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Year 6 - Surgery > Mr Hardy & Gupte > Flashcards

Mr Hardy & Gupte Flashcards

1
Q

What does management equal?

A

Mx = Dx + Tx

Where dx is the combination of hx, exam, ix

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2
Q

The Surgical Sieve

A

VITAMINS CDE

Vascular

Infection / Inflammation

Traumatic / Toxins

Autoimmune

Metabolic

Iatrogenic / Idiopathic

Neoplastic

Social

Congenital

Degenerative

Endocrine / Exocrine

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3
Q

How would you categorise the factors contributing to a complication of surgery?

A

Pre, Operative, Post

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4
Q

RFs for haemorrhage post op

A

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

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5
Q

Virchow’s Triad

A

Endothelial Injury
Hypercoagulability
Venous Stasis

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6
Q

RFs for superficial infection post op

A

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

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7
Q

Celsus Tetrad

A 
Rubor
Calor
Tumor
Dolor
Functio Laesa
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8
Q

How would you categorise complications of a fracture?

A

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

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9
Q

Haemorrhage: Reactionary vs Secondary

A

Reactionary - rise in bp following fluid therapy for hypovolaemia

Secondary - erosion of a vessel from a spreading infection

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10
Q

What is a late systemic comp of a right hemicolectomy?

A

Pernicious Anaemia

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11
Q

How are abx used in surgery?

A

Prophylactic: immunocomp, at inc risk of infection, consequences would be serious

Treatment: local + spreading

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12
Q

How are abx used prophylactically?

A

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

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13
Q

How are abx used as treatment?

A

Local (no abx: incision -> drainage) - abscess, empyema, pyelonephritis, osteomyelitis

Spreading (abx: broad -> narrow) - cellulitis, septicaemia, meningitis, ascending cholangitis

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14
Q

How can you categorise the presentation of any tumour?

A

Primary, Secondary, General vs Hx/Sx, Exam/Signs, Special Ix

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15
Q

Px of testicular seminoma

A

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

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16
Q

How would you describe a lump? (6)

A 
Site
Size
Shape
Surface
Surrounds
conSistency
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17
Q

Px of breast ca

A

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

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18
Q

What is breast triple assessment?

A

Hx+Exam, US/Mammography, FNA/Biopsy

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19
Q

What cancers metastasise to bone? (6)

A 
Bronchus
Breast
Brostate
Byroid
Bidney
\+ Sometimes Bowel
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20
Q

How would you categorise tumours of the bone?

A

Benign: simple cyst, osteoid osteoma, osteochondroma, enchondroma, fibrous dysplasia

1° Malignant: ewing’s, osteosarcoma, chondrosarcoma, myeloma

2° Malignant: metastasis

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21
Q

Mneumonic for describing any disease

A

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
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22
Q

What is myeloma?

A

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

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23
Q

What is the skull on x-ray like in MM?

A

Pepper Shaker / Moth Eaten

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24
Q

What does the median nerve supply?

A

2LOAF

Lateral two lumbicals
Oppones pollicis
Abductor pollicis brevis
Flexor pollicis brevis

NB: all other intrinsic hand muscles are supplied by the ulnar nerve

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25
Q

What does the hand look like following the three possible nerve lesions?

A

DR CUMA

Dropped wrist = Radial

Claw hand = Ulnar

Ape hand = Median

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26
Q

What is a mallet finger?

A

Avulsion of the extensor tendon from the distal phalynx requiring a splint for 6-8wks followed by 1-2wks at night

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27
Q

What should you NOT do when taping up a mallet splint?

A

Tape over the holes

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28
Q

What is the thickest cartilage in the body?

A

Patella hyaline cartilage

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29
Q

The four stages of # healing

A

Haematoma
Inflam
Callus
Remodelling

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30
Q

What do you do if there’s asymmetrical lympadenopathy in the neck?

A

Look in both the mouth and ears

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31
Q

How much does smoking reduce your oxygen carriage by?

A

Dec by 20% - due to the irreversible binding of carbon monoxide - takes 2wks of stopping to recover

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32
Q

How would you tell someone has a post op ileus?

A

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

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33
Q

What ix for you perform for a suspected ileus?

A

Bloods - FBC, ESR, CRP, U+Es (hypoNa, hypoK, hyperCa), TFTs (hypothyroidism)

Imaging - CT abdo + pelvis w contrast

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34
Q

RFs for post op ileus

A

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

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35
Q

Saint’s Triad

A

Cholelithiasis
Hiatal Hernia
Diverticular Disease

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36
Q

Direct vs Indirect Inguinal Hernias

A

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

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37
Q

What are the indications for intramedullary nailing?

