HTHSCI 2F03 Lecture Notes - Lecture 7: Humerus, Avascular Necrosis, Allodynia

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26 Dec 2020

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Testicular Tumours

Epidemiology

 Commonest male malignancies from 15-44yrs

 Whites > Blacks = 5:1

Presentation

 Painless testicular lump

 Often noticed after trauma

 Haematospermia

 2

O hydrocele

 Mets: SOB from lung mets

 Abdo mass: para-aortic lymphadenopathy

 Hormones: gynaecomastia, virilisation

 Contralateral tumour in 5%

Risk Factors

 Undescended testis

 10% occur in undescended testes

 Infant hernia

 Infertility

Pathology

Germ Cell: 95% of tumours

 Pure Seminomas: 40%

 Commonest single subtype

 30-40yrs

 ↑ βhCG in 15%

 ↑ placental ALP in some

 Very radiosensitive

 Non-seminomas (inc.mixed): 60%

 Mixed: commonest NSGCT

 Teratoma

 Arise from all 3 germ layers

 Common and benign in children

 Rare and malignant in adults: 15-30yrs

 Secrete βhCG and/or AFP

 Chemosensitive

 Yolk Sac

 Commonest testicular tumour in children

 Choriocarcinoma

 ↑↑ βhCG

Sex-cord Stromal

 Leydig Cell

 Mostly benign

 May secrete androgens or oestrogens

 Sertoli Cell

 Mostly benign

 May secrete oestrogens

Lymphoma / Leukaemia

 NHL: commonest malignant testicular mass >60yrs

 ALL: commonest malignant testicular mass <5yrs

Staging: Royal Marsden Classification

1. Disease only in testis

2. Para-aortic nodes involved (below diaphragm)

3. Supra- and infra-diaphragmatic LNs involved

4. Extra-lymphatic spread: lungs, liver

 Tumour markers

 Useful for monitoring

 ↑AFP and ↑hCG in 90% of teratomas

 ↑hCG in 15% of seminomas

 Normal AFP in pure seminomas

 Scrotum US

 Staging

 CXR

 CT

NB. Percutaneous biopsy should not be performed as it may

→ seeding along needle tract

 If both testes are abnormal, semen can be

cryopreserved

Seminomas

 Stage 1-2: inguinal orchidectomy + radiotherapy

 Groin incision allows cord clamping to prevent

seeding

 Stage 3-4: as above + chemo (BEP)

 Bleomycin, Etoposide, cisPlatin

Non-seminomas / Teratomas

 Stage 1: inguinal orchidectomy + surveillance

 Stage 2: orchidectomy + chemo + para-aortic LN

dissection

 Stage 3: orchidectomy + chemo

Close f/up to detect relapse

 Typically w/i 18-24mo

 Repeat CT scanning and tumour markers

Prognosis

 Stage 1: 98% 5ys

 Stage 2: 85% 5ys

 Stage 4: 60% 5ys

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The Penis

Balanitis

 Acute inflammation of the foreskin and glans

 Cause: Strep, staph infection, Candida (DM)

 RFs: DM, young children c

¯ tight foreskin

 Rx: hygiene advice, Abx, circumcision

Phimosis

 Foreskin occludes the meatus

 Children

 Pres: recurrent balanitis and ballooning

 Mx: Gentle retraction, steroid creams, circumcision

 Adults

 Pres: dyspareunia, infection

 Mx: circumcision

 Assoc. c

¯ balanitis xerotica obliterans: thickening of

foreskin and glans → phimosis + meatal narrowing

Paraphimosis

 Tight foreskin is retracted and becomes irreplaceable.

 ↓ venous return → oedema and swelling of the glans

 Can rarely → glans ischaemia

 Causes: catheterisation, masturbation, intercourse

 Mx:

 Manual reduction: use ice and lignocaine jelly

 May require glans aspiration or dorsal slit

Hypo- / epi-spadias

 Developmental abnormality of the position of the urethral

opening

 Hypospadia: opens on ventral surface of penis

 Epispadia: opens on dorsal surface

Penile Cancer

Epidemiology

 Incidence: 1:100,000/yr in UK

 Geo: commoner in Far East and Africa

Aetiology

 V. rare if circumcised

 Risk factors

 HPV (16, 18, 31) infection

 Chronic irritation 2O to smegma

Pathology

 Erythroplasia of Querat: penile CIS

 SCC

Presentation

 Chronic fungating ulcer

 Bloody / purulent discharge

 50% have inguinal nodes at presentation

 Medical

 Early growths c

¯ no urethral involvement

 DXT and iridium wires

 Surgical

 Amputation required if urethral involvement

 Lymph node dissection

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Orthopaedics

Contents

Bone and Fracture Physiology .................................................................................................................................................. 110

Fracture Classification ............................................................................................................................................................... 110

Fracture Management: 4Rs ....................................................................................................................................................... 111

Fracture Complications ............................................................................................................................................................. 112

Hip Fracture ............................................................................................................................................................................... 114

Distal Forearm Fractures ........................................................................................................................................................... 115

Scaphoid Fractures ................................................................................................................................................................... 115

Radial and Ulna Shaft Fractures ............................................................................................................................................... 115

The Shoulder ............................................................................................................................................................................. 116

Supracondylar Fractures of the Humerus ................................................................................................................................. 117

Femoral and Tibial Fractures .................................................................................................................................................... 118

Ankle Injuries ............................................................................................................................................................................. 118

Knee Injuries .............................................................................................................................................................................. 119

Osteoarthritis ............................................................................................................................................................................. 120

Back Pain .................................................................................................................................................................................. 121

Osteochondritis .......................................................................................................................................................................... 122

Traction Apophysitis .................................................................................................................................................................. 122

Osteochondritis Dissecans ........................................................................................................................................................ 122

Avascular Necrosis .................................................................................................................................................................... 122

The Limping Child ...................................................................................................................................................................... 123

Acute Osteomyelitis ................................................................................................................................................................... 124

Septic Arthritis ........................................................................................................................................................................... 124

Bone Tumours ........................................................................................................................................................................... 125

Brachial Plexus Injuries ............................................................................................................................................................. 127

Other Nerve Injuries .................................................................................................................................................................. 127

Carpal Tunnel Syndrome .......................................................................................................................................................... 128

Minor Hand Conditions .............................................................................................................................................................. 129

Minor Leg and Foot Conditions ................................................................................................................................................. 130

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Document Summary

Staging: royal marsden classification: disease only in testis, para-aortic nodes involved (below diaphragm, supra- and infra-diaphragmatic lns involved, extra-lymphatic spread: lungs, liver. Afp and hcg in 90% of teratomas. Percutaneous biopsy should not be performed as it may. If both testes are abnormal, semen can be cryopreserved. Groin incision allows cord clamping to prevent seeding. Stage 3-4: as above + chemo (bep) Stage 2: orchidectomy + chemo + para-aortic ln dissection. Acute inflammation of the foreskin and glans. Rfs: dm, young children c tight foreskin. Assoc. c balanitis xerotica obliterans: thickening of foreskin and glans phimosis + meatal narrowing. Tight foreskin is retracted and becomes irreplaceable. Venous return oedema and swelling of the glans. Manual reduction: use ice and lignocaine jelly. May require glans aspiration or dorsal slit. Developmental abnormality of the position of the urethral opening. Hypospadia: opens on ventral surface of penis. Geo: commoner in far east and africa.

HTHSCI 2F03 Lecture Notes - Lecture 7: Humerus, Avascular Necrosis, Allodynia

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