BLACKWELL'S

VIKAS BHUSHAN, MJI

llrlivt.r,sityof California, San Francisco, Clws or 1991
Series Editor. Di~~gnostic Radiologi<t

VISHAP, PALL,MBBS
Govert~rnentMedical Cc~llegc,Chandigarh. India, C h w nf 1996
Serirs Editol; U , of Texar, gal vest or^. Resident i11 Internal Medicine &c
Preven live %ledicine

TAO LE, MD
Universiry Califcirnia, San Francisco, Class of 1996
PARAG MATEFUR, MD
Mayo Schotll oT Medicine, Class nf 2001

JOSE M. ITERRO,
La Sallc I;nivrrsitv. hRlcxicn City
HOANG NGUYEN, MD, MBA
Northwestern U n i v e ~ ~ i tClash
v, of 2001

Blackwell
Science
CONTRIBUTORS
Fadi Abu Shahin. MD
Svl-ia. CF:ws of 19W
tv or Da~r~a*cr~u,
l~i~ivei-si
Aarchan Joshi, MD
lrCI.AJi~lesS ~ r i T;.vc
i ~ Knsti~~ite
Vipal Soni,
Ir(:L4 School nf \frrlirinc. C:la<snT 1 qI10
Diego R~uix,MD
F'CSF Schrml 01 Mcclirinc, [;law o f 1909
Notice
The :~urho~-s of 111ih tulumc IIAVP ~ ~ i 111artlir inthrm;~ric~n
t ; ~ k 13r.t' cunlair~ccl11crci11i q arcumrr and compui-
Ijlc wilt1 tlie \tnnrlartE~ge-rnrl.al11arrrptt-rl at the ~ i i n c of p~lhlicnrion.Y~vrrthrlesh~ it i?dim<rdt 10 C I I S U ~ C
that all thr ~nfnrmation~ v e r is r r r ~ tclv
i ~ accllrate I'or a17 crrrtImsrancc<. The p ~ ~ l , l i ~ h c r a~lthnrs,do nut
anrl
Fiamntee Lht- rtlntents of thih I>c~r)k and disciaim arlv liahilite 10%. o r rfanlagc iflcllI'red ac ii mTIVCqUeIlCe,
(lirt*cll\ ar intlircctlv, nf t l l r Il\r and hppliration o f any o f tllc con1cnL.u ol' l h t f vnltln~?.
CONTENTS
Acknowledgments
Preface t o the 3rd Edition
How t o Use This Book
Abbreviations
Cardio 1ogy
Gastroenterology
General Surgery
Arteriovenous Fistula
Atrial Septal Defect
Carhac Tamponade
Coarctation of the Aorta
Femoral Hematema
Patent Ductus Arteriosus
Tetralogy of Fallot
Ventricular Septal Defect
Hypoparathyroidism-Iatro genic
Choanal Atresia
Choking
Sialolithiasis
Thyroglossal Duct Cyst
Tonsillitis
Boerhaave's Syndrome
Congenital Biliary Atresia
Dmping Syndrome
Hiatal Hernia
Hirschsprung's Disease
Pancreatic Pseudocyst
Peptic Ulcer-Perforated
Portal Hypertension
Tracheoesophageal Fistula
Abdominal Aortic Aneurysm-
Ruptured
Femoral H e r n i a 4 txangulated
Hemorrhoids-Thrombosed External
Inguinal Hernia-Direct
Inguinal Hernia-Indirect
Meckel's Diverticulum
Mesenteric Ischemia
Petit's Triangle Hernia
Popliteal Fossa Trauma
Richter's Hernia
Sigrnoid Volvulus
Splenic Rupture
Straddle Injury
 Ureteral Injuy-Iatrogenic
Varicose Veins
Gynecology Gartner's Duct Cyst
Uterine Prolapse with Cystocele
Heme/Onc Squamous Cell Carcinoma-Lip
Immunology DiGeerge's Syndrome (Thymic Aplasia)
Neonatology Caput Succedaneum
Congenital Diaphragmatic Hernia
Duodenal Atresia
Hypertrophic Pyloric Stenosis
N~phroiogy/Urology Nephzoiithiasis
Vasectomy
Neurology Acoustic Schwannoma
Acute TorticoIlis
Aphasia-Wernieke's
Astrocgtoma
Bell's Palsy
Brown-Sequard Syndrome
Cavernous Sinus Thrombosis
Common Peroneal Nerve Damage
Deafness-Conductive
Epiphyseal Separation with Ulnar
Nerve Palsy
Erb's Palsy
Facial Nerve Injury
Femoral Nerpe Palsy
Hypoglossal Nerve Palsy
Humpke's Palsy
Long Thoracic Nerve Injuy
Mass in Jugular Foramen
Medial Medullary Syndrome
Obstructive Hydrocephalus
O b s t r u ~ v eSleep Apnea
ParEnson's Disease
Recurrent Laryngeal Nerve Lesion
Spina Bifida
Trigeminal Neuralgia
Wallenberg's Syndrome
Obstetn'cs Ectopic Pregnancy-Ruptured
Pudendal Nerve Block
Orthopedics Ankle Sprain
Arm-Radial Nenre Palsy
Clavicle Fracture
Elbow-Lateral Epicondylitis
 -
Elbow-Median Nerve Palsy (Nonearpal)
Elbow-Radial Head Subluxation F?7
Forearm-Monteggia's Fracture r+<1
Hand-Boxer's Fracture 1:. \
F "3
Hip-Legg-Calve-Perthes Disease
c- >r
Hip-Trendelenburg Gait
Hip Dislocation-Congenital 7 B
Hip Dislocation-Traumatic > :+?

Hip Fracture C- i
Knee-Combined Knee Injury 1- ,$

Knee-Osgood-Schlatter's Disease r A +t
~eg-compartment Syndrome
Pelvic Fracture
F"
, -- 1
* A
3

" - 8

Shoulder Dislocation I I
r.-- 4
Shoulder Separation
Spine-Prolapsed Intervestebral Disk
Temporomandibular Joint Dislocation r+''f
Thorax-Cervical Rb I
F
Wrist-Carpal Tunnel Syndrome
Wrist-Scaphoid Fracture I
,"
.1
<o

Wrist-Slash Injury i
Lung Cancer-Lymphatic Metastasis r -1
Lung Cancer-Pancoast's Syndrome -z,q
ACKNOWLEDGMENTS

T l i r ~ ~ ~ the
g h production
o~~ of this book, we have had the s u p
port of marly friends and colleagz~es.Special thanks to our sup-
port team including rZnu Gupta, Andrea Fellows, Anastasia
Anderson, Srishti Giipta, Mona Pal1,Jonathan Kirsch and Chirag
Amin. For prior con tril>t~tiotis
we thank Giarlrli LC N,pyen,
Tan111Mathur, Alex Grimm, Sonia S ~ I I ~ Cand
I S Elizabeth
Sand~rs.

Ilrc Irave elljoyed working with a world-class interna~ionalp u b

l i s h i n ~RI-OUP at BEackwell Science, irncluding Lnt~raDeYnrnlg,
Arny ?lutthrock, Lisa Flarlagan. Shawn Girsberger, Earna Hind
. help with securing images for the
and G o r d m ~T i b h i t ~For
entire series we also thank Lee Martin. Kristopher Jones, Tina
Panizzi and Peter Anderson at the University of Nabanla, the
.bed Forces Institute nf Pathology, and many of otir fellow
Rlackwell Scicnce authors.

For sublnitting cornmentr, corrections, editing, proofreading,

and a<sistat~ceacross all of the vignette titles in all eclitions, we
collectiveIy thank:

Tara hdamo\rich, Catnlyl A m x c k r , rCris rllden, Ht-nry E.

h y a n , Lynman Bacolor, Natalie Eartenem, Dcar~Earthnlom~w,
I)rhast-lish Bchera, Sumit Lhatia, Sanjay Binclra. Dave Erin tot],
Juliailne Brown, Alexander Brownie, Ta~naraCallahan. David
Canes. Bryan C:a?ey,h r o n Caughev, Hehert Chcn,Jonathan
Chet~g, Arnold Cllcung, Arnold Chin, Simion Chirlsea, Yoon QIO,
Samuel Chung, Gretchen Conant, Vladimir Coric, Christopher
Cosgrove. Ronald Cowan, Karelzin R. Cunningham, A. Sean
Dalley, Rama Dandam licli, Sunit Das, Ryan Armando Dave, John
Dnvid, Emmantiel rlr la Cruz, Robcrt DeMello, Nnvneet Dhillnn,
Sharmila nissanaike, David Donson, Adolf Etchegat-ay. N e a
Etwebio, Priscilla A. Frase, Ilavid Frenz, Kristin Gaurner,
Yohannes Gukreegziabhrr, Anil Gcbi, Toriy George, L.M.
Gotanco. Panrl GoyaI, Alex Griinnl, Rxjrev Gupta, Ahmarl
Halirn, Sue Hall. David Hasselhacher, Tamm Heimert, Mich tile
Higley, Dan H u i ~Eric , Jackson, Tim Jacksor-l, Sundar Jayarxtnan,
Pei-Ki Jot~e, L ~ r c h a n J o s h i Rajn
, i K. Jutla, E a i p Kapadi, Seth
Karp, Aaron S. I<essellieirn,Sana Khan, Atldrew Pin-wei KO,
Francis Kong, Pal11 Konitzky, Warren S.Ktac kov. Benjamin H.S.
Lau. ,Inn LaCxsce. Connie Lee, Srott Lee, Guillenno Lehmann,
k c i n h u n g , Pat~lLevett, Warren Levirlson, Eric Ley, Ken Lin,
 Pave1 Lobanov. J . Mark Maddox. Ararrl Mardian, Salnir Mehta.
Gil Melmerl, Joe Mesqina, liobert Mosca, Michael Murplly, Vivek
h'andkarni, Siva Naraynan, Carvell Nguven, Linh Nguyen,
Deanna Nnbleza, Craig NodurFt, George Naumi, Darin T.
Okuda, Adam E. PaIance, Pan1 Pamphn~s, Jinha Park, Sonny
Parcl. Ricardo Pictrohon. R i n L. Rahl. Xashita Randeria,
Rat-Iran Rcddy, Bcatriu Reig, Mali1011 Reyes, Jeremy Richmon,
Tai Roe, Rick Roller, Rajiv Roy. Diego Ruis, A11 thnny Russell,
Xnnjay SahgaI, Urm imala Snrkar, John Schilling, IsabcIl Schmitt,
Daren Schu hmacher, Sorlal Shah, Fadi Abu Shahin, Mae Sheikh-
Ali, Edic S l ~ c nJustin
, Smith, J o h n Stulak, Lillian Su, Julie
Surldaram. Ritii Suri. Seth Swuctser, ,;lritoriio TaIayero, Merita
Tail, Mark Tanaka. 'ric Taylot; Jess T ~ I O I I ~ ~ .Inrli
S C Ili-ehan,
R,
Ka)miond Tl~mer,Okafo L:cheilna, Ktic Ilygllatlco, Riclla
Vrrrma,John Wages. Alan IVang. Eunice UTang,,211dy Mrciss, Amy
IVilliarns, Brian Yang, Rally Zakr; Ashraf Zaman mcl David Zipf.

For genernnlsly cotlrributing images to the entire Unrlvpound

t ~ I wries, we coll~ctivelyt h a n k the starrat
CIinAl-nl I ' p ~ f Step
Blackxvell Science in Oxfard, Boston, and Berlin as well as:

Axford, J . iMrcIirirr~:Ostley Mead: R l a c k w ~ l lScience 1-id, 19%.

Figures2.14,2.I.5.2.lti,2.27,2.28,2.31,2.55,2.3f.2.38,2.41(,
2.65~.2.65h, 2.6.5c, 2.103h, 2.105h,3.20h, 3.21, 5.27. 8.2717,
8.731, S.77c, 10.81h, I0.96a. 12.28a, 14.6, 14.16, 14.50.
Bannister R, Begg N,Gillespic S. I nf~rte'oz~s
D k s ~ 2""
, Edition.
Osney Mrad: RIackwell Scierice t t d , 2000. Figures 2.8, 3.4,
5.28, 18.10, M'5.32, M75.(i.

Rerg D. Ad~t-r,nnrvrll J h Erul Sfca'llsnnd P$l ~irrrlI)irqytosis.

EPackwcll Science Ltd.. 1995). Figures 7.10. 7.12, 7.13, 7.2, 7.3,
7.7, 7 3 , "151, 8.1, 8.2, H . 1 , H.5, 9.2, 10.2, 11.3, 11.5. 12.6.
Cuschicri A, Hcnncssv TPJ, Gccnhalgh RV,Rowley DA,
Grace PA. trl S t c r q q . Osney Mead: 13lackwell Science
Ltd, 19i16. F i ~ ~ r 15.19,
es 18.22, 18.33.
GiIlespie ST-!,Eamf'ord IC lM~dirnliVlirml7ioIn~and Infedion at a
Glnrlcr. Osnev Mead: Blackwcll Scicnce Ltd, 2000. Figures 20, 23,
Ginsberg L. Lecturr h~oteson I ~ ' ~w ZI oI ~ , 7" Edition. Osney Mead:

-
Rlackwell Scierice I,td, 1999. Fig~ll-es12.3, 18.3, 1P.Sh.
EIliott 1': Hastings M nD e s s ~ r l x r g ~U.r I , P T ~ ~ I , ~ on
PN O~P.T
~Mprlirnl
Mirrohiolngy 3" Il,Jitiou~.Osney Mead: 5lackwell Science Ltd.
1997. Kgurcs 2, 5. 7 , 8. 9. 11. 12. 1.1. 15. 16. 17. 19, 20, 25, 26.
c - q
2 f , A, :<o,94, 35, 32.
 Mchta AB, FJoEFbmnd AV. Ho'oprnnroln~nf a C l ~ n r r .Osnev
.
Mead: Blackwell Science Ltd, 2000. Figures 22.1, 2?.2,22.5.

Pleaqe let us know if your name has been missed or mi~spelled

and we will he happv to make the update in the next edition.
PREFACE TO THE 3 R D EDITION

We were very pleased ~ i t the

h ovem~helminglypositive student
feeclhack for the 2nd edition of our L ' n h p n d C:Iiniru,/Vii$71,dt~.~
wries. M'ell over 100,000 copies of tllc LTLV books are in print
and have beer1 used hy student5 all over the world.

Over the last two years we have accumulated and incorporated

over a thousand "updates" and improvement5 suggested by ~ ' O L I ,
our waders, including:

marly additions of specific hoards and wards testable content

deletions of' redunclant and overTapping cases
reordering and reorganization of all cases in both series
a new master indcx bv case name in each Atlas
correction of a fcw factual errors
cliagnosis and treatment updates
acldition of 5-20 new cases in every book
and the addition or clinical exam photo4qgraphs within UCV-
An,ntomy

And most important of all, the 111ird edition sets now include
two brand new COLOR A T W suppIcmena, one for each
Clinical Vignette scries.

The UCV-Bnsir ScGnrr C:lrl~rAttm (St+ I ) includes over 250

color plates, divided into gross pathology, microscopic patl~ol-
ow (hi~tology).hematolom, and microbinlogy (sinears).
E has over 123 col nr
'I'he PICIT-CIinicn? Science CO?MA [lor ( , C ~ 2)
pIares, incIuding palien t images, dermatol~~gy, and fundus-
copv.

Each atlas image is descriptivelv captioned and linked to its cor-

responding S ~ e p1 case, Step 2 caw. and/or Step 2 MiniCase.
How Atlas Links Work:

step I Book Codes are: 2 = .2natomv Step 2 Book Eoden are: FR = Fmergeilcv hlerllc~nc
nS = H r h a v ~ na!~ Srlrnre IM 1 = Inremail \ft.rI~clr~e.
t'ol. 1
BC = I5tr1c11cnll\lrv 1M:! = lntri nal CIrdirir~e.\bl. 11
M1 = M ~ c m h ~ n l nYol. p. 1 SlCU = Nrrimln~?;
M'1 = M ~ c r n h m l nVnl. ~ ~ T~I nn = OH/(:W
PI = Pa~hopliwitrlc~gy. 1'111 T PEn = Pedistnrs
P2 = I ' a ~ l ~ t r p l ~ c ~ ~Xh1.
n l o p[I . SLIR = surge^ v
P.7 = I'a~hcrph~ctnln~. Vnl. TI1 SW = Pavchint~1
PT 1 = P h a r n ~ a r n l o q \lC = MinrGa~t.

T1--u
\/ A M-P3-032A
Case hlumber

ER-03 5A, ER-035B

/
Indicates Type of Image: I I = Hrrn,unlr,gv
M = MICI u~hinlncg
PL = C:I o s c Pdrhnlnp
7 Indicates UCVl ar UCV2 Series

PM = hllrrnwnprr I ' a r h o l o ~

If the Casr number (092, 035, etc.) is ntlt f~illowcdby a letter.

then there iq only one image. Othcnvisr A. R. C , I1 indicate
1113 10 4 i~na~;es.

Bold Faced Links: Fn order to ~ v you

o accps5 to the largest
tlurnl~erof irnages po%sibIe,we haye chosen rn rross link the
Step 1 m r l 2 series.

IT tlw lilik is holcl-Facccl this indicalcs t h a ~the link is direct

- ( i . ~ . Srep
, 1 Casc with h e Rasic S c i ~ n Step
c ~ f Atlas link).

TI' ~11elink is not bold-Eaced lhiri itidicates that the link is

indirt-ct (Step 1 case with Clinical Sciencr Step 2 Atlas link or
vice versal.

11'~11:1walso irnplement ~ adCew stn~ctliralchanges upon your

I-eq~~es~:

* Each current ancl Cuture crlition of our popular Ant Aid for
IJlr 1!SMfJ<S'lri, J (AppIeton Pr L;lrige/ McGra1t7-f1ill) and Firs[
Air1 Jrjr t f i p ILCZIIZ St? 2 (AppleLon k lAange/McGraw-Hill)
book ~villhe lir~kedLO I he cnrscspoilding UCX' case.
Wu eljxrlinated UCV + First Aid links a.i the? Frequently
b e c o r ~o1~1t~nf date, as thc Fir.r/ Aid 13ooks a r r revised yearly.
 The CoIor Atlas i s also speciallv designed for qui~zing-
captions are descriptive anrf rlo not give away t1lc caw name
directlv.

We hope the updated UCV series will remain a u n i q ~ and

l ~ rve!l-
inzegnted study tool that providc~cclrnpacL clinical con-eIations
to hasic scici~ceinfurmation. They are designed to bc casy and
fun (comparatively) to read, ancl helpful for both licensing
exams and the wards.

We invite yolxr corrections ancl suggestions For the fourth edi-

Eion of these hooks. For r he first submission of each factltal cop
rcctior~or new vignette that is seIccted for inclusion in the
rourth edition, yo11will rec~ivea personal acknowleclgment in
the revised hook. If vou submit ovc-1- 20 higliqual iiy corrections,
additions or new vignettes we will also consider inviting you to
become a "Contributor" on the book of your choice. Tf )roll are
interested in becorning a poten rial "Conrnihutor"ol-"12nthnr"
on a fi~tureUCV hook, or working with our teaor in devrloping
additional books, please also e-mail us ynur W/rcsllme.

Wc prefer illat you submit corrections or srqgesrions .via

elec trotlic mail to UCVteam@vahoo.com. Please incltide
"Und~rgro~ln d
vignettes" as thc subjecl of'your message. If you
not hwe access to e-mail, use the I;~IInwingmailing address:
1-10
Blackwcll Ptlblishi ng, Attn: Eclitors, 350 Main Stwet,
Malden, MA 021 48. USA.

IJikcas Bhushrrn
I/i.qhnl PnM
Tan 12
October 2001
This series was originalIv clevelopcd tu address the increasing
number of clinical ~-i;ignctteque5tions nn medical examinations,
including the USMLE Step I and Stcp 2. It is also drsihmed LO
supplcm t n t ancl conydempnt the popalas Fir~l,4i/f.[m! l i p
IJS,WIJ:'SIP/)I (Applernn XE Lange/McC;raw Will) and Fjrst Aid
/br 191r1i,Ti2111.Sf+ 2 (Applrtnr~k Lange/McCmW Hill).

Each LJCV 1 lmok rise%a series of approsirnatelv 100 "supra-

prototypical" cases as a way to condense testable facts and
e s his ser-ieq are cleqignect to
associations. The clinical ~ i ~ p e t t in
incorporare as man!: reqtable fact5 as posqi hle i tlto a cahesive
and nlemorahle clinical picture. The vigziertes represent
ctlrnpmites d r m n from general and special+ textbooks,
refel-cnce hnnks, zhr)~tqandso f IISMLE stvle q u ~ ~ t i o and n s the
personal experience of the authors and reviewers.

Alt h o u ~ heach case tends to presrn t all the signs, symptoms,

and diagnostic findings for il particular illness. patients gener-
ally will not present with such a "complete"picture either clini-
cally or on a medical examination. case^ are n o t meant to
sirn~~late a potential real patient o r an exam vignette. All thc
boIdfaced "hnzzwords" are Far learning purposes at14 are nor
nrresuarily expected to he fo~undin arlv nne palient with the
cliseasc.

Definitionl; ofLselrrtrdimpnrtant term? are plared within the

vignettes in (s~11.r t ~ ~ ins pamnthescs.
) O t h ~parcnthctical
r
retnar-kls oftell refer r t j the pathophvsinlngy o r tnechanism of
cli~ease.The format shonlrl also help stuclents lcarn to present
case5 s~~ccinrtlv during oral "bullet" p r c s e n ~ ~ t i o on
n s clinical
rotatiuns. TI-ICcases arc rneant to s c n e as a cnndensed review,
tlclt as x priman?refet-ence.The information provided in this
hook has heel1 prepared with a great deal of though^ and care-
€111 research. This hook should nut, however. I>rcousiilered as
your sole eoiirce o f infosma~ion.Correc~inns,suggestions and
submissions of new cases are encouraged and will bu acknorul-
rrlgerl and iiicorporxterl whet1 appropriate in fl~tur-reditions.
5-ASA 5aminosalicvlic acid
ARGs arterial hlood gases
ABVD adriamyc:cin/bleornycin/~incristi~c/daca~b~ine
,4CE angiotensin-converting enzyme
ACTH adrenocr>rticntmpic hormonr
,4RH antidiuretic hormone
AFI' aIpha feral protein
A1 aortic insufficietlcy
ATnS acquired i~nrni~nodeficiency
syndmmnp
.ALL acme lymphoc"ic kukernia
,4LT aIanine t r a n s a r n i i ~ ~ e
AWL acute myeIogennuq leukemia
ANA antinuclear antibody
mns adult respiratory distress syndrome
ASD atrial septa1 defect
AS0 anti-streptolysin 0
-4ST aspartate tlansam inaw
AV ;~rtcrio~renous
BE barium enema
BP hloocl pressllre
RUN blood urea nitrogen
CAD coronary artcry disease
CALLA common acute lymphohlastic leukcmia antigen
CBC curnplete blood count
CHE congestive hcart fajlure
CK creatirle kinast.
CIALA chronic Iympt~ocyticleukemia
CML chronic myeIogenous leltkemia
cwr cpornegalovirus
CNS cen trai nervous system
ccwn chronic ohstl-uctive p u l n ~ o n a ~disease
y
CPK creatinp pho~phokii~ase
CSF cere hrospinal fluid
CT computed tomographv
C17A cet-el~r;nvwc
izlar acciden 1
CXR chest x-ray
DIC disseminated intravascular coagulation
DIP disral inrerphalangeal
DTW diabetic ketoacidosis
DM diabetes rnellitus
DTRs deep tendon reflexes
DVT rlccp vcnoris thrombosis
E131' Ep=+tein-Rarr vi.inls
FCC; clcctmc:rl-cliography
Eclirs echocardiography
EF qjerti(111lLrac-tion
FGD t-sop~~a~op~~rod~1nc1~noscopy
EMG clec~rnii~v~~g~~phy
ERCP cndascopi~rrcrogr-;ldr c h o l a n ~ o p a n c r r a t u ~ ~ i ~ ~ h v
ESK erythrocyte s~clime~~tatic,n r-atr
FE\: rcrrcrti expirxtn1-v rwlunle
FNA fine irceclIe aspil.ation
FTtZ-,%I3 S [luorrsct-nt trrponcn~alant ihndy ahsorption
F5-(: Inrcrrl v i ~ dc i ~ p a r i ~
c;1:1-t glomcn~larfilrration r;~tc
1 grow111 l ~ o r m o n c
GI ~ a s t r o i trstinal
n
I;M-CSF granulocyte macroph;\gc coton\ qtirnt~lating
li~ctor
GP' gvlii~ o ~ ~ r i i ~ a r y
1 Li\' hcpatiti? h L~I-11s
I1cC hw11;~ncl-turirtnic gc~n;z<lntropt~il~
HEEKT head. evr.;, rai-9. nnsr, and thr-oar
Hn' hl~rnnnimtnunocleficici~cvvirus
I TL4 hnman lu~rkr>c),te a~~rigen
I IPl history of prrserlt illnesc
HR hcan rate
HKJC; lniman t-allies in~lnuneglr~hufin
f.lS hcrcclitarv spher.r>cy~usis
ID/C:C: identification anrl c hieC colnplain t
rDnv ii~.;itIin~lrlr~r~cletii rliahelc-3 rnellitus
IK itnm i ~ n o g l n h ~ ~ l in
rC:T; irls~tlin-likejirowth Cactor
I hl i13 traml~scul;t~*

.PT j~igularT-enouspreqsurr
RUE Iti~lneys/i~r~ter/t~IacLrler
1,DM Iariale deh~rlrr~genasr
LES lower tsophagewl splliilcler
LIT5 li\.er- li~tlctiontests
LP lumhar p~lnrizll-e
I ,I' left vetr tr-icular
LW-l Icft 'tvenfric(tl;tr hyperi rt)phy
1,l't PS electl-nlytey
R.IC:IIc mean cr>rplisct~f;lr hpnjt~glol>in
rnncrntration
MCW meail CCEI-~IISCZI~:II- ~ml~~rnt'
MEN rnilltiple endocrinc ncolslxia
MHC
Nl1
h,lOPP
pracarbazine Jprc-dnisone
hlK tnagnelic rcsonancc (imaging)
t\TfIl, norl-Modgkin's 1~mphorn:i
NIDDM non-in5uTin-clcpc11dent cliabetev mell i t u s
NPO nil per os (norhirlg h? ~ 1 1 ~ 1 u t h )
NSATD nonste~oiclalanti-inflan~mato~v dri ~g
PA poqteroantei-ior
PIP proximal in t erp halangeal
PBS peripheral I~loorlsnie;w
PE
PFTF
PMI
PMN
PT pr-othrombin time
PTCA percliiaileotis transIuminal angioplasy
l'TH pat-athyt-<)idliorn~o~lu
TTT partial t h rorn boplalirl ~ i m c
PUD peptic ulcer disexre
KHC: r r d blood cell
Rl'R
RR r-espiralnry rare
RS Rced-Sternbet~ (cell)
R17 right vcntricrilar
RXW ~ hypertropll!~
right v e n t ] - i r 11ar
S BFT s ~ r ~ abowrl
ll follow-through
SIiZDH sy~ldrorneof inappropriate secret ion 01' ,AnH
SLE systemic 111p1isei~tYlemat~sus
STT) srx~raI1yt~~i-lsrnitted disease
TITS tliyroirl lrlnctien tesw
P.4 tissrie pln5minc~genactir*;lzor
TSEI thyroirl-stim ~rlacingyhormone
TIIIC: rota1 ir-on-binding capacity
TIPS transjugular intrah epa tic pr>rtos).stumicshunt
TPO ~hyroiclpcroxiclase
*rsH 1hyrr3icl-stimulating hormone
-rrP t h r o ~ hatic
n thrornhr>cytopei~icpurpr~ra
LTA urinalysix
LTCl upper G1
LTS
VDRL Venereal Disease Researth Lahnratot?
VS vital si%gns
TJT yen I 1-icular tachpcal-clia
WXC: while blond cell
MT'M' Mbl IF-Parkinson-Whitc (.wndrome)
SR s-rav
 ID/CC A 29-year-old male cornes to the medical clirljc beca~iseof
palpitations, wexkne~s,atid fatigue that dr~esno( allow hirn
to 19-alk more than five blocks, togethrt- wit11 coldness of his
right foot.

