General Flashcards
Which tumours are associated with adrenal metastasis?
Lung and breast
Adrenaline vs Noradrenaline
Adrenaline Alpha and Beta Noradrenaline predominantly alpha Alpha - peripheral vasoconstriction Beta - cardiac chronotropic and inotropic
What is dopexamine
Splanchnic vasodilator
Scaly, thick and greasy appearance.
Keratin plugs
Seborrhoeic Keratoses
Name 4 clinical features of a mass/swelling that make it suspicious of being a sarcoma
> 5cm soft tissue mass
Deep / Intramuscular Location
Rapidly Growing
Painful
Ewings vs Osteosarcoma
Ewings is a diaphyseal, small round tumour.
Radiologically - Onion Skin appearance- represneting lysis with periosteal elevation.
Osteosarcoma is usually a tumour of the metaphysis (osteoblastic cell origin)
Radiologically - sunburst appearance = sclerotic destruction
Discuss Anterior Interosseus Nerve
Topography
Innervation
Topography:
Branch of the emdian nerve —> travels along anterior interossues membrane of the forear between flexor pollicus longus and flexor digitorum profondus ending at pronator quadratus
Innervates:
Flexor Pollicis Longus
Pronator Quadratus
Radial Half - FDP
Anion Gap
Calc
Causes
Calculation (Na+K+)-(Cl+HCO3)
Normal 10-18
Low Anion Gap
hypoalbuminaemia, increased cations (MG++, Ca++, IgG),
Normal Anion Gap - Hyperchloraemic
Bicarb Loss, Renal Tubular Acidosis (moreso in type II), Drugs (Acetozolamide), Chloride Injection, Addison’s Disease (Type IV RTA)
High Anion Gap
Lactate, Ketoacidosis, Urate, Exogenous Acids
Causes of delayed gastric emptying
Neuronal:
Vagotomy, Diabetic Gastroparesis (Vagal Nerve Disruption)
External Compression:
Pancreatic masses abutt the duodenum thereby delaying ewmptying,
Internal Obstruction:
Distal Gastric Malignancies, Pyloric Stenosis
Ileostomy
Location
Construction
Complications
Location: Triangle between ASIS, Umbilicus and symphysis pubis.
Construction: 2cm incision, stoma length 2.5 cm, spouted, one third between umbilicus and ASIS.
Complications: Dermatitis, necrosis, prolapse, retraction, high output
Normal stoma output: 5-10 ml/kg/24 hour period. If >20 ml/kg/24 hour period —> IV fluids and supplementation
Vagina lymph vessel drainage:
Superior
Inferior
Superior - drain into the internal + external iliac nodes
Inferior - drain into the superficial inguinal nodes
Contents of jugular foramen
Bones forming jugular foramen
Bones: Posterior Occipital bone + Petrous portion of temporal bone
Contents - CN IX, X, XI. Inferior Petrosal Sinus, Sigmoid Sinus, Meningieal arteries (from occipital and ascending pharyngeal artery)
Contents of Superior Orbital Fissure
CN III, IV, VI
Recurrent meningeal artery
Superior Opthalmic Vein
V1 - Lacrimal, Frontal and Nasociliary
What do each of these secrete:
Parietal Cells
Chief Cells
Surface Mucosal Cells
Parietal Cells - HCl, Ca, Na, Mg, IF
Chief Cells - Pepsinogen
Surface Mucosal Cells - Mucus and Bicarbonate
Dep Peroneal nerve
Course
Action
What (sometimes) atraumatic condition can it become compromised in?
L4-S2
Branch of common peroneal nerve at lateral aspect of fibula. Travels in anterior leg comparment. passes ankle anteriorly between two malleoli where it bifurcates:
Pre - Bifurcation: - Tibialis anterior, enxtensor hallucis longus, extensor digitorum longus, peroneus tertius
Lateral - Branch supplies extensor hallucis brevis and extensor digitorum brevis
Medial - cutaneous branch innervating skin at the webspace between 1st and 2nd digits
Acts to - evert foot, dorsiflex ankle and extend toes
It can become compromised in compartment syndrome of the anterior compartment
Berry’s Sign
Absence of carotid pulse due to thyromegaly
Thyroid Malignancy:
Psammoma Bodies
Skull Metastases
Elderly females
Pappilary - Psammoma Bodies. Picked up via FNA
Lymphatic spread
Follicular - Not well picked by FNA –> need hemithyroidectomy. Haematogenous spread (bones)
Anaplastic - Elderly females. Poor prognosis. palliative debulking
Otosclerosis
Patho
Treatment
Fixation of stapes to oval window
Treatment involes stapedectomy + prosthesis insertion
Pethidine caution in…
Renal patients
It has a toxic metabolite which accumulates in renal dysfunction —> Muscle twitching and convulsions
Pharyngeal Pouch
True diverticulum (Zenker’s)
Involves all layers of mucosa.
Posteromedial herniation between thyropharyngeus and cricopharyngeus
Discomfort after eating - think..
Chronic Mesenteric Ischaemia
Mesenteric Vascular Disease
Acute Mesenteric Ischaemia - Embolic. Sudden onset pain, vomiting and diarrhoea
Acute on chronic - Post-prandial discomfort –> Acute
Mesenteric Venous Thrombosis –> Picture of weeks. Symptoms present when arterial inflow is compromised
Low flow mesenteric infarction –> inotrope use, intercurrent cardiovascular compromise
Describe rectus sheath
Above costal margin –> Aponeurosis of external oblique aponeurosis
Between costal margin and arcuate line –> Anterior rectus sheath - External oblique aponeurosis + anterior internal oblique aponeurosis. Posterior rectus sheath- Posterior internal oblique aponeurosis + Transversus abdominus
Below arcuate line –> There is no posterior rectus sheath. External and internal oblique aponeurosis alongside transversus abdominus form anterior rectus sheath. posterior to this is transversalis fascia then peritoneum.
Arcuate line is 1/2 between umbilicus and pubic crest
Transfusion protocol in major haemorrhage due to trauma
1:1:1 - Packed Red Cells, FFP and platelets
What are adrenal rests
Adrenal rests - ectopic adrenal tissue.
Commonly located on broadligament or spermatic cord.
Extensor retinaculum
Attachments
Structures superficial to retinaculum
Tunnels
Tendons (8)
Attachments -
Medial - pisiform and triquetral
Lateral - Radius
Superficial structures -
Basilic + cephalic vein
Dorsal cutaneous branch of ulnar nerve
Superficial branch of radial nere
Tunnels -
6 tunnels in total.
Tendons-
Enxtensor Carpi Ulnaris, Extensor Digiti Minimi, Extensor Digitorum and indicis, extensor pollicis longus, extensor carpi radialis longus tendon, extensor carpi radialis brevis tendon, abductor pollicis longus, extensor pollicis brevis tendon .
What muscles are innervated by median nerve
Forearm
Distal forearm
Hand
Forearm - Pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor pollicis longus, flexor digitorum profondus (radial half)
Distal forearm - palmar cutaneous branch
Hand -
LOAF - Lateral 2 lumbricals, opponens pollicis, abductor pollicis previs, flexor pollicis brevis
Sensory innervation to thumb and lateral 2.5 fingers
Management of Renal Cell Carcinoma
T1 Malignancy - Partial Nephrectomy + Adjuvant chemotherapy
T2 Malignancies - Total radical nephrectomy. Patients need early venous control prior to resection to rpesent tumour seeding.
JVP
Absent a waves
Large a waves
cannon waves
prominent v waves
slow y descent
steep y descent
JVP rises during inspiration
Fixed Raised JVP
Absent A Waves - AF
Large A Waves - Right ventricular hypertrophy, triscupid stenosis
Cannon Waves - Complete Heart Block
Prominent v waves - Tricuspid Regurgitation
Slow y descent - Tricuspid stenosis, Right Atrial Myxoma
Steep y descent - Right ventricular failure, Constrictive pericarditis, Tricuspid regurgitation
JVP rises during inspiration - Kussmaul’s sign of constrictive pericarditis
Fixed Raised JVP - Superior Vena Cava Obstruction
Factors favouring EVAR
Long neck of aneurysm (For fusiform aneurysms - neck is the unaffected proximal portion of artery)
Good Groin Vessels
Straight Iliac Vessels
Billous Vomiting in Neonate - Rule out
Briefly describe embryological problem
What happens in the abdomen
Investigations
Intestinal Malrotation (+volvulus)
Normal embryology involves intestine entering abdominal cavity at 4 weeks –> Then a 270 degree rotation so the:
- caecum is in the RLQ
- DJ flexure is to the left of vertebrae
In intestinal malrotation - there is a missing 90% rotation –> the duodenal loop is adjacent to the caecum with Lads Bands fixing it in place.
