Open Fractures Classification and its clinical manifestations

Open fractures are surgical emergencies because of its complications (soft tissue damage, infection, hemorrhage).

We at emergency department need a classification system that it is intented to determine the degree of that damage.

We have to make a rapid (also a good) interrogation of lession mechanisms (what, when,  where, who, associated lessions). REMEMBER: If a low-grade open fracture has 6hrs from the begining, it’s considered infected.

On 1984, Gustilo and Anderson made a classification system, wich is the following:

Type I open fracture. Wound less than 1 cm, without contamination and minimal injury of soft tissue.
Type I open fracture - 1
Type I open fracture - 2

Type II open fracture. Wound between 1 and 10 cm, mild contamination, extensive soft tissue damage and minimal to moderate crushing component.
Type II open fracture - 1
Type II open fracture - 2

Type III-A open fracture. Wound larger than 10 cm, severe contamination and severe crushing component.

Type IIIA open fracture

Type III-B open fracture. Wound larger than 10 cm, severe contamination and severe loss of tissues.
Type IIIB open fracture - 1
Type IIIB open fracture - 2

Type III-C open fracture. Wound larger than 10 cm, severe contamination and neurovascular injury.
Type IIIC open fracture - 1
Type IIIC open fracture - 2

Gustilo, R.; Mendoza, R.; Williams, D. Problemsin the management of type III (severe) open fractures: A new classification of typeIII open fractures. J Trauma 24:742, 1984.

Jon Mikel Iñarritu, M.D.

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Cardiac Tamponade

Physical findings & Clinical Presentation:

• Severeconstant pleuritic pain that localizes over the anterior chest and may radiateto arms and back; it is differentiated from myocardial ischemia, becausethe pain intensifies with inspiration and is relieved by sittingup and leaning forward.
• Pericardial friction rub is best heard with patientupright and leaningforward and by pressing the stethoscope firmly against the chest; itconsists of three short, scratchy sounds:
• Signs and symptoms:

  1. Dyspnea
  2. Orthopnea
  3. Interscapular pain
  4. Tachycardia
  5. Refractary hypotension
  6. Distended neck veins
  7. Paradoxicalpulse
  8. Chest x-ray: Cardiomegaly, clear lungs (may be normal)
  9. ECG: Low amplitude of QRS, electrical alternans

Immediatepericardiocentesispreferably by needle paracentesis with the use of echocardiography, fluoroscopy,orCT Aspirated fluidshould be sent for analysis (protein, LDH, cytology, CBC, Gram stain, AFBstain) and cultures for AFB, fungi, and bacterial C&S.



Cardiac Tamponade


Cardiac Tamponade

Jon Mikel Iñarritu, M.D.

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Traumatic mediastinal hematoma

A 64 years old politraumatized male, arrive to ER department directly to trauma room. He was on shock.

  • Refractary hypotension
  • Tachycardia and tachypnea
He had no signs of tamponade.
Here we have the images (best viewed in large size):

Initial chest x-rayCT scan

Post-surgery image (best viewed in large size):

Post-op chest x-ray

The final diagnosis was Traumatic Mediastinal Hematoma.
You can notice esophagus displacement and complications of filling cardiac cavities.
Jon Mikel Iñarritu, M.D.

technorati tags: CXR, mediastinal hematoma, CT scan, Clinical cases, medicine, mediastinum, unbounded medicine, chest x-ray, x-ray, xray

An extremely rare case

22 year old female with painless slowly progressive, ophtalmoplegia with diplopia and ataxia.

On physical examination we found this:

  • Short stature.
  • Arrhythmic heart sounds.
  • Bilateral ptosis.
  • Ophtalmoplegia.

Ptosis & ophtalmoplegia

Bilateral fundoscopy examination:

Eye Another Eye

A characteristic bilateral pigmentary retinosis.

An EKG was performed:

1st degree AV block
A first degree AV block was found on this patient.

Then we ordered a lumbar punction to chemical and cytologic analysis.

The cerebrospinal fluid was cloudy with no other anormalities except elevated proteins (>100mg/dL).

With this data now we can think about a chronic progressive external ophtalmoplegia.

Differential diagnosis should include:

  1. Isolated CPEO
  2. Kearns-Sayre syndrome
  3. Oculopharyngeal muscular dystrophy
  4. Myotubular myopathy
  5. Myotonic dystrophy
  6. Oculopharyngeal muscular dystrophy

The next step in the diagnosis of this case is to perform an electromyography (myophatyc pattern), electrorretinography (slow transmission) and a muscle biopsy.

