Surgery Flashcards
summary of management of NoF fracture
sliding hip screw is same as dynamic hip screw
You review a middle-aged man with shoulder pain. He has limited movement of the right shoulder in all directions. Which of the following clinical findings is most consistent with a diagnosis of frozen shoulder (adhesive capsulitis)?
- external rotation is affected most
- both active and passive movement is affected
A 33-year-old businesswoman presents to the GP with persisting pain and swelling in her fore-foot. She describes that she moved to London 3 months ago for a new job, and as such she is often on her feet and usually wears high heels. She says that the pain is worse when she is weight bearing. Squeezing her foot recreates the pain. You suspect that she has a stress fracture.
What bone is most likely involved?
2nd metatarsal
hip fracture presentation
leg would be shortened and externally rotated
A 48-year-old man presents following a recurred episode of back pain. The patient has had multiple issues following a disc prolapse sustained during his career working in manual labour. The patient reports today he was bending over to pick something up and had an acute onset of lower back pain.
On exam, he had a unilateral, decreased sensation on the posterolateral aspect of the right leg and lateral foot. A straight leg raise test results in pain in the thigh, buttock and calf region and there is weakness on plantar flexion with reduced ankle reflexes.
What root compression has this patient experienced?
S1 lesion features = Sensory loss of posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex, positive sciatic nerve stretch test
A 48-year-old man presents following a recurred episode of back pain. The patient has had multiple issues following a disc prolapse sustained during his career working in manual labour. The patient reports today he was bending over to pick something up and had an acute onset of lower back pain.
On exam, he had a unilateral, decreased sensation on the posterolateral aspect of the right leg and lateral foot. A straight leg raise test results in pain in the thigh, buttock and calf region and there is weakness on plantar flexion with reduced ankle reflexes.
What root compression has this patient experienced?
S1 lesion features = Sensory loss of posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex, positive sciatic nerve stretch test
The straight leg raise test
is a fundamental maneuver during the physical examination of a patient with lower back pain.
It aims to assess for lumbosacral nerve root irritation. This test can be positive in a variety of conditions, though lumbar disc herniation is the most common.
A 56-year-old motorcyclist is involved in a road traffic accident and sustains a displaced femoral shaft fracture. Not other injuries are identified on the primary or secondary surveys. The fracture is treated with closed, antegrade intramedullary nailing. The following day the patient becomes increasingly agitated and confused. On examination he is pyrexial, hypoxic SaO2 90% on 6 litres O2, tachycardic and normotensive. Systemic examination demonstrates a non blanching petechial rash present over the torso. What is the most likely explanation for this?
fat embolism
A 65 year old man is admitted to the surgical assessment unit with urinary frequency. He has noticed particulate matter and air in his urine stream. He has felt unwell for several months with lower abdominal discomfort.
He has been treated by his GP for urinary tract infections several times in recent months.
What is the most likely diagnosis?
Diverticular disease with a colo-vesical fistula
Passing air in the urine (pneumaturia) is always pathological and most commonly suggests the presence of a fistula between the bowel and the urinary tract
A 78 year old man is admitted with acute right lower limb ischaemia. The patient has no sensation in their foot and cannot move their toes.
This is an image of the patient’s lower limbs:
He has been given opiate analgesia.
What is the most appropriate intervention for this man?
Above knee amputation
The patient presents with a well-demarcated ischaemic leg. It is blue and it will be painful. The leg will be cold to touch and pulseless. The skin will not blanch on pressure (fixed mottling).
It is now too late to salvage the leg through intervention, as the leg is ‘dead’. This is inferred by the fact that the patient has lost sensation (dead nerves) and cannot move it (dead muscle). Fixed mottling demonstrates that there is no blood flow within the skin. Therefore, in this situation the open option available (apart from a palliative approach) would be amputation, as there is no scope for revascularisation. If an ischaemic limb is not identified in time (less than 6 hours), this is the inevitable
consequence. That is why it is so important not to miss an acutely ischaemic limb as it will have life changing consequences for the patient.
