Surgery

Question 1

List some different types of myocutaneous flap.

Answer 1

Latissimus dorsi
Transverse rectus abdominis myocutaneous (TRAM)
Deep inferior epigastric perforator (DIEP)

NOTE: TRAM is supplied by the inferior epigastric arteries or internal thoracic artery, lat dorsi is supplied by thoracodorsal and subscapular arteries

Question 2

Which special test should you be careful about performing in a patient with a hip replacement?

Answer 2

Thomas’ test - checking for fixed flexion deformity
There is a chance that you can dislocate it
ALWAYS ask whether they have had surgery before you hyperflex the hip joint

Question 3

List some complications of hernia repair surgery.

Answer 3

EARLY
- urinary retention 
- haematoma 
- infection 
- intra-abdominal injury (laparoscopy)
LATE
- recurrence 
- ischaemic orchitis (due to thrombosis of pampiniform plexus) 
- chronic groin pain

Question 4

What are sebaceous cysts and what are the two histological subtypes?

Answer 4

Epithelial-lined cysts containing keratin arising from hair follicles
Epidermal cyst: arise from hair follicle infundibulum
Trichilemmal cyst: air from hair follicle epithelium, often multiple

Question 5

What are the two ways in which a dislocated shoulder can be reduced?

Answer 5

Should be done under sedation
Hippocratic: longitudinal traction with arm in 30 degree abduction and counter traction at the axilla
Kocher’s: external rotation of adducted arm, anterior movement, internal rotation

NOTE: rest arm in a sling for 3-4 weeks, physiotherapy

Question 6

What are the main things you need to elicit in a patient with a hernia?

Answer 6

Is it reducible?
Is it tender?
What do you think is in the sac (colon, small bowel, preperitoneal fat or omentum)?
How big is the defect? Is there a mesh?

Question 7

EPONYMOUS OPERATIONS: lower oesophageal cancer

Answer 7

Ivor-Lewis oesophagectomy - two-stage oesophagectomy (lateral thoracotomy and midline laparotomy)
McKeown oesophagectomy - three-stage (lateral thoracotomy, midline laparotomy and neck)
Transhiatal - only upper midline laparotomy and neck incision

Question 8

How is inflammatory bowel disease investigated?

Answer 8

AXR - toxic megacolon (UC), small bowel obstruction (CD)
Contrast - gastrograffin enema (UC), barium follow-through (CD)
MRI - perianal disease in CD
Endoscopy: ileocolonoscopy and biopsy, capsule endoscopy

Question 9

What are the advantages and disadvantages of EVAR?

Answer 9

ADVANTAGES: reduced perioperative mortality (1% vs 5%), reduced hospital stay, better cosmetically
DISADVANTAGES: no mortality benefit after 5 yrs, significant late complications, not better than medical treatment in unfit patients (i.e. not fit for open repair)

Question 10

What is the ulnar paradox?

Answer 10

Closer to the paw the worse the claw

Proximal lesions cause paralysis of flexor digitorum profundus which causes less clawing of the hand

Question 11

What is a major complication of pelvic fractures?

Answer 11

Urethral injury leading to urinary retention

Question 12

What are the X-ray features of osteoarthritis?

Answer 12

Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

Question 13

What is a cystic hygroma?

Answer 13

Congenital multicystic lymphatic malformation usually seen in the posterior triangle of infants

NOTE: it transilluminated brilliantly and is soft and fluctuant

Question 14

How are paraumbilical hernias managed?

Answer 14

Surgery is advised due to high risk of strangulation 
Mayo repair (mobilise sac and reduce contents)

Question 15

List some abdominal wall or soft tissue masses that can affect any part of the abdomen.

Answer 15

Sebaceous cyst
Lipoma
Sarcoma

Question 16

What is myositis ossificans?

Answer 16

Ossification of muscles at sites of haematoma formation leading to restricted painful movement (usually affects elbows and quads) and requires excision

Question 17

What are the main motor and sensory areas supplied by the radial nerve?

Answer 17

Motor: metacarpophalangeal joint extension
Sensory: 1st dorsal web space

Question 18

What are the layers of tissue that are cut in an abdominal incision?

Answer 18

Skin 
Camper's fascia (fatty layer or superficial fascia)
Scarpa's fascia (membranous layer of superficial fascia) 
External oblique deep fascia 
Internal oblique deep fascia 
Transversus abdominal deep fascia 
Transversalis fascia 
Extraperitoneal fat 
Parietal peritoneum

Question 19

List some differentials for anterior neck lumps.

Answer 19

Lymphnodes 
Chemodectoma
Goitre
Parotid tumour (e.g. mumps) 
Branchial cyst 
Laryngocele

Question 20

What is the first-line investigation for suspected prostate cancer?

Answer 20

Multiparametric MRI

This has superseded TRUS biopsy

Question 21

What is a radical cystectomy?

Answer 21

Men: bladder, prostate and iliac lymph nodes
Women: bladder, ovaries, uterus, cervix and anterior wall of vagina

Question 22

What is a Monteggia fracture?

Answer 22

Fracture of proximal 1/3 of ulna shaft + anterior dislocation of radial head at capitulum

NOTE: can cause palsy of deep branch of radial nerve (wrist drop but no sensory loss)

Question 23

EPONYMOUS OPERATIONS: rectal prolapse

Answer 23

Delorme procedure - perineal approach with mucosal excision

Question 24

List some complications of thyroid surgery.

Answer 24

Haemorrhage 
Recurrent laryngeal nerve palsy 
Hypocalcaemia (parathyroid damage) 
Thyroid storm 
Hypothyroidism and hypoparathyroidism 
Recurrence 
Keloid

Question 25

List some peripheral stigmata of thyroid disease.

Answer 25

``` Agitated or lethargic Body habitus Sweating Skin and hair (loss suggests hypothyroidism) Thyroid acropachy Palmar erythema Tremor AF ```

Question 26

What are the key aspects of a history you need to focus on in a patient with suspected osteoarthritis?

Answer 26

Pain - exertional, rest, night Disability - walking distance, stairs, giving way Deformity

Question 27

What are the four types of thyroid cancer and which is most common?

Answer 27

``` Papillary (80%) Follicular Medullary Anaplastic (Lymphoma) ```

Question 28

What are the advantages and disadvantages of braided sutures?

Answer 28

ADVANTAGES: easier to handle, knots slip less, greater tensile strength DISADVANTAGES: increased risk of infection, increased friction on tissues

Question 29

What are the three main reasons for having vascular bypass surgery?

Answer 29

Trauma Aneurysm Occlusion

Question 30

How do you test the reaction of a hernia to raised intra-abdominal pressure in a patient with a tracheostomy?

Answer 30

Lie them flat and ask them to lift their legs up

Question 31

List some reasons for having vascular access scars in the groin.

Answer 31

``` Bypass Embolectomy Endovascular aneurysm repair Stent insertion Femoral endarterectomy Angioplasty ```

Question 32

List some key differences between ileostomy and colostomy.

Answer 32

Ileostomy: RIF, spouted, watery contents Colostomy: LIF, flush, formed faeces (may be in RUQ - transverse loop colostomy) NOTE: ileostomy may be seen on the left side in patients who have previously had an ileostomy on the right (look for scar)

Question 33

Describe the classification of operative haemorrhages.

Answer 33

PRIMARY: continuous bleeding starting during surgery REACTIVE: bleeding within 48 hours post-op SECONDARY: bleeding at 7-10 days post-op (usually due to infection)

Question 34

Describe an antalgic gait.

Answer 34

Shortened stance-phase on the affected side

Question 35

What is the difference between a total and subtotal gastrectomy?

Answer 35

Total: entire stomach is removed, oesophagus is joined to jejunum with Roux-en-Y oesophagojejunostomy Subtotal: part of fundus of stomach is left, oesophagus is joined to jejunum with Roux-en-Y oesophagojejunostomy

Question 36

Outline the management of hydroceles.

Answer 36

Non-Surgical: watch and wait, aspiration for symptomatic relief Surgical - Lord's repair (plication of tunica vaginalis) - Jaboulay's repair (eversion of the sac)

Question 37

If you hear a bruit over a varicosity what does that suggest?

Answer 37

AV malformation

Question 38

What are some causes of subcutaneous lumps?

Answer 38

Lipoma Ganglion Lymph nodes NOTE: can move the skin over the lump

Question 39

What is the Monroe-Kelly doctrine?

Answer 39

The cranium is a rigid box, therefore the total volume of intracranial contents must remain constant if ICP is not to change An increase in the volume of one constituent required a compensatory reduction in another (usually CSF vs blood) These mechanisms allow a volume change of ~100 mL before ICP starts to rise

Question 40

What is the point of tunnelling a central line?

Answer 40

Cuffs promote tissue reaction which creates a better seal | The tunnel helps keep the catheter in place and reduces the risk of infection

Question 41

Why is acute on chronic limb ischaemia less time urgent than acute limb ischaemia?

Answer 41

Patients with established peripheral vascular disease will have developed collaterals that enable some perfusion even if a major artery is occluded (they will develop paraesthesia and paralysis later on)

Question 42

Which investigations are used for patients with intermittent claudication?

Answer 42

Exercise treadmill ABPI Duplex ultrasound (look at velocity of blood flow through artery) Angiography NOTE: with exercise ABPI, you measure the pressure and after exercise once they start complaining of calf pain (ABPI will have dropped after exercise)

Question 43

During an operation, how can a direct inguinal hernia be distinguished from an indirect inguinal hernia?

Answer 43

INDIRECT: arise lateral to the inferior epigastric vessels DIRECT: arise medial to the inferior epigastric vessels through Hesselbach's triangle NOTE: pantaloon hernias are both direct and indirect

Question 44

List some forms of definitive airway.

Answer 44

Orotracheal airway Nasotracheal airway Tracheostomy Cricothyroidotomy

Question 45

List some indications for using a disposable rigid sigmoidoscope.

Answer 45

Allows endoscopic examination of rectum and recto-sigmoid junction with biopsy if necessary Used to investigate rectal bleeding, colonic neoplasia and inflammatory bowel disease Complications: perforation (mechanical or pneumatic), bleeding

Question 46

List some complication of using a shouldered syringe to inject haemorrhoids.

Answer 46

IMMEDIATE: pain if injected below the dentate line, damage to nearby structures, primary haemorrhage LATE: prostatitis, impotence

Question 47

List some causes of knee locking.

Answer 47

Meniscal tear Cruciate ligament injury Osteochondritis dissecans Loose body

Question 48

How are thyroglossal cysts treated?

Answer 48

Sistrunk operation - removal of thyroglossal tract through transverse incision just above thyroid cartilage

Question 49

What is a triple phase CT scan and what is its purpose?

Answer 49

Used to further evaluate renal tumours Initial non-contrast phase (look for fat in the tumour) Arterial phase Venous phase NOTE: tells you location of tumour, size, renal vein involvement, lymph nodes, distant mets, state of contralateral kidney

Question 50

What should be offered to patients with chronic urinary retention who want to avoid surgery?

Answer 50

Intermittent self-catheterisation NOTE: if this fails, a long-term catheter can be offered

Question 51

What is the benefit of using an uncuffed ET tube?

Answer 51

Avoids damaging the larynx Typically used in children Cuffed ET tubes are better at preventing aspiration NOTE: in terms of size, men need 8.5 and women need 7.5

Question 52

What are the clinical features of radial nerve palsy?

Answer 52

Wrist drop Loss of sensation over the first dorsal interosseous (webbing) May have sensory loss over dorsal forearm

Question 53

Why does an anterior resection require a loop ileostomy?

Answer 53

Rectal blood supply is poor so the colorectal anastomosis must be rested and, hence, covered by a loop ileostomy

Question 54

What rehabilitation support should be offered to patients with a stoma?

Answer 54

Aim for normal diet Good skin care and hygiene Psychosexual support

Question 55

What is a subtotal colectomy?

Answer 55

All colon excised except distal sigmoid and rectum Temporary end ileostomy Rectosigmoid stump may be exteriorised as a mucus fistula Can be reverse 3 months later with complete proctectomy + ileal pouch anal anastomosis/permanent end ileostomy OR ileorectal anastomosis

Question 56

Other than the carpal tunnel, where else can the median nerve get trapped?

Answer 56

``` Pronator syndrome (between heads of pronator teres) Anterior interosseous syndrome (compression of anterior interosseous branch of median nerve in the deep head of pronator teres - causes muscle weakness only) ```

Question 57

Describe the management of ileus.

Answer 57

Correct underlying abnormalities (electrolytes and drugS) | Consider the need for parenteral nutrition

Question 58

What are the main indications for doing a total hip replacement as opposed to a hemiarthroplasty?

