Surgery Flashcards
Terminal ileum resection is associated with what kind of malabsorption?
Bile acids because they are resorbed in the terminal ileum.
Note that fats are resorbed in the jejunum. ***
Mobile, firm, smooth and rubbery breast lump in a young woman
Fibroadenoma ***
Do what with a solid testicular mass or acute hydrocele in a young patient?
Exclude malignancy
Diagnosis of testicular cancer
Diagnosis is established by pathological evaluation of specimen obtained by radical inguinal orchidectomy
Does orchiopexy reduce the risk of testicular carcinoma?
Surgical descent (orchiopexy) of undescended testis does not eliminate the risk of malignancy, but allows for earlier detection by self-examination and reduces the risk of infertility
Risk factors testicular cancer
- Cryptorchidism
- Atrophy
- Sex hormones
- HIV infection
- Infertility
- Family Hx
- Past Hx of testicular cancer
Tumour markers testicular ca
Beta-hCG, LDH, AFP
Risk factors for achilles tendon rupture
- Longstanding tendonitis
- Fluoroquinolones (famously ciprofloxacin)
- Rheumatoid arthritis
- Gout
- Corticosteroid use
What is Simmond’s Test?
Simmonds’ test (also called the Thompson test or Simmonds-Thompson test) is used in lower limb examination to test for the rupture of the Achilles tendon.
The patient lies face down with feet hanging off the edge of the bed. If the test is positive, there is no movement of the foot (normally plantarflexion) on squeezing the corresponding calf, signifying likely rupture of the Achilles tendon
Complications of achilles tendon rupture
- Sural nerve injury
- Re-rupture
- Infection
- Note the most common site of Achilles tendon rupture is 2-6 cm from its insertion where the blood supply is the poorest
Management achilles tendon rupture
- Athletic- surgical repair
- Non-athletic - cast in plantarflexion 8-12 weeks
Clinical features of scaphoid fracture
- pain with resisted pronation
- tenderness in the anatomical “snuff box”, over scaphoid tubercle, and pain with long axis compression into scaphoid
- usually nondisplaced
Management of anatomical snuff box tenderness with normal X-Ray
- A fracture may not be radiologically evident up to 2 wk after acute injury, so if a patient complains of wrist pain and has anatomical snuff box tenderness but a negative x-ray, treat as if positive for a scaphoid fracture and repeat x-ray 2 wk later to rule out a fracture;
- if x-ray still negative, order CT or MRI
Riskiest part of the scaphoid to fracture
The proximal pole of the scaphoid receives as much as 100% of its arterial blood supply from the radial artery that enters at the distal pole. A fracture through the proximal third disrupts this blood supply and results in a high incidence of AVN/nonunion
Brachial plexus injuries accompany clavicular fractures in which area?
Proximal third
The major risk factor for slipped capital femoral epiphysis
Obesity
Management of slipped capital femoral epiphysis
Once SCFE is suspected, the patient should be non-weight bearing + remain on strict bed rest.
In severe cases, after enough rest the patient may require physical therapy to regain strength and movement back to the leg. SCFE is an orthopaedic emergency, as further slippage may result in occlusion of the blood supply and avascular necrosis (25%). Almost all cases require surgery, which usually involves the placement of one or two pins into the femoral head to prevent further slippage
Which fracture is typically characterized by numbness and weakness of the pinkie finger with partial involvement of the ring finger as well, the “ulnar 1½ fingers”?
hamate bone
DVT Prophylaxis in Hip Fractures
LMWH (i.e. enoxaparin 40 mg SC bid), fondaparinux, low dose heparin on admission, do not give <12 h before surgery
High-voltage pulsed galvanic stimulation (HGVS) can be used to prevent what?
