Block 2

Question 1

Theme: Colonic resections

A.End ileostomy

B.Loop ileostomy

C.Ileo anal pouch

D.Loop colostomy

E.Pan proctocelectomy

F.Extended right hemicolectomy

G.Right hemicolectomy

H.Anterior resection

I.Anterior resection with covering loop ileostomy

Please select the most appropriate procedure from the list, each option may be used once, more than once or not at all.

A 75 year old man requires resection of an obstructing carcinoma of the splenic flexure.

A patient presenting with a large bowel obstruction from a low rectal cancer.

A 45 year old man presents with a carcinoma 10cm from the anal verge, he has completed a long course of chemoradiotherapy and has achieved downstaging with no evidence of threatened circumferential margin on MRI scanning.

Answer 1

Extended right hemicolectomy

Carcinoma of the splenic flexure requires extended right hemicolectomy. Or a left hemicolectomy. The ileocolic anastomosis has a lower leak rate, particularly when the bowel is obstructed.

Loop colostomy

This patient should be defunctioned, definitive surgery should wait until staging is completed. A loop ileostomy will not satisfactorily decompress an acutely obstructed colon. Low rectal cancers that are obstructed should not usually be primarily resected. The obstructed colon that would be used for anastomosis would carry a high risk of anastomotic dehisence. In addition, as this is an emergency presentation, staging may not be completed, an attempted resection may therefore compromise the circumferential resection margin, with an associated risk of local recurrence.

Anterior resection with covering loop ileostomy

Low rectal cancer is usually treated with a low anterior resection. Contraindications to this include involvement of the sphincters (unlikely here) and poor sphincter function that would lead to unsatisfactory function post resection. Most colorectal surgeons defunction resections below the peritoneal reflection as they have an intrinsically high risk of anastomotic leak. A loop ileostomy provides a safe an satisfactory method of defunctioning these patients. A contrast enema should be performed prior to stoma reversal.

Question 2

Next step after diagnosis of CRC?

Answer 2

Completely staged using CT CAP

Entire colon should be evaluated with colonoscopy or CT colonography.

Patients whose tumours lie below the peritoneal reflection should have their mesorectum evaluated with MRI

Question 3

What should be done for CRC patients with tumours below the peritoneal reflection?

Answer 3

Evaluation of mesorectum with MRI

Question 4

What is significant about the general approach to surgical management of CRC?

Answer 4

Surgery is only curative option.

Lymphatic drainage of the colon follows the arterial supply, most resections are thus tailored around resection of particular lymphatic chains (e.g. ileo-colic pedicle for right sided tumours).

Following resection, a decision must be made about restoration of continuity.

Question 5

What are the key technical factors in the healing of bowel anastomoses?

Answer 5

Adequate blood supply, mucosal apposition, no tissue tension.

Surrounding sepsis, unstable patients and inexperienced surgeons may compromise these key principles and in such circumstances it may be safer to contrsuct an end stoma rather than attempting anastomosis.

Question 6

Options for CRC presenting as an obstructing lesion

Exception

Answer 6

Stent or resect.

In modern practice is is unusual to simply defunction a colonic tumour with a proximal loop stoma.

Exception is in the rectum

Question 7

Chemotherapy following resection of CRC

Answer 7

5FU and oxaliplatin is common

Question 8

Approach to rectal cancer surgery

Answer 8

Can be an anterior or APER resection.

Involvement of the sphincter complex or very low rectal tumours require APER.

In the rectum, a 2cm distal clearance margin is required and this may also impact on the procedure.

Meticulous dissection of mesorectal fat and LNs (TME) is also an integral part of the procedure.

Question 9

Why can the rectum be irradiated?

Answer 9

It is an extraperitoneal structure- something that cannot be offered in colonic tumours

As a consequence patients may be offered neoadjuvent radiotherapy prior to resectional surgery

Question 10

T1 and T2/ N0 rectal tumours

Answer 10

Do not require irradiation-> surgery

Question 11

T4 rectal tumours

Answer 11

Long course chemo radiotherapy

Question 12

T3 N0 rectal tumour.

Answer 12

Shourt course of radiotherapy prior to surgery

Question 13

Management of rectal cancer causing large bowel obstruction

Answer 13

Will not undergo resectional surgery without staging as primary treatment (different from colonic cancer).

This is as rectal surgery is more technically demanding, the anastomotic leak rate is higher and the danger of a positive resection margin in an unstaged patient is high.

Patients with an obstructing rectal cancer should have a ?

Question 14

Patients with an obstructing rectal cancer should have a?

Answer 14

Defunctioning loop colostomy

Question 15

Right colon cancer

Type of resection

Answer 15

Right hemicolectomy

Question 16

Transverse CRC

Type of resection

Answer 16

Extended right hemicolectomy

Question 17

Splenic flexure CRC

Type of resection

Answer 17

Extended right hemicolectomy

or

Left hemicolectomy

Question 18

Sigmoid CRC

Type of resection

Answer 18

High anterior resection

Question 19

Upper rectum CRC

Type of resection

Answer 19

Anterior resection (TME)

Question 20

Low rectum CRC

Type of resection

Answer 20

Anterior resection (low TME)

Question 21

Anal verge CRC

Type of resection

Answer 21

APE of colon and rectum

Question 22

Type of anastomosis

Right hemicolectomy

Answer 22

Ileo-colic

Question 23

Type of anastomosis

Extended right hemicolectomy

Answer 23

Ileo-colic

Question 24

Type of anastomosis

Left hemicoloectomy

Answer 24

Colo-colon

Question 25

Type of anastomosis

High anterior resection

Answer 25

Colo-rectal

Question 26

Type of anastomosis

Anterior resection (TME)

Answer 26

Colo-rectal

Question 27

Type of anastomosis

Anterior resection (low TME)

Answer 27

Colo-rectal (+/- defunctioning stoma)

Question 28

Type of anastomosis

Anal verge

Answer 28

None

Question 29

Risk of anastomotic leak

Ileo-colic

Answer 29

Low <5%

Question 30

Risk of anastomotic leak

Colo-colon

Answer 30

2-5%

Question 31

Risk of anastomotic leak

Colo-rectal

Answer 31

5%

Question 32

Risk of anastomotic leak

Colo-rectal (low anterior resection)

Answer 32

10%

Question 33

Perforation in CRC management

Answer 33

Risk of anastomosis is much greater, particularly when colon-colon anastomosis.

End colostomy is often safer and can be resversed later.

When resection of the sigmoid colon is performed and an end colostomy is fashioned= Hatmann’s

Question 34

When resection of the sigmoid colon is performed and an end colostomy is fashioned=

Answer 34

Hartmann’s

Question 35

Ileo-colic anastomosis in the emergency setting

Answer 35

Relatively safe and do not need to be defunctioned.

Question 36

Theme: Breast disease

A.Tuberculosis

B.Actinomycosis

C.Duct ectasia

D.Fibroadenoma

E.Fat necrosis

F.Intraductal papilloma

G.Breast abscess

H.Breast cancer

A 32 year old woman presents with a tender breast lump. She has a 2 month old child. Clinically there is a tender, fluctuant mass of the breast.

A 53 year old lady presents with a creamy nipple discharge. On examination she has discharge originating from multiple ducts and associated nipple inversion.

A 52 year old lady presents with an episode of nipple discharge. It is usually clear in nature. On examination the discharge is seen to originate from a single duct and although it appears clear, when the discharge is tested with a labstix it is shown to contain blood. Imaging and examination shows no obvious mass lesion.

Answer 36

Breast abscess

This lady is likely to be breast feeding and is at risk of mastitis. This may lead to an abscess if not treated. Staphylococcus aureus is usually the causative organism.

Duct ectasia

Duct ectasia is common during the period of breast involution that occurs during the menopausal period. As the ducts shorten they may contain insipiated material. The discharge will often discharge from several ducts.

Intraductal papilloma

Intraductal papilloma usually cause single duct discharge. The fluid is often clear, although it may be blood stained. If the fluid is tested with a labstix (little point in routine practice) then it will usually contain small amounts of blood. A microdocechtomy may be performed.

Question 37

Patients usually present with nipple discharge, which may be from single or multiple ducts (usually present age >50 years)

The discharge is often thick and green

Answer 37

Duct ectasia

Question 38

Present at younger age than duct ectasia

May present with features of inflammation, abscess or mammary duct fistula

Strongly associated with smoking

Usually treated with antibiotics, abscess will require drainage

Answer 38

Periductal mastitis

Question 39

Breast lesion

Usually presents with clear or blood stained discharge originating from a single duct

No increase in risk of malignancy

Answer 39

Intraductal papilloma

Question 40

Lactational mastitis is common

Infection is usually with Staphylococcus aureus

On examination there is usually a tender fluctuant mass

Treatment is with antibiotics and ultrasound guided aspiration

Overlying skin necrosis is an indication for surgical debridement, which may be complicated by the development of a subsequent mammary duct fistula.

Answer 40

Breast abscess

Question 41

Affects women later in child bearing period

Chronic breast or axillary sinus is present in up to 50% cases

Diagnosis is by biopsy culture and histology

Answer 41

Breast TB

Question 42

Theme: Skin disease

A.Squamous cell carcinoma

B.Bowens disease

C.Actinic keratosis

D.Basal cell carcinoma

E.Malignant melanoma

F.Keratoacanthoma

G.Apthous ulcer

H.Pyogenic granuloma

A 53 year old man presents with a nodule on his chin. He is concerned because it has grown extremely rapidly over the course of the preceding week. On examination he has a swollen, red, dome shaped lesion with a central defect that contains a keratinous type material.

A 68 year old farmer presents with a skin lesion on his forehead. It has been present for the past 6 months and has grown slightly in size during that time. On examination he has an ulcerated lesion with pearly white raised edges that measures 2cm in diameter.

A 34 year old gardener presents with a lesion affecting the dorsum of his right hand. It has been present for the past 10 days and occurred after he had been pruning rose bushes. On examination he has a raised ulcerated lesion which bleeds easily on contact.

Answer 42

Keratoacanthoma

Keratoacanthomas are characterised by a rapid growth phase. This may mimic amelanotic melanoma (although such rapid growth is rare even in these lesions). The keratin core is the clue as to the true nature of the lesion.

Basal cell carcinoma

The raised pearly edges in an ulcerated lesion at a sun exposed site makes BCC most likely.

Pyogenic granuloma

Trauma is a common precipitant of pyogenic granuloma and contact bleeding and ulceration are common.

Question 43

Relative proportions of nonmelanoma skin malginancy?

Answer 43

80% BCC

20% SCC

Question 44

Pattern of UV light exposure in SCC

Answer 44

Chronic long term exposure

Question 45

Pattern of UV light exposure for BCCs

Answer 45

Sporadic exposures with episodes of burning

Question 46

Risk factors for SCC in transplant patients

Answer 46

Increased risk with increased duration of immunosuppression, ethnic origin, and associated sunlight exposure.

Question 47

Aetiological agent in majority of transplant associated SCCs?

Answer 47

HPV

Question 48

What is an issue in transplant patients following SCC treatment?

Answer 48

Locoregional recurrence

Question 49

What is the risk of SCC in a patient with 7 actinic keratoses?

Answer 49

10% at 10 years.

Question 50

Rough erythematous skin papule with a white to yellow scale. Lesions clustered at site of chronic sun exposure

Answer 50

Actinic keratosis

Question 51

Bowens disease=

Answer 51

SCC in situ

Question 52

Full thickness atypia of dermal keratinocytes over a broad zone. Nuclear pleomorphism, apoptosis and abnormal mitoses are seen.

Answer 52

SCC in situ

Question 53

Erythematous keratotic papule or nodule on a background of sun expsoure.

Ulceration may occur and both exophytic and endophytic areas may be seen.

Regional lymphadenopathy may be present

Answer 53

Invasive SCC

Question 54

Downward proliferation of malignant cells and invasion of the BM

Poorly differentiated lesions may show perineural invasion and require immunohistochemistry with S100

Answer 54

Invasive SCC

Question 55

How to differentiate between invasive SCC and MM

Answer 55

Immunohistochemistry with S100 (melanomas stain strongly positive with this marker)

Question 56

What are the subtypes of BCC?

Answer 56

Nodular

Superficial

Morpheaform

Cystic

Basosquamous

Question 57

What is the commonest variant of BCC?

Answer 57

Nodular BCC

Question 58

Commonest variant (60%)
Raised translucent papule
Usually affect the face
Large nodular BCC’s are locally destructive

Answer 58

Nodular BCC

Question 59

BCC

Usually appears as superficial erythematous macule affecting the trunk
Younger age at presentation (mean 57)
May show areas of spontaneous regression
Horizontal growth pattern predominates
High recurrence rate (due to sub clinical lateral spread)

Answer 59

Superficial BCC

Question 60

BCC

Macroscopically resembles flat, slightly atrophic lesion or plaque without well defined borders
Tumour has sub clinical lateral spread which increases recurrence rates

Answer 60

Morpheaform BCC

Question 61

BCC

Often have clear or blue - grey appearance
Cystic degeneration may not be clinically obvious and tumour may resemble nodular BCC

Answer 61

Cystic BCC

Question 62

Atypical BCC
Basaloid histological BCC features with eosinophillic squamoid features of SCC
Biologically more aggressive and are more locally destructive
Rare lesion accounts for 1% of all non melanoma skin cancers
Metastatic disease may occur in 9-10% of cases and resemble an SCC

Answer 62

Basosquamous carcinoma

Question 63

Dome shaped erythematous lesions that develop over a period of days and grow rapidly. They often contain a central pit of keratin. They then begin to necrose and slough off. They are generally benign lesions although some do view them as precursors of malignancy. They may be treated by curettage and cautery. If there is diagnostic doubt (they can mimic malignancy) then formal excision biopsy is warranted.

Answer 63

Keratoacanthoma

Question 64

These present as friable overgrowths of granulation at sites of minor trauma. They may be ulcerated and bleeding on contact is common. They may be treated with curretage and cautery, formal excision may be used if there is diagnostic doubt.

Answer 64

Pyogenic granuloma

Question 65

A 34 year old woman who has previously undergone a colectomy for familial adenomatous polyposis coli presents with a firm lesion at the inferior aspect of her rectus abdominis muscle. Which cell type is most typically associated with such tumours?

Myocytes

Proliferation of apocrine glands

Chondrocytes

Lipoblasts

Myofibroblasts

Answer 65

Desmoid tumours would be the most likely differential here and consist of a clonal proliferation of myofibroblasts

Question 66

Features of desmoid tumours?

Answer 66

Fibrous neoplasms arising from musculoaponeurotic structures, typically contain a clonal proliferation of myofibroblasts

Usually firm overgrowth with propensity to local infiltration

Question 67

What familial malignant condition is assoicated with desmoid tumours?

Answer 67

Desmoid tumours are seen in 15% of patients with FAP

Usually show biallelic APC mutations

Question 68

What is the most common demographic for desmoid tumours?

Answer 68

Women after childbirth in the rectus abdominis muscle.

Question 69

Management of desmoid tumours?

Answer 69

Radical surgical resection.

RTx and CTx may be considered in some patients.

Observation may be an option in selected cases of abdominal desmoids as some may spontaneously regress.

They have a high tendency to local recurrence

Question 70

A 23 year old is stabbed in the groin and develops hypovolaemic shock. What is the most likely finding on analysis of his urine?

Decreased specific gravity

Increased specific gravity

Increased urinary glucose

Increased urinary protein

Increased red blood cells in the urine

Answer 70

Hypovolaemic shock is likely to compromise renal blood flow especially if blood pressure falls below the range at which the kidney is able to autoregulate its blood flow. The result of this will be an increase of the specific gravity as water retention occurs in an attempt to maintain circulating volume.

Question 71

What are the features of substances that can be used to measure GFR?

Answer 71

Inert

Free filtration from the plasma at glomerulus (not protein bound)

Not absorbed or secreted at thetubules

Plasma concentration constant during urine collection

Question 72

Cerebral perfusion pressure=

Answer 72

MAP-intracranial pressure

Question 73

Mean arterial pressure=

Answer 73

Diastolic pressure + 1/3(systloic pressure-diastolic pressure)

Question 74

A healthy man has a blood pressure of 120/80 mmHg and an intra cranial pressure of 17 mmHg. What is the approximate cerebral perfusion pressure?

103 mmHg

63 mmHg

83 mmHg

91 mmHg

76 mmHg

Answer 74

Cerebral perfusion pressure= Mean arterial pressure - intra cranial pressure

The mean arterial pressure can be calculated as:
MAP= Diastolic pressure+ 0.333(Systolic pressure- Diastolic pressure)
In this situation the MAP = 93.
The ICP is subtracted from this value; 93 - 17 = 76

Question 75

Def: cerebral perfusion pressure

Answer 75

Net pressure gradient causing blood flow to the brain.

Tightly regulated to maximise cerebral perfusion.

Question 76

A 67 year old man is undergoing a transurethral resection of a bladder tumour using diathermy. Suddenly during the procedure the patient’s thigh begins to twitch. Stimulation of which of the following nerves is the most likely cause?

Femoral

Pudendal

Sciatic

Obturator

Gluteal

Answer 76

The obturator nerve is most closely related to the bladder

Question 77

Theme: Spinal disorders

A.Osteomyelitis

B.Potts disease of the spine

C.Scheuermanns disease

D.Transverse myelitis

E.Tabes dorsalis

F.Subacute degeneration of the cord

G.Brown-Sequard syndrome

H.Syringomyelia

I.Epidural haematoma

Which is the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.