Answer 58

Mobilises with no more than 1 walking stick Not cognitively impaired Medically fit for anaesthesia and surgery (minimal comorbidities)

Question 59

Outline how to examine a stoma.

Answer 59

Look at the stoma (colour, surface, bag, contents, surroundings, devices) Examine the rest of the abdomen Ask to examine the perineum Palpate around and inside the stoma with your little finger (need gloves and lube) REPORT: site, calibre, number of lumens, functioning, healthy

Question 60

What does Thomas' test look for?

Answer 60

Fixed flexion deformity in the knee | Causes: osteoarthritis, ACL injury, bucket handle meniscal tear, iliopsoas tightness

Question 61

Outline the management of popliteal aneurysms and its indications.

Answer 61

Surgical Indications: symptomatic, aneurysms containing thrombus, aneurysms > 2 cm ACUTE Rx: embolectomy, femoral-distal bypass STABLE: excision bypass

Question 62

What are some causes of intradermal lumps?

Answer 62

Sebaceous cyst Neurofibroma Dermatofibroma NOTE: the skin cannot be drawn over the lump

Question 63

What is the investigation of choice for suspected chronic pancreatitis?

Answer 63

CT scan with IV contrast (to look for pancreatic calcification)

Question 64

What is the difference between a true and false aneurysm?

Answer 64

TRUE: dilation of the blood vessels involving all layers of the wall, fusiform or saccular FALSE: collection of blood around a vessel wall that communicates with the lumen, usually iatrogenic (e.g. puncture)

Question 65

List some associations of Terry's nails.

Answer 65

``` Chronic liver failure Diabetes mellitus Congestive heart failure Hyperthyroidism Malnutrition ```

Question 66

Describe how the location of varicose veins relates to the veins involved.

Answer 66

Medial and above or below the knee - great saphenous Posterior and below the knee - short saphenous Few varicosities with prominent skin changes - calf perforators

Question 67

How should a breast lump be investigated further?

Answer 67

< 35 years: US > 35 years: US + mammogram (oblique and craniocaudal) MRI if multifocal disease or cosmetic implants present

Question 68

Outline the management principles of claudication.

Answer 68

CONSERVATIVE: structured exercise programme, stop smoking, weight loss, foot care MEDICAL: RF modification (BP, BM, lipids) , antiplatelets (clopidogrel), analgesia INTERVENTIONAL: angioplasty, stenting

Question 69

Under what circumstance is steroid injections for join pain contraindicated?

Answer 69

If they already have some form of join replacement (risks introducing infection)

Question 70

What is the main indication for a loin incision?

Answer 70

Nephrectomy

Question 71

How can you clear the C spine in a trauma patient?

Answer 71

CLINICAL: if any of the following are present (NEXUS criteria) then it cannot be cleared clinically and requires imaging - Neurological deficit - Spinal tenderness in the midline - Altered consciousness - Intoxication - Distracting injury RADIOLOGICAL: radiograph --> CT C-spine (if radiograph abnormal)

Question 72

List some differentials for epigastric masses.

Answer 72

``` Gastric cancer Hepatomegaly Pancreatic cancer Pancreatic pseudocyst AAA ```

Question 73

Which investigations are used for achalasia?

Answer 73

Barium swallow CXR - wide mediastinum, double right heart border Manometry - failure of relaxation OGD - exclude cancer

Question 74

Outline the management of wound dehiscence.

Answer 74

Cover in steril soaked gauze IV antibiotics Repair in theatre

Question 75

What operation might require a transverse muscle splitting incision?

Answer 75

Right hemicolectomy (along with a midline laparotomy and laparoscopic ports)

Question 76

What are the indications for operating on an AAA?

Answer 76

Symptomatic | Asymptomatic but > 5.5 cm or expanding > 1 cm/year

Question 77

What is the first-line investigation for diverticulitis?

Answer 77

CT scan Other investigations for diverticulosis include gastrograffin enema/swallow and colonoscopy

Question 78

List some conditions that are associated with carpal tunnel syndrome.

Answer 78

``` Hypothyroidism Pregnancy Rheumatoid arthritis Pregnancy Amyloidosis Diabetes mellitus ```

Question 79

List some complications of urinary catheterisation.

Answer 79

``` Creation of false tract Urethral rupture Paraphimosis Haematuria Infection Blockage ``` NOTE: urethral injury is a major contraindication for urinary catheterisation

Question 80

List the degrees of haemorrhoids.

Answer 80

1st Degree - haemorrhoids that do NOT prolapse 2nd Degree - prolapse with defecation but reduce spontaneously 3rd Degree - prolapse and require manual reduction 4th Degree - prolapse that CANNOT be reduced

Question 81

What is the main indication for a shouldered/Gabriel syringe?

Answer 81

Injection of haemorrhoids with 5% phenol in almond oil (sclerosant) Used with a proctoscope to allow visualisation of the haemorrhoids

Question 82

List some complications of laparoscopic cholecystectomy.

Answer 82

``` Conversion to open procedure Common bile duct injury Bile leak Retained stones Intra-abdominal haemorrhage ```

Question 83

If you see a stoma on examination, what else should you examine?

Answer 83

Perineum - do see if it is a permanent stoma or a temporary stoma or if the anus has been excised.

Question 84

What are the features of acute limb ischaemia and which features are indications for immediate revascularisation?

Answer 84

Painful Pulseless Pale Perishingly cold Indications for immediate revascularisation: paralysis, paraesthesia

Question 85

What classification system is used for peripheral nerve injury?

Answer 85

Seddon classification Neuropraxia: temporary interruption in conduction Axonotmesis: disruption of axon with preservation of connective tissue framework (recovery is possible) Neurotmesis: disruption of entire nerve fibre (recovery incomplete)

Question 86

What is refeeding syndrome?

Answer 86

Starvation (i.e. low carbs) leads to a catabolic state with low insulin and fat and protein catabolism leading to depletion of intracellular phosphate Refeeding leads to a rise in insulin in response to the carbs resulting in increased cellular phosphate uptake Hypophosphataemia --> rhabdomyolysis, respiratory insufficiency, arrhythmias, shock, seizures NOTE: treated with phosphate supplementation

Question 87

What are the advantages and disadvantages of the use of myocutaneous flaps for breast reconstruction?

Answer 87

ADVANTAGES: useful when little muscle/skin remaining, good cosmetic result DISADVANTAGES: increased blood loss, increased operation time, late complications (e.g. flap necrosis)

Question 88

What are the ways in which fractured can be held?

Answer 88

Closed --> plaster or traction (skin or skeletal) | Fixation

Question 89

Which investigation would provide a definitive diagnosis of small bowel obstruction?

Answer 89

Abdominal CT NOTE: AXR is first-line but not definitive

Question 90

List some causes of gangrene.

Answer 90

``` Diabetes (most common) Embolism and thrombosis Raynaud's phenomenon Thrombangiitis obliterans Injury (e.g. extreme cold, trauma) ```

Question 91

What is the main indication for hip resurfacing?

Answer 91

Young, active people who are expected to outlive the replacement

Question 92

Why are varicoceles much more likely on the left side?

Answer 92

Left testicular vein drains into the left renal vein at a more vertical angle than the right testicular vein which drains into the IVC Left renal vein can be compressed by bowel and renal pathology Left testicular vein is longer than the right Left testicular vein often lacks a terminal valve to prevent backflow

Question 93

What are the most common causes of epigastric hernias?

Answer 93

Lipoma | Incisional hernia where you can't see the incision (most commonly port site from lap chole)

Question 94

Which classification system is used for intracapsular neck of femur fractures?

Answer 94

``` Garden classification 1 - incomplete and minimally displaced 2 - complete and non-displaced 3 - complete and partially displaced 4 - completely displaced with no engagement of two fragments ```

Question 95

How should an NG tube be sized?

Answer 95

Measure from the tip of the nose to the epigastrium, going around the ear

Question 96

List some indications for total parenteral nutrition.

Answer 96

``` Unable to swallow (e.g. oesophageal cancer) Prolonged obstruction or ileus Short bowel syndrome Severe Crohn's disease Severe malnutrition ``` NOTE: parenteral nutrition has a high osmolality and is toxic to veins so requires central venous access

Question 97

List some complications of using ET tubes.

Answer 97

EARLY: oropharyngeal and laryngeal trauma, C-spine injury (atlanto-axial instability), oesophageal intubation, bronchial intubation DELAYED: sore throat, tracheal stenosis, difficult wean

Question 98

What do you 'feel' for when examining a joint?

Answer 98

Tenderness Effusion Temperature NOTE: the joint should be moved in every direction possible, first actively then passively

Question 99

Outline the conservative management of inguinal hernias.

Answer 99

Manage risk factors (e.g. chronic cough, constipation) Weight loss Hernia truss

Question 100

How can the integrity of a surgical bowel anastomosis be checked?

Answer 100

Intra-operative: fill pelvic cavity with saline, insufflate rectum with air and look for bubbles in the saline Post-operative: water-soluble contrast enema

Question 101

Which special test can be done to further assess a patient with suspected ulnar nerve injury?

Answer 101

Froment's sign - flexion of thumb at interphalangeal joint due to weak adductor policis brevis

Question 102

Describe the main physical characteristics of the spleen.

Answer 102

Located below ribs 9-11 Usually 9-11 cm in length Weighs 150 g Not usually palpable

Question 103

List some causes of splenomegaly.

Answer 103

Infection (EBV, CMV, cat scratch disease) Haemolytic disease (sickle cell, thalassemia, spherocytosis) Malignancy (lymphoma, leukaemia) Portal hypertension (cirrhosis) Other (sarcoidosis, Felty syndrome)

Question 104

List some types of absorbable suture.

Answer 104

Catgut (natural) Monocryl (used for subcuticular skin closure) Vicryl (subcutaneous closure, bowel anastomosis) PDS (closing abdominal wall)

Question 105

What should be done in the run up to thyroid surgery?

Answer 105

Make euthyroid using drugs (e.g. thionamides) Stop 10 days before surgery (as they increase vascularity) Alternative: just give propranolol Check for phaeochromocytoma if medullary thyroid cancer LARYNGOSCOPY: check vocal cords

Question 106

List some complications of chest drains.

Answer 106

``` Pain due to inadequate analgesia Haemorrhage Organ perforation Incorrect location (abdomen) Failure Long thoracic nerve damage (winging of scapula) Wound infection Blockage Lifting the bottle above the patient can lead to retrograde flow into the chest ```

Question 107

List some general surgical complications that can occur with most operations.

Answer 107

IMMEDIATE: oropharyngeal trauma (intubation), trauma to local structures, primary bleeding EARLY: secondary bleeding, VTE, urinary retention, atelectasis, pneumonia, wound infection and dehiscence, antibiotics-associated colitis LATE: scarring, neuropathy, treatment failure

Question 108

Outline the surgical options in the management of osteoarthritis.

Answer 108

Arthroscopic washout (mainly knees, trim cartilage) Realignment osteotomy (cut small area of bone to redistribute weight through the knee) Arthroplasty (replacement) Arthrodesis (surgical immobilisation of a joint) Microfracture Autologous chondrocyte implantation

Question 109

Describe a Trendelenburg gait.

Answer 109

Sideways lurch of trunk to bring body weight over limb

Question 110

List some surgical management options for varicose veins.

Answer 110

Trendelenberg (saphenofemoral ligation) Short saphenous vein ligation (in popliteal fossa) LSV stripping (no longer performed due to saphenous nerve damage) Multiple avulsions Cockett's operation (perforator ligation) SEPS (subfascial endoscopic perforator surgery)

Question 111

What are the three phases of venous gangrene?

Answer 111

Phlegmasia alba dolens (white leg) Phlegmasia cerulea dolens (blue leg) Gangrene secondary to acute ischaemia

Question 112

Outline how you would do a vascular examination.

Answer 112

``` Radial (and radio-radial delay) Brachial (and BP) Subclavian Carotid (listen for bruits) Auscultate the precordium ``` Look at the abdomen and flanks for scars Palpate for aneurysm (listen for aneurysm centrally and over renal vessels) Inspect the feet and feel temperature Femoral (and radio-femoral delay) Popliteal Pedal (dorsalis pedis and posterior tibial) Listen for bruits (iliac, common femoral and adductor hiatus) Request ABPI on both legs

Question 113

List some indications for using a Swan Ganz catheter.

Answer 113

Measure pulmonary wedge pressure (measure of LA filling pressure) Measure cardiac output Used when accurate haemodynamic data is needed (e.g. cardiogenic shock, septic shock)

Question 114

How long can a central line (e.g. PICC, Hickman or portacath) stay in place?