Then the intestine undergoes 720 degree rotation –> volvulus.
Investigations :
US - Abdomen: See where the SMA is in relation to the SMV (Normally SMA on left of SMV)
Contrast abdominal scan: see where the DJ flexure is (usually to the left of vertebral bodies)
What is the ligament of treitz
Ligament of Treitz:
Suspensory ligament arising from right crus of diaphragm and attaching at the DJ flexure and usually at the 3rd + 4th parts of duodenum
Microscopic difference between
Thyroid:
Follicular Adenoma
Follicular carcinoma
Carcinoma has invasion of the capsule whereas adenoma do not.
Posterior Interossus Nerve
Origin
Topography
Muscles Innervated
Origin - Division of the radial nerve (occurs by lateral epicondyle between brachialis and brachioradialis)
Crosses supinator where it formally becomes the posterior interossues nerve
Innervates - Supinator + Extensor carpi ulnaris
Extensor digitorum, indices, digiti minimi, extensor pollicis longus + brevis, abductor pollicis longus
Testicular Tumours
RFs
Investigations
RFs- Cryptorchidism, Kinefelter’s, Infertility, FH, Mumps orchitis
Investigations - US, Tumour markets, CT- TAP for staging
Classically Categorised:
Seminoma (40 year olds) - AFP -ve, HCG <20% +ve, LDH <20% +ve
Germ Cell (non-seminoma) (<30 year olds) - 70% AFP +ve, 40% HCG +ve
Cranial Nerve IX and X Muscle exceptions
IX - This innervates Stylopharyngues - muscle for swallowing. All other pharyngeal muscles are innervated by Vagus nerve
This is because the stylopharyngeus develops from III pharyngeal arch. CN IX is also developed from this arch.
X - Cricothyroideus is innervated by the external laryngeal nerve. All other laryngeal muscles are innerated by Recurrent laryngeal nerve
This is because Cricothyroideus originates from arch IV alongside the vagus nerve. the RLN originates from arch VI
Causes of dysphagia
Extrinsic: Mediastinal Masses, Cervical Spondylosis
Oesophageal Wall: Achalasia, Diffuse oesophageal Spasm, Hypertensive Lower Oesophageal Sphincter
Intrinsic: Stricture, Schatzki Ring, malignancy, Oesophagal Web
Neurological: CVA, Bulbar Palsy, Multiple Sclerosis, Parkinson’s Disease, Myasthaenia Gravis
On Sentinel Node Biopsy of breast what might you find?
Isolated Tumour Cells or Evidence of Micrometastases
Isolated Tumour Cells - Do not require axillary clearance
Micrometastases - Depends on the extend of nodes involved. If there are lots of suspect nodes then FNA of theese nodes is the first thing to do.
In practice –> Positive SNLB usually equates to axillary node clearance
Current best practice.
Varicose Veins
i) Investigation
ii) Treatment
i) hand held doppler and then Venous Duplex
ii)
1- Endothermal Ablation
2- Sclerotherapy
3 - surgery (trendelenberg procedure)
Obturator Nerve
Roots
Topography
Actions
Roots - L2 ,3 and 4
Topography - roots combine in psoas major and descend to lateral sacral margin –> Cros sacroiliac joint –> Descend through obturator internus entering the obturator groove. Lies lateral to internal iliac vessel + ureter
Actions -
Cutaneous - Medial thigh
Motor - External obturator, Adductor magnus - upper portion, Adductor Longus, Adductor Brevis and gracilis.
Options if common bile duct has been opened/damaged?
i) T Tube insertion and closure of the bile duct over it
ii) Cholecoduodenostomy
iii) Cholecojejunostomy
Options for relieving malignant obstructive jaundice (pancreatic head ca / cholangiocarcinoma)
i) ERCP
ii) PTC + Drainage + Stent Insertion
Tongue Lymph Drainage
Anterior two thirds:
Ipsilateral Drainage
Posterior Third:
Bilateral Drainage
Tip of tongue: Submental –> Deep cervical
Midtongue: Submandibular –> Deep cervical
Posterior tongue: Deep cervical
Tongue innervation + Nerve topography
Anterior Two thirds:
Lingual nerve - originates as a branch of mandibular nerve (V3). passes tensor veli palitini –> joined by chorda tympani (facial nerve CN VII). Courses by junction of vertical/horizontal mandibular ramus –> passes by the third molar .
The Trigeminal Portion –> Sensation (General Sensory)
The Facial Portion –> Taste (Special Sensory
Posterior Third
Glossopharyngeal nerve - Sensation + Taste (General and special senory)
Why may you have a normal ph acute mesenteric emobolus?
The bowel infarct –> Lowers pH
Vomiting –> Raises pH
Four mechanisms of vomiting
Gag - Touch Receptors in throat (CN IX), Pharyngeal Cosntrictors (CNX + CNIX for stylopharyngeus)
Labyrnthine disorders - Motion Sickness
Stomach and duodenal distension - stretch receptors
Central (brain) - chemically induced (drugs etc.)
PR Bleeds
Source:
Darker Blood
Dark Blood
Fresh red Blood
Melaena
Investigations
Darker Blood - Right sided bleed
Dark Blood - Left sided bleed
Fresh red Blood - Distal bleeding (haemorrhoids)
Melaena - Upper GI
Investigations:
When blood –> Flexi Sig first. If no lesion then consider colonoscopy
When blood + unstable –> Stabilise + CT Angio
When melaena –> OGD
When to admit for acute lower GI bleeding
Age >60
Significant Co-Morbidity
Unstable
Profuse bleeding
Aspirin/NSAID use
Surgical options for splenic flexure malignancies:
Obstructed
Non-Obstructed
Obstructed -
i) Stenting
ii) Extended Right Hemicolectomy. This involves taking the middle colic vessels (SMA) too unlike a right hemicolectomy. An ileo-colic anastamosis is fashioned. In general when performing resective colorectal surgery the arteries are followed and taken to ensure lymph nodes are removed as these are usually in close proximity to the arteries.
Non-obstructed -
i) Extended Right Hemi
ii) Left hemi
iii) Transverse colectomy (old-fashioned)
Rectal Cancer
What is the margin requirement
What precludes the use of Anterior Resection
What is TME
What surgery for obstructed rectal cancer
What additional treatment can be offered to rectal cancer patients (surgery, chemo + ?)
Margin - 2cm margin requirement
Anterior resection is precluded if there is sphincter involvement or if the margin would involve the sphincter –> The surgery of choice would be an APER (Abdomino-Perineal Resection)
TME - total mesenteric excision. This involves the dissection of mesorectal fat + lymph nodes
Obstructive rectal tumours –> Defunctioning Loop Colostomy( Differs from colonic tumours where aim can be to resect and anastamose immediately if safe)
Rectal cancer can be treated with radiotherapy as it is extraperitoneal
Management of Weber Fractures
Weber Fractures - malleolar fractures
A - Below syndesmosis. Full Weight Bearing with ankle boot
B - At level of syndesmosis. If stable (Unimalleolar) then ankle boot and mobilise. If unstable - Below knee plaster and no weight bearing for six weeks
C - Above level of syndesmosis - Inherently unstable. Fixation, syndesmosis reconstruction with screws.
By what mechanism does ECF Volume depletion cause Metabolic Alkalosis
Losing significant bodily fluid through vomiting or diuretics results in a loss of Na+ + Cl-
This leads to RAAS activation –> aldosterone causes increased ENaC channels so more Sodium crosses from lumen into cells.
Luminal K+ channels upregulated so potassium is lost to the lumen.
Na+K+ATPase at interstitial side of cells is upregulated —> K+ is moved into the cell whereas Na+ is moved into interstitium.
