Surgery

Question 1

summary of management of NoF fracture

Answer 1

sliding hip screw is same as dynamic hip screw

Question 2

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)?

Answer 2

• external rotation is affected most
• both active and passive movement is affected

Question 3

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?

Answer 3

2nd metatarsal

Question 4

hip fracture presentation

Answer 4

leg would be shortened and externally rotated

Question 5

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?

Answer 5

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

Question 6

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?

Answer 6

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

Question 7

The straight leg raise test

Answer 7

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.

Question 8

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?

Answer 8

fat embolism

Question 9

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?

Answer 9

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

Question 10

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?

Answer 10

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.

Question 11

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

Answer 11

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.

Question 12

6 Ps of ischaemia

Answer 12

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.

Question 13

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?

Answer 13

Stop metformin and start peri-operative variable rate insulin infusion

Question 14

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.

Question 15

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?

Answer 15

C6 nerve root impingement

Question 16

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?

Answer 16

calcium oxalate

Question 17

A 55 year old woman develops a hoarse voice following a a thyroidectomy.

Which nerve is most likely to have been injured?

Answer 17

recurrent laryngeal

Question 18

tamoxifen

Answer 18

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
• 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)

Question 19

which hormonal therapy for post-menopausal women with breast cancer

Answer 19

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.

Question 20

in situ breast cancer surgical treatment

Answer 20

wide localise excision- if localised

mastectomy

• High tumour: breast tissue ration
• Disease recurrence
• Patient choice (or in risk-reducing cases)

Question 21

common side effect of herceptin

Answer 21

cardiotoxicity, hence cardiac function must be monitored before and during treatment

Question 22

where is pain usually with intermittent claudication and important questions to ask in history

Answer 22

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

Question 23

signs of critical limb ischaemia

Answer 23

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

Question 24

all patients with PAD should be on

Answer 24

statins (regardless of cholesterol)

clopidogrel (anti-platelet)

+-

• diabetes medication
• antihypertensives

Question 25

types of colorectal resection for bowel cancer

Answer 25

**+ 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

Question 26

Hartmanns pouch

Answer 26

Question 27

analgesia for NOF

Answer 27

WHO pain ladder regional block: fascia iliac block **important**

Question 28

management of intracapsular NOF

Answer 28

Question 29

total hip replacement vs hemiarthroplasty

Answer 29

Question 30

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?

Answer 30

chemotherapy- RF for AVN

Question 31

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?

Answer 31

**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.

Question 32

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

Answer 32

**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.

Question 33

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.

Answer 33

Application of below knee plaster cast to include the midfoot ## Footnote Application of below knee plaster cast to include the midfoot**42%** 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.

Question 34

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.

Answer 34

Surgical fixation**74** ## Footnote 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.

Question 35

A 27-year-old man was admitted to hospital 6 hours previously following a fractured right tibia while playing a football match. His pain has been well controlled until 30 minutes ago, but he is now complaining of intense pain in his right lower leg. On examination he is in severe pain, worsened by passive movement of the foot. You are able to palpate the dorsalis pedis and posterior tibial pulse on the right foot. His heart rate and respiratory rate are both raised (110/min and 22/min respectively), and you notice he is sweating. Which is the definitive management for this condition?

Answer 35

fasciotomy * compartment syndrome

Question 36

remember presence of …… does not exclude compartment syndrome

Answer 36

pulses Pain of passive movement is characteristic of compartment syndrome, and it is important to remember presence of a pulse does not rule out compartment syndrome! He will need analgesia, but it is not the definitive treatment. Intracompartmental pressure measurements can aide in the diagnosis of suspected compartment syndromes that aren't clear, but the question asks for the definitive management, not investigations.

Question 37

dynamic hip screw

Answer 37

Question 38

A 24-year-old male patient presents to their GP with abdominal pain and bloody diarrhoea which started around six weeks ago. He has never had any previous episodes like this. He feels he may have lost some weight over the last three months. When asked about family history, he says that his father was diagnosed with bowel cancer aged 30, and though his Grandfather passed away when the patient was a child, he can remember him having a stoma. The GP suspects bowel cancer and is suspicious of an underlying genetic abnormality At colonoscopy, a large tumour is found in the ascending colon, close to the hepatic flexure. Other than this, the colonic mucosa looks normal. What is the most likely underlying genetic problem?

