Block 2 Flashcards
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.
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.
Next step after diagnosis of CRC?
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
What should be done for CRC patients with tumours below the peritoneal reflection?
Evaluation of mesorectum with MRI
What is significant about the general approach to surgical management of CRC?
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.
What are the key technical factors in the healing of bowel anastomoses?
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.
Options for CRC presenting as an obstructing lesion
Exception
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
Chemotherapy following resection of CRC
5FU and oxaliplatin is common
Approach to rectal cancer surgery
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.
Why can the rectum be irradiated?
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
T1 and T2/ N0 rectal tumours
Do not require irradiation-> surgery
T4 rectal tumours
Long course chemo radiotherapy
T3 N0 rectal tumour.
Shourt course of radiotherapy prior to surgery
Management of rectal cancer causing large bowel obstruction
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 ?
Patients with an obstructing rectal cancer should have a?
Defunctioning loop colostomy
Right colon cancer
Type of resection
Right hemicolectomy
Transverse CRC
Type of resection
Extended right hemicolectomy
Splenic flexure CRC
Type of resection
Extended right hemicolectomy
or
Left hemicolectomy
Sigmoid CRC
Type of resection
High anterior resection
Upper rectum CRC
Type of resection
Anterior resection (TME)
Low rectum CRC
Type of resection
Anterior resection (low TME)
Anal verge CRC
Type of resection
APE of colon and rectum
Type of anastomosis
Right hemicolectomy
Ileo-colic
Type of anastomosis
Extended right hemicolectomy
Ileo-colic
Type of anastomosis
Left hemicoloectomy
Colo-colon
Type of anastomosis
High anterior resection
Colo-rectal
Type of anastomosis
Anterior resection (TME)
Colo-rectal
Type of anastomosis
Anterior resection (low TME)
Colo-rectal (+/- defunctioning stoma)
Type of anastomosis
Anal verge
None
Risk of anastomotic leak
Ileo-colic
Low <5%
Risk of anastomotic leak
Colo-colon
2-5%
Risk of anastomotic leak
Colo-rectal
5%
Risk of anastomotic leak
Colo-rectal (low anterior resection)
10%
Perforation in CRC management
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
When resection of the sigmoid colon is performed and an end colostomy is fashioned=
Hartmann’s
Ileo-colic anastomosis in the emergency setting
Relatively safe and do not need to be defunctioned.
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.
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.
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
Duct ectasia
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
Periductal mastitis
Breast lesion
Usually presents with clear or blood stained discharge originating from a single duct
No increase in risk of malignancy
Intraductal papilloma
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.
Breast abscess
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
Breast TB
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.
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.
Relative proportions of nonmelanoma skin malginancy?
80% BCC
20% SCC
Pattern of UV light exposure in SCC
Chronic long term exposure
Pattern of UV light exposure for BCCs
Sporadic exposures with episodes of burning
Risk factors for SCC in transplant patients
Increased risk with increased duration of immunosuppression, ethnic origin, and associated sunlight exposure.
Aetiological agent in majority of transplant associated SCCs?
HPV
What is an issue in transplant patients following SCC treatment?
Locoregional recurrence
What is the risk of SCC in a patient with 7 actinic keratoses?
10% at 10 years.
Rough erythematous skin papule with a white to yellow scale. Lesions clustered at site of chronic sun exposure
Actinic keratosis
Bowens disease=
SCC in situ
Full thickness atypia of dermal keratinocytes over a broad zone. Nuclear pleomorphism, apoptosis and abnormal mitoses are seen.
SCC in situ
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
Invasive SCC
Downward proliferation of malignant cells and invasion of the BM
Poorly differentiated lesions may show perineural invasion and require immunohistochemistry with S100
Invasive SCC
How to differentiate between invasive SCC and MM
Immunohistochemistry with S100 (melanomas stain strongly positive with this marker)
What are the subtypes of BCC?
Nodular
Superficial
Morpheaform
Cystic
Basosquamous
What is the commonest variant of BCC?
Nodular BCC
Commonest variant (60%)
Raised translucent papule
Usually affect the face
Large nodular BCC’s are locally destructive
Nodular BCC
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)
Superficial BCC
BCC
Macroscopically resembles flat, slightly atrophic lesion or plaque without well defined borders
Tumour has sub clinical lateral spread which increases recurrence rates
Morpheaform BCC
BCC
Often have clear or blue - grey appearance
Cystic degeneration may not be clinically obvious and tumour may resemble nodular BCC
Cystic BCC
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
Basosquamous carcinoma
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.