These three transporter changes lead to an increase loss of K+ to the collecting duct lumen and a preservation of Na+
Loss of K+ Leads to K+/H+ Buffering. K+ moves from cells into ECF in exchange for H+ —–:> Alkalosis
Brisk duodenal ulcer
Treatment
Brisk Duodenal Ulcer - Usually posteriorly sited and invading the gastroduodenal artery. Duodenal ulcer pain occurs several hours after eating.
Treatment:
Resuscitate
Surgery - Laparotomy –> Duodenotomy. Underrunning the ulcer by biting above and below ulceration point which will also occlude artery. Transverse closure
Gastric Ulcer Surgical Management
Antral ulcer
Lesser Curve Ulcer
Antral Ulcer- Partial Gastrectomy (If underunning doesn’t work)
Lesser curve ulcer - Partial Gastectomy / Under Running (Usually involves Left gastric artery)
Some patients will need a total gastrectomy.
Size threshold for surgical repair of rotator cuff tear
> 2 cm
Where do the rotator cuff muscles attach
Lesser Tuberosity - Subscapularis (subscapualr fossa)
Greater Tuberosity - Supraspinatus (supraspinatus fossa), Infraspinatus (infraspinatus fossa), Teres Minor (lateral border)
Neer Classification
For proximal humeral fractures
Described as 2,3 or 4 part depending on how many fragments
- Greater Tuberosity
- LEsser Tuberosity
- ARticular Surface
- SHaft
Supports for the uteres
Central Perineal Tendon - Perineal body. This is essential. Extends between vagina and anus.
Round ligament - Uterine horns –> through inguinal canal –> mons pubis
Transverse Cervical/ Cardinal Ligament - Attaches to obutrator fascia on pelvc side wall
Uterosacral ligament - from uterus to anterior aspect of sacrum
what is the broad ligament
The broad ligament is a fold of peritoneum that envelops the uterus, ovaries and fallopian tubes.
It folds over the fundus of the uterus forming the:
Mesometrium (covers the uterus)
Mesovarium (covers the ovaries)
Mesosalpinx (covers the fallopian tubes)
investigating large bowel obstruction
First line:
DRE, AXR, ?Rigid Sigmoidoscopy
Then:
CT- AP
If inconclusive –> Gastrograffin follow through
Impending signs of perf in LBO
Caecal >12 cm
Competent Ileocaecal valve
Caecal tenderness
Managing local anaesthetic toxicity
Max Doses
Intralipid:
Bolus- 1.5 ml/kg over 1 minute
Infusion - 0.25 ml/kg/minute
If prilocaine is used then administere methylene blue
1st dose - neat/ 2nd dose w/adrenaline
Lignocaine - 3 mg/kg. 7 mg/kg
Bupivicaine - 2 mg/kg 2 mg/kg
Prilocaine - 6 mg/kg 9 mg/kg
Prilocaine
Procedures for lymphodoema
Homans - skin preserving procedure ( where skin is good). Skin flaps formed and then underlying subcutaneous tissue excised
Charles - skin and underlying subcut tissue all excised down to fascia. split skin grafts are applied. used for poor overlying skin condition.
Lymphonvenous anastamosis - exclusively for proximal obstruction + good distal lymphatics. Anastamoses between distal lymph structure and deep vein.
Why is tissue black in gangrene?
Hb degeneration and deposition of iron sulphide
Best test for vWD
Bleeding Time (factor VIII may also be low)
vWD can be Autosomal Dominant:
Type I - Quantitative deficiency of vWF
Type 2 - Qualitative impariment of synthesis of vWF
Autosomal Recessive
Type 3 - Absolute deficiency in vWF
Causes of diarrhoea
Campylobacter
Shigella
Salmonella
EColi
Yersinia
Vibrio Cholera
Camp - Most common. Gram Negative Rod (comma shaped). Reactive Arthritis, GBS
Shigella - Gram negative bacilli. Dysentry
Salmonella - Gram negative, facultative anaerobe, enterobactericiae.
ECOLI - ETEC, EIEC, EHEC
Yersinia Enterocolitica - Gram Negative coccobacilli. Terminal Ileitis - mimic Crohn’s/ Appendicitis.
Cholera - Gram Negative Rods. Watery diarrhoea
Sartorius
Supplied by Anterior Femoral Nerve (L2-L3)
ASIS –> proximal tibia
Flexes - knee and hip
Medially rotates femur.
Which Coag factors to the following influence:
Heparin
Warfarin
Liver Disease
Disseminated Intravascular Coagulation
Heparin - 2,9, 10, 11
Warfin - 2, 7, 9 , 10
Liver disease - 1, 2 , 5 , 7, ,9, 10, 11
DIC - 1, 2, 5, 8, 11
Lymphatic drainage of male genitalia
To the:
Inguinal Nodes
Iliac Nodes
Where is the external sphincter (urethral) in males?
Where does sperm enter urethra?
Deep Inguinal Nodes - Spongy urethra, Glans Penis
Iliac Nodes - membranous urethra, prostatic urethra
External Sphincter surrounds - Membranous urethra (membranous urethra extends from prostate –> perineal membrane)
Where does sperm enter urethra - prostatic urethra
Colonic Polyp Risk (colonoscopy)
Low
Medium
High
Low:
1-2 adenomas - < 1 cm No follow Up
Medium:
3-4 adenomas/ 1 adenoma >1cm - 3 year follow up
High:
5 or more Adenomas/ 3 adenomas + 1 being >1cm - 1 year follow up
Infective organism:
Large bowel ulcers and necrosis
EnteroInvasive E Coli
Structures passing through the Parotid Gland
Facial Nerve (superficial)
Retromandibular Vein ( next most superficial)
External Carotid Artery (deep to the vein)
Auriculotemporal nerve
What is diaphragm disease
Due to long term NSAID use
Small bowel becomes seperated into compartments where there is thickened circular mucosal abd submucosal membranes —> focal areas of small callibre lumens –> frequent small bowel obstructions
Which nerve is responsible for flexing thumb
Solely median nerve
Forearm - flexor pollicis longus
Hand - flexor pollicis brevis
What drain is used surgically after CBD exploration?
T Tube:
Latex. This is to induce a fibrotic reaction so a tract will form
What is sibson’s fascia?