Answer 38

Lynch syndrome (HNPCC) is characterised by development of bowel cancer (among other cancers) with little formation of adenomatous polyps differential FAP is ruled out here by the normal colonic mucosa aside from the tumour.

Question 39

A previously healthy 56-year-old man comes to the GP after noticing a lump in his groin. It is not painful but he says it gets bigger when he coughs. On examination, there is a soft, non-tender, ill-defined mass in the left inguinal region. Straining increases its size but the mass disappears with the patient supine. There are no overlying skin changes. Vital signs are within normal limits. A subsequent ultrasound reveals visible abdominal contents lateral to the inferior epigastric vessels, with no ischaemic changes noted. What is the most appropriate next step in management for this patient?

Answer 39

A non-tender protrusion of abdominal contents that is reducible and lateral to the inferior epigastric vessels is highly indicative of an uncomplicated indirect inguinal hernia. This should be **referred for routine repair** as the patient has no comorbidities and these cases often require surgery in the future.

Question 40

A 33-year-old male presents to your GP evening clinic complaining of pain in his abdomen. They have described pain which is located in the lower left abdomen which has become more severe across the day. He feels feverish, nauseous, and has vomited twice in the last hour. He cannot remember the last time he passed urine or stool, and he mentions that he has had a small painless lump on his lower left abdomen for the past month which he has not sought medical attention for. On examination, he appears clammy and looks unwell. He is tachycardic and normotensive. His abdomen appears mildly distended and is very tender to touch. There is evidence of localised tenderness in the left iliac fossa. You also notice a lump in the left inguinal area that is 2cm x 2cm in diameter which is erythematous and is now extremely painful to touch. What is the most appropriate next step?

Answer 40

strangulated inguinal hernia call 999 and arrange ASAP assessment in hospital

Question 41

difference in presentation of osteomalacia and osteoporosis

Answer 41

Osteomalacia is a condition characterized by soft bone due to vitamin and mineral deficiencies i.e**. will have low calcium** Osteoporosis is the deterioration of bone mass over time **i.e. calcium will be normal**

Question 42

**Osteomalacia**

Answer 42

[Osteomalacia](https://www.healthline.com/health/osteomalacia#TOC_TITLE_HDR_1) is a condition that softens bones. In children, it’s called rickets. It involves problems with bone formation and the bone-building process, resulting in weakening of the bones. It is most often caused by a [vitamin D](https://www.healthline.com/health/food-nutrition/benefits-vitamin-d) deficiency, which helps you absorb calcium.

Question 43

osteoporosis

Answer 43

[Osteoporosis](https://www.healthline.com/health/osteoporosis) is when your bone mineral density and bone mass decreases, or when the quality or structure of the bone changes. Over time, this can cause a reduction in bone strength, increasing the risk of fractures. The inside of a bone typically has spaces akin to a honeycomb structure. **Osteoporosis is the more serious progression of osteopenia**.

Question 44

A 32-year-old lady has previously undergone a wide local excision and axillary node clearance (5 nodes positive) for an invasive ductal carcinoma. It is oestrogen receptor negative, HER 2 positive, vascular invasion is present. She has a lesion suspicious for metastatic disease in the left lobe of her liver.

Answer 44

Trastuzumab**76%** ## Footnote This ladies young age, coupled with ER negativity and extensive nodal disease with suspicion of metastatic disease makes her a candidate for treatment with trastuzumab (herceptin).

Question 45

A 22-year-old lady has severe peri anal crohns disease with multiple anal fistulae, the acute sepsis has been drained and setons are in place. She is already receiving standard non biological therapy. **%**

Answer 45

Infliximab is a popular choice in managing complex peri anal crohns. It is absolutely vital that all sepsis is drained prior to starting therapy.

Question 46

A 63-year-old man presents with a locally unresectable gastrointestinal stromal tumour. Biopsies confirm that it is KIT positive.

Answer 46

Imatinib is licensed for treatment of GIST in the United Kingdom for this situation. The guidance from the National Institute of Clinical evidence is that patients be reviewed at 12 weeks after initiating therapy.

