DDX Of Herina/Lump in the Groin

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#Hernia
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■ General Causes & Features of Hernia

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#Hernia
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Herina Examination (P1) ■

▪︎Assessing the groin lump to determine if it is a hernia or other pathology (e.g. testicular mass, lipoma, abscess, lymph node).

▪︎You should always assess both sides of the groin to avoid missing pathology.


▪︎Hernias of the groin typically present with the following clinical features:

•Single lump in the inguinal region

•Positive cough impulse (unless incarcerated)

•Soft on palpation

•Reducible (unless incarcerated)

•Unable to get above the lump during palpation

•Painless (unless incarcerated)

•Bowel sounds on auscultation (may be absent if incarcerated)



▪︎Not Herina :

•Multiple lumps (e.g.lymphadenopathy)

•Hard or nodular consistency (e.g. malignancy)

•Able to get above the lump during palpation (e.g. scrotal mass)

•Transillumination (hydrocoele)

•Bruit on auscultation (e.g. arteriovenous malformation)

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#Hernia
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Herina Examination (P2) ■

🔹Hernia Should first be examined like any mass by

▪︎Inspection For
Site/Size/Shape/Over Skin/Surrounding Skin/Symmetry/Number

▪︎Palpation
•Superficial ➡️ Hotness/Tenderness
•Deep ➡️ Mobility/Reducibility/Consistency/Edge/Lobules

▪︎Cough Impulse
▪︎Occlusion Tests
▪︎3 Finger Test
▪︎Invagination Test
▪︎Trans illumination Test


▪︎While the patient is standing upright. Inspect the inguinal and femoral canals and the scrotum for any lumps or bulges.


▪︎Ask the patient to cough; look for an impulse over the femoral or inguinal canals and scrotum.


▪︎Inguinal hernias : located above and medial to the pubic tubercle (Direct/Indirect).


▪︎Femoral hernias : located below and lateral to the pubic tubercle.


■ Is it Direct or indirect inguinal Hernia ? (Ring occlusion test)👇

1.Ask the patient To lie Down

2.Locate the deep inguinal ring (midway between the anterior superior iliac spine and pubic tubercle).

3. Manually reduce the patient’s hernia by compressing it towards the deep inguinal ring starting at the inferior aspect of the hernia.

4. Once the hernia is reduced, apply pressure over the deep inguinal ring (close it) and ask the patient to cough.

• If reappears: Direct inguinal hernia 

• if not reappears : indirect inguinal hernia


▪︎Inguinal hernias can extend into the scrotum (indirect). So If a testicular swelling is noted or there is suspicion of an inguinal hernia, palpation of the scrotum should be performed : 👇

•When palpating an inguinal hernia in the scrotum you will not be able to get above the mass.


■Comparison

●Direct inguinal hernias:

•Mostly Occurs in adult males.

•caused by a weakness in the muscles of the abdominal wall (develops over time, or are due to straining or heavy lifting).

•Reappears after deep ring occlusion

•Not enter the Scrotum

•Reducible (Wide Neck)


●Indirect inguinal hernias:

•In children (Present at birth).

•caused by a birth defect in the abdominal wall (congenital).

•Enter the Scrotum (Pass with spermatic cord).

•Not reappears when close the deep ring

•Reducible (Wide Neck)


●Femoral Herina:

•weakness in the lower groin

•Mostly in females

•more prone than inguinal hernias to develop incarceration or strangulation

•Mostly not reducible (Narrow Neck)

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Types of ulcer edges ■

▪︎Sloping edge : healing, traumatic and ischaemic venous ulcers.

▪︎Undermined edge : TB

▪︎Punched-out edge : ischaemic and syphilitic ulcers

▪︎Rolled edge : basal cell carcinoma

▪︎Everted edge : squamous cell carcinoma and the ulcerated adenocarcinoma.