Keratoacanthoma
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.
Pyogenic granuloma
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
Desmoid tumours would be the most likely differential here and consist of a clonal proliferation of myofibroblasts
Features of desmoid tumours?
Fibrous neoplasms arising from musculoaponeurotic structures, typically contain a clonal proliferation of myofibroblasts
Usually firm overgrowth with propensity to local infiltration
What familial malignant condition is assoicated with desmoid tumours?
Desmoid tumours are seen in 15% of patients with FAP
Usually show biallelic APC mutations
What is the most common demographic for desmoid tumours?
Women after childbirth in the rectus abdominis muscle.
Management of desmoid tumours?
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
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
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.
What are the features of substances that can be used to measure GFR?
Inert
Free filtration from the plasma at glomerulus (not protein bound)
Not absorbed or secreted at thetubules
Plasma concentration constant during urine collection
Cerebral perfusion pressure=
MAP-intracranial pressure
Mean arterial pressure=
Diastolic pressure + 1/3(systloic pressure-diastolic pressure)
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
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
Def: cerebral perfusion pressure
Net pressure gradient causing blood flow to the brain.
Tightly regulated to maximise cerebral perfusion.
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
The obturator nerve is most closely related to the bladder
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.
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.
Flaccid paralysis of the upper limbs
Central cord lesion
Dorsal column signs (loss of proprioception and fine discrimination)
Infarction spinal cord
C2 to C4
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.
C5 to T1
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.
T2 to T12
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.
L1 to L5
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.
S1 to S5
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.
Myotomes
C5
Elbow flexors/biceps
Myotomes
C6
Wrist extensors
Myotomes
Elbow extensors/triceps
C7
Myotomes
Long finger flexors
C8
Myotomes
Small finger abductors
T1
Myotomes
Hip flexors
L1 and L2
Myotomes
Knee extensors
L3
Myotomes
Ankle dorsiflexors
L4 and 5
Myotomes
Toe extensors
L5
Myotomes
Ankle plantar flexors
S1
There is decreased secretion of which one of the following hormones in response to major surgery:
Insulin
Cortisol
Renin
Anti diuretic hormone
Prolactin
Endocrine parameters reduced in stress response:
Insulin
Testosterone
Oestrogen
Insulin is often released in decreased quantities following surgery.
What hormones are increased by the stress response?
GH
Cortisol
Renin
ACTH
Aldosterone
Prolactin
ADH
Glucagon
What hormones are decreased by the stress response
Insulin
Testosterone
Oestrogen
What hormones show no change in stress response
TSH
LH
FSH
How does perioperative increased prolactin occur?
Release of inhibitory control
How is the reduced insulin release after surgery mediated?
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
Metabolic effects of endocrine response to surgery:
Carbohydrate metabolism
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
Metabolic effects of endocrine response to surgery:
Protein metabolism
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
Metabolic effects of endocrine response to surgery:
Lipid metabolism
Increased catecholamine, cortisol and glucagon secretion and insulin deficiency promotes lipolysis and ketone body production
Metabolic effects of endocrine response to surgery:
Salt and water metabolism
ADH causes water retention, concentrated urine and K loss
Renin causes sodium and water retention
What is the main cytokine associated with surgery?
Il-6
Peaks 12-24h post surgery and increase by the degree of tissue damage
How can the hormonal response to surgery be modified?
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
A patient presents with superior vena caval obstruction. How many collateral circulations exist as alternative pathways of venous return?
None
One
Two
Three
Four
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.
What does the SVC drain?
Head and neck
Upper limbs
Thorax
Part of abdominal walls
Formation of the SVC
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
Anterior relations of the SVC
Anterior margins of the right lung and pleura
Posteromedial relations of the SVC
Trachea and right vagus nerve
Posterolateral relations of the SVC
Posterior aspects of right lung and pleura
Pulmonary hilum is posterior
Right lateral relations of the SVC
Right phrenic nerve and pleura
Left lateral relations of the SVC
Brachiocephalic artery and ascending aorta
What are some recognised developmental variations in the SVC
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
What is the commonest developmental lesion for the IVC?
Abdominal course interruption with drainage achieved via the azygos venous system
May occur in patients with left sided atrial isomerism
Left sided atrial isomerism
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.
