Clicking knee

A sharp pain on the knee associated with swelling and a clicking noise can be a meniscus tear. This is the common sporty injury. However, the tear can occur in a traumatic incident on the knee. A meniscus tear refers to rapture of a fibrocartilage that play a role in holding the knee joint in a stable position.

Mechanism of Meniscus tear

There are various ways in which the fibrocartilage can be torn: a traumatic force during a sporty event can be the cause, in an accident, the twisting movement of the knee while it is in a bent position and lastly it can be by pure wear and tear due to old age.

Signs and Symptoms

Pain on the knee- this pain is severe on weigh bearing or movement but when it’s rested, the pain subsides. Also there is an associated swelling on the particular knee.

Clicking sound- as the patient moves, the joint makes a sound and there is limitation in stretching the knee fully. The patient can also remember a particular incident that brought about the symptoms

Treatment

Depending on the type of the tear, a small tear can be managed by elevating the affected leg, physiotherapy, ant- inflammatory drugs and knee cap to hold the joint firmly.

Surgery

 It can be done partially or completely a procedure commonly referred to as Arthroscopy.

Surgery is not recommended to patients whose cause for the tear is degenerative, unless there is locking of the knee and severe pains.

Hernia

A hernia is a protrusion of a structure beyond the normal covering of the cavity in which it is contained. Hernias occur frequently in the inguinal, femoral, and umbilical areas. They can be congenital or acquired. Congenital hernias occur in infancy due to the patent processus vaginalis hence a rise in inguinal hernias. Acquired hernias occur mostly at point of weakness like sites of surgical incisions.

Predisposing factors

        I.            Increased intra-cavity pressure when lifting heavy objects

      II.            Chronic cough

    III.            Abdominal distention due tumors or ascites

    IV.            Straining while passing urine or faeces

Components of a hernia

        I.            Sac- consist of mouth, neck, body and fundus

      II.            Covering- these are layers that the hernia comes out with like aponeurosis, muscle and skin

    III.            Contents-mostly consists of the small intestines or the greater omentum

Classification of hernias

Reducible – contents can be returned back but the sac persists.

Irreducible hernia- contents cannot be reduced due to the narrow neck.

Incarcerated hernia- this is an irreducible hernia but there is maintained blood supply.

Strangulated hernia- contents of the hernia are stuck in the sac with impaired blood supply.

Obstructed hernia- this is where a part of the intestines is obstructed.

Abdominal hernias

Inguinal hernias

Inguinal hernias take up to 80% of all abdominal hernias. They are common in children and elderly. They are also common in males than females.

Indirect inguinal hernias-passes through the internal ring and is lateral to the epigastric artery. It may extend to the scrotum.

Direct inguinal hernias- protrude through the posterior wall of canal and are medial to the epigastric artery.

Pantaloon hernia- consists of both indirect and direct inguinal hernias.

Differences between direct and direct inguinal hernias

	Indirect	Direct
Patients age	Any age though common in the young	older
Cause	Congenital	Acquired
Protrusion on coughing	Oblique	Straight
Reduction	Not immediate	Reduces immediately
Descent to scrotum	Always	Rare
Neck of sac	Narrow	Wide
Rate of strangulation	High	Low
Position to inferior epigastric vessels	Lateral	Medial

 

Investigations

1.       Clinical findings is gold standard

2.       Ultrasound

3.       Ct scan- especially in obese patients

4.       Herniography

Management

Patients with hernias come with a long progressive history. Risks of strangulation increase with time hence it is important to repair them

Surgical technique

Herniotomy- This is the removal of the sac and closure of the neck. Commonly done to infants.

Herniorrhaphy- This aims at restoring the normal anatomy increasing abdominal wall strength and creating a barrier to counter recurrence.

Laparoscopic repair- includes Trans abdominal pre-peritoneal (TAPP) and total extra peritoneal (TEP) approaches.

Blood Transfusion Complications

Blood transfusion is the process of receiving blood products intravenously. There are various reasons for doing blood transfusion which include; Anemia, Surgical procedures, Hemorrhage, Patients with cancers, Hereditary blood disorders like Thalassemia and burns. Blood transfusion is lifesaving, however, before deciding on it, it is good to exhausted other avenues for your patient like iron therapy or plasma substitutes. Over the years, the procedure has been made safer with introduction of screening methods for infections like Hepatitis B and HIV. it is important to note that, blood should be transfused 48hrs preoperative to prevent red blood cell depletion of 2,3-biphosphoglycerate that can lead to a reduced red blood cell capacity in the body.

There are two types of Blood transfusion complications; Early and Late.

Early complications

Fluid overload- patients with reduced renal or cardiac failure are prone to this, it is the practice to give IV 20mg of furosemide while transfusing.

Coagulation disorders- blood contains red blood cells, as the run into a patient’s body; they tend to dilute platelets and coagulation factors. Transfused blood contains citrate which is an anticoagulant. It is therefore advisable to monitor patient and correct any coagulation issues.

Hyperkalemia-transfused blood tend to be leaky, this in return increases serum potassium. Patients with no kidney damage can clear it, but those with damage can complicate, therefore it is important to check urea and creatinine during the procedure.

Incompatibility reaction-this occurs when patient reacts to the blood given. It can be treated by holding the transfusion, giving fluids and antihistamines.

Thrombophlebitis

Late complication

Infections- this is not common but can occur in unscreened blood. Hepatitis B and HIV are among the highest. Malaria is also a common infection. In different practice, antimalarial have been given during blood transfusion.

Reduced cell immunity- it has been noted that wound infections and metastasis rise in patients with carcinomas who have received transfusion.

Hemochromatosis- over the years, patients who have received multiple transfusions later on develop iron overload.

As a clinician, it is important to ensure before transfusion, the blood is correct and well screened, patients vitals are monitored every 15mins, an input-output chart and in case of a reaction, proper management is executed.

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a lifethreatening complication in diabetic patients. It is associated with type 1 diabetes mellitus otherwise called Juvenile Diabetes Mellitus. Under certain circumstances, it can occur in type 2. DKA occurs due to insulin insufficiency.Signs and symptoms
Polyuria,Polydipsia,Kussmaul breathing,Dehydration,Coma,Hypotension,ketotic breath
Investigations
Blood sugar, Urinalysis that show ketonuria,Full haemogarm,Urea and Creatinine,Arterial blood gases
Management
fluid therapy,insulin,potassium and bicarbonates
Patients in coma need intensive care. Advice patients on compliance to medication,regular checkups to counter infections which precipitate this medical emergency.

Is the Tetanus Vaccine a Contraceptive?

The recent stand by the Kenyan catholic church has made tetanus vaccine controversial. With the recent vaccination campaign going on targeting women between 14-49 years, the claims indicate that the vaccine is a contraceptive and it is being used to control reproduction. However, studies done have shown that the vaccine induces antibodies against the Human Gonadotropic Hormone(hCG) which is involved in ovulation and a woman would require antibody titres of more than 50ng of hCG per ml to reduce fertility. This means that to reach the targeted 50ng, a booster is needed and funny enough the campaign is providing them. The question remains, is it therefore a way to control fertility on Kenyan women? We wait for the parliamentary committee to give us their findings as the samples were taken for chemical analysis, though they had tested positive for normal hCG levels.