A 68 year old man presents to the plastics team with severe burns to his hands. He is not distressed by the burns. He has bilateral charcot joints. On examination; there is loss of pain and temperature sensation of the upper limbs.

A 24 year old man presents with localised spinal pain over 2 months which is worsened on movement. He is known to be an IVDU. He has no history suggestive of tuberculosis. The pain is now excruciating at rest and not improving with analgesia. He has a temperature of 39 oC.

A 22 year man is shot in the back, in the lumbar region. He has increased tone and hyper-reflexia of his right leg. He cannot feel his left leg.

Answer 77

Syringomyelia

This patient has syringomyelia which selectively affects the spinotholamic tracts. Syringomyelia is a disorder in which a cystic cavity forms within the spinal cord. The commonest variant is the Arnold- Chiari malformation in which the cavity connects with a congenital malformation affecting the cerebellum. Acquired forms of the condition may occur as a result of previous meningitis, surgery or tumours. Many neurological manifestations have been reported, although the classical variety spares the dorsal columns and medial lemniscus and affecting only the spinothalamic tract with loss of pain and temperature sensation. The bilateral distribution of this patients symptoms would therefore favor syringomyelia over SCID or Brown Sequard syndrome. Osteomyelitis would tend to present with back pain and fever in addition to any neurological signs. Epidural haematoma large enough to produce neurological impairment will usually have motor symptoms in addition to any selective sensory loss, and the history is usually shorter.

Osteomyelitis

In an IVDU with back pain and pyrexia have a high suspicion for osteomylelitis. The most likely organism is staph aureus and the cervical spine is the most common region affected. TB tends to affect the thoracic spine and in other causes of osteomyelitis the lumbar spine is affected.

Brown-Sequard syndrome

Brown -Sequard syndrome is caused by hemisection of the spinal cord. It may result from stab injuries or lateral vertebral fractures. It results in ipsilateral paralysis (pyramidal tract) , and also loss of proprioception and fine discrimination (dorsal columns). Pain and temperature sensation are lost on the contra-lateral side. This is because the fibres of the spinothalamic tract have decussated below the level of the cord transection.

Question 78

Flaccid paralysis of the upper limbs

Answer 78

Central cord lesion

Question 79

Dorsal column signs (loss of proprioception and fine discrimination)

Answer 79

Infarction spinal cord

Question 80

C2 to C4

Answer 80

The C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle. C4 covers the area just below the clavicle.

Question 81

C5 to T1

Answer 81

Situated in the arms. C5 covers the lateral arm at and above the elbow. C6 covers the forearm and the radial (thumb) side of the hand. C7 is the middle finger, C8 is the medial aspect of the hand, and T1 covers the medial side of the forearm.

Question 82

T2 to T12

Answer 82

The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is situated at the umbilicus. T12 ends just above the hip girdle.

Question 83

L1 to L5

Answer 83

The cutaneous dermatome representing the hip girdle and groin area is innervated by L1 spinal cord. L2 and 3 cover the front part of the thighs. L4 and L5 cover medial and lateral aspects of the lower leg.

Question 84

S1 to S5

Answer 84

S1 covers the heel and the middle back of the leg. S2 covers the back of the thighs. S3 cover the medial side of the buttocks and S4-5 covers the perineal region. S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.

Question 85

Myotomes

C5

Answer 85

Elbow flexors/biceps

Question 86

Myotomes

C6

Answer 86

Wrist extensors

Question 87

Myotomes

Elbow extensors/triceps

Answer 87

C7

Question 88

Myotomes

Long finger flexors

Answer 88

C8

Question 89

Myotomes

Small finger abductors

Answer 89

T1

Question 90

Myotomes

Hip flexors

Answer 90

L1 and L2

Question 91

Myotomes

Knee extensors

Answer 91

L3

Question 92

Myotomes

Ankle dorsiflexors

Answer 92

L4 and 5

Question 93

Myotomes

Toe extensors

Answer 93

L5

Question 94

Myotomes

Ankle plantar flexors

Answer 94

S1

Question 95

There is decreased secretion of which one of the following hormones in response to major surgery:

Insulin

Cortisol

Renin

Anti diuretic hormone

Prolactin

Answer 95

Endocrine parameters reduced in stress response:

Insulin

Testosterone

Oestrogen

Insulin is often released in decreased quantities following surgery.

Question 96

What hormones are increased by the stress response?

Answer 96

GH

Cortisol

Renin

ACTH

Aldosterone

Prolactin

ADH

Glucagon

Question 97

What hormones are decreased by the stress response

Answer 97

Insulin

Testosterone

Oestrogen

Question 98

What hormones show no change in stress response

Answer 98

TSH

LH

FSH

Question 99

How does perioperative increased prolactin occur?

Answer 99

Release of inhibitory control

Question 100

How is the reduced insulin release after surgery mediated?

Answer 100

Inhibition of beta cells in the pancreas by the alpha2-adrenergic inhibitor effects of catecholamines.

Insulin resistance by target cells occurs later.

The perioperative state is characterised by a state of functional insulin deficiency

Question 101

Metabolic effects of endocrine response to surgery:

Carbohydrate metabolism

Answer 101

Hyperglycaemia is main feature- increased glucose production and reduced utilisation

Catecholamines and cortisol promote glycogenolysis and gluconeogenesis.

Initial failure of insulin secretion followed by insulin resistance affects the normal responses.

Degree of hyperglycaemia is proportional to the severity of the surgery.

Hyperglycaemia impairs wound healing and increases infection rates

Question 102

Metabolic effects of endocrine response to surgery:

Protein metabolism

Answer 102

Initially there is inhibition of protein anabolism followed later by enhanced catabolism

Mainly skeletal muscle protein is affected.

Amino acids released from acute phase proteins and are used for gluconeogenesis.

Nutritional support has little effect on preventing catabolism

Question 103

Metabolic effects of endocrine response to surgery:

Lipid metabolism

Answer 103

Increased catecholamine, cortisol and glucagon secretion and insulin deficiency promotes lipolysis and ketone body production

Question 104

Metabolic effects of endocrine response to surgery:

Salt and water metabolism

Answer 104

ADH causes water retention, concentrated urine and K loss

Renin causes sodium and water retention

Question 105

What is the main cytokine associated with surgery?

Answer 105

Il-6

Peaks 12-24h post surgery and increase by the degree of tissue damage

Question 106

How can the hormonal response to surgery be modified?

Answer 106

Opioids suppress hypothalamic and pituitary hormone secretion.

At high doses the response can be abolished, though this may prolong recovery and increase the need for post-operative ventilatory support.

Spinal anaesthesia can reduce the glucose, ACTH, cortisol, GH and epinephrine changes.

Cytokine release is reduced in less invasive surgery.

Nutrition prevents the adverse effects of the stress response- enteral feeding enhances recovery.

Growth hormone and anabolic steroids may improve outcome.

Normothermia decreases the metabolic response

Question 107

A patient presents with superior vena caval obstruction. How many collateral circulations exist as alternative pathways of venous return?

None

One

Two

Three

Four

Answer 107

There are 4 collateral venous systems:

Azygos venous system

Internal mammary venous pathway

Long thoracic venous system with connections to the femoral and vertebral veins (2 pathways)

Despite this, venous hypertension still occurs.

Question 108

What does the SVC drain?

Answer 108

Head and neck

Upper limbs

Thorax

Part of abdominal walls

Question 109

Formation of the SVC

Answer 109

Subclavian and IJV unite to form the right and left brachiocephalic veins

These unite to form the SVC

Azygos vein joins the SVC before it enters the right atrium

Question 110

Anterior relations of the SVC

Answer 110

Anterior margins of the right lung and pleura

Question 111

Posteromedial relations of the SVC

Answer 111

Trachea and right vagus nerve

Question 112

Posterolateral relations of the SVC

Answer 112

Posterior aspects of right lung and pleura

Pulmonary hilum is posterior

Question 113

Right lateral relations of the SVC

Answer 113

Right phrenic nerve and pleura

Question 114

Left lateral relations of the SVC

Answer 114

Brachiocephalic artery and ascending aorta

Question 115

What are some recognised developmental variations in the SVC

Answer 115

Persistent left sided SVC draining into the RA via an enlarged orifice of the coronary sinus.

More rarely, left sided vena cava may connect directly with superior aspect of left atrium, usually associated with an un-roofing of the coronary sinus

Question 116

What is the commonest developmental lesion for the IVC?

Answer 116

Abdominal course interruption with drainage achieved via the azygos venous system

May occur in patients with left sided atrial isomerism

Question 117

Left sided atrial isomerism

Answer 117

Heterotaxy syndrome or situs ambiguus (also commonly, but etymologically less correctly, spelled situs ambiguous) is a disturbance in the usual left and right distribution of the thoracic and abdominal organs which does not entirely correspond to the complete or partial mirror image.

It occurs from an early embryological developmental disturbance with most cases being sporadic. It is also classified under the group of cardiosplenic syndromes.

Question 118

An 18 year old man is cutting some plants when a small piece of vegetable matter enters his eye. His eye becomes watery. Which of the following is responsible for relaying parasympathetic neuronal signals to the lacrimal apparatus?

Pterygopalatine ganglion

Otic ganglion

Submandibular ganglion

Ciliary ganglion

None of the above

Answer 118

The parasympathetic fibres to the lacrimal apparatus transit via the pterygopalatine ganglion.

Question 119

Components of the lacrimal gland?

Answer 119

Orbital part and palpebral part that are continuous posterolaterally around the concave lateral edge of levator palpebrae superioris muscle.

Ducts open into the superior fornix.

Those from the orbital part penetrate the aponeurosis of LPS to join those from the palpebral part.

Therefore excision of the palpebral part is functionally similar to excision of the entire gland

Question 120

Blood supply of the lacrimal gland

Answer 120

Lacrimal branch of the ophthalmic artery.

Venous drainage via the superior ophthalmic vein

Question 121

Innervation of the lacrimal gland

Answer 121

Secretomotor PNS fibres from the pterygopalatine ganglion which may reach the gland via the zygomatic or lacrimal branches of the maixllary nerve or pass directly to the gland

The preganglionic fibres travel to the ganglion in the greater petrosal nerve (branch of the facial nerve at the geniculate ganglion)

Question 122

Passage of the nasolacrimal duct

Answer 122

Descends from the lacrimal sac to open anteriorly in the inferior meatus of the nose

Question 123

Describe the lacrimation reflex

Answer 123

Conjunctival irritation

Sends signals via the ophthalmic nerve

Pass to the superior salivary centre.

Efferent signals pass via the greater petrosal nerve and the deep petrosal nerve which carries the post-ganglionic sympathetic fibres.

Parasympathetic fibes relay in the pterygopalatine ganglion. Sympathetic fibres do not synapse

Question 124

Which of the nerves listed below is directly responsible for the innervation of the lateral aspect of flexor digitorum profundus?

Ulnar nerve

Anterior interosseous nerve

Radial nerve

Median nerve

Posterior interosseous nerve

Answer 124

The anterior interosseous nerve is a branch of the median nerve and is responsible for innervation of the lateral aspect of the flexor digitorum profundus.

Question 125

Origin of:

FCR

Answer 125

Common flexor origin and surrounding fascia

Question 126

Origin of:

PL

Answer 126

Common flexor origin

Question 127

Origin of:

FCU

Answer 127

Small humeral head arises from the common flexor origin and adjacent fascia.

Ulnar head comes from medial border of olecranon and posterior border of ulna

Question 128

Origin of:

FDS

Answer 128

Long linear origin from common flexor tendon, adjacent fascia and septa and medial border off the coronoid process

Question 129

Origin of:

FDP

Answer 129

Upper two thirds of the medial and anterior surface of the ulnar, medial side of the olecranon, medial half of the interosseuous membrane

Question 130

Insertion of:

FCR

Answer 130

Front of bases of second and third metacarpals

Question 131

Insertion of:

PL

Answer 131

Apex of palmar aponeurosis

Question 132

Insertion of:

FCU

Answer 132

Pisiform and base of fifth metacarpal

Question 133

Insertion of:

FDS

Answer 133

Via tendons in the fibrous flexor sheath.

At the level of the metacarpophalangeal joint, each tendon splits into two. These bands pass distally to their insertions

Question 134

Insertion of:

FDP

Answer 134

Via tendons that lie deep to those of flexor digitorum superficials to insert into the distal phalanx

Question 135

Nerve supply:

FCR

Answer 135

Median

Question 136

Nerve supply:

Palmaris longus

Answer 136

Median

Question 137

Nerve supply:

FCU

Answer 137

Ulnar

Question 138

Nerve supply:

FDS

Answer 138

Median

Question 139

Nerve supply:

FDP

Answer 139

Medial part= ulnar

Lateral part= anterior interosseous nerve

Question 140

Action of:

FCR

Answer 140

Flexes and abducts the carpus, part flexes the elbow and part pronates the forearm

Question 141

Action of:

Palmaris longus

Answer 141

Wrist flexor

Question 142

Action of:

FCU

Answer 142

Flexes and adducts the carpus

Question 143

Action of:

FDS

Answer 143

Flexor of MCP and PIP joints

Question 144

Action of:

FDP

Answer 144

Flexes the DIP and the wrist

Question 145

A 45 year old lady is undergoing a Whipples procedure for carcinoma of the pancreatic head. The bile duct is transected. Which of the following vessels is mainly responsible for the blood supply to the bile duct remnant?

Cystic artery

Hepatic artery

Portal vein

Left gastric artery

None of the above

Answer 145

Do not confuse the blood supply of the bile duct with that of the cystic duct.

The bile duct has an axial blood supply which is derived from the hepatic artery and from retroduodenal branches of the gastroduodenal artery. Unlike the liver there is no contribution by the portal vein to the blood supply of the bile duct. Damage to the hepatic artery during a difficult cholecystectomy is a recognised cause of bile duct strictures. In this scenario the distal vessels have been removed as the patient is undergoing a resection.

Question 146

Nerve supply of the gallbladder

Answer 146

Sympathetic: mid thoracic spinal cord

PNS: anterior vagal trunk

Question 147

A 43 year old lady is undergoing a total thyroidectomy for an extremely large goitre. The surgeons decide that access may be improved by division of the infra hyoid strap muscles. At which of the following sites should they be divided?

In their upper half

In their lower half

In the middle

At their origin from the hyoid

At the point of their insertion

Answer 147

Should the strap muscles require division during surgery they should be divided in their upper half. This is because their nerve supply from the ansa cervicalis enters in their lower half.

Question 148

Boundaries of the anterior triangle of the neck

Answer 148

Anterior border of sternocleidomastoid

Lower border of mandible

Anterior midline

Question 149

What are the subtriangles of the anterior triangle of the neck

Answer 149

Muscular triangle: neck strap muscles

Carotid triangle: carotid sheath

Submandibular triangle: digastric

Question 150

What divides the anterior triangle of the neck into its sub triangles?

Answer 150

Digastric above

Omohyoid below

Question 151

Answer 151

Question 152

Nerve supply to anterior of digastric muscle?

Answer 152

Mylohyoid which is a branch of the mandibular branch of the trigeminal

Question 153

Nerve supply to posterior digastric?

Answer 153

Facial nerve

Question 154

What are the six possible positions of the appendix?

Answer 154

Retrocaecal 74%

Pelvic 21%

Postileal

Subcaecal

Paracaecal

Preileal

Question 155

A 34 year old man undergoes a sub total colectomy to treat fulminant ulcerative colitis. What type of stoma is most likely to be fashioned?

End colostomy

Loop colostomy

End ileostomy

Loop ileostomy

End jejunostomy

Answer 155

A sub total colectomy involves the removal of the entire right, transverse, left and part of the sigmoid colon. The rectal stump is closed and an end ileostomy fashioned in the right iliac fossa.

Question 156

A 22 year old women has recently undergone a surgical excision of the submandibular gland. She presents to the follow up clinic with a complaint of tongue weakness on the ipsilateral side to her surgery. Which nerve has been damaged?

Hypoglossal nerve

Lingual nerve

Inferior alveolar nerve

Facial nerve

Lesser petrosal nerve

Answer 156

Three cranial nerves may be injured during submandibular gland excision.

Marginal mandibular branch of the facial nerve

Lingual nerve

Hypoglossal nerve

Hypoglossal nerve damage may result in paralysis of the ipsilateral aspect of the tongue. The nerve itself lies deep to the capsule surrounding the gland and should not be injured during an intracapsular dissection. The lingual nerve is probably at greater risk of injury. However, the effects of lingual nerve injury are sensory rather than motor.

Question 157

What three cranial nerves may be injured during submandibular gland excision?

Answer 157

Marginal mandibular branch of the facial nerve

Lingual nerve

Hypoglossal nerve

Question 158

Superficial relations of the submandibular gland?

Answer 158

Platysma, deep fascia and mandible

Submandibular lymph nodes

Facial vein (facial artery near mandible)

Marginal mandibular nerve

Cervical branch of facial nerve

Question 159

Deep relations of the submandibular gland

Answer 159

Facial artery (inferior to mandible)

Mylohyoid

Submandibular duct

Hyoglossus

Lingual nerve

Submandibular ganlgion

Hypoglossal nerve

Question 160

What is the submandibular duct?

Answer 160

Wharton’s duct, opens lateral to the lingual frenulum on the anterior floor of mouth

Question 161

Relation of the lingual nerve to Wharton’s duct

Answer 161

Lingual nerve wraps around Wharton’s duct.