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
The parasympathetic fibres to the lacrimal apparatus transit via the pterygopalatine ganglion.
Components of the lacrimal gland?
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
Blood supply of the lacrimal gland
Lacrimal branch of the ophthalmic artery.
Venous drainage via the superior ophthalmic vein
Innervation of the lacrimal gland
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)
Passage of the nasolacrimal duct
Descends from the lacrimal sac to open anteriorly in the inferior meatus of the nose
Describe the lacrimation reflex
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
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
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.
Origin of:
FCR
Common flexor origin and surrounding fascia
Origin of:
PL
Common flexor origin
Origin of:
FCU
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
Origin of:
FDS
Long linear origin from common flexor tendon, adjacent fascia and septa and medial border off the coronoid process
Origin of:
FDP
Upper two thirds of the medial and anterior surface of the ulnar, medial side of the olecranon, medial half of the interosseuous membrane
Insertion of:
FCR
Front of bases of second and third metacarpals
Insertion of:
PL
Apex of palmar aponeurosis
Insertion of:
FCU
Pisiform and base of fifth metacarpal
Insertion of:
FDS
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
Insertion of:
FDP
Via tendons that lie deep to those of flexor digitorum superficials to insert into the distal phalanx
Nerve supply:
FCR
Median
Nerve supply:
Palmaris longus
Median
Nerve supply:
FCU
Ulnar
Nerve supply:
FDS
Median
Nerve supply:
FDP
Medial part= ulnar
Lateral part= anterior interosseous nerve
Action of:
FCR
Flexes and abducts the carpus, part flexes the elbow and part pronates the forearm
Action of:
Palmaris longus
Wrist flexor
Action of:
FCU
Flexes and adducts the carpus
Action of:
FDS
Flexor of MCP and PIP joints
Action of:
FDP
Flexes the DIP and the wrist
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
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.
Nerve supply of the gallbladder
Sympathetic: mid thoracic spinal cord
PNS: anterior vagal trunk
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
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.
Boundaries of the anterior triangle of the neck
Anterior border of sternocleidomastoid
Lower border of mandible
Anterior midline
What are the subtriangles of the anterior triangle of the neck
Muscular triangle: neck strap muscles
Carotid triangle: carotid sheath
Submandibular triangle: digastric
What divides the anterior triangle of the neck into its sub triangles?
Digastric above
Omohyoid below
Nerve supply to anterior of digastric muscle?
Mylohyoid which is a branch of the mandibular branch of the trigeminal
Nerve supply to posterior digastric?
Facial nerve
What are the six possible positions of the appendix?
Retrocaecal 74%
Pelvic 21%
Postileal
Subcaecal
Paracaecal
Preileal
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
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.
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
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.
What three cranial nerves may be injured during submandibular gland excision?
Marginal mandibular branch of the facial nerve
Lingual nerve
Hypoglossal nerve
Superficial relations of the submandibular gland?
Platysma, deep fascia and mandible
Submandibular lymph nodes
Facial vein (facial artery near mandible)
Marginal mandibular nerve
Cervical branch of facial nerve
Deep relations of the submandibular gland
Facial artery (inferior to mandible)
Mylohyoid
Submandibular duct
Hyoglossus
Lingual nerve
Submandibular ganlgion
Hypoglossal nerve
What is the submandibular duct?
Wharton’s duct, opens lateral to the lingual frenulum on the anterior floor of mouth
Relation of the lingual nerve to Wharton’s duct
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
Innervation of the submandibular gland
SNS: superior cervical ganglion
PNS: submandibular ganlion via lingual nerve
Arterial supply of the submandibular gland
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
Venous drainage of the submandibular gland
Anterior facial vein (lies deep to the marginal mandibular nerve)
Lymphatic drainage of the submandibular gland
Deep cervical and jugular chains of nodes
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
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.
Superior border of the femoral triangle
Inguinal ligament
Lateral border of the femoral triangle
Sartorius
Medial border of the femoral triangle
Adductor longus
Floor of the femoral triangle
Iliopsoas, adductor longus and pectineus
Roof of the femoral triangle
Fascia lata and superficial fascia
Superficial inguinal LNs
Long saphenous veins
Contents of the femoral triangle medial to lateral
Vein
Artery
Femoral nerve
Lateral cutaneous nerve
Great saphenous vein
Femoral branch of the genitofemoral nerve
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
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.