Question 47

A 67-year-old male presents to the emergency department complaining of new-onset pain in his left groin. On examination, a large, warm, non-reducible mass located inferolateral to the pubic tubercle can be observed. It is accompanied by erythema of the overlying skin. When asked, he admits to vomiting twice and passing stools with blood mixed in them once. He looks in pain and sweaty. He has a past medical history of peptic ulcer disease, managed with omeprazole. Which one of the following is the most likely diagnosis?

Answer 47

strangulated femoral hernia Strangulation is an important complication of femoral hernias

Question 48

A 46-year-old man with alcohol dependence presents to the emergency department with epigastric pain of sudden onset. He describes the pain as severe and radiating to the back. He admits to consuming two bottles of vodka the night before. His heart rate is 70/min, his respiratory rate is 15/min, his blood pressure is 130/70 mmHg and his temperature is 38.1 ºC. Blood results show the following:

Answer 48

low calcium glasgow score (PANCREAS)

Question 49

A 46-year-old man with alcohol dependence presents to the emergency department with epigastric pain of sudden onset. He describes the pain as severe and radiating to the back. He admits to consuming two bottles of vodka the night before. His heart rate is 70/min, his respiratory rate is 15/min, his blood pressure is 130/70 mmHg and his temperature is 38.1 ºC. Blood results show the following:

Answer 49

low calcium glasgow score (PANCREAS)

Question 50

best test for acute pancreatitis

Answer 50

* serum amylase * raised in 75% of patients - typically \> 3 times the upper limit of normal * levels do not correlate with disease severity * specificity for pancreatitis is around 90%. Other causes of raised amylase include: pancreatic pseudocyst, mesenteric infarct, perforated viscus, acute cholecystitis, diabetic ketoacidosis * serum lipase * more sensitive and specific than serum amylase * it also has a longer half-life than amylase and may be useful for late presentations \> 24 hours

Question 51

best test for acute pancreatitis

Answer 51

* serum amylase * raised in 75% of patients - typically \> 3 times the upper limit of normal * levels do not correlate with disease severity * specificity for pancreatitis is around 90%. Other causes of raised amylase include: pancreatic pseudocyst, mesenteric infarct, perforated viscus, acute cholecystitis, diabetic ketoacidosis * **serum lipase (BETTER)** * more sensitive and specific than serum amylase * it also has a longer half-life than amylase and may be useful for late presentations \> 24 hours

Question 52

A 38-year-old woman attends the Emergency Department with central, tearing chest pain that does not radiate. Upon questioning, she reveals she had food poisoning and had been vomiting roughly every hour for the past day. She described the vomit as liquid with no blood. She is alert, appears thin and has dry mucous membranes. Upon questioning, she has no relevant past medical history or family history, is a non-smoker, drinks 8 units a week and works as a cleaner. When placing the ECG leads, the doctor notices crepitus over her chest wall. The ECG reveals sinus tachycardia. What is the most likely cause of her presentation?

Answer 52

Subcutaneous emphysema may be found in **Boerhaave's syndrome** (oesophageal rupture)

Question 53

A 65-year-old man with a history of dyspepsia is found to have a gastric MALT lymphoma on biopsy. What treatment should be offered?

Answer 53

H.pylori eradication therapy

Question 54

A 55-years-old man presents to the emergency department with severe epigastric pain and fever. He looks unkempt and affirms to be drinking 40 units of alcohol per week. He presented to the emergency department after suffering from the symptoms for two days, due to a phobia of hospitals. Given the most likely diagnosis, which of the following is the single best investigation to order?

Answer 54

Serum lipase has a longer half-life than amylase when investigating suspected acute pancreatitis and may be useful for late presentations \> 24 hours

Question 55

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: ## Footnote What complication has developed?

Answer 55

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

Question 56

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?

Answer 56

CT pancreas is the preferred diagnostic test for chronic pancreatitis - looking for pancreatic calcification

Question 57

A 72-year-old man presents to his GP complaining of reduced sensation in his lower limbs that has been progressively worsening over the last 3 months. He feels increasingly unsteady on his feet but is otherwise well. On examination, vibration and pinprick sensation are reduced symmetrically and he has a wide-based ataxic gait. His ankle reflexes are absent however his knee reflexes are brisk. His past medical history includes hypertension, managed with ramipril, and gastric cancer, which was treated with a sub-total gastrectomy 4 years ago. He has a body mass index of 29.2kg/m² and drinks 10 units of alcohol per week. What is the most likely cause of this patient’s symptoms?

