Block 5 Flashcards
Associated with inflammatory bowel disease/RA
Can occur at stoma sites
Erythematous nodules or pustules which ulcerate
Pyoderma gangrenosum
What condition most commonly leads to amputation in diabetics?
Plantar neuropathic ulcer
Which of the following statements about blood clotting is untrue?
Platelet adhesion to disrupted endothelium is dependent upon von Willebrand factor
Protein C is a vitamin K dependent substance
The bleeding time provides an assessment of platelet function
The prothrombin time tests the extrinsic system
Administration of aprotinin during liver transplantation surgery prolongs survival
Administration of aprotinin during liver transplantation surgery prolongs survival
Although aprotinin reduces fibrinolysis and thus bleeding, it is associated with increased risk of death and was withdrawn in 2007. Protein C is dependent upon vitamin K and this may paradoxically increase the risk of thrombosis during the early phases of warfarin treatment.
Which of the following upper limb muscles is not innervated by the radial nerve?
Extensor carpi ulnaris
Abductor digiti minimi
Anconeus
Supinator
Brachioradialis
Mnemonic for radial nerve muscles: BEST
B rachioradialis
E xtensors
S upinator
T riceps
Abductor digiti minimi is innervated by the ulnar nerve.
Root values of the radial nerve
C5-T1
Path of the radial nerve
In the axilla: lies posterior to the axillary artery on subscapularis, latissimus dorsi and teres major.
Enters the arm between the brachial artery and the long head of triceps (medial to humerus).
Spirals around the posterior surface of the humerus in the groove for the radial nerve.
At the distal third of the lateral border of the humerus it then pierces the intermuscular septum and descends in front of the lateral epicondyle.
At the lateral epicondyle it lies deeply between brachialis and brachioradialis where it then divides into a superficial and deep terminal branch.
Deep branch crosses the supinator to become the posterior interosseous nerve.
Theme: Surgical analgesia
A.Amitriptylline
B.Pregabalin
C.Duloxetine
D.Paracetamol
E.Diclofenac
F.Nefopam
G.Morphine
Please select the most appropriate analgesic modality for the scenario given. Each option may be used once, more than once or not at all.
1.A 72 year old man attends vascular clinic after having an amputation 2 months ago. He is having difficulty sleeping at night due to persistent tingling at the amputation site. He is known to have orthostatic hypotension.
A 64 year old type 2 diabetic is referred to vascular clinic with painful foot ulcers. His ABPI is 0.6. On further questioning the patient reports a burning sensation in both of his feet.
A 24 year old man has had a fracture of the tibia after playing football. He arrives in the emergency room distressed and in severe pain.
Pregabalin
This patient has phantom limb pain which is a neuropathic pain. First line management is with amitriptylline or pregabalin. However this patient has orthostatic hypotension, which is a side effect of amitriptylline, therefore pregabalin is the treatment of choice.
Duloxetine
This NICE guidelines state that duloxetine should be used as a 1st line agent in diabetic neuropathic pain.
Morphine
This type of injury will require morphine. However, timely fracture splinting will have a significant analgesic effect.
A 43 year old man from Greece presents with colicky right upper quadrant pain, jaundice and an urticarial rash. He is initially treated with ciprofloxacin, but does not improve. What is the most likely diagnosis?
Infection with Wucheria bancrofti
Infection with Echinococcus granulosus
Type III hypersensitivity reaction
Allergy to ciprofloxacin
Common bile duct stones
Infection with Echinococcus granulosus will typically produce a type I hypersensitivity reaction which is characterised by an urticarial rash. With biliary rupture a classical triad of biliary colic, jaundice and urticaria occurs. Whilst jaundice and biliary colic may be a feature of CBD stones they do not produce an urticarial rash. Antibiotic sensitivity with ciprofloxacin may produce jaundice and a rash, however it was not present at the outset and does not cause biliary colic.
Hydatid cysts are endemic in Mediterranean and Middle Eastern countries. They are caused by the tapeworm parasite
Echinococcus granulosus
Up to 90% cysts occur in the liver and lungs
Can be asymtomatic, or symptomatic if cysts > 5cm in diameter
Morbidity caused by cyst bursting, infection and organ dysfunction (biliary, bronchial, renal and cerebrospinal fluid outflow obstruction)
In biliary ruputure there may be the classical triad of; biliary colic, jaundice, and urticaria
Echinococcus granulosus
Which of the following forms the floor of the anatomical snuffbox?
Radial artery
Cephalic vein
Extensor pollicis brevis
Scaphoid bone
Cutaneous branch of the radial nerve
The scaphoid bone forms the floor of the anatomical snuffbox. The cutaneous branch of the radial nerve is much more superficially and proximally located.
Posterior border of the anatomical snuffbox
Tendon of extensor pollicis longus
Anterior border of the anatomical snuffbox
Tendons of extensor pollicis brevis and abductor pollicis longus
Proximal border border of the anatomical snuffbox
Styloid process of the radius
Distal border of the anatomical snuffbox
Apex of snuffbox triangle
Floor of the anatomical snuffbox
trapezium and scaphoid
Contents of the anatomical snuffbox
Radial artery
During a liver resection a surgeon performs a pringles manoeuvre to control bleeding. Which of the following structures will lie posterior to the epiploic foramen at this level?
Hepatic artery
Cystic duct
Greater omentum
Superior mesenteric artery
Inferior vena cava
The epiploic foramen has the following boundaries:
Anteriorly (in the free edge of the lesser omentum): Bile duct to the right, portal vein behind and hepatic artery to the left.
Posteriorly Inferior vena cava
Inferiorly 1st part of the duodenum
Superiorly Caudate process of the liver
Bleeding from liver trauma or a difficult cholecystectomy can be controlled with a vascular clamp applied at the epiploic foramen.
Structure of the liver
Right lobe
Supplied by right hepatic artery
Contains Couinaud segments V to VIII (-/+Sg I)
Structure of the liver
Left lobe
Supplied by the left hepatic artery
Contains Couinaud segments II to IV (+/- Sg1)
Structure of the liver
Quadrate lobe
Part of the right lobe anatomically, functionally is part of the left
Couinaud segment IV
Porta hepatis lies behind
On the right lies the gallbladder fossa
On the left lies the fossa for the umbilical vein
Structure of the liver
Caudate lobe
Supplied by both right and left hepatic arteries
Couinaud segment I
Lies behind the plane of the porta hepatis
Anterior and lateral to the inferior vena cava
Bile from the caudate lobe drains into both right and left hepatic ducts
Anterior relations of the liver?
Diaphragm
Xiphoid process
Posteroinferior relations of the liver?