Fascia overlying the apex of both lungs
C7-first rib (inbetween thoracic cage + parietal pleura)
Right Lung Anatomy
Three Lobes - Seperated by oblique and transverse fissure
Azygous Vein - Just above hilum
Superior vena cava + inominate vein - Groove is further above hilum
Oesophagus - Behind Hilum
Inominate Artarey - Near apex
IVC groove- near lower part of the oesophageal groove
Left Lung Anatomy
Two lobes - Seperated by oblique fissure
Groove for aortic arch - Above HIlum
Groove for subclavian artery - Furhter Above hilum
Groove for descendign aorta - behind hilum
Oesophagus - lower part of the lung
JVP Deflections
a
c
v
x
y
Ascents
a - trial contraction
c - ventricular contration
v - atrial venous filling
Descents
x - atrial relaxation
y - ventricular filling / atrial emptying
Superficial peroneal nerve
Deep peroneal nerve
Arise when common peroneal bifurcates between fibula and peroneus longus
Superficial -
peroneal longus and brevis
Cutaneous - lateral lower third of leg and most of dorsum of foot (except lateral foot which is supplied by sural nerve and medial leg which is supplied by saphenous nervee)
Deep -
Tibilaris anterior, peroneus tertius, Extensor hallucis longus, extensor digitorum longus + brevis
Terminates into medial and lateral branches
Cutaneous supply - first web space
Psoas Major and Minor
Major - originates from lumbar vertebrae and attaches onto lesser trochanter
Innervated - Anterior Rami of L1-L3
Minor - High lumbar origin and attaches to pubic crest (superior)
Innevated - anterior rami of L1
Blood tests for carcinoid tumours
Urine Tests
Chromogranin A
Neuron Specific Enolase
Substance P
Gastrin
Urine-
5 HIAA
5 Hdyroxytriptamine
Tumour Genetics Colorectal
FAP
HNPCC
Cowden
Peutz Jehger
FAP - APC mutations (TS Gene)
HNPCC - MSH2, MLH1, PMS2 + GTBP (Amsterdam Criteria, DNA Mismatch repair Genes)
Cowden - PTEN (Autosomal Dominant)
Peutz Jehger - LKB1, STK11
Divisions of the laryngeal cavity
Vestibule - Superior to vestibular folds
Ventricle - between vestibular folds and vocal cord
Infraglottic - vocal cord to cricoid cartilage
Muscles of the larynx (6/7)
Posterior Cricoarytenoid - Abduct vocal fold
Lateral Cricoarytenoid - Adduct Vocal fold
Thyroarytenoid - Relax Vocal Fold
Transverse + Oblique Arytenoids - Close Rima Glottidis
Vocalis - Relaxes posterior part of vocal ligament and tenses anterior part of vocal ligament
Cricothyroid - Tenses vocal ligament (Innervated by External Laryngeal Nerve)
Vascular Supply of Larynx
Lymph Drainage
Superior and Inferior Laryngeal Arteries ( branches of superior and inferior thyroid arteries )
Superior and inferior Laryngeal veins drain into the Superior and Middle thyroid veins Respectively
Lymph Drainage of Larynx:
Supraglottic - Upper Deep Cervical
Subglottic - Prelaryngeal + Pretracheal + Inferior Deep Cervical
Vocal Cords don’t have lymphatic drainage
Femoral Triangle:
Borders
Structures
Borders:
Lateral - Femoral Vein
Medial - Lacunar Ligament
Anterior - Inguinal Ligament
Posterior - Pectineal ligament
Structures:
Lymphatic Vessels, Cloquet’s Lymph Node
Desmoid Tumours
Associated with which GI Disorder
What Structures do they arise from
Associated with FAP (APC Tumour Suppressor Gene Mutations)
They are proliferations of myofibroblasts arising from Musculoaponeurotic Structures
Male Genital injuries
i) Meatal Haematoma, Perineal Haematoma, Urinary Retention
ii) High Riding Prostate, Perineal Oedema/ Haematoma, Pelvic Fracture
iii) haematuria, suprapubic pain, inability to retrieve all irrigation through bladder
i) Bulbar Urethral Rupture
ii) Membranous Urethral Rupture
iii) Bladder Rupture
For Urethral Injury:
Ix - Ascending Urethrogram
Mx - Surgical Suprapubic Catheter
For Bladder Injury:
Intraperitoneal - Laparotomy
Extraperitoneal - Conservative
Diaphragmatic Apertures:
T12
T10
T8
T12 - Aortic
T10 - Oesophageal
Oesophagus + Vagus Trunks
T8 - Caval
IVC +Right Phrenic Nerve
Classifying Open Fractures
What should be empirically done
Gustillo and Anderson Classification System:
I Low Energy wound <1cm
II - >1cm wound with modeate soft tissue damage
IIIA - High Energy (>1cm) + Adequate tissue coverage
IIIB - High Energy (>1cm) + Inadequate soft tissue coverage
IIIC - High Energy (>1cm) + Arterial Injury
Empirically - Tetanus Prophylaxis + Broad Spectrum Abx + Check neurovascular status + Debride and lavage
p53 germline mutations –> Cancer<45
Li-Fraumeni Syndrome
p53 is a tumour suppressor gene
Individuals develop sarcoma <45 years old
Gardner Syndrome
APC Gene Mutations
Multiple Polyposis
Supernumeray Teeth
Jaw + Skull Osteoma
Hypertrophic Retinal Pigment
Thyroid Cancer
Cutaneous Lesions
Which hormones are reduced in stress response?
Insulin
Oestrogen
Testosterone
Superior Vena Cava
Formation
What joins before entering right atrium?
Sites of collateralisation in SVCO
Forms from - Right and left Inominate veins ( these respectively form from Internal + Subclavian Veins)
Azygous vein forms before entring right atrium - Forms from union of ascending lumbar veins and subcostal veins.
Collateralisation -
Primarily Azygous
Internal Thoracic Vein - originates at superior epigastric vein and terminates in brachiocephalic vein
Long thoracic Vein - drains from serratus anterior and pectoralis major to axillary vein. A connection between LTV and superficial epigastric vein (the thoracoepigastric vein) alows shunting
Median Nerve
Which branches supply what
Median nerve supplies:
Flexor Carpi Radialis, Palmaris Longus, Flexor Digitorum Superficialis
Anterior interosseus nerve: (branch given off in upper forearm) (Deep forearm muscles)
Lateral part of flexor digitorom profondus, flexor pollicus longus, pronator quadratus
Palmar Cutaneous Branch: (given off in the forearm) s
Sensation to thenar eminence
Recurrent Muscular Branch: (hand branch given off just after flexor retinaculum) Opponens Pollicis, Abductor Pollicis Brevis, Flexor Pollicis Brevis)
Digital Cutaneous branch: (hand branch given off just after flexor retinaculum) Lateral lumbricals,
Blood Supply to CBD
Hepatic Artery and branches of Gastroduodenal artery
Hepatobiliary Triangle
Medially - Common Bile Duct
Inferiorly - Cystic Duct
Superiorly - Inferior Lobe of liver
Contents Cystic Artery
Workup in oesophogeal Ca
Staging CT
Diagnostic Laparascopy –> look for peritoneal disease
PET CT
If none of these are positive then proceed to consider for surgery
Distal Ca –> Ivor Lewis Two stage
Proximal –> Mckeown three stage
Blood supply to rectum
What is the extraperitoenal rectum Surrounded by?
Fascia surrounding rectum
Three arteries
Superior - From IMA
Middle - From Internal Iliac
Inferior - From Internal Pudendal (branch of internal iliac)
Extraperitoneal rectum is surrounded by - Mesorectal fat containing lymph nodes (hence need for total mesorectal excision)
Anterior rectal fascia - Denonvillers
Posterior rectal Fascia - Waldeyers
Innervation of the infrahyoid strap muscles
Sternohyoid - Ansa cervicalis
Sternothyroid - Ansa Cervicalis
Thyrohyoid - C1 Spinal nerve (through hypoglossal nerve)
Omohyoid - Superior belly - Superior root of ansa cervicalis - C1)
Inferior Belly - Ansa Cervicalis
Ansa cervicalis - Cervical plexus exists in carotid triangle
- Two roots - Superior Originates from C1, Inferior orginiates from C2+C3
Ligamentous Anatomy of the Ankle Joint
Medial -
Lateral - 3 components
Between Tibia and Fibula - 4 components
Medial - Deltoid Ligament
Lateral - Lateral ligament complex: 3 components
Anteriotalofibular ligament
Calcaneofibular ligament
Posteriotalofibular ligament
Syndesmosis - ligament complex between distal fibula and tibia - 4 components
Anterior-inferior tibiofibular ligament
Transverse tibiofibular ligament
Interosseus membrane
Posterior-Inferior tibiofibular ligament
X Ray indicators of Ankle Syndesmotic Injury
Decreased tibiofibular overlap
Lateral/Medial joint clear space
Lateral Talar Shift
principles for operating in acute cholecystitis
<48 hours surgery is a good idea
>5 days - surgery is best left deferred to 3 months to allow inflammation to settle
Mucinous colorectal cancer at young age
Family history
Likely to be Lynch Syndrome or HNPCC
Immunlogics and their uses
Bevacizumab
Trastazumab
Imatinib
Basiliximab
Cetuximab
Bevacizumab (anti-VEGF) - Colorectal, Renal, Glioblastoma
Trastazumab (anti-HER2) - Breast
Imatinib (TK inhibitor) - GIST, CML
Basiliximab (IL2 R) - Post renal transplant
Cetuximab (Epidermal Growth Factor Receptor inhibitor) - Colorectal
Fistulae
When is it safe to conersvatively manage?
Drug therapy for high output fistula
Contraindication to probing perianal fistulae
How to delinieate fistula tract?
Conservative management - In the absence of IBD or distal obstruction
Octreotide si used to reduce pancreatic secretions in the context of high output fistulae
Perianal fistulae should not be probed in teh context of acute inlammation
Fistula anatomy can be delineated using CT and barium studies
Management of Liver Metastases
Patients with good physiological reserve - Chemotherapy + Surgical Resection
5 Year Survival can be as good as 20%
With poor physiological reserve - Radiofrequency ablation
Glucocorticoids
At a cellular level - MOA
Metabolic effects
Regulatory Effects
They bind to intracellular receptors -these migrate to the nucleus acting as transcription factors
Metabolic:
Decrease uptuake and utilisation of glucose –> increase gluconeogenesis
Increase protein catabolism
Potentiate lipolysis
Regulatory:
Negative Feedback on hypothalamus
Prevent vasodilation and fluid loss from vessels
Increase osteoclastic activity/ Decrease osteoblastic activity
Decrease inflammation (Decrease B/T Cell clonal expansion)
Hip Joint
Vascular Supply
Gold Standard Investigation for fractures if plain films are inconclusive
Internal Fixation, Hemiarthroplasty or THR
Vascular Supply - Medial and lateral femoral circumflex arteries (branches of profunda femoris) which go onto anastamosis and enter the joint capsule at the posterior neck base.