HPI H e underwent suFgery 4 wccks ago for a punctrating stahwound

n
injury in his right groin that h e sus~ainecld u ~ i n ga fight. P
XI

PE VS: marked tachycardia. PE: continuous murmur anrl easilv E

r
palpahle thriIl over area of woutlrl: skin over wound warm to 0
G7
touch; right Coot rolrl to touch with diminished puke: <
tachycardia diminished when pl-ussure appliecl to site of fistula
( RK\~VTIAM's
SIC~K).

Labs CBC/Lytes: normal. LlTs, glucose. BUN, creatinine normal.

Imaging MR/.4n*o: largr A17 connection (fistula) in gruin arra with

significant diversion of hlnnrl flnw. IJS: color-flow Uopplel- s l ~ n w ~
rainbow-colorcd turbulence in fistula: high-velocitv and arterial-
ized (pulsatile) wavcform in draining vein.

G ~ S Pathology
S Ahnurmal communic;itiun between artcry ar~clvcirl. iri this case
as a result or a penctrating injury.

Treatment Surgical repair if symptomatic and large: angiographic

cmbolisation if smallcr. Ultrasound-guicled direct compressiuri i s
snmecimrs an option.

Discussion Arteriovenouq fistula rnav clinically prcscn t ar high-output

cardiac failure. larrogenic AY fistulas rnav be seen die]-
artrriography.

ARTERIOVENOUS FISTULA
 ID/CC th prr,gi.essive shortness of
,4 I2-ycai.uld furnalc pl-csrnts ~vi
breath on exertion artd palpitations.

HPI T h e p~tiriithas Ileeti ymptoin fi-ec until now.

PE VS: irregl~lal-lvil-l-egilal-~ I I I S P . PE: Eel? pal-asternal hcavr: grade

111/V1 v t o l i c ejection flow murmur in lcfi second intcl-custal
qpace: widely split, fixed 52 (docs no1 changc nith breathing).

Labs EC:C;: atrial fibrillation: RSR pattern in riglit pru~~r~rlial

leads:
riglrl-xis clexi:itioii (rig111 \,en~ r ii~lar
c hyper-1.1-ophy).

Imaging C S R clilxtcd proxinlal pnlmonary nrterics: increased pulmonary

vascularity enlai-grrl right atrium anrl right vcntriclc.: small aor-
tic knoh. Eclln: paradoxical septa1 movement; left-t (>-rightflow
Gtr-cliac cathcttrization confir lniltory.

Gross Pathology The iiiost cniiirliclil (r $r.nl iq i t ) fie midseptum, in the area of the
I tllosr in tllc Tower scptlinl
Soramen omle (OSI 1 1 . h S~ I ~ . I , C I U DIM):
((n\nrlu P K I M I I Z ~ ) are associatc,d with AV valve iincsnl;~lieu(rnosr
cclrnnlurl in D o M ~ ' "11ir1sr ~ ; ill he 11ppts srpltlin ( s r ~ r l sv i . ~ t l s ~ s )
arc. awx-ixterl wirh anomaln~lspulmot~aryvenous return.

Treatment Sz~rgicalor intcrrrntionnl angiographic clos~~rc. of'drfect with

pros111r.ric patch. Operalive repair i q r.ecotnmenderli r all ~ symp
wirh ostitun secunrlutn rlefeclts re~ardlessof size
i t m ~ a t i ct>;lti~iitq
of'rlcfrct.

Discussion Oxygerlaterl hlt~urlli-rrin l l ~ el ~ f a1 i rit~rn~ ~ S S Pinto

T the right
atrium. irlcrcasing r i g h ~ventricular ontput ancl pulrnonasy flow.
Acyanotic (Iefi-ro-I-i~hr s h u n t ) ; ~ t l emnqt cotntnotl congenital
11c;lrr rliscasc in aclults. Scquclae r ~untreatedf acrial scptal
clcfrc t~ inrIudc paradoxic emboli, infective endocarditis, ; ~ n d
congestive heart failure.

Atlas Link LTT-= PEA-002

A T R I A L SEPTAL DEFECT
 ID/CC A 25-vearuld male postal worker whn waq stabbed in the chest
a n~tygingis brought to the cmer-getlcy room in a semi-
rh~rit~g-
conscious shte, gasping for air (DWPKEA).

HPI T h c knife penetrated the 1ho1.acicwall at (he luvc.1 of the f o ~ ~ r t h

intel-cmtal ?pace alor~gthe left sternal borcIcr.

PE VS: hypotension (BP 'JOJ40) that does not respond to rehydra-

;o
S
tion; ir~spira~ory Io~veringoTq5rolic RP hv > 10 mmHg (~rrr.sris s
r;la~ncrxrls).PE: increase in venous pressure wi Ih itlspiratory
lilling nf rlerk veins during inspiri~tion(Eirrss~.e.ku~'s
SIGN);
R<
cI(n-ingdrawing of venous hlootl, svl-inge filler1 qpon tat-ieo~~sly
(clue to increased venous pt-ess~wef : apical impulse diminished;
heart sounds seem distant; paticnc a150 cyanotic.

Labs ECG: reduced vnl tage.

Imaging CXR: car-cliomegalv,I N I ( ivitli acute heinopericardi~~m , tlte heart

shadnw may not enlarge; thus d i a ~ o s i iss clinical. Echo:
pericardial fluid; dias~cdic collapse of right ventricle ailrl atria.

Gross Pathology BIood rrom sitrs of injury fills pericardial sac, causing conlpres-
sion of all l ~ e a rrhamlwrs
t anct pl-ruenting vennns i-etril-11,heart
filling, and artcrial Q I I ~ ~ O ~ V .

Treatment Immediate pericardiocentesis ancl subseqllelzt operative thorn-

cotomv and pci-icar-dialcFecornprrssion with rrpair of laceration.

Discussion Unlike this case, the ma-jnrir), oi"pat irrits ~ vt h i penetrating cltest
11-aumawill have a pnrumothorax or hetnothorax. The triad nf
Ecck (hypotension,distant heart sounds, and increased venom
pressure) is c h a r a c t w i ~ f i cnT cardiac tampolrade.

7 C A R D I A C TAMPONADE
 IO/CC A 57-year-oid male is seen l3y the resident on call hecausr hc
complains of pain in the p i n area and coldness in the right
foot.

HPI He ~lndcfwentcoronary angiography that morning for evalua-

cion of coronary artery disease.
n-
B
m
PE LTS:tachycardia (FIR 98) ; hypotension (BP 90/60); no fever. PE:
pallor; right groin examination discloses inarked swelling and g6
deformation at site of femoral artery plrncture with skin I 3
discoloration (ecchymosis) to middle third of thigh anteriorly <
ancl posteriorly (patients are anticoagulated for a n g i o p p h y ) ;
peripheral puIses present I ~ udiminished.
t

Labs CBC: low hematocrit. Prolonged clotting. time, PT, and MT.

Imaging US: shows humatuma (no flow, nonpulsatile) and excltides

pseucioaneurysrn.

Gross Pathology Large subcutaneous henlatoma at site of puncture. c a ~ ~ s i ncom-

g
pression of femoral artery.

Treatment Evacuation nC hematoma. con~pressivehandage. and drainage.

Discussion The external iliac artery passes in close proximiry to tile

i n p i n a l ligament, where it is susceptible to injury during hernia
repair. DistaI to this landmark, the artery changes its name to
the common ferno~ilartery, which is the main blood supply to
the leg. In the groin, the netlrovascular bundle suppIying the
lowcr cxtremitv consists of the femoral vein, artery, and nerve,
in that order, from medial to lateral.

fl
^ : I
FEMORAL HEMATOMA
 ID/CC /In S-yeal--old femalr with a history of recurrent pneumonia and
low exercise tolerance i s referred to a pediatric carlrtliolo~stfor
evaluation.

HPI The child was horn prcrnaturely and has a history of recur-rent
her mother had rubella during her
rerpiratory tract infcctio~~s;
P'eP='cY -
PE Delayed growth and development (fdth percentile); wide pulse
premure: prominent carotid pl~lsation;increased JGT;
continuous "ma&eryU murmur with systolic accentuation and
thrill at second intercostal space at left pwaq~ernalho~-der:
increastd intensill: of apical impiilw.

Labs ECG: increased voltage of I< in V,-V, and S in V,-V,: Icft-axis

rlevial ion (left vcn tricular hypertrophv) .

Imaging CXR: enlarged cardiac shadcrw wit11 increased pulnlonarv blood

flow (left atriurn, left ventricle, aorta, and pulmonary artery).
Echo: Dopplcr flow mapping confi rmar ol-y. Angio: definitive.

Gross Pathology Pa ten1 rl~lcrusarturiosus (PIIA) connects the aorta and left
pzhonary artery just distal to the origin of the left subclavian
artery.
I

Brachiocephallc artery Left subclavian

artev

Right pulmonary angry -.

Ductus
arterlosus
Aorta
Left
Superior vena cava pulmonary
artery
Septum II
Foramen ovale Pulmonary
trunk
Septum l

Aorta

Inferlor vena cava

Clmbilrcal arteries

Figure A-006A Fetd circ~~larinn.

"*mr PATENT DUCTVS ARTERIOSUS

Treatment Surk+I or catherer (umbl-ellaj closure. hdomethacin alone
mav br successfilI in closing the PDA in rluonates (due to inhibi-
tion of synthesis of prostaglandin E2,which normally keeps the
ductus arteriasus open prior to birth).

Discussion Acyanotic. Patent ductus arteriasus is suer1 in association with

congeni ti11 rubella.

Atlas Link E E I T " 3 PG-A-006

 ID/CC rS. fivr;>r-nld child is referr-ed r r, :i pedinil-ir ral-dioln@st for uval iz-
a t i c l r ~uT dyspnea on exertion.

HPI Sincc birth. Iic l ~ a shad se1~~1;11-iiiin~lr~-lonff "blue spells" rl~iring

whirl1 I I P ~ P C ~ T I I II ~ ~I I SY ~ ~ I I I P ~ C , cyn(>tic,and rr\tIrw: at time4 h e
113s alsn lost corlscio~~snes~. I-le has hecn ohscrvad lo arisume a
squatting position in order to relieve tlyspnea due I r ) physiral eF
for1 {irtcrcaws vennlis rettlrn to right hc'art and pl1ltno1iar.vflow).

PE Dclrycd growth: ccntral cyanosis;gi-ade 111 clubbing of fingers:

svstolic* tl~rillp ~ l p 7 t 1 l aloog
e lefi ~ x ~ i ~ : ~ s tl>orrlcr
~ r ~ i a (Id ~ i ctn Y C ~ I I -
tr.iculnr srprill def(3ct): svs~nlirmllrrnur hccl hcartl tliircl leT1 in-
c~rcoqtalspare (ptllmon:~ryrtcuosis) : murintrl- disi~ppear-5d~u-ing
qxnntir spell ( n o hlootl llow ~ h r o l ~ gwive) li : single seconrl heal-t
stmrld (only ,42; 5oR. inaudible P:! clue t t ) pulmnnarv sro~iosis) .
Labs ,
CBC: polycytl~rmin.M G s : 11 ypnx~rnia (Pat 72Yh). ECC:: I-ight-
i1xi.c clevis tion : evidrtl r e of right ventricular hypertmphy and
right at~ialclilntarion.

Figure A-007A Narrrnvrrl puln~onar!ar.leiy, ve~~lrici~lat. septa! delrrt. aorta overlying !>oh
rigti1 ant1 left vt~11tr.i~
Icr. :I nd h v p ~ ~lnptiic
r rig11t vrn trirlc.

TETRALOGY O F FALLOT
 Imaging CXR: concalitv in region nf main pulnit>r~ar). artei-~:rigllt
veu~ricularenlargement (13ocr1-sri.zvtoI I LZRT); diminished
pulmonary vascularity. Echo: shows all Fimr gross li~~dings.
cA,II:cl~accathett=rizariouconlirmatorv.

Grass Pathology Four defects norrcl: ( 1) right ventricular outflow obstruction

(pulmonary \xlvc stcnosis): (2) large ventricular septa1 defect;
(3) "overriding" large ascending aorta; (4) right ventricular
hypertrophy.

Treatment Palliative shnnt 01- corruc ti7.c opun hcarr surgery.

Discussion Trti-alogvof Fallot is a lifc-zlir-ea~rningcondirion and i~ a

catnlnorl callse of cyznosis in rhildhonrl. Synptomatolup is
directly pr~)pnrtifinillto the amount c ~ right f ventricular 0 ~ 1 1 -
flow ob~tl-uction.It is caused bv an emhryalogic defect that
cariscs antemsuperior displacement o f the inFundibular
septrtm, ~+osultii~g in 1wequ;h division of'ihe aorta atlrl
~ x i l t ~ ~ n r ~~a1i-- ty~ r y .

AtZas Link PG-A-007

 ID/CC rZ 2-montIl+Id I'emnle presents with dyspnea, feecliilg difficul-
ties. poor p w t h , and profuse perspiration.

HPI Thc cllild had pneumonia when she was 7 days old. at which
~ i m c11er parLen&
we]-e informed of a c*otlgenital heart tnurtnur-.

PE VS: pulse normal. PE:tio edema, ryanoqis, 01- rluhlling; palpable

parasternal heave: apical thrust ancf s?stolic thrill: loud PT com-
ponent of 52;harsh pansystolic murmur heard best over left
lower sternal border: short apicill dim1olic rumble ( c l ~ trj
~e
increased flow across mitral valve.).

Labs IJCG: biventricular hyperwophy with peaked P Tvavcs cltir to

right atrial hypet-tropl~y(pulmonary artcry h!perter~sion).

Imaging CXR: carcliumcg.aly (all chambers and p ~ ~ l t i i o n a wterv

ry except
r.igli I atri~inl)will1 ii~creaserlp~iltnnctal-~vascularitv. Echo: large
vrntl-ictilar sephl defcct {lTSD):Doppler shows left-to-right
clirrc~ionc ~ shunt
f (lcft vrr~triclcto right vrntnclr).

Gross Pathology Faillwe of fusion of interventridar septum with aortic septum.

Fonr t y p r s of LrSDs: perimeml~ranous( H W ) . mt~suular( 10%~).
rupracrista7 (5%).and rndocardial cr~shiondefer t (5%).

Treatment Stu-qical clr>sii~-e r l pel-formed heforc

of' large \tSIls s h n ~ ~ lI>e
nppcarancc of irrcvr.rsil>lr puln~onaryvasculai. hvperrensinn.

Discussion Acyanotic. Ventricular scptal dcfect is a common cardiac malfor-

mation that accounts for 25% of all cases of congrnital lirart
C I ~ S Small
P : ~~lelkc-ts
~. niav r l o ~ e~ p n n ~ a n ~ o ~Tihsel develop
y
rnrnlt of p~ilmonarv vnsuular hypcrtrnsion m a v Icad rt) reversal
(11' the shun 1 (illto I-iglit-(+left\ and cyanosis (F;ISF:NMF,N(;FK'S
SITIIR~I F,} .

Atlas Link

" VENTRICULAR SEPTAL DEFECT

 A 46-year-olcl female on 1lt.r third postopcralive day rings the
nurse because of tlre development uf numbness arottnd her
mouth and a h g h g sensation in her legs and Fingertips.

The patient 11aq spastic ccrntrrtcturr of the k e t and wrists in

outwar-d mtatiorl and flexion, wi ~h her fingcrtipr; touching
SPASKI). She had just hiid a total
rach o ~ h e r((AI<Pc)PED,~~.
thymidectomy.

13:normal. PE: surgicaI W O U ~ Chcalecl:

~ n o signs of infection
or I~clnatninaformation; cr~nrractionof F~cialmtiscles when
rapping facial nerve a n terior to ear (rnsrrim CH~CISTEK'S SIGN);
carpal spasm after occlusio~~ uf brachial artery with RP cuff
' S SIC.N) : abductiun anr! flexinn nf foot ~vhen
(TROLJSSF.,UJ
pcrorreal nerve i~ tappcd (P(J\ITIXT P L K( INFAL. SIC:^) (a11 signs of

Labs CRC: normal. Hypocalcemia. ABGs: rlol-ma!. ECG: normal.

Imaging CXR/KU R: normal.

Gross Pathology Kesectccl thyroid tissue shows ztnaplas~iccarcinoma with incipi-

unl invaqion into trachea (a sir~allsquare r~fantel-iol-d
k n.as
resrcred); on car-cfirl exanlination, all four parathyroid glands
Cotind 10 1 1 deeply
~ adherenl to the thyroid; n o evidenre nE
nerve tiss~ic(bryngeal nerve).

Treatment Calcium supple11ient.s.

Discussion The parahyeid glands are the rmhrvnlogic rlerira lives or the
dorsal endodem of the third and folrrth brachial pouches.
T l ~ eglands may bc found anywhere Crom thc sl~periormecli-
a s r i n t ~ r nto thc carotid hifi~rcatinnbut arc usually located on
he posterior aspect and in close proximity in or embedded in
the thyroid gland. L~suallvtl~crearr turn superior and two
i~lFc:r.iol-glands. but superrliirnerary and absent gla1-td3arc not
uncommon.

HYPOPARATHYROIDISM-IATROGENIC
 ID/CC (1newborn male is evaluated Ibv a neonatologist brcause of
~ o s i 5 .

HPI T11r child p~rsentswith qailosis that increases with feeding

(while thc chilcl uses she m o ~ t t hfor eating, n o air gocs in the
lungs) and is relieved with crying.

PE M'ell developer1 and hydratecl; heart sounds normal: no mur-

murs: I ~ t n clear;
~s no increase in JVP: resident rvas unable to
pass a catheter thmr~ghthe nose (rliagnnstir frahrre) .

Labs Lab stl~rliesand nennatal scrtcn normal.

Imaging CT: con lirmatory.

Treatment Snrgical correction.

Discussion Newborns are obligate nose breathers. so pat ientq nit11 chnanal
atresia cannot inhale cnough air and thus become cyanntic.
\$'hen the child cries, air i s breathed into his lungs via the
inouth, correcting the qanosis. ,4 normal choana allows cam-
munication hehveen the nasal fossa and the nawpharynx.

CHOANAL ATRESIA
 IDJCC An IS-y=ar-old college freshman suddenly collapses in the
middle of a dinner a t 11is fri-itert~iyhouse: shortlv thereafter
s ) he qtruggles cle~pcratclyto
his face turns blue ( c u ~ ~ o s rand
I>reathe.

MPI He had hecn drinking heavily most of the dtcrnoon while cele-
hratin~his school's football victory (and thus was less able to
chew his food properly, had decruased sensation in his mouth,
exel-cised less caution, and had impairment of tile cough
reflex). He W ~ also
C laughing hcartilv while eating.

PE VS: tachycardia. PE: in acute distress, clutching throat with both

hatldl;; qwnotic; sweatv, with inspiratory stridor and high-
pircherl expiratory sounrls while attempring to hreathe; altered
!c-r~clof consciousness; piece of meat lodged at inlet of laryax;
spasm of laryngeal muscles. Patien1 slopped breathing and
collapsed.

Imaging : neck may show foreign hndy causing alrwav

XR: latcral V ~ M of
ol~ststiction(obtained in stable patients with partial ohsauction).

Treatment Manual retnoval OF ohsiructing foreign bodv. rapid back blows,

Heimlich maneuver, o r emergency cricothyroidotomy (incision
tl~roug-hcricoid ligament inferior to thyroid cartilage and
superior to d c o i d cartilage).

Discussion Preren tion of chnking is the k e e mainly in children; teaching

the Heimlich maneuver tr3 lapeople has savrd the lives of marly
"raE coronarv" victims.

CHOKING
 ID/CC A S4vear-old male complains of acute pain on the left side of
his Face whenever he eats accompanied by swelling of the same
siclt of his face (ducl to trapping of saliva in the parotid duct);
he also complains of l-tavingeexpullud "saridy*'milterial with h i s
saliva.

HPZ The patierit has hacl frequent hnuts of i n f e d o ~ l sparotitis

(C'IIRONIC:SLC,~\DENI?-IS~.

PE Fir m , round mass palpable below zygornatic process of temporal

bone (stone in parotid duct).

Imaging C1T or sialographp: irregularly enlarged Stenson's duct; may

cisualize stone.

Gross Pathology S ~ o n c scomposed of a m ~ ~ c i n o core

u s surmunded hv calcium
and pfiosphat~s a l ~depmition.

Treatment Have patien r suck on lemon to atrempt stone expzilsion through

incl-easedsalivation. I<emt>val cri' stones (1 I-~HC)T~\')
hy duct
gland removal.
dilatatinn n r s~~rgical

Iliscussion All the salivarv gland4 and tl~ictsnrav present wiih stnrtp rnrma-
tinn (SIAIX)~.I I 1 tl,e<~s):the condition is Creqnentlv associated wit11
r t>ronicinrection of the glands. Apprnximately 80% of salivary
gIand stones are rorincl in the submandibular gland (Mrhal-ton's
duct).
 ID/CC A 19-year-old woman presents with a painless sweUig just
beneath her hyoid bone.

HPI The swelliag has been getting larger over the past several weeks
but has not been p a i n f ~ ~ l .

PE Rounded, midline. w-ell-den~arcaterl,painless, fluid-filled mass

that is not fixed and moves superiorly when patient mallows
(vs. dermoid cysts, whicla do not move) ; no othcr neck masses or
Iyrnphadct~~opathy presenc.

Labs Basic lab work and thyroid ftfncrion tests normal.

Imaging XR, lateral neck: may see mass compo~edof soft tissue with n o
calcification. Nuc: ratlioactive iodine may localize in cyst if cyst
corltains Cunrtionin~;thyroid tissue.

Treatment t , and midportiotl of

Surgical removal of ~hyroglossald ~ ~ ccyst, m 8'
Z
Ilyoid aftcr confirnzing presence of adequate-furlctioning 4
1
tllj~oidtissue rlsrwhere. o
-0
I
--I
Discussion Cysts may arise rrom the remnant of the thyroglossal duct, an x
e~nhr~yolopic structure formed during migration of the thyroid $
3
from the base of the tong~e(at the foramen cecum) to its final 0
r
position in the neck. Thev frequentlv become infrcted. The o
I 3
fordrncn cec~ilnis the normal rcmnant of the ihvroglossal duct. <

THYROGLOSSAL DUCT CYST

 :I 10-year-nld boy is hrouglzt to the pedian-ician complainirlg r>f
h i ~ hfever, sore throat, cardchc, swollen gIands. and prodnctive,
greenish-~t~hite, bIood-tinged spu turn.

His mother statcs that the b q has had recurrent bouts of sore
throat several times a year Col-the past 5 F r s . crzch lime trearerl
r f f r c t i v r l y w i ~ hant ihiolics.

Mouth parlially open (mvollen pharyngeal tonsil c~l~stri~cls

nasophar!-nge;ll isthmus) ; tonsiTs markedly enlarged, hyperemic,
and cryptic with spotted area5 of pus; infl:immatioil of I( lrus
t 11hal-ius{protech opening of eustachian t111~r:ii~ldit<>rr in ratus
is imn~ediatelyanterior a n d inferior to pharsngeal lonsil, and
infrction or p h a r ~ n g e dtonsils sprcads up aucli~orvt ~ i l ~ r ,
causing otitis media).

Labs CRC: neu trophilic leukocytosis.Antistreptolysin titer ( A S 0 )

high; throat culture st1 ows Phemolytic streptococcus.

Imaging XR, lateral neck: thickened retrophww~gealprcvcrtuhl-a1 tissue.

CT: pharyngeal or retropharyngeal mass (abscesf) rttav he
present.

Treatment I'enicillin . Re~opharvng-ealabscess is a serious complicalioti

that reqriircs drainage. Evaluale for- tonsillectonlv.

Qiscussion Tonsillrctnniy is performed Iess frrquently now Llun a decarl~

ago: nevertheless, a n maltlation rnrist be done w ~ i g l ing
i surgical
risks wit11 those of recurrent p-ctreptococcal infrctions and
posssihle rheumatic fever. Walduyer's ring consists r>l' the
nasopharyngeal tonsils, the palaline tonsils, and tile lingual
tonsils.

Atlas Link
 IDJCC A 35-vear-nld woman i s kr-nllght to the enlergency room by
amhutance because of the suddcn appearance of'severe
retrosternal pain with radiation to the hack and ahrtornen along
~vihdvspnea; the pain i~ppearedafter vigorous vomiting.

HPE Shc wfkrs frnm episodes or hinge eating and self-ind~tcedvnm-

iting ( I W I ~ I M I ~ ~ ) .

