Surgery 11 Flashcards
What are the Centor criteria for tonsillitis?
Fever
Tonsillar exudates
Tender anterior cervical lymphoadenopathy
No cough
3 or more = give antibiotics
What is the difference between metachronous and synchronous cancers?
Synchronous - secondaries occurring within 6 months of primary cancer
Metachronous - secondaries occurring over 6 months after primary cancer
List some reasons for enucleation of the eye.
Trauma Tumour (retinoblastoma) Infection Phthisis bulbi (shrunken non-functional eye) Sympathetic ophthalmia
Why do anastomoses of the sigmoid colon require a defunctioning loop ileostomy?
The sigmoid colon contains more solid faecal matter so exerts a higher pressure on its walls
This means that there is a higher risk of perforation/leak following anastomosis
Outline the management of diverticulitis.
Mild - bowel rest at home (fluids only)
Severe - NBM, drip and suck, antibiotics (ceftriaxone and metronidazole), analgesia
Obstruction/Perforation - Hartmann’s resection
What are the main types of perianal fistula and how are they treated?
Superficial - no involvement of sphincters - fistula laid open
Intersphincteric - only through internal sphincter - progressively tighten seton
Transphincteric - through both external and internal sphincters - fibrin glue to plug the fistula
Outline the management of haemorrhoids.
Conservative: fibre
Medical: topical hydrocortisone, laxatives
Surgical: rubber band ligation, injection sclerotherapy, haemorrhoidectomy
What is taken into account by the modified Glasgow score for pancreatitis?
PaO2 < 8 kPa Age > 55 yrs Neutrophils Calcium < 2 mmol/L Renal function (urea > 16 mmol/L) Enzymes (liver and LDH) Albumin < 32 g/L Sugar (glucose > 10 mmol/L)
NOTE: use on admission and repeat within 48 hours; 3 or more is severe pancreatitis
List some causes of chronic pancreatitis.
Gallstones Ethanol Recurrent acute pancreatitis Cystic fibrosis Haemochromatosis Autoimmune
NOTE: complications include DM, pseudocysts and cancer
Define osteoarthritis.
Degenerative joint disorder characterised by loss of hyaline cartilage and new bone formation at the joint surface.
Which ligaments are sacrificed in total knee replacement?
ACL is usually sacrificed (however newer replacements may spare it)
IMPORTANT: do not do anterior draw on TKR patients
What are the pros and cons of cemented vs uncemented total hip replacement?
Cemented: better for older patients with poor bone quality and turnover
Uncemented: porous and bone in-growth, makes revision of hip more difficult
What are the 6 As of dealing with open fractures?
Analgesia
Assess neurovascular status, soft issues, photograph
Antisepsis: wound swab, copious irrigation, cover with betadine soaked dressing
Alignment (splint)
Anti-tetanus - check status (booster in last 10 years)
Antibiotics (flucloxacillin and benpen or co-amoxiclav)
What is the normal pressure of the lower oesophageal sphincter?
14-20 mm Hg
NOTE: oesophagus is 25 cm in length starting at cricoid cartilage, upper 2/3 has striated muscle, lower 1/3 is smooth muscle
What is a paramedian incision used for?
Access to kidneys, spleen and adrenals
NOTE: paramedian is technically more difficult but was thought to be associated with improved healing as the rectus abdominus is vascular unlike the linea alba (midline)
What is taken into account when deciding whether to use a dynamic hip screw or cannulated screws for fixation of a neck of femur fracture?
DHS: safer in patients who cannot partially weight bear so are at risk of fracture displacement (standard = 4 hole), better for intertrochanteric fractures
Cannulated screws: easier to remove in the future when patients need a hip replacement, less soft tissue damage, minimally invasive, used when NOT displaced
List the mechanisms that could cause GORD.
Anatomical disruption of gastro-oesophageal junction (e.g. hiatus hernia)
Hypotensive lower oesophageal sphincter (leads to transient lower oesophageal relaxation)
Delayed oesophageal acid clearance (e.g. cigarette smoking)
List some risk factors for gastric cancer.
H. pylori
Atrophic gastritis (pernicious anaemia)
Diet (cured meats)
Smoking
Wht are the three points at which the ureter narrows?
Uretopelvic junction
Pelvic rim
Vesicoureteric junction
How can the point during micturition at which blood is seen allude to the location of the pathology?
Beginning of stream = urethral
Throughout = renal
End = bladder
List some indications for 2 week cystoscopic referral.
All frank haematuria
Persistent haematuria + dysuria
Haematuria + lower urinary tract symptoms
Female retention
Outline the staging of renal cell carcinoma.
T1 - < 7 cm T2 - > 7 cm T3 - involves perinephric tissue/renal vein T4 - beyond renal (Grota's) fascia N0 - no nodal disease N1 - regional nodal disease M0 - no mets M1 - mets
List some investigations for varicose veins.
Duplex ultrasound
MR venography
What are the two types of below knee amputation?
Skew flap - joining loose lateral flaps of skin over the end of the bone, vertical longitudinal scar along stump
Long posterior flap (Burgess) - using posterior calf muscle to cover bone, horizontal circumferential scar around stump
What is the pes anserinus?
Conjoined tendons of three muscles entering into the anteromedial surface of the proximal tibia (semitendinosus, gracilis, sartorius)
Which bursae are found around the knee joint?
Suprapatellar Pre-patellar Infrapatellar (subcutaneous and deep) Semimembranosus Pes anserine
What are the main differences between epidural and spinal anaesthesia?