As the duct passes forwards it crosses medial to the nerve to lie above it and then crosses back, lateral to it, to reach a position just below the nerve

Question 162

Innervation of the submandibular gland

Answer 162

SNS: superior cervical ganglion

PNS: submandibular ganlion via lingual nerve

Question 163

Arterial supply of the submandibular gland

Answer 163

Branch of the facial artery- passes through the gland to groove its deep surface. Emerges onto the face by passing between the gland and the mandible

Question 164

Venous drainage of the submandibular gland

Answer 164

Anterior facial vein (lies deep to the marginal mandibular nerve)

Question 165

Lymphatic drainage of the submandibular gland

Answer 165

Deep cervical and jugular chains of nodes

Question 166

Where can the femoral artery be accessed to gain the sample?

Mid point of the inguinal ligament

Mid inguinal point

2cm inferomedially to the pubic tubercle

2cm superomedially to the pubic tubercle

3cm inferolaterally to the deep inguinal ring

Answer 166

The mid inguinal point is midway between the anterior superior iliac spine and the symphysis pubis

The mid inguinal point in the surface marking for the femoral artery.

Question 167

Superior border of the femoral triangle

Answer 167

Inguinal ligament

Question 168

Lateral border of the femoral triangle

Answer 168

Sartorius

Question 169

Medial border of the femoral triangle

Answer 169

Adductor longus

Question 170

Floor of the femoral triangle

Answer 170

Iliopsoas, adductor longus and pectineus

Question 171

Roof of the femoral triangle

Answer 171

Fascia lata and superficial fascia

Superficial inguinal LNs

Long saphenous veins

Question 172

Contents of the femoral triangle medial to lateral

Answer 172

Vein

Artery

Femoral nerve

Lateral cutaneous nerve

Great saphenous vein

Femoral branch of the genitofemoral nerve

Question 173

Theme: Appendicitis

A.Colonoscopy

B.MRI Abdomen

C.Appendicectomy

D.Abdominal CT scan

E.Barium enema

F.Exploratory laparotomy

G.Conservative management with intravenous antibiotics

H.Re-assure and discharge

I.Abdominal ultrasound scan

A 24 year old man presents with a 10 day history of right sided abdominal pain. Prior to this he was well. On examination he has a low grade fever and a mass palpable in the right iliac fossa. The rest of his abdomen is soft. An abdominal USS demonstrates matted bowel loops surrounding a thickened appendix.

A 22 year old man presents with a 48 hour history of right iliac fossa pain. On examination he has a low grade pyrexia and is tender with voluntary guarding in the right iliac fossa. His blood tests reveal a WCC of 13 and a CRP of 6. A urine dipstick is positive for leucocytes.

A 63 year old man presents with a 48 hour history of right iliac fossa pain. On examination he has a low grade pyrexia and is tender with some voluntary guarding in the right iliac fossa. Some of his blood tests are reproduced below:

Hb8.1

WCC13.8

Platelets438

Albumin22

CRP24

Answer 173

Conservative management with intravenous antibiotics

This man is likely to have an appendix mass. There is no history suggestive of inflammatory bowel disease. These are usually managed without surgery, especially in the absence of peritoneal signs. Broad spectrum antibiotics are required. In the past an interval appendicectomy was performed. This is rare now and in most cases the process resolves with fibrosis of the appendix.

Appendicectomy

This is a typical history for acute appendicitis and in a young male, few differentials would be compatible with this history and signs. Whilst inflammatory markers may be raised this is by no means universal. Further imaging will delay treatment and is unlikely to alter the eventual surgical outcome.

Abdominal CT scan

This man’s investigations point to a more longstanding disease process (Hb and albumin), right sided colonic cancer being the most likely. For this reason a CT scan is a sensible option as it will adjust the surgical planning.

Question 174

DRE in appendicitis

Answer 174

Digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even tenderness with a pelvic appendix.

Question 175

Urinalysis in appendicitis?

Answer 175

Mild leucocytosis but no nitrites

Question 176

Theme: Parotid gland disease

A.Pleomorphic adenoma

B.Adenoid cystic carcinoma

C.Sarcoid

D.Sjogrens syndrome

E.Sialolithiasis

F.Wharthins tumour

Please select the most likely explanation for the following patients with parotid gland symptoms. Each option may be used once, more than once or not at all.

A 50 year old female presents with bilateral parotid gland swelling and symptoms of a dry mouth. On examination she has bilateral facial nerve palsies. This improved following steroid treatment.

A 50 year old women presents with a diffuse swelling in the region of her right parotid together with facial pain. On examination she has a right sided facial nerve palsy.

A 50 year old lady presents with symptoms of a dry mouth that has been present for the past few months. She also has a sensation of grittiness in her eyes. On examination she has a diffuse swelling of her parotid gland. There is no evidence of facial nerve palsy.

Answer 176

Sarcoid

Sarcoid occurs bilaterally in 70% of cases and facial nerve involvement is recognised. Treatment is conservative in most cases although individuals with facial nerve palsy will usually receive steroids with good effect.

Adenoid cystic carcinoma

Adenoid cystic carcinoma commonly infiltrates the facial nerve and may cause neuropathy and facial pain.

Sjogrens syndrome

Most patients with Sjogrens present in the post menopausal years. Multi system involvement is common.

Question 177

Benign neoplasms of the salivary gland proportions

Answer 177

80% of salivary gland tumours occur in parotid and up to 80% of these are benign.

Question 178

Epidemiology of parotid gland neoplasms

Answer 178

With the exception of Warthin tumours, they are commoner in women than men.

Median age of developing a lesion is 5th decade of life

Question 179

Most common parotid neoplasm (80%)
Proliferation of epithelial and myoepithelial cells of the ducts and an increase in stromal components
Slow growing, lobular, and not well encapsulated
Recurrence rate of 1-5% with appropriate excision (parotidectomy)
Recurrence possibly secondary to capsular disruption during surgery
Malignant degeneration occurring in 2-10% of adenomas observed for long periods, with carcinoma ex-pleomorphic adenoma occurring most frequently as adenocarcinoma

Answer 179

Benign pleomorphic adenoma or benign mixed tumor

Question 180

What proportion of benign pleomorphic adenomas undergo malignant degeneration?

Answer 180

2-10%

Question 181

Second most common benign parotid tumor (5%)
Most common bilateral benign neoplasm of the parotid
Marked male as compared to female predominance
Occurs later in life (sixth and seventh decades)
Presents as a lymphocytic infiltrate and cystic epithelial proliferation
May represent heterotopic salivary gland epithelial tissue trapped within intraparotid lymph nodes
Incidence of bilaterality and multicentricity of 10%
Malignant transformation rare (almost unheard of)

Answer 181

Warthin tumor (papillary cystadenoma lymphoma or adenolymphoma)

Question 182

What is the most common bilateral parotid tumour?

Answer 182

Warthin tumour

Question 183

Account for less than 5% of parotid tumours
Slow growing
Consist of only one morphological cell type (hence term mono)
Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas

Answer 183

Monomorphic adenoma

Question 184

Should be considered in the differential of a parotid mass in a child
Accounts for 90% of parotid tumours in children less than 1 year of age
Hypervascular on imaging
Spontaneous regression may occur and malignant transformation is almost unheard of

Answer 184

Haemangioma

Question 185

30% of all parotid malignancies
Usually low potential for local invasiveness and metastasis (depends mainly on grade)

Answer 185

Mucoepidermoid carcinoma

Question 186

Parotid malignancy

Unpredictable growth pattern
Tendency for perineural spread
Nerve growth may display skip lesions resulting in incomplete excision
Distant metastasis more common (visceral rather than nodal spread)
5 year survival 35%

Answer 186

Adenoid cystic carcinoma

Question 187

What malignant salivary gland tumours has a tendency to perineural spread?

Answer 187

Adenoid cystic carcinoma

Question 188

Parotid malignancy

Often occuring in previously benign parotid lesion

Answer 188

Mixed tumours

Question 189

Parotid malignancy

Intermediate grade malignancy
May show perineural invasion
Low potential for distant metastasis
5 year survival 80%

Answer 189

Acinic cell carcinoma

Question 190

Develops from secretory portion of gland
Risk of regional nodal and distant metastasis
5 year survival depends upon stage at presentation, may be up to 75% with small lesions with no nodal involvement

Answer 190

Parotid adenocarcinoma

Question 191

Large rubbery lesion, may occur in association with Warthins tumours
Diagnosis should be based on regional nodal biopsy rather than parotid resection
Treatment is with chemotherapy (and radiotherapy)

Answer 191

Parotid lymphoma

Question 192

Diangostic evaluation of parotid masses

Answer 192

Plain XR to exclude calculi

Sialography to delineate ductal anatomy

FNAC in most cases

Superficial parotidectomy may be diagnostic or therapeutic.

Where malignancy is suspected, the primary approach should be definitive resection rather than excisional biopsy

Question 193

Treatment of parotid tumours

Answer 193

For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical parotidectomy is performed. The facial nerve is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement.

Question 194

Parotid manifestations of HIV infection

Answer 194

Lymphoepithelial cysts associated with HIV occur almost exclusively in the parotid

Typically presents as bilateral, multicystic, symmetrical swelling

Risk of malignant transformation is low and management usually conservative

Question 195

Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunctivitis sicca

90% of cases occur in females

Second most common connective tissue disorder

Bilateral, non tender enlargement of the gland is usual

Histologically, the usual findings are of a lymphocytic infiltrate in acinar units and epimyoepithelial islands surrounded by lymphoid stroma

Treatment is supportive

There is an increased risk of subsequent lymphoma

Answer 195

Sjogren syndrome

Question 196

Parotid involvement in sarcoidosis

Answer 196

Occurs in 6% of patients with sarcoid

Question 197

A 28 year old man undergoes an ileocaecal resection to treat terminal ileal Crohns disease. Post operatively he attends the clinic and complains of diarrhoea. His CRP is within normal limits and small bowel enteroclysis shows no focal changes. Which of the following interventions is most likely to be beneficial?

5 ASA drugs

Azathioprine

Pulsed methylprednisolone

Infliximab

Oral cholestyramine

Answer 197

Malabsorption of bile salts is a common cause of diarrhoea following ileal resection. A normal small bowel study and CRP effectively excludes active Crohns disease and therefore immunomodulator drugs are not appropriate.

Question 198

Physiogical function of the ileum

Answer 198

Absorption of B12 and bile salts

Neuroendocrine cells in the ileal wall may secrete hormones

Question 199

What are the risks following significant ileal resection

Answer 199

Bile salt malbsorption-> bile salt diarrhoea and increased risk of gallstones.

Lack of B12 may predispose to macrocytic anaemia

Question 200

A 2 day old baby is noted to have voiding difficulties and on closer inspection is noted to have hypospadias. Which of the following abnormalities is most commonly associated with the condition?

Cryptorchidism

Diaphragmatic hernia

Ventricular - septal defect

Bronchogenic cyst

Atrial septal defect

Answer 200

Hypospadias most commonly occurs as an isolated disorder. Associated urological abnormalities may be seen in up to 40% of infants, of these cryptorchidism is the most frequent (10%).

Question 201

A 62 year old man has previously undergone a left hemicolectomy for carcinoma of the descending colon. On follow up imaging he is found to have two deposits of metastatic disease located in the right lobe of his liver. What is the best treatment strategy?

Chemotherapy alone

Chemotherapy followed by surgical resection

Radiofrequency ablation

Chemoradiotherapy

Palliation

Answer 201

Liver metastasis from colorectal cancer are still potentially curable. Without resection, survival at 5 years is around 5%. With resection, this figure rises to around 20%. The best outcomes are seen where chemotherapy is given, followed by resection. Radiofrequency ablation is an option for those patients who lack the physiological reserve for surgery. However, there is longer term recurrence rates will all the non resectional strategies. There is no role for radiotherapy.

Question 202

Theme: Testicular disorders

A.Antibiotics

B.Aspiration

C.Testicular exploration after 6 hours

D.Testicular exploration within 6 hours

E.Orchidectomy via inguinal approach

F.Orchidectomy via scrotal approach

G.No treatment needed

H.Ligation of patent processus vaginalis via inguinal approach

I.Jaboulay procedure via scrotal approach

For each scenario please select the most appropriate management. Each option may be used once, more than once or not at all.

7.A parent brings her 4 year old child to the surgical clinic. She has noticed an intermittent swelling in the right scrotum that is worse in the evening. On examination he has a soft fluctuant swelling in the right scrotum that cannot be separated from the testis. It transilluminates when a pen torch is held against it.

A 20 year old complains of severe pain in the right scrotal area after jumping onto his moped. He has noticed discomfort intermittently in this area over the past few months. Clinically the testis is tender.

A 44 year old man is referred to the clinic because of an swelling and discomfort in the right scrotum. This is present most of the time and he is otherwise well with no urinary symptoms. On examination he has a soft, fluctuant swelling in the right scrotum that transilluminates easily. An ultrasound is performed that confirms that the underlying testicle is structurally normal.

Answer 202

Ligation of patent processus vaginalis via inguinal approach

In children, a hydrocele is most commonly due to a persistent processus vaginalis. The swelling is intermittent and in most cases that are diagnosed in infancy the hydrocele resolves. Cases that persist beyond two years of age are best managed surgically and the surgical approach is usually made via the inguinal canal where the patent processus is identified and ligated.

Testicular exploration within 6 hours

Testicular torsion: Severe pain which can be spontaneous or precipitated by minor trauma. The patient may have noticed pain previously. Surgical intervention is needed as soon as possible to prevent the risk of loss of the testis.

The correct answer is Jaboulay procedure via scrotal approach

Adult hydroceles are less commonly due to the persistence of embryonic remnants and therefore can be managed via a scrotal approach. Both the Lords and Jaboulay procedures are reasonable options.

Question 203

If inguinoscrotal swelling; cannot “get above it” on examination
Cough impulse may be present
May be reducible

Answer 203

Inguinal hernia

Question 204

Often discrete testicular nodule (may have associated hydrocele)
Symptoms of metastatic disease may be present
USS scrotum and serum AFP and β HCG required

Answer 204

Testicular tumours

Question 205

Often history of dysuria and urethral discharge
Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be associated with underlying structural abnormality

Answer 205

Acute epididymo-orchitis

Question 206

Single or multiple cysts
May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to “get above the lump”

Answer 206

Epididymal cysts

Question 207

Non painful, soft fluctuant swelling
Often possible to “get above it” on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young men

Answer 207

Hydrocele

Question 208

Severe, sudden onset testicular pain
Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by elevation
Urgent surgery is indicated, the contra lateral testis should also be fixed

Answer 208

Testicular torsion

Question 209

Varicosities of the pampiniform plexus
Typically occur on left (because testicular vein drains into renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles may affect fertility

Answer 209

Varicocele

Question 210

Differential management of hydroceles in adults vs children

Answer 210

Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

Question 211

A 67 year old man undergoes a carotid endarterectomy and seems to recover well following surgery. When he is reviewed on the ward post operatively he complains that his voice is hoarse. What is the most likely cause?

Damage to the accessory nerve

Damage to the cervical plexus

Damage to the glossopharyngeal nerve

Damage to the hypoglossal nerve

Damage to the vagus

Answer 211

Many of these nerves are at risk of injury during carotid surgery. However, only damage to the vagus would account for a hoarse voice.

Question 212

Functions of the vagus nerve

Answer 212

Mixed: supplies structures from fourth and sixth pharyngeal arches, also the fore and midgut sections of the embryonic gut tube.

Carries afferent fibres from these areas

Efferent fibres are of two main types:

first are preganglionic parasympathetic fibres distributed to the parasympathetic ganglia that innervate smooth muscle of the innervated organ.

Second have direct skeletal muscle innervation and are largely to the muscles of the larynx and pharynx

Question 213

Superior ganlgion of the vagus nerve

Answer 213

Located in jugular foramen

Communicates with the superior cervical sympathetic ganglion, accesory nerve.

Two branches: meningeal and auricular (the latter may give rise to vagal stimulation following instrumentation of the external auditory meatus)

Question 214

Inferior ganglion of the vagus nerve

Answer 214

Communicates with superior cervical sympathetic chain, hypoglossal nerve and loop between first and second cervical ventral rami.

Two branches: pharyngeal (supplies pharyngeal muscles) and superior laryngeal nerve

Question 215

What are the branches of the vagus in the neck

Answer 215

Superior and inferior cervical cardiac branches

Right recurrent laryngeal nerve

Question 216

Superior and inferior cervical cardiac branches

Answer 216

Arise at various points and descend into thorax.

On the right these pass posterior to the subclavian

On the left, the superior branch passes between the arch of the aorta and the trachea to connect with the deep cardiac plexus.

Inferior branch descends with the vagus itself

Question 217

Right recurrent laryngeal nerve

Answer 217

Arises from vagus anterior to the first part of the subclavian artery, hooks under it and ascends superomedially.

Passes close to the common carotid and finally the inferior thyroid to insert into the larynx

Question 218

Branches of the vagus in the thorax?

Answer 218

Left RLN

Thoracic and cardiac branches

Question 219

Left RLN

Answer 219

Arises from vagus on the aortic arch, hooks around the inferior surface posterior to the ligamentum arteriosum and passes through the superior mediastinum and lower part of the neck.

Lies in the groove between the oesophagus and the trachea and passses with inferior thyroid artery to insert into larynx

Question 220

Thoracic and cardiac vagus nerve branches

Answer 220

Extensive branches to the heart and lung roots.