The diagnosis is:

Kearns-Sayre syndrome wich is a mitochondrial cytopathy that is characterized by CPEO, retinal pigmentary changes, and heart block. Patients are typically normal at birth. Progressive ophthalmoplegia usually develops between 5 and 20 years of age, although it may occur earlier. Most cases are sporadic.

The ocular findings include bilateral and symmetric involvement of the horizontal and vertical muscles, bilateral ptosis, and normal pupils. An atypical pigmentary retinopathy (“salt and pepper”) may be present; some patients have a corneal opacity. The ophthalmoplegia progresses slowly over many years and is often asymptomatic because it is insidious and bilaterally symmetric. As the extraocular myopathy progresses, generalized muscle weakness and other systemic manifestations may occur.

Nonocular manifestations include:

  • Cardiac — Heart block, sometimes even sudden death (may require monitoring with sequential electrocardiograms or treatment with a pacemaker) [2,3]
  • Neurologic — Deafness and vestibular dysfunction, cerebellar ataxia, corticospinal dysfunction, electroencephalogram abnormalities, elevated cerebrospinal fluid protein (>100 mg/dL), or widespread muscular dystrophy
  • Endocrine and metabolic — Short stature.

Images and clinical case information provided by: Dr. Arturo Ramírez M. from Mexico City.

Thank you for your support, Arturo.


Jon Mikel Iñarritu, M.D.

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RA & Pulmonary disease

A 76 years old female comes to the emergency department because shortness of breath. She has been postrated since 2 months ago, when she wasn’t able to move her legs anymore. Shortness of breath since 1 week ago (NYHA IV). She states that she has “rheumas”. She gives no other information. She has been taking methotrexate since 4 years ago, in interval periods of time, she doesn’t know which doses. On physical examination you note a postrated elder woman with severe physical deformities. You also found this:

general appearence deformity

clubbing swan neck

cxr lat cxr

This is an extremely advanced case of rheumatoid arthritis. But, what associations with pulmonary disease does RA have? What kind(s) of pulmonary disease(s) does this patient have (or could have)?

USMLE-like exam results in Mexico

Here in Mexico there is a similar exam to the USMLE, who is proposed to select those medicine graduated into residents to get a speciality.

This exam is called “Examen Nacional de Aspirantes a Residencias Médicas – ENARM” (National Exam of Aspirings to Medical Residences). This exam was on September 3rd and 4th this year, it consists in 700 multiple option questions, of wich 600 evaluate medical knowledge (clinical vignette questions), and 100 evaluate understanding capacity of english-based medical texts. The results was published yesterday. There were 22,985 aspirings for 4,299 vacant places in 22 specialities.

Public and private institutions offer main specialities as follows (annual and national offers):

  • Anatomic Pathology (54 places)
  • Anesthesiology (420 places)
  • General Surgery (460 places)
  • Audiology and phoniatrics (19 places)
  • Epidemiology-Public Health (25 places)
  • Medical Genetics (16 places)
  • Obstetrics & Gynecology (422 places)
  • Sports Medicine (7 places)
  • Rehabilitation Medicine (56 places)
  • Occupational Medicine (58 places)
  • Family & Primary Care Medicine (724 places)
  • Internal Medicine (607 places)
  • Legal & Forensics Medicine (10 places)
  • Nuclear Medicine(12 places)
  • Ophtalmology (102 places)
  • Traumatology and Orthopedics (229 places)
  • Otorhinolaryngology (73 places)
  • Clinical Pathology (17 places)
  • Pediatrics (531 places)
  • Psychiatrics (86 places)
  • Radiology (156 places)
  • Emergency Medicine (183 places)

That give us a number of 18.7% of selected residents-to be, of the total population of aspirings. That’s sounds BAD. I don’t know the facts and numbers of the USMLE, but i think it’s much easier to get a residency at USA, by far.

Congratulations to all my dear colleagues that had approved this important part of our careers. I’m very proud of you guys!


Jon Mikel Iñarritu, M.D.

technorati tags: ENARM, USMLE, unbounded medicine

Pulmonary tuberculosis: a common diagnosis at INER

A 24 year old woman who presented at INER (Instituto Nacional de Enfermedades Respiratorias) at Mexico City complaining of shortness of breath, weight loss, and chronic cough. This image shows a classic radiographic appearance of pulmonary tuberculosis. An heterogeneous image with alveolar filling pattern and homogeneous opacity are observed at the right apex. Elevation of right hemidiaphragm due to atelectasia is also shown.