Proctalgia fugax
Usual site for diverticulsosis
95% involve sigmoid colon
Clinical features of diverticulosis
- uncomplicated diverticulosis: asymptomatic (70-80%)
- episodic abdominal pain (often LLQ), bloating, flatulence, constipation, diarrhea
- absence of fever/leukocytosis
- no physical exam findings or poorly localized LLQ tenderness
Investigation of choice in acute episodes of diverticulitis
Contrast CT
Colonoscopy 4-6 weeks after acute episode is over
Diverticulitis complications
Complications (25% of cases)
- Abscess: palpable, tender abdominal mass
- Fistula: colovesical (most common), coloenteric, colovaginal, and colocutaneous
- Colonic obstruction: due to scarring from repeated inammation
- Perforation: generalized peritonitis (feculent vs. purulent)
Diverticultis treatment
Medical treatment - NPO, IVF, and IV antibiotics (e.g. IV ceftriaxone + metronidazole)
- Phlegmon/small pericolic abscess - Medical
- Large abscess/fistula - Medical, abscess drainage ± resection with primary anastomosis
- Purulent peritonitis (ruptured abscess) - Resection or Hartmann procedure
- Feculent peritonitis - Hartmann procedure
Risk factors for haemorrhoids
increased intra-abdominal pressure:
- chronic constipation
- pregnancy
- obesity
- portal HTN
- heavy lifting
Definition of an anal fissure
Tear of anal canal below dentate line
(very sensitive squamous epithelium)
Treatment options for chronic anal fissures
- Stool softeners, increased fibre intake, and sitz baths
- topical nitroglycerin or calcium channel blocker (nifedipine or diltiazam): increases local blood flow, promotes healing, and relieves sphincter spasm
- Lateral internal anal sphincterotomy (most effective): relieves sphincter spasm to increase blood flow and promote healing; reserved for medically-refractory cases due to 5% chance of fecal incontinence
- Alternative treatment: botulinum toxin A; inhibits release of acetylcholine (ACh), reducing sphincter spasm
Benefits of laparoscopic vs open appendicectomy
- Wound infection less likely
- Intra-abdominal abscesses 2x more likely
- Reduced pain on POD #1
- Reduced hospital stay by 1.1 d
- Sooner return to normal activity, work, and sport
- Costs outside hospital are reduced
Breast cancer risk factors
- Gender (99% female)
- Age (83% >50 yr)
- Personal history of breast cancer and/or prior breast biopsy (regardless of pathology)
- FH of breast cancer (greater risk if relative was first degree and premenopausal)
- High breast density, nulliparity, first pregnancy >30 yr, menarche <12 yr, or menopause >55 yr
- Decreased risk with lactation, early menopause, and early childbirth
- Radiation exposure (e.g. mantle radiation for Hodgkin’s disease)
- >5 yr HRT use, >10 yr OCP use
- BRCA1 and BRCA2 gene mutations
- Alcohol use, obesity, and sedentary lifestyle
What is the triple test for diagnosis of breast cancer?
- Clinical breast exam
- Imaging (U/S for <30 yr, mammography + U/S for >30 yr)
- Pathology (biopsy)
Bad prognostic indicators breast cancer
- >5cm
- High grade lesion’
- Node positive
- Oestrogen receptor negative
- Inflammatory cancer
- Positive margins
- Lymphovascular invasion
- Epidermal inclusion cyst
- Dermal lymphatics involved
Treatment options for stage I + II breast cancer
For stage I
Breast Conserving Surgery + axillary node dissection + radiotherapy
For stage II
Chemotherapy for premenopausal women or
postmenopausal and ER negative, followed by tamoxifen
if ER+
Mastectomy offers no survival benefit for stage I+II
Women who have received tamoxifen require follow up for which other malignancy?