Answer 114

Until the end of treatment (this can be months to years)

Question 115

What is an Ivor-Lewis oesophagectomy?

Answer 115

2-stage surgical procedure for removing tumours of the distal 2/3 of the oesophagus 1) abdominal roof top incision to assess for subdiaphragmatic spread and mobilise the stomach, remove para-oesophageal and cardiac lymph nodes 2) right thoracotomy to mobilise and resect the oesophagus and form anastomosis

Question 116

How are oropharyngeal and nasopharyngeal tubes sized?

Answer 116

Oropharyngeal - from incisors to angle of mandible (insert upside down and rotate) Nasopharyngeal - from the tragus of the ear to the tip of the nose (diameter of the little finger)

Question 117

What are the borders of the femoral canal?

Answer 117

Lateral: femoral vein Medial: lacunar ligament Anterior: inguinal ligament Posterior: pectineal ligament

Question 118

Define stridor and list the different types.

Answer 118

Harsh, high pitched sound indicative of airway obstruction INSPIRATORY: supraglottic or glottic BIPHASIC: subglottic, extrathoracic trachea EXPIRATORY: intrathoracic trachea Causes: infection (croup), foreign body, stenosis, malignancy, trauma

Question 119

List some complications of EVAR.

Answer 119

``` MI Spinal or mesenteric ischaemia Renal failure Graft migration of stenosis Leakage ```

Question 120

Which classification system is used for distal fibula fractures?

Answer 120

Weber classification A: below joint line (syndesmosis) B: at joint line C: above joint line NOTE: B and C indicate possible injury to the syndesmotic ligaments between the tibia and fibula that can lead to instability

Question 121

What are the main motor and sensory areas supplied by the ulnar nerve?

Answer 121

Motor: hypothenar muscles, medial lumbricals, interossei, adductor policis Sensory: pulp of little finger NOTE: in the forearm, the ulnar nerve innervates flexor carpi ulnaris and the medial half of flexor digitorum profundus

Question 122

What flow rate and percentage of oxygen can be administered through a non-rebreathe mask?

Answer 122

10-15 L/min | 60-90% oxygen

Question 123

List some differentials for subacromial impingment.

Answer 123

``` Rotator cuff tear (supraspinatus) Frozen shoulder (global reduced range of motion) Osteoarthritis Septic arthritis Gout Rheumatoid arthritis ``` NOTE: patients with a type 3 acromion (very hooked) are more likely to develop impingement

Question 124

In what scenario will it be difficult to both actively and passively move a joint?

Answer 124

Osteoarthritis

Question 125

Outline the management of varicoceles.

Answer 125

Non-Surgical: scrotal support, radiological embolisation Surgical: generally recommended because of risk of infertility - Palomo operation (vein exposed and ligated) - Laparoscopic is possible

Question 126

Which test can be done when palpating a varicose vein?

Answer 126

Tap test (Chevrier's test) - tap proximally and feel for an impulse distally

Question 127

List some operations that may require a Kocher's incision?

Answer 127

Right: open cholecystectomy Left: splenectomy

Question 128

What are the main motor and sensory areas supplied by the median nerve?

Answer 128

Motor: abductor policis brevis Sensory: pulps of index and middle finger

Question 129

Describe the anatomy of Bouttoniere and Swan neck deformity.

Answer 129

Boutonierre: rupture of central slip of extensor expands allowing PIPJ to prolapse through the button hole Swan neck: rupture of lateral slips allows PIPJ hyperextension

Question 130

How is a patient with suspected testicular cancer worked up?

Answer 130

Tumour markers (AFP, hCG, LDH) Ultrasound CT TAP Histology after inguinal orchidectomy (out of deep inguinal ring) NOTE: BEP and CHOP are the main chemotherapy agents used for testicular cancer (mainly non-seminoma)

Question 131

List some complications of AAA.

Answer 131

``` Rupture Embolisation (trash foot, missing pulses in popliteal aneurysms) Thrombosis (acutely ischaemic leg) Pressure (DVT) Fistulation ``` NOTE: trash foot usually happens after AAA surgery

Question 132

What are the borders of the inguinal canal?

Answer 132

Anterior: external oblique and internal oblique (lateral 1/3) Posterior: transversalis fascia + conjoint tendon (medial 1/3) Floor: inguinal ligament Roof: arching fibres for transversus abdominis + internal oblique

Question 133

Outline the treatment of nasal fractures.

Answer 133

If seen very early, reduce immediately before the swelling Otherwise review at 7 days to assess alignment Open fractures will require antibiotics If a septal haematoma develops, patients should be referred for drainage

Question 134

What are the three compartments of the knee?

Answer 134

Medial Lateral Patellofemoral

Question 135

Outline the surgical management of intracapsular neck of femur fractures.

Answer 135

Garden 1 + 2: ORIF with cancellous screws Garden 3 + 4: < 55 yrs - ORIF with screws; > 55 yrs - THR or hemiarthroplasty NOTE: subtrochanteric fractures can be treated with intramedullary nails

Question 136

How should patients be prepared before a mastectomy?

Answer 136

Explain that a suction drain will be used to close the cavity and reduce the risk of haematoma/seroma formation Explain that there will be an anaesthetised patch of skin in the upper medial part of the arm (intercostobrachial nerve)

Question 137

What is the order of size of peripheral venous cannulas?

Answer 137

``` Yellow (SMALLEST - 24 gauge) Blue Pink Green Grey Brown (BIGGEST - 14 gauge) ``` NOTE: flow rate is proportional to r^4 (Poiseuille's law)

Question 138

List some indications for long-term catheterisation.

Answer 138

``` Chronic bladder outlet obstruction Neurogenic bladder (e.g. MS, DM) with chronic retention ``` Alternative: clean intermittent self-catheterisation

Question 139

What is the technical term used to describe chronic neuropathic pain that occurs after an injury or fracture?

Answer 139

Reflex sympathetic dystrophy Complex regional pain syndrome type 1 (Sudek's atrophy) NOTE: CRPS type 2 is persistent pain following injury due to nerve lesions

Question 140

List some complications of central venous catheter insertion.

Answer 140

IMMEDIATE: pneumothorax, arrhythmia, malposition into artery, air embolus, lost guide wire EARLY: haematoma, infection, catheter occlusion LATE: thrombosis, Horner's syndrome (disruption of sympathetic chain), phrenic nerve damage (hiccup, weak diaphragm), venous stenosis, line-related sepsis

Question 141

Which follow-up treatment should be recommended for women who have had breast cancer treatment by wide local excision?

Answer 141

Whole breast radiotherapy IMPORTANT: wide local excision should only be offered for DCIS < 4 cm

Question 142

What is a neobladder?

Answer 142

When a small segment of bowel is reconstructed to make a new bladder Ureters are joined on to it at the top and the bottom is joined to the urethra Patients can pee normally

Question 143

List some indications for a stoma.

Answer 143

Perforated or contaminated bowel (e.g. Hartmann's) Permanent (e.g. AP resection) Diversion (protection of distal anastomosis (e.g. faecal peritonitis)) Decompression (e.g. bypass distal obstruction lesion) Feeding (gastrostomy, jejunostomy)

Question 144

Outline the management of high risk superficial transitional cell carcinoma of the bladder.

Answer 144

Intravesical immunotherapy (BCG) Close cystoscopic surveillance Radical cystectomy NOTE: carcinoma in situ is treated with BCG initially and radical cystectomy is offered if it fails. Laser therapy may be offered for low grade tumours

Question 145

What is a pyogenic granuloma?

Answer 145

Rapidly growing capillary haemangioma that appears bright red and bleeds very easily NOTE: usually found on hands, face, gums and lips, often associated with previous skin trauma

Question 146

List some features you may notice on examination of an osteoarthritic hip.

Answer 146

``` May be Trendelenburg positive Pain Stiffness Reduce range of motion (especially internal rotation) Fixed flexion deformity ```

Question 147

What are some complications of shoulder dislocation?

Answer 147

Recurrent dislocation Axillary nerve injury Avulsion injury/rotator cuff tear

Question 148

List some complications of knee replacement.

Answer 148

IMMEDIATE: fracture, cement reaction, vascular injury (superficial femoral artery), nerve injury (common peroneal nerve --> foot drop) EARLY: DVT, deep infection LATE: loosening, periprosthetic fracture, reduced range of motion and instability due to lost ACL

Question 149

How can inguinal and femoral hernias be distinguished on the basis of their location?

Answer 149

Inguinal: above and medial to pubic tubercle Femoral: below and lateral to pubic tubercle

Question 150

List some causes of lymphoedema.

Answer 150

Primary: congenital absence of lymphatics, Milroy syndrome Secondary: fibrosis (post-radiotherapy), infiltration (prostate cancer, filariasis), infection (TB), trauma NOTE: primary lymphoedema can be congenital, praecox (after birth < 35 yrs) or tarda (> 35 yrs)

Question 151

What are the advantages and disadvantages of monofilament sutures?

Answer 151

ADVANTAGES: reduced risk of infection, less friction against tissues DISADVANTAGES: harder to handle, knots may slip, less tensile strength

Question 152

What might require a thoracoabdominal incision?

Answer 152

Oesophagogastrectomy

Question 153

List some anatomical structures that are found at the transpyloric plane of Addison.

Answer 153

``` Pylorus Fundus of gallbladder Origin of SMA Duodenojejunal junction Neck of the pancreas Hila of the kidneys L1 Formation of the portal vein 9th costal cartilage ``` NOTE: it is half way between jugular notch and syphysis pubis

Question 154

Outline the screening programme for AAA.

Answer 154

Single ultrasound scan for males aged 65 years < 3 cm = normal 3-4.5 cm = rescan in 1 year 4.5-5.4 cm = rescan in 3 months >5.5 cm = 2 week vascular surgery referral

Question 155

EPONYMOUS OPERATIONS: hydrocele

Answer 155

Lord's repair - plication of tunica vaginalis | Jaboulay's repair - eversion of tunica vaginalis

Question 156

List some complications of surgical drains.

Answer 156

Infection Damage caused by mechanical pressure or suction Limit patient mobility

Question 157

List some causes of varicose veins.

Answer 157

Primary (95%): prolonged standing, pregnancy, obesity Secondary (5%): valve destruction (DVT), obstruction (pelvic mass), AV malformation, syndromes (Klippel-Trenaunay, Parkes-Weber)

Question 158

Outline the management of chronic limb ischaemia.

Answer 158

CONSERVATIVE: optimise risk factors, clopidogrel and statin, foot care INTERVENTIONAL: angioplasty, stenting, chemical sympathectomy SURGICAL: endarterectomy, bypass grafting, amputation

Question 159

List some complications of feeding NG tubes.

Answer 159

Nasal trauma Malposition (cranium) Blockage Electrolyte imbalance (refeeding syndrome)

Question 160

List some complications of gastrectomy.

Answer 160

PHYSICAL: increase gastric cancer risk, reflux/bilious vomiting, abdominal fullness, stricture, stump leakage METABOLIC - Dumping syndrome (abdo distension, flushing, fainting, sweating) - Blind loop syndrome (malabsorption and diarrhoea) - Vitamin deficiency (B12, iron and folate) - weight loss due to malabsorption

Question 161

What specific type of X-ray should be taken in orthopaedic patients with hip and knee problems?

Answer 161

Weight-bearing X-ray NOTE: for knee, also take lateral and skyline X-rays to look for patelofemoral joint osteoarthritis

Question 162

How does the angle of shoulder abduction at which pain is elicited relate to the cause of the pain?

Answer 162

60-120 degrees: impingement or rotator cuff tendonitis | 140-180 degrees: acromioclavicular osteoarthritis

Question 163

What are the contents of the inguinal canal in females?

Answer 163

Round ligament Ilioinguinal nerve Genital branch of the genitofemoral nerve

Question 164

What is swinging of the chest drain?

Answer 164

The fluid level moves up and down with inspiration and expiration If there is no bubbling, it either means that the lung is up, the air leak is sealed off or the drain is blocked

Question 165

What is the investigation of choice for hydroceles?

Answer 165

Ultrasound

Question 166

What demarcates the 9 quadrants of the abdomen?

Answer 166

Transpyloric plane: across L1 from the tip of the 9th costal cartilage Supracristal plane: across L4 at the highest point of the iliac crest

Question 167

What are the three compartments of the abdomen in which you may feel for masses?

Answer 167

Subcutaneous Visceral Retroperitoneal

Question 168

List some causes of salivary gland swelling.

Answer 168

``` DIFFUSE - infection (parotitis) - Sjogren' syndrome - sarcoidosis - systemic (bulimia, anorexia, chronic liver disease) LOCALSED - calculus - lipoma - salivary gland neoplasm - lymphoma/leukaemia ```

Question 169

What urine dipstick results would you expect to see in post-hepatic jaundice?

