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Orthopaedic Surgery
Published in Gozie Offiah, Arnold Hill, RCSI Handbook of Clinical Surgery for Finals, 2019
SymptomsPAINPain out of proportion to the injuryDo not simply try to manage pain with increasing opioid use. Look for signs of compartment syndrome and plan to operate immediately if signs are present and other short term measures (below) fail
Arterial disorders
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
The classical clinical picture is that of severe pain out of proportion with clinical findings that worsens with time, despite appropriate analgesia. The patient often complains of numbness/paraesthesia in the distribution of nerves running within the compartment (non-myelinated type C sensory fibres are most sensitive to hypoxia). Examination of the limb reveals a tense compartment with passive flexion and extension of muscles causing pain. The presence of palpable pulses does not rule out compartment syndrome.
Limb trauma
Published in Ian Greaves, Military Medicine in Iraq and Afghanistan, 2018
There is no place for monitoring compartment pressures in a deployed hospital environment. Furthermore, the need for aeromedical evacuation from the deployed facility back to the United Kingdom, sometimes taking more than 24 hours, occurring very soon after injury, is unique to military medical practice. The patient must be optimised both physiologically and from a surgical/orthopaedic viewpoint, in the form of adequate analgesia, fracture stabilisation and extremity vascularity. Compartment syndrome initially presents with pain out of proportion to that expected from the injury. It is frequently intractable, and patients are restless and agitated. Even if ventilated, their oxygen consumption rises and the need for further analgesia is identified. Nursing and medical staff in the military environment are very aware of these developing signs. If there is any concern regarding the possibility of a developing compartment syndrome, then four-compartment decompression of the extremity should be performed. It is most common in the lower leg. However, buttock, thigh, foot, forearm and hand decompressions were all undertaken during the conflicts.24,34 Perhaps one of the most controversial areas in which compartment decompression might be performed is in association with foot injury, frequently as a result of crush or blast. Clinical experience demonstrates that the casualty’s pain in such cases is uncontrollable by any conventional analgesia, including regional blockage. Although the actual procedure is unsatisfactory to the orthopaedic surgeon, if foot compartments are released correctly, the pain is rapidly relived.35
The pharmacological management of dental pain
Published in Expert Opinion on Pharmacotherapy, 2020
Joseph V. Pergolizzi, Peter Magnusson, Jo Ann LeQuang, Christopher Gharibo, Giustino Varrassi
Neuropathic pain is a complex painful condition that can occur anywhere in the body and can be extremely challenging to treat effectively. Neuropathic pain is the result of a diseased or damaged nerve or a lesion on a nerve such that aberrant pain signaling takes place, unconnected to an external stimulus or with an exaggerated pain experience in relation to the stimulus [73]. Neuropathic pain may be treated with gabapentinoids, antidepressants, nonopioid analgesics, or a combination of these. Opioids are less effective in treating neuropathic pain than other analgesics. Neuropathy may result in hyperalgesia or allodynia, where the patient reports pain out of proportion to the stimulus. Neuropathic pain can occur in the oral cavity. Such cases of peripheral neuropathy may be treated with the dental blockade, but if the neuropathy involves central sensitization, that type of blockade will not be effective [66]. Therapeutic modalities other than NSAIDs will be required.
Acute wound infections management: the ‘Don’ts’ from a multidisciplinary expert panel
Published in Expert Review of Anti-infective Therapy, 2020
Gabriele Sganga, Federico Pea, Domenico Aloj, Silvia Corcione, Marina Pierangeli, Stefania Stefani, Gian Maria Rossolini, Francesco Menichetti
However, the recognition of acute wound infections may be challenging in some circumstances. Necrotizing fasciitis is a life-threatening, rapidly progressive, soft tissue infection that can start at the site of a wound (including a major trauma or a surgical wound). Its delayed recognition is associated with high mortality and morbidity, but diagnosis is challenging. Pain out of proportion is a warning sign of necrotizing fasciitis [20]. Thus, it represents a sign that clinicians should not minimize, even in case of wound without or with minimal signs of infections. Conversely, the lack of pain in a wound with minimal surrounding erythema does not exclude a severe wound infection. As a matter of fact, elderly, frail, and obese patients can present with negligible local signs and nonspecific general signs (such as loss of appetite, malaise, or deterioration of glycemic control in diabetic patients). Importantly, in case of suspected wound infection a complete patient evaluation should be performed, taking into account the presence of systemic signs and symptoms, such as fever, tachycardia, hypotension, and the alteration of serum biomarkers, such as deterioration of renal function, increase in white blood cells count, CPK and C-reactive protein.
Benign subcutaneous emphysema: a rare and challenging entity a case report and review of the literature
Published in Case Reports in Plastic Surgery and Hand Surgery, 2021
Samuel M. Christen, Joerg G. Gruenert, Stefan Winsauer
Only a few reports of non-infectious SE after minor skin lesions exist [10–16]. The non-infectious emphysema has to be clearly distinguished from potentially life-threatening infections with gas-forming germs such as clostridium perfringens, pyogenic streptococcus, coliform or anaerobic spore-forming bacteria [1,19]. The clostridial gas gangrene usually occurs with a delay of 12–18 h after the initial trauma and develops in a fulminant manner. Non-clostridial gas gangrene proceeds more insidiously over few days and mostly affects patients with an underlying chronic disease such as diabetes, chronic organ insufficiency or malignancies [19]. The most common form of an NSTI is monomicrobial necrotizing fasciitis with group A streptococcus (GAS) [1]. Often, a superficial skin lesion can be identified. The GAS infection begins with relatively mild local skin changes (discoloration, erythema and swelling); significant crepitus develops after 12–18 h. Over 24 h the affected skin becomes purple and bullae appear. Typically, patients suffer from severe pain (‘pain out of proportion’) and the inflammation spreads rapidly accompanied by progressive tissue destruction within a few hours. The patients deteriorate dramatically, showing systemic signs of toxicity (high fever, hemodynamic instability, organ failure). The clinical evaluation and decision-making can be supplemented by routinely performed blood samples. The LRINEC score (tab. 1) was introduced in 2004 and proved a helpful adjunct for risk stratification in such cases [20,21]. A score of more than 8 points is strongly predictive for an NSTI (PPV 93.4%). However, a low LRINEC score does not exclude necrotizing fasciitis. Therefore, the threshold for early surgical exploration should be low. In a clinically unstable patient supportive therapy and immediate treatment is vital including high-dose antibiotic therapy (with toxin-suppressor), exploration of the wound with aggressive soft-tissue debridement and eventually hyperbaric oxygen therapy [22,23]. Hu N et al. suggest a novel therapeutic strategy of vacuum therapy combined with continuous irrigation with potassium permanganate [24]. Despite advances in intensive care medicine and general awareness of NSTI, mortality rates remain high, even with appropriate treatment [25].