DRE in appendicitis
Digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even tenderness with a pelvic appendix.
Urinalysis in appendicitis?
Mild leucocytosis but no nitrites
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.
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.
Benign neoplasms of the salivary gland proportions
80% of salivary gland tumours occur in parotid and up to 80% of these are benign.
Epidemiology of parotid gland neoplasms
With the exception of Warthin tumours, they are commoner in women than men.
Median age of developing a lesion is 5th decade of life
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
Benign pleomorphic adenoma or benign mixed tumor
What proportion of benign pleomorphic adenomas undergo malignant degeneration?
2-10%
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)
Warthin tumor (papillary cystadenoma lymphoma or adenolymphoma)
What is the most common bilateral parotid tumour?
Warthin tumour
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
Monomorphic adenoma
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
Haemangioma
30% of all parotid malignancies
Usually low potential for local invasiveness and metastasis (depends mainly on grade)
Mucoepidermoid carcinoma
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%
Adenoid cystic carcinoma
What malignant salivary gland tumours has a tendency to perineural spread?
Adenoid cystic carcinoma
Parotid malignancy
Often occuring in previously benign parotid lesion
Mixed tumours
Parotid malignancy
Intermediate grade malignancy
May show perineural invasion
Low potential for distant metastasis
5 year survival 80%
Acinic cell carcinoma
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
Parotid adenocarcinoma
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)
Parotid lymphoma
Diangostic evaluation of parotid masses
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
Treatment of parotid tumours
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.
Parotid manifestations of HIV infection
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
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
Sjogren syndrome
Parotid involvement in sarcoidosis
Occurs in 6% of patients with sarcoid
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
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.
Physiogical function of the ileum
Absorption of B12 and bile salts
Neuroendocrine cells in the ileal wall may secrete hormones
What are the risks following significant ileal resection
Bile salt malbsorption-> bile salt diarrhoea and increased risk of gallstones.
Lack of B12 may predispose to macrocytic anaemia
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
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%).
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
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.
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.
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.
If inguinoscrotal swelling; cannot “get above it” on examination
Cough impulse may be present
May be reducible
Inguinal hernia
Often discrete testicular nodule (may have associated hydrocele)
Symptoms of metastatic disease may be present
USS scrotum and serum AFP and β HCG required
Testicular tumours
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
Acute epididymo-orchitis
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”
Epididymal cysts
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
Hydrocele
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
Testicular torsion
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
Varicocele
Differential management of hydroceles in adults vs children
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.
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
Many of these nerves are at risk of injury during carotid surgery. However, only damage to the vagus would account for a hoarse voice.
Functions of the vagus nerve
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
Superior ganlgion of the vagus nerve
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)
Inferior ganglion of the vagus nerve
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
What are the branches of the vagus in the neck
Superior and inferior cervical cardiac branches
Right recurrent laryngeal nerve
Superior and inferior cervical cardiac branches
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
Right recurrent laryngeal nerve
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
Branches of the vagus in the thorax?
Left RLN
Thoracic and cardiac branches
Left RLN
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
Thoracic and cardiac vagus nerve branches
Extensive branches to the heart and lung roots.
Pass through both of these viscera before reuniting prior to passing into the abdomen
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
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.
Which muscle initiates abduction of the shoulder?
Infraspinatus
Latissimus dorsi
Supraspinatus
Deltoid
Teres major
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.
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
HLA DR
What are the relative importance of the HLA antigens when matching for a renal transplant?
DR > B > A
Post-op problems with renal transplant
ATN of graft
Vascular thrombosis
Urine leakage
UTI
Due to antibodies against donor HLA type 1 antigens
Rarely seen due to HLA matching
Hyperacute rejection
Usually due to mismatched HLA
Other causes include cytomegalovirus infection
Management: give steroids, if resistant use monoclonal antibodies
Acute graft failure (< 6 months)
Causes of chronic graft failure (>6m)
Chronic allograft nephropathy
Ureteric obstruction
Recurrence of original renal disease (MCGN > IgA > FSGS)
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
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.
Contents of the popliteal fossa from medial to lateral
Artery, vein, tibial nerve, common peroneal nerve
Lateral boundary of popliteal fossa
Biceps femoris above
Lateral head of gastrocnemius and plantaris below
Medial boundary of popliteal fossa
Semimembranosus, semitendonosus above
Medial head of gastrocnemius below
Floor of popliteal fossa
Popliteal surface of the femur, posterior ligament of knee joint and popliteus muscle
Roof of popliteal fossa
Superficial and deep fascia
Contents of the popliteal fossa
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
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
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.