Answer 169

High bilirubin | No urobilinogen

Question 170

What bony and soft tissue lesions may be seen on an X-ray in shoulder dislocation?

Answer 170

Bankart lesion: damage to glenoid labrum | Hill-Sachs lesion: cortical depression in posterolateral part of humeral head

Question 171

What is gangrene and what are the different types?

Answer 171

Definition: irreversible tissue death from poor vascular supply Wet: tissue death + infection Dry: tissue death only

Question 172

List some complications of using a laryngoscope.

Answer 172

Laryngeal and oropharyngeal trauma | C-spine injury (e.g. in atlanto-axial instability)

Question 173

What is a dermatofibroma?

Answer 173

Benign neoplasm of dermal fibroblasts Usually seen on the legs of women, firm, woody feel may look like malignancy

Question 174

What is Admirand's triangle?

Answer 174

A system outlining the conditions under which cholesterol crystallises to form gallstones The following conditions favour the crystallisation of gallstones Low lecithin Low bile salts High cholesterol

Question 175

What is the main benefit of a port a cath?

Answer 175

Very low risk of infection as skin breech is minimal | Typically used for long-term administration of chemotherapy/antibiotics

Question 176

EPONYMOUS OPERATIONS: refractory GORD

Answer 176

Nissen fundoplication - wrapping the fundus around the lower oesophageal sphincter

Question 177

List some causes of problems with fracture union.

Answer 177

``` Infection Ischaemia Interfragmentary movement Interposition of soft tissue Intercurrent illness ```

Question 178

What is a Ryles nasogastric tube used for?

Answer 178

Draining the stomach (part of drip and suck) Also used for persistent vomiting (e.g. pancreatitis) NOTE: Ryles tubes are wide-bore, stiffer (prevent collapse during aspiration) and have a radio-opaque line with a metal tip (whereas feeding NG tubes are finer bore and made of soft silicone)

Question 179

How can you check for correct positioning of an ET tube?

Answer 179

``` Inspect for symmetrical chest movements Listen over the epigastrium for gurgling Listen over each lung for air entry Use CO2 monitor CXR (should be just above carina) ```

Question 180

List some causes of radial nerve palsy.

Answer 180

VERY HIGH (triceps paralysis + wrist drop + finger drop) - compression just below brachial plexus (e.g. crutches) HIGH (wrist drop + finger drop) - mid-shaft humeral fracture LOW (finger drop) - occurring at elbow, only involves posterior interosseous nerve (sensation preserved), fracture or dislocation

Question 181

What signs in the hand would you see in ulnar nerve palsy?

Answer 181

Partial claw hand (little and ring fingers) Wasting of hypothenar eminence and dorsal interossei Loss of sensation in ulnar distribution

Question 182

What are the principles of dealing with any fracture?

Answer 182

Reduce (closed or open) Hold (no metal or metal) Rehabilitate (move, physiotherapy and use)

Question 183

Outline the post-operative advice given to patients undergoing surgical hernia repair.

Answer 183

``` Pee before leaving Early mobilisation Provide effective analgesia Avoid constipation (lactulose) Keep the area clean and dry Can bathe immediately Work in 1-2 weeks (6 weeks if heavy lifting) ```

Question 184

What electrolyte is an indicator of pancreatitis severity?

Answer 184

Hypocalcaemia NOTE: hypercalcaemia causes pancreatitis

Question 185

Why might the pedal pulses of a patient with diabetes be preserved until late in the disease?

Answer 185

Calcification in the walls of the vessel NOTE: this also causes an abnormally high ABPI

Question 186

Outline the surgical approaches to managing femoral hernias.

Answer 186

ELECTIVE: Lockwood Low approach (low incision over hernia with herniotomy/herniorrhaphy) EMERGENCY: McEvedy High approach (approach through inguinal region to allow inspection and resection of non-viable bowel, then herniotomy/herniorrhaphy)

Question 187

What are the two different techniques of breast reconstruction?

Answer 187

Implants | Myocutaneous flap

Question 188

List some operations that may require a midline laparotomy.

Answer 188

EMERGENCY: perforated ulcer, trauma, ruptured AAA ELECTIVE: colectomy, AAA, vascular bypass NOTE: midline laparotomy offers good access, bloodless lien, minimal nerve/muscle injury but involves a long midline scar and pain

Question 189

List some indications for using a disposable proctoscope.

Answer 189

Investigation of perianal pathology (e.g. haemorrhoids, low rectal cancer) Examination or biopsy of anal canal and lower rectum Therapeutic (banding or sclerotherapy)

Question 190

List some complications of cannulation.

Answer 190

Haematoma Malplacement Blockage Superficial thrombophlebitis

Question 191

What is the upper limit of a post-void residual volume in patients under 65 yrs and over 65 yrs?

Answer 191

< 65 yrs = < 50 mL | > 65 yrs = < 100 mL

Question 192

What are the roles of nerves L4, L5 and S1?

Answer 192

L4: foot inversion and dorsiflexion L5: great toe dorsiflexion, great toe and medial dorsum sensation S1: foot eversion and plantar flexion, ankle jerk, little toe and lateral sole sensation

Question 193

Outline the management principles of osteoarthritis.

Answer 193

Modification of ADLS and risk factors (e.g. weight loss) Physiotherapy, OT Analgesia according to WHO ladder (paracetamol --> NSAIDs --> codeine --> morphine) Steroid injection Surgery (arthroplasty)

Question 194

What are the consequences of depressed fractures of the zygoma?

Answer 194

Binocular vision post-facial trauma and pain on opening the jaw

Question 195

Which veins can be used as access for central venous catheters?

Answer 195

Internal jugular vein Subclavian vein Femoral vein They are inserted using Seldinger technique under local anaesthetic with ultrasound guidance. A CXR should be ordered after insertion to confirm correct placement.

Question 196

EPONYMOUS OPERATIONS: Pharyngeal pouch repair

Answer 196

Dohlman procedure - minimally invasive endoscopic stapling

Question 197

What is a PICC line?

Answer 197

Peripherally inserted central catheter | Inserted into a peripheral vein (e.g. cephalic vein) and it is advanced until the tip is in the SVC

Question 198

List some indications for partial nephrectomy.

Answer 198

Solitary kidney Bilateral renal masses Renal impairment NOTE: radiofrequency ablation and cryotherapy are minimally invasive way of treating small renal cancers

Question 199

What are the main radiological features of rheumatoid arthritis?

Answer 199

Soft tissue swelling Periarticular osteopaenia and erosions Severe deformity NOTE: fewer patients have deformities now because of adequate treatment

Question 200

Outline the national bowel cancer screening programme.

Answer 200

Faecal immunochemical test (FIT) - all men and women aged 60-74 every 2 years (can be done at home) FlexiSig - one-off test for all men and women ageed 55 years (if positive --> full colonoscopy)

Question 201

What is enhanced recovery after surgery (ERAS) and how is it achieved?

Answer 201

Aims to optimise patients before surgery and reduce the risk of adverse outcomes PRE-OP: aggressive physiological optimisation, smoking cessation for > 4 weeks, avoid prolonged fast, carb loading INTRA-OP: short-acting anaesthetics, epidural, minimally invasive, avoid drains and NG tubes POST-OP: aggressive pain/nausea management, early mobilisation and physiotherapy, early resumption of oral intake, remove drains and catheters ASAP

Question 202

Outline the management of meniscal tears.

Answer 202

Symptomatic (analgesia) Arthroscopic or open partial meniscectomy/meniscal repair IMPORTANT: the lateral 1/3 of the meniscus has a rich blood supply so tears may heal by themselves or with surgery; the medial 2/3 has a poor blood supply so requires meniscectomy

Question 203

Which changes in the skin give rise to a seborrhoeic keratosis?

Answer 203

Hyperkeratosis - thickening of corneum Acanthosis - thickening of spinosum Hyperplasia of basal cells

Question 204

List the special tests used in a shoulder exam and state the anatomical structure that is being tested.

Answer 204

Jobe's empty can test: supraspinatus Forced external rotation of shoulder with elbow at 90 degrees: infraspinatus + teres minor Gerber's lift off: subscapularis Scarf test: acromioclavicular joint dysfunction Hawkin's test: impingement Apprehension test: glenohumeral joint instability

Question 205

Which investigation should be requested in suspected renal tract cancer?

Answer 205

Renal tract ultrasound

Question 206

List some differentials for RIF masses.

Answer 206

``` Transplanted kidney Caecal cancer Appendix mass Incisional hernia Ovarian tumour/fibroid uterus Ectopic kidney Iliac artery aneurysm ```

Question 207

What adjacent structures can be damaged during a fracture?

Answer 207

Nerves Vessels Ligaments Tendons

Question 208

List some different types of bypass surgery for chronic limb ischaemia.

Answer 208

Anatomical: femoral-popliteal, femoral-distal, aorto-bifemoral Extra-Anatomical: axillo-fem, fem-fem crossover

Question 209

What are the two main techniques used for hip replacement? Describe them.

Answer 209

Posterior Approach: involves reflecting the short external rotators, good access, higher dislocation rate, sciatic nerve injury (footdrop) Anterolateral Approach: incision over greater trochanter dividing fascia lata, abductors are reflected, lower dislocation risk, superior gluteal nerve injury (Trendelenburg gait)

Question 210

What features of a fracture can be described from a plain X-ray?

Answer 210

``` Location (which bone) Pieces (simple, multifragmentary?) Pattern (transverse, oblique, spiral) Displaced/undisplaced (speaking about the distal end) Translated/angulated Plane of radiograph ``` NOTE: translated means lateral movement of the fracture' (lateral, medial, anterior, posterior) and angulation is rotation of the fracture component (varus or valgus)

Question 211

What are the boundaries of Hesselbach's triangle?

Answer 211

Medial: rectus abdominis muscle Lateral: inferior epigastric artery Inferior: inguinal ligament

Question 212

List some types of non-absorbable suture.

Answer 212

Silk (used to secure drains) Prolene (skin wounds and arterial anastomosis) Ethilon (skin wounds) Metal (skin wounds, sternotomy closure)

Question 213

What does limited active movement but normal passive movement suggest?

Answer 213

Either a muscular problem (e.g. tendon rupture) or an innervation issue

Question 214

List some contraindications for IV urography.

Answer 214

``` Contrast allergy Renal impairment Pregnancy Severe asthma Metformin ```

Question 215

List some causes of thoracic outflow obstruction.

Answer 215

Cervical rib Clavicle fracture Pathological enlargement of 1st rib NOTE: DDx - Raynaud's, axillary vein thrombosis, cervical spondylosis, Pancoast tumour

Question 216

Describe the examination features of a sebaceous cyst.

Answer 216

Occur at sites of hair growth (e.g. scalp, face, neck, chest) Central punctum Firm, smooth and intradermal

Question 217

List some differentials for RUQ masses.

Answer 217

Hepatomegaly Hepatic mass (e.g. cyst) Gallbladder Right kidney

Question 218

When should the COCP be stopped prior to elective surgery?

Answer 218

4 weeks

Question 219

What is a trigger finger?

Answer 219

Flexion of middle or ring finger Caused by tendon nodule catching on the proximal side of the tendon sheath (usually FDS tendon) NOTE: managed with steroid injections or sheath incision

Question 220

At what vertebral levels do the coeliac trunk, SMA and IMA branch off the aorta?

Answer 220

``` Coeliac trunk: L1 SMA: L1 Renal arteries: L2 IMA: L3 Bifurcation of aorta: L4/L5 ```

Question 221

List some gastrointestinal causes of clubbing.

Answer 221

Cirrhosis Crohn's disease Coeliac disease GI lymphoma

Question 222

Describe two types of urostomy.

Answer 222

Ileal conduit (incontinent) - ureters are attached to a portion of resected ileum which is exteriorised as a stoma (remaining ileum is re-anastomosed) Indiana pouch (continent) - pouch created from 2 feet of resected ascending colon and portion of ileum including the ileocaecal valve. Ureters anastomosed to colonic end and ileal end is exteriorised. IC valve prevents leak, patient self-catheterises to drain into a pouch. NOTE: there are two types of ileal conduit - Bricker (2 ureters straight into the ileal conduit) and Wallace (2 ureters joined together before entering the ileal conduit)

Question 223

Outline the management of arterial ulcers.

Answer 223

``` Pain management Risk factor modification Clopidogrel IV prostaglandins Chemical lumbar sympathectomy ```

Question 224

How can you confirm the location of an NG tube?