Pass through both of these viscera before reuniting prior to passing into the abdomen

Question 221

A 25 year old man has an inguinal hernia, which of the following structures must be divided (at open surgery) to gain access to the inguinal canal?

Transversalis fascia

External oblique aponeurosis

Conjoint tendon

Rectus abdominis

Inferior epigastric artery

Answer 221

This question is asking what structure forms the anterior wall of the inguinal canal. The anterior wall is formed by the external oblique aponeurosis. Once this is divided the canal is entered, the cord can be mobilised and a hernia repair performed. The transversalis fascia and conjoint tendons form the posterior wall and would not routinely be divided to gain access to the inguinal canal itself.

Question 222

Which muscle initiates abduction of the shoulder?

Infraspinatus

Latissimus dorsi

Supraspinatus

Deltoid

Teres major

Answer 222

The intermediate portion of the deltoid muscle is the chief abductor of the humerus. However, it can only do this after the movement has been initiated by supraspinatus. Damage to the tendon of supraspinatus is a common form of rotator cuff disease.

Question 223

In matching donated kidneys to the most appropriate recipient, apart from ABO matching, which of the following is most important?

HLA DR

Rhesus

HLA A

HLA B

Duffy antigen

Answer 223

HLA DR

Question 224

What are the relative importance of the HLA antigens when matching for a renal transplant?

Answer 224

DR > B > A

Question 225

Post-op problems with renal transplant

Answer 225

ATN of graft

Vascular thrombosis

Urine leakage

UTI

Question 226

Due to antibodies against donor HLA type 1 antigens

Rarely seen due to HLA matching

Answer 226

Hyperacute rejection

Question 227

Usually due to mismatched HLA

Other causes include cytomegalovirus infection

Management: give steroids, if resistant use monoclonal antibodies

Answer 227

Acute graft failure (< 6 months)

Question 228

Causes of chronic graft failure (>6m)

Answer 228

Chronic allograft nephropathy

Ureteric obstruction

Recurrence of original renal disease (MCGN > IgA > FSGS)

Question 229

A 34 year old man is shot in the postero- inferior aspect of his thigh. Which of the following lies at the most lateral aspect of the popliteal fossa?

Popliteal artery

Popliteal vein

Common peroneal nerve

Tibial nerve

Small saphenous vein

Answer 229

The contents of the popliteal fossa are (from medial to lateral):
Popliteal artery
Popliteal vein
Tibial nerve
Common peroneal nerve

The sural nerve is a branch of the tibial nerve and usually arises at the inferior aspect of the popliteal fossa. However, its anatomy is variable.

Question 230

Contents of the popliteal fossa from medial to lateral

Answer 230

Artery, vein, tibial nerve, common peroneal nerve

Question 231

Lateral boundary of popliteal fossa

Answer 231

Biceps femoris above

Lateral head of gastrocnemius and plantaris below

Question 232

Medial boundary of popliteal fossa

Answer 232

Semimembranosus, semitendonosus above

Medial head of gastrocnemius below

Question 233

Floor of popliteal fossa

Answer 233

Popliteal surface of the femur, posterior ligament of knee joint and popliteus muscle

Question 234

Roof of popliteal fossa

Answer 234

Superficial and deep fascia

Question 235

Contents of the popliteal fossa

Answer 235

Popliteal artery and vein

Small saphenous vein

Common peroneal nerve

Tibial nerve

Posterior cutaneous nerve of the thigh

Genicular branch of the obturator nerve

Lymph nodes

Question 236

A 67 year old man has an abdominal aortic aneurysm which displaces the left renal vein. Which branch of the aorta is most likely to affected at this level?

Inferior mesenteric artery

Superior mesenteric artery

Coeliac axis

Testicular artery

None of the above

Answer 236

The left renal vein lies behind of the SMA as it branches off the aorta. Whilst juxtarenal AAA may sometimes require the division of the left renal vein, direct involvement of the SMA may require a hybrid surgical bypass and subsequent endovascular occlusion.

Question 237

Inferior phrenic arteries

Level, Paired? Type

Answer 237

T12 (upper border)

Paired

Parietal

Question 238

Coeliac

Level?

Paired?

Type?

Answer 238

T12

No

Visceral

Question 239

SMA

Level?

Paired?

Type?

Answer 239

L1

No

Visceral

Question 240

Middle suprarenal

Level?

Paired?

Type?

Answer 240

L1

Yes

Visceral

Question 241

Renal artery

Level?

Paired?

Type?

Answer 241

L1-L2

Paired

Visceral

Question 242

Gonadal arteries

Level?

Paired?

Type?

Answer 242

L2

Paired

Visceral

Question 243

Lumbar arteries

Level?

Paired?

Type?

Answer 243

L1-L4

Paired

Parietal

Question 244

IMA

Level?

Paired?

Type?

Answer 244

L3

Unpaired

Visceral

Question 245

Median sacral artery

Level?

Paired?

Type?

Answer 245

L4

Unpaired

Parietal

Question 246

Common iliac artery

Level?

Paired?

Type?

Answer 246

L4

Paired

Terminal

Question 247

Which of the following statements related to the coagulation cascade is true?

The intrinsic pathway is the main pathway in coagulation

Heparin inhibits the activation of Factor 8

The activation of factor 8 is the point when the intrinsic and the extrinsic pathways meet

Tissue factor released by damaged tissue initiates the extrinsic pathway

Thrombin converts plasminogen to plasmin

Answer 247

The extrinsic pathway is the main path of coagulation. Heparin inhibits the activation of factors 2,9,10,11. The activation of factor 10 is when both pathways meet. Thrombin converts fibrinogen to fibrin. During fibrinolysis plasminogen is converted to plasmin to break down fibrin

Question 248

Features of the intrinsic coagulation cascade?

Answer 248

Components already present in blood

Minor role in clotting

Subendothelial damage e.g. collagen.

Formation of primary complex on collagen by high-moelcular-weight kininogen (HMWK), prekallikrein and factor 12

Prekallikrein is converted to kallikrein and factor 12 becomes activated.

Factor 12 activates factor 11

Factor 11 activates factor 9, which with its co-factor 8a forms the tensae complex-> factor 10

Question 249

Features of the extrinsic pathway?

Answer 249

Needs tissue factor released by damaged tissue

Factor 7 binds to tissue factor

This complex activates factor 9

Factor 9 works with factor 8 to activate factor 10

Question 250

Common pathway

Answer 250

Activated factor 10 causes the conversion of prothrombin to thrombin

Thrombin hydrolyses fibrinogen to form fibrin and also activates factor 8

Question 251

Factors in intrinsic pathway

Answer 251

Factors 8,9,11,12

Question 252

Factors involved in extrinsic pathway

Answer 252

TF, 7, 9, 8 -> 10

Question 253

Factors involved in common pathway

Answer 253

2, 5, 10

Question 254

Vitamin K dependent factors

Answer 254

2, 7, 9, 10

Question 255

Increased APTT what pathway?

Answer 255

Intrinsic

Question 256

Increased PT what pathway

Answer 256

Extrinsic pathway

Question 257

A 53 year old man presents with a mass lesion slightly inferior to the tragus of his right ear. An FNA and USS are performed and a 2cm pleomorphic adenoma is diagnosed. What is the most appropriate course of action?

USS guided core biopsy

Radical parotidectomy

Superficial parotidectomy

Discharge

MRI scanning of the region

Answer 257

Pleomorphic adenoma of the parotid= surgical excision

Pleomorphic adenomas a usually benign tumours. However, they will enlarge over time and a proportion can undergo malignant transformation. Therefore, all pleomorphic adenomas are excised and a superficial parotidectomy is generally the procedure of choice. The facial nerve is preserved. More recently, there has been a move towards partial superficial parotidectomy. However, complete resection of the lesion is still madatory.

Question 258

Which of the following is not directly affected by warfarin?

Protein C

Factor II

Factor VII

Factor IX

Factor VIII

Answer 258

Warfarin affects synthesis of factors II, VII, IX, X and protein C.

Question 259

Action of Warfarin

Answer 259

Warfarin is an oral anticoagulant which inhibits the reduction of vitamin K to its active hydroquinone form, which in turn acts as a cofactor in the formation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C

Question 260

Mechanism of warfarin causing skin necrosis

Answer 260

Skin necrosis: when warfarin is first started biosynthesis of protein C is reduced. This results in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administration. Thrombosis may occur in venules leading to skin necrosis.

Question 261

A 12 year old boy undergoes surgery for recurrent mastoid infections. Post operatively he complains of an altered taste sensation. Which of the following nerves has been injured?

Glossopharyngeal

Greater petrosal

Olfactory

Trigeminal

Chorda tympani

Answer 261

The chorda tympani branch of the facial nerve passes forwards through itrs canaliculus into the middle ear, and crosses the medial aspect of the tympanic membrane. It then passes antero-inferiorly in the infratemporal fossa. It distributes taste fibres to the anterior two thirds of the tongue.

Question 262

Supply of the facial nerve

Face, ear, taste, tear

Answer 262

Face: muscles of facial expression

Ear: nerve to stapedius

Taste: anterior 2/3rds of tongue

Tear: parasympathetic fibres to lacrimal glands also salivary glands

Question 263

Subarachnoid path of the facial nerve

Answer 263

Motor: pons, sensory: nervus intermedius

Pass through petrous temporal bone to the internal auditory meatus with the vestibulocochlear nerve-> facial nerve

Question 264

Facial canal path of facial nerve

Answer 264

Superior to the vestibule of the innerear

At the medial aspect of the middle ear it becomes wider and contains the geniculate ganglion: 3 branches

greater petrosal nerve (at level of the geniculate ganlgion)

nerve to stapedius

chorda tympani

Question 265

3 branches of the facial nerve at the geniculate ganglion

Answer 265

Greater petrosal

Nerve to stapedius

Chorda tympani

Question 266

Passage of the facial nerve through stylomastoid foramen

Answer 266

Passes through foramen (tympanic cavity anterior, mastoid antrum posteriorly)

Posterior auricular nerve and branch to posterior belly of digastric and stylohyoid muscle

Question 267

A 45 year old man undergoes an upper gastrointestinal endoscopy for a benign oesophageal stricture. This is dilated and he suffers an iatrogenic perforation at the site. His imaging shows a small contained leak and a small amount of surgical emphysema. What is the most appropriate nutritional option?

Nil by mouth and intravenous fluids alone

Intravenous fluids and sips orally

Total parenteral nutrition

Nasogastric feeding

PEG tube feeding

Answer 267

Iatrogenic perforations of the oesophagus may be managed non operatively. This usually involves a nil by mouth regime, tube thoracostomy may be needed. Total parenteral nutrition is the safest option. Insertion of NG feeding tubes and PEG tubes may complicate the process or allow feed to enter the perforation site.

Question 268

Theme: Management of pancreatic malignancy

A.Gastrojejunostomy

B.Pancreatoduodenectomy

C.MRI guided pancreatic stent

D.Endoscopic pancreatic stent

E.Duodenoduodenostomy

F.Pancreatic radiotherapy

Please select the most appropriate treatment for these patients with pancreatic cancer. Each option may be used once, more than once or not at all.

A 40 year old lady presents with new onset dyspepsia. She is diagnosed as having a localised cacinoma of the pancreatic head.

A 67 year old lady presents with jaundice and abdominal pain. Her investigations show a dilated common bile duct, a carcinoma of the pancreatic head compressing the pancreatic duct. Her liver contains bi-lobar metastasis.

A 67 year old lady presents with symptoms of persistent vomiting. Her investigations show gastric outlet obstruction from a carcinoma of the pancreatic head. Her liver contains bi-lobar metastases.

Answer 268

Pancreatoduodenectomy

Localised carcinoma of the pancreas is treated with a pancreatoduodenectomy, the eponymous name for this is a Whipples procedure. Newer variants of the procedure include pylorus preservation. Adjuvent chemotherapy is often used.

Endoscopic pancreatic stent

Jaundice associated with pancreatic cancer is best managed with a stent. These are usually inserted at the time of ERCP. Consideration here should be given to the use of a metallic stent (which is contra indicated where resection is contemplated).

Gastrojejunostomy

Gastric outlet obstruction from pancreatic cancer is best managed with a surgical bypass procedure or a duodenal stent (if the disease is not resectable or curable).

Question 269

Pain due to pancreatic malignancy

Answer 269

Usually due to invasion of the coeliac plexus- late feature

Question 270

Origin of the brachial plexus

Answer 270

C5 to T1

Question 271

Sections of the brachial plexus

Remember to drink cold beer

Answer 271

Roots, trunks, divisions, cords, branches

Question 272

Where can the roots of the brachial plexus be found?

Answer 272

Posterior triangle of the neck

Pass between scalenus anterior and medius

Question 273

Where can the trunks of the brachial plexus be found?

Answer 273

Posterior to the middle third of the clavicle

Upper and middle trunks related superiorly to the subclavian artery

Lower trunk passes over 1st rib posterior to the subclavian artery

Question 274

Divisions of the brachial plexus

Answer 274

Apex of the axilla

Question 275

Cords of the brachial plexus

Answer 275

Related to axillary artery

Question 276

Theme: Management of jaundice

A.ERCP

B.MRCP

C.Percutaneous transhepatic cholangiogram

D.Laparotomy

E.Laparotomy and formation of hepatico-jejunostomy

F.Laparoscopic biliary bypass

G.CT scan

A 65 year old man is admitted with jaundice and investigations demonstrate a carcinoma of the pancreatic head. An ERCP is attempted but the surgeon is unable to cannulate the ampulla.

A 48 year old lady is admitted with attacks of biliary colic and investigations show gallstones. A laparoscopic cholecystectomy is performed. The operation is technically challenging due to a large stone impacted in Hartmans pouch. Following the operation she fails to settle and becomes jaundiced and has bile draining into a drain placed at the surgical site.

A 34 year old lady is admitted with jaundice and undergoes an ERCP. The procedure is technically difficult and she is returned to the ward still jaundiced. Unfortunately she now has severe generalised abdominal pain.

Answer 276

Percutaneous transhepatic cholangiogram

Cancer of the pancreatic head will cause obstructive jaundice and intrahepatic duct dilatation. When an ERCP has failed the most appropriate option is to attempt a PTC. This procedure is always preceded by an ultrasound (which presumably this patient has already had or they would not be undergoing an ERCP). Prior to performing the PTC it is important to stage the disease and establish resectability or not. This is because the PTC drains frequently dislodge and fall out. It is usually desirable to pass a stent at the time of doing the PTC to mitigate the effects of this problem.

ERCP

In this scenario it must be assumed that the bile duct has been damaged. In most cases an ERCP is the most appropriate investigation. This can also allow the passage of a stent if this is deemed to be safe and sensible.

CT scan

There are two main differential diagnoses here. One is pancreatitis, repeated trauma to the ampulla and duct (if partially cannulated) is a major risk factor for pancreatitis. The second is the possibility that the duodenum has been perforated. ERCP is performed using a side viewing endoscope, the manipulation of which can be technically challenging for the inexperienced operator in a patient with abnormal anatomy. A CT scan is the best investigation to distinguish between these two differential diagnoses.

Question 277

Normal or high bilirubin

Normal ALT/AST

Normal ALP

Answer 277

Pre-hepatic jaundice

Question 278

High bilirubin

Elevated ALT/AST

ALP elevated but seldom to high levels

Answer 278

Hepatic jaundice

Question 279

High bilirubin

Moderate AST/ALT elevation

Very high ALP

Answer 279

Post-hepatic jaundice

Question 280

What is the anatomical level of the transpyloric plane?

T11

T12

L1

L4

T10

Answer 280

Level of the body of L1

Pylorus stomach

Left kidney hilum (L1- left one!)

Right hilum of the kidney (1.5cm lower than the left)

Fundus of the gallbladder

Neck of pancreas

Duodenojejunal flexure

Superior mesenteric artery

Portal vein

Left and right colic flexure

Root of the transverse mesocolon

2nd part of the duodenum

Upper part of conus medullaris

Spleen

Question 281

When the brachial plexus is injured in the axilla as a result of a crutch palsy, which of the nerves listed is most commonly affected?

Thoracodorsal nerve

Suprascapular nerve

Radial nerve

Ulnar nerve

Long thoracic nerve

Answer 281

The radial nerve is most commonly injured and results in a wrist drop. The ulnar nerve arises from the medial cord and is rarely affected as a result of this injury mechanism.

Question 282

A 43 year old lady undergoes a live donor related renal transplant. Over the next few years it is noted that her renal function progressively deteriorates. What is the most likely underlying explanation?

Type I hypersensitivity reaction

Type III hypersensitivity reaction

Type II hypersensitivity reaction

Type IV hypersensitivity reaction

None of the above

Answer 282

Chronic rejection of renal transplants is mediated via T lymphocytes and is therefore a type IV hypersensitivity reaction. This process can be mitigated by immunosupression.

Question 283

Hyperacute organ rejection is due to?

Answer 283

ABO mismatch

Question 284

Cellular infiltrate in acute organ rejection

Answer 284

Mononuclear cell infiltrates.

