Case of the Day: Hand Trauma

Today in minors I saw 2 interesting cases of hand trauma. 

Case 1: Builder 

I first saw a builder who sustained a laceration to the dorsal aspect of his dominant hand following a heavy pack of slate tiles falling on it. The wound was irrigated using 1.5 litres of saline. We then gave him a nerve block - followed by some local to the tissue surrounding the wound - ouch, this was the most painful part for the patient. The wound was then explored - which had lots of debris. The man was very veiny - and bleeding was a problem! Without adequate methods of haemostasis we used a more old school method.  It became evident that the ligament to the ring finger had been 100% cut and the capsule of the MCP joint had been breached. We used sterile water to clean the wound along with hydrogen peroxide. Finally we sutured the wound using mattress sutures and then placed him in a volar block. He was referred to plastics for further management.

Ok, so here are some questions on this case  -

1. What nerves did we block and how?

2. What do the nerves that we blocked supply in the hand?

3. What did we use to aid haemostasis?

4. What ligament had been cut and what is its function?

5. What crucial investigation have I not mentioned?

6. What crucial piece of management have I missed?

7. What other piece of important information do you think the plastic surgeons asked for?

8. Why would water rather than saline be better at cleaning the wound?

Hand Anatomy and local anaesthesia will be discussed in another post. 

Topic 1.1 Dysphagia

More likely to see this in clinic. I have never actually clerked in a patient with dysphagia as a sole symptom.
In simple terms, dysphagia is defined as difficulty in swallowing.  The list of causes are long. A good way to remember them is to divide causes into:


 Inside the lumen

• foreign body
• oesophagitis
• infection - candidiasis

In the wall

• benign stricture
• malignant stricture
• achalasia
• oesophageal spasm 
• oesophageal Web - Plummer Vinson syndrome (middle aged females with Fe def anemia)
• scleroderma
• presbyoesophagus - associated with old age

Outside the wall

• pharangeal pouch
• rolling hiatus hernia
• tumour
• retrosternal goitre
• vascular structures - thoracic AA

Systemic causes

• MG
• MS
• PD
• psuedobulbar palsy

Ok so its going to be hard to remember all of these, but if we just think about in terms of structure then it will be a lot easier.

In very very simple terms, the oesophagus is the food pipe, anything that blocks this pipe or stops it from it from contracting will cause dysphagia - which is difficulty in swallowing. The blockage can be in the lumen - forigen body, inflammation or infection; it can be in the wall of the pipe - stricture, achalesia, oesophageal web, scleroderma and age related changes; it can be outside the pipe pressing in on it - pharangeal pouch, large thyroid, HH, tumour or aneurysm. Systemic causes are listed above.

How to investigate dysphagia?

Coming soon...

Anatomy of the oesophagus will be covered in topic 1.2

What do I need to know?

Ok, so I thought the best place to start would be the MRCS website. Here is the syllabus of part A and B. I will be using this as a guide, as well as other sources.

Sample of things to come - here are some sample questions from the MRCS website.

Hey everyone

This blog will be an account of my revision for the MRCS part A in April 2011.

OK its now February, I've procrastinated for the last several months and have had several attempts at starting to study. To be honest, I don't know where to start - there is no structure that I can follow. I have tried a few books and online question banks - both very useful but tend to get boring after a while. Answering online questions is a good way to revise, but I feel more comfortable actually reading first, and tackling the questions along side.


What I am going to do is tackle 5 topics every day, these will be randomly chosen. As I progress I will therefore build up a bank of notes which I will organize according to subject. This may help others revising for the exam by providing a structure for revision and revision notes.

At the end of every 30 topics I will post some questions on the topics covered.

I will start posting from Saturday 5th Feb 2011.