Oesophagus
Stomach
Duodenum
Hepatic flexure of colon
Right kidney
Gallbladder
Inferior vena cava
Location of the porta hepatis
Postero inferior surface, it joins nearly at right angles with the left sagittal fossa, and separates the caudate lobe behind from the quadrate lobe in front
Porta hepatis transmits
Common hepatic duct
Hepatic artery
Portal vein
Sympathetic and parasympathetic nerve fibres
Lymphatic drainage of the liver (and nodes)
2 layer fold peritoneum from the umbilicus to anterior liver surface
Contains ligamentum teres (remnant umbilical vein)
On superior liver surface it splits into the coronary and left triangular ligaments
Falciform ligament
Ligament that joins the left branch of the portal vein in the porta hepatis
Ligamentum teres
Remnant of ductus venosus
Ligamentum venosum
Theme: Management of bleeding
A.Ligate vessel
B.Underrun vessel
C.Use of diathermy
D.Application of surgicell
E.Digital pressure
In each of the following scenarios the surgeon has encountered bleeding. Please select the most appropriate immediate management of the situation from the list below. Each option may be used once, more than once or not at all.
7.A 23 year old man is undergoing an open appendicectomy. The surgeons extend the incision medially and suddenly encounter troublesome bleeding.
A 45 year old man is undergoing a laparotomy and following incision of the skin multiple bleeding points are identified in the dermis and sub dermal tissues.
A 38 year old lady is undergoing a laparotomy when the surgeons damage the common iliac vein whilst commencing a pelvic dissection.
Ligate vessel
Theme from April 2012 Exam
Medial extension of an appendicectomy incision carries the risk of injury to the inferior epigastric artery. This can bleed briskly and is best managed by ligation.
Use of diathermy
Multiple bleeding points are best managed through the use of diathermy.
Digital pressure
Major venous bleeding such as this should be controlled with digital pressure in the first instance. The definitive management will usually consist of suturing the defect closed with prolene sutures. Transection of the common iliac vein will necessitate a major venous reconstruction.
Management of superficial dermal bleeding
This will usually cease spontaneously. If it is troublesome then direct use of monopolar or bipolar cautery devices will usually control the situation. Scalp wounds are a notable exception and the bleeding from these may be brisk. In this situation the use of mattress sutures as a wound closure method will usually address the problem.
Superficial arterial bleeding
If the vessel can be safely identified then the easiest method is to apply a haemostatic clip and ligate the vessel.
Major arterial bleeding
If the vessel can be clearly identified and is accessible then it may be possible to apply a clip and ligate the vessel. If the vessel is located in a pool of blood then blind application of haemostatic clips is highly dangerous and may result in collateral injury. In this situation evacuating the clot and packing the area is often safer. The pack can then be carefully removed when the required instruments are available. Some vessels may retract and bleeding may then be controlled by dissection of surrounding structures or under-running the bleeding point.
Major venous bleeding
The safest initial course of action is to apply digital pressure to the bleeding point. To control the bleeding the surgeon will need a working suction device. Divided veins may require ligation. Incomplete lacerations of major veins (e.g. IVC) are best repaired. In order to do this it is safest to apply a Satinsky type vascular clamp and repair the defect with 5/0 prolene.
Achieving haemostasis in surgery: bleeding from raw surfaces
This may be mixed bleeding and can be troublesome. Spray diathermy and argon plasma coagulation are both useful agents. Certain topical haemostatic agents such as surgicell are useful in encouraging clot formation and may be used in conjunction with, or instead of, the above agents.
Next question
Lateral border of femoral canal
Femoral vein
Medial border of femoral canal
Lacunar ligament
Anterior border of femoral canal
Inguinal ligament
Posterior border of femoral canal
Pectineal ligament
Contents of the femoral canal
Lymphatic vessles
Cloquet’s lymph node
Cloquet’s lymph node
It is named for French surgeon Jules Germain Cloquet,or German anatomist Johann Christian Rosenmüller. It can be considered the uppermost of the deep inguinal lymph nodes or the lowest of the external iliac lymph nodes.
Theme: Right iliac fossa pain
A.Urinary tract infection
B.Appendicitis
C.Mittelschmerz
D.Mesenteric adenitis
E.Crohns disease
F.Ulcerative colitis
G.Meckels diverticulum
Please select the most likely cause for right iliac fossa pain for the scenario given. Each option may be used once, more than once or not at all.
11.A 17 year old male is admitted with lower abdominal discomfort. He has been suffering from intermittent right iliac fossa pain for the past few months. His past medical history includes a negative colonoscopy and gastroscopy for iron deficiency anaemia. The pain is worse after meals. Inflammatory markers are normal.
A 14 year old female is admitted with sudden onset right iliac fossa pain. She is otherwise well and on examination has some right iliac fossa tenderness but no guarding. She is afebrile. Urinary dipstick is normal. Her previous menstrual period two weeks ago was normal and pregnancy test is negative.
A 21 year old male is admitted with a 3 month history of intermittent right iliac fossa pain. He suffers from episodic diarrhoea and has lost 2 kilos in weight. On examination he has some right iliac fossa tenderness and is febrile.
Meckels diverticulum
This scenario should raise suspicion for Meckels as these may contain ectopic gastric mucosa which may secrete acid with subsequent bleeding and ulceration.
Mittelschmerz
Typical story and timing for mid cycle pain. Mid cycle pain typically occurs because a small amount of fluid is released at the time of ovulation. It will usually resolve over 24-48 hours.
Crohns disease
Weight loss and chronic symptoms coupled with change in bowel habit should raise suspicion for Crohns. The presence of intermittent right iliac fossa pain is far more typical of terminal ileal Crohns disease. Both UC and Crohns may be associated with a low grade pyrexia. The main concern here would be locally perforated Crohns disease with a small associated abscess.
Mainly affects children
Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp.
Patients have a higher temperature than those with appendicitis
If laparotomy is performed, enlarged mesenteric lymph nodes will be present
Mesenteric adenitis
Both left and right sided disease may present with right iliac fossa pain
Clinical history may be similar, although some change in bowel habit is usual
When suspected, a CT scan may help in refining the diagnosis
Diverticulitis
Ddx for RIF pain
Appendicitis
Crohn’s disease
Mesenteric adenitis
Diverticulitis
Meckel’s diverticulitis
Perforated peptic ulcer
Incarcerated right inguinal or femoral hernia
Bowel perforation secondary to caecal or colon carcinoma
Gynaecological causes
Urological causes
A 22 year old lady presents with an episode of renal colic and following investigation is suspected of suffering from MEN IIa. Which of the following abnormalities of the parathyroid glands are most often found in this condition?
Hypertrophy
Hyperplasia
Adenoma
Carcinoma
Metaplasia
MEN IIa
Medullary thyroid cancer
Hyperparathyroidism (usually hyperplasia)
Phaeochromocytoma
In MEN IIa the commonest lesion is medullary thyroid cancer, with regards to the parathyroid glands the most common lesion is hyperplasia. In MEN I a parathyroid adenoma is the most common lesion.
MEN1
Three Ps
Mnemonic ‘three P’s’:
Parathyroid (95%): Parathyroid adenoma
Pituitary (70%): Prolactinoma/ACTH/Growth Hormone secreting adenoma
Pancreas (50%): Islet cell tumours/Zollinger Ellison syndrome
also: Adrenal (adenoma) and thyroid (adenoma)
Most common presentation of MEN I?
Hypercalcaemia
Gene causing MEN1?
MENIN gene (chromosome 11)
MEN IIa
Phaeochromocytoma
Medullary thyroid cancer (70%)
Hyperparathyroidism (60%)
Gene causing MEN IIa?
