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Head injuries
Classification of head injuries
· Wounds of the scalp
· Fractures of skull
· Intracerebral injuries
Causes of cranio-cerebral injuries
· Trauma
- Dynamic injuries
§ Acceleration/deceleration injuries
§ Rotational injuries
- Direct trauma
§ Penetrating
§ Blunt trauma
Injuries of scalp
Types
· Closed à Haematoma
- Connective tissue
- Sub aponeurotic
- Sub-periosteal
· Open
- Lacerated
- Incised
- Avulsed
Haematoma of scalp
Haematoma of sub cutaneous tissue
Brain injuries
Mechanism of injury
· Dynamic
· Direct (Static)
· Penetrating
Dynamic injuries
· These occur when head is not fixed in the space
· These occur because of the jelly nature of brain which moves in relation to skull in
a dynamic injury
· The velocity of force at the impact is important
- If the force of impact is dampened by cushioning, e.g., helmet, the severity of
the effects is greatly reduced
Acceleration injury:
It is produced due to abrupt acceleration of the head when a moving object strikes the
head, (e.g., when a stationary vehicle is struck in the rear so that the victim sitting in
the vehicle is suddenly thrown forwards or speeding vehicle hits a person on the road)
Deceleration injury:
It is produced due to abrupt stopping of moving head by striking against a stationary
object. A well fixed head, when sustains a dynamic injury, the force of impact is taken
by the skull bones resulting in fracture and with little or no brain damage.
Plan of management
StepI:ABCD
Step II:
Evaluation of injuries
Management in casualty
First-aid
· Resuscitation of the injured by ABCD
· Assessment of head injury:
- History from a witness about
§ Time and nature of injury
§ Presence and duration of unconsciousness immediately after injury
§ Presence of fits after the injury
§ Right or left handed
- Examination
§ Level of consciousness – graded by “Glasgow coma scale”
Prognosis
Encephalocele
Similar to meningocele, if skull bones are not developed, it results in meningocele
(Protrusion of arachnoid through the defect)
Encephalocele
The meningeal herniation contains brain
Hydrencephalocele
The brain in the herniation contains ventricle
Physiology
Changes after nerve injury – Wallarian degeneration
After injury to a nerve –
· Distal to the injury, the nerve undergoes degeneration: there will be lysis of the
axoplasm, fragmentation of myelin sheath producing empty endoneural tube
containing Schwann cells.
· Proximal to the injury, degeneration occurs upto the node of Ranvir and later,the
remaining nerve regenerates into the endoneural tube.
Neurotmesis
There will be anatomical disruption of whole nerve including the sheath. Wallerian
degeneration occurs distally, but regeneration can not occur because of lack of
continuity of endoneural tube. If surgical repair is done, recovery occurs, but is not
perfect.
Causes:
· Cut injury, avascular injury, severe stretch, injection of toxic drugs
Clinical manifestations
They depend upon the nature of injury. The types of clinical manifestations are –
· Degenerative (axontmesis and neurotmesis) injuries
· Non-degenerative (neuropraxia) injuries
Claw hand – DD
· Both median and ulnar nerve paralysis
· Inner cord of brachial plexus injury
Glossopharyngeal nerve
Causes
· # base of skull
Lesions
· Paralysis of stylopharyngeus, which could not be tested
· Absence of gag reflex and sensation of palate and posterior third of tongue
Vagus nerve
Clinical presentation
· Affect muscles of palate and larynx àdifficulty in swallowing and vocal cord
paralysis
Recurrent laryngeal nerve lesion
· Partial – paramedian position
· Complete –cadaveric position
Accessory nerve
Causes
· # base of skull
· Operations on posterior triangle of neck
Lesions
· In anterior triangle of neck, it causes paralysis of sternomastoid and trapezius
· In posterior triangle of neck, it causes paralysis of trapezius àdrooping of
shoulder
Hypoglossal nerve
CHEST INJURIES
Classification
According to nature of injury
· Blunt injuries
· Open injuries
- Crush injuries
§ Road traffic injuries
§ Blast injuries
§ Under water explosions
- Penetrating wounds – stabs, gunshot wounds
According to the organs injured
· Chest wall injuries
- Contusion chest wall
- Rib fracture
§ Isolated
§ Multiple
· Haemo thorax, pneumo thorax or both
· Lung injuries
- Contusion or laceration
· Aorta and great vessels injury
· Diaphragmatic injuries
· Abdomino-thoracic injuries
Incidence
· Thoracic trauma is responsible for 70% of deaths following road traffic accidents
Fracture ribs
Types of presentation
· Fracture of isolated rib
Flial chest
It is caused by automobile accidents of serious nature. It is usually associated with
other major injuries. Several adjacent ribs are fractured in two places – either on one
side or on either side of the sternum
Pathology
1) The fractured segment (flial segment) of chest wall moves inwards during
inspiration and outwards during expiration (paradoxical respiration)
¯
Reduced gasseous exchange
¯
Hypoxia
Traumatic haemothorax
Sources
· Chest wall, lung, heart and great vessels
Complications
· Pleural thickening
· Empyema
Treatment
· Mild: aspiration every 24 hours
· Rapidly accumulating or associated with pneumothorax: under water seal drainage
· Progressive (>200ml/hr): thoracotomy and arrest of bleeding
Diaphragm injuries
It presents as diaphragmatic hernia, which can be –
· Acute or
· Chronic
DISEASES OF OESOPHAGUS
Anatomy
It measures 25 cms in length extending from cricopharyngeal junction (15 cms from
incisor teeth) to cardiac orifice (40 cms from incisor teeth). It has 3 physiological
constrictions –
· From incisor teeth at 15cms (cricopharyngeal jn) – narrowest part of alimentary
tract
· From incisor teeth at 25cms (crossing of aorta)
· From incisor teeth at 40cms (OG jn)
Its muscle coat has striated muscle in its upper part and much of lower part has smooth
muscle.
