BACKGROUND Extrahepatic bile duct injuries (EHBDIs) are a rare consequence of blunt abdominal trauma. The purpose of this study was to establish mechanisms of injury, clinical indicators of EHBDI following blunt trauma (both with investigative modalities and intraoperatively), method and timing of injury detection, and definitive treatment options. METHODS A systematic review was performed to gather data on patients with an EHBDI secondary to blunt trauma. Three databases (MEDLINE, PubMed, and EMBASE) were searched to July 19, 2018. RESULTS Our systematic review included 51 studies, compromising a study population of 66 patients with EHBDIs sustained from blunt trauma. The three most common injuries included complete transection of the suprapancreatic common bile duct (29%, n = 19), complete transection of the intrapancreatic common bile duct (23%, n = 15) and partial laceration of the left hepatic duct (20%, n = 13). Of the hemodynamically stable group managed nonoperatively (n = 23), mean timing postinjury to diagnosis of EHBDI was 11 days. An EHBDI was recognized at initial laparotomy in 87% (n = 13) of hemodynamically stable patients. An EHBDI was recognized at initial laparotomy in 57% (n = 8) of hemodynamically unstable patients. CONCLUSION The EHBDIs are a rare yet serious consequence of blunt trauma. To establish a timely diagnosis and limit complications of missed injuries, a heightened awareness is required by the attending surgeon with particular attention to subtle yet important clinical indicators. These vary depending on the hemodynamic stability of the patient and decision to manage injuries conservatively or surgically on presentation. LEVEL OF EVIDENCE Systematic review, level III.

Background Work-related musculoskeletal disorder (WRMD) is a collective term for preventable work-related disorders that cause musculoskeletal symptoms. The growing prevalence of these disorders amongst surgeons has been labelled an ‘impending epidemic’ and currently there is a lack of awareness and no existing intervention programme. Aims To estimate prevalence and identify risk factors for developing work related neck, shoulder and upper back pain in surgeons. Methods Cross-sectional questionnaire survey of surgeons and surgical trainees across Australia. We collected data on demographics, nature of regular operative work, hours working/operating per week, and prevalence and severity of musculoskeletal disorders based on the Nordic Musculoskeletal Questionnaire [1]. We assessed associations between categorical predictors and pain over 7 days and 12 months using Pearson’s chi-square test. We assessed associations involving continuous variables using Student’s t-test. Tests were two-tailed and assessed at the 5% alpha level. Results From ~2058 recipients, 329 (16%) responded; 137 (42%) surgeons reported shoulder, neck or upper back pain in a 7-day period, 245 (75%) reported pain and 101 (31%) had pain preventing normal work in a 12-month period. Significant predictors of increased prevalence included female sex (P < 0.001), decreasing age (P < 0.01) and fewer years working (P < 0.01). Body mass index (BMI) and mode of practise did not significantly affect prevalence of WRMDs. Conclusions The prevalence of WRMDs amongst surgeons is high, females and younger surgeons reporting increased rates. There is a need to build awareness and educate surgical trainees about WRMDs.

Alkaptonuria is a rare autosomal recessive genetic disorder where an accumulation of homogentisic acid in the tissues leads to ochronosis-a pathological dark pigmentation. It can affect various tissues and the weight bearing joints of the body, leading to degenerative arthropathy. On the rare occasion, it causes cardiac manifestations. We describe a case of aortic valve stenosis due to ochronosis secondary to alkaptonuria requiring aortic valve replacement.