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Although aprotinin reduces fibrinolysis and thus bleeding, it is associated with increased risk of death and was withdrawn in 2007.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
An 18 year old lady with troublesome hyperhidrosis of the hands and arms is due to undergo a sympathectomy to treat the condition. Which of the following should the surgeons divide to most effectively treat her condition?
Sympathetic ganglia at T1, T2 and T3
Sympathetic ganglia at T2 and T3
Sympathetic ganglia at T1 and T2
Stellate ganglion
Superior cervical ganglion
To treat hyperhidrosis the sympathetic ganglia at T2 and T3 should be divided. Dividing the other structures listed would either carry a risk of Horners syndrome or be ineffective.
General arrangement of the SNS?
Cell bodes of the pre-ganglionic efferent neurones are found in the lateral horn of the grey matter of the spinal cord in the thoraco-lumbar regions.
Pre-ganglionic efferents leave the SC at T1-L2. These pass to the sympathetic chain.
Lateral branches of the sympathetic chain connect it to every spinal nerve.
These post ganglionic nerves will pass to sturctures that receive sympathetic innervation at the periphery
Localtion of the cervical sympathetic chain?
Lie anterior to the transverse processes of the cervical vertebrae and posterior to the carotid sheath.
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
Location of the lumbar sympathetic chains?
Enter by passing posterior to the medial arcuate ligament. Lie anteriorly to the vertebrae and medial to psoas major.
Superior cervical ganglion?
Lies anterior to C2 and C3
Middle cervical ganglion?
C6
Stellate ganglion
Anterior to transverse process of C7, lies posterior to the subclavian artery and cervical pleura
Thoracic ganglia?
Usually segmentally arranged
What is the usual number of lumbar ganglia?
4
Issues with lumbar sympathectomy to treat vasospastic diseases of the lower limbs?
In patients with vascular disease of the lower limbs a lumbar sympathetomy may be performed, either radiologically or (more rarely now) surgically. The ganglia of L2 and below are disrupted. If L1 is removed then ejaculation may be compromised (and little additional benefit conferred as the preganglionic fibres do not arise below L2.
A 44 year old lady is recovering following a transphenoidal hypophysectomy. Unfortunately there is a post operative haemorrhage. Which of the following features is most likely to occur initially?
Cavernous sinus thrombosis
Abducens nerve palsy
Bi-temporal hemianopia
Inferior homonymous hemianopia
Central retinal vein occlusion
The pituitary is covered by a sheath of dura and an expanding haematoma at this site may compress the optic chiasm in the same manner as an expanding pituitary tumour.
Adenohypophysis hormones?
GH
TSH
ACTH
Prolactin
LH and FSH
Melanocyte releasing hormone
Neurohypophysis hormones?
Oxytocin
ADH
During a right hemicolectomy the caecum is mobilised. As the bowel is retracted medially a vessel is injured, posterior to the colon. Which of the following is the most likely vessel?
Right colic artery
Inferior vena cava
Aorta
External iliac artery
Gonadal vessels
The gonadal vessels and ureter are important posterior relations that are at risk during a right hemicolectomy.
Posterior relations of the caecum?
Psoas
Iliacus
Femoral nerve
Genitofemoral nerve
Gonadal vessels
Why is the caecum the most likely site of eventual perforation in large bowel obstruction?
The caecum is the most distensible part of the colon and in complete large bowel obstruction with a competent ileocaecal valve the most likely site of eventual perforation.
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.
Def: thoracic duct?
Continuation of the cisterna chyli in the abdomen
Location of the thoracic duct?
Enters the thorax at T12.
Lies posterior to the oesophagus for most of its intrathoracic course. Passes to the left at T5.
Lymphatic drainage of the left side of the head and neck?
Join the thoracic duct prior to its insertion into the left brachiocephalic vein
Lymphatics draining the right side of the head and neck?
Lymphatics draining the right side of the head and neck drain via the subclavian and jugular trunks into the right lymphatic duct and thence into the mediastinal trunk and eventually the right brachiocephalic vein.
Which of the following represents the root values of the sciatic nerve?
L4 to S3
L1 to L4
L3 to S1
S1 to S4
L5 to S1
he sciatic nerve most commonly arises from L4 to S3.
Where is the sciatic nerve formed?
At the inferior border of piriformis
Medial relations of the sciatic nerve?
Inferior gluteal nerve and vessels and the pudendal nerve and vessels.
Cutaneous innervation of the sciatic nerve?
Posterior aspect of thigh (via cutaneous nerves)
Gluteal region
Entire lower leg (except the medial aspect)
What is the only muscle in the foot not innervated by the tibial nerve?
Extensor digitorum brevis, which is innervated by the common peroneal nerve
What is the inflammatory response to MTB infection?
T4HS
Theme: Wound closure
A.Split thickness skin grafting
B.Full thickness skin graft
C.Local flap
D.Leave wound as it is and apply a simple dressing
E.Primary closure using interrupted 3/0 silk
F.Primary closure using 4/0 interrupted nylon
G.Use of vacuum assisted closure device
Please select the most appropriate wound closure modality for the scenario given. Each option may be used once, more than once or not at all.
11.A 68 year old man undergoes a wide local excision of a squamous cell carcinoma from the lateral aspect his nose. At the completion of the operation the alar cartilage is visible.
A 68 year old man has a seborrhoiec wart on his left cheek this is removed by use of curretage leaving a superficial defect approximately 1cm in diameter.
Local flap
This type of wound should be managed with a local rotational flap.
Leave wound as it is and apply a simple dressing
This type of superficial wound will re-epithelialise satisfactorily without grafting.
Use of vacuum assisted closure device
Ray amputations for diabetic foot infections do not heal well and should never be primarily closed. The use of vacuum assisted closure devices has been shown to improve healing rates.
Types of surgical wound?
Incisional or excisional:
Clean
Clean contaminated
Dirty
The common peroneal nerve, or its branches, supply the following muscles except:
Peroneus longus
Tibialis anterior
Extensor hallucis longus
Flexor digitorum brevis
Extensor digitorum longus
Flexor digitorum is supplied by the tibial nerve.
Innervation of the common peroneal nerve?
This nerve supplies the skin and fascia of the anterolateral surface of the leg and the dorsum of the foot. It also innervates the muscles of the anterior and peroneal compartments of the leg, extensor digitorum brevis as well as the knee, ankle and foot joints.
Where does the common peroneal nerve divide into its deep and superficial branches?
At the posterior aspect of the fibular head
Branches of the common peroneal nerve in the thigh?
Nerve to short head of biceps
Articular branch (knee)
Branches of the common peroneal nerve in the popliteal fossa?
Lateral cutaneous nerve of the calf
Lateral border of the femoral canal?
Femoral vein
Medial border of the femoral canal?
Lacunar ligament
Anterior border of the femoral canal?
INguinal ligamnet
Posterior border of the femoral canal?
Pectineal ligament
Theme: Upper limb injuries
A.Pulled elbow
B.Fracture of the coronoid process
C.Scaphoid fracture
D.Fracture of the distal humerus
E.Bennets fracture
F.Fracture of the shaft of the radius and ulnar
G.Galeazzi fracture
H.Fracture of the olecranon
I.Fracture of the radial head
Please select the most likely injury for the scenario given. Each option may be used once, more than once or not at all.
16.A 32 year old man presents with a painful swelling over the volar aspect of his hand after receiving a hard blow to his palm. On examination, he experiences pain on moving the wrist and on longitudinal compression of the thumb.
A 26 year old man presents to the emergency department with a swelling over his left elbow after a fall on an outstretched hand. On examination, he has tenderness over the proximal part of his forearm, and has severely restricted supination and pronation movements.
A 56 year old lady presents with a painful swelling over the lower end of the forearm following a fall. Imaging reveals a distal radial fracture with disruption of the distal radio-ulnar joint.
Scaphoid fracture
Scaphoid fractures usually occur as a result of direct hard blow to the palm or following a fall on the out-stretched hand. 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
Fracture of the radial head
Fracture of the radial head is 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).
Galeazzi fracture
Galeazzi fractures 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 a displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.
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
What are the 3 features of Colles fracture?
- Transverse fracture of the radius
- 1 inch proximal to the radio-carpal joint
- Dorsal displacement and angulation
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
Commonest carpal fracture?
Scaphoid 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
A 20 year old man develops acute appendicitis, his appendix is removed and he makes a full recovery. Which of the following pathological processes is least likely to be present in the acutely inflamed tissues?
Altered Starlings forces
Sequestration of neutrophils
Formation of fluid exudate
Formation of granulomas
None of the abov
Formation of granulomas
Acute inflammation:
3 phases
1. Changes in blood vessel and flow: flush, flare, wheal
2. Fluid exudates (rich in protein i.e. Ig, coagulation factors) produced via increased vascular permeability
3. Cellular exudates mainly containing neutrophil polymorphs pass into extravascular space.
Neutrophils are then transported to tissues via:
a. Margination of neutrophils to the peripheral plasmatic of the vessel rather than the central axial stream
b. Pavementing: Adhesion of neutrophils to endothelial cells in venules at site of acute inflammation
c. Emigration: neutrophils pass between endothelial cells into the tissue
Vascular changes in acute inflammation
Vasodilation occurs and persists throughout the inflammatory phase.
Inflammatory cells exit the circulation at the site of injury.
The equilibrium that balances Starlings forces within capillary beds is disrupted and a protein rich exudate will form as the vessel walls also become more permeable to proteins.
The high fibrinogen content of the fluid may form a fibrin clot. This has several important immunomodulatory functions.
Potential sequelae of acute inflammation
Resolution
Organisation
Suppuration
Progression to chronic inflammation
Theme: Liver lesions
A.Haemangioma
B.Hepatocellular carcinoma
C.Hepatic metastasis
D.Polycystic liver disease
E.Simple liver cyst
F.Hyatid cyst
G.Amoebic abscess
H.Mesenchymal hamartoma
Please select the most likely liver lesion for the scenario given. Each option may be used once, more than once or not at all.