RET oncogene (Chromosome 10)
MEN IIb
Same as MEN IIa with addition of:
Marfanoid body habitus
Mucosal neuromas
Gene causing MEN IIb
RET oncogene (chromosome 10)
Theme: Nasal diseases
A.Ethmoid sinus cancer
B.Maxillary sinus cancer
C.Ethmoid adenoma
D.Maxillary adenoma
E.Ethmoidal fracture
F.Nasal polyps
G.Sphenoid osteoma
H.Ethmoidal sinusitis
I.Maxillary sinusitis
Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.
2.A 56 year old man presents with symptoms of nasal pain, anosmia and rhinorrhea. He has been well until recently and has worked as a wood carver for many years.
A 32 year old female presents with recurrent episodes of rhinorrhoea, the discharge is watery. She has a medical history of asthma and intolerance of aspirin. On examination she has multiple soft, semi- transparent polyps within her nasal cavity.
A child is brought to casualty complaining of a headache and a sensation of pressure between the eyes. On examination she is febrile with a smooth swelling overlying the superomedial aspect of the right eye. The eye is uncomfortable and there is a purulent discharge from the inner canthus.
Ethmoid sinus cancer
Nasopharyngeal cancer is strongly associated with wood work. Most cases require an occupational exposure of greater than 10 years and are adenocarcinomas on histology.
Most cases are ethmoidal in origin (Hadfield E. Ann R Coll Surg Engl. 1970 June; 46(6): 301319)
Nasal polyps
The combination of nasal polyps and atopy is well described. Some cases will respond favourably to systemic steroids and avoid surgery.
Ethmoidal sinusitis
Ethmoidal sinusitis may spread to the periorbital tissues resulting in periorbital cellulitis. The superomedial distribution makes a maxillary sinusitis less likely.
What are the benign tumours of the nose and sinuses?
Simple papillomas
Transitional cell papillomas
Pleomorphic adenomas
Benign osteomas
Nasal poylps
Benign nasal tumour may be an incidental finding or present with obstructive symptoms. Excision under general anaesthesia is sufficient management.
Simple papillomas
Benign nasal tumour may be more extensive and produce obstructive symptoms. Erosion of local structures is a recognised complication. These lesions may rarely undergo malignant transformation and therefore careful and complete excision is required, some cases may require partial or total maxillectomy.
Transitional cell papillomas
Benign nasal tumour of the maxillary sinuses are reported but are extremely rare, their symptoms typically include nasal obstruction and pain if the sinus is obstructed. Treatment is by complete surgical excision, the diagnosis is not infrequently made post operatively.
Pleomorphic adenomas
Benign nasal/sinus tumours may develop in the paranasal sinuses, the frontal sinus is the most frequent location of such lesions. Symptoms include; pain, rhinorrhoea and anosmia. Most osteomas may be observed if asymptomatic, sphenoid osteomas should be resected soon after diagnosis as enlargement may compromise visual fields. Many sinus osteomas can now be resected endoscopically, complete surgical resection is required.
Osteomas
Benign lesions of the ethmoid sinus mucosa. Many patients may also have asthma, cystic fibrosis and a sensitivity to aspirin. Symptoms include watery rhinorrhoea, infection and anosmia. The polyps are usually a semi transparent grey mass. They are rare in childhood. Treatment is either with systemic steroids or surgical resection. The latter should be combined with antral washout. Low dose, nasal, steroid drops may reduce the risk of recurrence.
Nasal polyps
Malginancies encountered in the nose and paranasal sinuses?
Adenoid cystic carcinoma
SCC
Adenocarcinoma
What carcinoma of the paranasal sinuses and nasopharynx is strongly linked to exposure to hard wood dust (after >10 years exposure).
Adenocarcinoma
Where do adenoid cystic carcinomas normally arise?
Smaller salivary glands
Where do the majority of nasal cancers arise?
The majority of cancers (50%) arise from the lateral nasal wall, a smaller number (33%) arise from the maxillary antrum, ethmoid and sphenoid cancers comprise only 7%.
Signs of malignancy in ?nasopharyngeal cancer?
Loose teeth
CN palsies
Lymphadenopathy
Risk factors for nasopharyngeal cancers
Chinese/asian
Wood working
EBV
Treatment of nasopharyngeal cancers?
RTx and CTx
Common symptoms include post nasal discharge, pain, headache and toothache.
Imaging may show a fluid level in the antrum.
Common organisms include Haemophilus influenzae or Streptococcus pneumoniae.
Treatment with antral lavage may facilitate diagnosis and relieve symptoms. Antimicrobial therapy has to be continued for long periods. Antrostomy may be needed.
Maxillary sinusitis
Usually presents with frontal headache, nasal obstruction and altered sense of smell.
Inflammation may progress to involve periorbital tissues. Ocular symptoms may occur and secondary CNS involvement brought about by infection entering via emissary veins.
CT scanning is the imaging modality of choice. Early cases may be managed with antibiotics. More severe cases usually require surgical drainage.
Frontoethmoidal sinusitis
Theme: Statistics
A.LSD post hoc test
B.Bonferroni test
C.Mann Whitney U test
D.Paired T test
E.Chi squared test
F.Fishers exact test
G.Unpaired T Test
Please select the statistical test that is most appropriate for the scenario provided. Each option may be used once, more than once or not at all.
6.A surgeon has conducted a piece of research and is try to make his data appear interesting for publication. To do this he is conducting multiple analyses of sub group data using multiple tests.
A surgical unit are conducting a study to determine whether patients who have bowel preparation have a lower risk of colonic anastomotic leakage than those having none. The planned sample size is 25.
A surgeon wishes to conduct a national study relating patient weight to the length of inpatient stay following all major operations.
Bonferroni test
This is a process referred to as “data dredging” and can lead to erroneous results. Post hoc testing in general can be a problem in research and to try and minimise the potential for error some advocate the use of the Bonferroni method. This adjusts the test to take account of the number of tests that have been performed on the data.
Fishers exact test
It is likely to be underpowered with the number provided. However, it would be possible to classify such data into a 2x2 contingency table. However, when the sample size is small the Chi squared test is not suitable and in these situations the Fishers exact test is used.
Unpaired T Test
Weight is likely to be normally distributed and when a large size is used it is possible that this will be suitable for testing using a parametric method. The T Test is a powerful test providing it is used correctly and would probably be best suited for analysis of this data set.
Data can be allocated a numerical code that is arbitrary. For example allocating people as alive or dead using codes of 0 or 1
Nominal
Data using numbers that can be used on a scale. Severity of pain is often measured in this way
Ordinal data
Data is measured numerically. However, the zero point is arbitrary
Interval scale
Data is measured numerically where the numerical value is a real number and may be any value. Examples include height and weight
Continuous
Parametric tests
Used to examine normally distributed data
e.g. T test
Non parametric data
Data that is not normally distributed
e.g. Chi squared and Mann Whitney U tests
Issues with Chi squared tests
There are some assumptions that are made in relation to Chi squared tests; these include the need to use 2 degrees of freedom (usually) and the minimum sample size. Where the sample size is small then a different test is appropriate and the Fishers exact test is often used.
When may the paired T test be used?