A 78 year old man is admitted with acute right lower limb ischaemia. The patient has no sensation in their foot and cannot move their toes.
This is an image of the patient’s lower limbs:
He has been given opiate analgesia.
What is the most appropriate intervention for this man?
A. Above knee amputation
B. Angioplasty to occluded vessel
C. Embolectomy
D. Femoral-popliteal bypass graft
E. Intra-arterial thrombolysis
Above knee amputation
The patient presents with a well-demarcated ischaemic leg. It is blue and it will be painful. The leg will be cold to touch and pulseless. The skin will not blanch on pressure (fixed mottling).
It is now too late to salvage the leg through intervention, as the leg is ‘dead’. This is inferred by the fact that the patient has lost sensation (dead nerves) and cannot move it (dead muscle). Fixed mottling demonstrates that there is no blood flow within the skin. Therefore, in this situation the open option available (apart from a palliative approach) would be amputation, as there is no scope for revascularisation. If an ischaemic limb is not identified in time (less than 6 hours), this is the inevitable
consequence. That is why it is so important not to miss an acutely ischaemic limb as it will have life changing consequences for the patient.
6 Ps of ischaemia
pain, pale, pulseless, perishingly cold, paraesthesia and paralysis
Note that these findings are a continuum and by the time there is paraesthesia and paralysis, it is usually too late to save the limb.
A 46 year old man with Type 2 Diabetes is due to have an anterior resection next month. He takes metformin with good control of his diabetes (HbA1c 6.7% or mmol/L).
He is likely to miss more than two meals following the surgical procedure.
What is the best approach to managing his diabetes?
Stop metformin and start peri-operative variable rate insulin infusion
In a cohort study of elderly women, the relative risk ratio for hip fractures among those who exercise regularly is 1.2 (95% confidence interval of 1.1 to 1.8).
Which is the most appropriate conclusion about the effect of regular exercise on the risk for hip fracture?
A. It is not possible to draw a conclusion with the available data
B. There is a statistically non-significant increase in risk of hip fracture
C. There is a statistically non-significant overall decrease in risk of hip fracture D. There is a statistically significant overall decrease in risk of hip fracture
E. There is a statistically significant overall increase in risk of hip fracture
Explanation:
The relative risk ratio is a statistical analysis. It estimates the strength of the association between treatments or risk factors, and outcome.
Assuming the causal effect between the exposure and the outcome, the RR can be interpreted as follows:
RR = 1 means the exposure does not effect the outcome
RR < 1 means the risk of the outcome is decreased by the exposure
RR > 1 means the risk of the outcome is increased by the exposure
In our example the outcome is a hip fracture and the risk factor is exercise in a cohort of elderly women.
The RR is 1.2 which means the risk of hip fracture is increased by exercise.
This conclusion is statistically significant because the confidence interval range starts above 1. If the CI started below 1 ie was from 0.8 to 1.8 then both outcomes for exercise could be valid – exercise could either increase or decrease the risk of a hip fracture.
A 35 year old female long distance lorry driver has an 8-week history of pins and needles in the right thumb and index finger with weakness of wrist extension.
She suffers from neck and right-sided shoulder pain.
What is the most likely cause of her symptoms?
C6 nerve root impingement
A 56 year old man presents with a 36-hour history of colicky right flank pain that radiates to the groin and dipstick haematuria.
CT KUB shows a 7mm distal ureteric stone, which is visible on plain x-ray.
What is the stone most likely to be formed from?
calcium oxalate
A 55 year old woman develops a hoarse voice following a a thyroidectomy.
Which nerve is most likely to have been injured?
recurrent laryngeal
tamoxifen
Indication
- Pre-menopausal women with breast cancer
MOA
- SERM- selective oestrogen receptor modulator
- converse effects in breast and endometrial tissue
- in endometrium = ER agonist
- in breast = ER antagonist
- cell cycle arrest
- converse effects in breast and endometrial tissue
- Blockage of oestrogen receptor in breast tissue
ADR
- Risk of thromboembolism during and after surgery or during periods of immobility
- Uterine carcinoma (due to pro-oestrogenic effect on the uterus)
which hormonal therapy for post-menopausal women with breast cancer
Aromatase Inhibitors (post-menopausal)
e.g such as Anastrozole, Letrozole, or Exemestane
Indication
- Post-menopausal patients as adjuvant therapy, shown to be superior in this patient subgroup to Tamoxifen, however are more expensive.
