Induration/nodulation of prostate & seminal vesicles.
 Lab findings:
 Persistent pyuria without organism on culture. But acid-fast stains:  60%(+).
 Culture for TB (1st morning urine): (+) percentage very high.
 Tuberculin test: (+) against TB.
 Excretory urogram:
 “Moth-eaten” appearance of ulcerated calyces.
 Obliteration of 1/more calyces.
 Dilation of calyces.
 Abscess cavities connecting with calyces
 Ureteral stricture with secondary dilatation.
 Absence of function of the kidney.
3. Treatment:
 Renal TB:
 Combination of drugs (1st line): Isoniazid (INH),Rifapin (RFP), Ethambutol (EMB), Streptomycin,
Pyrazinamide (PZA).
Prefer —— INH + RFP + EMB
 Nephrectomy:
 A nonfunctioning kidney with or without calcification;
 Extensive disease involving the whole kidney, together with hypertension and
ureteropelvic junction (UPJ)obstruction;
 Coexisting renal carcinoma;
 After 6-9m, urine culture still (+) and gross involvement radiologically evident.
 Severe sepsis, pain or bleeding from 1 kidney.
 Marked advanced on 1 side and minimal damage on the other.
 Vesical TB:
 Tends to heal when treatment for the “primary” infection is given.
 Ulcers: Trans-urethral electrocoagulation.
 Extreme bladder contraction: Urinary diversion; augmentation cystoplasty.
4. Infecting organism: Mycobacterium tuberculosis, Tubercle bacilli.
5. Infecting route: Hematogenous route from the lungs, Primary sites (Kidney, Prostate), Other organs
involved (Direct extension).
6. Autonephrectomy: Complete ureteral stenosis. An entire kidney empty extensive calcification, loss
of kidney functions completely. Tuberculosis bacilli can’t flow into the bladder, urine bladder
secondary TB becomes gradually improving and healing.
7. TB is a combination of caseation, cavitation and healing by fibrosis & scarring. Depending on
virulence vs resistance.
8. Differential diagnosis: Chronic nonspecific cystitis, Epididymitis, Multiple small renal stones and
medullary sponge kidneys, Urinary bilharziasis, Bladder stones or cancer.
9. A male, 40 years old, was diagnosed left renal tuberculosis. His bladder capacity is only 20ml with
severe right hydronephrosis and uraemia. What is the best option to do right now? Right
nephrostomy.
10. A 25 years old female had received right nephrectomy because of tuberculosis half a year ago and
taken antituberculosis therapy from then on. Her complain of odynuria had released but frequency
became worse with nocturia 7 to 8 times. The intravenous pyelography revealed slight left
hydronephrosis with bladder contracture and negative urine routine examination. Cystectasy
11. One patient diagnosed renal tuberculosis has non-function in one of his kidney. While the other
kidney was in good functions. What kind of operation you will choose for him? Nephrectomy
12. A 32 years old female had progressive LUTS but had no reaction to antibiotic therapy. Meanwhile
she had significant pain in her right back and mild fever in the afternoon. What will most likely be
found in her urine test? Acid-fast bacilli test and culture
13. What is the chief component in acid-fast bacilli? Lipid
14. If one patient who had been diagnosed renal tuberculosis, what kind of therapy would be chosed
except for his general condition? The discovery in intravenous pyelography and retrograde
pyelography
15. What kind of urinary disease has its pathological changes in kidney, but with the clinical
presentation in bladder? Urinary tuberculosis
16. For a patient whose urine culture discovers Mycobacterium, which of the following examination is
best for diagnosis and treatment. Excretory urography
17. What is the most common complication at the late stage of renal tuberculosis? Contracture of
bladder and hydronephrosis of the other kidney
18. What may be the clinical presentation of urinary tuberculosis? Purulent hematuria
19. Young male has a long history of frequency and urgency, normal antibiotic therapy has no function,
ultrasound examination reveals inflammatory changes in the triangular area of bladder, what kind of
examination must be done to confirm the diagnosis? Cystoscopy for biopsy
20. Young male with sever bladder irritation, normal antibiotic therapy has no function, negative culture
for nonspecific infection, what may be the diagnosis? Urinary tuberculosis

Chapter 26. Brain herniation

1. Cranial cavity is divided by dural septa into 3 compartments, which are left/right supratentorial
spaces & infratentorial space.
2. Tentorial notch & foramen magnum are the anatomic incisures to connect different intracranial
compartments.
3. Brain herniation: The displacement of part of brain tissue from its original location into anatomic
incisures which is caused by pressure gradients that develop between craniospinal compartments.
4. 3 major brain herniation: Transtentorial herniation, Transforaminal herniation, Subfalcine
herniation.
5. The presentation of transtentorial herniation: Deterioration of increased ICP, Deterioration of
conscious state, Papillary dilatation, Hemiparesis, Changes of vital signs.

Chapter 27. Increased ICP

1. Intracranial pressure: Pressure inside the cranial vault, created by total volume of intracranial
contents & exerts on cranial wall.
2. Normal value of ICP is between 0.7 KPa and 2.0 KPa.
3. Increased ICP is when ICP constantly higher than 2.0 KPa.
4. Major causes of increased ICP: Increased volume of normal intracranial contents, Space occupying
lesion, Constrictive cranial cavity.
5. Typical clinical presentations of increased ICP: Headache, vomiting, papilloedema.
6. Treatment of increased ICP: Hyperventilation, dehydration, steroids, removal of occupying
lesion/other masses.