Inferior phrenic arteries
Level, Paired? Type
T12 (upper border)
Paired
Parietal
Coeliac
Level?
Paired?
Type?
T12
No
Visceral
SMA
Level?
Paired?
Type?
L1
No
Visceral
Middle suprarenal
Level?
Paired?
Type?
L1
Yes
Visceral
Renal artery
Level?
Paired?
Type?
L1-L2
Paired
Visceral
Gonadal arteries
Level?
Paired?
Type?
L2
Paired
Visceral
Lumbar arteries
Level?
Paired?
Type?
L1-L4
Paired
Parietal
IMA
Level?
Paired?
Type?
L3
Unpaired
Visceral
Median sacral artery
Level?
Paired?
Type?
L4
Unpaired
Parietal
Common iliac artery
Level?
Paired?
Type?
L4
Paired
Terminal
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
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
Features of the intrinsic coagulation cascade?
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
Features of the extrinsic pathway?
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
Common pathway
Activated factor 10 causes the conversion of prothrombin to thrombin
Thrombin hydrolyses fibrinogen to form fibrin and also activates factor 8
Factors in intrinsic pathway
Factors 8,9,11,12
Factors involved in extrinsic pathway
TF, 7, 9, 8 -> 10
Factors involved in common pathway
2, 5, 10
Vitamin K dependent factors
2, 7, 9, 10
Increased APTT what pathway?
Intrinsic
Increased PT what pathway
Extrinsic pathway
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
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.
Which of the following is not directly affected by warfarin?
Protein C
Factor II
Factor VII
Factor IX
Factor VIII
Warfarin affects synthesis of factors II, VII, IX, X and protein C.
Action of Warfarin
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
Mechanism of warfarin causing skin necrosis
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.
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
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.
Supply of the facial nerve
Face, ear, taste, tear
Face: muscles of facial expression
Ear: nerve to stapedius
Taste: anterior 2/3rds of tongue
Tear: parasympathetic fibres to lacrimal glands also salivary glands
Subarachnoid path of the facial nerve
Motor: pons, sensory: nervus intermedius
Pass through petrous temporal bone to the internal auditory meatus with the vestibulocochlear nerve-> facial nerve
Facial canal path of facial nerve
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
3 branches of the facial nerve at the geniculate ganglion
Greater petrosal
Nerve to stapedius
Chorda tympani
Passage of the facial nerve through stylomastoid foramen
Passes through foramen (tympanic cavity anterior, mastoid antrum posteriorly)
Posterior auricular nerve and branch to posterior belly of digastric and stylohyoid muscle
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
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.
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.
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).
Pain due to pancreatic malignancy
Usually due to invasion of the coeliac plexus- late feature
Origin of the brachial plexus
C5 to T1
Sections of the brachial plexus
Remember to drink cold beer
Roots, trunks, divisions, cords, branches
Where can the roots of the brachial plexus be found?
Posterior triangle of the neck
Pass between scalenus anterior and medius
Where can the trunks of the brachial plexus be found?
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
Divisions of the brachial plexus
Apex of the axilla
Cords of the brachial plexus
Related to axillary artery
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.
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.
Normal or high bilirubin
Normal ALT/AST
Normal ALP
Pre-hepatic jaundice
High bilirubin
Elevated ALT/AST
ALP elevated but seldom to high levels
Hepatic jaundice
High bilirubin
Moderate AST/ALT elevation
Very high ALP
Post-hepatic jaundice
What is the anatomical level of the transpyloric plane?
T11
T12
L1
L4
T10
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
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
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.
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
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.
Hyperacute organ rejection is due to?
ABO mismatch
Cellular infiltrate in acute organ rejection
Mononuclear cell infiltrates.
May occur in up to 50% of cases
Histological changes seen in chronic rejection
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
Exclusion criteria for renal transplant
Active malignancy
Old age
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.
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.
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
Haemangioma
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
Liver cell adenoma
Congential and benign, usually present in infants. May compress normal liver
Mesenchymal hamartomas
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
Liver abscess
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
Amoebic abscess
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
Hyatid cysts
Usually occurs in association with polycystic kidney disease
Autosomal dominant disorder
Symptoms may occur as a result of capsular stretch
Polycystic liver disease
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
Cystadenoma
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
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).