Gerardo Morales-Mora

technorati tags: Tb, Pulmonary tuberculosis, tuberculosis, INER, clinical cases, medical images, unbounded medicine

Horrible: Child abuse

Another case of Child abuse was shown today on TV news.

It seems that we can’t stop this and some parents preffer to remain in silence rather than to speak out loud about this impunity.

I think it is time to recognize this cases and report them to the authorities. So today’s matter is to know the facts about child abuse & neglect.

Also know as child maltreatment it is a group of comission, omission and lack of actions, that result in morbidiy and/or mortality.

It is every agression or omission of intentional nature, indoor or outdoor, against child(s), before or after the birth that affects their bio-psycho-social integrity. This actions can be from an individual, a group of people (society), an institution taking advantage of their physical and/or intelectual superiority.

There is a triad of child abuse:

  1. Child: Often a non-accepted (desired) kid, malformation, chronic or acute diseases.
  2. Agressor: Often a parent or caretaker, alcoholic or drug abuse problem, background of abuse.
  3. Triggers: Unemployment, marital disfunction, social and economic problems.

It’s importance: 2,900,000 cases / year on U.S.A of wich 33% is physical abuse. Second leading cause of death in child less than 5 years old.

Burn by iron Circular burn


You should always suspect child abuse when:

Clinical aspects on child: Non-correlated history given by parents, small height, poor hygiene, previous lesions, malnutrition, non-desired/non-accepted child, incomplete vaccination schedule.

Clinical aspects on child’s family: Delayed medical attention, abuse background, step-mother/father, alcoholism, ask for medical attencion by someone else outside the central group of family.

It is required a multidisciplinary team: Primary care Physician, Pediatrician, Social work, Mental Health, Lawyer, Voluntaries.

The action of preventive mesures should include all levels of society: International organizations, Federal instances, Local community (church, school, friends, pediatrician, etc), Child’s family and Child.

Who where ever you are do: Let’s stop this.


Jon Mikel Iñarritu, M.D.

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Concern about appearence

24-year-old male comes to you with the chief complaint that his nose is too big to the point of being hideous. He has been avoiding contact with others and has left his studies.

The patient states that his nose is a constant embarrassment to him and he would like it surgically reduced. He tells the physician that three previous plastic surgeons had all refused to operate on him because they said his nose was fine, but the patient states that “they just didn’t want such a difficult case”. You observe that the patient’s nose is of normal size and shape.

What do you think?

This is a typical manifestation of body dysmorphic disorder (also know as dysmorphophobia), that is an extreme feeling of dislike or concern about some aspect of the appearence in spite of a normal or nearly normal shape The fear of being ugly or repulsive is not decreased by reassurance and compliments and has almost a delusional quality. The social, academic, and occupational lives of this individuals are greatly affected, due to avoidance of social interactions for fear of embarrassment, the time spent in checking mirrors and seeking surgical treatment or cosmetic remedies, and the chronic emotional distress that accompanies the disorder.

Complications: As the presentation of this patient, social withdrawal is common, and patients may be unable to work or to sustain relationships with others. Suicidal ideation is common, and completed suicide may occur.

Treatment: As this patients are loath to consider their pathologic concerns per se, they rarely stay in treatment. Both fluoxetine and clomipramine are effective in reducing the intensity of the patients’ concerns, and there is some preliminary evidence for the effectiveness of behavior therapy.

So, what you don’t like about yourself?


Jon Mikel Iñarritu, M.D.

technorati tags: body dysmorphic disorder, dysmorphophobia, unbounded medicine, psychiatry, medicine

Doctor’s Day

Congratulations to all my colleagues in Mexico, because today is the celebration of Doctor’s Day.

Background & History:

On October 19 of 1833, Valentín Gómez Farías ordered the clossure of the Universidad Nacional y Pontificia and The School of Surgery. Then it inagurated on October 23 of 1833 the establishment of Medical Sciences wich then became in Facultad de Medicina of Universidad Nacional Autónoma de México.

So, October 23rd is our day here in Mexico.

Other dates in other countries:

March 30 – National Doctor’s Day – USA (Anniversary of the first use of general anesthetic in surgery March 30 1842 by Dr. Crawford Long)

December 2 – Doctor’s Day – Argentina, Spain, etc. (Anniversary of the birth of the cuban Dr. Carlos Finlay, who discovered the vector of yellow fever).


Jon Mikel Iñarritu, M.D.

technorati tags: doctor’s day, UNAM, National Doctor’s Day, unbounded medicine