20.A 42 year old lady has suffered from hepatitis C for many years and has also developed cirrhosis. On routine follow up, an ultrasound has demonstrated a 2.5cm lesion in the right lobe of the liver.
A 25 year old man from the far east presents with a fever and right upper quadrant pain. As part of his investigations a CT scan shows an ill defined lesion in the right lobe of the liver.
A 42 year old lady presents with right upper quadrant pain and a sensation of abdominal fullness. An ultrasound scan demonstrates a 6.5 cm hyperechoic lesion in the right lobe of the liver. Serum AFP is normal.
Hepatocellular carcinoma
In patients with cirrhosis the presence of a lesion >2cm is highly suggestive of malignancy. The diagnosis is virtually confirmed if the AFP is >400ng/mL.
Amoebic abscess
Amoebic abscesses will tend to present in a similar fashion to other pyogenic liver abscesses. They should be considered in any individual presenting from a region where Entamoeba histiolytica is endemic. Treatment with metronidazole usually produces a marked clinical response.
Haemangioma
A large hyperechoic lesion in the presence of normal AFP is likely to be a haemangioma. An HCC of equivalent size will almost always result in rise in AFP.
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
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 liver 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
Which of the following best accounts for the action of PTH in increasing serum calcium levels?
Activation of vitamin D to increase absorption of calcium from the small intestine.
Direct stimulation of osteoclasts to absorb bone with release of calcium.
Stimulation of phosphate absorption at the distal convoluted tubule of the kidney.
Decreased porosity of the vessels at Bowmans capsule to calcium.
Vasospasm of the afferent renal arteriole thereby reducing GFR and calcium urinary loss.
PTH increases the activity of 1-α-hydroxylase enzyme, which converts 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol, the active form of vitamin D.
Osteoclasts do not have a PTH receptor and effects are mediated via osteoblasts.
An 83 year old lady presents with a femoral hernia and undergoes a femoral hernia repair. Which of the following forms the posterior wall of the femoral canal?
Pectineal ligament
Lacunar ligament
Inguinal ligament
Adductor longus
Sartorius
Pectineal ligament
Embryology of the spleen
It develops from the upper dorsal mesogastrium, remaining connected to the posterior abdominal wall and stomach by two folds of peritoneum; the lienorenal ligament and gastrosplenic ligament. The lienorenal ligament is derived from peritoneum where the wall of the general peritoneum meets the omental bursa between the left kidney and spleen; the splenic vessels lie in its layers. The gastrosplenic ligament also has two layers, formed by the meeting of the walls of the greater sac and omental bursa between spleen and stomach, the short gastric and left gastroepiploic branches of the splenic artery pass in its layers. Laterally, the spleen is in contact with the phrenicocolic ligament.
White pulp of the spleen
Immune function. Contains central trabecular artery. The germinal centres are supplied by arterioles called penicilliary radicles.
Red pulp of the spleen
Filters abnormal red blood cells.
Function of the spleen
Filtration of abnormal blood cells and foreign bodies such as bacteria.
Immunity: IgM. Production of properdin, and tuftsin which help target fungi and bacteria for phagocytosis.
Haematopoiesis: up to 5th month gestation or in haematological disorders.
Pooling: storage of 40% platelets.
Iron reutilisation
Storage monocytes
Splenomegaly in SCD?
*the majority of adult patients with sickle-cell will have an atrophied spleen due to repeated infarction
A 45 year man presents with hand weakness. He is given a piece of paper to hold between his thumb and index finger. When the paper is pulled, the patient has difficulty maintaining a grip. Grip pressure is maintained by flexing the thumb at the interphalangeal joint. What is the most likely nerve lesion?
Posterior interosseous nerve
Deep branch of ulnar nerve
Anterior interosseous nerve
Superficial branch of the ulnar nerve
Radial nerve
This is a description of Froment’s sign, which tests for ulnar nerve palsy. It mainly tests for the function of adductor pollicis. This is supplied by the deep branch of the ulnar nerve. Remember the anterior interosseous branch (of the median nerve), which innervates the flexor pollicis longus (hence causing flexion of the thumb IP joint), branches off more proximally to the wrist.
Branches of the ulnar nerve?
Muscular branch
Palmar cutaneous branch
Dorsal cutaneous branch
Superficial branch
Deep branch
Muscular branch of the ulnar nerve supplies?
Flexor carpi ulnaris
Medial half of the flexor digitorum profundus
Palmar cutaneous branch (Arises near the middle of the forearm) of the ulnar nerve supplies?
Skin on the medial part of the palm
Dorsal cutaneous branch of the ulnar nerve supplies
Dorsal surface of the medial part of the hand
Superficial branch of the ulnar nerve supplies?
Cutaneous fibres to the anterior surfaces of the medial one and one-half digits
Deep branch of the ulnar nerve supplies
Hypothenar muscles
All the interosseous muscles
Third and fourth lumbricals
Adductor pollicis
Medial head of the flexor pollicis brevis
Wasting and paralysis of intrinsic hand muscles (claw hand)
Wasting and paralysis of hypothenar muscles
Loss of sensation medial 1 and half fingers
Damage at the wrist
Radial deviation of the wrist
Clawing less in 4th and 5th digits
Damage at the elbow
Which of the following drugs does not cause syndrome of inappropriate anti diuretic hormone release?
Haloperidol
Carbamazepine
Amitriptylline
Cyclophosphamide
Methotrexate
Methotrexate
Drugs causing SIADH: ABCD
A nalgesics: opioids, NSAIDs
B arbiturates
C yclophosphamide/ Chlorpromazine/ Carbamazepine
D iuretic (thiazides)
Theme: Hand injuries
A.Admission and surgical debridement
B.Application of futura splint and fracture clinic review
C.Application of tubigrip bandage and fracture clinic review
D.Admission for open reduction and fixation
E.Discharge with reassurance
F.Commence oral prednisolone
G.Commence oral diclofenac
Which of the following options is the best management plan? Each option may be used once, more than once or not at all.
29.A 42 year old skier falls and impacts his hand on his ski pole. On examination he is tender in the anatomical snuffbox and on bimanual palpation. X-rays with scaphoid views show no evidence of fracture.
A 43 year old man falls over landing on his left hand. Although there was anatomical snuffbox tenderness no x-rays either at the time or subsequently have shown evidence of scaphoid fracture. He has been immobilised in a futura splint for two weeks and is now asymptomatic.
A builder falls from scaffolding and lands on his left hand he suffers a severe laceration to his palm. An x-ray shows evidence of scaphoid fracture that is minimally displaced.
Application of futura splint and fracture clinic review
A fracture may still be present and should be immobilised until repeat imaging can be performed. If clinical suspicion persists then subsequent imaging should be with MRI scanning or CT if MRI is contra-indicated.
Discharge with reassurance
This patient is at extremely low risk of having sustained a scaphoid injury and may be discharged.
Admission and surgical debridement
This is technically an open fracture and should be debrided prior to attempted fixation (which should occur soon after).
80%s in scaphoid fracture
80% of all carpal fractures
80% occur in men
80% occur at the waist of the scaphoid
Management of non-displaced scaphoid fracture
- Casts or splints
- Percutaneous scaphoid fixation
Management of displaced scaphoid fracture
Surgical fixation, usually with a screw
Complications of scaphoid fracture?
Non union of scaphoid
Avascular necrosis of the scaphoid
Scapholunate disruption and wrist collapse
Degenerative changes of the adjacent joint
A 30 year old man is trapped in a house fire and sustains 30% partial and full thickness burns to his torso and limbs. Three days following admission he has a brisk haematemesis. Which of the following is the most likely explanation for this event?
Dieulafoy lesion
Curlings ulcers
Mallory Weiss tear
Depletion of platelets
Depletion of clotting factors
Curlings ulcers typically occur secondary to thermal injuries and are caused by loss of GI protective mechanisms. They are at greater risk of perforation than stress ulcers and may also haemorrhage.
Theme: Adrenal gland disorders
A.Nelsons syndrome
B.Conns syndrome
C.Cushings syndrome
D.Benign incidental adenoma
E.Malignant adrenal adenoma
F.Waterhouse- Friderichsen syndrome
G.Metastatic lesion
H.Walker - Warburg syndrome
I.Phaeochromocytoma
Please select the most appropriate adrenal disorder for the scenario given. Each disorder may be selected once, more than once or not at all.
33.A 19 year old lady is admitted to ITU with severe meningococcal sepsis. She is on maximal inotropic support and a CT scan of her chest and abdomen is performed. The adrenal glands show evidence of diffuse haemorrhage.
A 34 year old lady is admitted with recurrent episodes of non-specific abdominal pain. On each admission all blood investigations are normal, as are her observations. On this admission a CT scan was performed. This demonstrates a 1.5cm nodule in the right adrenal gland. This is associated with a lipid rich core. Urinary VMA is within normal limits. Other hormonal studies are normal.
A 38 year old man is noted to have a blood pressure of 175/110 on routine screening. On examination there are no physical abnormalities of note. CT scanning shows a left sided adrenal mass. Plasma metanephrines are elevated.
aterhouse- Friderichsen syndrome
WaterhouseFriderichsen syndrome is defined as adrenal gland failure due to bleeding into the adrenal glands. It is caused by severe bacterial infection (most commonly the meningococcus Neisseria meningitidis).
The bacterial infection leads to massive hemorrhage into one or (usually) both adrenal glands. It is characterised by overwhelming bacterial infection meningococcemia leading to massive blood invasion, organ failure, coma, haemodynamic shock, disseminated intravascular coagulation with widespread purpura, rapidly developing adrenocortical insufficiency and deat
Benign incidental adenoma
This is typical for a benign adenoma. Benign adenomas often have a lipid rich core that is readily identifiable on CT scanning. In addition the nodules are often well circumscribed.
Phaeochromocytoma
Hypertension in a young patient without any obvious cause should be investigated. Urinary VMA and plasma metanephrines are typically elevated.