Answer 57

Subacute combined degeneration of the spinal cord is **a neurological complication of vitamin B12 (cobalamin) deficiency**. A deficiency of vitamin B12 can occur as a result of nutritional deficiency, reduced absorption due to altered gastrointestinal anatomy or function, or due to the intake of certain drugs.

Question 58

A 68-year-old man is brought into the emergency department with sudden onset epigastric pain which he describes as burning in nature, radiating into his back. He has had an episode of vomiting and reports feeling nauseated still. His only past medical history is recurrent gallstones and is awaiting a semi-elective cholecystectomy. He takes no regular medications. On examination, he has jaundiced sclera. His abdomen is diffusely tender with guarding and there is some periumbilical superficial oedema and bruising. Bowel sounds are decreased on auscultation. Given the likely diagnosis, what is an important feature of this patient's immediate management?

Answer 58

Aggressive fluid resus One of the key management protocols in acute pancreatitis is **early and aggressive fluid resuscitation** which is to correct the third space losses and increase tissue perfusion with the aim of preventing severe inflammatory response syndrome which can lead to pancreatic necrosis.

Question 59

signs of radial head fracture on x-ray

Answer 59

The **sail sign** on an elbow radiograph, also known as the **anterior fat pad sign**, describes the elevation of the [anterior fat pad](https://radiopaedia.org/articles/missing?article%5Btitle%5D=anterior-fat-pad&lang=gb) to create a silhouette similar to a billowing spinnaker sail from a boat. It indicates the presence of an [elbow joint effusion](https://radiopaedia.org/articles/elbow-joint-effusion?lang=gb). in children may be sign of supracondylar fracture

Question 60

types of wrist fracture

Answer 60

* **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).

Question 61

colles fracture referred to as

Answer 61

dinner fork deformity * distal radius is dorsal * within 2cm or articular surface (joint)

Question 62

bisphosponates e.g. alendronic acid work by

Answer 62

Q bisphosponates e.g. alendronic acid A reducing ***osteoclasts*** activity, preventing the reabsorption of bone. There are a few key side effects to remember: * ***Reflux*** and ***oesophageal erosions*** (oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this) * Atypical fractures (e.g. atypical femoral fractures) * Osteonecrosis of the jaw * Osteonecrosis of the external auditory canal

Question 63

Fracture healing

Answer 63

(1) Haematoma- tissue damage and bleeding at the fracture site; the bone ends die back for a few mm (2) Inflammatory reaction- inflammatory cells appears in the haematoma (3) Callus- the cell population changes to osteoblasts and osteoclasts; dead bone is mopped ip and woven bone appears in the fracture callus (4) Consolidation- woven bone is replaced by lamellar bone- fracture is united 5) Remodelling- newly formed bone is remodelled to resemble the normal structure he is cool cat rapping

Question 64

investigation for compartment syndrome

Answer 64

A * Is made by measurement of intracompartmental pressure measurements. * Pressures in excess of **20mmHg** are abnormal and **\>40mmHg** is diagnostic * Compartment syndrome will typically not show any pathology on an x-ray

Question 65

A 60-year-old male is admitted to A&E with a fall. He lives with his wife and still works as a restaurant manager. He has a past history of benign prostatic hypertrophy and is currently taking tamsulosin. He is otherwise fit and healthy. On examination there is right hip tenderness on movement in all directions. A hip x-ray confirms an intertrochanteric fracture.

Answer 65

Dynamic hip screw

Question 66

An 86-year-old retired pharmacist is admitted to A&E following a fall. She complains of right hip pain. She is known to have hypertension and is currently on bendrofluazide. She lives alone and mobilises with a Zimmer frame. Her right leg is shortened and externally rotated. A hip x-ray confirms a displaced intracapsular fracture.

Answer 66

Hemiarthroplasty

Question 67

A 74-year-old male is admitted to A&E with a fall. He is known to have rheumatoid arthritis and is on methotrexate and paracetamol. He lives alone in a bungalow and enjoys playing golf. He is independent with his ADLs. He complains of left groin pain, therefore has a hip x-ray which confirms a displaced intracapsular fracture.