PE VS: tachycardia (HR 110); mild hvpotcnsjor~(BP 100/65); n o

fever. PE:: i t 1 acute distress; complains of scvert chest pain; no
heart murmurs; left lung field hypoaerated (due to pneumotho-
1-ax); cracklitla sound heard over precordium (HAMVAK'S SIGY
OF I ' N F ~ ' M ~ ~ ~ ~ ~ I ) ~ . - L ' ; T ~ N L I ~ ~ ) .

Labs CBC: le~lkocylosis.Amvlase elevated.

Imaging UGI: extravasation of contrast in to medias~inurn.CXR/CT

left pleural effusion and hpdropneitr~~othorax;
mediastid
emphysema. Esophagoscopy: complete rupture of esophageal
wall.

Gross Pathology All layers or the esophaps arc tori1 completely in posterior
lateral wall of esophagus on left side (vs. Mallory-ZI7c"iss tear of
otlll; superficial esophageal lavers; presents as pnstetnetic m+
hl~eding} . %
-+
n
0
Treatment RI-<)ad-spcclrumantibiotics, chest tube and surgical repair. z
rn

7
A
Discussjon Postemetic rupture of the esophageal wall (BOFRJZMKES' 0
r
SYNDROMF:) i~ lisl~allvqeen f ~ l l n ~ ~protracted
ing and forceful 0
G
I
vomiting of snlid fond; it is common in alcoholics, bulimics, and -<
pmcpantwomen and in any cvndi tion that increases in tra-
ahd(~mini1presstire. The esophaps has three anatomic
constrictions:the cardiac (the most common site of rupture},
t h r aortic arch, ancl the cricopharyng-eal.

* BOERHAAVE'S SYNDROME
 A ft~ll-term,3-week-old male is ht-ol~glit to his family physician
for his second welIkabv visit, at which time the physician notices
lhat the in fan^ is jaundiced (jaundice clid not start i~nmediately
aCter I~irth,as is the case wit11 physiologic jaund ice).

HPI On directt-d questioning, the r n o ~ l ~ also

e r reports that he has
dark urine staining his diaper along w i ~ hpassage olC "clay-
colored" (AC:HOI.IC:) stools (due to ohstnictive jaundicc) .

PE lcteric skin and sclera; firm milcl hcpatosplenom~galy;no signs

of portal hypertension or liver f~ilure.

Labs Direct hyperbilirubinemia; increased alkaline phosphatase, ALT,

and ,\ST: low serlm albumin; increased globidin; lack OF
urobilinogen in urine.

Imaging US: norinaI. Nuc-HIDA scan: unimpaired liver uptake with

absent excretion into intestine over 24 hotus.

Gross Pathology Livcr increased in size with gree~~xolol-ed,granulnr surface;

p~riportalfibrosis if long-standing; eximhepatic bile duct
consists o f fibrous cords with no lumen (atretic bilr ducts).

Micro Pathology Livcr biopsy shows bile d ~ i cproliferatinn

l with dilatation of
canaliculi and presence of inspissated bile plugs.

Treatment Surgery hcforc 2 m o n t l ~ sof age lo prevent liver clamage; Kasai

procedure to directly attach borucl to surfice of liver; liver
transplant.

Discussion Rif iat-v au-esia is t h e nlost corninan cause of persistentjaundice

in infancy and is associated with the presence of rnnre than one
spleen (POI,YSPLF:NIA). Differential diapods includes cholc-
rlnchal cyst {inxw u~uallypalpable). a,-antitrypin deficiency,
and neonatal hepatitis. If long~tanchg,liver cirrhosis will
rlevelop: other cornpFications include chronic rholangitis,
fai-soluble vitamin drfjciencies, and portal hypertension.

" <?. CONGENITAL B I L I A R Y ATRESIA

 ID/CC A 37-ycar-oId male is admitted to the ER fo!lowing; the develop-
rn ent c ~ marked
f lighfheadedness, sweaty palms, palpitations,
and nausea.

HPI He has a history of duortenal ulcers that have been unrespon-

sivc to medical treatment, for which he underwent surgery
2 months agn (vagocnmy and BilIroth I1 anastotnosis
[gastrojej~ostomy]) .

PE \'.$: mild hypotension; tacliycardia; n o

fever. PE: abdominal
exam discloses well-healed upper midfine incision wit11 no
hematom-as, tlelliscence, or ~igrlsor infection; no peritoneal
signs.

Labs Hypoglycemia (50 mg/dL) . CBCJLytes: normal. LETS, amylasc

nor-ma!.

Imaging CT: no fluid collections in suhphrenic, sul,hepatic, o r pelvic

spaces.

Treatment Low-carbohydrate, hfgh-pmtrin, small, frequent, dl-y ineals.

Discussion A complication of duodenal surgery, dumping syndrome is d ~ l e

to the rapid, ~~nirnpeded passage of high+smolarity rood to the 0-
B
jej~mxm,wit11 onset half an hour aftur meals (there is also a Cn
-4
delayed r q ~ e )Symptoms
. appear relaled to the development o f m
0
hypoglycemia. The blood supply LO the distal stontach- z
m
duoder~umis derived from the gastrocluodenal artery, a branch rn
--I
OF t11p collimon hepatic artery. The pancreaticoduodenals are n
0
r
bratlcl-lesof the gastroduodenal, as is t h e right gastroupiploic. 0
C;r
which courses through the greater curvature to join the left 4
gas1rn~piploicartcry, a branch of the splenic artery. The
hranchcs uf the celiac axis are the left gastric, splenic, and
common hepatic arteries.

DUMPING SYNDROME
 ID/CC A 57-vear-old white male complains of deep, burning retraster-
R N ) worsens when he lies down,
nd pain (I I ~ . L ~ W ~ B L ~that

HPI The patient i s a heavy cigarette smoker and alcohol drinker. He

also complains of regurgitation of so~~l-m;~tertalon and off Tor
years. Hr. has been overweight fcjr the past 10 vears and has
recently experienrecl insomnia.

PE Obew and mod~ratelynrrvous; slight diwomfort on palpation

of epigastrium.

Labs CBC may show rlnemi a if ulcer is preqeir t .

Imaging UGT: gnstroesophageal jtmction and part of stomach protrude

above diaphragm. EGD: may show esophageal ir-rfl;linmatint~.

Micro Pathology Esophageal mucosa with varial~lt degrres o f inflammation.

Treatment Mkiglzt losl;. cessation of smoking. avoid lying down after-meals,

prokinrtics, H, rrccptr3r. hlockers, pro1o n pump in hihitors,
qurgesy.

Discussion Most hiatal hernias are sliding (the srnii-racli herniate5 intn the
thorax ~ogetl~el-
w i ~ hthe g a s t t ~ e s ~ p l l a g ejunction,
a! producing

Figure A-018 Protrusinn of thc stomach above the rliaphmpn, causiilg l~~ll-shaped
supraphrtnir dilatation.

r- HIATAL H E R N I A
 reflux), but they may also he paraesophageal (the gastm-
esopha~eal. junction remains fixed below t11r diaphragm with no
reflux; symptoms are due lo pressure). Complica~ionsaworiated
with pataesophagcal hiatal hernias arc s~nngltlation, ohstr~tc-
tion. incarceratior~.and hrmorrhk~gr.Chronic untreated
pstroesophageal reflux disease secondary tr, a sliding l l i a ~ ~ l
hernia mav lead to Barren's esophagus (columna~metaplasia of'
the distal esophagus), which i s associated with an increased risk
of esophageal adenocarcinoma.

H I A T A L MEFNIP,
 lD/CC A Mav-old male is brought to the emergency room with bilious
vomiting, ahdomind distention, and failure ta pass stools.

HPI The full-term hahy faiIed to pass rneconium in the first 24 hours
afier birth hut did so i~nmediatelyfollowing a rectal exam.

PE A k d o m ~ ndistended and tytnpanic; loops oCintestine palpable;

increaqed anal tone; rectum empty; clzild passes Foul-smelling
~t0o1following I-ectalexam.

Imaging XR, ahclomen: massively dilated colon with gas and feces; rectal
air nurmally tisible in presacral area is ahsent on lateral erect
~ I Ecaliber between gxnglienic and
view, BE: a h r ~ ~ cI~ar~ges
pt
a911glinnic segments: fail t~l-eto evacuate barium.

Micro Pathology RcctaI biopsy rcveals ahnormal developmenr n i Meissner's and

Auerllac11's plexuses with aganglionosis in myenteric nerve and
suhrnucosa: hypertt-ophv of nervr fil~ersin Meissner's plextis.

Treatment Stu-gical excision of agar~gIionicsegment and anastnrnosis to

anal canal.

Discussion Hirw hsprung's disease is due to railure of mip-atian of' cells of

the embryonic neural crest to the howuE ~ 1 1 o1 f distill segment5
with absence of*pamsympatheticganglion cells in the anal and
rectosigmoid areas. lrading to Functional (not anatomic)
obstruction and colonic dilatation proximal to the affected
segment. I t niav be associaterl with Down's syndrome and
~ ~ r i n a ranomalies.
y The pl-esrnting wmptom mq. he acute
enterncolitis with watery, foul-smelling diarrhea.

fi HIRSCHSPRUNG'S D I S E A S E
 TD/CC X 45-ycar-oIcI female prcscnts with pain and compiaitls of
heaviness and a "twnar" in her abdomen; she also has a fever.

HPI Eight wreliq ago rhe harl heen I~ospitaIizedfor epigastric pain,
nauwa, and rnmiring due to acr~tepancreatitis.

PE VS: Ipvet-. PE: pallot-;epigastric mass tender to palpation; Inass

not motile and scems to he deep-seared; no change of overlyirlg
skin; tlu peritoneal signs.

Labs CBC: elevated WBCs. Amylase and lipase elevated (although n o t

10 extent of her. firsl. aclmission) ; AST and i4ZT slightly elevated:
bilirubin moderately increased. UA, normal .

Imaging CT/US: large cystlike fluid cnllect ion in close proximity to pos-
terior wall OF stomach, origi-inatit~gin pancreas.

GKISS Pathology Collertion arennme-ricl-t fluid aro~itldpancreas walled off Ily

inflammatory adl~esionsof peritoneal ~urfaces,large bowel, and
diaphmgin; no tsue capsule or epithelial lining ( ~ s ~ : r n c ) r f i ~ r ) .

Treatment Imaging-pided intervention for placement of drainage

cathctcr. Sometinies slu-gical drainage required.

Discussion Pancreatic pseudocysts are a compljca tion of pancreatitis that

occur in about 3% of cases. Tlie pancreas has a hcad, neck,
body a i ~ dtail. The mail1 pancreatic duct (nrlc-t. OF WIR~UNG)
drai rru into the ampulla of Vazer loget her with the comrnon bile
duct. The accessury duct (nrlcx nr S L i ~ ~drains c ~ Innre
~ ~ prox-
~ )
imallv or in to onp of the above-mentioned ducts.

I - I PANCREATIC PSEUDOCYST
 ID/CC A 56-year-old male bus driver is rnsl~edto the emergency room
with generalized, excruciating abdominal pain that began in the
epigastric area aftcr he atc a large meal; 11e also cr>inplainsof
nausea and vomiting.

HPI I-le is a heavy smoker. For the past 3 years he Ilas suffcscd frorn
chronic. episodic, burning epigastric pain that was diagnosed
as a p s i r i c dcer and treated with antacids and H2 receptor
blockers.

PE VS: tachyrardia (HR 110) ; mild hypotensinn (BP 100J 6 0 ) .

PE: weary and in acute distress; marked, generalized abdominal
trndrrncss. predominantly in cpigasmic area. with positivs.
rebound tenderness; n a peristalsis heard; abdominal rigidity
~ peritonitiq).
( ~ 1 1 10

Labs CBC: neutrophilic Ie~tkoqtosis.Slightly elevated amylase.

Imaging XR. ahdonlen: generalized small bowel loop diIntation. CXR

tnav F I ~ Wintraprr-toneal rubdiaphragmatic free air.

Treatment Surgical removal of ulcer or c l o s ~ ~ of r e perforation in gastric

wnll, peritorleal lavage and drainage. Antibiotics Cur pcrironi tis.
~ r on clisch arge.
Treatment for F l r l i c o l l ~ r tpyhn'

Discussion Perfom~ioui s cornmorl in the gastric antril~nor lesser curva

nlre. The pqmic conteilts n1av spill into the lcsscr or greater sac.
The boundaries of the lesser sac are the hepatoduodenal Iiga-
ment, caudate lobe of liver. d~rodenum,and inferior vena cam.
The lesser sac communicates with the peritoneal cavity via the
foramen of Winslow. Anterior duodenal ulcer4 ran rause perf*
sati on, while posterior duodenal ulcers are associated wit11 hcrn-
orrhage ~econdarvto ulcer erosion in to the gaqt t-oduodenal
artery.

Atlas Links

PEPTIC ULCER-PERFORATED
 ID/CC A 47-yeasoId male is brought by ambulance to t h cmergcncy
~
roorn vomiting copious amounts of blood ( x ~ : w s nH~E U ~ ~ M E S I S. )

HPI He has a history o f heavy alcoholism; h e has gotten drunk at

least thrre times a werk fnr many vearq.

PE VS: tachycarclia (T-IR103) ; hypotension (BP 90/4C!) {cllie ro

hypoiwtemia) ; no fcvcr. PE: marked pallor; thin, wastrd, delil-i-
nus man with strong alcohol smeU on breath; pupils reactivr a ~ t d
equal; enlargement of parotid glands; no focal ne~~rologic sign^;
abdomen enlarged due to aqcitic fluid; spider angiomas over
abdominal skin: palmar erythema.

Labs CBC: low hemoglobin (7.3 mgJdL) : leukocytosis. increased ALT

and AST; mild hvperl~ilir~ibinemia.

Imaging Esophagoscopy: active bleeding of markedly dilatcd and tortii-

ous suhmucosal veins (BLEEDING V ~ R I G E S ) .

Gross Pathology illcoholic hepali~isgives rise to fibrosis (CIRRHOSIS) of the livcr,

rr.hich inmaws portal vein resistance.With the dcwlopmen t of
portal hypertension f > 10 ~ n m H g )there
, nre portal-ysternic
anastomoses fornled such as the left gastric-qgou.4 (esophageal
varices ), the superior-middle and inferior rectal veins
(hemorrhoids), the paraumbilical-inferior gastric (navel
caput medusae), and the retroperitoneal-red vein svstem.

Treatment ScIcrothcrapy. In emergency bleeding. balloon ~mponade,

entloscopic cauterization. ligation, IV vasopressin, surgery.
Consider spFeilorena1 or transhepatic portal-svstemic shunt.

Discussion The portal vein i5 formecl hv the joining of the mesenreric vein
and the splenic vein; tributaries include the left and right gastric
veins. On occasion the inferior meseriteric vein drains into the
superior mesente~icvein rather than in to the splenic vein.

Atlas l i n k

PORTAL HYPERTENSION
 ID/CC A newborn rnalc. haky prchents with inahilily to accept food:
he chokes, coughs, and vomits with each attempt to feed him.

HPI Fr~n;ilalultrasound sF~owtldexcess a m ~ o t i cfluid

( and no fluid in stomach.
, S ' H \ ~ R , ~ M N I15)
(13clr

RE Ft111-tel-in hahv; excessive salivation; ahdomen diste~~ded

and
t!mp;ir~Itic: catheter cannot be passed into stomach: chest exam
nnrmal.

Figure A-023A PI-ouirnxlcnrl of ~ h t rsoljtlagr~s

. enrlinq in a I d i r ~ c l
prmcli anrI sexmen1 con~nl~rr~ic;~tii~q wi t l ~the r r a r h ~ a .

F- TRACHEOESOPHAGEAL FISTULA
 Imaging CXR: coiled feeding catheter in upper esophageal pouch;
gastric air bubbIe present.

Gmss Pathology The most common type of rracheoesophageal fistula is that

x~sociatedwith a hlinrl proxi~nalesnphageal pmzch and a distal
esophageal pouch that communicates via a fiqtula with the Ir~wcr
~rachea.

Treatment Treat aspiration pneumunia. Keep esophageal pouch empty b y

constant s ~ ~ c t i oSurgical
n. repair i I S early as possible.

Discussion Anomalies are due to defective differen tiation oI' primitive

foregut into the trachea and esophagus,defective growth of
endodrrmal cells leading to atresia, and incomplete firsion of
the lateral walls of the forc'pt during separalion of the trachea
from the foregut. Thcre may hc esophageal atl-esia without
trachcoesophagcal fistula and tracheaesophageal f i ~ n ~without
la
esoph;tgeal atresia. Maternal polyhydramnios is associated with
esophageal/duodenal atresia and anencephaIy (t11e fetus can 11ot
amniotic fluid), whiIe maternal oligohydramnios is
swallo-rz~
associated 14th bilateral renal agenesis and postdor urethral
valves (fetal vritle is allsent o r obstructed).
 ID/CC A 7&year~ldhypertensive male was hrought to the emergency
w sudden development or severe, tearing
~ the
room I ~ e c a ~of
abdominal pain that radiated to the back.

HPI H e lost consciousness when he waq being transported to the

11ol;pitalin his rteighbor's car.

PE VS: hypotension (BP '713/30);tachycardia (HR 110): marked

tachypnea. PE: ronfirsed, disoriented, and in a delirious state;
skin cold and claminy; peribuccal cyanosis: pulsatile mass in
abdomen; rvllile cen tl-a1 lincs were bejng placed, patient snfel-ed
a fatill cardiac arrest.

Imaging abdomen: diagnostic; arteriography i~acfiilfor planning

sr~rgicaltrcatrntnt.

Gmss Pathology showed a lO-cm4iameter aneurysmal dilatation of

At~ii~psv
abdominal aorta (normal diarnutcr is 2 cm) with abundant
atherosclerosis of the wall and rupture.

Micro Pathology .4rherosclerosis (Marfan's syndrome pati~nisshaw rvstic npcrosis

of the tunica media).

Treatment Immedialr surgical resection and grarting, Patients with asymp-

inmatic ahilorninal aorric aneurysms > -5 r m us~tallyundergo
elective ~urgicalresection.

Discussion Atheroscferosis is the most comnlon cause of ait>dotnitlalaortic

;ineut.ysm (lucalized dilatation of its I~irnen).Other cauqeq
include syphilis and ttaunra. Aneurysms are most common in
males. partir~~larly the clclerly. They arc ~ ~ s u a llocated
ly helow
rile lrvel of the renal arteries,

? A B D O M I N A L AORTIC ANEURYSM-RUPTURED
 ID/CC A iT5vear-old woman prese~irswith groin pain, vomiting, and
abdominal distention Tor R honrs.

HPI Shc has also noticed "a Ilunp" in the Ieft groin.

PE VS: normal. PE: abdominal exam reimeals mild ahrlominal

distenrion, increased howel sounds, and diffuse tenderneqs to
palpatinn (withour any rigidiq. guarding, o r rel~ound
lendernev,); tense, very tender, irreducible, mrrnded mass in
Ieft groin inferolateral to the puhic ruherclc.

Labs normal.
CRT;/LVI~S:

Imaging KLrB: dilated small 'bowel loops with multiple air-fluid levels;
rounded area of intesi inal gaq over3ving left groin area.

Treatment Incarcerated and strangdated hemias warrant emergent

surgery;otherwise. manual redudtion followed by elective
herniorrhaphy is tlze rreatmrnt af choice.

Mscussion The defect in ftmoral hernias is ~rsuallymuch smaller than in

inguinal hernias, which makes incarceration Jstrang~~Iation
more likelv. The incider~cenf fernnraI hernias is higher in
females and rhe eldertv.

FEMORAL HERNIA-STRANGULATED
 I DJCC 11 58-year-cllrl ollese Inan presents 10s an evaluation ol"a "lump"
in the anal area of 3 davq>dt~ratinn,ra11qingacute, mnstant pain
t t ~ a rinrrcascs d1ir.irlg defecation.

HPI He i s a S Y T I O ~ivit11 C ~ a chronic cough anrl is overweight. He i t 1 ~ 0

st~fft-rs fro111proststtic hyperplasia Illat forcrs him ttr strain in
n i . r l ~ rn
i i n i ~ i a t 1nict~1ri1i0.11.
r

PE Patient r17alksvery slowly with both ?ear apart anrl sits down in
r'liair .;irlewavr; extert~alr ~ c l aex;lm
l r.pvp;~lsprewnce d ' a
rounded.3c-111, purple mass in thr anal verge i l ~tais tense and
extremely painfill to the touch: ititeri~aldigital rectal exam
P acllte pain: maw Ir)caIi7~rIto nuter anal
impcr~cibleC ~ I I tcl
region.

Labs CBC: ?light Irrtkou~tosis.

Gross Pathology ~ngorgcctvein wit 11 clot.

Dilil~<>~I.

Micro Pathology Ariite illflam~natorvneliwophilic infiltrate

Treatment Acute tlii~ornl~c~sis\vill suhride ~ p o n ~ a i i e o ~ iin

s l ymnqt cases with
sitz baths, atrti-it~fla~nn~atorie~~local sternirls, xncl laxatives. If
rccul-l-rn't,snrgic;~lrcscction is warrantccl. IF ;ic~~iely painf~tlor if
rniict-l-vativr rreatmpiit Ii~ils.exciriora wiih local aneqthesia mav
IIC clone.

Discussion Exlernal hcrnorrllc~idsa r r dilatations of' the ;in;ll veins fmtw the
inii.rior hemnr~rhoidal~jlexlcs,which drains it110 thr internal
pudur~dalveins. Intcrnal hemorrhoids lie a l ~ o v rthe mucocura-
nerlus junction (pectinate line) ancl helong to [lie wperior
hemol-1hoitlal plexus, wliich dt;linr inro the pol-tal vein through
rhc inferior rncsrntcric vein. Intcrnal hcmerrhoids arc painless
(\.iscel-al in t~erratiotl)anrl are covererl hy Inucosa. Extcrnal
hcmorrhoirls arc piiinfr~l(somatic innrr-ralir,r~)arlcl nl-e covered
1~ skin.

Attas Link 1
' 1 1 '1 I SUR-028

" HEMORRHOIDS-THROMBOSED EXTERNAL

 ID/CC .A 73-year+ld male i 5 r-efkrred 10a wrgcon bccausc of a pxinf~tl
mass in the left ingriinal area: [ h e milw prntrildes wit11 straitling
and dbappears at rest.

HPI The palie111has Fretluet~tbrjl~tsor constipation ( i . e s ~ting

~ l in
increased inm-abdominal pressurr.) .

PE Rrctal exam shows mar-ked prr~s~atic cr~largcn~ent (st rairsing at

~nictliritinnis pl-eilispoqing ticlor); in w p i n r p o ~ i t i oleft
~~,
inguinal region dnrs not di.~cIoseany apparent pxthologp-, I ~ u t
when patient stands 2nd is askrcl to c r l ~ ~ gahmass
, is felt in the
i n g ~ ~ i n ncanal
l that ran he rasilv rrcIucec1.

Treatment Sirrgical repair: IT eatmerlt for prostatic hyperplasia comrs first.

Discussion Direcl 11er11iasare mnl-e frrqlwntlv seen in rldcrlv people with

weak abdominal wall musculature; they protrude directly
throu~hthe floor of the muscular inguinal canal,whirl1 is the
11-ansrrcrsalisfi+sci;l (inljidr Hrsselbach'~triangle). On srrotal
ex;lrnination, wir h t h e finger introduced in the inguinal canal
thrn~lghthe external inguinal ring, thc Ilrrnin is S i l t i n the putp
of the fingcr (indirrct hr.~+ni;~.; AT-c- fell i l l the l i p of the fingrr).
VIPIin~itr;nf Hesselbacll's triangle are thc dccp (inferior)
epigastric arter!: latcral rectus TIILIPCIP I I O I . ~ P ~ ; 3nd inguinal
ligarncnt. Direct herniils mav cui~rrtintlrinary hladder that ran
be darnaged during s11rp;er-l;.

Atias Link r_I1A:1_- SUR-029

* I N G U I N A L HERNIA-DIRECT
 ID/CC .% P,%eal--nEd male weight liftel- come5 to the emergency room
I~ecauseof a painful lump in the right scmtal area that began
cal-licr in the morning.

HPL Hr is hualrhv with a n unremarkable pas1 medical history; h e

Srcqucntly cngagcs in strenuous physical labor,

PE Z'S: tachycarrfia. PE: abdomen distended and h l p a n i c with

inrl-eawrl peristaltic mnvemenls; render tn palpition with no
~ c l backward
rehnurlcl tendcr~irsv(intestine i 5 o h s t r ~ ~ c twith
accum~rlatiunc,I gas and k c w ) ; tender, tense, and painful mass
in right i n ~ ~ l i n area
a l that continues thror~ghextcrnal inguinal
ring into strrotum; masq clops not tranrillu~ninate.

Labs CRC: neutropt~ilicl e u k o u ~ ~ o(intestinal

is loop is sufrering
iscl~cmia).Incr.rawd BUN: normal creatinine (dehydration due
to in tra-akdorn inal sequestration ) .

Imaging KLTR: dilated sm;lll bowel locjpv will1 air-fluirl levels in steplarlrlcr
pattern; mass in right scrotum.

Treatment Surgical tl-eannenlt tn Cree inteqtinal lonp and repair hernia.

Discussion Indircct inguinal iicrnia is thc most common type of hernia i 13

ma1r.s (usirally va~mg)and frrnales. T l ~ ch e r ~ i i nrnmes out
h internal inguirtal ring with thr spcnnatic cord anti
t h r o ~ ~ gtlzc
t h ~ . m ~ pl11e
hrq tirntly prr )tr,utles into tlir scroti~rl~ h extrrnal
ingt~inalring. Indircct hernias lie lateral-superiorto the inferior
epiga~tricartery, outside Hesselhach's triangle. Inclirect
inguinal hernias are most cr)mmonly dlic tcr a congenitally
patent processus vaghalis.

I N G U I N A L HERNIA-INDIRECT
 lD/CC \t2-yearald boy is ! , m ~ i ~t lo
h the en-lergencyroom I>? his par-
ents l~ecausrof a n increase in the size o f his beIIy and persi5tent
vomiting.

HPI Two weeks ago the hnv had bright red blood in his stools For
4 davs.

PE VS: tachvcarciia. PE: pallor in co11,jtuictiva; abdomen distended

and *panic with incrpawl howel sn~lnds:on palpation.
aT>rfonzeni s tender with small, sau.sa~-shapedmass in right
lower quadrant (due to inmssu~ceptionl .