Which of the following statements relating to the right phrenic nerve is false?
It lies deep to the prevertebral layer of deep cervical fascia
Crosses posterior to the 2nd part of the subclavian artery
It runs on the anterior surface of the scalene muscle
On the right side it leaves the mediastinum via the vena cava hiatus at a level of T8
The right phrenic nerve passes over the right atrium
Crosses posterior to the 2nd part of the subclavian artery
Phrenic nerve supplies
Diaphragm, sensation central diaphragm and pericardium
Passage of the phrenic nerve?
The phrenic nerve passes with the internal jugular vein across scalenus anterior. It passes deep to prevertebral fascia of deep cervical fascia.
Left: crosses anterior to the 1st part of the subclavian artery.
Right: Anterior to scalenus anterior and crosses anterior to the 2nd part of the subclavian artery.
On both sides, the phrenic nerve runs posterior to the subclavian vein and posterior to the internal thoracic artery as it enters the thorax.
Passage of the right phrenic nerve
In the superior mediastinum: anterior to right vagus and laterally to superior vena cava
Middle mediastinum: right of pericardium
It passes over the right atrium to exit the diaphragm at T8
Passage of the left phrenic nerve
Passes lateral to the left subclavian artery, aortic arch and left ventricle
Passes anterior to the root of the lung
Pierces the diaphragm alone
A 43 year old man presents with dyspepsia and undergoes an upper GI endoscopy. During the procedure diffuse gastric and duodenal ulcers are identified. A Clo test confirms the presence of Helicobacter pyloriinfection. What is the most likely explanation for the ulcers?
Decreased gastric motility
Increased urease activity
Decreased release of mucous and bicarbonate
Decreased gastrin levels
Increased acid production
H-Pylori has a number of pathological effects. In this question the main issue is by what mechanism the organism is able to induce both gastric and duodenal ulceration. Without modestly elevated acid levels, the duodenum would not undergo gastric metaplasia. H-Pylori cannot colonise duodenal mucosa and therefore the development of ulcers at this site can only occur in those who have undergone metaplastic transformation (mediated by increased acidity).
It is a gram negative, helical shaped rod with microaerophillic requirements. It has the ability to produce a urease enzyme that will hydrolyse urea resulting in the production of ammonia. The effect of ammonia on antral G cells is to cause release of gastrin via a negative feedback loop.
H. Pylori
Pathophysiology of H. pylori
Once infection is established the organism releases enzymes that disrupt the gastric mucous layer. Certain subtypes release cytotoxins cag A and vac A gene products. The organism incites a classical chronic inflammatory process of the gastric epithelium. This accounts for the development of gastric ulcers. The mildly increased acidity may induce a process of duodenal gastric metaplasia. Whilst duodenal mucosa cannot be colonised by H-Pylori, mucosa that has undergone metaplastic change to the gastric epithelial type may be colonised by H- Pylori with subsequent inflammation and development of duodenitis and ulcers.
Complications of H. pylori colonisation
In patients who are colonized, there is a 10-20% risk of peptic ulcer, 1-2% risk gastric cancer and <1% risk MALT lymphoma.
Which of the following cranial foramina pairings are incorrect?
Carotid canal and internal carotid artery.
Foramen ovale and mandibular nerve.
Optic canal and ophthalmic artery.
Optic canal and ophthalmic nerve.
Foramen rotundum and maxillary nerve.
The optic canal transmits the optic nerve. The ophthalmic nerve traverses the superior orbital fissure.
A 22 year old man is involved in a fight and sustains a stab wound in his upper forearm. On examination there is a small, but deep laceration. There is an obvious loss of pincer movement involving the thumb and index finger with minimal loss of sensation. The most likely nerve injury is to the:
Ulnar nerve
Radial nerve
Anterior interosseous nerve
Axillary nerve
Median nerve
The anterior interosseous nerve is a motor branch of the median nerve just below the elbow. When damaged it classically causes:
Pain in the forearm
Loss of pincer movement of the thumb and index finger (innervates the long flexor muscles of flexor pollicis longus & flexor digitorum profundus of the index and middle finger)
Minimal loss of sensation due to lack of a cutaneous branch
A 17 year old man undergoes an elective right hemicolectomy. Post operatively he receives a total of 6 litres of 0.9% sodium chloride solution, over 24 hours. Which of the following complications may ensue?
Hyperchloraemic acidosis
Hypochloraemic alkalosis
Hyperchloraemic alkalosis
Acute renal failure
None of the above
Excessive infusions of any intravenous fluid carry the risk of development of tissue oedema and potentially cardiac failure. Excessive administration of sodium chloride is a recognised cause of hyperchloraemic acidosis and therefore Hartmans solution may be preferred where large volumes of fluid are to be administered.
Which of the following changes are not typically seen in established dehydration?
Rising haematocrit
Urinary sodium <20mmol/ litre
Metabolic acidosis
Decreased serum urea to creatinine ratio
Hypernatraemia
Diagnosing dehydration can be complicated, laboratory features include:
Hypernatraemia
Rising haematocrit
Metabolic acidosis
Rising lactate
Increased serum urea to creatinine ratio
Urinary sodium <20 mmol/litre
Urine osmolality approaching 1200mosmol/kg
A 66 year old man is undergoing a left nephro-ureterectomy. The surgeons remove the ureter, which of the following is responsible for the blood supply to the proximal ureter?
Branches of the renal artery
External iliac artery
Internal iliac artery
Direct branches from the aorta
Common iliac artery
The proximal ureter is supplied by branches from the renal artery. For the other feeding vessels - see below.
Theme: Paediatric gastrointestinal disorders
A.Meconium ileus
B.Biliary atresia
C.Oesophageal atresia
D.Pyloric stenosis
E.Intussusception
F.Malrotation
G.Hirschsprung disease
H.Mesenteric adenitis.
What is the most likely diagnosis for each scenario given? Each option may be used once, more than once or not at all.
43.A 3 day old baby presents with recurrent episodes of choking and cyanotic episodes. There is a history of polyhydramnios.
A 3 day old neonate is developing increasing problems with feeding. On examination she has a pan systolic murmur and her forearms have not developed properly.
Oesophageal atresia
Diagnosis is confirmed when an nasogastric tube fails to reach the stomach.
Oesophageal atresia
This child has VACTERL, which is a combination of Vertebral, Ano-rectal, Cardiac, Tracheo-oesophageal, Renal and Radial limb anomalies. Half of babies with oesophageal atresia will have VACTERL.
Mesenteric adenitis.
Mesenteric adenitis may complicate upper respiratory tract infection and clinical exclusion of appendicitis can be difficult.
VACTERL
VACTERL, which is a combination of Vertebral, Ano-rectal, Cardiac, Tracheo-oesophageal, Renal and Radial limb anomalies. Half of babies with oesophageal atresia will have VACTERL.
Associated with tracheo-oesophageal fistula and polyhydramnios
May present with choking and cyanotic spells following aspiration
VACTERL associations
Oesophageal atresia
Genetics of Peutz-Jehgers
AD
Responsible gene encodes serine threonine kinase LKB1 or STK11
A 7 year old boy is due to undergo a circumcision for phimosis. Which of the following devices would be the most appropriate agent to use for achieving haemostasis?
Monopolar unit in cutting mode
Bipolar unit
Monopolar unit in coagulation mode
Monopolar unit in blend mode
Monopolar unit configured to spray mode
The danger with the use of any source other than bipolar diathermy in this setting is the risk of causing trauma to end vessels. All the monopolar units, regardless of the setting will carry this risk.
Theme: Paediatric orthopaedics
A.Musculoskeletal pain
B.Congenital dysplasia of the hip
C.Slipped upper femoral epiphysis
D.Transient synovitis
E.Septic arthritis
F.Perthes disease
G.Tibial fracture
Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.
3.A 4 year boy presents with an abnormal gait. He has a history of recent viral illness. His WCC is 11 and ESR is 30.
A 6 year old boy presents with groin pain. He is known to be disruptive in class. He reports that he is bullied for being short. On examination he has an antalgic gait and pain on internal rotation of the right hip.
An obese 12 year old boy is referred with pain in the left knee and hip. On examination he has an antaglic gait and limitation of internal rotation. His knee has normal range of passive and active movement.
Transient synovitis
Viral illnesses can be associated with transient synovitis. The WCC should ideally be > 12 and the ESR > 40 to suggest septic arthritis.
Perthes disease
This child is short, has hyperactivity (disruptive behaviour) and is within the age range for Perthes disease. Hyperactivity and short stature are associated with Perthes disease.
Slipped upper femoral epiphysis
Slipped upper femoral epiphysis is commonest in obese adolescent males. The x-ray will show displacement of the femoral epiphysis inferolaterally. Treatment is usually with rest and non weight bearing crutches.
Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies.
Developmental dysplasia of the hip
Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc
Developmental dysplasia of the hip
Treatment of DDH
Splints and harnesses or traction- Pavlik. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision
Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%.
Perthes Disease
Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%.
Slipped upper femoral epiphysis
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
What gives degree of disease severity in SUFE?
Southwick angle
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.
Treatment of Perthes disease
Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly.
Treatment of SUFE
Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required.
Theme: Management of peripheral arterial disease
A.Primary amputation
B.Angioplasty
C.Arterial bypass surgery using vein
D.Arterial bypass surgery using PTFE
E.Conservative management with medical therapy and exercise
F.Watch and wait
G.Duplex scanning
Please select the most appropriate management for the scenario given. Each option may be used once, more than once or not at all.
6.A 63 year old man is admitted with rest pain and foot ulceration. An angiogram shows a 3 cm area of occlusion of the distal superficial femoral artery with 3 vessel run off. His ankle - brachial pressure index is 0.4.
A 72 year old man present in the vascular clinic with calf pain present on walking 100 yards. He is an ex-smoker and lives alone. On examination he has reasonable leg pulses. His right dorsalis pedis pulse gives a monophasic doppler signal with an ankle brachial pressure index measurement of 0.7. All other pressures are acceptable. There is no evidence of ulceration or gangrene.