Chapter 28. Brain injury

1. Intracranial hematoma general manifestations & diagnosis: Signs of increased ICP, Depressed
consciousness, New neurological signs, Cushing’s response, Signs of transtentorial herniation, CT
scanning.
Treatment:
 Removal of hematoma
 Decompressive operation- lobectomy, craniectomy
 General treatment
 Management of complication
2. Epidural hematoma: Collection of blood between the inner table of the skull and the dura. Sources
of bleeding: skull diploic veins, middle meningeal artery/ its dural branches, dural venous sinus.
Manifestations:
 Contact loading
 Complication of skull fractures
 Minor primary brain injury
 Coma- lucid interval- coma
 Xray: fracture line cross middle meningeal groove or venous sinuses
 CT: fusiform (biconvex) hyperdense lesion between inner table of skull & dura
3. Subdural hematoma: Collection of blood between the dura and the brain (under the dura). Source
of bleeding: cortical vessels, intracerebral hematomas.
Manifestations:
 Inertial loading, countercoup injury
 Complication of contusion & laceration
 Serious primary brain injury
 Persisten coma, seldom lucid interval
 CT: crescent high density mass lesion between inner table of skull and the brain
4. Clinical presentation of basal skull fracture: Ecchymosis, Cranial nerve injury, CSF leak, Intracranial
pneumatosis.
5. Primary brain injury includes brain concussion, brain contusion & laceration, diffuse axonal injury.
6. Most common intracranial hematomas: Epidural & subdural.
7. Intracerebral hematoma:
 Complication of brain contusion & laceration
 Severe primary head injury
 Persistent coma
 Hematoma at the place of contusion & laceration
 CT: intracerebral hyperdense lesion
8. Craniocerebral trauma: The injury to head by mechanical forces.
9. It can be classified into cranial injury & brain injury.

Keypoints for ortho.

1. Dugas sign: When the elbow close to the chest, the hand can’t touch the opposite shoulder. If the
hand touched the opposite shoulder, the elbow can’t close to the chest.
2. Colles fracture: It happens when wrist extends & forearm pronate and hand touches the ground.
3. Compartment syndrome: Acute medical condition characterized by raised pressure within a closed
space with irreversible damage to the nerves & muscles containing in the compartment.
4. Tinel sign: After nerve injury, axonal regeneration is fast than remylelination, then axons exposed,
allergic phenomenon outside tapping can cause pain, radiating pain & a sense of shock. Along the
nerve repair cadre, arrived at front end of neurite regeneration by far the feeling, which is positive,
that reaches the part of nerve regeneration.
5. Mills sign: Use for lateral epicondylitis (tennis elbow). Elbow held in extension -> one hand to
compress lateral condyle -> other hand to resist wrist rotation & distal extension -> reproduce pain.
6. Therapeutic principles of dislocation: Reduction, fixation, early functional training.
7. Main diffuse pathway of abcess in acute hematogenous osteomyelitis:
 Direct spread through skin wound (exogenous).
 From distant infection site through blood flow (hematogenous).
 From adjacent local soft tissue.
8. What may influence heal of bone fracture:
 Systemic: Age and systemic condition.
 Local: Pattern of fracture (stable, non-stable), blood supply (good for both fragment, good for
one, bad for both, absent), infection, injury soft tissue, soft tissue interposition between
fragments gap, local disease.
 Treatment method: Repetitive reduction/manipulation, over-traction of fragments, incorrect
reduction/fixation/debridement, influence of open reduction, incorrect functional exercise.
9. Management of fractures consists of: Reduction, Immobilization, Rehabilitation, Medication.
19. Intervetebral disc in adults composed of: Cartilage plate, Annulus fibrosus, Nucleus.
10. Accurately diagnose bone tumor, doctors must combine the information from: Clinical feature,
Imaging appearance, Biopsy.
11. Special signs of fracture are: Deformity, Abnormal mobility, Crepitus/grating.
12. Highest incidence of intervetebral space in lumbar disc herniation : L4/5 and L5/S1.
13. The anterverted angle of femoral neck is 12-15.
14. Which one is commonly injured in the fracture at the junction of middle and distal thirds of the
femoral shaft: Deep femoral artery.
15. CASE. (10 points)
11 y/o children presented with red, swell, pain for 5 days in right knee. T.39C. right knee were red
and high skin temperatue, haphalgesia and limitation of motion. WBC increase (16.7x109) with
relative neutrophile granulocyte (86.7%).
 What may be the diagnosis? Acute osteomyelitis. Ddx: Acute septic arthritis.
 Which test is the most helpful for diagnose? Imaging test, X-ray (still negative until 2nd weeks),
CT, MRI (not specific), Blood culture for detecting bacteria, ESR rate, Aspiration of pus, Bone
scan tc99.
 How to treat? Hydration, electrolyte replacement, analgesic, immobilization; Antibiotic;
Surgical drainage.