Labs CBC: normochromic, r~orniocyticanemia; nelltl-nphilic 2cukocv-

tnsis. Tncreased BUN: c r r a t i n i ~ ~~r~ o r n ~ a l .

Imaging KLlB: air-fluid Icvcls with small howcl Inop rlistenrion. Nuc:
prvsencc of ectopic gasltric mucosa confirmed.

Gross Pathology Five-cen timeter-Iong divertirulum situated on xntimesen~eric

border or ileum located IiO cm from ilt-ocecal \.nIve.
nit-erticultim fnnns tip of'an in1 uwllwep~inn.

Micro Pathology Con tai 11s ectopic acid-secrehg gastric mucosa irrlrl pancreatic
tiswe.

Treatment S~rl-gicalexcisio~l.

Discussion Mcckul's diverticulum i~ the mosl colnmon congenjtal anornalv

ot I h r GI tract; it consists OF a diverticular sac oat~sedhv
persistence o f the vitelline duct nl- yolk sialk. The five 2'q 19
m
rlescrihe it: 2 inchec long, 2 feet from thr ileocccal v a l ~ e 2% . of' z
m
n , 2 years of life, 2 v r s of cpithelil~tn.It tnav
t h r p o p l ~ l a t i ~ first m
he Lwwnptom;lticor mav give rise to intuss~~scrptiotl and $
VI
intcstin;~lokqrr-uction,rlivel-tic~lli~is from
(indisting~~isf~ahle c
;E)
ap~endiciris),nr hleerling. m
CI
;D
<
Atlas Link LT_mlPG-A-032

MECKEL'S DIVERTICULUM
 IDJCC A 73-vca~oldmail is hruughl lo the E:K Frnm his nursing hnme
because of thc sutldcn developmpnt r)C intcnse abdominal pain.

HPI T h e p a t i c n t s t a t c s ~ l ~t11epainissevere;tndevenworsethan
at
his prior MI. He Ilas a history of similar hut less severe rrrampy
abdominal pain aftw meals (inrestinal angina); he is a Iieaw
smoker.

PE C'ln palpation. abdomen is only moderatclr teiider atlil

dislend~drvirli IIO parding; peristalsis not heard (pain is out of
proportion to clinical Findings); rectal exam shows blood.

Labs C13Cl: markcd lcukocyto~js(27.700) with neutrophilia; IIO ane-

mia. h ~ y l i s cmotlerately
. high; CK elevated.

Imaging KUB: marked distention of borvlcl loops to splenic flextire; p q in

bowel wall. BE: thumbprinting or howcl wall ( d t ~ e10 ~l~l~rnucosal
hrmorrhagc- arid edema). hlgio: vascular occlusion by embolus.

Cross Pathology Smgiral ~ p ~ c i n reveals

~ c n cotnpletelp black ancl i ~ e c r o ~ileum
ic
ai~d~jcjunuin;multiple clots in superior mesenteric artery (SMA)
branc hu?.

Treatment lrnmcdiatc surgical in tcl.\,en~ inn ir massive: intrrt'er)tional ai~gio-

grapllic t h ~ - o r n l ~ o iT
l ~Cocal.
si~

Discussion Occlusive cIiscas~of rhe h o r z ~ mav

l be due to thromhosir or
cinl>oli,giving rise to lire-thrr-atening inrestinal infxctio~r.The
ShIA is a clircct hrarlch of the aorta and suppIies the right side
of thc colon, the appendix, anrl the jejr~rlurn;tnd ilelrm (its
hrai~chebare 11ie~nirlcllecolic. right colic, arrd i!eocolic). The
itifetior. tneqenteric artery ( M A ) alsrl hr-;~ilchesfrom t l ~ caorta
and sripplirs tht. lefi colon, sigmoid, and upper r-ectz~mthrough
i t 9 hraii~hes(IeCt coIic, sigmoid, and wperior hemorrhoidal).

fl MESENTERIC I S C H E M I A
 IQ/CC A '1-~ueek-nlrlmale i s hrougt~tto the f;amilv cloc;tnl-brcause his
parent5 t~nticrrla "lump near the child's buttocks'" the lump
son~urimcsdisappears hut invariahlp reappears when rEle chiIcI
cries.

HPI Hc is the first-horn child of a healihy Hispanic cotiple. The

pse~mancyand tIclir~crvwere lineven tf ril.

PE VS: no frvcr. PE: no abdominal mwws palpable; no neurnlogic

qignq; zipon examiniition of left lumbar area, nothing was
noticed until child criec2, at which point a 2-cm-diamuter,
rolmded mass was felt on edge ol'iliac crest.

Labs RaGc lab work norm~al:~rreeningfor inlieri ted metabolic

deficirnries normal,

Treatment Sm-gical.

isc cuss ion Petit's tri:~nglei s for-merl h v the iliac crest iihferiorlv, thr. poste-
rior border or the external ohliqlzc anteriorly, :;ntl the an ierior
bnrrler or I h e latissimus ctnrsi rnuqclc pc>stcriorly.Petit's triangle
hernias arc srcr~irl all age groltps ancI are more common in
males, arising morp frequwtIy on the left side.

PETIT'S TRIANGLE H E R N I A
 lD/CC A 33-year-old gas station attencIant is brought to the emergency
room after sustaining a bulIet wound on the back o f his leg.

HPI He panickcd and ran when confronted by hvc1 muggers on a

.
dark. deserted street (shot from behi~ld)

PE Lert foot is cold; inability to dorsiflex foot; overlving ski11

cynnotic; no dorsalis pedis pulse palpahle (artery lies hetween
tendons of extensor llalliicir;longus and extensor digitorurn
langus); entrv wound located on poplitral rnssa and exit wound
on anterolatcral portion of knee; lower third of thigh and tipper
third 01-legtense, .swollen, and painful.

Imaging XR comminuted (multiple fragments) fracture of tibial plateau.

h g i o : traumatic Wansection of poplited artery.

Treatment Emergency surgical repair of artetv.

Discussion The popliteal fossa is a diamond-shaped zone houndcd 011 the

lateral superior tnargin by rhe biceps fernoris musclc, the medial
superioi- margin by thc rcnlinlen~branousmuscle, and the
inferior margins hy the gastrocnemius muscle. Ir I~arborsthe
poplitcal artery and vein ( I - ~ C T C the lesser saphenous vein
clrains), tibial nerve, peroneal nerve. and obturatot-and
ikmorocutaneous nerve branche~.T r a m t i c knee cli~locsttions

POPLITEAL FOSSA TRAUMA

 EDJCC A 37-year-nld remale comes to tiw emergency room because of
the sudden development of pain in B e right <groinarea and a
tender mass of 2 ho~rrs'duration.

HPI She is a heaIthy mother offour with no pertinent mcdical

historv.

PE VS: tachycardia; mild hypertension (clue to pain). PE: patient in

pain: chest and abdomcn normal; no signs of intestinal
ohstniction; small, ror~nded,very tense and tender mass felt; on
palpation of right groin area, mass is not sed~icihleand causes
intense pain.

Labs CBC: marked neutrophilic Ieukocycosis.

Imaging KUR: normal appearance of gas in rectum; no signs of intestitla1

obstruction.

Treatment Immediate surgery to reIease ischemic, ga~ngrenousbowel and

hernia repair.

Discussion Richter's hernia refers to a type nf hernia in which only one wall
l y antimcsentcric border) is trapped
of the intestine ( u s ~ ~ dthe
by the constriction ring of the hernia; ia can occur with l'emoral,
inguinal. or timbilical hernias (more common in the femoral
type hecause of the narrow orifice). Since gas and feces may still
pass through thr. nonconstricted area, s i p s of olwtruction are
usualIy ahsen t. Femora1 (crunl) hel-nias, found medial to the
Femoral vein in the femoral canal. arc more common on the
right side, more cotrimon in w o m m , and prone to strangulate
early. The Femoral ring is formed by thc inguinal ligament, the
lacunar (GIMRERVAT'S) ligament, the Femoral vein (easily darn-
aged during repair). and the pelvic border.

RICHTER'S HERNIA
 ID/CC R T%year-olrl Temalc corneq ro the emerge~encyroom cornplaitling
of acute abdominal pain that is colicky in naturc, d u n g with
pain in between contractiorw and inability to pass f l a w .

HPI She s~ll'f'ers€rot11 chronic constipation and takes Iaxativeq every

day

PE IS:tachycardia (I-IR 97) ; borderline hvpertcn~ion(BP 140/95) :

t'rvcr (58.1"C). PE: dehydration with clry mucotls mr-~nbrancs;
abdomen markedly distended md painfill wit11 guneralited ~ y m -
tone on p~rcussionand absence of perisraltir movements,

Labs CBC: neutrophil ic leukocpsis. Increaserl RUN; nrlrnlal crea ti-

nine: amylaso mildly clc\~atcd.GTX: increascd specific gravity.

Imaging KCR: massive distention of sigrnoid colon. RE: bid's-beak

appearance of contrast at point of vol~,'~~Ius.

Gross Pathology Sigmoid excessively mobile and twisted over its own mesentery
with massive distention and thinning (paperlike qualitv) of
intestinal wall.

Treatment Sigmoicloscopic decompl-ussion; with failure. surgical operation.

Discussion Vnlvulus (twistitla) of the colon is mote frequent in the elderly

and most commonly orcurs itr the stgmoid area: thc sccond
most common site is the ccclrrn. Closcd-loop intestinal o k s t r ~ ~ c -
f i o ~ it ' t ~ s ~ i t -and,
s if per-sistunt,]nay lead t o ganzrenr a n r l perrnra-
tion with peritonitis. Bloodv colonic clischarge with shcclding uf
dark colonic muuosa suggusts colonic necroris and warrants,
ernergrnr wtrgical resectiun uf r~ecrcltichowel.

9 SIGMOID VOLVULVS
 ID/CC A 2Syear-old tnale is hrougl~tto the ernergen7 room i11 a con-
fused state after being iilvolvccl in a high-speed rlorvnhill skiing
accident.

HPI We complains of severe abdominal pain radiating to the left

scapula.

PE VS: marked hypotension (BP 70J.50). PE: cold, clammy skin;

acute distress; generalired abdominal tcndetness and rebound
tenderness with guarding, especiallv in Iefr ilpper quadrant;
pair1 in left scapula when foot of'bed is devated or an palpation
of left .rubcostal reffion {&HR'sSIGN) (due co presence of free
in rmperitoneal blood tl~atirritates diaphragm) : dullness to per-
cussion un lcft flank and dullness to pcrcltssion on sight flank
that changes with position ( B A L I ~ ~ SFI G' Ns ) .

Labs lAowhematocrit; peritoneal tap grossly bloody. Uh: negative.

Imaging CT/US: he~natnmasurrounding spl~enwith obliteration ofL

splenic outline; peritoneal flnid.

Treatment Immcdiatc blood and volume replacernen t; emergency surgical

splcen removal (srr E ~ C T O M Y ) or. when possible, rplenorrhaphy
(SPI.ENIC SUTURE). Postsplenrctomv patients slloulcl receive pncu-
mococcal vaccine for prophylaxis.

Discussion The splcen is the mosl commonlv in,jui-eclorgan in blunt a b

dominal trauma. So~lletimesa few clays will pass h e t w ~ e na
trauma and syrnptomatolog (I)I..IAWD SPLENIC R U ~ I R E ) With
.
splcnic enlar-gement, wen minor trauma can cause rupture.

SPLENIC RUPTURE
 ID/CC A 13-year-old boy: is hrmigh t to the ernergcncy rorm ljr? his par-
ents a r c r a n accident at school: hc was walking along n $[eel
d whcn he slipped and fell, straddling the rail.
~ ~ ' n i -rail

HPI H e was in extreme pain initially. 1121 home the pain subsided
'iotneWt~at.Upor1 2 wination, a few dmps of bloody urine wcrc
pi-utlilcucl. T l t e child also nolicerl qwelling 01- his scrontrn.

PE VS: racl~ycardia(HR 1") ; frvcl- (3K.3"C).PE: p a ~ i ~ t linr pain:

grni tal examination ruwi11s vru.it< of' blood on meatus,
ecchymosis. and painful swelling of s c r o t u m and perheal
region:abdominal exam cliscloses a rounrlrrl, tcndcr rnlal-gerncri1
un the suprapubic area that is ~ i o r l ~ r i o ~arid
i l e dull 10 percuqsion
(hlarld~1-is frill).

Labs CHC::leukocytosis (1 7,0003 with ncutrnphilia. Slightly increased

R U N wirh nc>rmal rrpatinit~e.C.4 was not possihlc in thc ER
Fcrlrv cathrter w;+s rantraindi-
{duc to inahiliv to void; i~lsor-tine
c x l e d b ~ c a u v eof pl-ohable m-elhral rlanlage).

Imaging Ure~hmgl.aphv:extrxva5ation t~rirleinro scrota1 ri~stieand

perincum (rupture of urethra).

Treatment Surgical rrpair, trmpur;lrv cvsrostoniv.

Discussion The n~;iIcu r e t l ~ mi.: d k i d e d inlc, sevel.al pt,rtinn<: rhe pr-oqtatic

(wiclest), t - ~ e m l ~ i x n n (narroivest),
ns h u l h n ~ ~(in
s the hufh part of
the corpus sponposrtm) , and s p o n p portions (Iongvsr, withit1
the C ~ I - ~ I sI pF ~ i ~ g i o ~it'irlr),
t ~ n i enrlinq in the fbssa naviculnris
a n d meatus. I Y i t t~ fnrr~f111rnn~trirtionof the tlrerhra against
thc pubic arch, n urr.thr:il ruptrlrt. may enstlr. The Iascial plane5
i 13 rhe region rli rect urine to flow allreriorly ro the louse arrolar
t i s s ~ i rof rhr scrotum arlcl silperficial perinril space. This q p c e
lies belween r h e inferior ihscia of he t~rngeuitaldinphmgm nnd
the s1q3rrficial peri11eal I'awia.

7 STRADDLE INJURY
 ID/CC A 42-year-olcl fcrr~alron the p n e c o l o e ward cumplains OF a
dull, aching pain on her left Bank as well a3 riausea and vomiting
on lier t tiirrl postoperative clxy; [the in tern notices that the
palient has alsn heen olipric o~ernight.

HRI Shc recen rly unrEer\vent a tc~talabdominal hysterectomy due ro

large uterine fi hmids.

PE VS: l o w p d e fever; BP normal. PE: @ent well hydrated; no

pallor notrd; surgical woumct is tnidli~leinfratlnlbilical; dressing
noted to be wet with urine; al~clome~l has muscle g~rarding;
peri~talsisdiminished without ubviol~speritoneal signs.

Labs CBC:: le~~kocytosis with neutrophilia. BLT and crearinine

i~icreased.T.yte5: normal. UA: proleinuria and rnicm~mpic
llernaturia.

Imaging Lxcretor~uro-qapliy: blockage of urine at level of lefi ureter

and intra-abdominalleakage of urine from right ureter.

Treatment Exploration and surgical repair of rlrrtel-swi rh end-to-cnd arm+

lr>mosisor ?' stent.

Discussion T h e ureters mrty be injurer1 r l ~ ~ i i n tomy T h c crilical

h?~stel-ec
g
point comes di~ritlg;ligation of the uterine vesscIs at the vicinity
of the C P H T ~ X Thc
. ureter crosses underneath the uterine arteries

* URETERAL INJURY-IATROGENIC
 IDJCC A 43-vuar-ald female complains of numhness and swelling of the
legs; qhe also ha5 muscIe fati-gue in the afturnuvt~qwi~lia feeling
of heaviness in t h r Inwei. exrt-emi ties aswcia~erlwirli cutaneous
lumps and humps.

HPL Sht.i s overweight, works behind the corintcr at a fast-food

I-rsLmran t (associated 1virI1 prolongrd sta~lding), and h a given
birth to five chilclrcn. Hrr symptoms are alleviated when she
elevates her l e p by placing them t>n;i chair.

PE Ohese: rliffiri~lryI>reart~ir~g
after clinlhing a flight nT stairs; facial
pletliorn; examination of lo~vcrextremities rrvrals swelling with
dilatation of veins in territory n l greater saphenous vein.

Treatment Low weight, elastic stockings. dimiu is11 prnlongcd stanclin~,

SLlrRCry (<apf~c.nucturriy).

Discussion The greater uapl~ei~cl~is vein start., at he atiterior aspect of the

rncclial inailuolus, origii-tating in thc dorsal venous arch o f the
Foot: it asc~~lclxin the ar~~ercsrncdial portion of tlie k g and thigh
tu drain in the frrrloral vein just hefore rhe inguinal ligament. Tt
has ilunlernus cnnltnunicating veins with the deep vcnous
nf.;tcn1. Prinl;u+v varicoqities ilrr a rev 111 o f incompetence of the
valves in the s a p h e n n ~ ~ ~ o r in the communicating rein<.
vein
thus increasing hydrustatic prussrlru and pr.oducir~gdilaratinn
arid tortuous veins. Sccondiu-vvaricoqities ;ire a r ~ s ~ lor lt
nhstl-uction ol'tt~er l e e j ~v e n o m svstem ~ v j r j ~resultant
t~ increased
flow and pressure.

Atlas Link TT'T? MC-364

7 VARICOSE VEINS
 I DJCC A 3 1-yearilld white female comes to her- Fatnilv physician for a
routine physical examination.

HPI He]- rl~edicalhistory is unr-emarkal3le. She has hcen on birth

control pill4 for the past fi months.

PE Three-cen t i i t fusiform fluid-filled submucosal mass along

lateral wall of vagina on speci~lumexam; no discharge; cervix
ilormal; on palpalion, no pain or mobilization; no pelvic masscs
on bimanual palpatiorl; I-eclalexam normal.

Labs Rvu tine lab rxarns n n r m ~ lpregnarlcv

; test negative.

Imaging US: rranslahial approach shows k r n cyst in v;lg-ina.

Micro Pathology Simple. cyst wilh serous fluid, lincd with a single layer of col~tm-
nar epitl~eliun~.

Treatment Surgical excision if large or syrnpi ornatic.

Discussion M o s ~vaginal cysts larger than 2 cm are Gartner's duct ~ysts,

whir11 are of mcsonephsic {WOI.FFIAV) duct origin (due to
incompIute cIostre during embryonic life) and are Found along
i l ~ eanternlateral aspect of the vulva or vagina. Thcy may a l ~ o
he
I'ound in the broad ligament.

GARTN ER'S DUCT CYST

 ID/CC A 54yei1r-old nursc complains of a E~rqsensatinn in her lower
abdomen that worsens when she lifts heavy objects. together
with hack pair1 a t ~ r increased
l Ii-eqllencv of'ui-ination with a
burning sensatio~i(due to a1tererl location of bladder,
ailhsequent stagnation OF ~irine,and thns bacteria!
proliferarion).

HPT She has given birth to five children, all by vaginal delivery. She
co nlplairl s nS urine leakage while coughing, sneezing, or running
(STIZFSS I N ( : O ~ I I M F V I:F.). Her menses are irregular. hut she has

otherwise hren in good health.

PE Downward bulging o f anterior wall of vagina (CWTOC:I<I.E) with

1 0 ~ sof urrthro\cqical angEe exacerlxiled Ijy straining; protrl~sion
of cervix (PRC~LIPSE OF ~ T E R L ~ S ) .

Imaging X i d i n g cvs~ourethroffram:hladdcr dropping l3elow syrnphysi~

putris during voiclin~;loss of un-ethrovesicalangle.

Treatment L%laddrsrew~spensionsllrgery.

Discussion LTtrrinc prr~lapsui> nls~vallya result of the stserchi ng or peIvic

s ~ i p p o r l i nstrncttlres
~ during delivery coupled with years of
grnci tational weight and m~nopausallorn nC muwle tone. Pelvic
Ilnnr slipport is given hv the levator ani inuscle and its fascia,
which continues with thr urogenital diaphragm, endopelvic
ra~cia,and cardinal ancl l~terosacrallipmetlts.

UTERINE PROLAPSE W I T H CYSTOCELE

 A GG-\:ear-oldrliah~tichigll-~cllonlhirlloq teacher goel; to a Fllr-
geon for an cvaluatinn or n smalI nodule on his lower lip.

The n o r l ~ ~ il lea ~heen tl~crcfur o w r vcal; and h c wclnders if it

might he re1;lted to his llahil of chewing tobacco while watching
bas~hallFanre5 aftrr w-hc)ol.
x --
rn
Ind~~ralcrt, ill-defi~lcd,vir,laceous, rlc)~imo~ile mars fell in IOM~PT 3
m
lip: uiilargernent nf submental lymph nodes (wli irh drain the =.
0
Z
rnedial ~>or-lion of t h e lower. lip) arlrl suhrnandibular lymph rn
nodes (wl-tichdi;lii~ the Iaiel-a! pnl-tinn o f lower lip): enlarge-
r t i r a

Inenl o I deep cervical lymph nodes neat. omohvoid m ~ ~ s c l e .

Labs

Ernaging

Grass Pathology Sitrgicnl pi~tholowspecimen rnnsirtl; elf a wrdgr oI'lowrr lip

wiih an ulreraterl lesiml a ~ l drnI!ecl edges.

Micro Pathology

Treatment Si~rgicaIreinoral nf nnrlule on lip and radical neck cli~section

(removnl of ~ubmandihillargland [adhcrrcl to ; i f f t c t d s u b
rnandi hular nodrs] . sccrnoclriclomastoid muscle, omo hyoirl,
accessnry nerve, and in~errialJz 1g111ai.
\.pi tt ) .

Discussion I n l p ~ r t a n trqions in tile anatomy nf'sqnamous cell carcinoma

nf the lip I I I C I U ~ P the s~thrnanrlil>r~lal- triangle (hchvccn tl~cbase
of the mandihlc and the antcrior and po~tuliorhcllics of thr
tliga\tric); the mttsctilar triangle (omollyoici, s~ernocleidomas-
toid. fnprlian Eitle. rnntait~ingsnme deep cervical Imp11 nodes):
thc carotid rriangli- (stcrnoclrido~n:istoid,omohvoid, posterior
belly ol'digr~slric.con tainir~ginternal jugular vein at~cldeep
cervical noclrs): ; l r ~ r itlte P C , ~ ~ P I . ~ Ocervical
!- ~ r - i a n g(ttapezil~s,
l~
strnroclridnn~astoid,ornol~void,containing dccp ccrlical
nodes near accewnry nrt-re).

Atlas Links

* SQUAMOUS CELL CARCINOMA-LIP

 IOJCt A I P-ruuckuld male in Fat11 is brought to the hospi~alTor e ~ d u a -
tion of recurrent oral thrush and t R L 5 .

HPI T h e cllild had seizures (due LC, Ilypocalccmia) s h o x ~ l yaftcr

birth. I4is mother is an Il' drug uscr.

PE Full-trrm in rant: jittery; incl-easecl muscle tone; ur;111I1r11sh;

midfincia1 hypoplasia.

Labs Hypncalcemia; T-cell count markedly low.

Ernaging CXR: absent thymic shadow.

Treatment Tranrpiant of an immature fetal thymus: meat upportu11is;tic

infections: irradiatim~of Illnod producrs.

Discussion DiGeorge's syndl-ome is duc to a11 e m bryologir dcfec t ctiaracter-

izcd hv lack nf rlev~lopnientof the third and fourth pharyngeal
pouches. It is associated ~ i t l lack
l of thymus and thur 110
cell-incdiatrcl irnrril~niq(henre recurrcnl viral and fungal inkc-
tions) as well as wit la congenital hcart defec tq. The associated
lack of parathyroid gtands rcsults in livpocalce~nia.leading to

DIGEORGE'S SYNDROME (THYMIC A P L A S I A )

 ID/CC ;2 newborn female presents with a r~onplllsatilemass on the left
.iicle oF11rrhead: an irr tern is called to ;~ddresuthe mother'q
colic-et-n~.

MPI The in t ~ r nhas been tl-ving [to reassure t h p chilrl's mnther that
he]. rhilrl's rot~ditiot~
i'; benign, Imt hi< re:issurnrlce5 hirvc bren
LO nu avail. Thc rlclivcrv was unrvcntful except fnr a pmlongrrl

expulsive perind.

PE Ncwlmrn fc~nalcin no aclltr dis~rcss;1-10 cyatinais or pallnr; n o

signs ol rarrliopulmon;u-l~ involvement; scalp exam cliscloses skin
inn wi ttl ecchymosis and rliff~lsrswelling of soft tissue
rlisct~lol-at
in left parietal arca involving most nf the left parictal bone and
unc-third of the rig11t parietal bone (crosses suture lines).

Labs C:RC:/I,vt es: nnrmal.

Imaging or r~vcrlappingof bones at srrtzu-eq:large

XR, 5kllll: n o fract~~rt.
scalp maw unrelated to skull clcarlv lius acr-usssutures.

Treatment Observation.

Discussion Ci~p~ir s~tccedaneumrefers tn a benign edema or the soft tissues

of the head during ddelivcry: it charxctel-iqticallvcrosses the
midline and cranial suh~lasand is riot assr~cialerltvith an
onrlerlyir~gfi-act11re. The diiTerer1iiaI dizgnosis includes
crphal hrmatoms. rvltich does not prcscn t wit11 C C C ~ I ) T ~ ~ O is S~S,
som~tinicsassociated with a fracture. docs not cross suturr line5
(a~l~pcrictstral hlcccling is limiter1 to o n e hnne), anrl may take
F P I I P ~ ~ I 1 1 o 1 1 r ~to heco n ~ eviclent
e (caprlt i q imtnecliateIv srcn) .

* CAPUT SUCCEDANEUM
 ID/CC A neonatologist is ca!led into the nursery for an emergency; a
newborn hahv girl has hecome dyspndc and turned blue
(cymo~rr.)upon her arrival from the delivery room.

MPI T h e ytitient i s the product of a normal delivery. Her mother did

not receive any prenatal care.

PE Full-term fernaIt. baby; cyanosis: severe dyspnea wilh olwious

intercostal retractions; small and scaplloid abdomrn; absent
breath sound.?anrl positive peristaltic bowel sounds: in left chest;
heart sout~dsheard best nver- sight h ~ m ihol-ax
t (clue to cardia-
mecliascinal shirt).

Imaging CXR: coils of air-filled stomach or bowel seen in left

hemithorax. displaciri g treart to r i g h ~sick. Prenatal diagnosis
can Ile made by ultrasonogl-aphy.

