The ankle and foot
David Silver in Silver's Joint and Soft Tissue Injection, 2018
Achilles tendon. Rupture is characterised by sudden and severe pain in the calf (as if being suddenly kicked from behind), in the absence of any obvious injury. The tear may be palpated and the patient is unable to stand on the toes of the affected foot. Immediate referral for suture or immobilisation is indicated. Achilles tendinosis is caused by inflammation of the tendon at the insertion into the calcaneum or along the length of the tendon, or in the bursa separating the tendon from the calcaneum. Crepitus may be felt, as in any other form of tenosynovitis. The popularity of jogging has increased the incidence of these problems. It should be noted that tendon inflammation and rupture are a recognised complication, occurring rarely, during therapy with some quinolone antibiotics (e.g. ciprofloxacin). The reason for this is not understood, but the author can confirm from personal experience the rupture of two posterior tibial tendons and one Achilles tendon following medication with ciprofloxacin. In any patient considered to be prone to tendinosis problems or similar tenosynovitis problems, avoidance of such antibiotic prescription must be advised.1
Anorectal Conditions Requiring Urgent or Emergency Intervention
Peter Sagar, Andrew G. Hill, Charles H. Knowles, Stefan Post, Willem A. Bemelman, Patricia L. Roberts, Susan Galandiuk, John R.T. Monson, Michael R.B. Keighley, Norman S. Williams in Keighley & Williams’ Surgery of the Anus, Rectum and Colon, 2019
Like other necrotising infections, Fournier’s gangrene results in a characteristic appearance of grey necrotic tissue, lack of bleeding, thrombosed vessels, ‘dishwater’ pus and non-contractile muscle. All necrotic tissue, including skin, subcutaneous tissue, fascia, and muscle, must be excised down to healthy, bleeding tissue. Again, there is usually much more necrotic tissue than the superficial appearance suggests, and the surgeon must be psychologically prepared for this. If crepitus is present over an area of what appears to be normal skin, the area should be explored to make sure the underlying soft tissue is viable. Although rarely involved, it may be necessary to debride the anal sphincters, irrespective of the concerns about post-operative incontinence. Vulvar, penile and scrotal skin should be excised if involved. However, an orchiectomy is almost never necessary as the blood supply to the testicles is usually preserved.16,41–42
Examination of the Ulnar Side of the Wrist
J. Terrence Jose Jerome in Clinical Examination of the Hand, 2022
If an older patient has pain with direct palpation of the pisiform in the absence of trauma, PT arthritis should be considered as a diagnosis. PT arthritis is easily overlooked as a source of ulnar wrist pain and can confound the accurate testing of other structures, in particular the LT. The pisiform tracking test or PT grind test is performed with the patient's wrist in slight flexion, which relaxes the FCU tendon. The examiner then grasps the pisiform between index and thumb, while stabilizing the dorsal aspect of the wrist with the other hand. As pressure is applied onto the pisiform and into the PT joint, the pisiform is “shucked” radially and ulnarly. Pain and possibly crepitus should be present in patients with pathology at this joint [2].
The use of stromal vascular fraction (SVF), platelet-rich plasma (PRP) and stem cells in the treatment of osteoarthritis: an overview of clinical trials
Published in Artificial Cells, Nanomedicine, and Biotechnology, 2019
Sahar Mehranfar, Isa Abdi Rad, Ebrahim Mostafavi, Abolfazl Akbarzadeh
Osteoarthritis (OA) is the most prevalent degenerative joint disease, which mostly impairs mobility and subsequent quality of life in elder individuals. Patients experience signs of pain, morning stiffness and a grating sound during joint motion known as crepitus. Although the pathogenesis of OA has been poorly understood, it has often defined with changes in articular cartilage. Tissue fluid, proteoglycans and type 2 collagen form the main structure of cartilage. Furthermore, chondrocytes, as the main cell type found in this area, can generate and maintain the extracellular environment. It has been reported that chondrocytes have no mitotic and regenerating capacities under physiologic condition. These cells can maintain the minimal turnover of collagens to make permanent structures in front of mechanical forces exerted on the joints. However, any mechanical stress or injury can stimulate chondrocytes to proliferate and increase their ability to synthesize the extracellular matrix as part of the repair process. The subsequent changes in matrix composition can induce chondrocytes to release catabolic factors leading to cartilage degradation. This can cause friction between bones and make pain and immobility in the affected patients [1].
Spontaneous pneumomediastinum secondary to electronic cigarette use
Published in Baylor University Medical Center Proceedings, 2020
Sean Burgwardt, Arnes Huskic, Gary Schwartz, David P. Mason, Leonidas Tapias, Eitan Podgaetz
The patient was admitted for observation, withholding food and fluids by mouth. Physical exam showed crepitus along the supraclavicular region, extending to the anterior chest and neck. This slowly improved over the next 2 days. Additional imaging with a soluble contrast esophagram showed no esophageal perforation. Upon further questioning, the patient stated he had begun vaping with NJOY Ace Pods 6 weeks earlier in an attempt to quit smoking. He had smoked approximately 1 pack of cigarettes per week for the past 6 to 7 years without any acute complications. The night before admission, however, at a social gathering he utilized his e-cigarette in much greater frequency than normal. After careful observation for 48 h, the patient was discharged home without operative intervention. Strong recommendations to stop utilizing e-cigarettes were given as well as smoking cessation advice and counseling.
Progressive subcutaneous emphysema of unknown origin: a surgical dilemma
Published in Acta Chirurgica Belgica, 2019
Lynn De Roeck, Lauranne Van Assche, Veronique Verhoeven, Ina Vrints, Jana Van Thielen, Thierry Tondu, Filip Thiessen
Acute widespread SE of the upper extremity is a rare clinical entity and faces the physician with an important surgical dilemma. It can be an alarming clinical feature since it can be caused by a NSTI. However, noninfectious etiologies exist and should be recognized. Benign SE has been described after surgical procedures [5,6], penetrating wounds [4,7,8], pneumothorax [9] or pneumomediastinum [10], an insect bite [11] or due to factitious manipulations [12–15]. The term NSTI describes a group of limb- and potentially life-threatening infections of the skin, soft tissues and muscles, which tend to progress rapidly throughout the fascia planes. The mortality rate is as high as 40%. Early diagnosis is mandatory, since any delay in surgical treatment is associated with higher rates of amputation and higher mortality rates. If a high clinical suspicion exists, no laboratory result or radiological finding should delay surgical intervention [1,2,16]. A thorough history and examination is essential to assess timing of possible trauma and crepitations, overall health status, systemic symptoms and signs of an aggressive soft tissue infection such as loss of function. Generally, patients with noninfectious SE are devoid of systemic symptoms. Crepitus will develop within minutes to hours after injury and pain is mild. In contrast, patients with NSTI often appear toxic and show inflammatory changes as swelling and erythema. Disproportionate pain is often the first sign [8,10].