Answer 224

Aspirate gastric contents and check pH (< 5.5) Insufflate air and auscultate for bubbling (do not do this in bowel obstruction) CXR - tip below the diaphragm NOTE: contraindicated in basal skull fracture

Question 225

List some indications for using an oropharyngeal or nasopharyngeal airway.

Answer 225

Airway adjunct in patients with impaired consciousness

Question 226

EPONYMOUS OPERATIONS: varicose veins

Answer 226

Trendelenberg - saphenofemoral junction ligation | Cockett - perforator ligation

Question 227

List some complications of surgical management of varicose veins.

Answer 227

EARLY: haematoma, wound sepsis, nerve damage (long saphenous) LATE: superficial thrombophlebitis, DVT, recurrence

Question 228

List some complications of pancreatitis.

Answer 228

EARLY: hypovolaemia (shock), SIRS, hyperglycaemia, hypocalcaemia LATE: pseudocyst, pancreatic necrosis, infection, abscess, bleeding, thrombosis, fistula

Question 229

How can varicose veins be treated?

Answer 229

CONSERVATIVE: weight loss, avoid prolonged standing, compression stockings, emollients Injection sclerotherapy Endovernous laser or radiofrequency ablation Surgery

Question 230

Which operations are likely to require an end colostomy?

Answer 230

Permanent: AP resection (colon cancer) Temporary: Hartmann's (diverticulitis)

Question 231

How can a seminoma be distinguished from a teratoma?

Answer 231

Seminoma: usually normal markers Teratoma: high AFP + high bhCG NOTE: seminomas are treated with radiotherapy of para-aortic nodes and combination chemo (BEP); teratomas are treated with combination chemo (BEP) alone NOTE: BEP = bleomycin, etoposide, cisPlatin

Question 232

What causes Trendelenburg sign?

Answer 232

Weakness of hip abductors (mainly gluteus medius) | May be caused by superior gluteal nerve injury

Question 233

List some causes of spider naevi.

Answer 233

More than 3 is abnormal Chronic liver disease Pregnancy COCP

Question 234

Which Foley catheters tend to be used in men and women?

Answer 234

Male: 16-18 French Female: 12-14 French NOTE: French is the diameter of the catheter in mm

Question 235

What is the main reason for using external fixation?

Answer 235

When there is extensive soft tissue injury (open fracture) or a complex periarticular fracture You don't want to put hardware in if there's no soft tissue or if the tissue is contaminated - wait for inflammatory response to stop

Question 236

What are the pros and cons of an anterolateral approach to hip replacement as opposed to a posterior approach?

Answer 236

Anterolateral: lower dislocation rate but higher risk of trendelenberg gait Posterior: higher dislocation rate but you don't go through abductors so you do not get a trendelenberg gait

Question 237

Outline the management of compartment syndrome.

Answer 237

Elevate and remove any bandages/cast | Fasciotomy

Question 238

Describe the tourniquet test/Trendelenberg test for venous insufficiency.

Answer 238

Position the patient supine, elevate their legs and milk their veins Apply the tourniquet as high up as possible or compress the SFJ Stand the patient CONTROLLED: incompetence above tourniquet, release tourniquet to confirm filling UNCONTROLLED: incompetence below tourniquet

Question 239

List some differentials for posterior neck lumps.

Answer 239

Lymph nodes Cervical rib Cystic hygroma Pharyngeal pouch

Question 240

What are the main indications for adenoidectomy?

Answer 240

OSA in children Glue ear with failed grommets Malignancy

Question 241

What is a Galeazzi fracture?

Answer 241

Fracture of radial shaft between middle and distal 1/3 + dislocation of distal radio-ulnar joint

Question 242

What is the Parkland formula for fluid resuscitation in burns?

Answer 242

Fluid resuscitation in the first 24 hours = % surface area x weight x 4 mL

Question 243

List some complications of Nissen fundoplication.

Answer 243

Gas-bloat syndrome (can't belch or vomit) | Dysphagia (if wrap around is too tight)

Question 244

What are the features of critical limb ischaemia?

Answer 244

Ankle artery pressure < 40 mm Hg Rest pain or tissue loss Symptoms for > 2 weeks NOTE: classified using Fontaine classification (1 - asymptomatic, 2 - claudication, 3 - rest pain, 4 - ulceration and gangrene)

Question 245

What are some key differences between hypertrophic scars and keloids?

Answer 245

Hypertrophic scars are confined to the wound margins and appears soon after injury and regress spontaneously Keloids extend beyond the wound margin, appear months after injury and continue to grow

Question 246

Outline the criteria for having a tonsillectomy.

Answer 246

Clinically significant tonsillitis 7 or more times for 1 year, 5 or more times for 2 years or 3 or more times for 3 years

Question 247

What are the surgical management options for BPH?

Answer 247

TURP HoLEP (holmium laser enucleation of the prostate) Urolift (involves stapling back the lateral lobes of the prostate - lower risk of retrograde ejaculation so better for younger people) NOTE: HoLEP is used for very big prostates

Question 248

Outline the management of Raynaud's phenomenon.

Answer 248

Wear gloves and avoid cold Stop smoking CCBs (e.g. nifedipine) IV prostacyclin

Question 249

What is the normal range of flexion in a knee joint?

Answer 249

0-140 degree

Question 250

List some complications of stomas.

Answer 250

``` EARLY - haemorrhage - ischaemia - high output (hypokalaemia - use loperamide/codeine) - parastomal abscess - stoma retraction DELAYED - parastomal hernia - obstruction (adhesions, herniation) - dermatitis - stoma prolapse - stenosis or stricture - fistulae - psychosexual dysfunction ```

Question 251

List some causes of jaundice after cholecystectomy.

Answer 251

``` Gallstone retention Biliary sepsis Thermal injury Ligation of common hepatic or common bile duct Haemolysis after transfusion Halogenated anaesthetics ```

Question 252

List some complications of joint prosthesis.

Answer 252

``` Cement reaction Deep infection Fracture Dislocation Loosening Failure ```

Question 253

What is a major issue with the use of fine needle aspiration to investigate a thyroid lump?

Answer 253

Cannot distinguish between adenoma and follicular cancer NOTE: before thyroid surgery, patients need to have their vocal cords assessed

Question 254

What are the contents of the spermatic cord?

Answer 254

3 Fascia: external and internal spermatic fascia, and fascia or cremasteric muscle 3 Arteries: testicular artery, artery of the ductus deferens, cremasteric artery 2 Nerves: testicular nerves, nerve to cremaster Pampiniform plexus Vas deferens Lymphatic vessels Tunica vaginalis

Question 255

What are the indications for an urgent CT head scan (within 8 hours) in patients who have had a head injury?

Answer 255

Age 65 years or older Any history of bleeding or clotting disorders Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs) More than 30 minutes' retrograde amnesia of events immediately before the head injury

Question 256

List some indications for surgical treatment of CD.

Answer 256

``` ACUTE - obstruction secondary to stenosis - perforation - severe GI bleed CHRONIC - perianal disease (e.g. fistula, abscess) - failure of medical treatment - entero-cutaneous fistulae ```

Question 257

What are the three main sites at which valvular incompetence occurs?

Answer 257

Saphenofemoral junction: 3 cm below and lateral to pubic tubercle Saphenopopliteal junction: popliteal fossa Perforators: draining the great saphenous vein (Cockett - 3 medial calf perforators; Hunter - 1 medial thigh perforator)

Question 258

Define herniorrhaphy and herniotomy.

Answer 258

Herniotomy - ligation and excision of hernial sac | Herniorrhaphy - repair of abdominal wall defect

Question 259

List some indications for using a circular bowel stapler.

Answer 259

Rectal anastomosis Gastrectomy Haemorrhoids Rectal prolapse

Question 260

List some features of chronic venous insufficiency.

Answer 260

``` Haemosiderosis Atrophie blanche Lipodermatosclerosis Venous eczema Venous ulcers ```

Question 261

Which types of grafts can be used for bypass surgery in patients with peripheral vascular disease?

Answer 261

Saphenous vein graft (preferred for bypass below inguinal ligament) Above IL: Dacron graft Below IL: PTFE graft NOTE: saphenous vein grafts are preferred for more distal operations because the risk of thrombosis is lower and the graft has better longevity

Question 262

List some causes of smooth and irregular hepatomegaly.

Answer 262

Smooth: CCF, cirrhosis, lymphoreticular disease, Budd-Chiari syndrome, amyloidosis Irregular: secondary mets, macronodular cirrhosis, polycystic disease, primary HCC

Question 263

What is a post-phlebitic limb?

Answer 263

A limb which has features of chronic venous insufficiency due to previous deep vein thrombosis

Question 264

What are the indications for carotid endarterectomy?

Answer 264

``` SYMPTOMATIC (ECST or NASCET guidelines) Usually > 70% stenosis Some recommend > 50% stenosis Perform within 2 weeks of presentation ASYMPTOMATIC: patients with stenosis >60% benefit ```

Question 265

List some indications for using colloids.

Answer 265

Fluid challenge Hypovolaemic shock Burns Complications: anaphylaxis, volume overload

Question 266

What ABPI is required for the use of compression bandages?

Answer 266

ABPI > 0.8 NOTE: other treatment options include oral pentoxyfylline, topical antiseptics and split-thickness skin grafts

Question 267

List some complications of varicose veins.

Answer 267

Itching (venous eczema) Bleeding Swelling Skin changes (haemosiderin deposition, lipodermatosclerosis, venous ulcers)

Question 268

How is thyroid cancer managed?

Answer 268

Total thyroidectomy T4 to suppress TSH With or without radioiodine NOTE: thyroglobulin is used as a tumour marker (and calcitonin in medullar thyroid cancer)

Question 269

What is the normal range for central venous pressure?

Answer 269

0-6 mm Hg NOTE: fluid overload is associated with a high CVP

Question 270

List some secondary causes of Raynaud's phenomenon.

Answer 270

Blood: polycythaemia, cryoglobulinaemia, cold agglutinins Arterial: atherosclerosis, thrombangiitis obliterans Drugs: beta-blockers, OCP Cervical rib: thoracic outlet obstruction Autoimmune: SLE, RA, SS

Question 271

What is Saint's triad?

Answer 271

A condition in which diverticular disease, hiatus hernia and cholelithiasis occur at the same time

Question 272

List some complications of using proctoscopes.

Answer 272

Haemorrhage | Perforation

Question 273

List some differentials for exophthalmos.

Answer 273

``` Graves' disease Orbital cellulitis Trauma Masses (meningioma, glioma) Cavernous sinus thrombosis ```

Question 274

Describe the national AAA screening programme.

Answer 274

Men aged 65 years offered a one-time ultrasound scan

Question 275

What is a Fogarty embolectomy catheter used for?

Answer 275

Management of an acutely ischaemic limb NOTE: insert into femoral artery at groin, pass catheter distal to embolus, inflate balloon and withdraw

Question 276

List some complications of tracheostomy.

Answer 276

IMMEDIATE: haemorrhage, trauma, pneumothorax EARLY: tracheal erosion, tube displacement/obstruction, surgical emphysema, aspiration pneumonia LATE: tracheomalacia, tracheo-oesophageal fistula, tracheal stenosis

Question 277

Describe the typical presentation of ACL injury.

Answer 277

``` Caused by deceleration and rotational movements Hear a pop Inability to continue activity Haemarthrosis within 4-6 hours Instability/giving way following injury ```

Question 278

What are the two different types of prosthesis that can be used for hip arthoplasty?

Answer 278

Cemented (e.g. Thompson) - recommended by NICE, better in porous bone Uncemented (e.g. Austin-Moore) - better for good quality bone (i.e. young patients)

Question 279

Outline the measures taken to prevent DVT in orthopaedic patients.

Answer 279

``` TED stockings Hydration Minimise length of surgery Intermittent pneumatic compression devices LMWH (also DOACs) Early mobilisation Good analgesia Physiotherapy ```

Question 280

List some complications of appendicectomy.

Answer 280

Abscess formation Increased risk of hernia (injury to ilioinguinal nerve) Adhesions Bleeding NOTE: at the operation, if the appendix looks macroscopically normal you remove it anyway (may have microscopic inflammation) and check for other causes (Meckel's, gynaecological)

Question 281

What are the advantages of tracheostomy over ET tubes?

Answer 281

``` Easier to wean patients No need for sedation Reduced discomfort Reduced risk of glottis trauma Reduced dead space (reduced work of breathing) ```

Question 282

Which special tests can be used to elicit symptoms in patients with suspected carpal tunnel syndrome?