Gross Pathology Left pulmonary hypoplasia; left posterolate~.alcongenital

diaphragmatic hernia uilh failure of fr~sionof pleuroperitoneal
canal.

Treatment c i and stal~ilireneemale, intubatiotl, aqsisted ventilation

R e s ~ ~ state
follo~verlkv ~urgicalrepair.

DTscussion Congenital diaphragmatic lterrlia usually rcprcsents failnre of

the pleul-operiioneal canal LO close cclmpletely ( F ~ K A M E NOF

S p ~ n a cord
l
Vertebra

Rib
Aorta

pleuroperttoneal Mesentery of
oesophagus
Cef t
pleuroperitoneal
lnferror vena.. membrane

Contr~bution
from body wall
traosversum
Oesophagus

Figure A-044 Muscular structure composed of the sepninl transver-

rum, dorsal rsophageal meqrntrry, hncly~vall,ancl plcuroperitoneal
rnernlxar~e.

7 CONGENITAL DIAPHRAGMATIC H E R N I A
BOCHU,ULIC), leading to protrr~sionof [he abdomina! viscera
into the chest; it is usually located on the left side. Parasternal
or- retrosternal (FORLIEN OF MOR~;AC;NI) hernias are also congen-
ital bur usrlally do not produce symptoms so early and are
located antcriorlv (11s. Roclida~ek'spostcrolateral location).
Pulmonary hypoplasia is the tnort common cause o f death in
infants w i ~ hdiaphragmaric hernia.
 ID/CC A l-day-old male infant pvIoric sirnr~sis.which i q xsqociated
(i7.s.

with 3-week-old infants) has persisten r bilious vomiting (vs.

pvloric ~tenosis,which is n o n h i t i o ~ when
~ ~ ) his motller attempts
10feed him.

HPI Hr. was horn a1 36 w c k s of gestation and w e i ~ h e d2.3 kg at

birth (vs. f~~ll-tcrmfor pvlorlc steriosis). His morhrt. harl excess
amniotic fluid ( ~ n ~ k F W I 3 ~ k h . l ~ l o s ) .

PE VS: ~arhvcarrlia.PE:: dehydrated: no ja~rncliccpresent; on che41

ar~scultalion, con tinuouc machinery mtlrmur- @tent c l u c t ~ ~ s
artrriosus) present: single palmar crease and ~ypicalCxcies of
Down's syndr-ome; abdomen distended, tympanic tn pcrcussio11.
and painhil: nr, mass Celt; no visihlr pcristarsis; narrnal-lookirlg
mcconillm on rcctal oxam.

Imaging KUB: gaseous tlila~a1ior-1

o f stnniarh anri dundenurn ("nur30r,~
I3ITRKI F").

Treatment Sl~rgicalrepair.

Discussion Iluodenal a ~ r e s i ai s asqociatecl with ~ t l i e rinusculoskelutaI and

\iscrral abnarmaIitic<, notal)ly Down's syndrome, as well as with
congenital heart disease. It n-pically present5 with bilious
vomiting on the F i t day of life.

DUODENAL ATRESIA
 ID/CC A 3-week-old male is hrcmght to the pediatricia~ifor projectile,
nonhilious vomiting t I ~ h1 e ~ p ntotl,w s11or.rlv afl'rur feerlin~.

HPI H e hiis ZIPPH rpffrlrgit-aringh o d and has l ~ a doccasional hoirts

oi-vt~mitingfm- 1 week. The chilcl is thc first-barn son of n
28-~~ar-old white feimalc and i s the p r o d ~ ~ of
c ~ ;+
t 1101-ma!r1eliver.y.
His mother had hypermphic pyloric stenosi5 w1lt.n she was bar-n.

PE Letharqc. moderately dehydrated hahv: low weight for age;

wrinklecl. "old man" appcarancc: visible peristalsis ii-c)m l ~ f c
llpprr qtiarlrint tcnm~-rlright llppel- q~larlt.antFol Ion-cd by
projectile vomiting: hard, rnohilr, nonlendr~;olive-like mm felt
z
to right rcc~usnlrrwle.
in epigastriwrn d c ~ p m
0
Z
Labs Lytcs: hvpokalrmia: hyonatrcnria. ARCS: hyporbloremir alhdu- 3
o
siq (rllre ro loss ofg-astl-ic hudrochlnric acid in votnitus). 6
C)
<
Imaging PIS: pylorus mrrscle thickening (target sign of pyloric st et~nsis) :
rlongated pvlnric canal; ~zridcncdpt lor-us. UGI: pylnr-ic ~ 2 1 1 1
iliickening; elongated and rial-rrwrd ~ l v l n r i cchannel (%TRAM.
SIC;N) ; vianrcntsly perisialf is stntnacl~with almost no ga5h-i~

Gross Pathology Diffiise hypertrnph y and hyper-placia or smooth nlusclc involvi~~g

pvEnric sphincter; muscular thickening r-xtenrls p r o x i ~ ~ ~ aIOl l v
;Intrum ;inrl end.; w h e r ~r l ~ ~ o dt r1111
t ~hegin$.

Treatment Carl-ection nS Il\~iiland cllectrofvtr abnormalities, nasognstric

rl113e decompressinn. Surgical wlicf of pvloric ohst rtlct inn
(R~XISTEDT ~\z~Ro\I\T.Y~c)\~Y).

Discussion Hvpertrnphic p~loricsto~iosisrlsu:illv preseilts "verks afzer

birth. although it Inav 11uthecoinr appal-rtnt1111ti1 s~veral
tnorlt h s of' age.

HYPERTROPHIC PYLORIC STENOSIS

 ID/CC ,\ 48-yea~oldmale cornpu ler prugrdmmrt is kzougli t to the
emergency room with intermittent, e x m c i a h g pain in the
right flank: r h e pain radiates to his inner thigh and testicle and
is accompa~lierlby nausea anrl vomiting.

HPX Orfcsa pcriod of a frw hour<. the pain migrated toward his
p i n . I t lasrerl for 30 minutes anrl then stoppcd for anothur
30 minutes before n~ddenlvrecurring (due to periodic
pesiqtal~ic111r )tion nf' 1.1re~er).

PE hhdomirlal exam shows no rebound tenderness (vs, peritonitis

07- ;~ppenldicitis); guar-ding i q present; painrul and difficult
urination ( n k s ~ l ~ mblood
); ill urine (HF:MATI.KI~); patient is
rrstlesv and keeps witching position (vq. peritonitis. in which
~ t still bccause of pain).
p a t i c ~ lies

Labs t!A: hematuria; I>;lcteri~~ria;

leukoryturia.

Imaging ILT or CT urngram: fiTli~rgrlefects in umtcr and renal calyces

due to stoncs. Obstruction proxirrial tu storle.

Treatment HvrZratinn, analgesics, antispasmodic?: many patients pass stones

syontat~eoz~sly; treat metabolic ahnormalitius: pcrcutarleotls
stonc extraction (PEKC:LT.~NEO~SKEPI-IROLITH~TCIMY), shock wave
i )n (+,xI KACOKPOKI.AI. L.ITHCITRIPSY), or surgical
storle f r a ~ p e itaiir
rcmoval.

Discussion Renal ir-act stones may produce one or the most severe forms of
pain known duc to obstruction arid s ~ n o o t hmtiscle contraction.
Ihlculi inav he bornirrl of calcium oxalate, inagnesium
arnmoraium phnspl~ate,cvstitle, or uric acid. Approximately 85%
of renal calculi ai-e radiopaque calcium oxdate stones. Uric acid
stoncs arc radioluccnt.

Atlas Link U-1111-J PG-A-047

NEPH R O L I T H I A S I S
 ID/CC A 4.5-year-old man. ~tlefarher of swen children, comes to a ram-
ily planning clinic fnr acl~-iceregarding birth control.

HPI Afcer carefi~llpweighing all possible alternatives with the doctor,

h e decides to 11avr a vasectomy.

PE Physical exam unrcmarkahle cxcepl for an old McRurnev

appendectomy war; no coutraitwlications fnr surgery.

Imaging CXR: within normal litnits I'or age.

Treatment 1';wvctomy (complications include scrota1 hematoma. infection,

spermatic ~ a n u l o m asperrnatocele,
, an<?spontaneous
recanalization).

Discussion \'asectornv is an increa5inglv popuIar rnethocl of permanent

birth contrd (regzarded as such, although repnrrs o f up to 70%
successftll reversal exist, mostly in men under 30 years ofage
w h o ~lnderwer~r the proceclltre lesg rhan 7 years ago). T h e Iayess
to clit d ~ r o ~ t gare
l l skin, superficial scrota1 fascia ( n , w o s msc;r,$),
external spel-matic fascia. cremasteric fascia and muscle, internal
spermatic f'wcia, pwperitoneal fat, and ~rlnicavaginalis.The
d~ictusdefer-enr is tied in n w place5 and transccted.
 IDJCC A 59-\!ear-old femalc comes to her family physici;m hecause of
left-side hearing loss, ~iutnbnessover the lefi hall' of her Face,
a n d unqteadiness of gait of ahorit 1 innn th's duration.

HPE She nlsa rornplnins of intermittent vertigo and ringing in the ear
(TINNITI!S). She has no history of earachc, car clisclaitrge, or
eri~ptionaver the pinna.

PE P a t i ~ n tCalls lo left when star~rlingwith eyes closed ( F ~ s I ~ .

K ~ ~ M I J ~SIC : I ~ L;; Lirnclus
's normal; gait wide and ataxic; whrtr
runi11gL'ork is pli~cedin midline of skull, patient reports that she
hears best on right sidr (Wcher test laterafizec t c ~the right, i.e.,
he normal sidr, becanse r h e leh suffers a senrori~lc~~ral loss);
caloric testing SIIOIVS left canal paresis.

Labs Ar~diometryshows sensorinenrd hearing loss un left side that is

m o w pronounced with high frequencies.

Imaging CT/MR: cnntrasren hanceil cerebelIopontine (CP)angle mass

cxtcrlding into internal auditory canal.

GTOSS Pathology Slow-growing sc hwann n m a nf eighth nerve.

Treatment S l ~ r ~ i crmn~ov;tl.
i~l

Discussion :Zcoustic schwanno tnas art=Schwann cell-rleriv~dneoplasms

that comprise about three-fourths of CF-anglc nec~plasms,They
arise mainly frt ,111 the vestib~11a1-
divisiori of CN V'III. Other
CI'-iati~Ieinawrq include ~neningirrina,arachnoid cyst, and
epiclermnid tntnot Bilateral acnustic schwannomas are seen in
type 2 neurofibmmatosis (NF-3).

Atlas Link DJ-LA PG-A-049

ACOUSTIC SCHWANNOMA
 ID/CC A 42-year-old man presents ro his fararnilv doctor rnrnpjaining tof
pain and stiffness on one side of his neck that precIudes normal
moi~pmpllts.

HPI Tlir patient is obese and sedenlarv and never exercises. His paill
startccl after h e wenk outside and shovelet-I rhe firqt m o w withor~t
ws~rmingup (sudden, ~ i g o r o l ~plysiral
s rserrise).

PE I-Iead tilted t o one side: par ieut callnut straighten hear1 without
rnnsiderahlc pain: accornpn ied by considerable muscle s p m
in left drle or neck.

Imaging XR. cervical spine: no fract~iroor siil>litxation

Treatment Muurle ~ . e l a x a r ~ tKSMDs,

s. local h a t , masxilge.

Discussion Acittc torticullis is causer1 by acute spasm of neck muscles due tn

irlfl atn t~ratorpchanges Iwcause of ~tncluestraining; thc r n u s c l ~ ~ ,
that arc. usuallv i n v o l \ ~ darc the trapczilis, suprahpinat~is.thorn-
I~oicl,splcnius capitis, Icvator scapt~la,s c a l ~ n rnedilis.
~~s qplenius
cervicis, and, in severe cases, transverse li~a-imenr.allowing
subluxation nf one vertrhra on another. Tortjcolliq may also bc
congenital due to unilateral fibrosis of the steniocleido~nastoid

ACUTE TORTICOLLIS
 ID/CC A -57-year-nlcl rig11t-handerl male is Ix-ought to the emergcncv
I-OOHI 13v his relatives hccause t l ~ noticed
y that altl~oughhe
speaks flt~rrltly.he has beg1111ro use inappropriate words and
phrases to rprer to ol-dii~al-yn l j e c t ~a n d event? in his daily lifc

HPX I Ic suflers fi-om chronic hypertension that has been treated with
calcium channel hlnckerr.

PE 1'5: hypertension (BP I i 0 / 120). PE: confusion; constructianal

ncurolugic deficit; Bahiirski's reflex prcscnt.

Labs n a l activity in leR ter-nporal lolw over supra-

KEG: a f > ~ ~ o r ~brain
marginal anrl marginal pri.

Imaging CT/MR: infarct in left tnirldl~cerebral at.tc-1-)*t eyrir or-y.

Treatment Supportive. Speech therapy.

Discussion IVel-nick's ("receptive") aphasia is a disorder of spcech that is

cluc to a lcsion in the superior temporal gyms that occurs
w i h ~nidtlltccrebral xi-wry o c c l ~ ~ s i o n
Speech
. is fluent hut
nonsensical. a11d I here i s ;11~nat) iiiahili~yto ~~nrlerqtand spoken
01. written I a i ~ g u a gNonfluent
~. ("expressive") aphasia (BROCA'S
.krti/~rc\) is chi~rdctcrizedby thr i l ~ ~ bty i l i fc~rtnwords: patients
knnw what thev want In 5ay h ~ are ~ t lt~lahleto clo so.IU~atever
thev do say, houvever, is appropriate ancl rneani~~#~ul. This
diwrder rcsults frarri a Iusiori ill the ir~furiorfrorllal gyrus.

Figure A-051 Demonstration

of ir~voluritarytlorsiflexio~iof
thr lees in rcspolnsr to stroking
, ",,,
,
, , on the sole of the fool
G

1:
, A ,

':
A ,

(A-Rahinski'ssign) and altcrna-

;
, ,
, ,,
,il
j::$ tivrs: anterior tihiat surface
I ., ,$
<
(bOppenhrinl3,rsign), and
l;lier:~ltn:xlleolt~s(GC:hadrlock's
sign} o r to tir~nlvahdk~ctirig(lie
,, ,
,, , , , " ,,
, . , ,
, ," A
, " ,
, , , , A
::,,;!
I ,; -\ ,+
,,, ,
,
,,
,
, ,
,, , ,
A

A
,
, , , , , , , ,<
,
A,
fifih cligii Tor 2 s ~ c o i ~ d s .
k.:;>,,--,,,< ;, :, ; " , , , , ,
", , , ,, , ,,,
., ..
8
, A , ,
(n-Srru~isky'ssign).

blCq
c - APHASIA-WERNICKE'S
 lD/CC A 7-year-olrl girl is hl-oiqht hy her parents to the pcdiatric umer-
gencv drpartrnen t hecarl~eor a severe headache t11:t~does not
respo~ldto treatment wit11 analgesics.

HPE Her fa~lieris cot-rcerned aho-iit "weird movements" of thr girl's

ryes (NIS I-AC;~TLIS).

PE M'ell dcvelopecl and nourished I~utconfi~sedwith ataxic gait;

chest and abdominal exams unrem;~rkahlc-; fiinduscopic exam
reveals left papilledema (due to incr-ei~scclintracranial pres-
snrc) : nvstagmus also noted; patie111 exprrienced prqjectile vom-
iting during examination (also due 10 increased intracraniaf
p"es""'e ) .
Imaging MR/CT: cystic posterior fossa tumor.

Gross Pathology Grayish cystic mass; zones af necrosis, hemorrhage, and calcifi-
cation; cerebral edema.

Treatment Surgerv, chpmothcrap): radiotherapy

'Discussion hsrrocvton~al;are slo.rt,-growingmalignant tumors that originate

from neuroectodermal neuroglia. In ch il tlrpn I hey are usually
located iri the cerrbelltirri (posterior fossa), whereas in acl~lults z
m
the)' are located in the cerebrum. OCten cvstic in cl~iIdrcn,heir c
A
growth mas calrsr increasecl intracranial prc~sitr.e.seix~rt-es,and o
r
h y ~ l r n s ~ p l ~ aThe
l t ~ posterior
~. cranial fossa is limited antrriorlv o
Gi
the dorsum sella, laterally Iw thc parirtal bones, and posteri- <
or117 hv the occipital bone; it contains the fm-amen rrlagnum h r
l h e spinal cord as well aq rhe jug71lal-fornmetl anrl rhe internal
acoustic meatus.

Attas Link UPG-A-052

 ID/CC A 43-ycar-old diabetic male comcs to the emergency room fear-
ing that he has had a strolic; he conlplains oCinabiIity to move
the right side of his face and cannot blink his right eye or s e d
his lips (lesion (31' CN %TI-Facial iiCrre).

HFI The pi-evinuq night, Elis wi€e 1101 iced thac he was sleeping with
his right eye open and l h a t the righi sirle nT t i i q race was droop-
ing. That morning, the patient couId not cop drooling on the
right side of his ~nouth.He has no1 c l o s u l ~monitored
~ his blood
Sllrdr for sr\,cral months.

PE Kight-siderl Facial tnl~sclc.iflaccid: t ~ t ~ d ernrcerl

r rlonlre of right
cvr, cycball rotates l~prvard(BEL.I.'sP I I E N O ~ ~ E V O N :) cognitive
~ r n is askcd to smiIc, right side of
function normal; ~ ~ l patient
innuth rcrnains flaccid (B).

Cabs CRC/ I ,vt PS: nnrtnal. Myp~rglvcen~ia;

Z.FTF: nol-inal.

Gross Pathology lnflarnmation of GN VII in thc v i c i n i ~of the shdr>mastnid

fr>ramt.11.

Treatment Steroids,artificial tears or eve covering.

Discussion Bell's palsv is seen as a cornplicatiou of diabe~es.AIDS. Lvme

diwase. rumors. ancl sarcoirlosip but i~most c o ~ n m o n l yirlio-
pathic. InvoI~ernent or tile en tire half of the i'ac~rle~nonqtrates
lowc-r motor neuron (CN\FI)patholop; ir~voIver~lrrl t or nrilv 111e
lower halt'd'the f a c ~ S I I ~ R P S ~llpper
S 1noro1-nrlsrnll pathology
(11ppe1-mator neurons have ct-nqq-innet-i~tionto the Cnrehead).
It is sclf-limited in mast cases (~picaI1yrrsolves in F, to 12 ~nonths).
with only a small pclrentage oTcases i-es~~ltinfi: i l l permanent
disfiglrr.munt. It is lIiougl~tto rrprrsunt a viral cranial polyneu-

* BELL'S PALSY
 Figure A-053A Drnlnnstmtion
01' ~~rurnlogic
drficit secol~dary
I
tr, a cr;tnial nervr lesion-
.. t dur in
unable to close r i ~ l l ryc
m .
ol-himlaris nclllns muscle palsy.

my
-
& \

'I

Figure A-053B Detnnnstra~inn

of n v ~ ~ r o l o f deficit
ic secondarv
rn a cranial nerve Frsion-low
of tipturn of right angle of
?'
:- $<i mouth on heitig asked to smile
-. clue to orl~iczilarisoris muscle
"3. palsy.
>..,1': <, A,:,

>
,
+
I
. ,

,,<,A
, A

; " ^ ", +
+ A ,
, ", ,
,, <;">
, ,
, ,,
<*<< ', , ' '
, A,

,+ ,
,,,,,
, , ,,,
- , ,,,, ,, , I
,,
< ,,
' g ., , Figure A-053C Denio~~strittion
! deficir secondi~ry
ol~ilcl~rolagic
i' toacr~~~ialner~~elcsion-loss
OF liarisverse f r o n d wrinkling
on l~pwal-rlRue due to right
ri.011 talis rn uscle palsy.
 ID/CC A 45-pear-old man i s broughl by ambulance lo the emergency
department of rhe local cortlrn unity hospital cotnplaining of
hbility to move his left leg.

HPI H e was stabbed in the back 2 houl-s ago while defending his wife
frotn a nlligger.
PE Modcrdtr bleeding; stab wtlund at Irvcl of the positlrior cervical
spinous prominence (C"7) on leIi sicle; loss of position sense of
lefi leg; weakness of finger- flexinn: extet~sionor left finger: in-
ability to sense vibration o f nming fork along left lower limb;
loss of pain and temperature sense in con~alaterallower limb.

Imaging MR: liematoma at level ol'C7-TI i n left hair of spinal cord.

Gross Pathology Hemisection and compression of spinal cord at level of C7.
Treatment Surgical removal of hematoma.
Discussion Rsown-Skpard syndrome consists of ipsilateral upper and lower
motor paralysis helow the level of the injury (corricospinal tract),
ipailateral cumncous anesthesia, ipsilateral loss of vibrations and
proprioception (dorsal colurnil) , and contralateral loss of pain

A B C

Sensory deficit

Figure A 4 5 4 A Lnqq on flip =me

nnf tibratoy se~~satiori qide as h e spl~lallesion.

9 BROWN-SEQUARD SYNDROME
 and trmpcrature sense helow the Iwel of thr lesion (spi11otha1i1-
mic tract). It is risually clue to a pench-ating injr~syto the spine,
resuli ing in functional hemisection of the spinal cord.

Sensory deficit D E
Figure A-054B Loss u f pain. pi~lprick.ard tennpe~;ilure sensation or1 the
srtle couualareial to the spinal lesion (describer1 in coniunctin~~ will1 F i p ~ r
.
A-034.4, ;tq rlissnciatcd ar~rsthesia)
 ID/CC .4 45-vear-nld hov-scour ins~ructnrI- turns fi-om a 2-wrpk c a m p
ing trip with a high Fever. a sewre headarhe, and a pus-rded
boil on his right cheek that appcar~dafter he cut himsclf on a
tree branch.

HPI The patienr has a long hiqtory o f diabetes mellitus that has been
11-ea~edwith irtsulin. H e also complairls of in tertnittent vomiting,
nau5ea, and episorlec o l deliri iim. His hearlaclie i 5 particularlv
severe on the right sidy.

PE \;St fever. PE: neck muscles stiff; right cheek swollen and red
~ i t area
h of plirulcnt discharge: right side of nose hard and
swollen:rixh t rye very painful ancl pro tr~tdes(EXOPETI~ 4 1 , ~ o . :S )
right rvelicl srvo1lc.n wit t i hlack discoloralinn; loss of'f ~ ~ n c t i oon
r
right extraocular eye muscles; 'tingling and burning
(P~XRFSTI-EESIA)of right upper quadrant of facc.

Labs Stnj~hylocurcusnlcrPrrs on blond and wound pus culrttt-e.

Imaging CT/MR: b c k of cavernous sinus enliancernent: clot in cav-

ernous sitltls.

Gross hthotogy Septic venous thromhosiq l>lockingtributaries of orbit; cyelid

edcrna ancl discoloration.

Treatment Agerewive cmirse of TV antibiotics

b
G)
Discussion T h e infection b ~ g a nat the in$~irysire and progressed along the -<
Facia1 vein and superior ophthilmic vtin to one of the paired
cavernous sinuses, onr on each side of the ?ella turcica: lack of
valves in the vein5 of the face facilirared migration of infectious
thrnmhosis throughout the race. Pulmonary septic thronlbi and
meningitis are common complications.

CAVERNOUS SINUS THROMBOSIS

 IO/CC A 34-year-olrl rorlstr~~ctinn wol-k~r- i.s 1,roilghr 1r1 a clinic arirr. a
fl!ing pic-ce or s1lr;tpnel cut his l e g < j ~h~~' il ~o uI 'he lateral surface
of the head of the fibula: the paticn t also cornplnir~qof numb-
ness and tingling along the dorslun of his foot and thc lateral
qiirfacr. of hi.: leg.

HPI Ffe complains of Inss or qrahiliry when walking and inability to

domiff ex h is foot ( F C K ~I ) K ~ I ~ , )[-It=
. nllzst raise Elig i 11j11t-erIleg
higher than not-rnal during walking to prevent his toes ~YCEIII
hilti rlg thr grc>imd. and his foot slaps against the ground w h e n
walking (steppage gait rl11e to tinoppc>svrIactinn ol'plantar flrx-
ars; n~rlsclesinnrrvaterl I n prror~ealn e i w are pa~xlvzed:extm-
sor digitorurn longus, tihialis anterir)r, extensor h:llIri~islong11s).

PE \t'r,unrl in proxi~niryot head of Rbtila { ; ~ l .whcl-P

~a rhe common
fihular riel-vr i s most ~nperfirialas i t wraps arnunrl rlre head of
the f?hula): diminished cutaneous sensation nicer antt=rolateral
aspcci of leg and cIor.s~rtnor root (cutaneous h r a n r h e ~or thc
uupf=r-fitialfibl~larnerrr .;ul>plyt h i s arr%i):i ~ ~ a l ~ i l10i t )extend
'
toer (pal-alv~iq or t ihiali~atllerinl; peroneti5 Inngl15 and tit-evi5).

Imaging XR, I r ~ : fractrn-r of hu:~clof fibula.

Treatment Spring-loadecl b~-;iceof foot to prcvcn t Foot drop during walking

m1cI tn provide i~drlitinnal~tal>iliry.

Discussion The common peroncal ncrve is hi.cquuntly inj~lrcrldue to tr;iam;i

o f the ilppel- leg (..a,. krokrti Libula) owing tn i i q ulrperficial
location arounrl ttlc lateral sur.face of t tie head of the fibula.

Figure A-056R I h.rnnl-isrration nl p o . c ~ ~ i oIIJI.

n ixhwcsincnt nTlowrr
t l e ~ plerirlor~reflexes-patcll;lr
rsir-rrr~ilr; rct1r.x.

COMMON PERONEAL NERVE DAMAGE

Figure A-056% E ) c i i l o i ~ s ~ i - ; u iut i ( . ~; ~ s v t s s n ~ c r-)I-
< >pos~lior~
~~ ~ >1orvc1-
t r~strcmi~
cIerp lrnrlun I-eflexes-,Achilles reflex.
 ID/CC Tlle parents of a 9-year-olcl bov are called into his teacher's
n f f ~ c eto talk ahalit academic proMems tlze child has been
having; the teacher suspects that the child cannot hear properly.

HPI Since infancy, he has had recurrent ear Sections ivi ~ 1 1discharge.

