Mr Hardy & Gupte Flashcards
What does management equal?
Mx = Dx + Tx
Where dx is the combination of hx, exam, ix
The Surgical Sieve
VITAMINS CDE
Vascular
Infection / Inflammation
Traumatic / Toxins
Autoimmune
Metabolic
Iatrogenic / Idiopathic
Neoplastic
Social
Congenital
Degenerative
Endocrine / Exocrine
How would you categorise the factors contributing to a complication of surgery?
Pre, Operative, Post
RFs for haemorrhage post op
Pre: failure to stop NSAIDs + hereditary clotting disorders
Op: use of monopolar diathermy causing collateral damage
Post: started on anticoagulants + infection that moves the suture knot
Virchow’s Triad
Endothelial Injury
Hypercoagulability
Venous Stasis
RFs for superficial infection post op
Pre: young/old, smoker, diabetic, steroids, immunocomp, cardiac/renal/vasc disease, preexisting infection
Op: death by a thousand cuts, failure to wash out dead tissue, too much suture tension causing ischaemia
Post: poor wound care
Celsus Tetrad
Rubor Calor Tumor Dolor Functio Laesa
How would you categorise complications of a fracture?
IMMEDIATE <24h
Local: 1° haemorrhage and soft tissue injury
Syst: hypovolaemic shock and asphyxia
EARLY <2w
Local: reactionary/2° haemorrhage, wound dehiscence, infection, compartment syndrome, Volkmann’s contracture
Syst: fat embolism, DVT, PE, ARDS, atelectasis, c diff, constipation, acute urinary retention, confusion, bed sores
LATE >2w
Local: malunion, nonunion, stiffness, loosening, CRPS
Syst: atelectasis - pneumonia, acute urinary retention - cystitis - sepsis, psychological
Haemorrhage: Reactionary vs Secondary
Reactionary - rise in bp following fluid therapy for hypovolaemia
Secondary - erosion of a vessel from a spreading infection
What is a late systemic comp of a right hemicolectomy?
Pernicious Anaemia
How are abx used in surgery?
Prophylactic: immunocomp, at inc risk of infection, consequences would be serious
Treatment: local + spreading
How are abx used prophylactically?
Immunocomp: young/old, smoker, diabetic, steroids, chemo, cancer, HIV, TB
At inc risk of infection: surgery involving the appendix, large bowel, gynae
Consequences would be serious: heart valve, prosthetic limb, VP shunt, mesh
How are abx used as treatment?
Local (no abx: incision -> drainage) - abscess, empyema, pyelonephritis, osteomyelitis
Spreading (abx: broad -> narrow) - cellulitis, septicaemia, meningitis, ascending cholangitis
How can you categorise the presentation of any tumour?
Primary, Secondary, General vs Hx/Sx, Exam/Signs, Special Ix
Px of testicular seminoma
Hx: 1° painless lump + 2° inguinal lump, abdo pain, back pain + 3° FLAWS
O/e: 1° SSSSSS, can get above, no transillumination + 2° inguinal LN, retroperitoneal lesion, chest lesion + 3° anaemic
Ix: 1° imaging and histology + 2° CT-CAP + 3° FBC, hyperCa, tumour markers
How would you describe a lump? (6)
Site Size Shape Surface Surrounds conSistency
Px of breast ca
Hx: 1° lump, pain, bloody discharge + 2° axillary lump, night bone pain, cough + 3° FLAWS
O/e: 1° inverted nipple, tethering, peau d’orange + 2° axillary lymphadenopathy, bony tenderness, oedema + 3° anaemic
Ix: 1° imaging and histology + 2° CXR + 3° FBC, hyperCa, tumour markers
What is breast triple assessment?
Hx+Exam, US/Mammography, FNA/Biopsy
What cancers metastasise to bone? (6)
Bronchus Breast Brostate Byroid Bidney \+ Sometimes Bowel
How would you categorise tumours of the bone?
Benign: simple cyst, osteoid osteoma, osteochondroma, enchondroma, fibrous dysplasia
1° Malignant: ewing’s, osteosarcoma, chondrosarcoma, myeloma
2° Malignant: metastasis
Mneumonic for describing any disease
Dressed In a Surgeon’s Gown A Physician Might Make Some Significant Progress
Definition Incidence Sex Geography Aetiology Pathogenesis Macroscopic Path Microscopic Path Symptoms Signs Prognosis
What is myeloma?