Nerve supply: vagus by its oesophageal plexus
Mucosa is lined by stratified squamous epithelium except its lower 2 – 3 cms , which
is lined by columnar epithelium .
Physiology
Functions
· Propagation of food into stomach
· Clearance from refluxed food or fluid
· Prevention of reflux of acid gastric juice
· Prevention of reflux of food into trachea
These functions are due to its peristalsis, lower oesophageal sphincter and upper
oesophageal sphincter (cricopharyngeus)
Peristalsis
Primary peristalsis
· It occurs in response to a food bolus and it is for clearance and neutralisation of
acid
Secondary peristalsis
· It occurs in response to a stubborn food bolus or to the presence of fluid in the
lower oesophagus (refluxed material from stomach)
Investigations
1) Radiography
· Plain X-ray: Not useful
· Barium swallow: it is indicated in motility disorders, identification of hiatus hernia
(done in Trendlenberg’s posture), and in space occupying lesions.
2) Upper GI endoscopy
- To evaluate mucosal lesions
- It is the most commonly performed investigation
· Diagnostic endoscopy
- Biopsy or cytology from suspected lesions
· Therapeutic endoscopy: it is done for
- Removal of foreign bodies,
- Dilatation of strictures,
- Injection of varices,
- Insertion of stents,
- Luminisation of tumours
Types of endoscopy
· Rigid endoscopy
- Negus oesophagoscope or Earlam oesophagoscope is used. It is useful in
examination of cricopharyngeal area and the lower pharynx. The risk of
perforation is high. It needs high skill.
· Flexible fibre-optic endoscopy
- It has supplanted rigid scope. It is safer to use.
3) Manometry
It is a gold standard in the assessment of motor disorders. A polyvinyl tube of about 4
mm in dia is passed into the oesophagus. This tube consists of multiple microcapillary
tubes connected to external presuure transducers, which pass signals to a computer for
real time displayIt is useful in evaluating motility disorders like achalasia, diffuse
Congenital diseases
· Atresia with or without tracheo-oesophageal fistula
· Stenosis (rare)
· Short oesophagus with hiatus hernia (rare)
· Dysphagia lusoria
Atresia and tracheo-oesophageal fistula
Pathology
Types:
The oesophagus is atretic and the upper or lower segments of the oesophagus open
into the trachea in one of the four ways –
· A) Lower segment opens into trachea (85%),
· B) Upper segment opens into trachea (2%),
· C) Both segments open into trachea (1%),
· D) Both segments end blindly and the mid oesophagus is absent (12%)
Clinical features
· Regurgitation of first and subsequent feeds by new born baby with pouring out of
saliva from the mouth – the sign
· Coughing and cyanosis on feeding
· Associated with hydramniosis in the mother
· It may be part of VACTER anomalies
VACTOR anomalies
· V – vertebral body defects
· A – anal atresia
· C – cardiovascular disease:- VSD/PDA
Injuries of oesophagus
Causes
· Spontaneous injury
- Full thickness rupture
- Partial thickness rupture
· Iatrogenic injury
· Penetrating injury
· Foreign body
· Corrosive injury
· Drug- induced injury
· Due to Barret’s ulcer
Full thickness rupture (Boerhaave’s syndrome)
Causes
· Rupture of oesophagus due to severe barotrauma when a person vomits against
closed glottis
Site
· At the weakest point of oesophagus, i.e., lower 1/3 of oesophagus
Pathology
Rupture
¯
Passage of oesophageal contents into mediastinum
Diaphragmatic hernia
The diaphragm has certain defects through which herniation of abdominal contents
can occur into the chest. These foramina are –
· Congenital foramen –
- Foramen of Morgagni
- Foramen of Bochdalek
Hiatus Hernia
TYPES
· Sliding or oesophago-gastric hiatus hernia – 85%
· Rolling or paraoesophageal hiatus hernia – 5%
· Mixed or transitional hiatus hernia – 10%
Tumours of Oesophagus
Classification
· Benign (very rare)
- Leiomyoma
Carcinoma of oesophagus
Aetiology
· Smoking
· Alcohol
· ? Fungal contamination of food
Pre cancerous conditions
· Barrett’s oesophagus
· Corrosive stricture
Pathology
Types
· Squamous cell carcinoma arising from squamous cell layer of upper 2/3 of
oesophagus
· Adenocarcinoma arising from lower 1/3 of oesophagus and from Barret’s
oesophagus
Incidence
Geographical variation
· Highest incidence in the world is in Linxian in Henan provinence of China (100 in
1,00,000popultion)
· Common in Transkei region of South Africa and mid-Asia and some areas of
France
· Japan does not have a high incidence of oesophageal cancer
Type
· Squamous cell carcinoma was the commonest type during earlier days, but now,
adenocarcinoma is commonest (60-70%)
· The change in the incidence of type is probably due to increased incidence of
Barrett’s oesophagus
· Systemic spread
- To liver, bone, brain, skin etc
Clinical features
· Early disease
- Feeling of something sticking in the throat
- Non-specific dyspeptic symptoms
· Late disease
· Painless, progressive dysphagia
· Weight loss
· Features due to infiltration
- Hoarseness of voice ( recurrent laryngeal n. involvement)
Plummer-Vinson syndrome
Syn:Brown Kelly-Paterson syndrome, Sideropenic dysphagia
Clinical features
· Iron-deficiency anaemia
· Kaolinychia
· Dysphagia
- Due to web or spasm in the post cricoid area
· Glossitis
Complications
· Ulcer
· Stricture
· Carcinoma