A

Fractures: extracapsular NOF+ humerus/femur/tibial shaft

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38
Q

What are the CIs for intramedullary nailing? (3)

A

Small medullary canal, prior malunion, infection

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39
Q

What are the indications for internal fixation?

A 
Joint #
Compound #
Multiple Injury
Diff Reduction
Lost Reduction
Malignancy
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40
Q

How can a fracture be described on a radiograph?

A

Pt Details, Skeletal Maturity, Location

Open vs Closed

Simple vs Comminuted

Displaced, Translated, Angulated

Any Other Abnormalities

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41
Q

How can gout lead to OA?

A

Gout - Chondrocalcinosis - Meniscal Tear - OA

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42
Q

List of PMHx to ask

A 
Asthma
Allergies
Angina
TB
Jaundice
Epilepsy
Diabetes
Rh Fever
Heart Attack
Stroke
High BP
Gout
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43
Q

How do you tx a #?

A 
Classify
Comps
Displacement
Reduction
Stability
Immobilise
Rehabilitate
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44
Q

Which meniscus is more likely to tear horizontally?

A

Lateral

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45
Q

What are the different meniscal tears and their progressions?

A

Horizontal -> Flap

Radial -> Parrot Beak

Vertical -> Bucket Handle

46
Q

What should you consider when treating a pt?

A

CAGES: comps, age, general condition, etiology, site/sx/stage

47
Q

What instrument is used to measure joint ROM?

A

Goniometer

48
Q

Why is Lister’s tubercle important?

A

It acts as a pulley to EPL

49
Q

Osteophyte vs Spur

A

Location

Osteophyte: found at the joint margin w hyaline cartilage

Spur: found at the tendon insertion into bone

50
Q

Which foods predispose to gout?

A
  1. Chocolate
  2. Offal
  3. Oily Fish
  4. Game Birds
  5. Shellfish
  6. Red Meat
  7. Cruciferous
  8. Chickpeas

Fizzy Drinks + ETOH

51
Q

Bone vs Calcium

A

Bone - heterogenous - trabeculae

Calcium - homozygous - arteriosclerosis

52
Q

What are the layers of the periosteum?

A

Outer Fibrous + Inner Cambial

53
Q

What are the planes of translation?

A

X: medial v lateral

Y: proximal v distal

Z: anterior v posterior

54
Q

What are the planes of angulation?

A

X: valgus v varus

Y: int v ext rotation

Z: volar v dorsal

55
Q

Ddx for Ant Knee Pain

A

OA, Plicae/Meniscal Tear, Hoffa’s Syndrome, Patella Bursitis, Referred

56
Q

What are the four plicae of the knee?

A

Medial
Lateral
Suprapatellar
Infrapatellar

57
Q

Which plicae is most/least likely to tear?

A

Most: medial

Least: lateral

58
Q

Why does a smaller meniscal tear result in more damage?

A

Pressure = Force / Area

Therefore small area high pressure

59
Q

Maisonneuve #: DISGAPMMSSP

A

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

60
Q

How do you inc the likelihood of seeing Hoffa’s syndrome on MRI?

A

Get the pt to run before scanning

61
Q

When does Hoffa’s syndrome become chronic?

A

@6wks

62
Q

Tx for Hoffa’s Syndrome

A

If acute and no wear of cartilage mx consrv w NSAIDs, physio, taping/bracing vs chronic requires day case arthroscopic resection of scarring

63
Q

Sepsis Six

A

3 IN: oxygen, abx, fluids

3 OUT: lactate, blood cultures, urine output

64
Q

What is the order of insertion in the pes anserinus?

A

Work ant-post w Say Grace before Tea: Sartorius, Gracilis, semiTendinosus

65
Q

How many sacral and coccygeal vertebrae are there?

A

S5 + C4

66
Q

What are the three main causes of a Baker’s cyst?

A

OA, semimembranosus tendonitis, meniscal tear

67
Q

What does a ruptured bakers cyst mimic?

A

DVT

68
Q

Which direction is a THR likely to wear the polyethylene?

A

Superior + Anterior

69
Q

What are the most common hip pathologies in the adult?

A
  1. OA
  2. Impingement
  3. Congenital Leg Length Discrepancy
70
Q

The Hip Examination

A

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

71
Q

What are you looking for in the gait?