In situations where data is normally distributed and paired samples are taken from the same individuals (such as following an intervention) then the paired T Test may be used.
What can be used to adjust data to allow for post-hoc multiple analyses?
Bonferroni correction
Which muscle is responsible for causing flexion of the distal interphalangeal joint of the ring finger?
Flexor digitorum superficialis
Lumbricals
Palmar interossei
Flexor digitorum profundus
Flexor digiti minimi brevis
Flexor digitorum superficialis and flexor digitorum profundus are responsible for causing flexion. The superficialis tendons insert on the bases of the middle phalanges; the profundus tendons insert on the bases of the distal phalanges. Both tendons flex the wrist, MCP and PIP joints; however, only the profundus tendons flex the DIP joints.
Arrangement of the interossei?
7 Interossei - Supplied by ulnar nerve
3 palmar-adduct fingers
4 dorsal- abduct fingers
Arrangement of the lumbricals?
Flex MCPJ and extend the IPJ.
Origin deep flexor tendon and insertion dorsal extensor hood mechanism.
Innervation of the 1st and 2nd lumbricals?
Median nerve
Innervation of the 3rd and 4th lumbricals?
Deep branch of the ulnar nerve
Muscles of the thenar eminence?
AOF (L->M)
Abductor pollicis brevis
Opponens pollicis
Flexor pollicis brevis
Muscles of the hypothenar eminence?
Opponens digiti minimi
Flexor digiti minimi brevis
Abductor digiti minimi
Arrangement of the palmar fascia
Continuous with antebrachial fascia and fascia of dorsum of the hand
Thin over the thenar and hypothenar eminences but thicker in the middle.
Apex of the palmar aponeurosis is conintuous with the flexor retinaculum and palmaris longus.
Distally it forms four longitudinal digital bands that attach to the bases of the proximal phalanges, blending with the fibrous digital sheaths
Where is the medial fibrous septum of the palm?
Extends from the medial border of the palmar aponeurosis to the 5th metacarpal.
Medial to this are the hypothenar muscles
Where is the lateral fibrous septum of the palm?
Extends from the lateral border of the palmar aponeurosis to the 3rd metacarpal
The thenar compartment lies lateral to this area
What are the contents of the central compartment of the palm?
Flexor tendons and their sheaths
Lumbricals
Superficial palmar arterial arch and the digital vessels and nerves
What is the deepest muscular plane of the hand?
The adductor compartment which contains adductor pollicis
Long flexor tendons and sheaths in the hand
Tendons of FDS and FDP enter the common flexor sheath deep to the flexor retinaculum
Enter the central compartment and fan out to their respective digital synovial sheaths.
FDS splits near the base of the proximal phlanax to allow passage of FDP.
FDP is attached to the margins of the anterior aspect of the base of the distal phalanx
The fibrous digital sheaths contain the flexor tendons and their synovial sheaths, extending from the heads of the metacarapls to the base of the distal phalanges
A 33 year old lady develops a thunderclap headache and collapses. A CT scan shows that she has developed a subarachnoid haemorrhage. She currently has no evidence of raised intracranial pressure. Which of the following drugs should be administered?
None
Atenotol
Labetolol
Nimodipine
Mannitol
Nimodipine is a calcium channel blocker. It reduces cerebral vasospasm and improves outcomes. It is administered to most cases of sub arachnoid haemorrhage.
Most common cause of SAH
Intracranial aneurysms.
Approximately 10% of cases will have normal angiography and the cause will remain unclear.
Ix of SAH
CT scan for all (although as CSF blood clears the sensitivity declines)
Lumbar puncture if CT normal (very unlikely if normal)
CT angiogram to look for aneurysms.
Mx of SAH
Supportive treatment, optimising BP (not too high if untreated aneurysm) and ventilation if needed.
Nimodipine reduces cerebral vasospasm and reduces poor outcomes.
Untreated patients most likely to rebleed in first 2 weeks.
Patients developing hydrocephalus will need a V-P shunt (external ventricular drain acutely).
Electrolytes require careful monitoring and hyponatraemia is common.
Treatment of intracranial aneurysm
>80% aneuryms arise from the anterior circulation
Craniotomy and clipping of aneurysm is standard treatment, alternatively suitable lesions may be coiled using an endovascular approach. Where both options are suitable data suggests that outcomes are better with coiling than surgery.
Theme: Oesophageal disease
A.Oesophagectomy
B.Endoscopic sub mucosal dissection
C.Photodynamic therapy
D.Insertion of oesophageal stent
E.Chemotherapy
F.Radiotherapy
Please select the most appropriate treatment modality for the scenario given. Each option may be used once, more than once or not at all.
11.A 52 year old man with long standing Barretts oesophagus is diagnosed with high grade dysplasia on recent endoscopy. The lesions are multifocal and mainly distally sited.
A 82 year old man presents with dysphagia. He is investigated and found to have an adenocarcinoma of the distal oesophagus. His staging investigations have revealed a solitary metastatic lesion in the right lobe of his liver.
An 83 year old lady with long standing Barretts oesophagus is diagnosed with a 1cm focus of high grade dysplasia 3cm from the gastrooesophageal junction.
Oesophagectomy
Some may argue for local therapy. However, in young patients who are otherwise fit, multifocal disease such as this should probably be resected.
Insertion of oesophageal stent
Although he may be palliated with chemotherapy a stent will produce the quickest clinical response. Metastatic disease is usually a contra indication to oesophageal resection.
Endoscopic sub mucosal dissection
As she is elderly and the disease localised EMR is an appropriate first line step.
The technique involves raising the mucosa containing the lesion and then using an endoscopic snare to remove it. This technique is therefore minimally invasive. However, it is only suitable for early superficial lesions. Deeper invasion would carry a high risk of recurrence.
Neoadjuvant therapy in oesophageal cancer
Given in most cases prior to surgery
Use of Ivor Lewis oesophagectomy?
In patients with lower third lesions an Ivor - Lewis type procedure is most commonly performed. Very distal tumours may be suitable to a transhiatal procedure. Which is an attractive option as the penetration of two visceral cavities required for an Ivor- Lewis type procedure increases the morbidity considerably.
Operative details of Ivor- Lewis procedure
Combined laparotomy and right thoracotomy
McKeown oesophagectomy?
More proximal lesions will require a total oesphagectomy (Mckeown type) with anastomosis to the cervical oesophagus.
Preparation for Ivor-Lewis oesophagectomy?
Staging with a combination of CT chest abdomen and pelvis- if no metastatic disease detected then patients will undergo a staging laparoscopy to detect peritoneal disease.
If both these modalities are negative then patients will finally undergo a PET CT scan to detect occult metastatic disease. Only those in whom no evidence of advanced disease is detected will proceed to resection.
Patients receive a GA, double lumen endotracheal tube to allow for lung deflation, CVP and arterial monitoring.
Procedure in Ivor Lewis oesophagectomy?
A rooftop incision is made to access the stomach and duodenum.
Laparotomy
Right Thoracotomy
Laparotomy in Ivor-Lewis oesophagectomy
The greater omentum is incised away from its attachment to the right gastroepiploic vessels along the greater curvature of the stomach.
Then the short gastric vessels are ligated and detached from the greater curvature from the spleen.