An 83 year old lady is admitted from a nursing home with infected lower leg ulcers. She underwent an attempted long superficial femoral artery sub initimal angioplasty 2 weeks previously. This demonstrated poor runoff below the knee.
Angioplasty
Short segment disease and good run off with tissue loss is a compelling indication for angioplasty. He should receive aspirin and a statin if not already taking them.
Conservative management with medical therapy and exercise
Structured exercise programmes combined with medical therapy will improve many patients. Should his symptoms worsen or fail to improve then imaging with duplex scanning would be required.
Primary amputation
Poor runoff and sepsis would equate to poor outcome with attempted bypass surgery.
Indications for surgery to revascularise limb
Intermittent claudication
Critical ischaemia
Ulceration
Gangrene
Intermittent claudication that is not disabling may provide a relative indication, whilst the other complaints are often absolute indications depending upon the frailty of the patient.
Assessment in peripheral vascular disease
Clinical examination
Ankle brachial pressure index measurement
Duplex arterial ultrasound
Angiography (standard, CT or MRI): usually performed only if intervention being considered.
Requirements for angioplasty success
In order for angioplasty to be undertaken successfully the artery has to be accessible. The lesion relatively short and reasonable distal vessel runoff. Longer lesions may be amenable to sub-intimal angioplasty.
Distal run off
Blood flow in post-stenotic region of a blood vessel
Indications for surgery in PVD
Surgery will be undertaken where attempts at angioplasty have either failed or are unsuitable. Bypass essentially involves bypassing the affected arterial segment by utilising a graft to run from above the disease to below the disease. As with angioplasty good runoff improves the outcome.
Procedure of superficial femoral artery bypass surgery
Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped
Longitudinal arteriotomy
Graft cut to size and tunneled to arteriotomy sites
Anastomosis to femoral artery usually with 5/0 ‘double ended’ Prolene suture
Distal anastomosis usually using 6/0 ‘double ended’ Prolene
Which of the following statements relating to the pharmacology of warfarin is untrue?
Interferes with clotting factors 2,7,9 and 10
It may not be clinically effective for up to 72 hours
The half life of warfarin is 40 hours
Warfarin has a large volume of distribution
It is metabolized in the liver
Factors 2,7,9,10 affected
Warfarin interferes with fibrin formation by affecting carboxylation of glutamic acid residues in factors 2,7,9 and 10. Factor 2 has the longest half life of approximately 60 hours, therefore it can take up to 3 days for warfarin to be fully effective. Warfarin has a small volume of distribution as it is protein bound.
If a 2 x 2 cm autologus skin graft is placed on an area of healthy granulation tissue. After about a week, a thin bluish - white margin appears around the graft and spreads at a rate of 1mm per day. What is it?
Epidermis alone
Epidermis and dermis
Dermis alone
Inflammatory exudate
Fibrin
Epidermis alone
This is the process of re-epithelialisation.
Which of the following is not a typical feature of acute appendicitis?
Neutrophilia
Profuse vomiting
Anorexia
Low grade pyrexia
Small amounts of protein on urine analysis
Profuse vomiting and diarrhoea are rare in early appendicitis
Whilst patients may vomit once or twice, profuse vomiting is unusual, and would fit more with gastroenteritis or an ileus. A trace of protein is not an uncommon occurrence in acute appendicitis. A free lying pelvic appendix may result in localised bladder irritation, with inflammation occurring as a secondary phenomena. This latter feature may result in patients being incorrectly diagnosed as having a urinary tract infection. A urine dipstick test is useful in differentiating between the two conditions.
Which of the following structures does not pass behind the lateral malleolus?
Peroneus brevis tendon
Sural nerve
Short saphenous vein
Peroneus longus tendon
Tibialis anterior tendon
Tibialis anterior tendon passes anterior to the medial malleolus.
Structures posterior to the lateral malleolus and superficial to superior peroneal retinaculum
Sural nerve
Short saphenous vein
Structures posterior to the lateral malleolus and deep to superior peroneal retinaculum
Peroneus longus tendon
Peroneus brevis tendon
A 78 year old man presents with symptoms consistent with intermittent claudication. To assess the severity of his disease you decide to measure his ankle brachial pressure index. To do this you will identify the dorsalis pedis artery. Which of the following statements relating to this vessel is false?
It originates from the peroneal artery
It is crossed by the tendon of extensor hallucis brevis
Two veins are usually closely related to it
It passes under the inferior extensor retinaculum
The tendon of extensor hallucis longus lies medial to it.
The dorsalis pedis artery is a direct continuation of the anterior tibial artery.
What are the two arches of the foot?
Longitudinal arch
Transverse arch
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.
Transverse arch of the foot
The transverse arch is situated on the anterior part of the tarsus and the posterior part of the metatarsus. The cuneiforms and metatarsal bases narrow inferiorly, which contributes to the shape of the arch.
What are the intertarsal joints?
Subtalar joint
Talocalcaneonavicular joint
Calcaneocuboid joint
Transverse tarsal joint
Cuneonavicular joint
Intercuneiform joints
Cuneocuboid joint
Formed by the cylindrical facet on the lower surface of the body of the talus and the posterior facet on the upper surface of the calcaneus. The facet on the talus is concave anteroposteriorly, the other is convex. The synovial cavity of this joint does not communicate with any other joint.
Sub talar joint
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
The talocalcaneonavicular joint and the calcaneocuboid joint extend across the tarsus in an irregular transverse plane, between the talus and calcaneus behind and the navicular and cuboid bones in front. This plane is termed the transverse tarsal joint.
Transverse tarsal joint
Formed between the convex anterior surface of the navicular bone and the concave surface of the the posterior ends of the three cuneiforms.
Cuneonavicular joint
Between the three cuneiform bones.
Intercuneiform joints
Between the circular facets on the lateral cuneiform bone and the cuboid. This joint contributes to the tarsal part of the transverse arch.
Cuneocuboid joint
Muscles of the foot supplied by the medial plantar nerve?
Abductor hallucis
Flexor digitorum brevis
Flexor hallucis brevis
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.
Muscles of the foot supplied by the lateral plantar nerve
Abductor digit minimi
Adductor hallucis
Action of flexor digitorum brevis
Flexes all the joints of the lateral 4 toes except for the interphalangeal joint.
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
Action of flexor hallucis brevis
Flexes the metatarsophalangeal joint of the great toe.
Origin and insertion of the abductor digiti minimi
From the tubercle of the calcaneus and from the plantar aponeurosis
Together with flexor digit minimi brevis into the lateral side of the base of the proximal phalanx of the little toe
Origin and insertion of adductor hallucis
Arises from two heads. The oblique head arises from the sheath of the peroneus longus tendon, and from the plantar surfaces of the bases of the 2nd, 3rd and 4th metatarsal bones. The transverse head arises from the plantar surface of the lateral 4 metatarsophalangeal joints and from the deep transverse metatarsal ligament.
Lateral side of the base of the proximal phalanx of the great toe.
Action of abductor digit minimi
Abducts the little toe at the metatarsophalangeal joint
Action of adductor hallucis
Adducts the great toe towards the second toe. Helps maintain the transverse arch of the foot.
Muscles in the foot innervated by deep peroneal
Extensor digitorum brevis
Origin and insertion of extensor digitorum brevis
On the dorsal surface of the foot from the upper surface of the calcaneus and its associated fascia
Via four thin tendons which run forward and medially to be inserted into the medial four toes. The lateral three tendons join with hoods of extensor digitorum longus.
Extensor digitorum brevis
Extend the metatarsophalangeal joint of the medial four toes. It is unable to extend the interphalangeal joint without the assistance of the lumbrical muscles.
Passage of the lateral plantar nerve
Passes anterolaterally towards the base of the 5th metatarsal between flexor digitorum brevis and flexor accessorius. On the medial aspect of the lateral plantar artery. At the base of the 5th metatarsal it splits into superficial and deep branches.
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
This vessel is a direct continuation of the anterior tibial artery. It commences on the front of the ankle joint and runs to the proximal end of the first metatarsal space. Here is gives off the arcuate artery and continues forwards as the first dorsal metatarsal artery. It is accompanied by two veins throughout its length. It is crossed by the extensor hallucis brevis
Dorsalis pedis artery
Which of the following is not a content of the anterior triangle of the neck?
Vagus nerve
Submandibular gland
Phrenic nerve
Internal jugular vein
Hypoglossal nerve
The phrenic nerve is a content of the posterior triangle. The anterior triangle contains the carotid sheath and its contents.
A 32 year old attends neurology clinic complaining of tingling in his hand. He has radial deviation of his wrist and there is mild clawing of his fingers, with the 4th and 5th digits being relatively spared. What is the most likely lesion?
Ulnar nerve damage at the wrist
Ulnar nerve damage at the elbow
Radial nerve damage at the elbow
Median nerve damage at the wrist
Median nerve damage at the elbow
The ulnar paradox- the higher the lesion, the less the clawing of the fingers seen clinically.
At the elbow the ulnar nerve lesion affects the flexor carpi ulnaris and flexor digitorum profundus.
Theme: Eponymous fractures
A.Smith’s
B.Bennett’s
C.Monteggia’s
D.Colles’
E.Galeazzi
F.Pott’s
G.Barton’s
Link the most appropriate eponymously named fracture to the scenario described. Each scenario may be used once, more than once or not at all.
19.A 28 year old man falls on the back of his hand. On x-ray he has a fractured distal radius demonstrating volar displacement of the fracture.
A 38 year old window cleaner falls from his ladder. He lands on his left arm and notices an obvious injury. An x-ray and clinical examination demonstrate that he has a fracture of the proximal ulna and associated radial dislocation.
A 32 year old man falls from scaffolding and sustains an injury to his forearm. Clinical examination and x-ray shows that he has sustained a radial fracture with dislocation of the distal radio-ulna joint.