Endometrial cancer
Antibiotics in the management of appendicitis
- Cefazolin + metronidazole if uncomplicated, peri-operative dose is adequate
- Consider treatment with post-operative antibiotics for perforated appendicitis
- For patients who present with an abscess (palpable mass or phlegmon on imaging and often delayed diagnosis with symptoms for >4-5 d), consider radiologic drainage + antibiotics x 14 d ± interval appendectomy once inflammation has resolved = (controversial)
- Recent research supports antibiotic only treatment as reasonable for uncomplicated appendicitis, with 10-20% recurrence rates
Elderly ppl presenting with appendicitis should have what investigation and why?
Colonoscopy to exclude neoplasm
Management of epidural hematoma
Treatment is generally by urgent surgery in the form of a craniotomy or burr hole. Without treatment, death typically results.
Indications for surgery in a blowout fracture
- Any size defect with enopthalmos or hypoglobus
- Diplopia
- Entrapment of extraocular muscles
- Fracture of orbital floor >50%
Indications for surgical decompression in subdural haematoma
- Unstable vital signs
- Raised intracranial pressure
- Clinical or CT signs of brain herniation (eg midline shift)
Characteristics of lumbar spinal stenosis pain
- Worse on extension of the spine (therefore worse walking downhill)
- Relieved by flexion of the spine
- Relieved by sitting down
Assessment of cruciate ligaments
The drawer test is used in the initial clinical assessment of suspected rupture of the cruciate ligaments. The pt is supine with hips flexed to 45 degrees, knees flexed to 90 degrees and feet flat on table. The examiner sits on the examination table in front of the knee and grasps the tibia just below the joint line of the knee. The thumbs are placed along the joint line on either side of the patellar tendon. The tibia is then drawn forward anteriorly. If the tibia pulls forward or backward more than normal, the test is considered positive. Excessive displacement of the tibia anteriorly suggests ACL injury, and excessive posterior displacement of tibia may indicate injury of posterior cruciate ligament.
Best treatment for a buckle (greenstick) fracture
Removable splint for 3 weeks
What is the system by which toxic levels of thyroid hormone can contribute to premature death?
Via the SERCA-phospholamban system which affects contractility of cadiac muscles leading to potential palpitations, sinus tachcarida and atrial fibrillation.
Rubber band ligation is a treatment for which type of haemorrhoid?
Internal only. Would be too painful otherwise.
What’s the appropriate management of a thrombosed haemorrhoid presenting within 48 hours?
Elliptical excision of the haemorrhoid under local anaesthetic
What’s the mainstay of treatment for patellofemoral syndrome?
Exercise
Nerves potentially injured in a proximal humerus fracture
Axillary (supplies motor to deltoid and sensory to a patch over deltoid) and suprascapular
Management of thyroid nodule with normal TSH
FNA + ultrasound
If TSH is suppressed do a radionucleide scan and then only do an FNA if there is no increased uptake
Investigation of choice for a middle aged or elderly person presenting with pain LLQ, fever, peritonism, anorexia and leukocytosis
CT abdo
Cause of scapular winging after axillary lymph node dissection in breast cancer surgery
Long thoracic nerve injury
What’s this and what is it for?
Supination-flexion technique for radial head subluxation
What is autonomic dysreflexia?
Autonomic dysreflexia (AD) is a condition of uncontrolled sympathetic response secondary to a precipitant, that generally occurs in patients with injury to the spinal cord at levels of T6 and above.
What is this? Which vessel is usually responsible?
Epidural hematoma
Middle meningeal artery
Poor Prognostic Indicators for Epidural Hematoma
- Older age
- Low GCS on admission
- Pupillary abnormalities (especially nonreactive)
- Longer delay in obtaining surgery (if needed)
- Post-operative elevated ICP
Structures potentially at risk in knee dislocation
Popliteal artery 30-35%
Common peroneal nerve 15-30%
Tibial nerve
What does a high serum ascites albumin gradient (SAAG) gradient (SAAG >1.1 g/dL) indicate?
Portal hypertension
What are the first and second biggest causes of ascites?