The lesser omentum is incised, preserving the right gastric artery.
The retroperitoneal attachments of the duodenum in its second and third portions are incised, allowing the pylorus to reach the oesophageal hiatus. Some surgeons perform a pyloroplasty at this point to facilitate gastric emptying.
The left gastric vessels are then ligated, avoiding any injury to the common hepatic or splenic arteries. Care must be taken to avoid inadvertently devascularising the liver owing to variations in anatomy.
Right thoracotomy in Ivor Lewis?
Through 5th intercostal space
Dissection performed 10cm above the tumour
This may involve transection of the azygos vein.
The oesophagus is then removed with the stomach creating a gastric tube.
An anastomosis is created.
Post-operative recovery following Ivor-Lewis oesophagectomy?
Patients will typically recover in ITU initially.
A nasogastric tube will have been inserted intraoperatively and must remain in place during the early phases of recovery.
Post operatively these patients are at relatively high risk of developing complications:
Post-op complications following Ivor-Lewis
* Atelectasis- due to the effects of thoracotomy and lung collapse
* Anastomotic leakage. The risk is relatively high owing to the presence of a relatively devascularised stomach. Often the only blood supply is from the gastroepiploic artery as all others will have been divided. If a leak does occur then many will attempt to manage conservatively with prolonged nasogastric tube drainage and TPN. The reality is that up to 50% of patients developing an anastomotic leak will not survive to discharge.
* Delayed gastric emptying (may be avoided by performing a pyloroplasty).
A 23 year old man is stabbed in the right upper quadrant and is haemodynamically unstable. A laparotomy is performed and the liver has some extensive superficial lacerations and is bleeding profusely. The patient becomes progressively more haemodynamically unstable. What is the best management option?
Pack the liver and close the abdomen
Occlude the hepatic inflow with a pringles manoeuvre and suture the defects
Occlude vascular inflow and resect the most severely affected area anatomically
Perform a portosystemic shunt procedure
Suture the defects without vascular occlusion
Packing of the liver is the safest option and resection or repair considered later when the physiology is normalised. Often when the packs are removed all the bleeding has ceased and the abdomen can be closed without further action. Definitive attempts at suturing or resection at the primary laparotomy are often complicated by severe bleeding.
Trimodal death distribution following trauma
Immediately following injury. Typically as result of brain or high spinal injuries, cardiac or great vessel damage. Salvage rate is low.
In early hours following injury. In this group deaths are due to phenomena such as splenic rupture, sub dural haematomas and haemopneumothoraces
In the days following injury. Usually due to sepsis or multi organ failure.
Aspects of trauma mangement
ABCDE approach.
Tension pneumothoraces will deteriorate with vigorous ventilation attempts.
External haemorrhage is managed as part of the primary survey. As a rule tourniquets should not be used. Blind application of clamps will tend to damage surrounding structures and packing is the preferred method of haemorrhage control.
Urinary catheters and naso gastric tubes may need inserting. Be wary of basal skull fractures and urethral injuries.
Patients with head and neck trauma should be assumed to have a cervical spine injury until proven otherwise.
Thoracic traumatic injuries
Simple pneumothorax
Mediastinal traversing wounds
Tracheobronchial tree injury
Haemothorax
Blunt cardiac injury
Diaphragmatic injury
Aortic disruption
Pulmonary contusion
Management of simple pneumothorax in thoracic trauma?
insert chest drain. Aspiration is risky in trauma as pneumothorax may be from lung laceration and convert to tension pneumothorax.
These result from situations like stabbings. Exit and entry wounds in separate hemithoraces. The presence of a mediastinal haematoma indicates the likelihood of a great vessel injury. All patients should undergo CT angiogram and oesophageal contrast swallow. Indications for thoracotomy are largely related to blood loss and will be addressed below
Mediastinal traversing wounds
Unusual injuries. In blunt trauma most injuries occur within 4cm of the carina. Features suggesting this injury include haemoptysis and surgical emphysema. These injuries have a very large air leak and may have tension pneumothorax.
Tracheobronchial tree injury
Usually caused by laceration of lung vessel or internal mammary artery by rib fracture. Patients should all have a wide bore 36F chest drain. Indications for thoracotomy include loss of more than 1.5L blood initially or ongoing losses of >200ml per hour for >2 hours.
Haemothorax
Usually cardiac arrhythmias, often overlying sternal fracture. Perform echocardiography to exclude pericardial effusions and tamponade. Risk of arrhythmias falls after 24 hours.
Cardiac contusions
Commonest cause of death after RTA or falls. Usually incomplete laceration near ligamentum arteriosum. All survivors will have contained haematoma. Only 1-2% of patients with this injury will have a normal chest x-ray.
Traumatic aortic disruption
Common and lethal. Insidious onset. Early intubation and ventilation.
Pulmonary contusion
Thoracic trauma
Usually left sided. Direct surgical repair is performed.
Diaphragmatic injury
What is most commonly injured in blunt trauma requiring laparotomy?
Spleen (40%)
Abdominal stab wounds most commonly affect?
Liver
Abdominal gunshot wounds most commonly affect?
Small bowel (50%)
Outcome of patients with abdominal stab wounds and no peritoneal signs?
25% of stab wounds will not enter the peritoneal cavity
Investigations in abdominal trauma?
DPL
Abdominal CT
USS
Indication for DPL
Document bleeding in abdominal trauma if hypotensive
Advantages of DPL
Early diagnosis and sensitive; 98% accurate
Disadvantages of DPL
Invasive and may miss retroperitoneal and diaphragmatic injury
Indications for abdominal CT scan post trauma
Document organ injury if normotensive
Advantages of abdominal CT in trauma
Most specific for localising injury; 92 to 98% accurate
Disadvantages of abdominal CT scan?
Location of scanner away from facilities, time taken for reporting, need for contrast
Indication for USS in abdominal trauma?
Document fluid if hypotensive
Advantages of abdo USS in trauma?
Early diagnosis, non invasive and repeatable; 86 to 95% accurate
Disadvantages of abdominal USS in trauma
Operator dependent and may miss retroperitoneal injury
A 22 year old man is admitted to hospital with a lower respiratory chest infection. He had a splenectomy after being involved in a car accident. What is the most likely infective organism?
Haemophilus influenzae
Staphylococcus aureus
Rhinovirus
Mycobacterium tuberculosis
Moraxella catarrhalis
Organisms causing post splenectomy sepsis:
Streptococcus pneumoniae
Haemophilus influenzae
Meningococci
Encapsulated organisms carry the greatest pathogenic risk following splenectomy. The effects of sepsis following splenectomy are variable. This may be the result of small isolated fragments of splenic tissue that retain some function following splenectomy. These may implant spontaneously following splenic rupture (in trauma) or be surgically implanted at the time of splenectomy.
Why does splenectomy increase the risk of sepsis from encapsulated organisms?
Hyposplenism, by whatever mechanism it occurs dramatically increases the risk of post splenectomy sepsis, particularly with encapsulated organisms. Since these organisms may be opsonised, but this then goes undetected at an immunological level due to loss of the spleen. For this reason individuals are recommended to be vaccinated and have antibiotic prophylaxis.