Answer 67

total hip replacement

Question 68

A 23-year-old rugby player falls directly onto his shoulder. There is pain and swelling of the shoulder joint. The clavicle is prominent and there appears to be a step deformity.

Answer 68

Acromioclavicular dislocation**78%** Acromioclavicular joint (ACJ) dislocation normally occurs secondary to direct injury to the superior aspect of the acromion. Loss of shoulder contour and prominent clavicle are key features. Note; rotator cuff tears rarely occur in the second decade.

Question 69

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.

Answer 69

**Glenohumeral dislocation****61%** 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.

Question 70

An 82-year-old female presents to A&E after tripping on a step. She complains of shoulder pain. On examination there is pain to 90^o on abduction.

Answer 70

Supraspinatus tear**78%** ## Footnote A supraspinatus tear is the most common of rotator cuff tears. It occurs as a result of degeneration and is rare in younger adults. ***Supraspinatus*** – ***abducts*** the arm

Question 71

extra articular fracture

Answer 71

fracture doesnt extend into joint * colles * smiths articular fracture which extends into joint is more serious e.g. bartons

Question 72

which types of distal radius fracture are intra-articular

Answer 72

bartons fracture * associated dislocation of radio-carpal joint

Question 73

MOA of smiths

Answer 73

FOOSH backwards

Question 74

Three measurements on a plain radiograph help with the **diagnosis of a distal radius fracture**:

Answer 74

Three measurements on a plain radiograph help with the **diagnosis of a distal radius fracture**: * **Radial height \<11mm** * **Radial inclination \<22 degrees** * **Radial (volar) tilt \>11 degrees**

Question 75

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

Answer 75

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.

Question 76

A 34-year-old kitchen worker presents with a two week history of pain in her right wrist. She has recently emigrated from Ghana and has no past medical history of note. On examination she is tender over the base of her right thumb and also over the radial styloid process. Ulnar deviation of the wrist recreates the pain. What is the most likely diagnosis?

Answer 76

Pain on the radial side of the wrist/tenderness over the radial styloid process ? **De Quervain's tenosynovitis**

Question 77

A 90-year-old lady is brought to the emergency department by ambulance after falling over the rug in her bedroom. On examination, her left leg is shortened and internally rotated. Her carer states that the patient underwent left total hip arthroplasty four years ago and is taking amitriptyline for pain. What is the most likely cause of the patient's clinical findings?

Answer 77

Posterior hip dislocations present with a shortened and internally rotated leg

Question 78

A 56-year-old woman presents to her GP with left-sided hand pain. She points to the site of the pain, which is at the base of her left thumb and describes the pain as a constant ache that is worse on movement. She says the pain has been getting worse over the last 12 months. The patient has a past medical history of gout in her big toe, for which she takes regular allopurinol. Her mother was diagnosed with rheumatoid arthritis five years ago, and she is worried that she may also have this. On examination, there is unilateral squaring of the left thumb and tenderness on palpation of the left thumb base. Based on this history and clinical examination, what is the most likely diagnosis?

Answer 78

squaring of the thumb base characteristic of **osteoarthritis**

Question 79

causes of degenerative hip disease

Answer 79

**systemic** * obesity * inflammatory * RA * ankylosing spondylitis **local** * traumatic * primary OA * congenital DDH * septic arthritis

Question 80

Developmental dysplasia of the hip (DDH)

Answer 80

**where the "ball and socket" joint of the hip does not properly form in babies and young children**.

Question 81

anticoagulation for hip and knee

Answer 81

low molecular weight heparin (dalteparin) * hip= 28 days * knee= 14 days

Question 82

perthes disease

Answer 82

* 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

Question 83

main x-ray finding for perthes

Answer 83

flattening of the femoral head.

Question 84

gait for OA of hip

Answer 84

antalgic trendelenburg

Question 85

SUFE

Answer 85

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

Question 86

An X-ray is arranged and confirms and un-displaced scaphoid fracture in the right wrist. Based on the information provided, what is the most appropriate management option?

Answer 86

undisplayed scaphoid fracture- cast for 6-8 weeks displaced scaphoid fracture - screw fixation

Question 87

why is displaced scaphoid at risk of AVN

Answer 87

The scaphoid received a retrograde blood supply from the **dorsal carpal branch of the radial artery**, making avascular necrosis a risk of these fractures go undetected. → esp proximal fracture