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
Extradural haematoma
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.
Subdural haematoma
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.
Subarachnoid haemorrhage
ICP monitoring in head injury
Appropriate in those with GCS 3-8 and normal CT scan
Mandatory in those with same GCS and abnromal CT scan.
Unilaterally dilated pupil
Sluggish or fixed response to light
Context of brain injury
3rd nerve compression secondary to tentorial herniation
Head injury
Bilaterally dilated pupils
Sluggish or fixed light response
Poor CNS perfusion
Bilateral 3rd nerve palsy
Unilaterally dilated or equal pupil size
Cross reactive light response
Optic nerve injury
Bilaterally constricted pupils
Opiates
Pontine lesions
Metabolic encephalopathy
Unilaterally constricted pupil
Sympathetic pathway disruption
Epidemiology of achondroplasia
Mutation in FGFR- sporadic (70%)
Advancing parental age is the main risk factor
Radiological features of achondroplasia
Large skull with narrow foramen magnum
Short, flattened intervertebral bodies
Narrow spinal canal
Horizontal acetabular roof
Broad, short metacarpals
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
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.
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
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.
Two main fractures carrying risk of compartment syndrome
Supracondylar fractures
Tibial shaft injuries
Symptoms and signs of compartment syndrome
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
Diagnosis of compartment syndrome
Measurement of intracompartmental pressure, >20 is abnormal, >40 is diagnostic
Where are the greatest proportion of musculi pectinati found?
Right ventricle
Left ventricle
Right atrium
Pulmonary valve
Aortic valve
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.
Walls of the cardiac chamber
Epicardium
Myocardium
Endocardium
Venous drainage of the heart
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
Structures supplied by the right coronary artery
Right atrium
Diaphragmatic part of the right ventricle
Posterior third of the interventricular septum
SAN in 60%
AVN in 80%
Structures supplied by the LCA
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
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
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.
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
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.
What is used to classify the severity of diverticulitis?
Hinchey classification
I: paracolonic abscess
II: pelvic abscess
III: purulent peritonitis
IV: faceal peritonitis
Diagnosis of stable diverticular disease
Colonoscopy, CT cologram or barium enema.
Ix in patients acutely unwell with diverticular disease
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
Treatment of diverticular disease
Increased dietary fibrre intake
Recurrent episodes of acute diverticulitis are a relative indication for
Segmental resection
Management of Hinchey IV diverticulitis
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
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.
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.
Association of bladder injury with pelvic trauma
85% associated with pelvic fractures
Up to 10% of male pelvic fractures are associated with?
Urethral or bladder injuries
What are the two types of urethral injury
Bulbar rupture
Membranous rupture
Urinary retention
Perineal haematoma
Blood at the meatus
Urethral injury
Features of bulbar urethral injury
Most common
Straddle type injury
Features of membranous urethral injury
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)
Investigation of urethral injury
Ascending urethrogram
Features of bladder injury
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
Management of bladder injury
Laparotomy if intraperitoneal
Conservative if extraperitoneal
Which of the following structures separates the subclavian artery and vein?
Digastric muscle
Prevertebral fascia
Anterior scalene muscle
Middle scalene muscle
Omohyoid
The anterior scalene muscle is an important anatomical landmark and separates the subclavian vein (anterior) from the subclavian artery (posterior).
What are the three paired scalene muscles?
Scalenus anterior
Scalenus medius
Scalenus posterior
Action of scalenus anterior
Elevate 1st rib and laterally flex the neck to the same side
Action of scalenus medius
As for scalenus anterior
Action of scalenus posterior
Elevate 2nd rib and tilt neck to opposite side
Innervation of scalene muscles
Spinal nerves C4-6
Origin of the scalene muscles
Transverse process C2 to C7
Insertion of scalene muscle
First and second ribs
Important relations of the scalene muscles
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
Scalene muscle and thoracic outlet syndrome
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
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
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.
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
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.
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
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.
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
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.
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.
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.
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)
Thyroglossal cyst
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
Branchial cyst
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
Dermoids
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
Lymphatic malformations
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
Infantile haemangioma
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.
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!
What are the main categories of amputations?
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
Features of above knee amputations
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
Features of below knee amputation
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.
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
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.