Vaccinations and elective splenectomy
PCV, HIb and MCV 2 weeks prior to spleenctomy or two weeks following splenectomy
Other vaccinations and splenectomy
Annual influenza vaccination
Antibiotic prophlyaxis in patients without spleen
Antibiotic prophylaxis is offered to all. The risk of post splenectomy sepsis is greatest immediately following splenectomy and in those aged less than 16 years or greater than 50 years. Individuals with a poor response to pneumococcal vaccination are another high risk group. High risk individuals should be counselled to take penicillin or macrolide prophylaxis. Those at low risk may choose to discontinue therapy. All patients should be advised about taking antibiotics early in the case of intercurrent infections.
In what patient groups is post-splenectomy sepsis greates risk?
Greatest risk immediately after spleenctomy
<16y/o or >50y/o,
Individuals with poor response to PCV.
Prophylactic abx dosing post-splenectomy?
Pen V 500mg BD or amoxicillin 250mg BD
A 28 year old male presents with painful, bright red, rectal bleeding. On examination he is found to have a posteriorly sited, midline, fissure in ano. What is the most appropriate treatment?
Topical GTN paste
Sub lingual GTN paste
Anal stretch
Advancement flap
Tailored division of the external anal sphincter
Topical vasodilator therapy is the most commonly utilised treatment for fissure in ano. Surgical division of the internal anal sphincter is a reasonable treatment option in a young male. Division of the external sphincter will almost certainly result in incontinence and is not performed. Anal stretches were associated with a high rate of external sphincter injuries and have been discontinued for this reason.
Most effective first line agents in anal fissure?
The most effective first line agents are topically applied GTN (0.2%) or Diltiazem (2%) paste. Side effects of diltiazem are better tolerated.
A 34 year old lady undergoes a thyroidectomy for Graves disease. Post operatively she develops a tense haematoma in the neck. In which of the following fascial planes will it be contained?
Gerotas fascia
Waldeyers fascia
Pretracheal fascia
Sibsons fascia
Clavipectoral fascia
The pretracheal fascia encloses the thyroid and is unyielding. Therefore tense haematomas can develop.
Apex of thyroid
Lamina of thyroid cartilage
Base of thyroid
4th-5th tracheal ring
Anteromedial relations of the thyroid?
Sternothyroid
Superior belly of omohyoid
Sternohyoid
Anterior aspect of sternocleidomastoid
Posterolateral relations of the thyroid?
Carotid sheath
Medial relations of the thyroid?
Larynx
Trachea
Pharynx
Oesophagus
Cricothyroid muscle
External laryngeal nerve (near superior thyroid artery)
Recurrent laryngeal nerve (near inferior thyroid artery)
Posterior relations of the thyroid?
Parathyroid glands
Anastomosis of superior and inferior thyroid arteries
Relations of the isthmus of the thyroid
Anteriorly: Sternothyroids, sternohyoids, anterior jugular veins
Posteriorly: 2nd, 3rd, 4th tracheal rings (attached via Ligament of Berry)
Arterial supply of the thyroid?
Superior thyroid artery (1st branch of external carotid)
Inferior thyroid artery (from thyrocervical trunk)
Thyroidea ima (in 10% of population -from brachiocephalic artery or aorta)
What proportion of the population have thyroid ima?
10%
Venous drainage of the thyroid?
Superior and middle thyroid veins - into the IJV
Inferior thyroid vein - into the brachiocephalic veins
Theme: Management of vomiting
A.Ondansetron
B.Metoclopramide
C.Cyclizine
D.Erythromycin
E.Cisapride
F.Haloperidol
Please select the most appropriate drug for the given scenario. Each option may be used once, more than once or not at all.
18.A 78 year old man with diabetes develops autonomic gastropathy with persistent and troublesome vomiting.
A drug which blocks the chemoreceptor trigger zone in the area postrema.
A 48 year old man with oesphageal varices has a profuse haemorrhage on the ward.
Erythromycin
Unlike metoclopramide. the effects of erythromycin on gastric emptying are not mediated via the vagus nerve.
Ondansetron
5 HT3 blockers are most effective for many types of nausea for this reason.
Metoclopramide
Intravenous metoclopramide causes increased oesophageal pressure and this may temporarily slow the rate of haemorrhage whilst more definitive measures are instigated.
Where is the vomiting centre?
Medulla oblongata
What locations have input on the vomiting centre?
Labyrinthine receptors of ear (motion sickness)
Over distention receptors of duodenum and stomach
Trigger zone of CNS - many drugs (e.g., opiates) act here
Touch receptors in throat
Which of the following cell types is least likely to be found in a wound 1 week following injury?
Macrophages
Fibroblasts
Myofibroblasts
Endothelial cells
Neutrophils
Myofibroblasts
Myofibroblasts are differentiated fibroblasts, in which the cytoskeleton contains actin filaments. These cell types facilitate wound contracture and are the hallmark of a mature wound. They are almost never found in wounds less than 1 month old.
Remember the question asks about the cell type asks about which cells are least likely to be found.
What are the phases of wound healing?
Haemostasis
Inflammation
Regeneration
Remodelling
Cells involved in wound haemostasis
Erythrocytes and plts
Features of haemostasis in wound healing?
Vasospasm in adjacent vessles
Platelt plug formation and generation of fibrin rich clot
Cells involved in inflammation phase of wound healing?
Neutrophils, fibroblasts and macrophages
Timeframe in the inflammation phase of wound healing?
Days
Features of the inflammatory phase of wound healing?
Neutrophils migrate into wound (function impaired in diabetes).
Growth factors released, including basic fibroblast growth factor and vascular endothelial growth factor.
Fibroblasts replicate within the adjacent matrix and migrate into wound.
Macrophages and fibroblasts couple matrix regeneration and clot substitution.
Cells involved in regenerative phase of wound healing?
Fibroblasts, endothelial cells, macrophages
Features of regenerative phase of wound healing?
Platelet derived growth factor and transformation growth factors stimulate fibroblasts and epithelial cells.
Fibroblasts produce a collagen network.
Angiogenesis occurs and wound resembles granulation tissue.
Timescale of regenerative phase of wound healing
Weeks
Timescale of remodelling phase of wound healing
6w to 1 year
Cells involved in remodelling phase of wound healing?
Myofibroblasts
Key features of remodelling phase of wound healing?
Longest phase of the healing process and may last up to one year (or longer).
During this phase fibroblasts become differentiated (myofibroblasts) and these facilitate wound contraction.
Collagen fibres are remodelled.
Microvessels regress leaving a pale scar.
The blood - brain barrier is not highly permeable to which of the following?
Carbon dioxide
Barbituates
Glucose
Oxygen
Hydrogen ions
The blood brain barrier is relatively impermeable to highly dissociated compounds.
A 43 year old presents to the urology clinic complaining of impotence. Which of the following will occur in response to increased penile parasympathetic stimulation?
Detumescence
Ejaculation
Erection
Vasospasm of the penile branches of the pudendal artery
Contraction of the smooth muscle in the epididymis and vas deferens
Memory aid for erection
p=parasympathetic=points
s=sympathetic=shoots
Parasympathetic stimulation causes erection. Sympathetic stimulation will produce ejaculation, detumescence and vasospasm of the pudendal artery. It will also cause contraction of the smooth muscle in the epididymis and vas to convey the ejaculate.