May occur in up to 50% of cases

Question 285

Histological changes seen in chronic rejection

Answer 285

Vascular changes are most prominent with myointimal proliferation-> ischaemia

Organ specific changes are also seen e.g. loss of acinar cells in pancreas and rapidly progressive CAD in heart transplants

Question 286

Exclusion criteria for renal transplant

Answer 286

Active malignancy

Old age

Question 287

Theme: Liver lesions

A.Cystadenoma

B.Hydatid cyst

C.Amoebic abscess

D.Mesenchymal hamartoma

E.Liver cell adenoma

F.Cavernous haemangioma

Please select the most likely lesion for the scenario given. Each option may be used once, more than once or not at all.

A 38 year old lady presents with right upper quadrant pain and nausea. She is otherwise well and her only medical therapy is the oral contraceptive pill which she has taken for many years with no ill effects. Her liver function tests are normal. An ultrasound examination demonstrates a hyperechoic well defined lesion in the left lobe of the liver which measures 14 cm in diameter.

A 37 year old lady presents with right upper quadrant pain and nausea. She is otherwise well and her only medical therapy is the oral contraceptive pill which she has taken for many years with no ill effects. Her liver function tests and serum alpha feto protein are normal. An ultrasound examination demonstrates a 4cm non encapsulated lesion in the right lobe of the liver which has a mixed echoity and heterogeneous texture.

A 38 year old shepherd presents to the clinic with a 3 month history of malaise and right upper quadrant pain. On examination he is mildly jaundiced. His liver function tests demonstrate a mild elevation in bilirubin and transaminases, his full blood count shows an elevated eosinophil level. An abdominal x-ray is performed by the senior house officer and demonstrates a calcified lesion in the right upper quadrant of the abdomen.

Answer 287

The correct answer is Cavernous haemangioma

Cavernous haemangioma often presents with vague symptoms and signs. They may grow to considerable size. Liver function tests are usually normal. The lesions are typically well defined and hyperechoic on ultrasound. A causative link between OCP use and haemangiomata has yet to be established, but is possible.

Liver cell adenoma

Liver cell adenomas are linked to OCP use and 90% of patients with liver cell adenomas have used the OCP. Liver function tests are often normal. The lesions will typically have a mixed echoity and heterogeneous texture.

Hydatid cyst

Hyatid disease is more common in those who work with sheep or dogs. Liver function tests may be abnormal and an eosinophilia is often present. Plain radiographs may reveal a calcified cyst wall.

Question 288

Most common benign tumours of mesenchymal origin

Incidence in autopsy series is 8%

Cavernous haemangiomas may be enormous

Clinically they are reddish purple hypervascular lesions

Lesions are normally separated from normal liver by ring of fibrous tissue

On ultrasound they are typically hyperechoic

Answer 288

Haemangioma

Question 289

90% develop in women in their third to fifth decade

Linked to use of oral contraceptive pill

Lesions are usually solitary

They are usually sharply demarcated from normal liver although they usually lack a fibrous capsule

On ultrasound the appearances are of mixed echoity and heterogeneous texture. On CT most lesions are hypodense when imaged prior to administration of IV contrast agents

In patients with haemorrhage or symptoms removal of the adenoma may be required

Answer 289

Liver cell adenoma

Question 290

Congential and benign, usually present in infants. May compress normal liver

Answer 290

Mesenchymal hamartomas

Question 291

Biliary sepsis is a major predisposing factor

Structures drained by the portal venous system form the second largest source

Common symptoms include fever, right upper quadrant pain. Jaundice may be seen in 50%

Ultrasound will usually show a fluid filled cavity, hyperechoic walls may be seen in chronic abscesses

Answer 291

Liver abscess

Question 292

Liver abscess is the most common extra intestinal manifestation of amoebiasis

Between 75 and 90% lesions occur in the right lobe

Presenting complaints typically include fever and right upper quadrant pain

Ultrasonography will usually show a fluid filled structure with poorly defined boundaries

Aspiration yield sterile odourless fluid which has an anchovy paste consistency

Treatment is with metronidazole

Answer 292

Amoebic abscess

Question 293

Seen in cases of Echinococcus infection

Typically an intense fibrotic reaction occurs around sites of infection

The cyst has no epithelial lining

Cysts are commonly unilocular and may grow to 20cm in size. The cyst wall is thick and has an external laminated hilar membrane and an internal enucleated germinal layer

Typically presents with malaise and right upper quadrant pain. Secondary bacterial infection occurs in 10%.

Liver function tests are usually abnormal and eosinophilia is present in 33% cases

Ultrasound may show septa and hyatid sand or daughter cysts.

Percutaneous aspiration is contra indicated

Treatment is by sterilisation of the cyst with mebendazole and may be followed by surgical resection. Hypertonic swabs are packed around the cysts during surgery

Answer 293

Hyatid cysts

Question 294

Usually occurs in association with polycystic kidney disease

Autosomal dominant disorder

Symptoms may occur as a result of capsular stretch

Answer 294

Polycystic liver disease

Question 295

Rare lesions with malignant potential

Usually solitary multiloculated lesions

Liver function tests usually normal

Ultrasonography typically shows a large anechoic, fluid filled area with irregular margins. Internal echos may result from septa

Surgical resection is indicated in all cases

Answer 295

Cystadenoma

Question 296

A 35 year old man falls and sustains a fracture to the medial third of his clavicle. Which vessel is at greatest risk of injury?

Subclavian vein

Subclavian artery

External carotid artery

Internal carotid artery

Vertebral artery

Answer 296

The subclavian vein lies behind subclavius and the medial part of the clavicle. It rests on the first rib, below and in front of the third part of the subclavian artery, and then on scalenus anterior which separates it from the second part of the artery (posteriorly).

Question 297

Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.

Features

Raised intracranial pressure

Some patients may exhibit a lucid interval

Answer 297

Extradural haematoma

Question 298

Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. May be either acute or chronic.

Risk factors include old age and alcoholism.

Slower onset of symptoms than a extradural haematoma.

Answer 298

Subdural haematoma

Question 299

Usually occurs spontaneously in the context of a ruptured cerebral aneurysm, but may be seen in association with other injuries when a patient has sustained a traumatic brain injury.

Answer 299

Subarachnoid haemorrhage

Question 300

ICP monitoring in head injury

Answer 300

Appropriate in those with GCS 3-8 and normal CT scan

Mandatory in those with same GCS and abnromal CT scan.

Question 301

Unilaterally dilated pupil

Sluggish or fixed response to light

Context of brain injury

Answer 301

3rd nerve compression secondary to tentorial herniation

Question 302

Head injury

Bilaterally dilated pupils

Sluggish or fixed light response

Answer 302

Poor CNS perfusion

Bilateral 3rd nerve palsy

Question 303

Unilaterally dilated or equal pupil size

Cross reactive light response

Answer 303

Optic nerve injury

Question 304

Bilaterally constricted pupils

Answer 304

Opiates

Pontine lesions

Metabolic encephalopathy

Question 305

Unilaterally constricted pupil

Answer 305

Sympathetic pathway disruption

Question 306

Epidemiology of achondroplasia

Answer 306

Mutation in FGFR- sporadic (70%)

Advancing parental age is the main risk factor

Question 307

Radiological features of achondroplasia

Answer 307

Large skull with narrow foramen magnum

Short, flattened intervertebral bodies

Narrow spinal canal

Horizontal acetabular roof

Broad, short metacarpals

Question 308

The pudendal canal is a fascial canal located on the lateral wall of the ischioanal fossa. In this location, it lies on the inferior border of which of the following muscles?

Coccygeus

Obturator internus

Pubococcygeus

Iliococcygeus

Piriformis

Answer 308

Obturator internus

The coccygeus, pubococcygeus and iliococcygeus form part of the pelvic diaphragm and are not related to it. The piriformis exits the pelvis via the greater sciatic foramen and is not associated with the canal in the ischiorectal fossa.

The pudendal canal is located along the lateral wall of the ischioanal fossa at the inferior margin of the obturator internus muscle. It extends from the lesser sciatic foramen to the posterior margin of the urogenital diaphragm. It conveys the internal pudendal vessels and nerve.

Question 309

A 24 year old man is brought to the emergency department have suffered a crush injury to his forearm. Assessment demonstrates that the arm is tender, red and swollen. There is clinical evidence of an ulnar fracture and the patient cannot move their fingers. Which is the most appropriate course of action?

Application of an external fixation device

Closed reduction

Debridement

Discharge and review in fracture clinic

Fasciotomy

Answer 309

The combination of a crush injury, limb swelling and inability to move digits should raise suspicion of a compartment syndrome that will require a fasciotomy. Paralysis is a very late sign.

Question 310

Two main fractures carrying risk of compartment syndrome

Answer 310

Supracondylar fractures

Tibial shaft injuries

Question 311

Symptoms and signs of compartment syndrome

Answer 311

Pain, especially on movement (passive)

Parasthesiae

Pallor may be present

Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise

Paralysis

Question 312

Diagnosis of compartment syndrome

Answer 312

Measurement of intracompartmental pressure, >20 is abnormal, >40 is diagnostic

Question 313

Where are the greatest proportion of musculi pectinati found?

Right ventricle

Left ventricle

Right atrium

Pulmonary valve

Aortic valve

Answer 313

The musculi pectinati are found in the atria, hence the reason that the atrial walls in the right atrium are irregular anteriorly.
The musculi pectinati of the atria are internal muscular ridges on the anterolateral surface of the chambers and they are only present in the area derived from the embryological true atrium.

Question 314

Walls of the cardiac chamber

Answer 314

Epicardium

Myocardium

Endocardium

Question 315

Venous drainage of the heart

Answer 315

Coronary sinus lies in the posterior part of the coronary groove.

Great cardiac vein lies at its left and the middle and small cardiac veins lie on its right.

The anterior cardiac vein drains into the right atrium directly

Question 316

Structures supplied by the right coronary artery

Answer 316

Right atrium

Diaphragmatic part of the right ventricle

Posterior third of the interventricular septum

SAN in 60%
AVN in 80%

Question 317

Structures supplied by the LCA

Answer 317

Left atrium

Most of the left ventricle

Part of the right ventricle

Anterior two thirds of the interventricular septum

SAN in remaining 40% of cases

Question 318

Which of the nerves listed below provides sensory innervation to the skin overlying the lateral aspect of the nose?

Infratrochlear nerve

Zygomatic nerve

Nasopalatine nerve

Lateral nasal branches of the ethmoidal nerve

Frontal nerve

Answer 318

The lateral aspect of the external nose is innervated by lateral nasal branches of the anterior ethmoidal nerve. The ethmoidal nerve is a branch of the nasociliary nerve which is one of the divisions of the trigeminal.

Question 319

A 70 year old female is admitted with a history of passing brown coloured urine and abdominal distension. Clinically she has features of large bowel obstruction with central abdominal tenderness. She is maximally tender in the left iliac fossa. There is no evidence of haemodynamic instability. What is the most appropriate investigation?

Cystogram

Abdominal X-ray of the kidney, ureters and bladder

Computerised tomogram of the abdomen and pelvis

Flexible sigmoidoscopy

Barium enema

Answer 319

This lady is most likely to have a colovesical fistula complicating diverticular disease of the sigmoid colon. In addition she may also have developed a diverticular stricture resulting in large bowel obstruction. A locally advanced tumour of the sigmoid colon may produce a similar clinical picture. The best investigation of this acute surgical patient is an abdominal CT scan, this will demonstrate the site of the disease and also supply regional information such as organ involvement and other local complications such as a pericolic abscess. A barium enema would require formal bowel preparation and this is contra indicated where large bowel obstruction is suspected. A flexible sigmoidoscopy is unlikely to be helpful and the air insufflated at the time of endoscopy may make the colonic distension worse. A cystogram would provide only very limited information.

Question 320

What is used to classify the severity of diverticulitis?

Answer 320

Hinchey classification

I: paracolonic abscess

II: pelvic abscess

III: purulent peritonitis

IV: faceal peritonitis

Question 321

Diagnosis of stable diverticular disease

Answer 321

Colonoscopy, CT cologram or barium enema.

Question 322

Ix in patients acutely unwell with diverticular disease

Answer 322

Plain abdominal film and erect CXR

Abdominal CT scan (not CT cologram) with contrast can help identify acute inflammation and the presence of local complications

Question 323

Treatment of diverticular disease

Answer 323

Increased dietary fibrre intake

Question 324

Recurrent episodes of acute diverticulitis are a relative indication for

Answer 324

Segmental resection

Question 325

Management of Hinchey IV diverticulitis

Answer 325

Resection and usually a stoma

At high risk of post-operative complications and usually require HDU admission.

Less severe perforations may be managed by laparoscopic washout and drain insertion

Question 326

Theme: Urinary tract trauma

A.Urinary tract infection

B.Bladder outlet obstruction

C.Bulbar urethral rupture

D.Membranous urethral rupture

E.Bladder rupture

F.Bladder contusion

For the scenario given please select the most likely injury. Each option may be used once, more than once or not at all.

A 56 year old man is involved in a road traffic accident. He is found to have a pelvic fracture. He reports that he has some lower abdominal pain. He has peritonism in the lower abdomen. The nursing staff report that he has not passed any urine. A CT scan shows evidence of free fluid.

A 52 year old man falls off his bike. He is found to have a pelvic fracture. On examination he is found to have perineal oedema and on PR the prostate is not palpable. A urine dipstick shows blood.

A 52 year old woman falls out of a tree while rescuing a cat. Imaging shows no bony injury. She has suprapubic tenderness and complains of dysuria. Her abdomen is soft and non tender. A urine dipstick shows blood, nitrites and leucocytes.

Answer 326

Bladder rupture

A pelvic fracture and lower abdominal peritonism should raise suspicions of bladder rupture (especially as this man cannot pass urine).

Membranous urethral rupture

A pelvic fracture and highly displaced prostate should indicate a diagnosis of membranous urethral rupture.

The correct answer is Urinary tract infection

There is no indication of a more sinister diagnosis here. The patient’s abdomen is normal and she is able to pass urine. Her dipstick confirms an infection. Also in women urethral injury is rare.

Question 327

Association of bladder injury with pelvic trauma

Answer 327

85% associated with pelvic fractures

Question 328

Up to 10% of male pelvic fractures are associated with?

Answer 328

Urethral or bladder injuries

Question 329

What are the two types of urethral injury

Answer 329

Bulbar rupture

Membranous rupture

Question 330

Urinary retention

Perineal haematoma

Blood at the meatus

Answer 330

Urethral injury

Question 331

Features of bulbar urethral injury

Answer 331

Most common

Straddle type injury

Question 332

Features of membranous urethral injury

Answer 332

Can be extra or intraperitoneal

Commonly due to pelvic fracture

Penile or perineal oedema

Prostate may be displaced upwards (co-exisiting retroperitoneal haematomas may make examination difficult)

Question 333

Investigation of urethral injury

Answer 333

Ascending urethrogram

Question 334

Features of bladder injury

Answer 334

Rupture is intra or extraperitoneal

May present with haematuria or suprapubic pain.

If history of pelvic fracture and inability to void suspect bladder or urethral injury.

Inability to retrieve all the fluid used to irrgate the bladder through a foley catheter indicates bladder injury

Question 335

Management of bladder injury

Answer 335

Laparotomy if intraperitoneal

Conservative if extraperitoneal

Question 336

Which of the following structures separates the subclavian artery and vein?

Digastric muscle

Prevertebral fascia

Anterior scalene muscle

Middle scalene muscle

Omohyoid

Answer 336

The anterior scalene muscle is an important anatomical landmark and separates the subclavian vein (anterior) from the subclavian artery (posterior).

Question 337

What are the three paired scalene muscles?

Answer 337

Scalenus anterior

Scalenus medius

Scalenus posterior

Question 338

Action of scalenus anterior

Answer 338

Elevate 1st rib and laterally flex the neck to the same side

Question 339

Action of scalenus medius

Answer 339

As for scalenus anterior

Question 340

Action of scalenus posterior

Answer 340

Elevate 2nd rib and tilt neck to opposite side

Question 341

Innervation of scalene muscles

Answer 341

Spinal nerves C4-6

Question 342

Origin of the scalene muscles

Answer 342

Transverse process C2 to C7

Question 343

Insertion of scalene muscle

Answer 343

First and second ribs

Question 344

Important relations of the scalene muscles

Answer 344

Brachial plexus and subclavian artery pass between the anterior and middle scalenes through the scalene hiatus/fissure

Subclavian vein and phrenic nerves pass anteriorly to the anterior scalene as it crosses over the first rib

Question 345

Scalene muscle and thoracic outlet syndrome

Answer 345

At risk of adhering to the fascia surrounding the brachial plexus or shortening causing compression of the brachial plexus when it passes between the clavicle and first rib

Question 346

A 33 year old man is stabbed in the right chest and undergoes a thoracotomy. The right lung is mobilised and the pleural reflection at the lung hilum is opened. Which of the structures listed below does not lie within this region?

Pulmonary artery

Azygos vein

Pulmonary vein

Bronchus

None of the above

Answer 346

The pleural reflections encase the hilum of the lung and continue inferiorly as the pulmonary ligament. It encases the pulmonary vessels and bronchus. The azygos vein is not contained within it.

Question 347

A 56 year old man requires long term parenteral nutrition and the decision is made to insert a PICC line for long term venous access. This is inserted into the basilic vein at the region of the elbow. As the catheter is advanced, into which venous structure is the tip of the catheter most likely to pass from the basilic vein?

Subclavian vein

Axillary vein

Posterior circumflex humeral vein

Cephalic vein

Superior vena cava

Answer 347

The basilic vein drains into the axillary vein and although PICC lines may end up in a variety of fascinating locations the axillary vein is usually the commonest site following from the basilic. The posterior circumflex humeral vein is encountered prior to the axillary vein. However, a PICC line is unlikely to enter this structure because of its angle of entry into the basilic vein.

