Skin and Soft Tissue

Question 1

What seven initiatives have been shown to reduce surgical site infections?

Answer 1

• avoid hyperglycemia
• normothermia
• ppx within 60 minutes of incision
• selection of appropriate abx ppx
• abx ppx discontinued within 24hrs of OR end
• use a clipper (not razor) for hair removal
• remove urinary catheters within 2 days

Question 2

How are necrotizing soft tissue infections classified microbiologically?

Answer 2

• type I: polymicrobial
• type II: monomicrobial (MC group A strep)
• type III: gram negative marine organisms (V. vulnificus)

Question 3

What is the LRINEC score?

Answer 3

• scoring system for likelihood of NSTI
• 6 or higher is suggestive
• includes WBC (> 15), CRP (>150), Hgb (< 13.5), Na (<135), and Glucose (> 180)

Question 4

What are the initial antibiotics for treating NSTI?

Answer 4

• Vancomycin (gram + coverage)
• zosyn (gram - coverage)
• clindamycin (toxin coverage)

Question 5

What is the preferred treatment for a finger felon?

Answer 5

vertical incision preferred to limit risk of neuromuscular injury

Question 6

What is hidradenitis suppurativa?

Answer 6

recurring infection of the apocrine sweat glands

Question 7

What are the risk factors for hidradenitis suppurativa?

Answer 7

female, obese, smoking

Question 8

What are the stages and treatment of hidradenitis suppurativa?

Answer 8

• stage I: localized abscess without tracts/scarring, treat with lifestyle modifications and antibiotics
• stage II: recurrent abscess with tract/scarring but healthy skin separating areas of involvement, treat with TNF-a inhibitors and excision
• stage III: diffuse disease or multiple interconnected tracts/scarring, treat with wide excision and STSG or healing by secondary intention

Question 9

What are the risk factors for pilonidal disease?

Answer 9

• male
• obesity
• dense hear
• prolonged sitting

Question 10

How are pilonidal abscesses and cysts treated?

Answer 10

• acute abscess: I&D
• chronic disease: classically excision and marsupialization, primary repair, or secondary intention

Question 11

What is the most common skin cancer?

Answer 11

basal cell

Question 12

How are basal cell carcinomas managed?

Answer 12

with WLE to a 4-10mm margin

Question 13

What is the precursor lesion to a squamous cell carcinoma?

Answer 13

actinic keratosis

Question 14

How are squamous cell carcinomas treated?

Answer 14

with wLE to a 4-10mm margin

Question 15

What is a Merkel cell carcinoma? How does it present? How is it treated?

Answer 15

• a rare, neuroendocrine malignancy
• presents as a rapidly growing, firm, red/purple nodule without ulceration
• requires staging PET scan and then WLE with 1-2cm margins and SLNB
• adjuvant radiation for lesions > 2cm (stage II) or any lymph node involvement (stage III)

Question 16

For patients with dermatofibrosarcoma protuberans, what is indicative of metastatic disease?

Answer 16

fibrosarcomatous changes, most commonly going to lung

Question 17

What are the resection margins for melanoma?

Answer 17

• in situ: 5-10mm
• <1mm: 10mm
• 1-2mm: 10-20mm
• > 2mm: 20mm

Question 18

Which melanoma patients need SLNB?

Answer 18

those with stage IB or higher disease (i.e. with depth 0.8mm or with ulceration)

Question 19

What did the MSLT-II trial show?

Answer 19

that there is no difference in melanoma-specific survival for patients with positive sentinel lymph nodes who undergo observation versus completion lymphadenectomy, thus suggesting that these patients can be monitored with serial ultrasound

Question 20

What is the preferred agent for treating metastatic melanoma?

Answer 20

pembrolizumab, a monoclonal antibody against PD-1

Question 21

How is a subungual melanoma excised?

Answer 21

with amputation of the finger at the mid proximal phalanx or of the toe including the metatarsal head

Question 22

What are the boundaries of the femoral triangle?

Answer 22

• superior: inguinal ligament
• lateral: sartorius
• medial: adductor longus

Question 23

How is herpetic whitlow treated?

Answer 23

with observation and avoidance of contact

Question 24

What is the most common organism causing lymphangitis?

Answer 24

Streptococcus pyogenes

Question 25

What are the three most common bacteria associated with Fournier’s gangrene?

Answer 25

E. coli, Klebsiella, and Enterococci