Smith’s
This is a Smith fracture (reverse Colles’ fracture); unlike a Colles’ this is a high velocity injury and may require surgical correction. Note that Colles’ fractures are usually dorsally displaced.
Monteggia’s
This constellation of injuries is referred to as a Monteggia’s fracture.
Galeazzi
Isolated fracture of the radius alone can occur but is rare. Always check for associated injury.
A 32 year old woman attends clinic for assessment of varicose veins. She has suffered for varicose veins for many years and can trace their development back to when she suffered a complex tibial fracture. On examination she has marked truncal varicosities with a long tortuous long saphenous vein. What is the most appropriate next step?
Arrange a venogram
Arrange a venous duplex scan
List her for a trendelenberg procedure
List her for injection foam sclerotherapy
List her for multiple avulsion phlebectomies
This lady is likely to have deep venous incompetence as she will have been immobilised for her tibial fracture and may well have had a DVT. A duplex scan is mandatory prior to any form of surgical intervention. A venogram would provide similar information but is more invasive.
def: varicose veins
Saccular dilation of veins
Chronic venous insufficiency
Chronic venous insufficiency is a series of tissue changes which occur in relation to pooling of blood in the extremities with associated venous hypertension occurring as a result of incompetent deep vein valves.
Symptoms of varicose veins
Cosmetic appearance
Aching
Ankle swelling that worsens as the day progresses
Episodic thrombophlebitis
Bleeding
Itching
Symptoms of chronic venous insufficiency
Dependant leg pain
Prominent leg swelling
Oedema extending beyond the ankle
Venous stasis ulcers
Typical features of venous ulcer
Located above the medial malleolus
Indolent appearance with basal granulation tissue
Variable degree of scarring
Non ischaemic edges
Haemosiderin deposition in the gaiter area (and also lipodermatosclerosis).
Examination of varicose veins
Assess for dilated short saphenous vein (popliteal fossa) and palpate for saphena varix medial to the femoral artery
Brodie-Trendelenburg test: to assess level of incompetence
Perthes’ walking test: assess if deep venous system competent
Indications for surgery in varicose veins
Indications for surgery:
Cosmetic: majority
Lipodermatosclerosis causing venous ulceration
Recurrent superficial thrombophlebitis
Bleeding from ruptured varix
Management of minor varicose veins without complications
Reassure/cosmetic
Management of symptomatic uncomplicated varicose veins
In those without deep venous insufficiency options include; endothermal ablation, foam sclerotherapy, saphenofemoral / popliteal disconnection, stripping and avulsions, compression stockings
Management of varicsoe veins with skin changes
Therapy as above (if compression minimum is formal class I stockings)
Management of chronic venous insufficiency or ulcers
Class 2-3 compression stockings (ensure no arterial disease).
Side effect of injection sclerotherapy for varicose veins?
Transient blindness
First line treatment of varicose veins recommended by NICE?
In the United Kingdom the National Institute of Clinical Excellence guidance on varicose veins suggests that for patients with symptomatic varicose veins the first line procedure of choice should be endothermal ablation (see reference for more information). Where this is unavailable or unsuitable then foam sclerotherapy should be the second line option. Surgery is currently the third line treatment option.
How to perform Trendelenburg procedure (SFJ ligation)
Head tilt 15 degrees and legs abducted
Oblique incision 1cm medial from artery
Tributaries ligated (Superficial circumflex iliac vein, Superficial inferior epigastric vein, Superficial and deep external pudendal vein)
SF junction double ligated
Saphenous vein stripped to level of knee/upper calf. NB increased risk of saphenous neuralgia if stripped more distally
A 25 year old male pedestrian is involved in a road traffic accident. He sustains multiple injuries and is admitted to the intensive care unit, intubated and ventilated. Over the next week he develops adult respiratory distress syndrome. What is the main reason for hypoxaemia in this condition?
Increased lung compliance
Reduced diffusion
Reduced surfactant
Reduced elastase
Left to right shunt
The diffuse lung injury, which is associated with loss of surfactant and increased elastase release from neutrophils, results in fluid accumulation. This leads to reduced diffusion, which is the main reason for hypoxaemia.
def: ARDS
Defined as an acute condition characterized by bilateral pulmonary infiltrates and severe hypoxemia (PaO2/FiO2 ratio < 200) in the absence of evidence for cardiogenic pulmonary oedema (clinically or pulmonary capillary wedge pressure of less than 18 mm Hg).
It is subdivided into two stages. Early stages consist of an exudative phase of injury with associated oedema. The later stage is one of repair and consists of fibroproliferative changes. Subsequent scarring may result in poor lung function.
Causes of ARDS
Sepsis
Direct lung injury
Trauma
Acute pancreatitis
Long bone fracture or multiple fractures (through fat embolism)
Head injury (causes sympathetic nervous stimulation which leads to acute pulmonary hypertension)
Management of ARDS
Treat the underlying cause
Antibiotics (if signs of sepsis)
Negative fluid balance i.e. Diuretics
Recruitment manoeuvres such as prone ventilation, use of positive end expiratory pressure
Mechanical ventilation strategy using low tidal volumes, as conventional tidal volumes may cause lung injury (only treatment found to improve survival rates)
UC and ileitis
Ulcerative colitis is a form of inflammatory bowel disease. Inflammation always starts at rectum, does not spread beyond ileocaecal valve (although backwash ileitis may occur) and is continuous
Extraintestinal manifestations of CD and UC related to disease activity
Arthritis: pauciarticular, asymmetric
Erythema nodosum
Episcleritis
Osteoporosis
Extraintestinal manifestations of CD and IBD unrelated to disease activity
Arthritis: polyarticular, symmetric
Uveitis (UC)
Pyoderma gangrenosum
Clubbing
Primary sclerosing cholangitis (UC)
Red, raw mucosa, bleeds easily
No inflammation beyond submucosa (unless fulminant disease)
Widespread superficial ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
Inflammatory cell infiltrate in lamina propria
Neutrophils migrate through the walls of glands to form crypt abscesses
Depletion of goblet cells and mucin from gland epithelium
Granulomas are infrequent
Ulcerative colitis
Management of UC
Patients with long term disease are at increased risk of development of malignancy
Acute exacerbations are generally managed with steroids, in chronic patients agents such as azathioprine and infliximab may be used
Individuals with medically unresponsive disease usually require surgery- in the acute phase a sub total colectomy and end ileostomy. In the longer term a proctectomy will be required. An ileoanal pouch is an option for selected patients
Which virus is associated with Kaposi’s sarcoma?
Human herpes virus 8
Human papillomavirus 16
Human T-lymphotropic virus 1
Epstein-Barr virus
Human papillomavirus 18
Human herpes virus 8
A 22 year old man is undergoing an endotracheal intubation. Which of the following vertebral levels is consistent with the origin of the trachea?
C2
T1
C6
C4
C3
The trachea commences at C6. It terminates at the level of T5 (or T6 in tall subjects in deep inspiration)
Aterial and venous supply of the trachea
Inferior thyroid arteries and the thyroid venous plexus.
Which of the following is not a feature of Wallerian Degeneration?
May result from an axonotmesis
Typically occurs in the peripheral nervous systems
The axon remains excitable throughout the whole process
The distal neuronal stump is affected
Is a component of the healing process following neuronal injury
The axon loses its excitability once the process is established.
- Is the process that occurs when a nerve is cut or crushed.
- It occurs when the part of the axon separated from the neuron’s cell nucleus degenerates.
- It usually begins 24 hours following neuronal injury and the distal axon remains excitable up until this time.
- The degeneration of the axon is following by breakdown of the myelin sheath, a process that occurs by infiltration of the site with macrophages.
- Eventually regeneration of the nerve may occur although recovery will depend on the extent and manner of injury
Which of the following does not cause an increased anion gap acidosis?
Uraemia
Paraldehyde
Diabetic ketoacidosis
Ethylene glycol
Acetazolamide
Acetazolamide
Causes of increased anion acidosis: MUDPILES
M - Methanol
U - Uraemia
D - DKA/AKA
P - Paraldehyde/phenformin
I - Iron/INH
L - Lactic acidosis
E - Ethylene glycol
S - Salicylates
Which statement regarding post operative cognitive impairment is true?
Use of Benzodiazepines preoperatively reduces long-term post operative cognitive dysfunction
Pain does not cause delirium
Delirium has no impact on length of hospital stay
A regional anaesthetic rather than a general anaesthetic is more likely to contribute to post operative cognitive impairment
Visual hallucinations are not a feature of delirium
Anaesthetic technique and Post operative cognitive impairment (POCD):
Use of benzodiazepines preoperatively reduces long-term POCD (9.9% vs. 5%)
Do not stop drugs for cognitive function
Regional techniques reduce POCD in first week, but no difference at 3 months
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.
A 62 year old woman presents with acute bowel obstruction. She has been vomiting up to 15 times a day and is taking erythromycin. She suddenly complains of dizziness. Her ECG shows torsades de pointes. What is the management of choice?
IV Atropine
IV Potassium
IV Magnesium sulphate
IV Bicarbonate
IV Adrenaline
Torsades de pointes: Treatment IV magnesium sulphate
This woman is likely to have hypokalaemia and hypomagnasaemia as a result of vomiting. In addition to this, the erythromycin will predispose her to torsades de pointes. The patient needs Magnesium 2g over 10 minutes. Knowledge of the management of this peri arrest diagnosis is hence important in surgical practice.
Theme: Nerve lesions
A.Iliohypogastric nerve
B.Ilioinguinal nerve
C.Lateral cutaneous nerve of the thigh
D.Femoral nerve
E.Saphenous nerve
F.Genitofemoral nerve
Please select the most likely nerve implicated in the situation described. Each option may be used once, more than once or not at all.
35.A 42 year old woman complains of a burning pain of her anterior thigh which worsens on walking. There is a positive tinel sign over the inguinal ligament.
A 29 year old woman has had a Pfannenstiel incision. She has pain over the inguinal ligament which radiates to the lower abdomen. There is tenderness when the inguinal canal is compressed.