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🔴Diabetic Foot

▪︎It's Any Pathology Affect Lower Limbs (Specially Foot) That Results Directly From The Chronic Complications Of Diabetes Mellitus


▪︎Pathologies Affect Foot Could Be :
📍1. Infections
📍2. Ulcerations
📍3. Deep Tissue Destruction
📍4. Peripheral Vascular Disease
📍5. Neurological Abnormalities


▪︎Diabetic Foot Responsible For 40-60% Of Non-Traumatic Foot Amputation (Most Amputations Proceeded By Foot Ulcer)

▪︎Foot Ulcer is The Most Important Complications Of Diabetic Foot

▪︎15% Of Diabetic Patients Will Develop Foot Ulcers


🔷Pathophysiology For The Development Of Diabetic Foot
📍1. Peripheral Vascular Disease :
▪︎Chronic Elevation in Blood Sugar Levels Results in Arterial Atherosclerosis

▪︎This Will Results in Reduction Of The Blood Supply To The Foot


📍2. Neurological Dysfunction (Diabetic Neuropathy Most Common Long Term Diabetic Complication) :
🔻I. Sensory Neuropathy :
▪︎Decrease Superficial & Deep Sensations Of The Foot

▪︎Results in Recurrent Undiscovered Foot Trauma & Callus Formation


🔻II. Motor Neuropathy :
▪︎Alterations in The Biomechanics Of The Foot (Muscle Wasting/Ligaments Weakness/Bone Erosions)

▪︎Results in Foot Deformity & Unequal Pressure Distribution On The Foot That Contribute To More Foot Trauma (Metatarsal Head Exposure)


🔻III. Autonomic Neuropathy :
▪︎Decrease Skin Foot Sweating & Abnormal Blood Flow To The Foot (Veins Dilatation Due To AV Shunts)

▪︎Results in Skin Foot Fissuring/Warm Foot/OsteoPenia/Bone Collapse


📍3. Final Results On The Foot (Complications Of Diabetic Foot) :
🔻I. Symptomatic Foot :
▪︎Paraesthesia/Numbness
▪︎Claudication
▪︎Pain

🔻II. Decrease Healing Of Foot Wounds (Diabetic Or NeuroTrophic Or NeuroPathic Ulcers) نفس الاسم

🔻III. Recurrent Foot Infections & Abscess Formation

🔻IV. Progressive Foot Deformity & Joints Destruction (Charcot's Foot NeuroArthroPathy)

🔻V. Foot OsteoMyelitis & Cellulitis

🔻VI. Foot Or Toes Amputation Due To Gangrene (Necrosis)


🔷Risk Factors For Diabetic Foot Ulcers (High Risk Foot)
📍1. Poor Glycemic Control

📍2. Elderly & Blind People (Or Low Vision) & Uneducated

📍3. Obesity & High Alcohol Intake

📍4. Past Hx Of Foot Ulcers

📍5. Diabetic Neuropathy & Peripheral Vascular Disease

📍6. Foot Deformity (Callus/Claw Foot/Hallux Valgus/High Arched/Hammer Toes)


🔷Evaluation Of Diabetic Foot
📍1. Patient Hx To Detect :
▪︎Any Risk Factors Present For Diabetic Foot

▪︎General Medical Condition


📍2. Foot Examination :
🔻I. Ulcer Exam (Size/Shape/Number/Edge/Floor/Base/Temperature/Tenderness/Discharge/Surrounding Skin)

🔻II. Neurological Exam (Sensation/Motor/Autonomic)

🔻III. Vascular Exam (Peripheral Pulses/Skin Temperature & Color/Capillary Refill)

🔻IV. Identify Any Foot Deformity

🔻V. Special Tests (Imaging/Doppler/Angiography/Ankle Brachial Index/Electrophysiological Test)


📍3. Classification Of Diabetic Foot (Wagner Classification) :
▪︎Grade 0 ➡ Intact Skin (But Impending Ulcer Due To Presence Of Risk Factors)

▪︎Grade I ➡ Superficial Ulcer (Partial Or Full-Thickness & No Infection)

▪︎Grade II ➡ Deep Ulcer Extending To Underlying Tissue (But No Bone Involvement)

▪︎Grade III ➡ Deep Ulcer With Abscess & Bone Involvement (OsteoMyelitis)

▪︎Grade IV ➡ Limited Foot Gangrene (Only ForeFoot Or Heel Or Toes)

▪︎Grade V ➡ All Foot Gangrene

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