Ligament of teres provides small blood supply
Imaging - MRI is gold standard if plain radiographs aren’t good enough however in practice CT is sought
internal fixation - Young displaced/undisplaced, Elderly undisplaced
Hemiarthroplasty - Displaced and poor baseline mobility/ cognitive impariment/ medically unfit
THR - Displaced and good baseline mobility/ no cognitive impairment/ medically fit
Colonic cancers with threatened resection margin mangement
Rectal cancers with threatened resection margin management
Colonic cancers with threatened resection margin mangement - Primary Resection
Rectal cancers with threatened resection margin management - Long course chemotherapy.
Nerve most commonly injured during superficial parotidectomy
Greater Auricular Nerve
- ascending branch fo cervical plexus arising from 2nd and 3rd cervical nerves
- Ascends sternoclediomastoideus coming underneath the platysma muscle
- Branches into anterior and posterior overly the parotid.
Pancreatic Adenocarcinoma
RFs
Most common Location
Ix
Mx
RFs- Smoking, Diabetes, Adenoma, FAP
Most commonly in the head of pancreas
Ix - USS, CT Scan
IF on CT it is deemed unresectable no further staging
IF on CT it is deemed resectable –> PET/CT, ERCP/MRI, Staging Laparoscopy (peritoneal disease)
Mx -
Head - Whipple’s
Body/Tail - Distal Pancreatectomy
Adjuvant Chemotherapy
ERCP
Contents of the popliteal fossa
Most Medial
Artery
Vein
Tibial Nerve
Common Peroneal Nerve
Soemtimes sural nerve
Most Lateral
What level do the following branches come off the aorta?
Coeliac
Superior Mesenteric
Inferior Mesenteric
Coeliac - T12
Superior Mesenteric - L1
Inferior Mesenteric - L3
What level do the following branches come off the aorta?
Inferior phrenic
Lumbar
Median Sacral
Inferior phrenic - T12
Lumbar - L1-L4
Median Sacral - L4
What level do the following branches come off of the aorta?
Middle suprarenal
Renal
Gonadal
Common Iliac
Middle suprarenal - L1
Renal - L1-L2
Gonadal - L2
Common Iliac - L4
Colles Fracture
Dinner fork deformity
Transverse distal radius fracture
Dorsal displacement and angulation
Smiths Fracture
(reverse colles’)
Distal Radius transverse fracture
Volar angulation of fragment
Bennett’s Fracture
Intraarticular fracture of 1st MCP
Triangular fragment at ulnar base of metacarpal
Monteggia Fracture
Ulnar fracture
Proximal radioulnar joint dislocation
Galeazzi Fracture
Radial shaft fracture
Dislocation of distal radioulnar joint
Barton’s Fracture
Distal Radius fracture (Colles or Smiths)
with
radiocarpal dislocation
what nerve is responsible for otalgia post-tonsillar surgery
Glossopharyngeal nerve
What is the most common site of intessusception paediatric?
Ileo-caecal - This is usually maanged by fluroscopically guided air insufflation
Ileo-ileal is less common but needs a laparotomy
Origins of gluteal arteries
Gluteal Nerves
Inferior gluteal artery - anterior trunk of internal iliac artery
Superior gluteal artery - posterior trunk of internal iliac artery
Superior Gluteal Nerve - L4, L5, S1
Inferior Gluteal Nerve - L5, S1, S2
Epigastric Pain and Audible Bruit
Median Arcuate Ligament Syndrome:
The median arcuate ligament of the diaphragm compresses the coelic trunk and coeliac ganglia.
Pain realted to meals.
Aortic Aneurysm - Iliac Involvement
Open Repair
What is the level of the transpyloric plane
Contents of the transpyloric plane (13)
Transpyloric plane - L1!
Pylorus of the stomach
Left Kidney Hilum + Right Kidney Hilum (Note right lower than left)
Gall bladder fundus
Pancreatic Neck
Duodenojejunal Fixture
Superior Mesenteric Artery
Portal Vein
Left and right Colic Flexure
Roof of the transverse mesocolon
2nd part of the duodenum
Upper Part of conus medullaris
Spleen
Functional Renal Imaging
DMSA
Diethylene-triamine-penta-acetic acid
MAG 3 Renogram
Micturating Cystourethrogram
Intravenous Urography
PET/CT
DMSA - Localises in the renal cortes. –> Cortical defects, scarring, Ectopic or aborrhent kidneys.
Diethylene-triamine-penta-acetic acid DTPA - Glomerular Filtration Agent. Provides useful information about eGFR
MAG 3 Renogram - Secreted by tubular cells so good for imaging kidney in patients with existing renal impairment.
Micturating Cystourethrogram - Assessment of bladder reflux. Bladder filled with contrast via catheter
Intravenous Urography - Good for renal function, and detection of urinar tract calculi
PET/CT - Staging
Statistical Tests:
T Test
Fishers Exact Test
Spearmans Rank Test
Mann Whitney U Test
Bonferroni Test
T Test - normal distribution
Fishers Exact Test - determines the signfificance of athe deviation from null hypothesis.
Spearmans Rank Test - significant relationship between two sets of data
Mann Whitney U Test - nonparametric test of the null hypothesis that sample from one group is equally likely to be lesser than or greather than sample from another group
Bonferroni Test - counteracts problems of multiple comparisons
Brachial PLexus Questions
In which fascia are the upper 3 rami of the brachial plexus contained within pre-axillary artery?
Which part of the axillary artery does the plexus surround?
where are the cords formed?
Which divisions form which cords?
They are contained within the pre-vertebral fascia
The plexus surrounds the second aprt of the axillary artery
Cords are formed in the Axilla
Cords:
Posterior Cord - Dorsal divsions of C5- C8 (Upper, Middle and half of Lower Trunk)
Medial Cord- Ventral divisions of C8-T1 (Lower Trunk)
Lateral Cord - Ventral Divisions of C5-C7 (Upper and middle trunk)
Brachial Plexus Questions:
What are the terminal nerves of the brachial plexus (not branches)?
What forms the:
Long Thoracic Nerve
Dorsal Scapular Nerve
Upper Subscapular Nerve
Thoracodorsal Nerve
Lower Subscapular Nerve
Axillary Nerve
Suprascapular Nerve
Nerve to subclavius
Lateral pectoral Nerve
Musculocutaneous Nerve
Medial Cutaneous nerve of the arm
Medial cutaneous nerve of the forearm
Ulnar Nerve
Terminal Nerves are - Radial Nerve ( From Posterior Cord)
Median nerve (Lateral and Medial Cord)
Derived from:
Roots:
Posterior-
Long Thoracic Nerve- C5-C7
Dorsal Scapular Nerve - C5
Anterior -
Nerve to Subclavius - C5-C6
Trunks:
Suprascapular Nerve - Upper Trunk
Cords :
Upper Subscapular Nerve - Posterior Cord
Thoracodorsal Nerve - Posterior Cord
Lower Subscapular Nerve - Posterior Cord
Axillary Nerve - Posterior Cord
Lateral pectoral Nerve - Medial and Lateral Cord
Musculocutaneous Nerve - Lateral Cord
Medial Cutaneous nerve of the arm - Medial Cord
Medial cutaneous nerve of the forearm - Medial Cord
Ulnar Nerve - Medial Cord
Describe Subclavian Steal syndrome
Stenosis/ Occlusion of subclavian artery, proximal to the origin of the veryebral artery.
What surgery for Conjugated hyperbilirubinaemia in baby?
Biliary atresia:
Kasai procedure - Roux-en-Y portojejunostomy
if this fails —> Liver transplant
Phrenic Nerve Topography
C3- C5
Left:
Deep to prevertebral fascia across scalenus anterior
Crosses anterior to part 1 of subclavian artery
Posterior to Subclavian vein and Internal Thoracic —> enters the thorax
Lateral to left subclavian, aortic arch and left ventricle.