Answer 282

Phalen's test (hands in prayer position) Tinel's sign (tapping over the median nerve) Also look for wasting of thenar eminence and sensory loss over median nerve distribution

Question 283

Which operations would require a Pfannenstiel incision?

Answer 283

Caesarean section Gynaecological surgery Lower urinary tract surgery Extraction of excised organs (along with laparoscopic port sites)

Question 284

List some risk factors of incisional hernias.

Answer 284

PRE-operative: age, diabetes, drugs (e.g. steroids), obesity, malnutrition INTRA-operative: surgical skill, small suture bites, inappropriate suture choice, incision type POST-operative: increased intra-abdominal pressure (e.g. cough), infection, haematoma

Question 285

``` Which nerve roots are responsible for the following reflexes? Ankle Knee Triceps Biceps ```

Answer 285

Ankle: S1-S2 Knee: L3-L4 Biceps: C5-C6 Triceps: C7-C8

Question 286

Which two types of incision are used for appendicectomy and how are they different?

Answer 286

McBurney's: oblique Lanz: transverse NOTE: Lanz is favoured because it is hidden in a skin crease. Both follow Langer's lines and carry a risk of injury to the ilioinguinal and iliohypogastric nerve (risk of inguinal hernia)

Question 287

What are the main indications for amputation of a leg?

Answer 287

Dead (peripheral vascular disease, thrombangiitis obliterans) Dangerous (sepsis, malignancy) Damaged (trauma, burns, frostbite) Damned nuisance (pain, neurological damage)

Question 288

Define varus and valgus.

Answer 288

Varus: deformity characterised by displacement of the distal part towards the midline Valgus: deformity characterised by the displacement of the distal part away from the midline

Question 289

List some complications of Colles fracture.

Answer 289

Median nerve injury Frozen shoulder Tendon rupture (especially EPL) Mal-/non-union

Question 290

What is Calot's triangle and what are its borders?

Answer 290

An anatomical space located at the porta hepatis that is dissected during a cholecystectomy Superior: inferior edge of liver Medial: common hepatic duct Inferior: cystic duct Contains: cystic artery, Calot's node with or without aberrant hepatic artery

Question 291

What are the advantages and disadvantages of the use of implants for breast reconstruction?

Answer 291

ADVANTAGES: simpler technique DISADVANTAGES: worse cosmetic results, requires lots of available skin, risk of complications (capsular contracture, infection, implant leakage)

Question 292

What is a branchial cyst?

Answer 292

A cyst found in the anterior triangle of the neck at the anterior border of SCM due to failure fusion of the 2nd or 3rd branchial arches NOTE: it contains cholesterol crystals and can be medically treated with sclerotherapy or surgically excised

Question 293

Outline the management of carpal tunnel syndrome.

Answer 293

NON-SURGICAL: treat underlying cause, wrist splints (hold it in extension), local steroid injections SURGICAL: carpal tunnel decompression by dividing the flexor retinaculum

Question 294

What are the general recommendations on how to prepare for surgery regarding oral intake?

Answer 294

Drink clear fluids until 2 hours before the operation Do not consume solid fluids for 6 hours before the operation NOTE: for emergency surgery, rapid sequence induction will be conducted

Question 295

List some complications of hip arthroplasty.

Answer 295

IMMEDIATE: nerve injury (superior gluteal nerve, sciatic nerve), fracture, cement reaction EARLY: DVT, deep infection, dislocation LATE: loosening, leg length discrepancy, revision (most replacements last 10-15 years)

Question 296

Where can the ulnar nerve be compressed?

Answer 296

Elbow: cubital tunnel Wrist: Guyon's canal NOTE: other causes of ulnar nerve palsy include supracondylar fractures of the humerus and elbow dislocation

Question 297

Outline the ASA classification system.

Answer 297

1 - normal healthy patient 2 - mild systemic disease (e.g. hypertension, smoker) 3 - severe systemic disease (poorly controlled diabetes, COPD, morbid obesity, end stage renal disease) 4 severe systemic disease that is a constant threat to life (recent MI, severe valve dysfunction, sever heart failure) 5 - moribund and not expected to survive without an operation (ruptured AAA) 6 - declared brain dead and organs are being removed for donor purposes

Question 298

List some risk factors for wound infections.

Answer 298

PRE-OP: age, comorbidities (DM), pre-existing conditions (e.g. appendix perforation), colonisation (MRSA) OPERATIVE: type of operation, duration, pre-operative antibiotics POST-OP: contamination from staff

Question 299

List some causes of unilateral leg swelling.

Answer 299

DVT Trauma (e.g. compartment syndrome, muscle rupture) Venous disease Lymphoedema (Milroy syndrome, surgery, radiotherapy, TB, filariasis) Malignancy (sarcoma)

Question 300

What is the most common type of salivary gland neoplasm?

Answer 300

Pleomorphic adenoma (80% and usually in the parotid) Others: adenolymphoma, mucoepidermoid tumour (MALIGNANT), adenoid cystic tumour (MALIGNANT) NOTE: pleomorphic adenomas are treated with superficial parathyroidectomy

Question 301

List two major complications of acute sinusitis.

Answer 301

Periorbital cellulitis | Brain abscess

Question 302

Describe Perthes test.

Answer 302

Tests for deep vein occlusion High tourniquet around the leg and tell the patient to walk for 5 mins Deep obstruction causes swelling and pain

Question 303

What flow rate and percentage of oxygen can be administered through nasal prongs?

Answer 303

1-4 L/min | 24-40% oxygen

Question 304

List some indications for surgical treatment of UC.

Answer 304

``` ACUTE - Toxic megacolon - Perforation - Severe GI bleeding CHRONIC - Failure of medical management - Malignancy - Failure of maturation in children ```

Question 305

List some causes of knee effusions.

Answer 305

Synovial fluid: synovitis Blood: ACL rupture, intrarticular fracture, meniscal tear, bleeding diathesis Pus: septic arthritis

Question 306

What is a dominant peroneal artery?

Answer 306

Present in 5% of the population | Dorsalis pedis pulse is absent but a pulse can be felt just anterior to the lateral malleolus

Question 307

What is the most appropriate surgical management option for most rectal tumours?

Answer 307

Anterior resection NOTE: low rectal tumours should be managed with abdominoperineal resection NOTE: Hartmann's procedure is used for sigmoid tumours

Question 308

What operations are likely to require a loop ileostomy?

Answer 308

``` Anterior resection (colon cancer) Bowel rest (Crohn's disease) ``` NOTE: this stoma is used to rest the bowel distal to the stoma

Question 309

How should patients be positioned when examining their hernial orifices?

Answer 309

Start with them standing | Then repeat the examination with them lying down

Question 310

Which investigations are usually requested for patients attending a rapid access clinic for haematuria?

Answer 310

MSU Renal/bladder ultrasound CT urogram (all > 50 yrs + all with frank haematuria) Flexible cystoscopy

Question 311

What is a bunion?

Answer 311

Deformity of the metatarsophalangeal joint (swelling may be due to bursitits or a bony anomaly) NOTE: associated with wearing ill-fitting footwear and rheumatoid arthritis

Question 312

Outline the management of gangrene.

Answer 312

Take cultures Debridement Antibiotics (e.g. vancomycin, cephalosporins)

Question 313

EPONYMOUS OPERATIONS: umbilical hernia

Answer 313

Mayo repair: double-breast the linea alba +/- sublay mesh

Question 314

List some complications of open repair of AAA.

Answer 314

``` Mortality (elective: 5%; emergency: 50%) MI Renal failure Anastomotic bleeding Graft infection Spinal or mesenteric ischaemia Distal trash from thromboembolisation Aortoenteric fistula ```

Question 315

EPONYMOUS OPERATIONS: femoral hernia

Answer 315

Lockwood approach - low incision over hernia with herniotomy and herniorrhaphy (ELECTIVE) McEvedy approach - high approach in inguinal region with herniotomy and herniorrhaphy (EMERGENCY)

Question 316

Describe how neck of femur fractures are defined based on their anatomical location.

Answer 316

INTRAcapsular: subcapital, transcervical, basicervical EXTRAcapsular: intertrochanteric, subtrochanteric, reverse oblique intertrochanteric

Question 317

What do you 'look' for when examining a joint?

Answer 317

Scars Swelling Deformity Redness

Question 318

What are the ways in which you can reduce closed and open fractures?

Answer 318

Closed --> manipulation or traction (skin or skeletal pins in bone) Open --> mini-incision or full exposure

Question 319

What operations would require a Mercedez-Benz/Rooftop incision?

Answer 319

Hepatobiliary surgery (e.g. liver transplant, Whipple's, liver resection, gastric surgery)

Question 320

What is the normal range of motion for a hip joint?

Answer 320

``` Abduction: 45 Adduction: 30 Flexion: 130 Internal rotation: 20 External rotation: 45 ```

Question 321

What is mallet finger?

Answer 321

Flexion deformity of distal phalanx Caused by damage to extensor tendon of terminal phalanx (e.g. avulsion fracture due to catching a cricket ball) NOTE: managed by using a distal phalanx splint holding it in extension for 6 weeks to allow tendon reattachment

Question 322

EPONYMOUS OPERATIONS: chronic venous insufficiency

Answer 322

Trahere transplantation - transplant of axillary vein with valve into deep venous system Kistner operation - venous valvuloplasty Palma operation - bypass venous obstruction with contralateral great saphenous vein

Question 323

Outline bladder tumour staging.

Answer 323

Ta - within mucosa T1 - into submucosa T2 - into muscularis propria T3 - into perivesical fat

Question 324

EPONYMOUS OPERATIONS: undescended testicle

Answer 324

Dartos Pouch Procedure - mobilisation of testis and placement in a pouch via a hole in the dartos muscle

Question 325

What is a major contraindication for TED stockings?

Answer 325

``` Arterial disease (e.g. peripheral vascular disease) Severe skin breakdown (ulceration/infection) ```

Question 326

List some causes of haematuria.

Answer 326

``` Renal cell carcinoma Glomerulonephritis Calculi Bladder tumour Haemorrhagic cystitis Urethral injury Prostatitis Strenuous exercise ``` NOTE: 2 week wait should be used for all frank haematuria, persistent haematuria with dysuria, micro/macrohaematuria with LUTS, female retention with pain and haematuria

Question 327

What are the four stages of clubbing?

Answer 327

1) bogginess of nail bed 2) loss of nail angle 3) increased curvature 4) expansion of distal phalanx

Question 328

Which layers are cut in a midline laparotomy incision?

Answer 328

``` Skin Subcutaneous fat Camper's fascia Scarpa's fascia Linea alba Transversalis fascia Pre-peritoneal fat Peritoneum ``` NOTE: the reason the linea alba is a good place to make an incision is because it is avascular

Question 329

List some specific complications of colonic surgery.

Answer 329

EARLY: ileus, acute acalculous cholecystitis, anastomotic leak, enterocutaneous fistulae, abdominal abscess LATE: adhesions (obstruction), incisional hernia

Question 330

List the different colours of vacutainer and their uses.

Answer 330

PURPLE: FBC, X-match, CD4 (contains EDTA to prevent clotting and keep cells alive) YELLOW: serum biochemistry, enzymes (contains activated gel that promotes clotting and separates serum from cells) RED: immunology, antibodies, immunoglobulin, protein electrophoresis (contains nothing) GREEN: plasma chemistries, enzymes (contains lithium heparin) BLUE: coagulation (contains citrate which chelates calcium and prevents clotting) GREY: glucose (contains fluoride oxalate which anticoagulates and inhibits glycolysis) BLACK: ESR (contains citrate) Order of Draw: cultures (aerobic --> anaerobic), blue, yellow, green, purple, grey

Question 331

Define aneurysm.

Answer 331

Abnormal dilatation of a blood vessels to > 50% of its normal diameter

Question 332

What are ganglion cysts?

Answer 332

Cystic swelling related to a synovial-lined structure (e.g. joint or tendon) Often found around the wrist Examination: soft, subcutaneous, may be tethered to tendon NOTE: 50% recurrence after surgical excision

Question 333

After how long is a surgical drain usually removed?

Answer 333

Once drainage has stopped or < 25 mL/day Perioperative bleeding/haematoma = 24-48 hours Intestinal anastomosis = > 5 days T-tube = 6-10 days (this is inserted into the common bile duct) NOTE: the drain may be removed 2 cm per day to allow the tract to gradually heal

Question 334

List some complications of ERCP.

Answer 334

Pancreatitis (5%) Bleeding (check clotting beforehand) Bowel perforation Contrast allergy

Question 335

What are the different types of internal fixation?