A

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

72
Q

What does pain over the greater trochanter suggest?

A

Bursitis

73
Q

How do you measure the apparent leg length?

A

Fixed point in the midline ie xiphisternum to medial malleolus

74
Q

How do you measure the real leg length?

A

ASIS to medial malleolus

75
Q

What does Thomas’ test look for?

A

Fixed flexion of the hip

76
Q

How do you correctly perform Thomas’ test?

A

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

77
Q

What is a pos Thomas’ test?

A

The inability to straighten the leg past a point w/o losing lumbar lordosis

78
Q

Hip Pain Ddx

A

Ortho
Neuro
Gen Surg: hernia, vasc compromise, referred pain from back

79
Q

How would you complete any ortho exam?

A

Full hx, assess NV status, examine the contralateral side and joints above/below, imaging

80
Q

What is an antalgic gait?

A

The stance phase is reduced on the affected side

81
Q

The Knee Examination

A

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

82
Q

How do you perform Lachman’s test?

A

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

83
Q

When is hindfoot valgus within normal physiology?

A

It corrects on tip toes

84
Q

The Foot + Ankle Examination

A

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

85
Q

What are the muscles of foot inversion?

A

Foot in dorsiflexion: tibialis anterior

Foot in plantarflexion: tibialis posterior

86
Q

What are the muscles of foot eversion?

A

Foot in dorsiflexion: peroneus tertius

Foot in plantarflexion: peroneus longus

87
Q

What does the shoulder girdle consist of?

A

Scapula, supraspinus fossa, infraspinus fossa, glenohumeral joint, clavicle, sternoclavicular joint

88
Q

The Shoulder Examination

A

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

89
Q

What are the shoulder compound screening movements?

A

Hand behind head w elbow as far back as can go

Hand behind back w thumb as high up as can go

90
Q

How do you elicit the sulcus sign?

A

Pull down on the arm distal to elbow and look for inferior laxity and a sulcus to appear along the proximal humerus

91
Q

The Neck Examination

A

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

92
Q

How do you test the power of C5-T1?

A 
C5 - Arm aBduction
C6 - Wrist Extension
C7 - Elbow Extension
C8 - Finger Flexion
T1 - Finger aBduction
93
Q

What is spurling’s test?

A

Extend the neck, turn to one side and tilt down: pos if pain in neck shoulder arm

94
Q

The Back Examination

A

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

95
Q

Where can dorsalis pedis be felt?

A

Lateral to the extensor hallucis longus tendon on the dorsal aspect

96
Q

What is the normal ROM in degrees of a knee?

A

Ext-N-Flex: 10-0-140

97
Q

What order do you always perform movement in an ortho exam?

A

Active -> Passive

98
Q

When someone px w joint pain what should you ask in S of SOCRATES?

A

Ask pt to point with one finger where it is

99
Q

How do you correctly perform the sweep test?

A

You milk down the quad then sweep medial aspect distal to proximal then lateral aspect proximal to distal and observe the medial aspect

100
Q

What should you check for before the ant/post draw test?

A

For any posterior sag and that the hamstrings are fully relaxed

101
Q

How should you ask the pt to tense their quads to assess muscle bulk?

A

Ask them to push their knees into the coach and also observe how high the feet rise

102
Q

How do you test ab/adduction of the hip?

A

You square off the hip, place fingers on one ASIS and olecranon on the other, the angle is at the point of pelvic shift

103
Q

How do you correctly perform Trendelenburg’s test?

A

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

104
Q

Why are passive movements performed?

A

To see if the loss of ROM is due to stiffness vs pain/weakness

105
Q

Px of Shoulder Examination

A

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

106
Q

How would you explain external fixation?

A

Favoured when there is extensive soft tissue injury

If circular where + how many rings

If monoplanar where + any underlying scars

107
Q

% of Gait Cycle

A

Stance 60 + Swing 40

108
Q

How do you feel along the knee joint line?

A

Along tibial tubercle, patella tendon, inferior pole of patella, lateral joint line, head of fibula, medial joint line

109
Q

How do you test the lateral meniscus?

A

Rotate the tibia medially w the knee is full flexion and then extend at the knee

110
Q

How do you test the medial meniscus?

A

Rotate the tibia laterally w the knee is full flexion and then extend at the knee

111
Q

Where can posterior tibialis be felt?

A

Behind the MEDIAL malleolus

112
Q

How do you perform the Silfverskiold test?

A

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

Year 6 - Surgery (6 decks)

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