Anterior to lung hilum and pierces diaphragm
Right:
Deep to prevertebral fascia across sclaneus anterior
Croses anterior to 2nd part of subclavian artery
Posterior to Subclavian vein and Internal Thoracic —> enters the thorax
Travels anterior to right vagus and laterally to SVC
passes over R atrium and exits through the caval opening at T8 of diaphragm
Cancer arising of the kidney due to long term inflammation?
Squamous Cell Carcinoma
Scalenus Anatomy
Innervation
Which structures pass through
Scalenus Anterior Medius and Posterior
-Anterior and medius both insert onto first rib
Posterior inserts onto second rib
Innervation:
Spinal Nerves C4-C6
Brachial Plexus and subclavian artery both pass inbetween scalenus anterior and medius
Why use bupivicaine post-operatively over lidocaine?
It has a much longer duration of action than lignocaine and therefore can provide longlasting wound-site analgaesia
What would be the LA of choice in regional block?
Prilocaine - this is much less cardiotoxic
Basilic Vein Path
Cephalic Vein Path
Basilic - is Medial.
Originates from dorsla venous network —> passes most of the way superficially.
Anterior to the antecubital fossa —> joins the cephalic vein the the median cubital vein
Pierces the biceps fascia
Ascending medially it becomes the axillary vein
Cephalic - is Lateral
Ascends lateralyl from the dorsal venous network. Travels lateral to antecubital fossa.
Into Deltopectoral triangle inbetween pectoralis and deltoid
Empties into axillary vein
Prostate Disease-Which lobe
BPH
Carcinoma
Prostate
Arterial Supply
Venous Drainage
Lymph Drainage
BPH - Median Lobe
Carcinoma - Posterior Lobe
Arterial Supply - Inferior Vesical Artery (branch of internal iliac)
Venous Drainage - Prostatic Venous PLexus ( to paravertebral veins)
Lymph Drainage - internal iliac (+sacral)
When are hepatocellular adenomas resected?
>5 cm due to risk of rupture
or
In males due to high risk of malignancy
Coeliac Artery
Branches of coeliac artery
Level of coeliac artery from aorta
Level - T12
Branches:
Left Gastric - Oesophageal and stomach branches
Common Hepatic - Proper hepatic (branches into left and right hepatic- right giving off cystic artery), Right Gastric, Gastroduodenal (branches into r. gastroepiploic + superior pancreticoduodenal)
Splenic Artery - Dorsal pancreatic, Short Gastric, Left gastro-omental, Greater Pancreatic
Anatomy of the foot arches
Longitudinal:
Posteriorly supported by calcaneum
Laterally- passes over cuboid bone and lateral two metatarsal bones
Medially - head of talus (summit) between the subtentaculum tali and navicular bone. Anterior pillar is navicular, cuneiforms and medial three metatarsals.
Transverse:
Between Anterior tarsus and posterior metatarsus.
What constitutes:
Sub Talar Joint
Facet on lower surface of talus body + Posterior facet on the upper surface of calcaneus
Synovial
What constitutes:
Talocalcaneonavicular joint
Anteroinferiorly the navicular bone communicates with the subtentaculum tali of the calcaneus (Posteroinfeiorly) to provide a place for communication of the Talus to sit.
Hip Joint
Intracapsular ligamnets
Extra Capsular Ligaments
Majority of blood supply to head of femur?
Intrcapsular -
Transverse Ligament
Ligament of Teres
Extracapsular:
Ilofemoral
Pubofemoral
Ischofemoral
Medial and lateral circumflex femoral arteries (both branches of profunda femoris/ inferior gluteal artery)
Which strucures pass through
Inferior Sciatic Foramen
Superior Sciatic Foramen
Both
They are divided by sacrospinous ligament.
Lesser (Anterior - ischium tuberosity, Superior - Sacrospinous ligament + spine of ischium, Posterior - sacrotuberous ligament)
Obturator Internus Tendon
Greater (Anterior - greater sciatic notch of ilium, Posterior- sacrotuberous ligament, Inferior - sacrospinous ligament + ischial spine, superior - anterior sacroiliac ligament)
Nerves- sciatic, Superior (above piriformis) and inferior gluteal nerves, posterior femoral cutaneous nerve, nerve to quadratus femoris, nerve to obturator internus)
Arteries + Veins - Superior Gluteal A +V, Inferior Gluteal A+V, )
Both
Pudendal Nerve
Internal Pudendal A+V
Nerve to obturator internus
Deep Perineal Pouch
Anatomical Location
Contents
Anatomical location:
Bounded inferiorly by inferior fascia of urogenital diaphragm and superiorly by superior fascia of urogenital diaphragm
Contents:
Urethral sphincter
Transversus Perinei
Nerves - Dorsal nerve of penis, perineal nerve branches
Vessels - Urethral artery, deep artery of penis, dorsal artery of penis, origin of artery to bulb of penis
Left Common Carotid Anatomy
Thorax -
Neck -
Originates from arch of aorta -
Thorax - In contact with trachea, recurrent laryngeal nerve and oesophagus
Left brachiocephalic vein passes anteriorly in front of it
Neck -
Runs beneath SCM and enters anterior triangle
In carotid sheath with - vagus nerve, and (lateral to ) internal jugular vein
vertebral artery and thoracic duct lie posterior to the artery in the neck
Bifurcate at level of C3 vertebrae/ upper border of throid cartilage
Right Common Carotid -
Same except :
Branch of brachiocephalic trunk.
No thoracic duct on the right side
Sulphur Granules and Gram Positive Organisms - Histology
Actinomycosis
- Forms multiple sinuses
The sulphur granules (round or oval basophilic masses)
Within what time should an open fracture be internally fixated?
72 hours
Malignant Fibrous Histiocytoma
Four SubTypes
Treatment
Subtypes:
Storiform - Pleomorphic
Myxoid
Giant Cell
Inflammatory
Treatment:
Surgical resection + pseudocapsule resection
Chemotherapy
Large pathological deposit in bone
?management
Surgical Fixation - to prevent fractures
When do you consider surgery for polyps?
Incomplete excision of malignant polyp (endoscopically)
Malignant sessile polyp
Malginant peduncalated polyp with submucosal invasion
Polyops with poorly differentiated carcinoma
Familial polyposis syndromes
Growth Plate Fracture Classifications
SALTER
I S traight through growth plate
II A bove and through growth plate
- *III B** elow and through growth plate
- *IV T** hrough metaphysis epiphysis + growth plate
V E Everyything (crush injury)
Which space does LP go?
Subarachnoid
Popliteal Fossa
Borders
Contents
Borders:
Lateral: Biceps femoris, Lateral head of gastroc and plantaris
Medial - Semimembranosis and semitendinosis, medial head of gastroc
Floor - Popliteus, Femur
Roof - Superficial and deep fascia
Contents:
Vascular: Popliteal artery, Popliteal Vein, Short Saphenous Vein
Nerves: posterior cutaneous nerve of thigh, tibial nerve, genicular branch of of obturator nerve
Which vein is related to:
Sural Nerve
Saphenous Nerve
Sural nerve:
Short Saphenous Vein: Lateral side of foot. Passes inferio-lateral to the lateral malleolus. Enters popliteal fossa between gastroc heads.
Saphenous Nerve:
Long saphenous Vein: Medial side of foot. Passes anterior to medial malleolus. Traverses the medial posterior femoral epicondyle. Migrates laterally on anterior thigh.