Answer 335

Intramedullary --> pins or nails | Extramedullary --> plate/screws or pins

Question 336

List some differentials for knee osteoarthritis.

Answer 336

Septic arthritis Medial meniscus tear Gout Rheumatoid arthritis

Question 337

How are pharyngeal pouches treated?

Answer 337

Dohlman's procedure - minimally invasive endoscopic stapling

Question 338

What is a neurofibroma?

Answer 338

Benign nerve sheath tumour arising from Schwann cells associated with NF1 Solitary or multiple, pedunculated, fleshy consistency, pressure can cause paraesthesia NOTE: check for cafe-au-lait spots, Lisch nodules, axillary freckles

Question 339

EPONYMOUS OPERATIONS: cancer of the head of the pancreas

Answer 339

Whipple's - removal of head of pancreas | Also removes gastric antrum, gallbladder, proximal duodenum and regional lymph nodes

Question 340

Where are port sites usually found for a laparoscopic cholecystectomy?

Answer 340

Umbilicus Epigastrium Right costal margin Right flank

Question 341

Outline the management of lumbar disc herniation.

Answer 341

CONSERVATIVE: 2 days bed rest, keep active, lifting training, psychosocial support MEDICAL: simple analgesia, facet joint injections, short-term diazepam SURGICAL: percutaneous microdiscectomy, endoscopic discectomy, hemilaminotomy + discectomy

Question 342

List some complications of fractures.

Answer 342

GENERAL: fat embolus, DVT, infection, prolonged immobility (UTI, chest infections, sores) SPECIFIC: neurovascular injury, muscle/tendon injury, non-union/malunion, local infection, degenerative changes, reflex sympathetic dystrophy

Question 343

EPONYMOUS OPERATIONS: varicocele

Answer 343

Palomo operation - high retroperitoneal approach for ligation of testicular veins, transverse incision at midinguinal point on level of ASIS

Question 344

List some indications for surgical thyroidectomy.

Answer 344

``` Mechanical obstruction Malignancy Cosmetic Failure of medical treatment Mediastinal extension ```

Question 345

What are some causes of hip pain after a hip arthroplasty?

Answer 345

``` Post-operative abductor weakness/rupture Leg length discrepancy Loosened prosthesis Prosthesis infection Radiating back pain ```

Question 346

List some complications of carotid endarterectomy.

Answer 346

Stroke or death Haematoma MI Nerve injury (hypoglossal, great auricular (numb ear lobe), recurrent laryngeal nerve)

Question 347

What is the main indication for using a three-way urinary catheter?

Answer 347

Irrigate the bladder in patients at risk of clot retention (e.g. after TURP or patients with haematuria)

Question 348

List some causes of salivary gland swelling.

Answer 348

``` Duct strictures Calculi Sialadenitis Inflammatory (Sjogrens, sarcoid) Tumours (80% in parotid) ``` NOTE: three main pairs of salivary glands - submandibular, sublingual and parotid

Question 349

List some differentials for LIF masses.

Answer 349

``` Faecal mass Colon cancer Diverticular mass Transplanted kidney Ovarian tumour/fibroid Ectopic kidney Iliac artery aneurysm ```

Question 350

What test is used when assessing a patient with suspected de Quervain's tenosynovitis?

Answer 350

Finkelstein test - examiner grasps the thumb and sharply ulnar deviates the hand causing pain along the distal radius NOTE: main tendons affected are extensor policis brevis and abductor policis longus

Question 351

What are the benefits of Hickman lines over PICC lines?

Answer 351

PICC lines are not suitable for all medications PICC lines block more easily PICC lines may cause clots in your arm

Question 352

What are the features of Leriche syndrome?

Answer 352

Buttock claudication and wasting Erectile dysfunction Absent femoral pulses NOTE: caused by aorto-iliac insufficiency

Question 353

List some complications of TURP.

Answer 353

IMMEDIATE: TURP syndrome, haemorrhage EARLY: haemorrhage, infection, clot retention (requires bladder irrigation with 3-way catheter) LATE: retrograde ejaculation, erectile dysfunction, incontinence, urethral stricture, recurrence

Question 354

What are the advantages and disadvantages of suprapubic catheterisation?

Answer 354

ADVANTAGES: reduced risk of UTI, reduced risk of stricture formation, patient preference, maintain sexual function DISADVANTAGES: more complex, risk of serious complications (viscus perforation, haemorrhage, malignancy seeding) NOTE: contraindicated if suspected bladder cancer, undiagnosed haematuria or previous lower abdominal surgery (adhesions)

Question 355

What are the main types of testicular tumour?

Answer 355

Seminomatous (50%) Non-Seminomatous: teratoma is most common Yolk sac tumour (most common in children) Leydig or Sertoli cell tumour (may produce oestrogens) Lymphoma (NHL is most common testicular mass in > 60 yrs)

Question 356

Outline the surgical management of inguinal hernias.

Answer 356

Open surgery: Lichtenstein tension-free mesh, Shouldice suture repair Laparoscopic: TEP or TAPP repair TEP: totally extraperitoneal (peritoneum not incised) TAPP: transabdominal pre-peritoneal (peritoneum incised) NOTE: laparoscopic is better for bilateral hernias, no mesh needed in children

Question 357

List some conditions that cause lipomas.

Answer 357

Dercum's disease - multiple painful lipomas, peripheral neuropathy, obesity Familial multiple lipomatosis Madelung's disease (multiple symmetric lipomatosis - mainly causes symmetrical lipomas on shoulders) Bannayan-Zonana syndrome

Question 358

What is a cholesteatoma?

Answer 358

In-growing stratified squamous epithelium of the ear drum within the middle ear Leads to chronic foul discharge, hearing loss, facial nerve damage and vertigo Can lead to deafness, meningitis and brain abscess

Question 359

What are the borders of the femoral canal?

Answer 359

Medial: lacunar ligament Lateral: femoral vein Anterior: inguinal ligament Posterior: pectineal ligament NOTE: contains fat and Cloquet's node (femoral nerve, artery and vein are lateral to the femoral canal)

Question 360

What are the indications for immediate CT head scan (within 1 hour) in patients who have had a head injury?

Answer 360

GCS < 13 on initial assessment GCS < 15 at 2 hours post-injury Suspected open or depressed skull fracture. Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). Post-traumatic seizure. Focal neurological deficit. More than 1 episode of vomiting

Question 361

List some causes of shoulder pain with or without reduced range of motion.

Answer 361

``` Rotator cuff tear/tendonitis Subacromial bursitis Adhesive capsulitis (frozen shoulder) Synovitis Osteoarthritis Dislocation Fracture of the humeral head Referred pain from the diaphragm ```

Question 362

Which operations are likely to require a loop colostomy?

Answer 362

RUQ: defunctioning transverse colostomy to cover a distal anastomosis (RARE) LIF: apex of sigmoid exteriorised without resection for inoperable colorectal cancer that is likely to obstruct

Question 363

List some differentials for midline neck masses.

Answer 363

Thyroid isthmus mass Inclusion dermoid cyst Thyroglossal cyst

Question 364

What is a dermoid cyst?

Answer 364

Epidermal-lined cyst deep in the skin Congenital (inclusion cyst) - forms along lines of skin fusion (e.g. midline neck, lateral eyebrows) Acquired/implantation cyst - often secondary to piercing

Question 365

What does the McMurray test look for?

Answer 365

Meniscal tears

Question 366

EPONYMOUS OPERATIONS: pyloric stenosis

Answer 366

Ramstedt pyloromyotomy - longitudinal incision through muscularis propria at pylorus

Question 367

What is the main indication for abdomino-perineal resection?

Answer 367

Tumours lying within 4-5 cm of the anal verge

Question 368

List some complications of mechanical ventilation.

Answer 368

Pneumothorax Fluid retention Ventilator-induced lung injury Ventilator-associated pneumonia

Question 369

Outline the management of Dupuytren's contractures.

Answer 369

Non-Surgical: physiotherapy, steroid injections, allopurinol | Surgical: fasciotomy, partial fasciectomy (Z-plasty), arthrodesis

Question 370

List some complications of carpal tunnel decompression surgery.

Answer 370

Hypertrophic and keloid scars Scar tenderness Nerve injury (palmar cutaneous branch of median nerve, motor branch to thenar muscles) Failure to relieve symptoms

Question 371

What causes winging of the scapula?

Answer 371

Serratus anterior weakness | May be due to long thoracic nerve injury, upper brachial plexus injury and muscular dystrophy (fascio-scapulo-humeral)

Question 372

Outline the surgical management of extracapulsar neck of femur fractures.

Answer 372

ORIF with dynamic hip screw

Question 373

What are the different types of external fixation?

Answer 373

Monoplanar | Multiplanar

Question 374

What are the advantages and disadvantages of minimal access surgery?

Answer 374

``` ADVANTAGES - reduced post-op pain - reduced risk of wound infection - faster recovery - reduced hospital stay - better cosmetically DISADVANTAGES - reduced tactile feedback - old skills may be lost - complications (e.g. bleeding) may be harder to manage - expensive ```

Question 375

What are the main approaches to preventing problems with fracture union?

Answer 375

Optimise physiology: treat/prevent infection, bone graft, ensure adequate blood supply, bone morphogenetic protein Optimise mechanics: external fixation, internal fixation

Question 376

List some complications of surgical management of NOF fractures.

Answer 376

Avascular necrosis of femoral head (if displaced fracture) Non/malunion Infection Osteoarthritis

Question 377

What does pain on straight leg raise suggest?

Answer 377

Lumbosacral nerve root irritation NOTE: Lesague sign is worsening pain on dorsiflexion of the foot

Question 378

Which ducts connect the submandibular and parotid glands to the oral cavity?

Answer 378

Submandibular - submandibular duct (Wharton's duct) - adjacent to frenulum Parotid - parotid duct (Stensen's duct) - opposite 2nd maxillary molar

Question 379

Which operations are likely to require an end ileostomy?

Answer 379

Permanent: panproctocolectomy (e.g. UC) Temporary: total colectomy with later ileal pouch-anal anastomosis (e.g. FAP)

Question 380

EPONYMOUS OPERATIONS: Achalasia

Answer 380

Heller's cardiomyotomy - longitudinal incision through muscularis propria at lower oesophageal sphincter

Question 381

What are some major contraindications for using a nasopharyngeal tube?

Answer 381

Facial injuries | Basal skull fracture (Raccoon eyes, Battle sign, haemotympanum, CSF rhinorrhoea/otorrhoea)

Question 382

Which surgical treatment options are considered in UC patients?

Answer 382

Subtotal colectomy with end ileostomy +/- mucus fistula (can be followed with ileorectal anastamosis, IPAA or permanent end ileostomy) Proctocolectomy and end ileostomy

Question 383

Describe Buerger's test.

Answer 383

Lift both legs to 45 degrees and observe for pallor and venous guttering The angle at which the foot goes white is Buerger's angle When the foot blanches, swing the legs over the side of the bed and let them hang The ischaemic foot will go brick red (reactive hyperaemia) NOTE: this indicated significant peripheral arterial disease

Question 384

What is thoracic outlet syndrome?

Answer 384

Venous - upper limb DVT and swelling Arterial - Raynaud's, claudication, embolisation Neurological - pain, radiculopathy NOTE: caused by compression between the 1st rib, clavicle and scalenus anterior. It is investigated using MRI, Duplex and nerve conduction studies

Question 385

List some indications for using a larngeal mask airway.

Answer 385

Non-definitive airway for short day-case surgery | Emergency situations if unable to insert ET tube

Question 386

List some causes of gynaecomastia.

Answer 386

Drugs (spironolactone, digoxin, ranitidine, verapamil, captopril, anabolic steroids) Physiological (puberty) Hypogonadism (hyperprolactinaemia, renal failure, testicular atrophy, Klinefelter's) Increased oestrogens (sex cord stromal tumours, lung cancer, chronic liver disease, thyrotoxicosis)

Question 387

Which classification system is used for diverticulitis?

Answer 387

``` Hinchey Grading 1 = small confined pericolic abscess 2 = large abscesses extending into the pelvis 3 = purulent peritonitis 4 = faecal peritonitis ``` NOTE: 1-2 rarely require surgery, 3 requires at least on table washout, 4 requires Hartmann's

Question 388

Which classification system is used for pelvic fractures?

Answer 388

``` Young and Burgess classification Lateral compression (ipsilateral pubic ramus fracture) AP compress (open book fracture) Vertical shear (inherently unstable) ``` NOTE: complications include haemorrhage, urethral injury and bladder injury

Question 389

What is Goodsall's law?