MOA
- Act through binding to oestrogen receptors to inhibit further malignant growth and preventing further oestrogen production, as well as blocking the conversion of androgens to oestrogen in peripheral tissues.
in situ breast cancer surgical treatment
wide localise excision- if localised
mastectomy
- High tumour: breast tissue ration
- Disease recurrence
- Patient choice (or in risk-reducing cases)
common side effect of herceptin
cardiotoxicity, hence cardiac function must be monitored before and during treatment
where is pain usually with intermittent claudication and important questions to ask in history
the calves
- not many branches come off the tibial-perineal artery off into the lower leg
- lots of branches in the foot, so pain isn’t experiences so much into the foot
history
- worse on exercise
- important to ask how far patient can walk
- pain at night → critical limb threatening ischaemia (red flag)
- less gravity
- blood pressure decreases at night → reduced blood flow
- may sleep in a chair
signs of critical limb ischaemia
Pallor
Perishingly cold
Pain
Paraesthesia
Paralysis
Pulselessness
needs to be removed with 6 hours
→ symptoms may be less if chronic PAD→ development of collateral arteries
all patients with PAD should be on
statins (regardless of cholesterol)
clopidogrel (anti-platelet)
+-
- diabetes medication
- antihypertensives
types of colorectal resection for bowel cancer
+ Hartmans (a type of colectomy that removes part of the colon and sometimes rectum (proctosigmoidectomy). The remaining rectum is sealed, creating what is known as Hartmann’s pouch. The remaining colon is redirected to a colostomy.)
Anterior resection- removal of rectum and sigmoid colon- healthy tissue stiched back together
- low anterior- most of the rectum
- high anterior- less of the rectum
Hartmanns pouch
analgesia for NOF
WHO pain ladder
regional block: fascia iliac block important
management of intracapsular NOF
total hip replacement vs hemiarthroplasty
A 54-year-old woman visits her general practitioner with a painful right hip which has been bothering her for the last 10 months. Her pain control consists of codeine and paracetamol four times a day. There is no history of trauma or injury to her hip. She has a background of mild asthma, and she is in remission from breast cancer that was treated with a bilateral mastectomy and chemotherapy 3 years ago. She drinks 2 glasses of wine over the weekend and does not smoke.
On examination, there is no visible deformity of her right hip, but it is tender on palpation. She walks with a visible limp and appears to be in discomfort.
Pelvis X-ray: crescent sign.
Which of the following is the strongest risk factor for this patient’s presentation?
chemotherapy- RF for AVN
A 50-year-old man presents to his GP complaining of numbness and tingling in his left hand. He works as a building site manager, is right-handed, and denies any trauma. He has not had any symptoms like this before.
On questioning, he says the numbness and tingling wake him up at night and is mainly in his 4th and 5th fingers. On examination, there is no objective neurological deficit. Tinel’s sign is positive.
The GP recommends a splint and refers the patient to physiotherapy.
What is the most likely diagnosis?
cubital tunnel syndrome.
This affects the 4th and 5th fingers and is caused by compression of the ulnar nerve. Tinel’s sign, where tapping on the problematic nerve reproduces symptoms, is positive.
A 24-year-old man falls sustaining an inversion injury to his ankle. On examination he is tender over the lateral malleolus only. On x-ray there is a fibular fracture that is distal to the syndesmosis.
management
Application of below knee plaster cast to include the midfoot
These distal injuries are generally managed conservatively. Conservative management will involve a below knee cast, this will need to extend to the midfoot. It can be substituted for an aircast boot once radiological union is achieved.
An 86-year-old lady stumbles and falls whilst opening her front door. On examination her ankle is swollen with both medial and lateral tenderness. X rays demonstrate a fibular fracture at the level of the syndesmosis.