Question 348

A 72 year old man presents with symptoms and signs of benign prostatic hyperplasia. Which of the following structures is most likely to be enlarged?

Posterior lobe of the prostate

Median lobe of the prostate

Right lateral lobe of the prostate

Left lateral lobe of the prostate

Anterior lobe of the prostate

Answer 348

Carcinoma of the prostate typically occurs in the posterior lobe. The median lobe is usually enlarged in BPH. The anterior lobe has little in the way of glandular tissue and is seldom enlarged.

Question 349

An individual is noted to have a left sided superior vena cava. By which pathway is blood from this system most likely to enter the heart?

Via the coronary sinus

Via the azygos venous system and into the superior vena cava

Via anomalies in the pumonary vascular bed

Via the left atrium and persistent foramen ovale

Directly into the roof of the right atrium

Answer 349

Persistent left superior vena cava is the most common anomaly of the thoracic venous system. It is prevalent in 0.3% of the population and is a benign entity of failed involution during embryogenesis.

Question 350

Theme: Paediatric neck masses

A.Cystic hygroma

B.Thyroglossal cyst

C.Rhabdomyosarcoma

D.Branchial cyst

E.Dermoid cyst

Please select the most likely underlying diagnosis for the situation that is described. Each option may be used once, more than once, or not at all.

A 2 year old boy is brought to the clinic by his mother who has noticed that he has developed a small mass. On examination; a small smooth cyst is identified which is located above the hyoid bone. On ultrasound the lesion appears to be a heterogenous and multiloculated mass.

A 22 month old baby is brought to the clinic by her mother who is concerned that she has developed a swelling in her neck. On examination; she has a soft lesion located in the posterior triangle that transilluminates.

A 3 year old boy is brought to the clinic by his mother who has noticed a mass in his neck. On examination; he has a smooth mass located on the lateral aspect of his anterior triangle, near to the angle of the mandible. On ultrasound; it has a fluid filled, anechoic, appearance.

Answer 350

The correct answer is Dermoid cyst

Dermoid cysts are usually multiloculated and heterogeneous. Most are located above the hyoid, and their appearances on imaging differentiate them from thyroglossal cysts.

Cystic hygroma

Cystic hygromas are soft and transilluminate. Most are located in the posterior triangle.

Branchial cyst

Branchial cysts are usually located laterally and derived from the second branchial cleft. Unless infection has occurred they will usually have an anechoic appearance on ultrasound.

Question 351

Located in the anterior triangle, usually in the midline and below the hyoid (65% cases)

Derived from remnants of the thyroglossal duct

Thin walled and anechoic on USS (echogenicity suggests infection of cyst)

Answer 351

Thyroglossal cyst

Question 352

Six branchial arches separated by branchial clefts

Incomplete obliteration of the branchial apparatus may result in cysts, sinuses or fistulae

75% of branchial cysts originate from the second branchial cleft

Usually located anterior to the sternocleidomastoid near the angle of the mandible

Unless infected the fluid of the cyst has a similar consistency to water and is anechoic on USS

Answer 352

Branchial cyst

Question 353

Derived from pleuripotent stem cells and are located in the midline

Most commonly in a suprahyoid location

They have heterogeneous appearances on imaging and contain variable amounts of calcium and fat

Answer 353

Dermoids

Question 354

Usually located posterior to the sternocleidomastoid

Cystic hygroma result from occlusion of lymphatic channels

The painless, fluid filled, lesions usually present prior to the age of 2

They are often closely linked to surrounding structures and surgical removal is difficult

They are typically hypoechoic on USS

Answer 354

Lymphatic malformations

Question 355

May present in either triangle of the neck

Grow rapidly initially and then will often spontaneously regress

Plain x-rays will show a mass lesion, usually containing calcified phleboliths

As involution occurs the fat content of the lesions increases

Answer 355

Infantile haemangioma

Question 356

Theme: Amputations

A.Transfemoral amputation

B.Gritti - Stokes amputation

C.Digital amputation

D.Syme’s amputation

E.Hindquarter amputation

F.Below knee amputation

G.Trans metatarsal amputation

H.Amputation of digit

Please select the most appropriate procedure for the scenario given. Each option may be used once, more than once or not at all.

The operation of choice for a 90 year old lady with infected gangrene of the mid foot secondary to diabetes. She has fixed flexion deformity of the knee.

An operation in which Skew flaps are created.
An amputation of the lower limb in which the femoral condyles are removed and the patella retained.

Answer 356

The correct answer is Transfemoral amputation

An elderly patient with diabetes and peripheral vascular disease is a high risk surgical candidate. It is important that the chances of a successful outcome are maximised at the first operation. SInce above knee amputations usually heal more reliably than below knee amputations this is a preferable option, especially since she has a fixed deformity.

The correct answer is Below knee amputation

This is one variant of a below knee amputation. The Burgess flap is the other commonly practised approach.

Gritti - Stokes amputation

This is a Gritti - Stokes amputation. During a Gritti - Stokes operation the patella is conserved and swung posteriorly to cover the distal femoral surface.

Beware performing amputations in patients with peripheral vascular disease without optimising inflow first!

Question 357

What are the main categories of amputations?

Answer 357

Pelvic disarticulation (hindquarter)

Above knee amputation

Gritti Stokes (through knee amputation)

Below knee amputation (using either Skew or Burgess flaps)

Syme’s amputation (through ankle)

Amputations of mid foot and digits

Question 358

Features of above knee amputations

Answer 358

Quick to perform

Heal reliably

Patients regain their general health quickly

For this benefit, a functional price has to be paid and many patients over the age of 70 will never walk on an above knee prosthesis.

Above knee amputations use equal anterior-posterior flaps

Question 359

Features of below knee amputation

Answer 359

Technically more challenging to perform

Heal less reliably than their above knee counterparts.

However, many more patients are able to walk using a below knee prosthesis.

In below knee amputations the two main flaps are Skew flaps or the Burgess long posterior flap. Skew flaps result in a less bulky limb that is easier to attach a prosthesis to.

Question 360

An unusually tall 43 year old lady presents to the surgical clinic with bilateral inguinal hernias. She develops chest pain and collapses. As part of her investigations a chest x-ray shows evidence of mediastinal widening. What is the most likely underlying diagnosis?

Pulmonary embolus

Aortic dissection

Tietze syndrome

Boerhaaves syndrome

Myocardial infarct

Answer 360

Marfans syndrome may present with a variety of connective tissue disorders such as bilateral inguinal hernia. They are at high risk of aortic dissection, as in this case.

Question 361

Features of aortic dissection

Answer 361

More common than AAA rupture

33% of patients die within first 24 hours, 50% within 48 hours if no treatment received.

Associated with HTN.

Features of aortic dissection: tear in intimal layer followed by formation and propagation of subintimal haematoma. Cystic medial necrosis seen in Marfarn’s

90% occcur within 10 centimetres of the aortic valve

Question 362

Stanford classification of thoracic dissection

Answer 362

A: ascending aorta- surgery

B: descending aorta: medical therapy with antiHTNives

Question 363

De Bakey classification of aortic dissection

Answer 363

I: ascending aorta, aortic arch, descending aorta

II ascending aorta

III descending aorta distal to left subclavian artery

Question 364

Tearing. sudden onset chest pain

HTN or hypotension

BP difference in each arm >20mmHg

Neurologic deficits

Answer 364

Aortic dissection

Question 365

Investigations in aortic disection

Answer 365

CXR: widened mediasitinum, abnormal aortic knob, ring sign, trachial deviation

CT angiography

MRI angiography

Question 366

Mx of dissection

Answer 366

Beta blockers: aim HR 60-80bpm and systolic 100-120

Type A dissection- aortic root replacement

Question 367

A 53 year old man is undergoing a radical gastrectomy for carcinoma of the stomach. Which of the following structures will need to be divided to gain access to the coeliac axis?

Lesser omentum

Greater omentum

Falciform ligament

Median arcuate ligament

Gastrosplenic ligament

Answer 367

The lesser omentum will need to be divided. During a radical gastrectomy this forms one of the nodal stations that will need to be taken.

Question 368

Relations of the coeliac axis

Answer 368

Anteriorly: lesser omentum

Right: right coeliac ganglion and caudate process of liver

Left: left coeliac ganglion and gastric cardia

Inferiorly: upper border of pancreas and renal vein

Question 369

Which of the following renal stone types is most radiodense on a plain x-ray?

Calcium phosphate

Calcium oxalate

Uric acid

Struvite

Cystine

Answer 369

Calcium phosphate stones are the most radiodense stones, calcium oxalate stones slightly less so. Uric acid stones are radiolucent (unless they have calcium contained within them).

Question 370

Most common type of renal stone

Answer 370

Calcium oxalate (85%)

Question 371

Hypercalciuria is a major risk factor (various causes)
Hyperoxaluria may also increase risk
Hypocitraturia increases risk because citrate forms complexes with calcium making it more soluble
Stones are radio-opaque (though less than calcium phosphate stones)
Hyperuricosuria may cause uric acid stones to which calcium oxalate binds

Answer 371

Calcium oxalate

Question 372

Inherited recessive disorder of transmembrane cystine transport leading to decreased absorption of cystine from intestine and renal tubule
Multiple stones may form
Relatively radiodense because they contain sulphur

Answer 372

Cystine (1%)

Question 373

Uric acid is a product of purine metabolism
May precipitate when urinary pH low
May be caused by diseases with extensive tissue breakdown e.g. malignancy
More common in children with inborn errors of metabolism
Radiolucent

Answer 373

Uric acid 5-10%

Question 374

May occur in renal tubular acidosis, high urinary pH increases supersaturation of urine with calcium and phosphate
Renal tubular acidosis types 1 and 3 increase risk of stone formation (types 2 and 4 do not)
Radio-opaque stones (composition similar to bone)

Answer 374

Calcium phosphate (10%)

Question 375

Stones formed from magnesium, ammonium and phosphate
Occur as a result of urease producing bacteria (and are thus associated with chronic infections)
Under the alkaline conditions produced, the crystals can precipitate
Slightly radio-opaque

Answer 375

Struvite 2-20%

Question 376

Urine acidity in Calcium phosphate stones

Answer 376

Normal-alkaline

Question 377

Urine acidity in uric acid stones

Answer 377

Acidic

Question 378

Urine acidity in struvite stones

Answer 378

Alkaline

Question 379

Urine acidity in cystine stones

Answer 379

Normal

Question 380

A 76 year old man complains of symptoms of claudication. The decision is made to measure his ankle brachial pressure index. The signal from the dorsalis pedis artery is auscultated with a hand held doppler device. This vessel is the continuation of which of the following?

Posterior tibial artery

Anterior tibial artery

Peroneal artery

Popliteal artery

None of the above

Answer 380

The dorsalis pedis is a continuation of the anterior tibial artery.

Question 381

Theme: Disorders of the knee

A.Chondromalacia patellae

B.Dislocated patella

C.Undisplaced fracture patella

D.Displaced patella fracture

E.Avulsion fracture of the tibial tubercle

F.Quadriceps tendon rupture

G.Osgood Schlatters disease

Please select the most likely explanation for the scenario given. Each option may be used once, more than once or not at all.

1. A 19 year old sportswoman presents with knee pain which is worse on walking down the stairs and when sitting still. On examination there is wasting of the quadriceps and pseudolocking of the knee.
2. A tall 18 year old male athlete is admitted to the emergency room after being hit in the knee by a hockey stick. On examination his knee is tense and swollen. X-ray shows no fractures.
3. An athletic 15 year old boy presents with knee pain of 3 weeks duration. It is worst during activity and settles with rest. On examination there is tenderness overlying the tibial tuberosity and an associated swelling at this site.

Answer 381

Chondromalacia patellae

A teenage girl with knee pain on walking down the stairs is characteristic for chondromalacia patellae (anterior knee pain). Most cases are managed with physiotherapy.

Dislocated patella

A patella dislocation is a common cause of haemarthrosis and many will spontaneously reduce when the leg is straightened. In the chronic setting physiotherapy is used to strengthen the quadriceps muscles.

Osgood Schlatters disease

Athletic boys and girls may develop this condition in their teenage years. It is caused by multiple micro fractures at the point of insertion of the tendon into the tibial tuberosity. Most cases settle with physiotherapy and rest.

Question 382

Sport injury

Mechanism: high twisting force applied to a bent knee

Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis)

Poor healing

Management: intense physiotherapy or surgery

Answer 382

Ruptured anterior cruciate ligament

Question 383

Mechanism: hyperextension injuries

Tibia lies back on the femur

Paradoxical anterior draw test

Answer 383

Ruptured posterior cruciate ligament

Question 384

Mechanism: leg forced into valgus via force outside the leg

Knee unstable when put into valgus position

Answer 384

Rupture of medial collateral ligament

Question 385

Rotational sporting injuries

Delayed knee swelling

Joint locking (Patient may develop skills to “unlock” the knee

Recurrent episodes of pain and effusions are common, often following minor trauma

Answer 385

Menisceal tear

Question 386

Teenage girls, following an injury to knee e.g. Dislocation patella

Typical history of pain on going downstairs or at rest

Tenderness, quadriceps wasting

Answer 386

Chondromalacia patellae

Question 387

Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation

Genu valgum, tibial torsion and high riding patella are risk factors

Skyline x-ray views of patella are required, although displaced patella may be clinically obvious

An osteochondral fracture is present in 5%

The condition has a 20% recurrence rate

Answer 387

Dislocation of the patella

Question 388

2 types:

i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture

Answer 388

Fractured patella

Question 389

Occur in the elderly (or following significant trauma in young)

Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture

Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs

Classified using the Schatzker system (see below)

Answer 389

Tibial plateau fracture

Question 390

What can be used to classify tibial plateau fractures?

Answer 390

Schatzker classification system

Question 391

Type 1 Schatzker

Answer 391

Vertical split of lateral condyle

Fracture through dense bone, usually in the young. It may be virtually undisplaced, or the condylar fragment may be pushed inferiorly and tilted

Question 392

Type 2 Schatzker fracture

Answer 392

Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle

The wedge fragment (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop

Question 393

Type 3 Schatzker fracture

Answer 393

Depression of the articular surface with intact condylar rim

The split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable

Question 394

Type 4 Schatzker fracture

Answer 394

Fragment of the medial tibial condyle

Two injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe

Question 395

Schatzker Type 5

Answer 395

Fracture of both condyles

Both condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft

Question 396

Schatzker Type 6

Answer 396

Combined condylar and subcondylar fractures

High energy fracture with marked comminution

Question 397

A 72 year old man has just undergone an emergency repair for a ruptured abdominal aortic aneurysm. Pre operatively he was taking aspirin, clopidogrel and warfarin. Intra operatively he received 5000 units of unfractionated heparin prior to application of the aortic cross clamp. His blood results on admission to the critical care unit are as follows:
Full blood count

Hb8 g/dl

Platelets40 * 109/l

WBC7.1 * 109/l

His fibrin degradation products are measured and found to be markedly elevated. Which of the following accounts for these results?

Anastomotic leak

Disseminated intravascular coagulation

Heparin induced thrombocytopenia

Adverse effect of warfarin

Adverse effects of antiplatelet agents

Answer 397

The combination of low platelet counts and raised FDP in this setting make DIC the most likely diagnosis.

Question 398

Why does DIC readily develop in patients with extensive trauma?

Answer 398

Due to the release of tissue factor, a key mediator in the DIC pathway.

Question 399

Prolonged PT

Prolonged APTT

Prolonged bleeding time

Low plt

Answer 399

DIC

Question 400

Prolonged PT

Normal APTT

Normal bleeding time

Normal plt

Answer 400

?Warfarin

Question 401

Normal PT

Normal APTT

Prolonged BT

Normal plt

Answer 401

?Aspirin

Question 402

PT often normal though may be prolonged

Prolonged APTT

Normal BT

Normal plts

Answer 402

Heparin

Question 403

Trotter’s triad

Answer 403

Diagnosis of nasopharyngeal carcinoma:

Unilateral conductive hearing loss

ipsilateral facial & ear pain

Ipsilateral paralysis of the soft palate

Question 404

Featurs of NP carcinoma

Answer 404

Squamous cell carcinoma of the nasopharynx

Rare in most parts of the world, apart from individuals from Southern China

Associated with Epstein Barr virus infection

Local: otalgia, unilateral serous otitis media, nasal obstruction/discharge, cranial nerve palsy

Cervical lymphadenopathy

Question 405

Treatment of nasopharyngeal carcinoma

Answer 405

RTx is first line

Question 406

A 34 year old man receives morphine following an appendicectomy. He develops constipation as a result. Which of the following best accounts for this process?

Stimulation of DOPA receptors

Inhibition of DOPA receptors

Stimulation of µ receptors

Stimulation of serotonin release

Inhibition of serotonin release

Answer 406

4 Types of opioid receptor:

δ (located in CNS)- Accounts for analgesic and antidepressant effects

k (mainly CNS)- analgesic and dissociative effects

µ (central and peripheral) - causes analgesia, miosis, decreased gut motility

Nociceptin receptor (CNS)- Affect of appetite and tolerance to µ agonists.

Question 407

A 67 year old man is due to undergo a revisional total hip replacement using a posterior approach. After dividing gluteus maximus in the line of its fibres there is brisk arterial bleeding. Which of the following vessels is likely to be responsible?