Definition: neoplasia of plasma cells
Incidence: most common primary malignant bone ca affecting those b/w 50-70yrs
Sex: M>F | Geography: AfroC | Aetiology: genetics
Pathogenesis: production of monoclonal immunoglobulins
Macro + Micro Path: haematogenous spread, raised ESR, rouleaux on blood film, B cells w reduced cytoplasm, dense band on serum electrophoresis, bence-jones protein in urine
Sx + Signs: related to the high calcium, renal failure, anaemia, affect on bone
Prognosis: pt factors, staging and grading, response to therapy
What is the skull on x-ray like in MM?
Pepper Shaker / Moth Eaten
What does the median nerve supply?
2LOAF
Lateral two lumbicals
Oppones pollicis
Abductor pollicis brevis
Flexor pollicis brevis
NB: all other intrinsic hand muscles are supplied by the ulnar nerve
What does the hand look like following the three possible nerve lesions?
DR CUMA
Dropped wrist = Radial
Claw hand = Ulnar
Ape hand = Median
What is a mallet finger?
Avulsion of the extensor tendon from the distal phalynx requiring a splint for 6-8wks followed by 1-2wks at night
What should you NOT do when taping up a mallet splint?
Tape over the holes
What is the thickest cartilage in the body?
Patella hyaline cartilage
The four stages of # healing
Haematoma
Inflam
Callus
Remodelling
What do you do if there’s asymmetrical lympadenopathy in the neck?
Look in both the mouth and ears
How much does smoking reduce your oxygen carriage by?
Dec by 20% - due to the irreversible binding of carbon monoxide - takes 2wks of stopping to recover
How would you tell someone has a post op ileus?
I’d take a full history to gather the sx, an examination to elicit signs and perform appropriate ix
Hx: bloating, failure to pass flatus/faeces, N+V
O/e: abdo distention + absent BS
Ix: bloods + imaging
What ix for you perform for a suspected ileus?
Bloods - FBC, ESR, CRP, U+Es (hypoNa, hypoK, hyperCa), TFTs (hypothyroidism)
Imaging - CT abdo + pelvis w contrast
RFs for post op ileus
Pre: inc age, electrolyte derangement, use of anti-cholinergic meds
Op: XS intestinal handling, peritoneal contamination, type of op (intestinal resection + pelvic surgery)
Post: use of opioid meds
Saint’s Triad
Cholelithiasis
Hiatal Hernia
Diverticular Disease
Direct vs Indirect Inguinal Hernias
Direct - comorbid elderly obese heavy lifter w prev surg + emerge medial to inf epigastric + lump above pubic tubercle
Indirect - younger male pt + emerge lateral to inf epigastric + lump below pubic tubercle
What are the indications for intramedullary nailing?
Fractures: extracapsular NOF+ humerus/femur/tibial shaft
What are the CIs for intramedullary nailing? (3)
Small medullary canal, prior malunion, infection
What are the indications for internal fixation?
Joint # Compound # Multiple Injury Diff Reduction Lost Reduction Malignancy
How can a fracture be described on a radiograph?
Pt Details, Skeletal Maturity, Location
Open vs Closed
Simple vs Comminuted
Displaced, Translated, Angulated
Any Other Abnormalities
How can gout lead to OA?
Gout - Chondrocalcinosis - Meniscal Tear - OA
List of PMHx to ask
Asthma Allergies Angina TB Jaundice Epilepsy Diabetes Rh Fever Heart Attack Stroke High BP Gout
How do you tx a #?
Classify Comps Displacement Reduction Stability Immobilise Rehabilitate
Which meniscus is more likely to tear horizontally?
Lateral
What are the different meniscal tears and their progressions?
Horizontal -> Flap
Radial -> Parrot Beak
Vertical -> Bucket Handle
What should you consider when treating a pt?
CAGES: comps, age, general condition, etiology, site/sx/stage
What instrument is used to measure joint ROM?
Goniometer
Why is Lister’s tubercle important?
It acts as a pulley to EPL
Osteophyte vs Spur
Location
Osteophyte: found at the joint margin w hyaline cartilage
Spur: found at the tendon insertion into bone
Which foods predispose to gout?
- Chocolate
- Offal
- Oily Fish
- Game Birds
- Shellfish
- Red Meat
- Cruciferous
- Chickpeas
Fizzy Drinks + ETOH
Bone vs Calcium
Bone - heterogenous - trabeculae
Calcium - homozygous - arteriosclerosis
What are the layers of the periosteum?
Outer Fibrous + Inner Cambial
What are the planes of translation?
X: medial v lateral
Y: proximal v distal
Z: anterior v posterior
What are the planes of angulation?
X: valgus v varus
Y: int v ext rotation
Z: volar v dorsal
Ddx for Ant Knee Pain
OA, Plicae/Meniscal Tear, Hoffa’s Syndrome, Patella Bursitis, Referred
What are the four plicae of the knee?