Epidural: into epidural space, longer onset (30 mins), last longer, doesn’t give full motor block, can leave an epidural catheter for top ups
Spinal: into subarachnoid space, usually one-time, very quick onset, profound motor block, smaller dose, cannot be done above L2 (needs to be below the conus medullaris to avoid spinal cord injury)
List some complications of ocular protheses.
Lagophthalmos (incomplete closure of eyelid over eye) Enophthalmos Rotating prosthesis Prosthesis falling out Exophthalmos
Describe the classification of joints.
Synovial joint - most common, connected by connective tissue forming a capsule with synovial fluid within the joint cavity (e.g. knee, elbow)
Fibrous Joint - connected by dense connective tissue, three types: sutures (e.g. skull), syndesmosis (e.g. tibiofibular), gomphosis (teeth to mandible)
Cartilaginous - connected by fibrocartilage or hyaline cartilage, primary cartilaginous (synchondroses such as growth plates) and secondary cartilaginous (pubic symphysis)
List the main indications for operating on varicose veins.
Venous eczema and ulceration
Skin changes including lipodermatosclerosis
Oedema
Describe the management of low-risk and high-risk invasive bladder cancer.
Low-risk: TURBT + intravesical mitomycin
High-risk: TURBT + intravesical BCG
List some risk factors for umbilical and paraumbilical hernias.
Pregnancy
Ascites
Obesity
Which operations may be conducted in patients with Crohn’s disease?
Ileocaecectomy
Abscess drainage
Stricturoplasty
Colectomy
List some causes of leg length discrepancy.
True: congenital, post-traumatic, bone tumours
Apparent: scoliosis
What are the contents of the adductor canal?
Femoral artery
Femoral vein
Femoral nerve
Saphenous nerve
Boundaries: adductor longus and magnus, vastus medialis, sartorius
Which important pre-operative intervention reduces the risk of infection in patients undergoing an appendicectomy?
Single dose IV tazocin 30 mins before the operation
What are the main aspects of conducting a hernia examination?
Examine standing Cough (and feel for cough impulse) Palpate pubic tubercle to orientate Examine for extension into scrotum Auscultate for bowel sounds Ask patient to reduce hernia and attempt to control it by placing finger at midpoint of inguinal ligament (deep ring) Repeat with patients supine Palpate abdomen
What are the branches of the coeliac trunk?
Left gastric artery
Splenic artery
Common hepatic artery
Describe the main symptoms of ulnar collateral injury of the thumb.
Presents after abduction force to the thumb (e.g. falling when skiing)
Weak pincer grip
Reduced ROM of metacarpophalangeal joint of thumb
Needs immobilisation with thumb spica (complete rupture needs surgery)
NOTE: aka Skier’s thumb/Gamekeeper’s thumb
What is a Bennett’s fracture?
Intra-articular fracture of the first metacarpal bone (often associated with boxing)
NOTE: usually requires ORIF, high risk of osteoarthritis later in life
Where will you see scars other than in the breast for the different types of myocutaneous flap?
Latissimus dorsi - back over lat dorsi (looks a bit like lateral thoracotomy)
DIEP and TRAM - transverse lower abdominal scar (along the bikini line)
How is a DIEP flap different from a TRAM flap?
TRAM is connected to blood vessels that travel down in the rectus abdominis. Traditionally, TRAM is on a pedicle containing the blood supply and is passed under the skin up to the breast. (abdominal muscles sacrificed)
DIEP is removed with its blood vessels from the lower abdomen and transplanted into the breast and connected to a supply near the breast. (abdominal muscles spared)
NOTE: muscle sparing TRAM is now possible with microsurgery (no longer has to be on a pedicle)
What is the most common cause of cubitus varus?
Supracondylar fracture of the humerus
NOTE: can be corrected with osteotomy
List and describe some types of toe deformity.
Hammer toe - flexion of PIJ
Mallet toe - flexion of DIJ
Clawed toe - dorsiflexion of MTP + flexion of PIJ and DIJ
Causes of toe deformities include ill-fitting shoes, OA, RA, CMT and Friedreich ataxia
What is the most commonly used management option for Colles fractures?
Closed manipulation with haematoma block (local anaesthetic) followed by below-elbow backslab
NOTE: ORIF is sometimes needed however may not be the best option in elderly, osteoporotic patients with comorbidities and anaesthetic risks
NOTE: Smith’s fractures usually require manipulation under anaesthesia or ORIF
What are the boundaries of the anatomical snuffbox?
Medial: extensor pollicis longus
Lateral: abductor pollicis longus + extensor pollicis brevis
Floor: scaphoid
Crossed by: radial artery
Describe the incisions used in a 4-compartment fasciotomy.
Medial and lateral skin incisions
Through the lateral incision, you divide the fascia of the superficial and deep posterior compartments
What is the difference between tennis elbow and golfer’s elbow?
Tennis: lateral epicondylitis (insertion of extensor carpi radialis brevis)
Golfer: medial epicondylitis
List some risk factors for hernias.
Pregnancy
Obesity
Weight lifting
Chronic cough
Which blood artery is a transplanted kidney usually connected to?
External iliac artery
List some complications of supracondylar humerus fractures.
Gunstock deformity (cubitus varus due to malunion)
Compartment syndrome
Ischaemia (e.g. due to brachial artery injury) leading to a Volkmann ischaemic contracture
Median nerve damage
Define compartment syndrome.
An increase in pressure within an osseofascial compartment (usually > 30 mm Hg diastolic)
What operation is used to treat cataracts?
Phacoemulsification - involves emulsifying and aspirating the lens before inserting an implant