Autonomic nerves of erection
Sympathetic nerves originate from T11-L2 and parasympathetic nerves from S2-4 join to form pelvic plexus.
Parasympathetic discharge causes erection, sympathetic discharge causes ejaculation and detumescence.
Somatic nerves of erection
Supplied by dorsal penile and pudendal nerves. Efferent signals are relayed from Onufs nucleus (S2-4) to innervate ischiocavernosus and bulbocavernosus muscles.
def: priapsim
Prolonged unwanted erection, in the absence of sexual desire, lasting more than 4 hours.
How can priapism be classified?
Low flow
High flow
Recurrent
Low flow pripaism
Due to veno-occlusion (high intracavernosal pressures).
Most common type
Often painful
Often low cavernosal flow
If present for >4 hours requires emergency treatment
Blood flow in erection
Autonomic discharge to the penis will trigger the veno-occlusive mechanism which triggers the flow of arterial blood into the penile sinusoidal spaces. As the inflow increases the increased volume in this space will secondarily lead to compression of the subtunical venous plexus with reduced venous return. During the detumesence phase the arteriolar constriction will reduce arterial inflow and thereby allow venous return to normalise.
High flow priapism
Due to unregulated arterial blood flow.
Usually presents as semi rigid painless erection
Recurrent priapism
Typically seen in sickle cell disease, most commonly of high flow type.
Causes of priapism
Intracavernosal drug therapies (e.g. for erectile dysfunction>
Blood disorders such as leukaemia and sickle cell disease
Neurogenic disorders such as spinal cord transection
Trauma to penis resulting in arterio-venous malformations
Ix in priapsim
Exclude sickle cell/ leukaemia
Consider blood sampling from cavernosa to determine whether high or low flow (low flow is often hypoxic)
Mx of priapsim
Ice packs/ cold showers/exercise
If due to low flow then blood may be aspirated from copora or try intracavernosal alpha adrenergic agonists.
Delayed therapy of low flow priapism may result in erectile dysfunction.
A 32 year old lady complains of carpal tunnel syndrome. The carpal tunnel is explored surgically. Which of the following structures will lie in closest proximity to the hamate bone within the carpal tunnel?
The tendon of abductor pollicis longus
The tendons of flexor digitorum profundus
The tendons of flexor carpi radialis longus
Median nerve
Radial artery
The carpal tunnel contains nine flexor tendons:
Flexor digitorum profundus
Flexor digitorum superficialis
Flexor pollicis longus
The tendon of flexor digitorum profundus lies deepest in the tunnel and will thus lie nearest to the hamate bone.
What is interesting about the arrangement of carpal bones SLT?
No tendons attach to: Scaphoid, lunate, triquetrum (stabilised by ligaments)
Theme: Surgical complications
A.Anastamotic leak
B.Chyle leak
C.Air leak
D.Biliary leak
E.Deep vein thrombosis
F.Portal vein thrombosis
G.Biliary obstruction
Please select the most likely complication for the scenario given. Each option may be used once, more than once or not at all.
25.A 67 year old female undergoes an oesophagogastrectomy for carcinoma of the distal oesophagus. She complains of chest pain. The following day there is brisk bubbling into the chest drain when suction is applied.
A 20 year old man has a protracted stay on ITU following a difficult appendicectomy for perforated appendicitis with pelvic and sub phrenic abscesses. He has now deteriorated further and developed deranged liver function tests.
A 63 year old man undergoes an Ivor - Lewis oesophagogastrectomy for carcinoma of the distal oesophagus. The following day a pale opalescent liquid is noted to be draining from the right chest drain.
Air leak
Damage to the lung substance may produce an air leak. Air leaks will manifest themselves as a persistent pneumothorax that fails to settle despite chest drainage. When suction is applied to the chest drainage system, active and persistent bubbling may be seen. Although an anastomotic leak may produce a small pneumothorax, a large volume air leak is more indicative of lung injury.
Portal vein thrombosis
Such marked intra-abdominal sepsis may well produce coagulopathy and the risk of portal vein thrombosis.
Chyle leak
Damage to the lymphatic duct may occur during this procedure and some surgeons administer a lipid rich material immediately prior to surgery to facilitate its identification in the event of iatrogenic damage.
Why is the Miller cuff used in distal bypass surgery?
Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure
What is a Miller cuff?
If there is insufficient vein for the entire conduit of a distal graft then PTFE can be used for the body of the graft and the segment of vein used for the distal anastomosis.
i.e. “vein boot”
A 45 year old man sustains a significant head injury and a craniotomy is performed. The sigmoid sinus is bleeding profusely, into which of the following structures does it drain?
Internal jugular vein
Straight sinus
Petrosal sinus
Inferior sagittal sinus
External jugular vein
The sigmoid sinus is joined by the inferior petrosal sinus to drain into the internal jugular vein.
What is the significance of the cranial venous sinuses and the capacity for spreading sepsis?
The cranial venous sinuses have no valves
Which nerve supplies the interossei of the fourth finger?
Radial
Median
Superficial ulnar
Deep ulnar
Posterior interosseous
Deep ulnar
Mnemonic:
PAD and DAB
Palmer interossei ADduct
Dorsal interossei ABduct
Action of dorsal interossei?
Abduct the fingers
Action of the palmar interossei?
Adduct the fingers
Where are the interossei found?
Occupy the spaces between the metacarpal bones.
Each palmar interossei originates from the metacarpal of the digit on which it acts.
Each dorsal interossei comes from the surface of the adajcent metacarpal on which it acts. As a consequence the dorsal interossei are twice the size of the palmar ones
Where do the interossei insert?
The interossei tendons, except the first palmar, pass to one or other side of the MCPJ posterior to the deep transverse metacarpal ligament.
They become inserted into the base of the proximal phalanx and partly into the extensor hood
Clinical significance of the interossei?
Along with the lumbricals the interossei flex the metacarpophalangeal joints and extend the proximal and distal interphalangeal joints. They are responsible for fine tuning these movements. When the interossei and lumbricals are paralysed the digits are pulled into hyperextension by extensor digitorum and a claw hand is seen.
In which of the following cranial bones does the foramen spinosum lie?
Sphenoid bone
Frontal bone
Temporal bone
Occipital bone
Parietal bone
The foramen spinosum (which transmits the middle meningeal artery and vein) lies in the sphenoid bone.
Which of the following is not considered a major branch of the descending thoracic aorta?
Bronchial artery
Mediastinal artery
Inferior thyroid artery
Posterior intercostal artery
Oesophageal artery
The inferior thyroid artery is usually derived from the thyrocervical trunk, a branch of the subclavian artery.
Branches of the thoracic aorta?
Lateral segmental branches: posterior intercostal arteries
Lateral visceral: bronchial arteries supply bronchial walls and lung excluding the alveoli
MIdline branches: oesophageal arteries
Location of the thoracic sympathetic chains?