Application of below knee plaster cast to include the midfoot
Application of below knee plaster cast to include the midfoot42%
Although, this is a potentially unstable injury operative fixation in this age group generally gives poor results owing to poor quality bone. A below knee cast should be applied in the first instance. If this fails to provide adequate control it can be extended above the knee.
25-year-old man suffers an injury whilst playing rugby involving a violent twist to his left lower leg. On examination both malleoli are tender and the ankle joint is very swollen. On x-ray there is a spiral fracture of the fibula and widening of the ankle mortise.
Surgical fixation74
This is a variant of the Weber C fracture in which disruption of the tibio-fibular syndesmosis occurs leading to joint disruption. Surgical repair is warranted.
dynamic hip screw
You are asked to review a 65-year-old woman who has become breathless on the surgical ward. Earlier in the day she had a laparoscopic cholecystectomy for gallstone disease. A chest x-ray has already been obtained:
What complication has developed?
This radiograph demonstrates subcutaneous (surgical) emphysema which is a known complication of laparoscopic surgery. If the anterior chest wall is affected air can outline the pectoralis major muscle, giving rise to the ‘ginkgo leaf’ sign.
Discuss (11)Improve
A 65-year-old male presents to the GP with recurrent mild upper abdominal pain following a meal. He also complained of foul-smelling greasy stools. He has not experienced any weight loss or change in appetite, no nausea or vomiting, and is not clinically jaundiced. He has a past medical history of chronic alcohol abuse - he drinks 80 units per week and has been doing so for the past 10 years.
What is the most appropriate diagnostic test?
CT pancreas is the preferred diagnostic test for chronic pancreatitis - looking for pancreatic calcification
signs of radial head fracture on x-ray
The sail sign on an elbow radiograph, also known as the anterior fat pad sign, describes the elevation of the anterior fat pad to create a silhouette similar to a billowing spinnaker sail from a boat. It indicates the presence of an elbow joint effusion.
in children may be sign of supracondylar fracture
types of wrist fracture
- Colles’ fracture (distal radius with dorsal (more behind) displacement of fragments).
- Smith’s fracture (distal radius with volar (more forward) displacement of fragments).
- Scaphoid fracture.
- Barton’s fracture (fracture dislocation of the radiocarpal joint).
colles fracture referred to as
dinner fork deformity
- distal radius is dorsal
- within 2cm or articular surface (joint)
A 22-year-old man falls over and presents to casualty. A shoulder x-ray is performed, the radiologist comments that a Hill-Sachs lesion is present.
Glenohumeral dislocation61%
A Hill-Sachs lesion is when the cartilage surface of the humerus is in contact with the rim of the glenoid. About 50% of anterior glenohumeral dislocations are associated with this lesion.
which types of distal radius fracture are intra-articular
bartons fracture
- associated dislocation of radio-carpal joint
A 5-year-old boy is seen in the Minor Injury Unit after falling in the playground. His mother observed the fall and describes him falling on an outstretched hand.
The x-ray is shown below
Buckle fracture
Buckling of the cortex of the distal radius is seen without a distinct fracture line. Owing to the elasticity of bone in children, axial trauma leads to deformity, rather than a true fracture, resulting in a buckle fracture.
Developmental dysplasia of the hip (DDH)
where the “ball and socket” joint of the hip does not properly form in babies and young children.
perthes disease
- loss of blood supply (avascular necrosis) of the nucleus of the proximal femoral epiphysis.
- Abnormal growth of the epiphysis results.
- Eventual remodelling of regenerated bone.
presentation
- On examination all movements at the hip are limited. In the early phase there is limited abduction of the hip and limited internal rotation in both flexion and extension.
- There is an antalgic gait (due to pain) and a Trendelenburg gait is seen in the late phase
SUFE
slipper upper femoral epyphysis
- displacement of the proximal femoral epiphysis from the metaphysis
- MOA: atraumatic or associated with a minor injury
- management: no weight bearing and ORIF