Medial
Lateral
Suprapatellar
Infrapatellar
Which plicae is most/least likely to tear?
Most: medial
Least: lateral
Why does a smaller meniscal tear result in more damage?
Pressure = Force / Area
Therefore small area high pressure
Maisonneuve #: DISGAPMMSSP
A spiral fracture of proximal third of fibula a/w unstable ankle injury
Predominantly male pts from sporting injuries accounting for 5% of all ankle injuries
The pain is worse on ext rotation and can progress to valgus deformity, peroneal nerve palsy or OA but good recovery w fixation and physio
How do you inc the likelihood of seeing Hoffa’s syndrome on MRI?
Get the pt to run before scanning
When does Hoffa’s syndrome become chronic?
@6wks
Tx for Hoffa’s Syndrome
If acute and no wear of cartilage mx consrv w NSAIDs, physio, taping/bracing vs chronic requires day case arthroscopic resection of scarring
Sepsis Six
3 IN: oxygen, abx, fluids
3 OUT: lactate, blood cultures, urine output
What is the order of insertion in the pes anserinus?
Work ant-post w Say Grace before Tea: Sartorius, Gracilis, semiTendinosus
How many sacral and coccygeal vertebrae are there?
S5 + C4
What are the three main causes of a Baker’s cyst?
OA, semimembranosus tendonitis, meniscal tear
What does a ruptured bakers cyst mimic?
DVT
Which direction is a THR likely to wear the polyethylene?
Superior + Anterior
What are the most common hip pathologies in the adult?
- OA
- Impingement
- Congenital Leg Length Discrepancy
The Hip Examination
Intro, Consent, Pain
Gait + Trendelenburg’s Test
Look: aids, insoles, musc wasting, asymmetry, swelling, scars
Feel: greater trochanter, temp evenly down both legs, posterior tibial/dorsalis pedis pulses, cursory sensory exam
Move: active flexion + passive flexion, ad/abduction, int/ext rotation at 0° and 90° flexion, turn prone for extension
Special Tests: Thomas’s Test + measure for leg length discrepancy
What are you looking for in the gait?
Front: symmetry, tredenelburg, antalgic
Side: heel strike, toe off, time spent in stance phase, fixed hip flexion, flexed knee, varus/valgus thrust, rotation of the feet
What does pain over the greater trochanter suggest?
Bursitis
How do you measure the apparent leg length?
Fixed point in the midline ie xiphisternum to medial malleolus
How do you measure the real leg length?
ASIS to medial malleolus
What does Thomas’ test look for?
Fixed flexion of the hip
How do you correctly perform Thomas’ test?
Place your hand under the lumbar lordosis and ask the pt to fully flex both legs and then straighten each leg one at a time whilst holding the other knee
What is a pos Thomas’ test?
The inability to straighten the leg past a point w/o losing lumbar lordosis
Hip Pain Ddx
Ortho
Neuro
Gen Surg: hernia, vasc compromise, referred pain from back
How would you complete any ortho exam?
Full hx, assess NV status, examine the contralateral side and joints above/below, imaging
What is an antalgic gait?
The stance phase is reduced on the affected side
The Knee Examination
Intro, Consent, Pain
Gait + Crouch
Look: aids, insoles, foot arch, varus/valgus, musc wasting, asymmetry eg erythema, swelling eg bakers cyst, scars
Feel: diff part of quad, sweep test, patellar tap, cross fluctuance, plical folds, along joint line w bent thumb, posterior tibial/dorsalis pedis pulses, cursory sensory exam
Move: angle of active/passive extension and flexion
Special: inspect for posterior sag, ant/post drawer, Lachman test, collaterals at 0°/30° flexion w foot clamped tightly under your armpit, McMurray test, patella maltracking
How do you perform Lachman’s test?
Stabilise the femur w thumb anteriorly fingers posteriorly OR for larger pts place your opposite thigh under theirs just above pop fossa and one hand over supracondylar region then move the tibial tuberosity up/down
When is hindfoot valgus within normal physiology?
It corrects on tip toes
The Foot + Ankle Examination
Intro, Consent, Pain
Gait + Stand on Tip Toe/Heels
Look: aids, insoles, foot arch, asymmetry eg ulceration, swelling eg oedema, scars
Feel: down fibula, tibotalar joint, medial border of tibia, malleolus, navicular, calcaneus, midfoot joints, metatarsal heads, great toe, achilles tendon, base of heel, plantar fascia
Move: active/passive dorsi/plantarflexion, subtalar joint by pinching talus in place and rocking foot sideways, active eversion/inversion, passive great toe at MTP
Special: silfverskiold test, calf squeeze, test tendons against resistance
What are the muscles of foot inversion?