Lie anterior to the neck of the upper ribs and and lateral sides of the lower thoracic vertebrae.They are covered by the parietal pleura
Stellate ganglion
Anterior to transverse process of C7, lies posterior to the subclavian artery and cervical pleura
A 53 year old man with a carcinoma of the lower third of the oesophagus is undergoing an oesophagogastrectomy. As the surgeons mobilise the lower part of the oesophagus, where are they most likely to encounter the thoracic duct?
Anterior to the oesophagus
On the left side of the oesophagus
On the right side of the oesophagus
Immediately anterior to the azygos vein
Posterior to the oesophagus
The thoracic duct lies posterior to the oesophagus and passes to the left at the level of the Angle of Louis. It enters the thorax at T12 together with the aorta.
Fall onto extended outstretched hands
Described as a dinner fork type deformity
Colles’ fracture
Volar angulation of distal radius fragment (Garden spade deformity)
Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed
Smith’s fracture
Intra-articular fracture of the first carpometacarpal joint
Impact on flexed metacarpal, caused by fist fights
X-ray: triangular fragment at ulnar base of metacarpal
Bennett’s fracture
Dislocation of the proximal radioulnar joint in association with an ulna fracture
Fall on outstretched hand with forced pronation
Needs prompt diagnosis to avoid disability
Monteggia’s fracture
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Occur after a fall on the hand with a rotational force superimposed on it.
On examination, there is bruising, swelling and tenderness over the lower end of the forearm.
X Rays reveal the displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.
Galeazzi fracture
Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Fall onto extended and pronated wrist
Barton’s fracture
Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal 1/3)
The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb.
Ulnar deviation AP needed for visualization of scaphoid
Immobilization of scaphoid fractures difficult
Scaphoid fractures
Common in young adults.
It is usually caused by a fall on the outstretched hand.
On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).
Radial head fracture
Branches of the ulnar nerve?
Muscular branch
Palmar cutaneous branch
Dorsal cutaneous branch
Superficial branch
Deep branch
X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment.
Perthes Disease
X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity
Slipped upper femoral epiphysis
Southwick angle
A Southwick angle is a radiographic angle used to measure the severity of a slipped capital femoral epiphysis (SCFE) on a radiograph. It was named after Wayne O. Southwick, a famous surgeon.
The angle is measured on a frog lateral view of the bilateral hips. It is measured by drawing a line perpendicular to a line connecting two points at the posterior and anterior tips of the epiphysis at the physis. A third line is drawn down the axis of femur. The angle between the perpendicular line and the femoral shaft line is the angle. The angle is measured bilaterally. The slipped side is then subtracted from the normal side. The number calculated determines the severity. Mild is classified by < 30°. Moderate is 30°-50°. Severe is >50°. 12° is the normal control value and can be used in the case of bilateral involvement.
Longitudinal arch of the foot
The longitudinal arch is higher on the medial than on the lateral side. The posterior part of the calcaneum forms a posterior pillar to support the arch. The lateral part of this structure passes via the cuboid bone and the lateral two metatarsal bones. The medial part of this structure is more important. The head of the talus marks the summit of this arch, located between the sustentaculum tali and the navicular bone. The anterior pillar of the medial arch is composed of the navicular bone, the three cuneiforms and the medial three metatarsal bones.
The anterior part of the socket is formed by the concave articular surface of the navicular bone, posteriorly by the upper surface of the sustentaculum tali. The talus sits within this socket
Talocalcaneonavicular joint
Highest point in the lateral part of the longitudinal arch. The lower aspect of this joint is reinforced by the long plantar and plantar calcaneocuboid ligaments.
Calcaneocuboid joint
Origin and insertion of abductor hallucis
Medial side of the calcaneus, flexor retinaculum, plantar aponeurosis
Medial side of the base of the proximal phalanx
Origin and insertion Flexor digitorum brevis
Medial process of the calcaneus, plantar aponeurosis.
Via 4 tendons into the middle phalanges of the lateral 4 toes.
Origin and insertion of flexor hallucis brevis
From the medial side of the plantar surface of the cuboid bone, from the adjacent part of the lateral cuneiform bone and from the tendon of tibialis posterior.
Into the proximal phalanx of the great toe, the tendon contains a sesamoid bone
Passage of the medial plantar nerve
Passes forwards with the medial plantar artery under the cover of the flexor retinaculum to the interval between abductor hallucis and flexor digitorum brevis on the sole of the foot.
What are the plantar arteries and where do they arise?
Arise under the cover of the flexor retinaculum, midway between the tip of the medial malleolus and the most prominent part of the medial side of the heel.
Medial plantar artery. Passes forwards medial to medial plantar nerve in the space between abductor hallucis and flexor digitorum brevis.Ends by uniting with a branch of the 1st plantar metatarsal artery.
Lateral plantar artery. Runs obliquely across the sole of the foot. It lies lateral to the lateral plantar nerve. At the base of the 5th metatarsal bone it arches medially across the foot on the metatarsals
A young child undergoes a difficult craniotomy for fulminant mastoiditis and associated abscess. During the procedure the trigeminal nerve is severely damaged within Meckels cave. Which deficit is least likely to be present?
Anaesthesia over the ipsilateral anterior aspect of the scalp
Loss of the corneal reflex
Weakness of the ipsilateral masseter muscle
Anaesthesia of the anterior aspect of the lip
Anaesthesia over the entire ipsilateral side of the face
Anaesthesia over the entire ipsilateral side of the face
The angle of the jaw is not innervated by sensory fibres of the trigeminal nerve and is spared in this type of injury.
Remember the trigeminal nerve provides motor innervation to the muscles of mastication. The close proximity of the site of injury to the motor fibres is likely to result in at least some compromise of motor muscle function.
External carotid branches
Superior thyroid (superior laryngeal artery branch)
Ascending pharyngeal
Lingual
Facial (tonsillar and labial artery)
Occipital
Posterior auricular
Maxillary (inferior alveolar artery, middle meningeal artery)
Superficial temporal
Branches of the basilar artery
Anterior inferior cerebellar artery
Labyrinthine artery
Pontine arteries
Superior cerebellar artery
Posterior cerebral artery
Venous drainage of the tonsil?
Its veins pierce the constrictor muscle to join the external palatine or facial veins. The external palatine vein is immediately lateral to the tonsil, which may result in haemorrhage during tonsillectomy.
A 59 year old lady is referred from the NHS breast screening program. A recent mammogram is reported as showing linear, branching microcalcification with coarse granules. Which disease process is the most likely underlying cause of these appearances?
Invasive lobular cancer
Lobular carcinoma in situ
Cribriform type ductal carcinoma in situ
Comedo type ductal carcinoma in situ
Fibroadenosis
Comedo type DCIS is usually associated with microcalcifications. Cribriform lesions are usually multifocal but less likely to form microcalcifications. Lobular cancers and in situ lesions rarely form microcalcifications and are difficult to detect using mammography.
A man has an incision sited that runs 8cm from the deltopectoral groove to the midline. Which of the following is not at risk of injury?
Cephalic vein
Shoulder joint capsule
Axillary artery
Pectoralis major
Trunk of the brachial plexus
This region will typically lie medial to the joint capsule. The diagram below illustrates the plane that this would transect and as it can be appreciated the other structures are all at risk of injury.