PE Otoscopic exam s l z o perfomtion

~~ of right tympanic membrane;
when n ~ n i n gfork is placed in midline of skull, patient reporls
he hears best on right side (Urr.n~.lr msr I A . ~ F R A I.IZES UIC;HT) ;
bone conduction greater than air conduction in right ear
(rosma RIT,I-ITR ~ N NTEST).
E

Imaging XR, cranium and sinus cavities: within rlormal limits.

Treatment Myringoplasty is definitive treatznent.

Discussion This i~ a case of' conduc~ive(not nerve-associated) deafness in

the right ear secor~rlaryto a tympanic mernhrane perforation.
Normally, air cond~ictionis greater than bone conduction (i.e.,
it p v e s a negative Rinne test), whet-eaq the reverse is [he case in
conductive deafness. The Weher test lat~ralizesto the affected
ear in cases of conductive deafness and to the normal ear in
cases of sensorineural hearing loss. Tnlterprehtion of the two
tcsis togethcr can identify the type of hearing loss.

DEAFNESS-CONDUCTIVE
 I DJCC A 9-venrald hov complains of pain in his left elbow lthat began
after he feu off his bicycle, hitting the grouncl elhow first.

HPI He also has nl~mbnesson the medial side OF his hand (due to
damage of'[lie ulnar nerve at the rncdial cpicondvle-olecranon
yoove) .

PE Elhow skin shows dermal abrasions and soft tissue edema with
tenclernew on palpation: inability to abduct Ffingers; poor asp
of fourth and fifth digits (due to ulnar nerve damagc; all hut
Live ni' the in tern?seo~isnltlscles are innermtetl t h e ultlar ~lerve).

Imaging XR, PI how: separation of epiphysis of tnedial epicor~dyle

(children under IG have t~nfused epiphvseal plate).

Treatment Isolation of clhow after reunion of frdckirecl ends: physical ther-

apy for hai~drnovernen~(crusher1 ncne will regenerate).

Discussion Of all injl~riesto long bones during childhoacl, approximately

15'3 to 20% invrjlve the g~*owth platr. A y-owing hone subjected
to a s l l e a r i n ~force mav cause the epiphysi~to separate from the
growth plate, prnducing ~ignqand wmproms o f a liacture.
Imprnper healing of the growtll plate may 1-esult in Iengtl-t o r
bowing cleformity.
 ID/CC A I -wl-ek-old child is brought to the pediatrician bccause his
mother noticed that the child does not move his right arm
r l ormallv.

HPI His deliwry was dvs~opirand prolonged wit11 a breech

presentation.

PE Child well nourished and developed; n o focal neurologic

deficits; light arm extended, internally rotated, and in
adduction; prenation o f Forearm ( ~ V A ~ R TIP
' S POSIT[OK\.).

Labs hasic wnrkup and newborn screening nortnal.

Imaging XR: no fracture of cIaviclc nl- arm.

Treatment Physiotherapy, nervc repair in selected cases.

Discussion Erb-Duchenne palsy involves the upper brachial plexus

(C5-Cti), tisuallv by addnction traction o f the m with
hyperextension of the neck. At times the phrenic nerve [nay he

ERB'S PALSY
 ID/CC 11 45-qear-old female is scheduled to undergo a Iefi
parotidectomy d ~ ~toc l a tumor.

HPI Upon a w a k e n i ~ ~from

g anesrhe~iaafter removal nC the gland,
she was asked to smile hut could not d n so prnperlv.

PE Surgical wound ct)vered hy sterile gauze with n o apparent blued-

ing; small drain it1 place; when patient i s asked to wrinkle fore-
head, patient's left side woz~ldnut rvrinMe (affected side); left
comer of mouth does not rise tip as right one rloex when pa-
t i e n ~is asked to smile: patient cannot raise her left eyebrow or
lnwcr it when asked to frown: mouth does not lift on left side
when patient is asked to slloubteeth.

Gross Pathology Sl~rgicalspecimen consigts of a malignant adenocarcinoina of

parntirI gland; a I).5cm-long portion of facial nervc wns found
resected. enmeshed in carcinomatous lobules.

Treatment Facial nerve can he sun~redol-grafted with suraF nerve il'lesion

is voluntary or involun~rvhut cannot 11r overlooked: otherwive,
physiotherapy.

Discussion M~tsclesinnervated by the facial n w v e include most of the mus

cles that move the race and scalp, inclliding the huccinator and z F- -
rn
t h posterior
~ hclly of the digastric. The Llcial nerve gives taste c
;D
sensation to the anterior two-third? of the t o n g ~ eThe
. pal-oticl o
r
gland consists of two lobules, rhc anterior and posterior: the o
I 3
facial nerve ancl its branches (ceriical, buccal, qgomatic, 4
trmpoml, and mandibular) coursc between thc hvo after exiting

FACIAL NERVE INJURY

 ID/CC ,4 Pti-year-old professional cyclist visit5 a sport? medicine doctor
corn plai tiing of weakness in the right leg and lack of sensation
) h e anterior area of his thigh.
( ~ ~ N E S I - H E S I Ain

HPI Eight v:euI;s ago, he fell from his bicycle during a race and suf-
fered a pelvic fracture.He was treated through use of a sling
and bed resc and i s riow trying to hegin rehabilitation 14th
crutches.

PE Patient has significant weakness with extension of his right knee;

~ r h e npatient is asked to stand, there i s ohviouq instability
despite x-rav consof idation of fracture, and d i g is impossible
(due 1 0 weak hip ilexion).

I Imaging

Treatment
XI?: healed pelvic Fracture.

Phwiother-apy, ~ur~gical
exploration and repair in selected cases,

Discussion The quadriceps femoris muscle is innervated by dlft femoral

nerve. When there is a nerve injury, as is the case in penetrating
wounds or pelvic frncturrs, the patient is unaMe to extend the
knee and thrt-e i s anesthesia in the anterior area of the lower
extremity from the thigh to the foot.

FEMORAL NERVE PALSY

 ID/CC A '18vear-r~ldman wit11 tuberculol~sadenitis of the neck is being
l e regimen; 2 days ago he developed
twaced with a m ~ ~ l t i p drug
"strange movemen&" o f the tongue and cannot stick his tongue
out normally.

PE Mhen patient is asked to protrude his tongwe, it deviates to the

left (rlcviatiuil of ahr tungliu to t h r affectrd side i s caused hy dle
rinopposed ac tinri of t h e con tralarer-al geninglossus muscle,
which is normallv innerva~ed):left ride of tonqre atrophied and
flaccid with Fasciculations.

Labs HTV positive; PPD (tuberculin skin test) positive.

I Treatment

Discussion
Trexi callse (TR, tumnl; etc.):physiot11er;zpy

flaccid paralvsis accompanied IJV atrophv of t h e tongue de-

notes a lniver motor nenrt)n lesion of rhc liypoglo~s~l
riel-VP.
Cauqes includc parotid ancl casr~tidbody tuIrmrs, ~ubetculous
adcnitiq. ancl metastatic neck tumors.

Atkas Link E m 1 2-A-061

Figure A-061 l ) t ~ ~a ~~ ~~ c~ <~tI c t~~~ ~~~[ I,bI~\ ( !, I~. ~ (~0. 1 t l i ( 11 III torque
o ~ ~ i w ' i~u+
1 l e v ~ ~>I) r o n p r ro t h c rigt~rindicaung an ipsilaieral
~ ir >ct ~lir
I:K \'TI ltiwrr motor tirllrnn Ir<ion.

HYPOGLOSSAL NERVE PALSY

 ID/CC A newhorn chilcl is noted on his first complete phvsical exami-
nation to have h i s right hand in a "claw" position.

HPI H e is the son nf an lFCyea~--nldrernaIe who was attundcd at

homc. by a midwife; he was hurl1 with shorllder dystocia.

PE In adclition to claw hand, examination disclose%p~rpiIlat-ycon-

stric tion (vlcnrs) w i ~ hrishr-dr-oopinx welid ( i ~ r o s r . ; ) and lack or
sweating (,tusrr~~osrs).

Labs Nconatal enzrme drficiency screening and basic Inh work

oormal.

Imaging XR: n o Cract~il-enf clavic!e.

Treatment PI-lysiotherapy.ncrvc repair in seIected cases.

Discussion IUumpku's palsy is an abduction injury affecting the lower

brachiat plexu%, whereas Fib's i s an adduction injury affecting
t h e upper brachial plexus. Panlysi~of the lower brachial plexus
primarily affects the C7, C8, and TI mats and pmcluces paralysis
of the m~isclcsinnerv;lterl bv them (e.g., ulnal- nerve, claw
hand). Concomitant damage tn the .sympathetic fibers of T1
mav produce Homer's syndrome (\iro.;rs, rrr)sn, ;ZNI+II)KC)SIS).

7 KLUMPKE'S PALSY
 ID/CC A 65-year-old woman complains o f prngressirre difficulty
abducting her arm beyond 45 degrees.

HPT She r~nderwcnta mastectomy 4 months a ~ for o breast cancer.

Refore her surgPry. the patient had fuII rangu of rno~ionin
he]-arm.

PE Win-ged scapula noted whcn patient p u s h ~ against

s wall
(sen-atus antmior paralv~erlby zlrrve damage and therefarc
unable to fix scapula against chtxl wall).

Treatment Physiatherap);.

D i ~ c u s ~ i o nI n the course or surgcal: axillary

ltmph nr>drdi5section during
mastectomy, the long thnmcic nerve mav be injured.

Atlas Link C1.~ ~ ~ - 0 6 4

LONG THORACIC NERVE I N J U R Y

-
 ID/CG: ,475vear+ldman complainsoCdifficultydawing
and speaking ( I>WARTHRI.Z)(due to corn pression of
(n\.irrs.\cr~)
C N IX, X): Lhese s y p t o n have
~ ~ pr~~qessivclyworsened over
the past several months.

HPI I Ie has a140 noticed increasing pain during urinatic~n{ D ~ S U R ~ A )

ovcr lhe past several months and difficulty starting the flow of
urine (a consequence nf prc~.itaticcarcinoma).

PE IVeakness oC right p h z ~ ~ , y n and

~ r i llaryngeal muscles; atrophy of
sternocleidomastoid muscle and trapedus rntlscle (comprcssion
of CN XI}; rectal exam rcvcals rock-l~ard,fixed rnass in proslate.

la
vated

Uvr la not
. ,

Fr'gure A-064 Dernnnstration or ne11roIoh.i~ rleficits rerogni7rrl hv exanlina-

tion nf thc ~ ~ \ ~ i l a - m i d l i nu\.c~la
e at rrst and cle\-;ited u t ~ i l awith r l o c3tljatir,n
while tllr patrcnt says "ahhh" I~hormal);~n.r~la rlcriared tn (he nolmal side at
rest 3 r d elevated with rl~viationto the n o ~ m a sirlr l whilr the patient says
"aIihh" (unilateral CN IX. S plcgia); rnid1111~ ~ ~ v uai
l arev1 and elevatrd rrjih
tleviation t o thr normal side while the patient sav~"ahIih" ( ~ ~ n i l n t ~ .C5r' i a l IX,
X paresis); nlidli~iet~vulaat rest and no inovelnerlt utlile ~ h patient r say?
"ahhh " (I~ilatrsal1X.X plegia) .

M A S S I N JUGULAR FORAMEN
 Labs Mm-kedlv increased serunl-specific prosta~icantigen; increased
acicl phosphatase and alkaline phospha~ase.

Imaging CT,ncck:rnassinj~~gulaxfomen.

Gross Pathology Metastatic prostate carcinoma impinging- on CN IX,X, XI at

level afjugular foramen.

Micro Pathology Transrectal hiopw shows high-q;lrle prastauc adenocarcinoma.

Treatment Prostate carcinoma t seated bv orchiectnmv and hormonal

rnoclaIities: radiation.

Discussion Prostate carcinoma produces metastases in the axiaI skeleton

with d ~ possibiliv
e of involvetn~nc at all levels of the spine as
well as the cranial bones.

MASS I Y J V G U l A ? F 0 9 A M E N
 ID/CC An R~ear+Id maIe presrzits with progressive dyarthria,
dgSphagia, and weakness nf t h e right side nf his horlv of
'I months' duration.

HPI The child has n o history of fevei-.vaccinations, rxantl~em,dog

bites, or travel outside h e United Statel;.

PE Fundus normal; atrophy of left side of tongue; joint position

and vibration sense seduced on right side; spastic right-sided
l~cmiparcsis;face spared;d ~ c ptendon reflexcr brisk on right
sidr: extensor plantar response noted on right side: no
cerebellar s i p s present.

Imaging CT. hhcad: lcft medial medullary enhancing mass with edema.

Micro Pathology Infiltrating glioma.

Treatment Inop~rabletumor I>ecauseo f s~trgicallyinaccewihl~~ite;

irradiation is the primary form or treatment.

Discussion Midlii~e stslictr~l-es are invnlved. including CN XI1

( I ~ O T , L . O S S ~ I L . ) , pFmi rlal motor tracts, the medial lemniscus
(pmprinceptive senqatinn), and he medial longi~udinal
fascic.l~lus(connects various CN nuclei}. The hallmark of
brainstem lesions is ipsilateral cranial nerve pal^ with
contralateral hemiplegia. Lesions of the midlmain produce
partial c > p h t h a l m o p l e ~and
a contralate~alherniplegia. Legions
of the pons p r o d ~ ~ cipsilateral
e paraIysis of conjugate gaze or
inlurnnclcar uphthalmoplegia, contralatcrd hemiplepa, and
loss of position and vibratory scnscs. Lesions of the medulla
produce paralysis of the rong-ue on t h e same side and paralysisis
of zhr con~alatcriillimbs; lhr face is spared.
 ID/CC A 9-month+Fd infant is hrought to hir falnilv physician hecause
EI~P parents arc wwrricd that the child's head appears too Large.

HPL The mother- had art appwentlv unuvcntf~rlprt.gnilncv and drliv-

erv. At hirth the c h i l r l ' ~hodv weight atlrl head circumference
were at the fi5th percentile (normnl).

RE Lrthargic anrl irritahfc: anterior fon tanclle bulging; 1~1;hen

ighrly, it immediatelr pops hack (incrca~edintracranial
P I - P S S P ~ FI
presqure): head circumference enlarged (an infant's head
enlarge: \$+i
tli increased illtracmnial pressure, since ft~sionof
cranial sutures i s incomplete).

Labs RPR in mother n e g a t i ~ e(Tor ~vphilis).

Imaging MR. hrad: daated lateral ven~cles; dilated third ~entricles:

stenosis of cerebral aqueduct (noncommunicating hydro-
rephalas).

Gross Pathology of aquedrict of Sylvius duc to asach-

C o n g ~ n i t aoh~tructiun
l
noidiris, with marked ventrictllar dilatation anrl atrophy of ccre-
I~ralt i ~ s u e(most common site of congenital obstrucrion is at the
aqueduct).
Z
rn
Treatment Surgical inserrion of shunt either from lateral ventricle to infe- C
n
rior vena cam or directly l r n ~ nthird vet~tl-icletn subarachnoid 0
r
space. 0
m
<
Discussion .;tlrno?t half of infants 7l;itl.I IlydroccphaIus will 31;lve Arnold-
Chiari syndrome (hvdrocephalus, svringornvelia. platvhasia, and
myelomeningocele). Other causes include infections (TORCH),
he idiopathic. as in this case. Not~cornmunicating
hnt it can a l ~ o
(ohstrnctivc) Ilydrucephal~rsresults f r o ~ nobslrr~ctionlo CSF
flow within the ventricles. causing dilation uf ahe ~cntricles
upstrcam of tl~chrock. Communicating (rionoh~rrtrctive)
hydrocephalus results from failure of CSF reabsorption in the
suharac l~nniclspace.

OBSTRUCTIVE MYDROCEPHALUS
 ID/CC A 50-year-old obese man corncs to see liis physiciat~at the
11rgiiigof' hi<wi (P; ~ I I P state5 that her hushanri sleeps restlessly
and Iias headaches upon awakening (cluc to inabiliry to breathe
wI1Ilc ?Iceping).

HPI Hc is a hr-rgvy smoker. His wife cr)mplains that his Ioud snoring is
Leeping l ~ c rup at niglli. The patient also feels very ired during
SIIP ctay rlespite the fact that he gets 10 hours c l i slucp each
night.

PE ITS: hypertension (RP 1fiB/ 100). PE: patient markedly obese

with bull's-neck appearance; tongue large; nasal septum
deviated to lefl; heart sounds reveal arrhythmic rate
(pl-olotiged anr)xin): I ~rngshy[~cwentiIared:
pitting e d ~ r n ain legs.

Labs CBC: palycy~hemia(compensatory cffort for hypvxia). LFT?

and th!roid function tests nm-mal. ECG: p-elnature ventricular
co11t1-artionq.

Imaging Polvsnmnography: cyclic apt~eicepisodes.

Treatment I.n\ing weigh1 is rncjF1 iinpr)rcat)t rn~a\zu-e.ildjwat~ttherapy is

prolriptvline. ni~salpositive prrssiire ma&, repair- of septum,
nxllgen.

Discussion O h s t r ~ ~ c t i vslrep
c apnea is seen i l l middle-aged males who arc
usually mol-hidlvohcse, smokcrs. ancl I-typertensive.I1 i s due to a
n timber of causes, mainly obesity pharyngeal malformations,
dl-z~g~, a n d alcohnl. Patirn~qpre~entryrliral perioris or h y ~ o r ~ e n -
tilation and apnca sometimes lasting minutcs. which cause
anoxia, ar.rh.r?tl~mi;-ls, and lack of nrwrnal sleep. I t reqults in poor
phvsical well-being dl [ring the day, mood changes, and work and
rarnily pl-rjblern5.
 IDJCC X 65-scar-old male visits his farnil! medicine cliilic hccallse of
slowing of voll~nrary~nrwement s ( I < K ~ ~ ) ~ x I ~ ' T S unstable
IA). pit,
ancl rn~lsalarrigidity.

HFl IHc also complain5 OF tremor at rest that worsens when his
$-andchildren come to the hausc ancl make it 101 or noise
(emotional tension).

PE Sehorrheic clermatitis on scalp; i n f r e q \ ~ ~ blinking,

nt ui th
masklike (flat) facies; rarrliopul~nonaryand aI>rlo~ninal
cxamina~ionwi 111in normal limits; muscle rigidity with passive
movernen ts ((:or;~VHT.ELR I C I D ~;)pill-rollingmovement of' hands
ancl fingers (~rr.srmc,TREMOR) (VS. cet-rhellar tremor-inte~~tion
1 remor).

Labs Serut3-l copper levels normal (vq. Wilson's disease).

Gross Pathology Depigmentation of substantia nigra.

Micro Pathology Decreased dopamine concentxation in st~bqtar~tia tligra, locus

ccruleus. and striat~lm( L E ~ C C L R R4h-n ( ACII3ATE NUCLEI); i n ~ a -
r y trlplaqmic inclusion bodies (L1l:wzrl.
I I ( I I ) I E ~ )in suhstantia nigra.

Treatment Eromocript i t.ie (dopaminc agonist), an ticholiner~cs,levndopa z --

rn
(to prodlice rlopamine), selepline (selective MAO-B enzyme c
n
inhibitor). o
6
c-i
Discussion ,Ysc>caller1 pal-alysisagitans, Parkinson's disease is an idiopathic <
rlisnrder wit11 a male prerIornina~~ce: it is characterized by
decreas~ddopamine due to basal ganglia degeneration, mainly
in tlzc suhslantia nigra, with a resultanr relative exccss of acetyl-
choline. Sincc doparnine cannot crass thr blood-hrairl harrier.
lrvudopn, a dnp~mineprecursor, i q given; levodopa crosses Ihe
I~loodhminharrier and is converter1 tn doparnine in the brain.

Atlas Link IT' .CLL PM-A-069

.I" PARKINSON'S DISEASE

 ID/CC Durinx her first postope~ttivevivit, a 2ft.yfi1r-olrl [enlate corn-
pIain~to hcr surgenn or hoarseness.

H P I Shc had j u ~ t~ ~ n d r r g nn~ total

l e thyroidectomy far papillan!
~hvi.oirlr;wcer.

PE C'S: tlnrrnaf. PE: surgical wound hralcd: 110 sigls of ilifrc~ionor

hematoma fbrn~alitlr~: nn fi~calnr~~rt,logic rl~ficin:C:hvostek's
:11irl T l - o ~ r s ~ e~a ~
i ~g 'i ~~ fnl- I~ypocalceilliaclue to
l l ~> ~s e(checkii~g
~l~
posqil~lrp;~rathy-oirlrcmr)vaI); unilateral vocal cord palsy with
hoarseness n c ~ t ~ d .

Labs C13C/I,yrm: no!-mal. I;lurow, 131:N,rl-eatiriine normal; n o

Itvp.pncalccmia.

Gross Pathology 'rhe nerve was cliamageci during thyroid s u r ~ ~ ewr vh i l ~siiturirtg
I F I P t ~ l n o ~t,cssels
l of the inferior polr of llle tflvroitl.

Treatment Spccc FI t'tir~-apy.

Discussion e two recurrenr 131-yigealnrrves (alw c;lllerl inferior

T h ~ r :we
1:lryngc;ll). hot11 of which are hranct~esof the vagus nerve; they
th t%y
rrctrrrrri 1 I~uci~urc
arc- c6~lFcxrl Loop around the subclavian
artery on the right and thc aortic arch on the left hefore
;~scrnrlingin the t~~chcorsophagcal groovr iin closc proximity to
thc th~-roiclgIancl trb end up in the 1nry-m. IT t l ~ cleft rrcurrent
I;~r.vn<r;llnrrvo i h involecd. onc shoulrl cor~sirlermass lesiorir
such as enlarger1 Ir~~nph window.
norips in rile a o r t i c o p u l m o ~

* RECURRENT LARYNGEAL NERVE LESION

 ID/CC ,42-week+Id child is referred to the pediatric surgeon because
of a fleshv maw in his lower hack [hat ha5 heen present since
Kith.

HPI He is lkre second-born child of ;i 9Syear-nld womarl ~ h did o not

seek prenaraI c a r u~llild ~ rime
e of deEivurv (i.e., she took no
folk acid during prugnancy) .

PE Head diameter normal for age; patient forirlrl to have pes cavus
;rnd arched legs; deep tendon reflexcs hyporefl~xic;roundetl.
large mass that transilluminates parlially seen iri l ~ ~ t ~ ~ b m a c r a l
area.

Labs CRC/I,vtes: normal.

Imaging XR: lurnbar- spine defect in L5 i i e ~ ~ r aarch:

l lamina unfused;
~yiclenedcanal: soft tissue mass w e n on latenil film. MR: mass
communicales with spinal canal.

G ~ S Pathology
S Failure of Fusion of' nei~ropore:spinal cord (neurocc todel-tn
clerived) and nieniugcs (mesor!crni derived) are 01 11po11c hcd:
ski11 ( e c ~ o r l ~ r m )
, muscle (mvo tome), and hone (rclerotome)
I I not~ developed over surCnce pruperlt; ependjml;tl, I I I ~ I I ~ ~ ~ ,
and marginal layers or primitive spinal cord llav-e ~rlotdevelopccl. r
rn
C
;D
Treatment Early sm-gery. o
r
0
CI
Discussion Spina bifida is the most common de\.~lnpmcn~al defect of the <
central nervous system: it involves incomplete fusion of the
dorsal vertebral arches ancl is often aswciared rc-ith
hydrocephalus. There are screral degrers, Crom spina bifida
occulta. wllel-e 110 defect i q seen and che skin is inract. to
~net~ingocele ancl ~nyelorneningoccle,wl~ereleptomcningeal
and 11eitra1tiswe may protrt~dethrough a defect in the cIura
matel; hone, mcl skin, usually in thc lumbasacral area. Lack of
folic acid [luring preylatlc?, is associ;itrcl with spinra hifida. 1t is
also associated wil h elevatccl mater.~~al srrum a-fi'topl-oI~it~.

Atlas Link nIU7 MC-263

 ID/CC A 5 5 r e x - o l d woman rnmpIains of intermitteilt I~outsof
excruciating stabhing pain on tile lrft side of h w face between
the upper lip lower eyclid (region covered hy the maxillary
1,i.anch of CN V): the pain is so srvere that the patient ha?
conrrider-ecl suicide.

HPI She first cxperiencerl this paill 2 months ago, while she was
chewing gum. Shc also reports that cold drafts trigger the
attacks.

PE HEENT cxam rlormal: no Ivrnphadenopathp found; no

~ ~ ~ l l l - ~almnr~~~alities;
l~gic n o tenderness of affected region
(VF. sinus infection or nthel- infla~nmation).

Imaging MR: occasionallv shows tllickcned enhancing trjguminal nerve.

Treatment Carhama7epine7 phrnymin, alcohol injection of r~ervc,sur*caI

exploration.

Discussion Trigcmind neuralgia is also known as "tic douloureux."If

present in a young individual, multiple sclerosis ~ h o r ~ he
ld
sl~spectecl.Altho~ighimaging studies usually vieId no positive
findings, surgical explvration of thc posterior Fossa in patients
w h o d n not respond to medical tllerapv freql~entlyreveal5
abel-ranr blood vessels pressing on nerve root (amenable to

T R I G E M I N A L NEURALGIA
 ID/CC A 69-yar-old male prusunts with a persislent headache,
inrl-ea~ingclumsiness, ancl k e q u r n L tlot~nor nausea and vertigo
aF well as difficulty swallowing ( ~ T P I - I - \ ( ; I A ) .

HPI HP has no histol-yof' trauma, ~accination.fcwr. or exrrt~them.

T-Tis Ea~uiIvreports that Ile also has difficulty articulating some
words {r~wn~rr T IIZI,~).

PE T'S: BP normal. PI:.: alert and oricntecl; mild hoarseness (duc to

ipsilateral vocal cot-d paralvsis) wivjitl~sonle dil firulty swallowing
oral sect.~tions(CN TX, X): right side o f face rrve;lI~ptosis, miosis,
and anhidrosis (HOKWK'S ~ N ~ R C I M ;Ypronounced
) bilaleral
nystap1~3 in all directions o f ~ w , (CN
e VIII); duci-eased
sri~siriviryco ligl~tt o i ~ dand
i pain o n right sick of f a c r (CN V);
right-sidcrl incorl-ect appreriation of clis~ar~ce in linger-to-nosc
movements ( n \ s ~ ~ . n rimpaired
~); pain scnsa~ir>nin left
(conlralarel-al) ~ i d cof hod? {spino~hnla~nic tract).