Profunda femoris artery

External iliac artery

Internal iliac artery

Obturator artery

Inferior gluteal artery

Answer 407

The inferior gluteal artery runs on the deep surface of the gluteus maximus muscle. It is a branch of the internal iliac artery. It is commonly divided during the posterior approach to the hip joint.

Question 408

A 17 year old lady presents with right iliac fossa pain and diagnosed as having acute appendicitis. You take her to theatre to perform a laparoscopic appendicectomy. During the procedure the scrub nurse distracts you and you inadvertently avulse the appendicular artery. The ensuing haemorrhage is likely to be supplied directly from which vessel?

Inferior mesenteric artery

Superior mesenteric artery

Ileo-colic artery

Internal iliac artery

None of the above

Answer 408

The appendicular artery is a branch of the ileocolic artery.

Question 409

Which of the following is not well absorbed following a gastrectomy?

Vitamin c

Zinc

Vitamin B12

Copper

Molybdenum

Answer 409

Vitamin B12. The others are unaffected

Question 410

Features of post-gastrectomy syndrome

Answer 410

Post gastrectomy syndrome

Rapid emptying of food from stomach into the duodenum: diarrhoea, abdominal pain, hypoglycaemia

Complications: Vitamin B12 and iron malabsorption, osteoporosis

Treatment: High protein, low carbohydrate diet. Replace B12/Fe/Ca

Question 411

Which of the following statements in relation to fistula in ano is untrue?

High fistulae are safest treated with a seton insertion

Low fistulae may be laid open

They are typically probed with Lockhart Mummary probes

When discovered during incision and drainage of peri anal abscess; should always be probed to locate the internal opening

When complicating Crohns disease, may respond to infliximab

Answer 411

Probing fistulae during acute sepsis is associated with a high complication rate and should not be undertaken routinely.

Question 412

def: fistula

Answer 412

Abnormal connection between two epithelial surfcaes

Question 413

What are the four types of fistula

Answer 413

Enterocutaneous

Enteroenteric or enterocolic

Enterovaginal

Enterovesciular

Question 414

Theme: Management of nipple discharge

A.Prescribe danazol

B.Microdochectomy

C.Total duct excision

D.Cytology of duct fluid

E.Core biopsy

F.Prescribe co-amoxiclav

G.Reassure and discharge

H.Mastectomy

What is the best management for each nipple discharge presentation? Each option may be used once, more than once or not at all.

A 23 year old woman with greenish nipple discharge on one occasion. Clinical examination of the breast is normal. Ultrasound report is U1

A 43 year old woman has had recurrent episodes of periductal mastitis. She has received multiple courses of antibiotics and is troubled by persisting green nipple discharge. Clinical examination reveals green nipple discharge, but no discrete lump. Imaging with mammography and ultrasound is reassuring (U2, M2)

A 55 year old woman complains of nipple discharge. This was blood stained on one occasion. But not subsequently. Clinical examination shows clear fluid but no discrete lump. Imaging with ultrasound and mammography is normal.

Answer 414

Reassure and discharge

This is likely to be simple duct ectasia and U1 (normal USS) coupled with normal examination would favor discharge from clinic. Mammography is generally unhelpful in this age group

The correct answer is Total duct excision

This woman has troublesome duct ectasia and total duct excision is warranted.

The correct answer is Microdochectomy

Although this is likely to be benign disease, her age coupled with an episode of blood stained discharge would attract a recommendation for microdochectomy. She may have an intraductal papilloma. But the concern would be DCIS.

Question 415

A 63 year old man who smokes heavily presents with dyspepsia. He is tested and found to be positive for helicobacter pylori infection. One evening he has an episode of haematemesis and collapses. What is the most likely vessel to be responsible?

Portal vein

Short gastric arteries

Superior mesenteric artery

Gastroduodenal artery

None of the above

Answer 415

He is most likely to have a posteriorly sited duodenal ulcer. These can invade the gastroduodenal artery and present with major bleeding. Although gastric ulcers may invade vessels they do not tend to produce major bleeding of this nature.

Question 416

An orthopaedic surgeon makes a modification to an operative approach for total knee arthroplasty. After he has completed 25 cases, he stops and reviews his patient outcomes. He publishes the data. What level of evidence is supplied by this type of data?

II

IV

III

V

I

Answer 416

Case series that are non randomised and lack concurrent controls at best supply level IV evidence only. To qualify for level I and II evidence a prospective randomised controlled trial with appropriate blinding, control matching and power calculations is needed.

Question 417

Theme: Scrotal swellings

A.Haematocele

B.Epididymal cyst

C.Hydrocele

D.Testicular torsion

E.Orchitis

F.Epididymo-orchitis

For each case please select the most likely underlying diagnosis from the list. Each option may be used once, more than once or not at all.

17.A 32 year old male presents with a swollen right scrotum which has developed over 3 weeks after being kicked in the groin area. There is a non tense swelling of the right scrotum and the underlying testis cannot be easily palpated. A dipstick is positive for nitrates only.

A 40 year old male presents with a non painful, bilateral scrotal swellings over 3 years. The testis is felt separately and the swelling transilluminates

A 32 year old male presents with a swollen, painful right scrotum after being kicked in the groin area 1 hour ago. There is a painful swelling of the right scrotum and the underlying testis cannot be easily palpated.

Answer 417

The correct answer is Hydrocele

This is a secondary hydrocele which occurs in patients aged 20-40 years. It develops rapidly and there may not be a tense swelling. The underlying testis is NOT palpated therefore indicating a hydrocele. Causes include trauma, infection and tumour.

The correct answer is Epididymal cyst

The testis is palpated therefore this differentiates it from a hydrocele.

he correct answer is Haematocele

Acute haematocele: tense, tender and non transilluminating mass post trauma. A chronic haematoma causes a blood clot to surround the testis. The blood clot hardens and contracts causing a hard mass which may be indistinguishable from a tumour. Therefore the testis will need surgical exploration.

Question 418

Theme: Disorders affecting the ear

A.Acoustic neuroma

B.Otosclerosis

C.Preauricular sinus

D.Acute suppurative otitis media

E.Cholesteatoma

F.Long standing perforation of the pars tensa

G.Otitis externa

Please select the most likely underlying explanation for the disorder described. Each option may be used once, more than once or not at all.

A 34 year old lady presents with a long standing offensive discharge from the ear and on examination is noted to have a reduction in her hearing of 40 decibels compared to the opposite side.

A 4 year old is brought to the general practitioner by her mother. She has been distressed with ear pain for the past 14 hours. She is constantly touching and pulling at her ear. Whilst she is sat in the waiting room her mother notices a discharge of foul smelling fluid from the ear, following which the pain resolves.

A 4 year old child is brought to the clinic by his father. They are concerned because the child has been noted to have a small epithelial defect anterior to the left ear and is has been noted to discharge foul smelling material for the past 2 days.

Answer 418

Cholesteatoma

The combination of offensive discharge and hearing loss is strongly suggestive of cholesteatoma.

Acute suppurative otitis media

In young children acute suppurative otitis media is a common condition. Rupture of the tympanic membrane is a rare, but recognised complication.

Preauricular sinus

Pre auricular sinuses that a deeper may accumulate secretions and produce foul smelling discharge.

Question 419

Which of the following nerves is responsible for the cremasteric reflex?

Lateral femoral cutaneous nerve

Femoral nerve

Obturator nerve

Genitofemoral nerve

None of the above

Answer 419

The motor and sensory fibres of the genitofemoral nerve are tested in the cremasteric reflex. A small contribution is also played by the ilioinguinal nerve and thus the reflex may be lost following an inguinal hernia repair.

Question 420

An 8 year old boy presents with symptoms of right knee pain. The pain has been present on most occasions for the past three months and the pain typically lasts for several hours at a time. On examination; he walks with an antalgic gait and has apparent right leg shortening. What is the most likely diagnosis?

Perthes Disease

Osteosarcoma of the femur

Osteoarthritis of the hip

Transient synovitis of the hip

Torn medial meniscus

Answer 420

There are many causes of the irritable hip in the 10-14 year age group. Many of these may cause both hip pain or knee pain. Transient synovitis of the hip the commonest disorder but does not typically last for 3 months. An osteosarcoma would not usually present with apparent limb shortening unless pathological fracture had occurred. A slipped upper femoral epiphysis can cause a similar presentation although it typically presents later and with different patient characteristics.

Question 421

Idiopathic avascular necrosis of the femoral epiphysis of the femoral head

Impaired blood supply to femoral head, causing bone infarction. New vessels develop and ossification occurs. The bone either heals or a subchondral fracture occurs.

Answer 421

Perthes disease

Question 422

Males 4x’s greater than females

Age between 2-12 years (the younger the age of onset, the better the prognosis)

Limp

Hip pain

Bilateral in 20%

Answer 422

Perthes disease

Question 423

What can be used to stage Perthes disease?

Answer 423

Catterall staging

Question 424

Outline Catterall staging

Answer 424

1: clinical and histological features only
2: sclerosis with or without cystic chaanges and preservation of the articular surface
3: Loss of structural integrity of the femoral head.
4: loss of acetabular integrity

Question 425

A 42 year old man is admitted to surgery with acute appendicitis. He is known to have hypertension, psoriatic arthropathy and polymyalgia rheumatica. His medical therapy includes:
Paracetamol 1g qds
Codeine phosphate 30mg qds
Bendrofluazide 2.5 mg od
Ramipril 10mg od
Methotrexate 7.5mg once a week
Prednisolone 5mg od
You are called by the core surgical trainee to assess this man as he has become delirious and hypotensive 2 hours after surgery. His blood results reveal:

Na+132 mmol/l

K+5.2 mmol/l

Urea10 mmol/l

Creatinine111 µmol/l

Glucose3.5

CRP158

Hb10.2 g/dl

Platelets156 * 109/l

WBC14 * 109/l

What is the most likely diagnosis?

Septic shock secondary to appendicitis

Neutropenic sepsis

Phaeochromocytoma

Perforated bowel

Addisonian crisis

Answer 425

Features of an addisonian crisis:

Hyponatraemia

Hyperkalaemia

Hypoglycaemia

This man is on steroids for polymyalgia rheumatica. Surgery can precipitate acute adrenal deficiency. The diagnosis is further confirmed by the blood results of hyponatraemia, hyperkalaemia and hypoglycaemia. This patient urgently needs hydrocortisone.

Question 426

Management of Addisonian crisis

Answer 426

Hydrocortisone 100mg IM or IV

1L NS over 30-60 mins with dextrose if hypoglycaemic.

Continue hydrocortisone 6o until patient is stable.

Fludrocortisone is not required as high dose cortisol exerts weak MC action.

Oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days.

Question 427

A 22 year old man is stabbed in the chest at the level of the junction between the sternum and manubrium. Which structure is at greatest risk?

Left atrium

Oesophagus

Thyroid gland

Inferior vena cava

Aortic arch

Answer 427

At the level of the Angle of Louis (Manubriosternal angle), is the surface marking for the aortic arch. The oesophagus is posteriorly located and at less risk.

Question 428

What structures are found at the upper part of manubrium?

Answer 428

Left brachiocephalic vein

Brachiocephalic artery

Left common carotid

Left subclavian artery

Question 429

What structures are found at the lower part of the manubrium/manubrio-sternal angle?

Answer 429

Costal cartilages of the 2nd ribs

Transition point between superior and inferior mediastinum

Arch of the aorta

Tracheal bifurcation

Union of the azygos vein and superior vena cava

The thoracic duct crosses to the midline

Question 430

Which of these nerves passes through the greater and lesser sciatic foramina?

Pudendal nerve

Sciatic nerve

Superior gluteal nerve

Inferior gluteal nerve

Posterior cutaneous nerve of the thigh

Answer 430

Structures passing through the lesser and greater sciatic foramina (medial to lateral): PIN

Pudendal nerve

Internal pudendal artery

Nerve to obturator internus

The pudendal nerve originates from the ventral rami of the second, third, and fourth sacral nerves (S2, S3, S4).

It passes between the piriformis and coccygeus muscles and exits the pelvis through the the greater sciatic foramen. It crosses the spine of the ischium and reenters the pelvis through the lesser sciatic foramen. It passes through the pudendal canal.

The pudendal nerve gives off the inferior rectal nerves. It terminates into 2 branches: perineal nerve, and the dorsal nerve of the penis or the dorsal nerve of the clitoris.

Question 431

What are the nerves found in the GSF?

Answer 431

Sciatic Nerve

Superior and Inferior Gluteal Nerves

Pudendal Nerve

Posterior Femoral Cutaneous Nerve

Nerve to Quadratus Femoris

Nerve to Obturator internus

Question 432

What are the vessels found in the GSF?

Answer 432

Superior Gluteal Artery and vein

Inferior Gluteal Artery and vein

Internal Pudendal Artery and vein

Question 433

What is the use for piriformis w.r.t sciatic notch?

Answer 433

Piriformis
The piriformis is a landmark for identifying structures passing out of the sciatic notch

Above piriformis: Superior gluteal vessels

Below piriformis: Inferior gluteal vessels, sciatic nerve (10% pass through it, <1% above it), posterior cutaneous nerve of the thigh

Question 434

Boundaries of the GSF

Answer 434

Anterolaterally: greater sciatic notch

Posteromedially: sacrotuberous ligament

Inferior: sacrospinous ligament and ischial spine.

Superior: anterior sacroiliac ligament

Question 435

Contents of the lesser sciatic foramen

Answer 435

Tendon of the obturator internus

Pudendal nerve

Internal pudendal artery and vein

Nerve to the obturator internus

Question 436

A cervical rib is due to which of the following?

Hyperplasia of the annulus fibrosus

Proliferation of the nucleus pulposus

Fusion of the transverse processes of the 6th and 7th cervical vertebrae

An accessory cervical vertebra

Elongation of the transverse processes of the 7th cervical vertebra

Answer 436

Cervical ribs occur as a result of the elongation of the transverse process of the 7th cervical vertebra. It is usually a fibrous band that attaches to the first thoracic rib.

Question 437

Positive Adsons test

Answer 437

Compression of the subclavian artery may produce absent radial pulse on clinical examination and in particular may result in a positive Adsons test (lateral flexion of the neck towards the symptomatic side and traction of the symptomatic arm- leads to obliteration of radial pulse)

Question 438

Operative approach for surgical management of cervical rib?

Answer 438

Transaxillary approach

Question 439

Theme: Acute abdominal pain

A.Ruptured abdominal aortic aneurysm

B.Perforated peptic ulcer

C.Perforated appendicitis

D.Mesenteric infarction

E.Small bowel obstruction

F.Large bowel obstruction

G.Pelvic inflammatory disease

H.Mesenteric adenitis

I.Pancreatitis

J.None of the above

A 75 year old man is admitted with sudden onset severe generalised abdominal pain, vomiting and a single episode of bloody diarrhoea. On examination he looks unwell and is in uncontrolled atrial fibrillation. Although diffusely tender his abdomen is soft

A 19 year old lady is admitted with lower abdominal pain. On examination she is diffusely tender. A laparoscopy is performed and at operation multiple fine adhesions are noted between the liver and abdominal wall. Her appendix is normal.

A 78 year old man is walking to the bus stop when he suddenly develops severe back pain and collapses. On examination he has a blood pressure of 90/40 and pulse rate of 110. His abdomen is distended and he is obese. Though tender his abdomen itself is soft.

Answer 439

Mesenteric infarction

In mesenteric infarction there is sudden onset of pain together with vomiting and occasionally passage of bloody diarrhoea. The pain present is usually out of proportion to the physical signs.

Pelvic inflammatory disease

This is Fitz Hugh Curtis syndrome in which pelvic inflammatory disease (usually Chlamydia) causes the formation of fine peri hepatic adhesions.

Ruptured abdominal aortic aneurysm

This will be a retroperitoneal rupture (anterior ones generally don’t survive to hospital). The debate regarding CT varies, it is the authors opinion that a systolic BP of <100mmHg at presentation mandates immediate laparotomy.

Question 440

Which of the structures listed below is not a content of the carotid sheath?

Internal jugular vein

Internal carotid artery

Vagus nerve

Recurrent laryngeal nerve

Common carotid artery

Answer 440

Contents of carotid sheath:
Common carotid artery
Internal carotid artery
Internal jugular vein
Vagus nerve

Question 441

A 38 year old women undergoes a gastric bypass procedure. Post operatively she attends the clinic and complains that following a meal she develops vertigo and develops crampy abdominal pain. What is the most likely underlying explanation?

Insulin resistance

Irritable bowel syndrome

Biliary colic

Dumping syndrome

Enterogastric reflux

Answer 441

Dumping syndrome, which can be divided into early and late, may occur following gastric surgery. It occurs as a result of a hyperosmolar load rapidly entering the proximal jejunum. Osmosis drags water into the lumen, this results in lumen distension (pain) and then diarrhoea. Excessive insulin release also occurs and results in hypoglycaemic symptoms.

Question 442

Which form of gastrectomy typically gives the best functional outcomes?

Answer 442

Roux en Y

Question 443

What are some post-gastrectomy syndromes?