A 22 year man is shot in the groin. On examination he has weak hip flexion, weak knee extension, and impaired quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh.
Lateral cutaneous nerve of the thigh
The lateral cutaneous nerve supplies sensation to the anterior and lateral aspect of the thigh. Entrapment is commonly due to intra and extra pelvic causes. Treatment involves local anaesthetic injections.
Ilioinguinal nerve
Femoral nerve
This is a classical description of a femoral nerve injury.
Which one of the following is least associated with thrombocytopenia?
Heparin therapy
Rheumatoid arthritis
Infectious mononucleosis
Liver disease
Pregnancy
Rheumatoid arthritis, unlike systemic lupus erythematous, is generally associated with a thrombocytosis. In some cases of Felty’s syndrome thrombocytopaenia may be seen secondary to hypersplenism. This however represents a small percentage of patients with rheumatoid arthritis.
Causes of severe thrombocytopenia
ITP
DIC
TTP
haematological malignancy
Causes of carpal tunnel syndrome
MEDIAN TRAP Mnemonic
Myxoedema
Edema premenstrually
Diabetes
Idiopathic
Acromegaly
Neoplasm
Trauma
Rheumatoid arthritis
Amyloidosis
Pregnancy
Management of carpal tunnel syndrome
Conservative:
Spontaneous resolution. Avoid precipitants. Night time splints.
Medical:
Local steroid injections.
Surgical:
Complete division of flexor retinaculum and decompression of tunnel (successful in 80% of patients)
An 28 year old man presents with a direct inguinal hernia. A decision is made to perform an open inguinal hernia repair. Which of the following is the best option for abdominal wall reconstruction in this case?
Suture plication of the transversalis fascia using PDS only
Suture plication of the hernial defect with nylon and placement of prolene mesh anterior to external oblique
Suture plication of the hernia defect using nylon and re-enforcing with a sutured repair of the abdominal wall
Sutured repair of the hernial defect with prolene and placement of prolene mesh over the cord structures in the inguinal canal
Sutured repair of the hernial defect using nylon and placement of a prolene mesh posterior to the cord structures
Sutured repair of the hernial defect using nylon and placement of a prolene mesh posterior to the cord structures
Laparoscopic repair- bilateral and recurrent cases
During an inguinal hernia repair in males the cord structures will always lie anterior to the mesh. In the conventional open repairs the cord structures are mobilised and the mesh placed behind them, with a slit made to allow passage of the cord structures through the deep inguinal ring. Placement of the mesh over the cord structures results in chronic pain and usually a higher risk of recurrence.
Laparoscopic inguinal hernia repair is the procedure of choice for bilateral inguinal hernias.
Types of surgery include:
Onlay mesh repair (Lichtenstein style)
Inguinal herniorrhaphy
Shouldice repair
Darn repair
Laparoscopic mesh repair
Open mesh repair and laparoscopic repair are the two main procedures in mainstream use. The Shouldice repair is a useful procedure in cases where a mesh repair would be associated with increased risk of infection, e.g. repair of case with strangulated bowel, as it avoids the use of mesh. It is, however, far more technically challenging to perform.
Boundaires of Hesselbach’s triangle
Medial: Rectus abdominis
Lateral: Inferior epigastric vessels
Inferior: Inguinal ligament
Which of the following is not a branch of the external carotid artery?
Facial artery
Lingual artery
Superior thyroid artery
Mandibular artery
Maxillary artery
Mandibular artery
External carotid artery branches mnemonic:
‘Some Angry Lady Figured Out PMS’
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
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
Arrangement of the branches of the carotid artery
Three in front
Two behind
One deep
Three arteries in front: ECA
Superior thyroid
Lingual
Facial
Two arteries behind ECA
Occipital
Posterior auricular
One deep ECA branch
Ascending pharyngeal
Passage of the ECA
The external carotid commences immediately lateral to the pharyngeal side wall. It ascends and lies anterior to the internal carotid and posterior to the posterior belly of digastric and stylohyoid. More inferiorly it is covered by sternocleidomastoid, passed by hypoglossal nerves, lingual and facial veins.
It then pierces the fascia of the parotid gland finally dividing into its terminal branches within the gland itself.
Origin and insetion of adductor longus
Anterior body of pubis
Inserting into middle third of linea aspera
Action of adductor longus
Adducts and flexes thigh, medially rotates hip
Innervation of addcutor longus
Anterior division of obturator (L2, L3 L4)
Which of the following statements relating to the basilar artery and its branches is false?
The superior cerebellar artery may be decompressed to treat trigeminal neuralgia
Occlusion of the posterior cerebral artery causes contralateral loss of the visual field
The oculomotor nerve lies between the superior cerebellar and posterior cerebral arteries
The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the basilar artery
The labyrinthine branch is accompanied by the facial nerve
The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the basilar artery
The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the vertebral artery. The labyrinthine artery is long and slender and may arise from the lower part of the basilar artery. It accompanies the facial and vestibulocochlear nerves into the internal auditory meatus. The posterior cerebral artery is often larger than the superior cerebellar artery and it is separated from the vessel, near it’s origin, by the oculomotor nerve. Arterial decompression is a well established therapy for trigeminal neuralgia.
Formation of the circle of Willis
- Anterior communicating artery
- Anterior cerebral artery
- Internal carotid artery
- Posterior communicating artery
- Posterior cerebral arteries and the termination of the basilar artery
Passage of the vertebral arteries
Enter the cranial cavity via foramen magnum
Lie in the subarachnoid space
Ascend on anterior surface of medulla oblongata
Unite to form the basilar artery at the base of the pons
Branches of the vertebral artery
Posterior spinal
Anterior spinal
PICA
Branches of the basilar artery
Anterior inferior cerebellar artery
Labyrinthine artery
Pontine arteries
Superior cerebellar artery
Posterior cerebral artery
Branches of the ICA
Posterior communicating artery
Anterior cerebral artery
Middle cerebral artery
Anterior choroid artery
Theme: Abdominal closure methods
A.Looped 1 PDS (polydiaxone)
B.Looped 1/0 silk
C.1/0 Vicryl (polyglactin)
D.1/0 Vicryl rapide
E.2/0 Prolene (Polypropylene)
F.Re-inforced 1 Nylon
G.Re-inforced 1/0 Silk
H.Application of VAC system without separation film
I.Application of VAC System with separation film
J.Application of a ‘Bogota Bag’
Please select the most appropriate wound closure method (for the deep layer) for the abdominal surgery described.
44.A 59 year old man with morbid obesity undergoes a laparotomy and Hartmans procedure for perforated sigmoid diverticular disease. At the conclusion of the procedure the abdomen cannot be primarily closed. The Vac system is not available for use.
A 73 year old lady undergoes a low anterior resection for carcinoma of the rectum.
A 67 year old is returned to theatre after developing a burst abdomen on the ward. She has originally undergone a right hemicolectomy and the SHO who closed the wound had failed to tie the midline suture correctly. The wound edges appear healthy.
Application of a ‘Bogota Bag’
Application of a Bogota bag is safest as attempted closure will almost certainly fail. Repeat look at 48 hours to determine the best definitive option is needed.
Looped 1 PDS (polydiaxone)
Mass closure obeying Jenkins rule is required and this states that the suture must be 4 times the length of the wound with tissue bites 1cm deep and 1 cm apart.
Re-inforced 1 Nylon
Attempt at re-closing the wound is reasonable, in which case 1 nylon is often used in preference to a dissolvable suture.
How can abdominal wound dehiscence be categorised?
It can be subdivided into superficial, in which the skin wound alone fails and complete, implying failure of all layers.
Factors increasing risk of abdominal wound dehiscence
* Malnutrition
* Vitamin deficiencies
* Jaundice
* Steroid use
* Major wound contamination (e.g. faecal peritonitis)
* Poor surgical technique (Mass closure technique is the preferred method-Jenkins Rule)
Jenkins rule
The suture must be 4 times the length of the wound with tissue bites 1cm deep and 1 cm apart.
Management of sudden wound dehiscence
* Analgesia
* Intravenous fluids
* Intravenous broad spectrum antibiotics
* Coverage of the wound with saline impregnated gauze (on the ward)
* Arrangements made for a return to theatre
What are the options for the surgical management of wound dehiscence?
Resuturing
Application of wound manager
Application of Bogota bag
Application of VAC dressing system
Resuturing in abdominal wound dehiscence
This may be an option if the wound edges are healthy and there is enough tissue for sufficient coverage. Deep tension sutures are traditionally used for this purpose.
Wound manager
This is a clear dressing with removable front. Particularly suitable when some granulation tissue is present over the viscera or where there is a high output bowel fistula present in the dehisced wound.
Bogota bag
This is a clear plastic bag that is cut and sutured to the wound edges and is only a temporary measure to be adopted when the wound cannot be closed and will necessitate a return to theatre for definitive management.
VAC dressing in abdominal wound dehiscence
These can be safely used BUT ONLY if the correct layer is interposed between the suction device and the bowel. Failure to adhere to this absolute rule will almost invariably result in the development of multiple bowel fistulae and create an extremely difficult management problem.
A 30 year old male presents with a painless swelling of the testis. Histologically the stroma has a lymphocytic infiltrate. The most likely diagnosis is :
Differentiated teratoma
Malignant undifferentiated teratoma
Classical seminoma
Spermatocytic seminoma
Anaplastic seminoma
Seminoma is the commonest type of testicular tumour and is more common in males aged between 30-40 years. Classical seminoma is the commonest subtype and histology shows lymphocytic stromal infiltrate. Other subtypes include:
1. Spermatocytic: tumour cells resemble spermatocytes. Excellent prognosis.
2. Anaplastic
3. Syncytiotrophoblast giant cells: β HCG present in cells
A teratoma is more common in males aged 20-30 years.
What proportion of testicular cancers are germ cell tumours?
95%
How can germ cell tumours be categorised?