Imaging MR,brain: inrarction in rig1111ar~raImedullarv arcil. h ~ g i oright

:
posterior inferior cerebellar artery occlusio~l.

I Treatment
rch;il,il i tation.
t her. dan~agc;
emboli) I o prevent fur-
Treat causativc factors (at~~emscler~sis,
E
m
Discussion Also k n o ~ v nas the y n tlrotne or p o ~ ~ c r i inferior
os cei-ebellar o
r
artery occl~~qinn ancl lateral rn~du1lai.ysynclromc, N7alIenbrrg'~ o
tl
synrlrnme rcsults fi-orrl occlusion of the vertebral artery or its ;=

Figure A-073 Drmo~lstrarionof

neurolocjc clefirii rharacterized
h v right-stdecl ptosiq. miosis, an-
hidrosb, and ennpht11;tlmos
(Hornel-'<synrllmrnc secunrlary
or
In i~~tnlvcrnrnt the c e r ~ i r a l
t i r tihc-rr).
s y r n ~ ~ x l h ~chain

' <
WALLENBERG'S SYNDROME
branches (posterior i nferiol- cerebellar) to the laterdl medulla.
Findings w e consistent with involvement of structures that lie in
the territory of i t 5 distribution: the dorsolateral quadrant of the
medulla.
 IO/CC A 33-year-old female comes lo the emergency rourn wit11
sudden-onset left lower abdominal pain together with nausea
anti vomiting; she passed out near ~thcfi-on1 door. of the
I~ospital.

HPI Her last menstrual period waq 60 days ago (she 113s been regular
and has rlevur ~nissetla perinrl). Shc also has a I ~ i s t o r vo f pelvic
inflammatory disease.

PE VS: hypotension; tachycardia. PE: cold, clammy &in and ma1-kcd

pallor (?i?~povnlemia) ; on pal palion, ahdomcil s11ow.c musr ! P
spasm and guarding as well as tenderness of left iliac I'nssa;
pelvic exam cannot be performed hccause of'excessive pain:
needle punctnre of poqt~riorcnl-dc-~aczia vagina (c:t v ~ o c c ~ ~ s ~ s )
sllows frpe inrrapelitonral nondothg b!ood (due tn rupture).

Labs CBC: hcmatocrit low; mild lertkocytosis. Pregnancy test positive.

[!A: normal.

Imaging US: ectopic pl-rgnancv in arnpu1l;ll-yregion of the lefi Fallopian

nlhe with echogenic fluid in cul-de-sac.

Gross Pathology Gestational rac with traphoblast in arnpuIlat-y region of left

failnpian mhe.

Treatment Sragical exploration ancl hemostasiq.

Discussion Ectopic prcparlcy refer5 to extrauterinc locations or the fetus; it

may be tubal, abdomind, or in traligan~entous(brrbad ligament ) .
Riqk ractors for ectopic pregnancy incIt~drpelvic inflammatory o
m
disease, prior ectopic pregnancy, tubal pelvic surgery. and -+
w
rn
exposure t o leratogeils (e.g., DES) . In order-of frequency tuba1 4
pregnancieq cornnlonly occur a ( the ampx~lla,isthmus, ftmbriae, E
r,
V,
or interstitiurn. The blood supply to the tuhes comes from t h ~
ascenrlirig bl-anche~oCthr uturiile artel-); a brancll of the
ii~ternnliliac artery, and t h r ovariat~artery, a dii-ect l>ratlchof
the aorca (brisk I11~eclitig).

A
I ECTOPIC PREGNANCY-RUPTURED
 ID/CC A 22-yua1--oIdwonlan who is in late Ii~horIAequestsanesthesia
t~ecatiscst~ehas now given up on a "natural birth" delivery
(wir hr HI! r>l,st~tri~ .
at~~stliesia-at~algesia)

HPI T h e obstetrician in chargc clccicIes to perform a plideilclal

l~lock.

PE I-Ieacl d h a h y already o n perineum, and mothcr is having con-

tractions every 5 minlltes; FetaI heart t-ate 140/min with no
apparent d istres5: doctor identifies ischial spine with index fingcr
and iiijects a needle Ih rough ~arrospinousligamenr hct~vccn
hahv's head and vagina: applies anesthetic (after er~slrrirlglhar
the needle has riot pierced a pt~rlenda!vessel with risk of'
llemaloma fnrmat ion) in vicinitv of each ischial spine
(7 lL%NC;\''II:lNAI. P I II)IIND4l. YI:Rl'l? fil.o(:K).

Labs Prenatal lah studies tvitbin r~ozrnallimits, i t ~ r l ~ ~ r cnagulation

ling
teqtq.

Treatment Pudendal nerve hIock done (complications may incl~~cle

hemntoma formation, s v ~ t e ~ ntoxtcil~
ic w h e n ii~jectedintsavasc~t-
farly, nncl locati~edinfections).

Discussion The ~>udendal1icrl.e provides both motoi- w l d sensorv it1nerva.a-

tion lo tlle pelineal region: it passcs out of the peIvis through
the gl-ea~er sciatic Eora~nen,wraps around tllc rxtrrnaI srlrface
of rhc: isdiii~lspitjr, and enters the pelvis spin thro~rglithe
Icsses sciatic foramen (crt~ssingthc sacrospinuus ligamerit) .
The nerve travels within the fascia u f ' t f ~ cinternal ohrur;~tor

PUDENDAL NERVE BLOCK

 lD/CC A 1 &year-old ohesu male comes to the emergency room from
playing haskctb-dl because of acute pain and s w e m of his dght
ankle.

HPI MThiEe playing, he landed awkwardly on his right foot, which was
inverted, prod~lcingi~nmediateacute pain, ir-iabilitvto waIk, and
swell ing.

PE Right ankle joint mollen with ecchymosis in most of lateral side

of h o t ; acutely painful to touch, mostly underneath fibtilal- end;
no bony crepi~usfelt; distal tcrnperahlre, pulses, and ensa at ion
normal.

Imaging XR, ankle: no fracture; lateral rnalleolar soft tissue swelling.

Treatment Immobilization until pain ancl srvelling subside (usually 3 to

5 days).

Discussion Ankle sprains are the most cotntnon type of sprain in the body
and are usuaIIy undertrrated (i.e., the length of immobilization
timc is often too short), with frequent recurrences; with each
new sprain,the lignments becomr weaker. The ankle joint is
held in pIacu and is protected Crmn inversion 5rresse~by thc
lateral collateral ligatnent complex, which cotlsistq of the
anterior ralofihdar Iigamenc, the calcaneofibular lipmen t, and
the poqtel-ior talofibulir ligametlt. On thc medial side there is
the wide, broad delroid ligament, which confers protection from
eversion stresses. The anterior talofi'bular ligament is the most
common ligament injured in ankle sprains ancl is secondary to a
hyperinversion injury when the foot is p1antarflexed.

ANKLE S P R A I N
 ID/CC :\ 2$-~c;ir-r>lrlfuniille conlev t o s r r thchorthoperlia 4tlrgeon
hrcal~senT inability to extend her right wrist a n d lingel-s.

MPI Shc suffcrcd a middle third humeral rract~u-e4 wt-eks ago while
snow-skiing.

PE CVrivc,ri right sitlr ir "llangii~g"(U,WI\-IU I ~ O Iinability

)): to
dosiflex hand Dyer Crwear-tn:inabiliry lo r l ~ v a ~rhi~rnl,;
e
anesthesia on dorst~mo f hand over thumb and first three digitq.

Imaging XR: mitlcllc t llirrl of rig11t I~umcruss l ~ o ~ -s~r;t~~s~c-r~e

vs ~K*;~C~III.P
with c;tllus ti,rtriatir>n.

Treatment Clnrerl rerl~trtinn;111rl Il;~rqingrasl o r "I-'"-sl~;~perl

~ p l i n cW
. ri~t
irnmol>ili7arion. S111-gird radial riel-vp cxplol-ation if nerve
rt~nrllrrtinn~tltdie5are ahnol-m;~lfor several r n r ) n ~ l ~ s .

Discussion The I-iiciial11c.1-vuco1rrsc.i through thc spiralir~ggroovr- localerl in

tfit- midrlle third nl'thc hutnet-:~lshali, prerli\[losing it In I~sions.
li;trIial nerve palw mav I>? rlelav~dhv nir~ntf~s or r\,rn !.r;lr.s ( d l ~ c
r o trappir-q of thc- ncrvr. i l l osqcolrs c ; ~ l l ~oi rs Ycai lissue).

Figure A-077A nernr lnq~n'ntinn

r r l I>;i~i(.motor csarniiiatiorl of
the tntlial ncr~r-ar~irrr rxtrn-
<ion ;IT WT~FI ;IIICI finarm.

ARM-RADIAL NERVE PALSY

Figure A-077B Demons-itin11
o! h;rsic palmar srnwry
e x a ~ ~ ~ i ~ l a ~ ~ o n - r anerve
rlixl
tlirtr.ihution (.4):~~Irlxr nervr
rlistrihutio~~ (Bj.
I ID/CC A 1 &year-nld I~igh-schooltrack-team member experiences
intense pain in his right collarbone; he also notices a
prominence ~711rruthe midclle third arlci outer t hirr1 of his right
cla\bicle meet.

HPI 'The patient tripped over a hurdle and fell on hi outstretched

hand.

AE Markcd tenderness and deformity at rite of fracture; right arm

hangs lower than Ieft; arm medially rotated and painful (medial
roratnrs o f arm are stronger than lareral rotarors).

Imaging XR. clavicle: fracture of ck~viclcat middle third: lateral portior~

drpl-ossed.

Treatment Reunion of fracture by tipre-of-eighr bandage or clavicular

spiczi cast, with afrected arm placecl in a sling for comfort, and
isolation of arrn movement.

Discussion Fractures are usuallv located where the middle and outer third3
( ~the
r clavicl~meet. The m ~ d i a segment
l is displaced upward
hy thc sternoclcidornastoic1stirnr~scle.while the distal end is
rlepr~sserl11? the weight OF the shozlId~r.

CLAVICLE FRACTURE
 ID/CC A 44-year-old rxuc~~tive -eco~nesto see his pl~ysicianfor burning
pain in his right elbow.

HPI H e is an avid tennis player.

For the past sevcral weeks he has
~xpei-ieilcrda sharp pain in the right elhow (his playing arm)
during practice.

PE Mhcn askcd l o localite pain, p a t i ~ npoints

t tu lateral epicondyle
of humcrus (El: on palpation, area is warm and exquisitely
tender; pain increases with wrist extenshn against resistance; no
lrlhow defer-mitl;, swelling, or refines-; distaI pulses normal; no
spnat3ry disturbances.

Imaging X R , elbow: no frarture or dislocation.

G ~ S Pathology
S Uninn ol'tendon and ~rnclerlyiiigperinsteuin chronicallv
inflamer1 ivi tli ~mrlinj
tis, sylovitis, granulation i issue for ma ti or^,
ancl hone resorption.

Micro Pathology Angiolihrohlastic proliferat ion and degenerative fibrosis of the

estcnsoi- carpi rddialis brwis tendon.

Treatment Discontirr~~e i s 6 ~vcuks:NSAIDs, local heat-cold, topical

~ e n r ~Ibr
steroids, sllrgery in sclcctccl cnqes.

Discussion The lateral rpicondyle of the humerus serves as thr 01-ig-infor

~ h extensors
c or the wrist: tllc extellsor cal-pi radialis breviu,

d
Figure A-079 Demoncrratinn
-i+ j s elhow palpation-
of ~ l e of
-2 trirdial rpirondvlt. (A): cuhital
H
1 imn~tel(B); oleciation and over-
p. I
Ivin~ hurra {C); ulnar/huineral
6.b
articulntiol~(D); latrral
+
1 7 .
-F~:+ epicor~dyle( E ) .

ELBOW-LATERAL EPICONDYLITIS

.. - - - -
estrtlsor rligitorum, extcnsor rligiti minimi. 2nd cxtensor carpi
ulniiris. All arc innermted hv the radial nervc. 111 t h i s condition,
alw known as te& elbow, thc <trainof repeated extension of
the wrift aqainst a Col-ce,as in playing tcnnis: or tliro~vinga hase-
hall, places consideri~hlestress C~TI the si P. T,;~trl-alepicondylitir
tnost co~nlnonlvarects the extrnsor carpi radialis hrevis tendon.
OrI~cr- causr5 of lateral elhow pain includc pclsteriol-
in~~r.c~sseorlsnerve compressinn and radiocapitrll;~r;~rtlir-iris.
 lD/CC 1-2 23-year-old crnss-country motorcycle racer visits an orthopedic
surgeon hecause of weakness in b k right hand.

HPI Six weeks ago, he sliffered a fall during training that resulted in
an elbow fracture.

PE Mhen patient flexes his wrist, it deviates to the z h a r side (due

to unopposed action of the flexor carpi ulnaris; he median
nerve innervate4 the flexor carpi raclialis, which i s re~pnn~ihle
for fluxing the wrist and devialing i t radially):when patient is
a\kcd to clasp his hands tc~geti~er, right index finger cannot be
flexed (OCHSNFIZ'S TI:'~T) (due to inactivitv of the flexor digito-
rum suhlimis): paticnt cannot flex thumb (due to inactivity of
the flexor polliuis Ton~us)and cannot oppose rhumb (due to
inari ivity o f tlie oppunens pollicis brecis. iiitl~rvatedsolely by
the median nerve); fotn-th and fifth Fingers are flexed with
thumb and index finger extended (BFFU'EDICTIOVR~IYD).

Imaging X R kealing of el bow fi-aczul-e.

Treatment Phvsio therapy: surgical exploration if nerve crwnpression by frac-

ture c d l u s is suspectecl.

Figure A-OSOA De~rlo~~strntiol~o t 1 3 , 1 \ 1 ~ motor examination of the m e -

dian nerve---OK" sign (flexior~of thumb and ~ e c o n ddigit).

7 P
ELBOW-MEDIAN NERVE PALSY (NONCARPAL)
Discussion The media11nerve innervates the flexors nt h e twist and lingers
as welI as the ferrarm pronators. T h e ulnar nerve innervates the
flexor ral-pi l~lnaris,which, in addition to flexing the r t ~ i s talso
,
deviates it inedially.

Figure A-080% De~not~stration

of hasir pal~nal-srnsnry
examination- ulnar nerve
distribution (A): median nerve
d1~1ribu~iot1(B).
 ID/CC A '1-year-old girl i s brought to the pediatric cmcrgency room
crying with pain in the left elbow.

HPI While the child wa5 having a temper tantrum, the Father
forcefully pulled her by the hand.

PE Child is hoIding right forearm in pronation and ebow in

flexion; no swelling, ecchymosis, olrrviotls deformity, or hone
crepit~is.

Imaging XR (AT and lateral), elbow: no fracture or dislocaliotl; child

stopped crying righr after lateral view w a s taken.

Treatment GentIe supination of Corearm with elbow ill 90 degrees of

flexion often reduces snhluxation during positioning for
Iateral-view x-rays.

Discussion Also called nursemaid's elbow, subluxation of the radial head

occurs when the extended and pronilred arm is pulled, tearing
the annular ligament.

ELBOW-RADIAL HEAD SUBLUXATION

 ID/CC A 5)-yr.;ir-old male is brought tn thc ER with coinplaints of paill
atld irtahility lo usc his lrft forcarm.

HPI Ht= was l~lirrwhile ~ r y i to

r ~ward
~ off an a s s a t ~ l bt!. a dl-tinken
room~nat~.

PE PF,: unable to pronate and supinate left forearm: swelling

exarrl normal.
arnuncl the el bow: neu~.rrlogic

f maging XR. lefi forearm: fracture of upper half of ulna with dislocation
or the radial t~ead.

Treatment Open reduction and plating followcd 1 ~ y4 to 6 ~~etrbis

in plaster.

Discussion This i.; a. tiacturr of the upper third of the ulna with disIocatiun
o I ' t h e rarlial hear1 1-aiiserl 11y i t F,1l7 011 an o11rs11-etchedIia~irl,will1
thc forearm Forccd into e x c e ~ s i wpronacion. It mav also result
froxn a direct l ~ l u ~on v the hack of the upper forua~m.
Neurologic examination is importarit in ~ I I ; radial I~ iirr vc injzlry
may he asq~ciateclwi 111 Moiileggia'~Fr~cLure.

7 FOREARM-MONTEGGIA'S FRACTURE
 ID/CC X 19-ycar-old gas station aacndait comes to a local clirlic corn-
plainirlg of persistent. irlcrensing pain on the ulnar side of his
hand.

HPI Hu was involved in a fight \kith a truck drivrr I! days ago.

PE Prriorbital ecchymosis 011 Ieft side nit11 n o eye in~rolvemenl:

rratimatic absence ol' left upper- central incisor; ~'igl~thand
swollen; c hal-actet-istic depression of head oF fifth metacarpal
tv1ie11lookirlg a1 f i s ~
anteriorly; patient cannot flex pinkie
I~ecaineit elicil\ pain o n tifth metacarpal.

Imaging SR: transverse fracture of fifth metacarpal neck with palmar

angzllai ion.

Treatment lierlnce anrl apply rplint ulnar side

ot~ or hand.

Discussion Boxer's firactur.e is a common fracture when something hard is

hit with a closed fist.

HAND-BOXER'S FRACTURE
 IO/CC A 6-year-old male is referred to an orthopedic surgeon by his
pediatrician because uf thc recent onset of a limp tliar has
persisterl for more than 2 weeks 1vi111no apparent cauqe.

HPI He also complain5 of pain in the right p i n with radiation to the

inncr thigh ancl knce.

PE Child is well dei~elopedancl nourished; average wuigh t and

hcight for agc; chcst and abdomen show no pathology; on
palpation ovcr right coxofemoral joint there is tenderness and
muscle spasticity.

Imaging XR: small femoral head epiphysis; sclerosis of flal~rrletlfemoral

hcad cpiphysis. MR: marrow edema ancl fracture line in remora1
head epiphysis. Nnc: abnormal uptake in femoiaI l~pad.

Gross Pathotogy Collapsed, soft, anrl friable articular cartilage in Femoral head.

Micro Pathology Awscular nccrt,sis of proximal femoral epiphysis*

Treatment Petlie walking. cast (ahcl~ictiot~

Ilraci~lg),nlrgery (femoral .rrersus
acetabular osteotomv) .

Discussion L,eggXalve-Pet-tl~esdisease i q a rvpe of avascular necrosis that

occurs in the femoral heads of children bctwcen the of 3
and 10 years, affecting males more than fernaleq. I t is selfllimited
over a period of up to 3 years: roughly half of affcctud chi1drcn
mill have residual deformity.

F*l HIP-LEGG-CALVE-PERTHES DISEASE

 ID/CC A mother brings her 3-year-old child co an orthopedic surgeon
for oval uation of' his gait; she says the child "waddles" when he
rvnlks.

HPI T h e child had rlifficulty learning 11ow to walk and has always
heen rather unstahlc in his gait.

PE When patient stands an his 1cTt leg, his right Iluttnck sags
(TRFYDKLEWVKC SIGN): no sensory Ioss nolecl in gluteal area;
swing phase of leli Irg seems must affected; to swing lcft leg,
child leans over to right side and then swings lefr leg in front of
righr (the superior gluteal nerve is paralyzed): right Eeg swings
normally (hip rtbdi~ciors h~nctionnormally to prevent pelvis
from tilting over when leg i s winging).

Labs Sa-eer-tfor inheri~edmetabolic cliseases negative: basic lab work

normal.

Imaging XR: hip dislocation.

Treatment I4'alking stick or cane in leCt hand to prevent hip from tilting
over to left side when left lcg is swirigft~g.Sllrgery

Discussion Unilateral hip dislocatiorl causes Trendcle~lburggait, with tilting

of the trunk toward the affected side in each step. The sliperior
~ l r ~ l e nerve
al exits the <ciaticforamen ~uperiorto the piriformis
niliscle. 'Thiq nerve inncrva~esthe gluteus mcdius, glutel~smin-
imus. and tensor fascia lata, which arc medial rotators oC thr
thigh and abd~rclol-sor the hip when the high is fixcd. The itlfe-
rinr gluteal nrrve ancl arrery as well as the sciatic nerve exit the
sciatic foramen inferior to thc piriformis muscle co supplv t l ~ e
gluteus maximus.

>A<
HIP-TRENDELENBURG GAIT
 ID/CC A Y-we~k-oldhaby girl is Ilrnug11t in For a wellxhilcl checkup.

MPI The haby was deiiveretl I,? C-section after a full-term pregnancy
rom~TicarerlIIV breech presentation.

PE 1a:xarnination of the lower rxtr-ernilies reveals asymmetry of thigh

crrcaqes anrl unequal right and left leg length, limitation of
abd~~ction on left qide, inward deviation of'rnrrf'not (metatarsus
arlrl~~ctlts assnciated wi i II DT)H). ancl uneven knee level w11e11
both knees are flexed and k t arc placed nn the examining
table (Gill F~IZZI'S srcn.); lrft hip "pops ant" whm longit~~dirlal:
presuure is applied with 111rhip in adduction (B$I<~.~>II*'s slc;~);
another pop fell while abducting ant1 adtlucting th? flexecl hip
(C)K'II)~AVI'S sic;^).

Labs Normal uewhor~rscr-ecn

Imaging US, hip: didocation of left hip with irlqtahiliry and ahnormal
acecahul~tnrmorphology.

Treatment Ilace the hip joint in flexion and abduction (with a Pavl ik har-
ness or a Frejka pillow) st, that the femoral head inap initiate
and sustain normal acetabular devclopment. Early diagnosis
yirlrl~best results: for treatment. Sllrgrry niav be inrlicatetl when
rliagnosi~is delaved or for refractnrr cases.

Discussion D~wlnprnenlaldvsplasia oF t h e hip (previouslv callrd congenital

hip dislocatio~l)affects girls more -er,ftenthan boy (9:1). Thc
inridence increases ~ 4 t hl>r-eechpresentation and in balies with
a hmilv I~istoryof DD1.I. Complications include avastrular
necrosis of the femoral head.

Attas Links m - 5 1 PED-O51A.PED-051B

H I P DISLOCATION-CONGENITAL
 ID/CC A 23-year-oid mate is rushed eo the ER following a motor vehicle
accident.

HPI H e was on ihe passunger side of a compacr car when he sufferec!

a head-on collision with a pick-up truck. His knee impacted
against the dashboard.

PE VS: normal. PE: alert, awake, and in moderate disrr-esq;n o evi-

duncc of trauma to head, cheqt, or abdomen: right leg visihlv
shortened, internally rotated, adducted. and in slight Flexion;
olhcr associated in,juries include an obvious patellar fracture
and a knee laceration; n o neuro-vascular deficits noted.

Labs CBC/Lytes: normal. PT,PIT t~ormal.U h : normal.

Imaging hip: posterior rlislocation oE the right Semoral head.

Treatment Early mduction I'ollowed by immobilization. Surgicat correction

may he necessary when clmed reductinn fails or irdictated bv
associated fractures. Associated injuries (peliic fractures,
bladder nrpture, liver lacerations, or pneumothorax) must aIso
he saught and treated.

Discussion Hip dislocations am anatomicallv c1assific.d as posterior (most

rotnmon) , anterior (about IO%), or central (associated with
metabolic bone diseaqe). In anterior dislocations, the hip is in
external rotation and abduction. Emly complications include
injurv to the ~urrounrlingnerves (sciatic, femoral, or obtumtor)
arid pelvic organs. Late complications inclztde avascular necrosis
o f the femoral head (early reduction is the most effecrive rncans
nC prevenr ion) an tl early degenerative arthritis.
 ID/CC An 85-year-ald woman is taken to t k r emergency room after
falling wliile climbing our of the bathtub; slte has pain in her
n cannot move her left leg.
lcft ~ o i and

HPI She suffers from diabetes, hypertension, and osteoporosis. She

is c~lrrcntlybeing treated wit11 calcium supplcmcnts and
calcitonin.

PE Frail. elderly woman with poor mriscle tone and low body
weight; left leg externally rotated at resl (lateral rotators: piri-
formis. ohturator internus and externus, superior and inferior
~emcIlus.quadratus fernoris. glnteurj maxitnus) ; left leg slightly
shorter than riglit with tetrderness in remoral triangle; limb in
adduction: cannot raise heel off bed.

Imaging XR, plain: intertrochanteric rt-act~~re

of Cemur: osteoporosis.

Treatment NonrlisplacerI anrl minitnaIly dispIaced fractures can be treated

by pcrclrtaneous pinning vs. screw fixatiorl of the affected hip,
w h i l e displaced fract~n-es(associated with a high t-iqk of ar~ascular
necrosis) are treated with a hip hemiarthroplasty (femoral heail
p~-~>s~hesis).

A
Figure A-088 Demonstradon or classic limb po~ri11.c in an
t e r i Frrnoral Fracture-lrlt Icg shnrtened and cxternallv
i l l tel-~rochan
ro~atcd.

" H I P FRACTURE
Discussion Fcmoral neck Fracturr is f r ~ q ~ ~srcn l ~elderly post-
n t in
menopausal tvclrneli with osteoporosis. The mechanism nf frac-
lure is often a trivitd force. causing subcapital fract~~res,
irnpa~terlor not, as well as pr-etrochanteric, intertrochanteric, or
r s hip l'ractures are at high
c.xtracapsulai- fi+actures.P n t i e ~ ~ with
risk fbr rlevelnping cleep venouq thrombosis postoperatively:
r h ~ ~pmper
s, prophylactic measures ( e . ~ seq~icntial
., cornpres
ion stockings, anticoagulation) must he takcn.
 ID/CC X 17-year-old hi#li-sclint>l sn~denlis brought to the emergency
1-00rn straight from a footllall game hecalise of acute, severe
pain in the left knee and inability to walk.

HPI He could not gut back up on his feet nfter being "chop-blocked"
Iw a linenzan from the side during a football game.

PE Leg sligh try flexed; rnarkecl tenderness otl medial aspect of knee
(clamagc to medial cnlla~eralliprnen t) and a11[prior knee joint
spacc (damngc to m e d i ~ meniscus):
l positive anterior h w e r
sign ( r u p h ~ r e dantrrior cruciate lipment); marked b e e effusion.

Labs Aspiration of affected knec rwcals I-etum of grusslv bIuodv fluid

( H E MAHTHROSIS) .
Imaging MR,knee: anterior cruciate tear: tor11 medial ~neniscus;rupture
o f medial collateral ligamcn t; join t rftiision.