- Portal hypertension
- Peritoneal carcinomatosis
Management of clavicle fractures
1) Middle #
2) Displaced distal third #
3) Comminuted # in a child
- Conservative
- ORIF
- Conservative
What does the swirl sign indicate?
Active haemorrhage
What are grade I haemorrhoids and how do you treat them?
Grade I = bleeding without prolapse
High fibre diet, stool softeners, warm baths
What are grade II and III haemorrhoids and how do you treat them?
Grade II- prolapse w spontaneous reduction
Grade III- prolapse w manual reduction
Initially treat non-surgically w rubber band ligation
Preferred method of biopsy for any suspicious skin lesion
Complete elliptical excision
Management of 2nd + 3rd metatarsal stress fractures
Rest, ice, acetominophen
The testicular tumour with the worst prognosis
Choriocarcinoma
When should preoperative antibiotics be given?
An hour before surgery
Major side effects of azathioprine post renal transplant
BM suppression + hepatotoxicity
Gold standard invetigation for diagnosing a pituitary adenoma
Brain MRI
Treatment of alcohol withdrawl in a pt over 65 or with liver disease
Lorazepam (or a short acting benzo) 1-4mg 1-2hourly
Significance of intramural gas on abdo X-ray
Intramural gas can be seen in intestinal ischaemia and eventually bowel infarction. This is the most concerning aetiology for intramural gas.
Gas in the bowel wall in the neonatal period, whatever its shape, is diagnostic of necrotising enterocolitis.
What is this?
Generalised diffuse and constant pain, out of proportion to the clinical findings
Associated nausea and vomiting in around 75% of cases
Hx of AF or other embolic sources
Acute mesenteric ischaemia
Definitive Ix for mesenteric ischaemia
CT scan with IV contrast (as a triple phase scan, with thin slices taken in the arterial phase)
Key points about acute mesenteric ischaemia
- Acute mesenteric ischaemia is most commonly caused by an embolus, yet may also be caused by a thrombus-in-situ, venous occlusion, or non-occlusive causes
- Patients present with excessive pain, out of proportion to clinical findings with typically an otherwise unremarkable examination
- Ensure to assess for potential sources of embolus
- Definitive diagnosis is made via CT angiography
- Surgical treatment involves either bowel resection or revascularisation, however mortality rates are >50% even in treated cases
Compartment syndrome basics
- Compartment syndrome is most common in the lower limbs, typically following traumatic injury or fractures
- Diagnosis is clinical, the main symptom being pain disproportionate to the injury or worsening despite treatment
- Definitive treatment is with an emergency open fasciotomy
- Monitor the patient for rhabdomyolysis and reperfusion syndrome as potential complications
Left sided supraclavicular lymph node
Virchow’s node, ca stomach
Modality of choice for assessment of facial skeleton
CT
Complications of compartment syndrome
- Rhabdomyolysis
- Renal failure due to myoglobinuria
- Volkman’s ischaemic contracture
Management of compartment syndrome
Fasciotomy
Evaluate adolescents with varicoele with what?
Testicular volume estimation. If normal, observe with annual follow up
Varicose veins usually involve which vein system?
Saphenous
First step in a haemodynamically stable lower GI bleeed. Second step if this doesn’t identify the cource of bleeding.
- Colonoscopy
- CT angiography
The most common causes of mechanical small bowel obstruction
- Adhesions
- Hernias
Treatment for haemorrhoids with the best evidence base
Fibre
Canadian colorectal cancer screening programme
50-75 FOBT two yearly or sigmoidoscopy 10 yearly
Gold standard Ix for urthethral injury in men
Retrograde urethrography
Potential consequence of myoglobinuria
Acute kidney injury
First investigation in fibroadenomatous disease in symptomatic women under 30
Ultrasound- to establish cystic vs solid lesion
Haematoma after thyroidectomy- initial management
This is a life-threatening situation- explore the wound first before you intubate though
An emergency tracheotomy goes where?
Cricothyroid membrane
What is a Maisonneuve fracture?