Foot in dorsiflexion: tibialis anterior
Foot in plantarflexion: tibialis posterior
What are the muscles of foot eversion?
Foot in dorsiflexion: peroneus tertius
Foot in plantarflexion: peroneus longus
What does the shoulder girdle consist of?
Scapula, supraspinus fossa, infraspinus fossa, glenohumeral joint, clavicle, sternoclavicular joint
The Shoulder Examination
Intro, Consent, Pain
Look: deformity, wasting, asymmetry, swelling, scars, deltoid contour, thoracic kyphosis, winging
Feel: muscle bulk, SCJ, along border of clavicle, ACJ, greater tuberosity, scapular spine medial border inf angle, temp
Move: active ab/aduction w palms out towards front, tuck elbows in then ext/int rotation, compound screening movements + passive/vs resistance
Special: hawkins-kennedy, empty can test, scarf test, sulcus sign and apprehension test, winging
What are the shoulder compound screening movements?
Hand behind head w elbow as far back as can go
Hand behind back w thumb as high up as can go
How do you elicit the sulcus sign?
Pull down on the arm distal to elbow and look for inferior laxity and a sulcus to appear along the proximal humerus
The Neck Examination
Intro, Consent, Pain
Look: deformity, wasting, asymmetry, swelling, scars, cervical lordosis
Feel: place one hand on pts forehead, feel for C7/T1/C6-2, trap spasm, wasting of deltoids, sensation and power of C5-T1, pulses
Move: flexion, extension, right, left, tilt
Special: spurling’s test, tone, reflexes
How do you test the power of C5-T1?
C5 - Arm aBduction C6 - Wrist Extension C7 - Elbow Extension C8 - Finger Flexion T1 - Finger aBduction
What is spurling’s test?
Extend the neck, turn to one side and tilt down: pos if pain in neck shoulder arm
The Back Examination
Intro, Consent, Pain
Gait + Walk on Tip Toe/Heels
Look: deformity, wasting, asymmetry, swelling, scars, normal kyphosis/lordosis, scoliosis/rib hump
Feel: find PSIS, mark 5cm below and 10cm above, ask pt to bend and measure excursion
Move: active extend backwards, slide hands down left/right side, turn to left/right + passive SLR and ask about any pain below knee + vs resistance hip knee ankle flex/ext and e/inversion
Special: tone, reflexes, cursory sensory exam, pulses
Where can dorsalis pedis be felt?
Lateral to the extensor hallucis longus tendon on the dorsal aspect
What is the normal ROM in degrees of a knee?
Ext-N-Flex: 10-0-140
What order do you always perform movement in an ortho exam?
Active -> Passive
When someone px w joint pain what should you ask in S of SOCRATES?
Ask pt to point with one finger where it is
How do you correctly perform the sweep test?
You milk down the quad then sweep medial aspect distal to proximal then lateral aspect proximal to distal and observe the medial aspect
What should you check for before the ant/post draw test?
For any posterior sag and that the hamstrings are fully relaxed
How should you ask the pt to tense their quads to assess muscle bulk?
Ask them to push their knees into the coach and also observe how high the feet rise
How do you test ab/adduction of the hip?
You square off the hip, place fingers on one ASIS and olecranon on the other, the angle is at the point of pelvic shift
How do you correctly perform Trendelenburg’s test?
Find both ASIS working inf-sup, ask pt to put their hands on your forearms, look for lateral pelvic tilt and feel for weight on your forearms whilst the pt stands on each leg in turn
Why are passive movements performed?
To see if the loss of ROM is due to stiffness vs pain/weakness
Px of Shoulder Examination
To summarise this pt had full ROM and was non-tender over the SCJ and ACJ
There was however right sided weakness of supraspinatus and Hawkin’s test was positive indicative of ACJ impingement or a rotator cuff issue
I would like to take a full hx, perform a NV exam and examine the spine and elbow joints before considering an MRI
How would you explain external fixation?
Favoured when there is extensive soft tissue injury
If circular where + how many rings
If monoplanar where + any underlying scars
% of Gait Cycle
Stance 60 + Swing 40
How do you feel along the knee joint line?
Along tibial tubercle, patella tendon, inferior pole of patella, lateral joint line, head of fibula, medial joint line
How do you test the lateral meniscus?
Rotate the tibia medially w the knee is full flexion and then extend at the knee
How do you test the medial meniscus?
Rotate the tibia laterally w the knee is full flexion and then extend at the knee
Where can posterior tibialis be felt?
Behind the MEDIAL malleolus
How do you perform the Silfverskiold test?
Ask the pt to sit, bring the ankle up as far as it goes, with a relaxed knee bring their knee up then back down