Treatment Surl7ical gralt replacement of the anterior cruciatc ligament

(ACL), suture of rnudiaE ligament and repair of medial meniscus.

FigureA-089 l ~ t ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ i ~ ~ ~ ~ t ~ ~ ~ l ~ l ~ ~ ~ ~ .
valqr~qstrrss on thr knrc to assrss hinrtinn of thr mrdical collateral
liga~nent.

? KNEE-COMBINED KNEE INJURY

'Discussion Unhappy triad (lesion of the ACL, medial meniscus, and medial
collateral ligament) is a common occurrence when the knee
receives a blow laterally while the font is firmly planted and the
knee slightlv flexed, resulting in massive tension on these
suuctures and tearing.
 lD/CC A 13-yearuld male is rcfcn-ed to an orthoprdic surgeon 13:. his
~ > ~ d i n l t i c ibecause
an of pessjste~ltswelling and pain below the
knee illat i s in~crmittcntin nature.

HPI He is a snccer fa11and haq hcen playing soccer every afternoon in

anticipntion of the upcoillii>gWorld Cup. T h r paticrlt also repom
incre:~wtlpain jurt below r he knee while going rip and dnwl stairs.

PE Athletic-looking, fit teenager: exquisitely painful area o f swelling

4 c ~ I~cIow
r ~ knce,joint (tibid tuberosity); when patient exlet~ds
leg agiiinrl resistance. pain i s elicited r r r i r i ~ i - e a ~ ~ c l .

Imaging XR. knee: sli~1:lltawlsio~iof ti bial tube-rclc with nsseotlq reqorp-

lion ni~dnew bone formarion. res~iltingin a fragmented appeal--
atlce oT the secondary ossification center:

Treatment Avoid activities that placc prcssurr on area directlv or axially,

suclt as h e e l i n g and junnping. Hamstring strerching and ice
Inawage art. helpfill.

Discussion T h e par elfar ~crldoninserts in the al~resiof-tihial tu herosity,

which hy the encl or pu herty has an ossification center. With
I-epe;ited aauma, the ti bial titlm-cle i s avulued a n d c11l ofT rroln
L ~ blood
P supplv, suffering avasdar necrosis,The course of
0ynod-SchSa ttrr's rlisease il; self-limited, I,llt irl some patient5 a
painC~ilhens fi-agmenr remains w-i th nonunion.

Figure A-090 Demonstr.lsion of anterior knee bncln~arl+ir~fi-dp;~tellar

~IISVI ("4);l>rrpatellarl ~ ~ ~ (Bj:
r s ;palella
~ {C): <~tpix-pa~clTar (D);
1>11r<a
antri inr tihial spiur ( E ) .
 A 35-year-old computer programmer complains of severe,
persistent leg pain after beginning an inrense fitness program
involving long-distance running and weight lifting.

T h e pain is on the anternlateral aspect of tlic right leg radiating

from jwt below the knee to the ankle.

Poor muscle tone: pain cor.responrlq to anterior compartment of

right leg: region is swollen, tense, and warm; anterior tibia1
pulse weak (rearing ol ~nusclus,inflammation, a~irlerlema with
small hemorrhages lead to necrosiq); sensory deficit in foot;
immediateyy ;after exercise. patient has pain on passive extension
of toes. with subjective numbness and tingling in foot.

Imaging CTJMR: edema and possihlu hematoma of anterior compart-

ment rnl~scles.

Gross Pathology Grayish discoloration o f muscle with edema.

Micro Pathology T.;chemia ancl necrosis of muscle and nervr fibers.

Treatment Fasciolomy (cutting of raqcia) if in tracompartmen tal prpssure

is > 30 mmHg after exercise.

Discussion The an tel-ior compartment of the leg has rigid boundaries

(tibia, tihula. cs~rralFascia, anterior interrnusculal- septum) that
can trap blood, contribute to increased pressure, and thus lead
to an ischemic process. Acute compartment syndrome may be
cauqed by a crush injury or fracture to the involved extremity. In
l chronic exertiond compartment
this case, the p a t i ~ nhas
syndrome, which can be seen with unusually vigc~rousexercise.
A qequela of Corearm cornpartmerl t sytidrorne is Volkmann's
ischemic conlracture, which results in a stiff, noofr~nctioning
"claw hand" from nlusclt. necrosis and r-est~ltingfibrosis.

LEG-COMPARTMENT SYNDROME
 ID/CC A 17-year-old boy is rushed to the neilrrest emergency room after
l>einginvolvetl in a highspeed motorcycIe accident.

HPI c e ct-ysralloids,
I-Ie was treated for shock in the a r n h ~ ~ l a nwirh
pressors. and oxygen.

PE YS: tachycardia; hypote~lsion;no [ever. PE: pariei-ttin acute dis-

tres5; respiratory sounds heard in both lung fields: prri tnneal
lavage negative; pain tvi th pressure on iliac crest4 anrl
tmchan~rrshilaterally; blood present at urethral meatus (para-
medics correctly avoidecl inserting a Enlev cathrter) ; abdomen
shows no perironeal signs.

Labs CBC: hemoglnhin and h~tnatncritlow; leltkocflosis. UA: high

~pecificp-arity: Ilematuria.

Imaging XR, pelvis: fractlire of pelvis hilateralh. Retrograde ~lrcthrogm-

phy: membranous urethral rupture with extravasation of con-
11-a~tmrdia outside the peritoneal c a ~ l t y CT:
. large henlaloma
smrot~nding reginn nf pelvic frac~t~rm.

Treatment Treat shock. Drain urinr collection. Suprapubic cystustonly;

delay urethral repair. Pelvic sl15penqinn; l>loodreplacement.
Unstablu peliic fract~~res may require emergent stxhilization
wit11 a pelvic external fixator.

Discussion Griicrzlily, cornpouncl l ~ s i o n sa r r to h e expcctcd. Bladder and

urethral Lesions are comrnnn in pelvic fi'ac~~ires. Nso, rractlires
of the pelviq may conceal a large volume nT blood.

PELVIC FRACTURE
 ID/CC D l ~ r i n ganti-Gulf War protests in Ohio, a 2 3 - y e a ~ l drnan was
fnrcef~~llv dragged away by the arm becal~sehe waq blockirlg the
entrance- tu thc inccting.

HPI While in the potice car on the way lo heatlquarlers, lie corn-
pIain~dor pain in the shouldet- ancl inability to move his arm.

PE Pain in shotilder, deformity {lack of norn~aIrounded contour nf

shoulder), and inatjility to move arm; depression easil! palpabie
under acrr~mion;hr~meralh a d palpibIu through axilla. After
pa tie11t complains of numbness on
r e d u c t ion of' the CLisIocatio~~.
the lateral aspect of the forearm and weakness in biceps muscle
F~mdonwhrn comparcd to uninrwIvuc1 sicle.

Labs Basic lab work normal: n o iracc nf alcrlhol ill hlond: n o dl-ligs in
urinc.

Imaging XR: depr-e~sionFracnrre or the ponerolaceral articular rurface of

humeral head (H11.r-S4(:iis I . F ' s ~ ( > K;) axil l a y virw of ~ I P I I C ~
humcral ,joint 5hou.s h ~ ~ m r r head
al lo he anterior to glenoid
fossa.

Treatment Before reducing the rlislocation, one mllst Iook For powihle
nc~~rologic-vascular
damage.

Discussion The glenohumeral j o i n t is trequen~lydislocated d ~ l pto its poor

o s s c o ~ stabilil):
~s Anterior dislocations (the humcr;~lhcad

ior ~ I J O L I I ~ L lar~clti~a~
Figure A-093 I h I I M I I I ~ I I, I Tt o t ? 0 1 :i111ct ~I. ks-
Lruacoirl pl-ocras (A):acrorniucla~iclilararticulation (B);1,itipital
tcnrlon, (C:); strrnoclndcnlar articulation (n).

P SHOULDER DISLOCATION
b ?W,
nr~rnlaI1vlies in front of the cm-nrnid pl-ncrss of 111~scaptila)
usu;llly rcsult from a SaIl o n t h e m-111 in forced abrl~lctionand
exterlsion. Musculocutaneous ntrrve in$ury i s possible (it
supplieq [ l ~ cor;tcc~bracIrialis
c as rvcll as the brachidis ailrl biceps
rnriacles and provides s e ~ l s a ~ i o1 n the lateral area of the
lurearm). Posterior shoulcler dic;locarions are much less
cotiimon and arc sccn fullowing electric shock it~juriesand
g r ~ ~rnal
i d scizurcs.
 I DJCC -4 35-year-old ice-lluckcy p1avc.i. is br-ought t ( 3 the rinergencv
room after c~~ffrring a violent blow to his shoulder dlrring a
p m c ; his righi arm hangs nnticeal~lylower than the left and
tla~reis a pml-touncerl bulge ( t h e cla\icle qtick~cnit) at thc tip of
l i i 5 ~holllrler.

HPI I'ErIeo replav nf rhc galtie reveals rhar the pati~nrwas benrling
forward 1%hen an opponent speared into the superior portion of
the patient's ammion.

PE P~tientin pain; shoulder ha5 f'alletl artv;iyI'mm clavicle (due to

weight of arm); n o low nl'srt~sationin arm; on palpation, ten-
riel-ness in acrnrnioclarric1~2at~
and col-ncocla~~iculilr~jc~ints;when
external rnrl of clavicle is pressed. it retui-ns to original site
(PI %NO KEY SIGN ) .
Imaging XR. d~oulcfer(stress view): 1O-pnunclweight suspended from prl-
tient's tvris~cauqes mal-kerl ~ep;lrationat acromiocla~icularjoint
wit 11 acrotnial depresqion.

Treatment RerIucrion ;~nrFimmohilii-atinn; surgerv necc.isary only if cord-

coacmmial ligament is r~rpt~rrcrl (gr-adc 111) (Ir if patient has
perl;i?tent shoulder pain.

Discussion Mso known as ;I s l l o ~ ~ l d csepar.ltion.

r arrornir.~clavir
rllx lip-
mcnt clislocation may be coinplete or partial. The acromioclavic-
irlar lig;~nlenrpt-eren~sanrerior-postel-inr rlisplaccmcnt of thr
cl;lvi~Ie,while the coracoclavicular liganlenl pl-evrrltsvertical
displaccmcnt of Lllc clavicle.

* SHOULDER SEPARATION
 ID/CC A .l%-\re;t~--uld
mall con~plainsof lower back pain that began after
IIP lifted heavy objects while l~elpinghis son move out or the
famiIv home.

HPI HP is ovcrweigh? and ha5 not had any repliar e x ~ r s i ~~ Cp) Tthe
par1 t 0 years. 'The is aggravated by movement, coughing,and
sneezing; it radiates down h i 5 b~ittocks,thigh, and posterior calf.

PE Sensory loss over dorsal aspect of foot and I:tt~ri~l aspect of leg
(L5dermatome); weakness of darsiflexors of Font; nn palpa-
tion, left sciatic notch i~ tender: positive Lasepte's sign (straigl~1
Icg-rai~ingtest ) : deep teilclon rcfleses normal.

Imaging MR. lambar spinc: Focal hcrniarcd disk cuntrally at L+L5 touch-
i n s 25 I-oot.

Treatment Phy4ntherapy I~erlrmt: ac~lpllrlrimrr;rhil-opractir thcrap. if sy-mp-

tom5 are nlilrl. Consicler surgical lami~lectnmv o r Iminotomy if
pain I - ~ c o m prop-essive
e~ o r neurologic dcficits arc present.

Discussion I-Ierniation ol the irltel-vertel~ralrlisk (most commonly occurs at

L5-S 1 ) can Icad to irnpingemen t on spinal tlervt. roots. The

I., .-

stlation of the straight

ontcomc in this patirnl who

even ro a Herion
of almost ! I 0 rlrgrees.

* SPINE-PROLAPSED INTERVERTEBRAL DISK

rrgion of atlestlle5ia can be used to rlerlracc the specific lcvcl oi'
nerve impingcnlcnt. C:r.ntml disk herniation at thc. L4-L5 love1
will cause compression of tilu L5 ncrw mot, whilc pcriphural
disk herliintion at L4-C.5 can affrtt thr. L4 ncrw root. Sig~lsand
F Y H I ~ ! ( 11119 o f 1,4 HPT.YV r-no( romprrssioii i rtcl~tde;m ahnormal

patellar deep tendon reflex, n~~rnhuoss owr the mrdia8 aspect ui

the leg, and wrakn~sl;or rile tihialip :~ntet.ior. n ~ u ~ c - (root
I F rlorsI-
flexion). I ,5 nerve root comprewimi carlse\ n i ~ m h n e rnrel- ~ s thc
Zateral aqpeci nI' the leg anrl w e : ~ k n ~ ofs t~h e Putensor hatlucis
Inngus.
 ID/CC A 20-year-olcl college slr~clentcomplains of acute, severe pain on
both sides of his face Just in front of his ears tl~arbegan while
yawning ancl 1adiate5 to hoth ears; he cannot close his mouth,
and hc is unable to speak clearfy.

HPI H e was nntil thc pi-CEPII~

cnmplaint, and l l ~ i sis the first time
these 5ymptnrns have occui-red.

PE Pi-r,I rusin 11 nC lower jan,; dimpling of skin in temporomandibular

joint area.

Imaging XR: mandibular condyles clislocated ar-iterinrlyfrom letnporal

fossa.

Treatment Grip mandible tirmlv in hands with tf~~unl>r placed behind sec-
ond i-nolar; push mandible inferio1,ly and posteriorly in quick,
singlr n~orion( \ I A M ~ . ~ R. E D ~ C T I O K ) .

Discussion TIIP cli~licaldiagnosis o f remporomandibularjoin~dislocation i s

usually madc o n the spot. The plrysiciat~may elect to correct the
diclncarion 11nde1-genenl arles~heda,hut this is generally

- 1
TEMPOROMANDIBULAR JOINT DISLOCATION
 .smmdttu(ssaanpo~da~ snxqd p ~ t ? ZjaI ~ qr a m aorssna~ad
:i(.la~.reIr-c!At:pqnr ~ 3 3 ~1 2 2 z0 m q :(.I.s~~~.I s&~\iost q r ) I y8!e.t1s
B r t ! ~ uarlM
j 11?1rr~ou 01 srrln1a.r frron~~~dsrr! rr! ylea.iq ~slrl3urplotl
prrr! %rml!s ; ) I ~ M1.~31at11 OJ pearl S ~ F . I I I1I11,7!1rd r r a l n r SI? I p n l ST?
(X.1a1~euepiqsqns s n t p plrr: apsnnr .io!Jalrrr! s n u n l m s sassnrdrrro:,
q!.~1 ~ 3 ! . 4 ~ . 1IIIJI?
) JO rlng3npqe uo aqnd pIpe.1 3jal paqspqnna 3d

. p m q prm rtr.re i.lal s!tl JO ap!s mqn aw uo v d purr

~ w ~ u q n m'3uq%q
n ~n qr~!tydrnon(srun?A r p jn rrogmpqi: paStrnl
-01c1 san[onu! y . 1 0~~S O ~ MJnn!.rp
) 7nn.U qetrr nl!rp p10-.m3.{-55 y 23/11]
sy~dromcs.These entities compress ncurovascular Ftructures
;~~irl
thus give rise to similar signs and symptoms. Cervical ribs of
varying. ~ixrlsare present in a small percentage nf the normal
populatioil hut in some cases may in1phlfi.e on lower brachial
plexus branches or subdalian vcsscls.
 ID/CC A 4Gyra1--oldwoman comes to her hrnily physician cornplait~ing
ofApain,numbness, and a tingling sensation ( P ~ K T : S . T ~ - ~ E . S Io~nS )
the palmar aspect nf her rigli~rhumh. her second ancl third fin-
gel-5, and t1ie radi:~lside or h e r rourtli lingel- (fir111 finger is
alwq-5 spared) : her artacks occur primarily at night.

HPI She has wnr-ked rot. several vear.: in the "dam e n ~ r v "rlepartn~ent
crf a computer firm (atr activity associated with prnlongerl,
repeti~vemovements of the wrist).

PE Waqting o f thenar eminence: weakness of thutnh while opposing

to fifth di@t (weakness of oppotlerls pollicis) : tapping over-
radi;it qide of palmaris longits tendon produces a tingling
sellsation (Trur.~.'sSIGN): increslsecl sensation ( I ~ ~ R E S T F T E S I A )
over p;ilrn;~rS~IIF Fingers; fo~cedflexion of
of thtlrrlh LO r i n ~
wrists reproduces cJmptornr.while exrensiota relieves them
( ~ ' H A T . F , ~7'r'W).
's

Labs Nerve cur~cluctionstuclies of median nerve show rlecrea~edcon-

rlucr ion velnciiy atlil increawrl lalei7cy as tlerve en tel-s I~and.

Imaging MR: thickening and edcma of median ncrrc o r of acljace~lt

tcndons.

Treatment Extension splinting of affcctcd wrist and NSAIDs. Injection (>I'

canal tvitli lidocainu ancl corticclsteroid~;airpical clecnmpre~~ion
of iranwprse carpal liramert~(carpal runt~elr-elexqe) if not
responsive to local injcctians.

Discussion Carpal h ~ n n e s!rndro~n~'

l is a tvpc of stcnusing tcnvs~moritis131al
is sccn in p ~ o p l cw h o use their hands in a rcpetitire fjshiorl
(r.~., [hose rvl~oure cntnputers) . Thc median nerve lies I~etween
the flexor carpi radialis and flexor digitorurn sublimis tendons,
arid it is coverrd bv the flexor retinaculurn. In all. here are nine
tendons in the tunnel ihat compress ihe nerve agninrt the
retinac~rlurn.

WRIST-CARPAL TUNNEL SYNDROME

 ID/SC !I 19-yar+Id college nnder-grad comcs to an urgeril care center
at a ski rcsort bccar~scof pain in the wrist.

HPI Iie has suffered repeated -falls while snowboarding (failing

forward with ontstreicl~edpalms).

PE Hyperesihesia and marked tenderness in anatomical snliff box

.( C) (hounded by the extmor pllicis ion-ps arld the extensor
pollic& brevis; the scaphoid and hpeziurn hones lie in lhr flrlor)

Imaging XR, wrist: 110 definitc fcaot~n-e(a small fracture of the scaphoid
may not appear on x-ray for srve-r;tIweeks until the damaged borie
in t h y rt.gio11 is ~rnd~rgoing
resorption). Special rarliograpl~ic
tiews of the ~caphoic!a?well aq CTT, MR, or nuclear irledicin~
scans may be ohtainecl for di~~gnoqis if~trnng-clinical suspicion
exists.

Treatment ImmobiIizaliorl in a Ir>ng-areathunlb rpica cast, which inln~nki-

li7es he first thumb phalanx urltil there is radiologic evidence
of fracture healing (may takr tnore than 10 weeks).

Discussion T?lu scaphoirl and Iunate honeq articulate wit11 the radiw. The
scaphoid is a boat-shaped carpal hone that has a tuhercle;
Cracturcs mas involve Lhe tuhercle, the proximal pole, er llie
middle I hird. 'I'lie fracture oftcn guc5 LITII-ecognizetl,
and thcre
is a chance oCavasm11arnecrosis, rnainiv in disl>lacerlproximal
poIr fracnrrrs, since tlie scaphoirl bone. like the talus and
femoral hrad, has a very tenuous bloocl srlpplv.

Figure A-099 Demonnmtion nfsr~rlhrclandrnarh for sitrs d ~hurnl,

dl4tu1ctien-MCP joint (A):insertion of h e ulna. collateral lipmen1 ( B ) ;
anatomical s n u f f box-caphoid frac~ure(C); IPjnitit (D): MCI'jaint base.

WRIST-SCAPHOID FRACTURE
 ID/CC An 1 H-year-old Fitnale high-scl~nolstudent is brought to the
emergency room after slashing the palmar side of' her left wrist
at the ckin lines of flexion wit11 a rmor blade; shc is t~nableto
flex her wrist or oppose her th~unb.

HPl She l~adbeen severely rlepressrd for-wv~ralmonths because her

hoyfrieild had h e m weiiig other wnmen.

PE Mnclerate hleccling (superficial branch of radial artcry}; inahil-

iry LO flex wrist (severed tenclon oFpalmaris Iortgnr);failure to
oppose rhumb and anesthesia owr thumb and fil-st/second
digits (paralvsis d t h e n a r muscles and loss of scnsatiorl due to
severed median neme): thumb abd~ictionstill possible by
a b d ~ ~ c tpchlicis
ar l o n ~ ~innervated
s, by radial nerve.

Treatment Surgical hernostasir and repair of severed smictures. Psychiatric

treatment.

Discussion The media11 nerve p;isscs deep to tllc flexor retit~ac~ilrim: it

innervates t h e thenar and lumhrical muscles ant1 supplies
sensory hranches to the laterat palmar surface, thc sides of digits
1, 3, and 3, and the lateral side of d i p t 4. T h e rendon of the
palmaris Iongis lies medial, parallel, and sriperficial tn the
median riel-w. The ten structures that lie within the carpal
tunnel include thc four flexor rligitorllm superficialiq tendons,
tfir four fluxor digitorurn proftmdus 1.etidons. tlie flexor pollicis
longus tenclon, nnd !he median nerve. The palmaris longus
tendon, l~ltlarnerve. and ulnar artery all lie rolar to the
tmnwerse carpal ligament, wl?icll fnrms the roof of the carpal

WRIST-SLASH INJURY
 ID/CC A 65-vear-old Vie1 nam veteran complains of pro~~essivcly
wors-
ei~irighoarseness and persistent cough,

HPI He hal; smoked one pack ol'cigarettes each d a y for 45 years. lie
is currenrly being Lrr~ltcdFnr e~nphvrema.

PE S~tprarlavicttlar- t~odushard and enlarged (cancrr has inr tasta-

sizcd to these sentillel node$);ltmg fields filled wit11 dissenii-
n a z ~ ccrackIcs
l and 1- ale^: chesl barrcl-shapccl (ul~clrrlvit~g
er~~pl~vrenia) : c111hbing of t?nger.rior1 hot11 hands: patches of
velvety hyperpipentation (AC:,IN I Hr)srs NIL:RI~A~.;S) of both lower
Icp: purpunr s l ~ > t .seen
s on chest a i d arms.

Labs CBC: srcoiidai.y polyqthemia and le~~kocv~osic.

Imaging CXR: k m mass at lcft lung h i I m ruith thickenii~gof paratra-

chcal stripes a n d hilar fi~llr~css.

Micro Pathology S p u ~ u c)tology

r~~ and lymph tlnde Ijiopsy sllow small-cell
carcinoma.

Treatment Uppendq on stage: surget.y. radir~tlicrxpv.chernot tleuxp): tleoad-

juvnnt anrl i m r n ~ w ~ xi-ormrI 9% 5-ycar s~urvival
c ~l ~ c ~Overall,
~pv.
rate.

Discussion Lymphatic drainage of the lung goes lo t l ~ c hruricl~opnlnlc~~~arv

.
c h i d (s~tperiorant1
nnder (at hila or iungs), ~ r ~ : ~ r h ~ o b r - o n norles
inl'eriot- setc around trnrllea and inain I ~ r o n c h u ~pxmtraclieal
),
R O T ~ P T and
, bronchon~cdiastinalIvmph t r u n k (which form at the
jur~ctionof tile I rnct~col>ronchialnode^, the anterior mecliasti-
nal tiodes, ;lnrl the parastcrnal rlodes). Only when pleural aclhe-
,r l rt the asillary nocles clt.airl the lurlg. The lower
\ic>ns arc ~ ~ r c s e n
Inlw or the left lung drains Ln rlie right tracheohl-onchial nodes.
Srnal! cell (OAT CELL) carcinoinas r~~etar tasizc early to lymph

1 *
LUNG C A N C E R L Y M P H A T I C METASTASIS
 ID/CC .A 63-ycar-old woman nmIlois a I l r i ~smoker\~ comes to thc cmer-
gcncy room wit11 srvcrt swelling on the right side of the neck,
arm, ancl rare (r~tnpl-essiot~ ol' superior veils c a f i ~ ~) I J ~ C ~ ~ I L ' T
will1 srvel-e [ l a i n in the right arm.

HPI g gotten prngrcwivcIy worse over the paqt sevel-al

'I'he ~ ~ r e l l i nI1a~
7
months. In arldition. hcr voice. has ht-conie home nrTer-the samr c
period of timc (the rctlrr-rc11tlar-?r~~eal
to cotnpre5sir~nhv tllc tunlr~r).
nerve is 11aral77edd u e
S
Z
>
;El
<
PE Reduced radial pl~lse0 1 1 right sirlc (arterial flow i~ hlor.ked by
t~irnor); engorgement of right jugular vein (venouc remr-n is
hlcll-kctl duc 10 i r n p i n g e ~ r ~ r ~apical
~t rtlmor.); light ptosis
(dmc~pi rig) nf' right eye1 id, miosis (cnnrrartinn nf plrpil), and
anhidrosis (I;~ckof' qrve;~ting/I;lcrin~i~tion) (I IIIRNI.IR'SS\TDR(IWF;
c l ~ ~t to=qvnl-mtlletir ~h:linr ~ r n p ~ e s s i o nwasting
): of first dorsal
interosseous mllscle of right hand (supplied by TI): pain and
i n ~ ~ s catrophy
lc (invulrcmcnt o f hraclifal piex115)nf right arm.

Labs CDC: xnemia, L . v t ~ s :nnrlnal. EL'S :und crcatininr llormal: LFTs

ncirrnal.

Imaging CXR: Itmg tllmor in right apex, dcsh-uving first rib.

Gross Pathology Apical Innx tumor 'tias irivi~drdccrvicxl u!vmpatlleticplexus and

wrln cava.

Micro Pathology Bt-nnchial washings i ~ n dPap~riitolaou nf qplt t 11tn qhow sqna-

rlions cell carcinorrla.

Treatment Deprnrling on stilgt'; surgery rr;lrlictl~ei.;~py,

rl~eniotherapv,
net>ac!j~want and irnm~inotlierapv.

Di5c~ssion P;i t ~ c n i ~ swndr.c~rti~

~'s i s ~ll.odaced
1311anv tumor in close
proximity to the thoracic idet x ~ i dbv the coiiqeq~~en I
cr~mprrssionor thc I>rzlclibl plcs~isanrl hnr h I lir vrnous retzlrn
and ar-tck~lflow.

41 LUNG CANCER-PANCOAST'S SYNDROME