Seminoma
Non seminomatous germ cell tumours
What are the non-seminomatous germ cell tumours
Teratoma
Yolk sac tumour
Choriocarcinoma
Mixed germ cell tumours (10%)
Testicular tumour
Commonest subtype (50%)
Average age at diagnosis = 40
Even advanced disease associated with 5 year survival of 73%
AFP usually normal
HCG elevated in 10%
Lactate dehydrogenase; elevated in 10-20% (but also in many other conditions)
Seminoma
Testicular tumour
Younger age at presentation =20-30 years
Advanced disease carries worse prognosis (48% at 5 years)
Retroperitoneal lymph node dissection may be needed for residual disease after chemotherapy
AFP elevated in up to 70% of cases
HCG elevated in up to 40% of cases
Other markers rarely helpful
Non-seminomatous germ cell tumour
Testicular tumour
Sheet like lobular patterns of cells with substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen.
Seminoma
Testicular tumour
Heterogenous texture with occasional ectopic tissue such as hair
Non seminomatous germ cell tumours
RFs for testicular cancer
Cryptorchidism
Infertility
Family history
Klinfelter’s syndrome
Mumps orchitis
A painless lump is the most common presenting symptom
Pain may also be present in a minority of men
Other possible features include hydrocele, gynaecomastia
?testicular cancer
Diagnosis of testicular tumours
Ultrasound is first-line
CT scanning of the chest/ abdomen and pelvis is used for staging
Tumour markers (see above) should be measured
Mx of testicular tumours
Orchidectomy (Inguinal approach)
Chemotherapy and radiotherapy may be given depending on staging
Abdominal lesions >1cm following chemotherapy may require retroperitoneal lymph node dissection.
Prognosis in testicular cancer
5 year survival for seminomas is around 95% if Stage I
5 year survival for teratomas is around 85% if Stage I
Which of the following muscles does not recieve any innervation from the sciatic nerve?
Semimembranosus
Quadriceps femoris
Biceps femoris
Semitendinosus
Adductor magnus
The sciatic nerve is traditionally viewed as being a nerve of the posterior compartment. It is known to contribute to the innervation of adductor magnus (although the main innervation to this muscle is from the obturator nerve). The quadriceps femoris is nearly always innervated by the femoral nerve.
A 23 year old man is involved in a fight and is stabbed in his upper arm. The ulnar nerve is transected. Which of the following muscles will not demonstrate compromised function as a result?
Flexor carpi ulnaris
Medial half of flexor digitorum profundus
Palmaris brevis
Hypothenar muscles
Pronator teres
M edial lumbricals
A dductor pollicis
F lexor digitorum profundus/Flexor digiti minimi
I nterossei
A bductor digiti minimi and opponens
Innervates all intrinsic muscles of the hand (EXCEPT 2: thenar muscles & first two lumbricals - supplied by median nerve)
Pronator teres is innervated by the median nerve. Palmaris brevis is innervated by the ulnar nerve
Which of the structures listed below overlies the cephalic vein?
Extensor retinaculum
Bicipital aponeurosis
Biceps muscle
Antebrachial fascia
None of the above
None of the above
he cephalic vein is superficially located in the upper limb and overlies most the fascial planes. It pierces the coracoid membrane (continuation of the clavipectoral fascia) to terminate in the axillary vein. It lies anterolaterally to biceps.
Path of the cephalic vein
Dorsal venous arch drains laterally into cephalic vein
Crosses the anatomical snuffbox and travels laterally up the arm
Connected to the basilic vein at the ACF by the median cubital vein
Pierces deep fascia of deltopectoral groove to join axillary vein
Which of the following pairings are incorrect?
Aortic bifurcation and L4
Transpyloric plane and L1
Termination of dural sac and L4
Oesophageal passage through diaphragm and T10
Transition between pharynx and oesophagus at C6
Vena cava T8 (eight letters)
Oesophagus T10 (ten letters)
Aortic hiatus T12 (twelve letters)
The dural sac terminates at S2, which is why it is safe to undertake an LP at L4/5 levels. The spinal cord itself terminates at L1.
Theme: ASA scoring
A.ASA 1
B.ASA 2
C.ASA 3
D.ASA 4
E.ASA 5
The American society of anaesthesiologists physical status scoring system is a popular method for stratifying patients physical status. Please select the most appropriate ASA grade for each of the following scenarios. Each option may be used once, more than once or not at all.
6.A 66 year old man is admitted following a collapse whilst waiting for a bus. Clinical examination confirms a ruptured abdominal aortic aneurysm. He is moribund and hypotensive
A 23 year old man with a 4cm lipoma on his flank is due to have this removed as a daycase. He is otherwise well.
A 72 year old man is due to undergo an inguinal hernia repair. He suffers from COPD and has an exercise tolerance of 10 yards. He also has pitting oedema to the thighs.
ASA 5
Patients who are moribund and will not survive without surgery are graded as ASA 5.
ASA 1
Absence of co-morbidities and small procedure with no systemic compromise will equate to an ASA score of 1
ASA 4
Severe systemic disease of this nature is a constant threat to life. Especially as he also has evidence of cardiac failure.
ASA 1
No organic physiological, biochemical or psychiatric disturbance. The surgical pathology is localised and has not invoked systemic disturbance
ASA 2
Mild or moderate systemic disruption caused either by the surgical disease process or though underlying pre-existing disease
ASA 3
Severe systemic disruption caused either by the surgical pathology or pre-existing disease
ASA 4
Patient has severe systemic disease that is a constant threat to life
ASA 5
A patient who is moribund and will not survive without surgery
A 22 year old man is involved in a fight. He sustains a laceration to the posterior aspect of his wrist. In the emergency department the wound is explored and the laceration is found to be transversely orientated and overlies the region of the extensor retinaculum, which is intact. Which of the following structures is least likely to be injured in this scenario?
Dorsal cutaneous branch of the ulnar nerve
Tendon of extensor indicis
Basilic vein
Superficial branch of the radial nerve
Cephalic vein
The extensor retinaculum attaches to the radius proximal to the styloid, thereafter it runs obliquely and distally to wind around the ulnar styloid (but does not attach to it). The extensor tendons lie deep to the extensor retinaculum and would therefore be less susceptible to injury than the superficial structures.
Attachments of the extensor retinaculum
The pisiform and triquetral medially
The end of the radius laterally
Structures superifical to the extensor retinaculum
Basilic vein
Dorsal cutaneous branch of the ulnar nerve
Cephalic vein
Superficial branch of the radial nerve
Structures passing deep to the extensor retinaculum
Extensor carpi ulnaris tendon
Extensor digiti minimi tendon
Extensor digitorum and extensor indicis tendon
Extensor pollicis longus tendon
Extensor carpi radialis longus tendon
Extensor carpi radialis brevis tendon
Abductor pollicis longus and extensor pollicis brevis tendons
Passage of the radial artery into the hand
The radial artery passes between the lateral collateral ligament of the wrist joint and the tendons of the abductor pollicis longus and extensor pollicis brevis.
What passes between the lateral collateral ligament of the wrist joint and the tendons of the abductor pollicis longus and extensor pollicis brevis.
Radial artery
How does proteus infection predispose to staghorn calculus?
Infection with Proteus mirabilis accounts for 90% of all proteus infections. It has a urease producing enzyme. This will tend to favor urinary alkalinisation which is a relative prerequisite for the formation of staghorn calculi.
Effect of eating on renal stone formation
Urine pH will show individual variation (from pH 5-7). Post prandially the pH falls as purine metabolism will produce uric acid. Then the urine becomes more alkaline (alkaline tide). When the stone is not available for analysis the pH of urine may help to determine which stone was present.
What is mean urine pH?
~6
What stones form in acidic urine?
Uric acid
What stones form in alkaline urine?
Ca PO4
Struvite
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
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 stone
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
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
A 27 year old man sustains a single gunshot wound to the left thigh. In the emergency department, he is noted to have a large haematoma of his medial thigh. He complains of parasthesia in his foot. On examination, there are weak pulses palpable distal to the injury and the patient is unable to move his foot. The appropriate initial management of this patient is:
Conventional angiography
Immediate exploration and repair
Fasciotomy of the anterior compartment
Observation for resolution of spasm
Local wound exploration
The five P’s of arterial injury include pain, parasthesias, pallor, pulselessness and paralysis. In the extremities, the tissues most sensitive to anoxia are the peripheral nerves and striated muscle. The early developments of paresthesias and paralysis are signals that there is significant ischemia present, and immediate exploration and repair are warranted. The presence of palpable pulse does not exclude an arterial injury because this presence may represent a transmitted pulsation through a blood clot. When severe ischemia is present, the repair must be completed within 6 to 8 h to prevent irreversible muscle ischemia and loss of limb function. Delay to obtain a conventional angiogram or to observe for change needlessly prolongs the ischemic time. A CT angiogram may be a reasonable alternative. Fasciotomy may be required but should be done in conjunction with and after re-establishment of arterial flow. Local wound exploration is not recommended because brisk hemorrhage may be encountered without the securing of prior vascular control.
Management of vascular trauma
Almost always operative.
Obtaining proximal and distal control of affected vessels is crucial.
Simple lacerations of arteries may be directly closed, or a vein patch applied if there is a risk of subsequent stenosis.
Transection of the vessel should be treated by either end to end anastomosis (often not possible) or an interposition vein graft.
Use of PTFE in traumatic open injuries will invariably result in infection.
Assessment of vascular trauma
Check for signs of distal perfusion
Doppler signal distally (monophasic/ biphasic or triphasic)
Anatomical location (which vessel is likely to be involved)
Duplex scanning and angiography are “gold standard” tests but may not be immediately available in the trauma setting
Theme: Neonatal gastrointestinal disease
A.Ano-rectal atresia
B.Pyloric stenosis
C.Hirschsprungs disease
D.Duodenal atresia
E.Meconium ileus
F.Intussusception
G.Necrotising enterocolitis
H.Intestinal volvulus
I.Tracheo-oesophageal fistula
Please select the most likely diagnosis to account for the case described. Each option may be used once, more than once or not at all.
