Surgery

Question 1

Scaphoid fracture (Cause, Dx, Comp)
Colles fracture (Cause, RF, Association)
Supracondylar fracture (Cause, Dx ,Tx)

Answer 1

Scaphoid
Cause: Fall onto an outstretched hand
Acute pain at the wrist and snuff box
Dx:
- X ray of wrist in pronation and ulnar deviation.
- Initial xray can be negative if fracture is compressed on minimally displaced.
- Can obtain MRI or CT
- Placed in a thumb spica splint –> Repeat xray in 7-14 days
Comp if not corrected: nonunion or avascular necrosis
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Colles
Cause: Fall onto an outstretched hand
RF: Osteoporosis
Association: Ulnar styloid fracture, scaphoid fracture, wrist sprain, supracondylar humerus fracture
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Supracondylar fracture
Cause: Fall onto outstretched arm
Dx: Xray of posterior fat pad (which indicated occult fracture), fracture line, or displacement of humerus
PE: severe elbow pain, swelling, limited ROM
Tx:
- Nondisplaced: long arm splint and sling
- Displaced: surgical reduction & pinning
Comp: Neuromuscular injury, compartment syndrome

Question 2

Patellar tendon rupture
Cause, Sx, Exam, Tx

Answer 2

Cause: strong quad contraction with foot firmly planted and knee partially flexed

Sx: sudden severe pain, anterior knee swelling, difficulty walking

Exam: superior displacement of patella, can’t extend knee (if fully torn)

Tx: complete –> surgical repair within 10 days. Partial –> immobilization in extension x6 weeks –> PT

Question 3

Knee injury
1. ACL vs PCL causes, Dx
2. Prepatellar bursitis (Sx)
3. Patellofemoral pain syndrome (Sx, Dx , Tx)
4. Patellar tendinitis (Sx)
5. Osgood- Schlatter syndrome (sx)

Answer 3

ACL tear: caused by posterior force –> large hemarthrosis
PCL tear: caused by anterior force –> large hemarthrosis
Definitie dx: MRI
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Prepatellar bursitis
Anterior knee pain with people who work on their knees, visible swelling
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Patellofemoral pain syndrome
Sx:
- Poorly localized pain at the anterior knee that is worsened by quadriceps contraction (such as squatting or walking up and down steps).
DX:
- Clinical
- Patellofemoral compression test: pain elicited by extending the knee out while compressing the patella
TX:
- Exercise to stretch and strengthen the thigh muscles
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Patellar tendinitis
Pain and tenderness at inferior patella
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Osgood- Schlatter syndrome
Pain at the insertion of the patellar tendon at the tibial tubercle
Frequently follows growth spurt

Question 4

Transfusion reaction
1. Non-hemolytic: Pathogenesis , reduction
2. IgA reaction: pathogenesis, reduction

Answer 4

1. Non-hemolytic reaction
   - Occur within 1-6hrs
   - When RBCs and plasma are separated, a small amount of plasma/WBC remain –> WBC release cytokines –> fever, chills, malaise during transfusion
   - Reduction: Leukoreduction thru filtering
2. IgA reaction:
   When RBCs and plasma are separated, residual plasma contain IgA. IgA-deficient patients develop Ab –> anaphylactic reaction.
   - Reduce risk by washing RBC

Question 5

Drugs to stop pre-op

Answer 5

ACE - hold night before surgery for patient without HF to prevent possible hypotension

Diuretics -stop day of surgery to prevent possible hypovolemia and hypotension

Raloxifene/Tamoxifen - stopped 4 weeks before to reduce risk of venous thromboembolism.

Metformin: stopped due risk of lactic acidosis (esp in patients with renal or hepatic dysfunction). This is also the same concept if a large dose of IV iodine contrast is given, the risk for lactic acidosis increases.

Question 6

Things to do preoperatively : smoking, lung patholgies, a fib

Answer 6

Smoking cessation at least 4 week prior to surgery decreases risk of postoperative pulmonary complications

With COPD exacerbation: Delay elective surgery until respiratory status is optimized

Patients with COPD, Cigarette smoking, sleep apnea and HF have the greatest risk of post-operative pulmonary complications.

For patients with afib:
- Ensure hemodynamically stable with rate control
- Optimize anticoagulation
—stop direct oral anticoagulation
— For minimal risk procedures: Continue anticlot meds
—For other procedures, consider bleeding and patient clotting risk. Mainly, stop anticlot and don’t bridge unless taking warfarin or high risk of clot.

Question 7

De Quervain tendinopathy

Answer 7

Path: Myxoid degeneration of tendons/tendon sheaths.

Sx: lateral hand/wrist pain. provoked by lifting objects, thumb or wrist movement

Dx:
- Clinical features (+ provocative testing)
- Tenderness at radial styloid
- Pain with thumb flexion + ulnar wrist deviation

Tx:
- Thumb spica splint
- NSAIDs
- Persistent/severe: steroid injections

Question 8

Small bowel obstruction (SBO)
tx

Answer 8

Partial: air in distal colon
Tx: observation and supportive care. If no improvement within 12-24hrs –> surgery

Question 9

Organ transplant
Renal transplant AE

Answer 9

Renal transplant:
- New onset DM can be acquired, and highest in first few months
- Can be caused by immunosuppression medication AE: steroids can cause weight gain –> insulin resistance, calcineurin can cause reversible toxicity to the pancreas.
- Additionally, the healthy kidney causes increased insulin excretion and gluconeogenesis