Features of aortic dissection
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
Stanford classification of thoracic dissection
A: ascending aorta- surgery
B: descending aorta: medical therapy with antiHTNives
De Bakey classification of aortic dissection
I: ascending aorta, aortic arch, descending aorta
II ascending aorta
III descending aorta distal to left subclavian artery
Tearing. sudden onset chest pain
HTN or hypotension
BP difference in each arm >20mmHg
Neurologic deficits
Aortic dissection
Investigations in aortic disection
CXR: widened mediasitinum, abnormal aortic knob, ring sign, trachial deviation
CT angiography
MRI angiography
Mx of dissection
Beta blockers: aim HR 60-80bpm and systolic 100-120
Type A dissection- aortic root replacement
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
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.
Relations of the coeliac axis
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
Which of the following renal stone types is most radiodense on a plain x-ray?
Calcium phosphate
Calcium oxalate
Uric acid
Struvite
Cystine
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).
Most common type of renal stone
Calcium oxalate (85%)
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
Calcium oxalate
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
Cystine (1%)
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
Uric acid 5-10%
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)
Calcium phosphate (10%)
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
Struvite 2-20%
Urine acidity in Calcium phosphate stones
Normal-alkaline
Urine acidity in uric acid stones
Acidic
Urine acidity in struvite stones
Alkaline
Urine acidity in cystine stones
Normal
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
The dorsalis pedis is a continuation of the anterior tibial artery.
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.
- 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.
- 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.
- 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.
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.
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
Ruptured anterior cruciate ligament
Mechanism: hyperextension injuries
Tibia lies back on the femur
Paradoxical anterior draw test
Ruptured posterior cruciate ligament
Mechanism: leg forced into valgus via force outside the leg
Knee unstable when put into valgus position
Rupture of medial collateral ligament
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
Menisceal tear
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting
Chondromalacia patellae
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
Dislocation of the patella
2 types:
i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture
Fractured patella
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)
Tibial plateau fracture
What can be used to classify tibial plateau fractures?
Schatzker classification system
Type 1 Schatzker
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
Type 2 Schatzker fracture
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
Type 3 Schatzker fracture
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
Type 4 Schatzker fracture
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
Schatzker Type 5
Fracture of both condyles
Both condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft
Schatzker Type 6
Combined condylar and subcondylar fractures
High energy fracture with marked comminution
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
The combination of low platelet counts and raised FDP in this setting make DIC the most likely diagnosis.
Why does DIC readily develop in patients with extensive trauma?
Due to the release of tissue factor, a key mediator in the DIC pathway.
Prolonged PT
Prolonged APTT
Prolonged bleeding time
Low plt
DIC
Prolonged PT
Normal APTT
Normal bleeding time
Normal plt
?Warfarin
Normal PT
Normal APTT
Prolonged BT
Normal plt
?Aspirin
PT often normal though may be prolonged
Prolonged APTT
Normal BT
Normal plts
Heparin
Trotter’s triad
Diagnosis of nasopharyngeal carcinoma:
Unilateral conductive hearing loss
ipsilateral facial & ear pain
Ipsilateral paralysis of the soft palate
Featurs of NP carcinoma
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
Treatment of nasopharyngeal carcinoma
RTx is first line
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
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.
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
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.
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
The appendicular artery is a branch of the ileocolic artery.
Which of the following is not well absorbed following a gastrectomy?
Vitamin c
Zinc
Vitamin B12
Copper
Molybdenum
Vitamin B12. The others are unaffected
Features of post-gastrectomy syndrome
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
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
Probing fistulae during acute sepsis is associated with a high complication rate and should not be undertaken routinely.
def: fistula
Abnormal connection between two epithelial surfcaes
What are the four types of fistula
Enterocutaneous
Enteroenteric or enterocolic
Enterovaginal
Enterovesciular
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.
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.
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
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.
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
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.
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.
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.
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.
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.
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
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.
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
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.
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.
Perthes disease
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%
Perthes disease
What can be used to stage Perthes disease?
Catterall staging
Outline Catterall staging
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
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
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.
Management of Addisonian crisis
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.
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
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.
What structures are found at the upper part of manubrium?
Left brachiocephalic vein
Brachiocephalic artery
Left common carotid
Left subclavian artery
What structures are found at the lower part of the manubrium/manubrio-sternal angle?
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
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
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.
What are the nerves found in the GSF?
Sciatic Nerve
Superior and Inferior Gluteal Nerves
Pudendal Nerve
Posterior Femoral Cutaneous Nerve
Nerve to Quadratus Femoris
Nerve to Obturator internus
What are the vessels found in the GSF?