Common extracolonic manifestation of FAP
Duodenal and gastric polyps
Paediatric Neck Masses:
Cyst above the hyoid
Cyst below the hyoid
Anterior to SCM at the angle of mandible
Posterior to SCM
Cyst above the hyoid - dermoid - heterogenous appearane
Cyst below the hyoid - Thyrogossal cyst - thin walled and anechoic
Anterior to SCM at the angle of mandible - branchial cyst - failure of obliteration of usualy 2nd arch. anechoic. can become infected
Posterior to SCM - cystic hygroma - can be closely aassocated with surrounding structures. lymphatic malformation
Paediatric fluid management
100 ml/kg/day - first 10 kg
50 ml/kg/day - second 10 kg
20 ml/kg/day - subsequent kgs
Neonates:
First day- 50-60 ml /kg/day
Second day - 70 - 80 ml/ kg / day
Third day - 80 - 100 ml /kg / day
fourth day - 100-120 ml/kg/day
5-8 days - 120-150 ml /kg / day
Oxygen Dissociation Curve
Causes of Right Shift
Causes of left shift
Right shift - Reduced affinity for oxygen –> increased oxygen delivery
High
High H+ (Acidosis)
High temp
High 2-3 DPG
CO2
Left shift - higher affinity for oxygen–> lower oxygen delivery
Low
Low H+ (alkalosis
Low Temp
Low 2-3 DPG
DPG - is high in conditions where there is reduced oxygen delivery to tissues - High Altitude, Low Hb
Tymus Histology
ARterial Supply
Venous Drainage
Encapsulated Lobular Structure originating from III and IV pharyngeal arches
Cortex - Lymphocytes
Medulla - Concentric epithelial cells with keratinsed centre
Arterial Supply:
Internal mammary artery (or pericardiophrenic arteries)
Venous Supply:
Left Brachiocephalic vein
Scaphoid abdomen
Abdomen sucked inwards:
Think diaphragmatic hernia in newborn
management of diverticular stricture + LBO
Laparatomy and hartmann’s
Dilating - contraindicated
Stenting - often not useful
Wound healing - Predominant Cell Types
Inflammation
Regeneration
Remodelling (Contraction)
Inflammation
Neutrophils. Early phase (first week)
Regeneration
Fibroblasts. (8 weeks)
Microvascularisation
Remodelling (Contraction)
Differentiated fibroblasts.
Microvessels regress so the scar looks pale.
Exposure to vinyl chloride
Hepatic Angiosarcoma
Ileostomy effluent
Na - 126 mmol/ L
K+ - 22 mmol/L
Contents of Cavernous Sinus
O TOM CAT
Ophthalmic nerve
Trochlear Nerve
Ophthalmic nerve (V1)
Maxillary nerve (V2)
Internal Carotid Artery
Abducens Nerve
Foramen of Munro
Magendie
Lushka
Munro:
Lateral Ventircles into Third ventricle
lushka:
Anteromedial apertures of the fourth ventricle
magendie:
Posteriorinferor of the fourth ventricle
what provides sensory innervation to posterior thigh
Posterior Cutaneous Nerve of thigh:
Direct branch of Sacral PLexus
SMA
Origin from Aorta
Branches
L1
Inferior Pancreatico-duodenal artery
Jejunal and Ileal Arcades
ileocolic
right colic
middle colic
Musculocutaneous Nerve
Origin?
Action?
Origin: Branch of Lateral Cord of brachial plexus
Action:
Continues into forearm as lateral cutaneous nerve of forearm
Innervates - coracobrachialis, brachialis, biceps brachii
Structures passing through foramen ovale
Through which bone is the foramen
Sphenoid bone
OVALE
O - tic ganglion
V - V3 Mandibular nerve
A - accessory meningeal artery
L - lesser petrosal nerve
E- missary veins
Location and content of following skull foramina
Ovale
Ovale (sphenoid)
Otic Ganglion, V3, Accessory Meningeal Art., Lessor Petrosal Nerve, Emissary Veins
Spinosum
Spinosum (Sphenoid)
Middle Meningeal Artery, Meningeal branch of mandibular nerve
Rotundum
Rotundum (Sphenoid)
V2
Foramen Lacerum - Location and contents
Lacerum (Sphenoid)
ICA, Nerve + Art. of pterygoid canal
Jugular Foramen - Location and Contents
Jugular (temporal)
Inf. Petrosal Sinus, IX, X, XI, Sigmoid Sinus (becomes Int. jug), Meningeal branches of occipital and ascend. pharyngeal art.
Foramen Magnum - location and contents
Foramen Magnum (occipitaL)
Medulla oblongata, Ant. + Post. Spinal Art. , Vert. Art
Stylomastoid Foramen - Location and contents
Stylomastoid Foramen (Temporal)
Stylomastoid Artery, CNVII
Superior Orbital Fissure - Location and contents
Superior Orbital Fissure (Sphenoid)
III, IX, V1, Recurrent meningeal artery, VI, Superior Ophthalmic Vein
Lymph Drainage of Auricle (Ear)
Lateral upper Half
Cranial Superior half
Lower half and lobule
Lateral upper Half - Superficial parotid
Cranial Superior half - deep cervical + Mastoid
Lower half and lobule - Superficial cervical
parotid malignancy:
perineural skip lesions
Most common
derived from secretory portion
perineural skip lesions - Adenoid Cystic Carcinoma
35% 5 year survival. Tendency for visceral spread
Most common- Mucoepidermoid carcinoma
Don’t usually metastasise
derived from secretory portion - Adenocarcinoma
Pharyngeal Pouch is between?
Diverticulum between cricopharyngeus and thyropharyngeus
Oesophagus:
Arterial
Venous
Lymphatic
Beginning and termination
Location of strictures
Upper Third:
Arterial - Inferior Thyroid Artery
Venous - inferior thyroid vein
lymph - Deep cervical
Middle Third:
Arterial - Aortic Branches
Venous - Azygous
Lymph - Mediastinal
Lower Third:
Arterial - Left Gastric
venous - left gastric
lymph - gastric
Begins - C6, Ends , T11
Strictures:
Cricoid, Aortic Arch, Left Bronchus, Oesophageal Hiatus
Urine Calcium-Creatinine Clearance in :
Primary Hyperparathyroidism
Familial Hypocalciuric Hypercalcaemia
Primary Hyperparathyroidism (Kidneys try to remove calcium)
>0.01
Familial Hypocalciuric Hypercalcaemia (Autosomal Dominant loss of calcium sensing –> High PTH despite high calcium, normal calcium resorption despite high calcium)
<0.01
Drug Causes of Gynaecomasti
Digoxin, Cimetidine, Dopamine receptor antagonists, Methyldopa, Cannabis, Oestrogens, Anabolic Steroids, Spiro, Finasteride
Heroin Isoniazid etc. rare causes
Branches of External Carotid Artery
MASS FLOP
Maxillary
Ascending Pharyngeal
Superior Thyroid Artery
Superficial temporal artery
Facial Artery
Lingual artery
Occipital Artery
Posterior Auricular Artery
Branches of subclavian artery
VIT C&D
Verterbral
Internal thoracic
Thyrocervical Trunk ( Inferior Thyroid, Suprascapular, Transverse Cervical)
Costocervical Trunk (superficial intercostal + deep cervical)
Dorsal Scapular (joins with transverse cervical) becoming Transverse Cervical –> Superficial and Deep descending branches
What is in cryoprecipitate
VIII
Fibrinogen
XIII
vWF
What is anular ligament?
What articulates with the capitulum?
What articulates with trochloea?
Anular ligament- Proximally located liagment between ulnar and radius to permit supination and pronation movements at the proximal radioulnar joint
Capitulum - Distal end of humerus. This articulates with the concave groove on the radius head
Trochlea - articulates with ulnar.
Occluded posterior nasal airway in newborns
choanal atresia
Cyanotic episodes when feeding
Bilateral pulmonary infiltrates
CVP Reading
<18 mmHg
>18 mmHg
<18 mmHg = ARDS (fat embolus, sepsis, acute pancreatitis, trauma, lung injury, head injury)
Low tidal volume ventilation, diuresis
>18mmHg = Pulmonary Oedema
Margins for melanoma resection
Breslow thickness score:
1mm - 1cm margin
1-2mm - 1-2cm margin
3-4mm - 2-3 cm margin
>4mm - 3 cm margin
Lymph resection + isolated limb chemotherapy infusion as adjuncts
Malignancy Arising as a result of chronic oedema
Lymphangiosarcoma
- these are agressive lesions
What happens to the rectal stump
Ventilation
What are the three cerebral areas responsible for ventilation and what do they respond to?
Any non-cerebral areas involved?
Medulla Oblongata
This responds to increased interstitial H+ to increase ventilation (to blow off CO2). The Apneustic Centre in pons instigates inspiration whereas the Pneumotaxic Centre, also in the pons, inhibits inspiration.