12.A newborn baby boy presents with mild abdominal distension and failure to pass meconium after 24 hours. X- Ray reveals dilated loops of bowel with fluid levels. The anus appears normally located.
A premature infant (30-week gestation) presents with distended and tense abdomen. She is passing blood and mucus per rectum, and she is also manifesting signs of sepsis.
A newborn baby boy presents with gross abdominal distension. He is diagnosed with cystic fibrosis and his abdominal x ray shows distended coils of small bowel, but no fluid levels.
Hirschsprungs disease
Hirschsprung’s disease is an absence of ganglion cells in the neural plexus of the intestinal wall. It is more common in boys than girls. The delayed passage of meconium together with distension of abdomen is the usual clinical presentation. A plain abdominal x ray will demonstrate dilated loops of bowel with fluid levels and a barium enema can be helpful when it demonstrates a cone with dilated ganglionic proximal colon and the distal aganglionic bowel failing to distend.
Necrotising enterocolitis
Necrotising enterocolitis is more common in premature infants. Mesenteric ischemia causes bacterial invasion of the mucosa leading to sepsis. Terminal ileum, caecum and the distal colon are commonly affected. The abdomen is distended and tense, and the infant passes blood and mucus per rectum. X -Ray of the abdomen shows distended loops of intestine and gas bubbles may be seen in the bowel wall.
Meconium ileus
One in 5,000 newborns will have a distal small bowel obstruction secondary to abnormal bulky and viscid meconium. Ninety percent of these infants will have cystic fibrosis and the abnormal meconium is the result of deficient intestinal secretions. This condition presents during the first days of life with gross abdominal distension and bilious vomiting. x Ray of the abdomen shows distended coils of bowel and typical mottled ground glass appearance. Fluid levels are scarce as the meconium is viscid.
x Ray of the abdomen shows distended coils of bowel and typical mottled ground glass appearance. Fluid levels are scarce
Meconium ileus
A 54-year-old man presents to the Emergency Department with a 2 day history of a swollen, painful left knee. You aspirate the joint to avoid admission to the orthopaedic wards. Aspirated joint fluid shows calcium pyrophosphate crystals. Which of the following blood tests is most useful in revealing an underlying cause?
Transferrin saturation
ACTH
ANA
Serum ferritin
LDH
This is a typical presentation of pseudogout. An elevated transferrin saturation may indicate haemochromatosis, a recognised cause of pseudogout.
A high ferritin level is also seen in haemochromatosis but can be raised in a variety of infective and inflammatory processes, including pseudogout, as part of an acute phase response.
form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate in the synovium
Pseudogout
Risk factors for pseudogout
hyperparathyroidism
hypothyroidism
haemochromatosis
acromegaly
low magnesium, low phosphate
Wilson’s disease
knee, wrist and shoulders most commonly affected
joint aspiration: weakly-positively birefringent rhomboid shaped crystals
x-ray: chondrocalcinosis
Pseudogout
Management of pseudogout
aspiration of joint fluid, to exclude septic arthritis
NSAIDs or intra-articular, intra-muscular or oral steroids as for gout
Which of the following is not a content of the porta hepatis?
Portal vein
Hepatic artery
Cystic duct
Lymph nodes
None of the above
The cystic duct lies outside the porta hepatis and is an important landmark in laparoscopic cholecystectomy. The structures in the porta hepatis are:
Portal vein
Hepatic artery
Common hepatic duct
These structures divide immediately after or within the porta hepatis to supply the functional left and right lobes of the liver.
The porta hepatis is also surrounded by lymph nodes, that may enlarge to produce obstructive jaundice and parasympathetic nervous fibres that travel along vessels to enter the liver.
Which of the following will increase the volume of pancreatic exocrine secretions?
Octreotide
Cholecystokinin
Aldosterone
Adrenaline
None of the above
Cholecystokinin will often increase the volume of pancreatic secretions.
Theme: Facial nerve palsy
A.Adenoid cystic carcinoma
B.Cerebrovascular accident
C.Petrous temporal fracture
D.Warthins tumour
E.Sarcoidosis
F.Pleomorphic adenoma
G.Cholesteatoma
Please select the most likely cause of facial nerve palsy for the scenario given. Each option may be used once, more than once or not at all.
18.A 22 year old man presents with symptoms of lethargy and bilateral facial nerve palsy. On examination he has bilateral parotid gland enlargement.
A 21 year old man presents with a unilateral facial nerve palsy after being hit in the head. On examination he has a right sided facial nerve palsy and a watery discharge from his nose.
A 43 year old lady presents with symptoms of chronic ear discharge and a right sided facial nerve palsy. On examination she has foul smelling fluid draining from her right ear and a complete right sided facial nerve palsy.
Sarcoidosis
Facial nerve palsy is the commonest neurological manifestation of sarcoid. It usually resolves. The absence of ear discharge or discrete lesion on palpation is against the other causes.
Petrous temporal fracture
Nasal discharge of clear fluid and recent head injury makes a basal skull fracture the most likely underlying diagnosis.
Cholesteatoma
Foul smelling ear discharge and facial nerve weakness is likely to be due to cholesteatoma. The presence of a neurological deficit is a sinister feature
Which of the following structures is not closely related to the carotid sheath?
Sternothyroid muscle
Sternohyoid muscle
Hypoglossal nerve
Superior belly of omohyoid muscle
Anterior belly of digastric muscle
Anterior belly of digastric muscle
At its lower end the carotid sheath is related to sternohyoid and sternothyroid. Opposite the cricoid cartilage the sheath is crossed by the superior belly of omohyoid. Above this level the sheath is covered by the sternocleidomastoid muscle. Above the level of the hyoid the vessels pass deep to the posterior belly of digastric and stylohyoid. Opposite the hyoid bone the sheath is crossed obliquely by the hypoglossal nerve.
Theme: Paediatric emergencies
A.Manage conservatively
B.Immediate emergency theatre
C.Treat in emergency department
D.Treat in emergency department under sedation
E.Operate on next emergency list
Please select the most appropriate intervention for the scenario given. Each option may be used once, more than once or not at all.
22.A 3 year old child inserts a crayon into their external auditory meatus. Attempts to remove it have not been successful.
A 2 year old accidentally inhales a peanut. They arrive in the emergency department extremely distressed and cyanotic. Imaging shows it to be lodged in the left main bronchus.
A 10 year old boy is shot in the head with an airgun pellet. He is concerned that he will get into trouble and the injury remains concealed for 10 days. Imaging using CT scanning shows it to be lodged in the frontal lobe.
Operate on next emergency list
They would not tolerate removal in the emergency department. The tympanic membrane should be carefully inspected and again this will be easier under general anaesthesia.
Immediate emergency theatre
As they are cyanosed it requires immediate removal and this should be undertaken in a fully staffed theatre. Ideally a rigid bronchoscopy should be performed.
Manage conservatively
The pellet is small and no serious injury has occurred at this stage. This should therefore be managed conservatively.
Tonsilar artery is a branch of?
Facial 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.
Lymphatic drainage of the tonsil
Lymphatic drainage is the jugulodigastric node and the deep cervical nodes.
Why may delayed otalgia follow tonsillectomy?
Due to irritation of the glossopharyngeal nerve
Which statement is false about pethidine?
It is thirty times more lipid soluble than morphine
Structurally similar to morphine
Pethidine has a toxic metabolite (norpethidine) which is cleared by the kidney
Pethidine is metabolized by the liver
Can be given intramuscularly
It has a different structure. It is much more lipid soluble than morphine. It produces less biliary tract spasm than morphine.
What are the bulk forming laxatives?
Bran
Psyllium
Methylcellulose
What are the osmotic laxatives
Magnesium sulphate
Magnesium citrate
Sodium phosphate
Sodium sulphate
Potassium sodium tatrate
Polyethylene glycol
What are the stimulant laxatives
Docusates
Bisacodyl
Sodium picosulphate
Senna
Ricinoleic acid
MOA senna
Senna contains glycosides. It passes unchanged into the colon where bacteria hydrolyse the glycosidic bond, releasing the anthracene derivatives. These stimulate the myenteric plexus.
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.
Subtypes of DCIS
Comedo, cribiform, micropapillar and solid
Which DCIS is most likely to form microcalcifications?
Comedo DCIS
Which DCIS are most likely to be multifocal?
Cribiform and micropapillary
Lobular carcinoma and axillary node invovlvement
When an invasive component is found it is less likely to be associated with axillary nodal metastasis than with DCIS
Theme: Wound infections
A.<5%
B.5-10%
C.15-25%
D.25-40%
E.0%
F.75-100%
Please select the anticipated risk of surgical site infections for the procedures described. Each option may be used once, more than once or not at all.
30.A patient is undergoing a Hartmans procedure for perforated sigmoid diverticular disease.
A 23 year old male is undergoing an elective inguinal hernia repair.
A 43 year old women is undergoing a laparoscopic choelcystectomy for uncomplicated biliary colic.
25-40%
This is a ‘dirty’ procedure and carries an SSI risk of 25-40 %.
<5%
This is a clean procedure and carries the lowest risk of SSI.
5-10%
This is a clean contaminated procedure as the cystic duct is divided. Inadvertent spill of bile converts the operation to a contaminated one and the risk of infection rises.
A new test to screen for pulmonary embolism (PE) is used in 100 patients who present to the Emergency Department. The test is positive in 30 of the 40 patients who are proven to have a PE. Of the remaining 60 patients, only 5 have a positive test. What is the sensitivity of the new test?
8.33%
30%
40%
66.66%
75%
The sensitivity is therefore 30 / (30 + 10) = 75%
Which of the following anaesthetic agents is least likely to be associated with depression of myocardial contractility?
Propofol
Etomidate
Sodium thiopentone
Ether
None of the above
Of the agents mentioned, etomidate has the most favorable cardiac safety profile.
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.
Origin and insertion of pec major
From the medial two thirds of the clavicle, manubrium and sternocostal angle
Lateral edge of the bicipital groove of the humerus