Answer 443

Small capacity (early satiety)

Dumping syndrome

Bile gastritis

Afferent loop syndrome

Efferent loop syndrome

Anaemia (B12 deficiency)

Metabolic bone disease

Question 444

Theme: Management of testicular disorders

A.Fine needle aspiration cytology

B.Excision biopsy

C.Orchidectomy via an inguinal approach

D.Lords procedure

E.Orchidectomy via a scrotal approach

F.Division of patent processus vaginalis via an inguinal approach

G.Division of patent processus vaginalis via a scrotal approach

H.Fowler Stephens procedure

I.Immediate scrotal exploration

J.Conservative management

Please select the most appropriate management for the following testicular disorders. Each option may be used once, more than once or not at all.

An 85 year old man is diagnosed as having prostate cancer and is considered suitable for hormonal ablation. However, he does not want the repeated injections of GnRH analogues.

A 33 year old man presents with a painless lump in his left testes. USS and blood tests are suspicious for teratoma.

A 4 year old boy is brought to the clinic by his mother. He has a swelling in his right hemiscrotum. On examination is transilluminates brilliantly.

Answer 444

Orchidectomy via a scrotal approach

At one time bilateral orchidectomy was performed routinely when prostate cancer was diagnosed (sometimes under the same anaesthetic). A combination of modern agents (GnRH analogues) and better consent processes have made this almost obsolete. Where required a scrotal approach should be used.

Orchidectomy via an inguinal approach

Oncological orchidectomy is routinely performed via an inguinal approach to avoid contamination of another lymphatic field.

Division of patent processus vaginalis via an inguinal approach

Ligation of the patent processus vaginalis is performed via an inguinal approach. There is no indication for scrotal surgery for hydrocele in young children.

Question 445

Epidemiology of testicular cancer

Answer 445

Commonest malignancy in men aged 20-30 years.

95% of testicular cancers are germ cell tumours

Germ cell tumours can be seminomatous or non-seminomatous

Question 446

Testicular tumour:

Commonest subtype (50%)

Average age at diagnosis = 40

Even advanced disease associated with 5 year survival of 73%

Answer 446

Seminoma

Question 447

Tumour markers in seminomas

Answer 447

AFP normal

HCG elevated in 10%

LDH levated in 10-20%

Question 448

Tumour markers in non seminomatous germ cell tumours

Answer 448

AFP elevated in 70%

HCG in 40%

Other markers rarely helpful

Question 449

Subtypes of non seminomatous germ cell tumours

Answer 449

Teratoma

Yolk sac tumour

Choriocarcinoma

Mixed germ cell tumours

Question 450

Pathology of seminomas

Answer 450

Sheet like lobular patterns of cells with substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen.

Question 451

Pathology of non seminomatous germ cell tumours

Answer 451

Heterogenous texture with occasional ectopic tissue such as hair

Question 452

RFs for testicular cancer

Answer 452

Cryptorchidism

Infertility

Family history

Klinefelter’s syndrome

Mumps orchitis

Question 453

What is a recognised non infective cause of epididymitis

Answer 453

Amiodarone

Question 454

A 40 year old man undergoes a complex appendicectomy and the wound fails to heal satisfactorily. The wound site itself is associated with multiple sinuses and fistulas. Pus is sent for microbiology and shows gram positive organisms and sulphur granules. What is the most likely underlying diagnosis?

Infection with Staphylococcus aureus

Infection with Bacteroides fragilis

Actinomycosis

Crohns disease

Ulcerative colitis

Answer 454

The presence of chronic sinuses together with gram positive organisms and sulphur granules is highly suggestive of Actinomycosis. Crohns disease is associated with multiple fistulae, but not gram positive organisms with sulphur granules.

Question 455

Features of actinomycosis

Answer 455

Chronic, progressive granulomatous disease caused by filamentous gram positive anaerobic bacteria from the Actinomycetaceae family.

Actinomyces are commensal bacteria that become pathogenic when a mucosal barrier is breached.

The disease most commonly occurs in the head and neck, although it may also occur in the abdominal cavity and in the thorax.

The mass will often enlarge across tissue planes with the formation of multiple sinus tracts.

Abdominopelvic actinomycosis occurs most frequently in individuals that have had appendicitis (65%) cases.

Question 456

Pathology of actinomycosis

Answer 456

On histological examination gram positive organisms and evidence of sulphur granules.

Sulphur granules are colonies of organisms that appear as round or oval basophilic masses.

They are also seen in other conditions such as nocardiosis.

Question 457

Treatment of actinomycosis

Answer 457

Long term antibiotic therapy usually with penicillin.

Surgical resection is indicated for extensive necrotic tissue, non healing sinus tracts, abscesses or where biopsy is needed to exclude malignancy.

Question 458

Theme: Management of splenic trauma

A.Splenectomy

B.Angiography

C.CT Scan

D.Admit for bed rest and observation

E.Ultrasound scan

F.Splenic conservation

G.MRI of the abdomen

Please select the most appropriate intervention for the scenario given. Each option may be used once, more than once or not at all.

A 7 year old boy falls off a wall the distance is 7 feet. He lands on his left side and there is left flank bruising. There is no haematuria. He is otherwise stable and haemoglobin is within normal limits.

A 42 year old motorcyclist is involved in a road traffic accident. A FAST scan in the emergency department shows free intrabdominal fluid and a laparotomy is performed. At operation there is evidence of small liver laceration that has stopped bleeding and a tear to the inferior pole of the spleen.

An 18 year old man is involved in a road traffic accident. A CT scan shows disruption of the splenic hilum and a moderate sized perisplenic haematoma.

Answer 458

The correct answer is Ultrasound scan

This will demonstrate any overt splenic injury. A CT scan carries a significant dose of radiation. In the absence of haemodynamic instability or other major associated injuries the use of USS to exclude intraabdominal free fluid (blood) would seem safe when coupled with active observation. An USS will also show splenic haematomas.

Splenic conservation

As minimum damage, attempt conservation.

Splenectomy

Hilar injuries usually mandate splenectomy. The main risk with conservative management here is that he will rebleed and with hilar injuries this can be dramatic.

Question 459

Management:

Small subcapsular haematoma
Minimal intra abdominal blood
No hilar disruption

Answer 459

Conservative

Question 460

Management:

Increased amounts of intraabdominal blood
Moderate haemodynamic compromise
Tears or lacerations affecting <50%

Answer 460

Laparotomy with conservation

Question 461

Management

Hilar injuries
Major haemorrhage
Major associated injuries

Answer 461

Resection

Question 462

Technique in traumatic splenectomy

Answer 462

GA

Long midline incision (+/- self-retainng retractor)

Pack 4 quadrants of the abdomen

Remove packs and assess splenic viability- hilar injuries and extensive parenchymal lacerations usually require splenectomy.

Divide and ligate the short gastric vessels.

Clamp the splenic artery and vein. (Two clamps allow for double ligation as a safety net)

Be careful not to damage the pancreatic tail, it will need to be removed if this happens.

Washout abdomen and place tube into the splenic bed.

Some surgeons implant a portion of the spleen into the omentum.

Patient will require prophylactic penicillin and PCV

Question 463

Elective splenectomy process

Answer 463

Elective splenectomy is a very different operation from that performed in the emergency setting. The spleen is often large (sometimes massive). Most cases can be performed laparoscopically. The spleen will often be macerated inside a specimen bag to facilitate extraction.

Question 464

Complications of splenectomy

Answer 464

Haemorrhage (may be early and either from short gastrics or splenic hilar vessels

Pancreatic fistula (from iatrogenic damage to pancreatic tail)

Thrombocytosis: prophylactic aspirin

Encapsulated bacteria infection e.g. Strep. pneumoniae, Haemophilus influenzae and Neisseria meningitidis

Question 465

A 48 year old lady undergoes a laparotomy and a retroperitoneal tumour is identified. The surgeons suspect that the lesion is a liposarcoma. Which of the following is not typical of liposarcomas?

They are the most common variant of sarcoma in adults

Core biopsies in low grade liposarcomas may be normal

May have a pseudocapsule

It is unlikely in a lesion measuring less than 5cm

Pulmonary metastasis are more likely than regional nodal involvement

Answer 465

Malignant fibrous histiocytoma is the commonest variant of sarcoma and liposarcoma the second most common. The presence of a pseudocapsule should be borne in mind when performing surgery, as incomplete removal will result in local recurrence.

Question 466

Malignant fibrous histiocytoma

Answer 466

is a sarcoma that may arise in both soft tissue and bone.

Question 467

Features that should raise suspicion for sarcoma

Answer 467

Large >5cm soft tissue mass

Deep tissue location or intra muscular location

Rapid growth

Painful lump

Question 468

Assessment of sacroma

Answer 468

Imaging of suspicious masses should utilise a combination of MRI, CT and USS. Blind biopsy should not be performed prior to imaging and where required should be done in such a way that the biopsy tract can be subsequently included in any resection.

Question 469

Sarcoma

Commoner in males

Incidence of 0.3 / 1, 000, 000

Onset typically between 10 and 20 years of age

Location by femoral diaphysis is commonest site

Histologically it is a small round tumour

Blood borne metastasis is common and chemotherapy is often combined with surgery

Answer 469

Ewings sarcoma

Question 470

Mesenchymal cells with osteoblastic differentiation

20% of all primary bone tumours

Incidence of 5 per 1,000,000

Peak age 15-30, commoner in males

Limb preserving surgery may be possible and many patients will receive chemotherapy

Answer 470

Osteosarcoma

Question 471

Malignancy of adipocytes

Rare, approximately 2.5 per 1,000,000. They are the second most common soft tissue sarcoma

Typically located in deep locations such as retroperitoneum

Affect older age group usually >40 years of age

May be well differentiated and thus slow growing although may undergo de-differentiation and disease progression

Many tumours will have a pseudocapsule that can misleadingly allow surgeons to feel that they can ‘shell out’ these lesions. In reality, tumour may invade at the edge of the pseudocapsule and result in local recurrence if this strategy is adopted

Usually resistant to radiotherapy, although this is often used in a palliative setting

Answer 471

Liposarcoma

Question 472

Tumour with large number of histiocytes

Most common sarcoma in adults

Also described as undifferentiated pleomorphic sarcoma NOS (i.e. Cell of origin is not known)

Four major subtypes are recognised: storiform-pleomorphic (70% cases), myxoid (less aggressive), giant cell and inflammatory

Treatment is usually with surgical resection and adjuvant radiotherapy as this reduces the likelihood of local recurrence

Answer 472

Malignant Fibrous Histiocytoma

Question 473

A 63 year old lady with metastatic breast cancer presents with bone pain. Radiological tests show a metastatic lytic deposit to her femoral shaft. The lesion occupies 75% of the bone diameter. What is the most appropriate management?

Surgical fixation with a dynamic compression plate

Hemi-arthroplasty

Fixation with intramedullary nail

Radical radiotherapy

Chemotherapy

Answer 473

Fixation with intramedullary nail

Even with surgical fixation only 30% of pathological fractures unite. The type of fixation should be chosen accordingly.

A lesion of this nature is at high risk of spontaneous fracture. Whilst radiotherapy may palliate her symptoms of pain it will not reduce the risk of fracture. In fit patients, an intramedullary nail should be inserted. Very proximal lesions may be best managed by a total hip replacement

Question 474

Features of pathological fracture

Answer 474

Osteolytic lesions are the greatest risk for pathological fracture
The risk and load required to produce fracture varies according to bone site. Bones with lesions that occupy 50% or less will be prone to fracture under loading (Harrington). When 75% of the bone is affected the process of torsion about a bony fulcrum may produce a fracture.

Question 475

What can be used to help determine the risk of fracture in pathological fracutre?

Answer 475

Mirel Scoring system

Question 476

As a busy surgical trainee on the colorectal unit you are given the unenviable task of reviewing the unit’s histopathology results for colonic polyps. Which of the polyp types described below has the greatest risk of malignant transformation?

Hyperplastic polyp

Tubular adenoma

Villous adenoma

Hamartomatous polyp

Serrated polyp

Answer 476

Villous adenomas carry the highest risk of malignant transformation. Hyperplastic polyps carry little in the way of increased risk. Although, patients with hamartomatous polyp syndromes may have a high risk of malignancy, the polyps themselves have little malignant potential.

Question 477

Which of the following types of growth plate fractures may have similar radiological appearances?

Salter Harris types 1 and 5

Salter Harris types 4 and 5

Salter Harris types 3 and 5

Salter Harris types 1 and 2

Salter Harris types 1 and 3

Answer 477

Mnemonic: SALTER

S (Type 1): Straight through the growth plate
A (Type 2): Above - through growth plate and Above involving the metaphysis
L (Type 3): Lower -through growth plate and beLow involving the epiphysis
T (Type 4):Through - Through both metaphysis, epiphysis and growth plate
E (Type 5): Everything - Crush / compression injury
R (Type 5): Ruined
As recommended by one of our users

Salter Harris injury types 1 and 5 (transverse fracture through growth plate Vs. Compression fracture) may mimic each other radiologically. Type 5 injuries have the worst outcomes. Radiological signs of type 5 injuries are subtle and may include narrowing of the growth plate.

Question 478

A 56 year old surgeon has been successfully operating for many years. Over the past few weeks she has begun to notice that her hands are becoming blistering and weepy. A latex allergy is diagnosed. Which of the following pathological processes accounts for this scenario?

Type 1 hypersensitivity reaction

Type 2 hypersensitivity reaction

Type 4 hypersensitivity reaction

Type 3 hypersensitivity reaction

None of the above

Answer 478

Hypersensitivity reactions: ACID

type 1 –Anaphylactic
type 2 –Cytotoxic
type 3 –Immune complex
type 4 –Delayed hypersensitivity

Contact dermatitis of a chronic nature is an example of a type 4 hypersensitivity reaction. Type 4 hypersensitivity reactions are cell mediated rather than antibody mediated.

Question 479

Mediator in T1HS

Answer 479

IgE

Question 480

Mediator in T2HS

Answer 480

IgG, IgM

Question 481

Mediator in T3HS

Answer 481

IgG, IgA, IgM

Question 482

Mediator in T4HS

Answer 482

T-cells

Question 483

Antigens in HS reactions

Answer 483

T1: exogenous

T2: cell surface

T3: soluble

T4: Tissues

Question 484

Which vitamin is involved in the formation of collagen?

Vitamin A

Vitamin B

Vitamin C

Vitamin D

Vitamin E

Answer 484

Vitamin C is needed for the hydroxylation of proline during collagen synthesis.

Question 485

Features of osteogenesis imperfecta

Answer 485

-8 Subtypes
-Defect of type I collagen
-In type I the collagen is normal quality but insufficient quantity
-Type II- poor quantity and quality
-Type III- Collagen poorly formed, normal quantity
-Type IV- Sufficient quantity but poor quality
Patients have bones which fracture easily, loose joint and multiple other defects depending upon which sub type they suffer from.

Question 486

Features of Ehlers Danlos

Answer 486

• Multiple sub types
• Abnormality of types 1 and 3 collagen
• Patients have features of hypermobility.
• Individuals are prone to joint dislocations and pelvic organ prolapse. In addition to many other diseases related to connective tissue defects.

Question 487

A 56 year old motorcyclist is involved in a road traffic accident and sustains a displaced femoral shaft fracture. No other injuries are identified on the primary or secondary surveys. The fracture is treated with closed, antegrade intramedullary nailing. The following day the patient becomes increasingly agitated and confused. On examination he is pyrexial, hypoxic SaO2 90% on 6 litres O2, tachycardic and normotensive. Systemic examination demonstrates a non blanching petechial rash present over the torso. What is the most likely explanation for this?

Pulmonary embolism with paradoxical embolus

Fat embolism

Meningococcal sepsis

Alcohol withdrawl

Chronic sub dural haematoma

Answer 487

Triad of symptoms:

Respiratory

Neurological

Petechial rash (tends to occur after the first 2 symptoms)

This man has a recent injury and physical signs that would be concordant with fat embolism syndrome. Meningococcal sepsis is not usually associated with hypoxia initially. Pulmonary emboli are not typically associated with pyrexia.

Question 488

Imaging in fat emboli

Answer 488

May be normal

Fat emboli tend to lodge distally and therefore CTPA may not show any vascular occlusion, a ground glass appearance may be seen at the periphery

Question 489

Treatment of fat embolism

Answer 489

Prompt fixation of long bone fractures

Some debate regarding benefit Vs. risk of medullary reaming in femoral shaft/ tibial fractures in terms of increasing risk (probably does not).

DVT prophylaxis

General supportive care

Question 490

A 73 year old lady is admitted with brisk rectal bleeding. Despite attempts at resuscitation the bleeding proceeds to cause haemodynamic compromise. An upper GI endoscopy is normal. A mesenteric angiogram is performed and a contrast blush is seen in the region of the sigmoid colon. The radiologist decides to embolise the vessel supplying this area. At what spinal level does it leave the aorta?

L2

L1

L4

L3

T10

Answer 490

The inferior mesenteric artery leaves the aorta at L3. It supplies the left colon and sigmoid. Its proximal continuation to communicate with the middle colic artery is via the marginal artery.

Question 491

Location of the subcostal plane

Answer 491

Lowest margin of the 10th costal cartilage

Question 492

Intercristal plane

Answer 492

L4 (highest point of iliac crest)

Question 493

Intertubercular plane

Answer 493

L5

Question 494

|MA level

Answer 494

L3

Question 495

Aortic bifurcation level

Answer 495

L4

Question 496

Formation of IVC level

Answer 496

L5

Question 497

Vena cava pierces diaphragm at

Answer 497

T8

Question 498

Oesophagus pierces diaphragm at

Answer 498

T10

Question 499

Aortic hiatus is at

Answer 499

T12