Superior Gluteal Artery and vein
Inferior Gluteal Artery and vein
Internal Pudendal Artery and vein
What is the use for piriformis w.r.t sciatic notch?
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
Boundaries of the GSF
Anterolaterally: greater sciatic notch
Posteromedially: sacrotuberous ligament
Inferior: sacrospinous ligament and ischial spine.
Superior: anterior sacroiliac ligament
Contents of the lesser sciatic foramen
Tendon of the obturator internus
Pudendal nerve
Internal pudendal artery and vein
Nerve to the obturator internus
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
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.
Positive Adsons test
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)
Operative approach for surgical management of cervical rib?
Transaxillary approach
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.
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.
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
Contents of carotid sheath:
Common carotid artery
Internal carotid artery
Internal jugular vein
Vagus nerve
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
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.
Which form of gastrectomy typically gives the best functional outcomes?
Roux en Y
What are some post-gastrectomy syndromes?
Small capacity (early satiety)
Dumping syndrome
Bile gastritis
Afferent loop syndrome
Efferent loop syndrome
Anaemia (B12 deficiency)
Metabolic bone disease
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.
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.
Epidemiology of testicular cancer
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
Testicular tumour:
Commonest subtype (50%)
Average age at diagnosis = 40
Even advanced disease associated with 5 year survival of 73%
Seminoma
Tumour markers in seminomas
AFP normal
HCG elevated in 10%
LDH levated in 10-20%
Tumour markers in non seminomatous germ cell tumours
AFP elevated in 70%
HCG in 40%
Other markers rarely helpful
Subtypes of non seminomatous germ cell tumours
Teratoma
Yolk sac tumour
Choriocarcinoma
Mixed germ cell tumours
Pathology of seminomas
Sheet like lobular patterns of cells with substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen.
Pathology of non seminomatous germ cell tumours
Heterogenous texture with occasional ectopic tissue such as hair
RFs for testicular cancer
Cryptorchidism
Infertility
Family history
Klinefelter’s syndrome
Mumps orchitis
What is a recognised non infective cause of epididymitis
Amiodarone
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
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.
Features of actinomycosis
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.
Pathology of actinomycosis
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.
Treatment of actinomycosis
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.
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.
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.
Management:
Small subcapsular haematoma
Minimal intra abdominal blood
No hilar disruption
Conservative
Management:
Increased amounts of intraabdominal blood
Moderate haemodynamic compromise
Tears or lacerations affecting <50%
Laparotomy with conservation
Management
Hilar injuries
Major haemorrhage
Major associated injuries
Resection
Technique in traumatic splenectomy
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
Elective splenectomy process
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.
Complications of splenectomy
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
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
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.
Malignant fibrous histiocytoma
is a sarcoma that may arise in both soft tissue and bone.
Features that should raise suspicion for sarcoma
Large >5cm soft tissue mass
Deep tissue location or intra muscular location
Rapid growth
Painful lump
Assessment of sacroma
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.
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
Ewings sarcoma
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
Osteosarcoma
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
Liposarcoma
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
Malignant Fibrous Histiocytoma
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
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
Features of pathological fracture
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.
What can be used to help determine the risk of fracture in pathological fracutre?
Mirel Scoring system
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
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.
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
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.
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
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.
Mediator in T1HS
IgE
Mediator in T2HS
IgG, IgM
Mediator in T3HS
IgG, IgA, IgM
Mediator in T4HS
T-cells
Antigens in HS reactions
T1: exogenous
T2: cell surface
T3: soluble
T4: Tissues
Which vitamin is involved in the formation of collagen?
Vitamin A
Vitamin B
Vitamin C
Vitamin D
Vitamin E
Vitamin C is needed for the hydroxylation of proline during collagen synthesis.
Features of osteogenesis imperfecta
-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.
Features of Ehlers Danlos
- 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.
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
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.
Imaging in fat emboli
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
Treatment of fat embolism
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
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
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.
Location of the subcostal plane
Lowest margin of the 10th costal cartilage
Intercristal plane
L4 (highest point of iliac crest)
Intertubercular plane
L5
|MA level
L3
Aortic bifurcation level
L4
Formation of IVC level
L5
Vena cava pierces diaphragm at
T8
Oesophagus pierces diaphragm at
T10
Aortic hiatus is at
T12