Maisonneuve fracture refers to a combination of a fracture of the proximal fibula together with an unstable ankle injury (widening of the ankle mortise on x-ray), often comprising ligamentous injury (distal tibiofibular syndesmosis, deltoid ligament) and/or fracture of the medial malleolus. It is caused by a pronation-external rotation mechanism.
Signs of rotator cuff tear
Positive active painful arc test
Positive drop arm test
Weakness in external rotation
Name three nonsurgical modalities to investigate lower GI bleeding
- Colonoscopy
- Radionuclide scan
- Angiography
Tests of ACL stability
- Anterior Drawer
- Lachman
- Pivot Shift
Rovsing’s sign
If palpation of the left lower quadrant of a person’s abdomen increases the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing’s sign and may have appendicitis.
Cystoid macular edema is the most common complication of which operation?
Cataracts
The most common cause of unilateral nasal obstruction
Septal deviation
What is extended FAST?
- Focussed Assessment with Sonography for Trauma (FAST) scan is a point-of-care ultrasound examination performed at the time of presentation of a trauma patient.
- It is considered as an ‘extension’ of the trauma clinical assessment process, to aid rapid decision making.
- The chief aim of the study, in a trauma patient, is to identify intraperitoneal free fluid (assumed to be haemoperitoneum in the context of trauma) allowing for an immediate transfer to theatre, CT or other.
Procedure for a chronic anal fissure
Lateral sphincterotomy
Best treatment for persisting de Quervains tendinopathy
Local corticosteroid injection
Initial management of large spontaneous pneumothorax >3cm in a healthy and stable person
Just needle aspiration
Smaller ones <3cm you can just give supplemental oxygen and observe
If it is a tension pneumothorax and they are unstable they can have needle decompression then chest tube
Ca pancreas risk factors
- Male
- African origin
- Smoking
Also
- Chronic pancreatitis
- High fat diet
- Diabetes
The best test for detecting an ACL tear
Lachman test
Psoas sign
The psoas sign indicates irritation to the iliopsoas group of hip flexors in the abdomen, and consequently indicates that the inflamed appendix is retrocaecal in orientation (as the iliopsoas muscle is retroperitoneal).
Who gets an ankle x-ray in the Ottawa ankle rules?
There is any pain in the malleolar zone; and,
Any one of the following:
- Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR
- Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR
- An inability to bear weight both immediately and in the emergency department for four steps.
Clinical Predictors of Increased Perioperative Cardiovascular Risk
Major
- Unstable coronary syndromes
- Acute or recent myocardial infarction with evidence of important ischemic risk by clinical symptoms or noninvasive study
- Unstable or severe angina (Canadian class III or IV)
- Decompensated heart failure
- Significant arrhythmias
- High-grade atrioventricular block
- Symptomatic ventricular arrhythmias in the presence of underlying heart disease
- Supraventricular arrhythmias with uncontrolled ventricular rate
- Severe valvular disease
Which part of the duodenum is the most prone to rupture in blunt abdominl trauma?
The second part
What are these suggestive of?
a) Crescent-shaped haematoma
b) lens shaped haematoma
c) multiple petechial haemorrhages
d) whitening of subarachnoid cisterns
e) ring enhancing lesion
- a) subdural haemorrhage
- b) epidural haemorrhage
- c) diffuse axonal injury
- d) subarachnoid haemorrhage
- e) metastatic lesion, demyelinating disease, or brain abscess
Potential radiotherapy strategy for single, inoperable or deep seated brain metsastases
Stereotactic radiosurgery (SRS) is a non-surgical radiation therapy used to treat functional abnormalities and small tumors of the brain. It can deliver precisely-targeted radiation in fewer high-dose treatments than traditional therapy, which can help preserve healthy tissue.
Management of a basal cell carcinoma
Excise it with a 1cm margin
Lymph node clearance is not required
Metastatic work up is not required
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