Peripheral chemoreceptors are in the carotids and arch of aorta –> these respond to arterial pO2, pCO2 and H+
Ulnar Nerve
Origin
Innervates? (10)
Relationship to ulnar artery
Topography
Origin - C8 T1, derived from medial cord of plexus
Innervates:
Muscular Branch - Flexor Carpi Ulnaris+ Flexor Digitorum Profondus (medial)
Deep Branch- Flexor Digiti Minimi
Abductor Digiti Minimi
Opponens Digiti Minimi
Adductor pollicis
Interossei Muscles
Medial 2 lumbricals (III and IV)
Flexor Pollicis Brevis
Palmaris brevis
Also - Dorsal cutaneous branch, palmar cutaneous branch, Superficial (medial digits) branch
Medial to the ulnar artery
Topography:
Medial side of upper arm then passes posterior to medial epicondyle
Pierces two heads of flexor carpi ulnaris and travels deep to this near the ulna bone
where does the chorda tympani arise and from what?
Inside the facial canal from the facial nerve - so not effected in facial nerve lesion at the parotid
Facial Nerve Topography
order of canals through whence it travels?
3 branches within facial canal?
2 branches immediately after exits the temporal bone?
branches of facial nerve at parotid gland?
I) It enters the internal adutiory meatus travles through the facial canal and then exits via the stylomastoid foramen
ii) Greater petrosal nerve, nerve to stapedius and chorda tympani
iii) Posterior auricular nerve, branch to posterior belly of digastric +stylohyoid muscle
iv) temporal, zygomatic, buccalis, marginal mandibular nerve, cervical
Sensory innervation of the mouth
Inferior Molars
Inferior Canines and incisors
Gingiva and supportive structures
Upper teeth
Generally - upper teeth by the maxillary nerve
and lower teeth by the mandibular nerve
Lower Teeth:
Molars - inferior alveolar nerve
Canines and incisors - Incisive branch of inferior alveolar
gingiva and supportive - lingual nerve
Upper teeth:
Superior alveolar plexus:
Molars - Posterior Superior alveolar nerve (SAN)
premolars - middle SAN
front teeth - anterior SAN
Giant Cells most commonly arise from?
Macrophages
- Giant cells are collections of distinct cell types
Any distant metastases in oesophageal/gastric ca?
Not for surgery and chemotherapy reserved for young and fit
Below which blood pressure does renal autoregulation of flow fail?
<80 systolic blood pressure
WHat is a:
Bankart Lesion
Hill Sachs Lesion
Bankart Lesion - avulsion of anterior glenoid labrum
Hill Sachs Lesion - chondral impaction on posteriosuperior humeral head from contact with glenoid rim
What stimulates insulin release(6)
Glucose
Amino Acids
Secretin/CCK/Gastrin
Vagal Cholinergic Action
Fatty Acids
Beta adrenergic drugs (blockers block release)
Ansa Cervicalis
Origin
What fascia is it posterior to
What does it innervate
Origin - C1 (superior root), C2-3 (inferior root)
Posterior to - Pretracheal fascia
Innervates - sternohyoid, sternothyroid, omohyoid
Anal Sphincter
Smooth and striated components
Nervous supply
Smooth muscle- upper two thirds of anal canal
Striated muscle - superficial to smooth muscle but surrounds the entire canal
Nerve supply- inferior rectal branch of pudendal nerve and perineal nerve
Radial Nerve
Origin
Innervates
Branches
Origin: Posterior Cord of brachial plexus, C5 to T1
Innervates:
main branch -Triceps, Anconeus, Brachioradialis, Extensor Carpi Radialis
posterior interossues nerve (deep branch)- Supernator, extensor carpi ulnaris, extensor digitorum, extensor digitorum, extensor indicis, extensor digiti minimi, extensor pollicis longus and brevis, abductor pollicis longus
sensory -
Axilla
aBoundries
Contents
Boundaries:
Anterior - pec major,
Posterior - lat dorsi
Medial - serratus anterior + chest wall
Lateral - Humeral Head
Contents:
Long Thoracic Nerve
Thoracodorsal Trunk
Axillary Vein
Intercostobrachial nerves
Lymphatics
Lymphatic drainage
Inferior to the dentate line
Superior to the dentate line
Inferior to the dentate line - Inguinal lymph nodes
Superior to the dentate line - Mesorectal
Which genetic condition do you see plexiform neurofibromas?
NF Type I - can cause accelerated growth of limb
5 investigations for incidental adrenal lesions
Beyond which size lesion shoudl you worry?
Morning and midnight plasma cortisol
Dex Suppression Test
24 Hour urinary cortisol
24 hour urinary catecholamines
Serum potassium, aldosterone and renin
>4cm is 25% risk of malignancy
Absence Vas Deferens?
Cystic Fibrosis
Inguinal Canal
Borders
Contents
Where do the testes lymph drain
Borders:
Anterior - Aponeurosis of external Oblique
Posterior - Transversalis Fascia
Floor - Ingiinal Ligament and Lacunar Ligament (medially)
Roof - Arching fibres of the transversus abdominus and internal oblique
Superficial ring - External Oblqieu
Deep ring - Transversalis Fascia
Contents
3 Fascia - External Spermatic Fascia (External oblique), Cremasteric Fascia (internal oblique), Internal Spermatic Fascia (transversalis fascia)
3 Arteries - Testicular Artery, Artery to vas, Cremasteric Artery
2 Veins - Testicular Vein (Left into left renal, right into IVC), Pampiniform Plexus,
3 Others - Vas Deferens, Lymphatics
3 Nerves - Genitofemoral, Ilioinguinal, Iliohypogastric
Where do testes drain to? - para aortic
What is the inverse of odds ratio?
Number needed to treat
Smooth abdominal swelling in child - no worrying features. Mobile
Mesenteric cyst
- usually need to be surgically removed
- can undergo torsion rupture
hyposplenism blood film (4)
Howell - Jolly body
Target Cells
Pappenheimer cells
Irregularly contracted erythroyctes
What do you incise for median sternotomy?
Interclavicular ligament + interclavicular fossa
Sternum with bone saw
pericardium
Masounieve Fracture
Medial malleoulus Fracture
Spiral fracture of proximal 1/3 fibula
dorsal tibiofibular syndesmosis
key anatomical deformities of tallipes equinovarus (5)
Adductes and inverted calcaneus
Wedged shaped calcaneal articular surface +head of talus
tibio-talar plantar flexion
medial talar neck inclination
medially displaced navicular and cuboid
Parathyroid neoplasms:
Most common cause?
Indications for surgery in primary hyperparathyroidism?
Commonly - adenoma
Indication for surgery:
Ca++ >1 above normal
Calciuria >400 mg/day
Decreased creatinine clearance
Life threatening hypercalcaeima
Nephrolithiasis
<50 years age
Neuromuscular symptoms
Reduction in bone mineral density
what regulates ion exchange in the salivary glands?
Aldosterone
Management of traumatic pneumothorax and why?
Chest drain - Usually in context of traumatic pneumothorax there is damage to lung parenchyma = High chance of tension pneumo development
Describe the trendelenberg procedure
Head tild and legs abducted
Oblique incision medial to artery
Ligation of tributaries
Saphenofemoral junction double ligated
Stripping of vein proximal (knee or upper calf)
Muscles attaching to the greater trochanter of femur
POGGGO
Piriformis
Obturator Internus
Gemelli, Gluteus medius, Gluteus Minimus
Obturator Externus
What is the blood supply to the omentum
Left Gastroeipoloic Artery (branch of splenic)
Right Gastroepiploic Artery (branch of gastroduodenal)
What is common liver fluke?
Disease?
Fasciola Hepatica
Disease:
Two - Acute - fever, abdo pain, rash, and hepatomegaly
Chronic - Obstructive jaundice due to worm maturing in bile ducts
What enters the IVC and at what level?
Inferiorly:
I LIKE TO RISE SO HIGH
Common Iliacs fuse at L5
Lumbar veins L1-L5
Right Gonodal vein (Left generally drains into Left renal vein) L2
Suprarenal veins and renal veins L1
Hepatic vein, inferior phrenic vein T8 - also caval hiatus (diaphragmatic)
Body Fluid Volumes
60% of a person is fluid
Intracellular - 60%
Extracellular - 40%
Plasma - 5%
Interstitial - 24%
Transcellular - 3%
Treatments for meconium ileus
PR Contrast (diagnostic and therapeutic)
N-Acetyl Cysteine Enemas
Features of MEN conditions