Answer 389

If the external opening of an anal fistula is posterior to the transverse anal line, it will follow a curvilinear path opening in the posterior midline of the anal canal If it is anterior to the transverse anal line, it will have a radial fistulous tract.

Question 390

What is the difference between an open and a closed surgical drain?

Answer 390

Open: fluid collects into dressing or stoma bag (e.g. corrugated rubber, plastic sheets) Closed: tube is attached to a container (e.g. chest drain)

Question 391

What are the contents of the inguinal canal in males?

Answer 391

Spermatic cord | Ilioinguinal nerve

Question 392

Outline the staging of prostate cancer.

Answer 392

Stage 1 and 2 - can't be palpated on DRE Stage 3 - can palpate on DRE Stage 4 - metastasised

Question 393

List some indications for bypass grafting in chronic limb ischaemia.

Answer 393

Very short claudication distance Symptoms greatly affecting patient Rest pain

Question 394

What is the main purpose of a CT urogram?

Answer 394

Pick up filling defects NOTE: it takes a control film, then another image 5 mins after contrast administration and the final one at 15 mins after contrast

Question 395

List some causes of a persistent hoarse voice.

Answer 395

``` Nodules Polyps Reinke's oedema Granuloma Laryngeal cancer ```

Question 396

Which classification system is used for fractures of the growth plate?

Answer 396

Salter-Harris classification 1 - Straight across growth plate 2 - Above the growth plate (diaphyseal side) 3 - Lower than growth plate (epiphyseal side) 4 - Through the growth plate 5 - crush NOTE: 2 is most common and 5 has the worst prognosis

Question 397

Outline the management of incisional hernias.

Answer 397

Surgery not always necessary as hernias are usually broad-necked and low risk of strangulation Manage risk factors (e.g. treat cough, weight loss) Surgery: nylon mesh repair

Question 398

List some indications for central venous catheters.

Answer 398

Central venous pressure measurement (for fluid balance) Drug administration (amiodarone, mannitol, potassium) Total parenteral nutrition

Question 399

How can direct and indirect inguinal hernias be distinguished on examination?

Answer 399

Reduce the hernia Place 2 fingers over the deep inguinal ring (midpoint of inguinal ligament) Ask patient to cough (hernia pops out if it is direct) NOTE: ultrasound can be used to identify hernias

Question 400

What is the main indication for a urostomy?

Answer 400

Total cystectomy

Question 401

Which nerves may be damaged in a carotid endarterectomy?

Answer 401

Recurrent laryngeal nerve | Hypoglossal nerve

Question 402

What is the difference between true leg length and apparent leg length?

Answer 402

True: ASIS to medial malleolus Apparent: umbilicus to medial malleolus NOTE: Galeazzi test checks whether the shortening is due to tibial or femoral shortening

Question 403

List some causes of true leg shortening.

Answer 403

``` Fracture (e.g. NOF) Hip dislocation Growth disturbance (e.g. fracture, osteomyelitis) Surgery (e.g. THR) SUFE Perthes' disease ``` NOTE: apparent shortening maybe caused by scoliosis

Question 404

List some causes of small bowel obstruction

Answer 404

``` Adhesions Hernia Paralytic ileus Faeces Foreign body Gallstone ileus Benign stricture Malignant stricture Drugs (e.g. TCA) ```

Question 405

Outline the management of ACL rupture.

Answer 405

CONSERVATIVE: rest, physio to strengthen quads/hamstrings SURGICAL: autograft repair (using semitendinosus, gracilis or patella tendon), tendon is threaded through heads of tibia and femur and held using screws

Question 406

List some complications of open fractures.

Answer 406

``` Clostridium perfringens (gas gangrene) Hypovolaemic shock Neurovascular compromise Compartment syndrome Fat embolism ```

Question 407

Which classification system is used for open fractures?

Answer 407

Gustillo-Anderson classification 1 - wound < 1 cm in length 2 - wound > 1 cm with minimal soft tissue damage 3 - extensive soft tissue damage NOTE: compound fracture = open fracture

Question 408

List some complications of total parenteral nutrition.

Answer 408

Line-related: pneumothorax, arrhythmia, line sepsis, thrombosis Feed-related: villous atrophy, electrolyte disturbance (refeeding syndrome), hyperglycaemia, vitamin and mineral deficiencies

Question 409

In general terms, how does the management of intracapsular fractures differ from extracapsular fractures?

Answer 409

INTRAcapsular: blood supply is likely to be interrupted so the head of the femur needs to be replaced (unless it is undisplaced) EXTRAcapsular: blood supply less likely to be interrupted so it can be fixed (DHS) rather than replaced

Question 410

Outline the post-operative VTE prophylaxis that is offered for patients undergoing hip and knee replacements.

Answer 410

THR: LMWH 10 days + aspirin 75/150 mg 28 days OR LMWH for 28 days OR Rivaroxaban TKR: aspirin 75/150 mg for 14 days OR LMWH for 14 days OR Rivaroxaban NOTE: for fragility fractures, continue LMWH or fondaparinux until no longer has significant reduced mobility

Question 411

Which arteries supply blood to the head of the femur?

Answer 411

Retinacular vessels which are a branch of the medial and lateral circumflex femoral arteries which are branches of the profunda femoris Profunda femoris branches off the femoral artery, which comes from the external iliac artery IMPORTANT: medial circumflex is more important for NOF than lateral

Question 412

List some differentials for monoarthritis.

Answer 412

``` Septic arthritis Crystal (gout, pseudogout) Trauma Haemarthrosis Reactive Psoriatic arthritis ```

Question 413

List some indications for using a central line.

Answer 413

Central administration of medication (vasopressors, inotropes, chemotherapy) TPN Access for extra-corporeal circuit (haemodialysis) Monitoring central venous pressure NOTE: the tip should be seen at the cavo-atrial junction (2 vertebrae down from the carina). Insertion confirmed with CXR.

Question 414

List some interventions that use Seldinger technique.

Answer 414

Central venous access Arterial access (angiography) Intra-abdominal/biliary/ureteric drainage PEG insertion

Question 415

List some indications for a chest drain.

Answer 415

Pneumothorax Pleural effusion Haemothorax Post-surgical (cardiac, thoracic, oesophageal) NOTE: in pneumothorax the tube should point upwards, in pleural effusion it should point downwards

Question 416

List some indications for using surgical drains.

Answer 416

Drain potential space post-surgery Removal of harmful fluid (blood, pus, bile) Detection of bleeding or leakage (anastomosis)

Question 417

List some complications associated with surgical drains.

Answer 417

``` Ascending infection Foreign body reaction (fibrosis/granulation) Migration Obstruction/kinking Fistulation ```

Question 418

What CXR features would suggest that an NG tube is sited correctly?

Answer 418

Does it follow the path of the oesophagus? Does it bisect the carina or bronchi? Does it cross the diaphragm in the middle? Is the tip clearly visible below the left hemidiaphragm?

Question 419

What is the main indication for using a feeding NG tube?

Answer 419

Short or medium-term feeding (4-6 weeks) provided the patient has a functional GI tract (major surgery, malnutrition, coma, dysphagia) Can also be used for administration of drugs/contrast in patients with an unsafe swallow

Question 420

List some complications of NG tubes.

Answer 420

``` Aspiration pneumonia (due to incorrect position) Pneumothorax Malposition in GI tract Obstruction/knotting/kinking Reflux oesophagitis Gastritis Visceral perforation ```

Question 421

List some indications for post-pyloric feeding.

Answer 421

Gastroparesis (DM, critical illness, neurological (MS, PD), scleroderma) Gastric outlet obstruction (PUD, malignancy) Recurrent aspiration Pancreatitis (less stimulation of pancreas)

Question 422

What are the two materials that urinary catheters can be made of?

Answer 422

Silicone (artificial) Latex (natural - can cause allergic reaction) NOTE: Coude/Tiemann catheters have a curved tip and they are used to get past enlarged prostates

Question 423

List some indications for using a urinary catheter.

Answer 423

``` Urinary retention Measurement of urine output During abdominal/pelvic surgery Neurogenic bladder Immobility (e.g. stroke) End of life care Urinary incontinence ```

Question 424

What are the three main types of scalpels?

Answer 424

10 - traditional blade with large cutting curve for skin incisions 11 - pointed apex for puncturing movements 15 - smaller cutting surface for more delicate control (for fine cutting)

Question 425

Outline the general rules for using absorbable, non-absorbable and monofilament sutures.

Answer 425

Absorbable: deep or rapidly healing tissues (e.g. bowel/biliary/urinary anastomosis) Non-Absorbable: permanent support and slower healing tissues (e.g. vascular, tendon, fascia) Monofilament: superficial wounds (less tissue reaction)

Question 426

Why is CO2 used to insufflate the abdomen in laparoscopic surgery?

Answer 426

It is inert, highly soluble and rapidly cleared by expiration NOTE: techniques for laparoscopic trocar insertion include Veress needle and Hasson technique

Question 427

What are the two forms of diathermy?

Answer 427

Monopolar: current flows between pen and electrode placed on the patient's skin Bipolar: both electrodes are mounted on forceps, used when tissue can be grabbed NOTE: current can be continuous (pure cut) for cutting tissues or intermittent (coag) for coagulation of small vessels

Question 428

What are some risks of using an oropharyngeal airway?

Answer 428

Vomiting Aspiration (If gag reflex present) NOTE: nasopharyngeal airway is used in patients with reduced consciousness but an intact gag reflex (can cause ulceration and epistaxis and should be avoided in maxillofacial trauma)

Question 429

List some indications for using a laryngeal mask airway.

Answer 429

Bridge to ET intubation during cardiac arrest Elective or short surgery with low risk of aspiration Rescue if failed intubation NOTE: does NOT protect against gastric aspiration and should be avoided in patients with reduced chest compliance (risk of insufflating stomach and compressing chest)

Question 430

What is a definitive airway?

Answer 430

Infraglottic Secure (cuffed) Prevents aspiration of gastric contents Can deliver maximum concentrations of oxygen

Question 431

List some indications for tracheostomy.

Answer 431

Weaning off mechanical ventilation | Severe maxillofacial trauma

Question 432

List some indications for intubation.

Answer 432

Decreased consciousness and loss of airway reflexes Failure to oxygenate (respiratory pathology, ARDS, pulmonary oedema) Failure to ventilate (tiring patient in life-threatening asthma) Failure to maintain upper airway patency (upper airway obstruction, angioedema, facial/upper airway trauma)

Question 433

Outline the management options for hypertrophic and keloid scars.

Answer 433

Topical silicone gel sheets Intralesional steroid and local anaesthetic injections Antihistamines Surgery: revision of scar

Question 434

List some differentials for a groin lump.

Answer 434

``` Inguinal hernia Femoral hernia Saphena varix Undescended testicle Femoral artery aneurysm Lymph node Lipoma/sebaceous cyst ```

Question 435

Which hand muscles are innervated by the median nerve?

Answer 435

Lateral two lumbricals Opponens policis Abductor policis brevis Flexor policis brevis LLOAF

Question 436

List some causes of a positive Trendelenburg test.

Answer 436

``` Abductor muscle paralysis (e.g. due to superior gluteal nerve injury caused by hip fracture, hip dislocation and IM injections) Unstable joint (e.g. DDH, NOF) Insertion/origin of abductor muscles are approximated (e.g. severe coxa vara, dislocation) ``` NOTE: coxa vara is when the angle between the head and the shaft is < 120 degrees

Question 437

What are the main stages of wound healing?

Answer 437

Haemostasis (vasospasm, platelet plug formation) Inflammation (neutrophils migrate to wound and release growth factors) Regeneration (fibroblasts produce collagen network) Remodelling (collagen fibres remodelled)

Question 438

Which routine bloods are one before any operation?

Answer 438

``` FBC U&E Group and Save Clotting Glucose ```

Question 439

How should insulin-dependent diabetic patients be managed around an elective operation?

Answer 439

First on morning list and should be admitted the night before Night before: reduce basal insulin by 1/3 Morning of: omit morning insulin, start IV variable rate insulin infusion (usually contains 50 U Actrapid) Whilst NBM: 5% dextrose at 125 mL/hour, 2-hourly BM Once eating/drinking: overlap insulin infusion with SC insulin

Question 440

How should non-insulin dependent diabetic patients be managed around an elective operation?

Answer 440

Diet controlled: no extra action required Metformin should be stopped on the day of surgery Other hypoglycaemics (e.g. gliclazide) should be omited 24 hours before the operation Place on variable rate insulin infusion with 5% dextrose (as for T1DM)

Question 441

What are the risks of operating on a jaundiced patient?

Answer 441

Obstructive jaundice --> increased risk of renal failure Coagulopathy Increased infection risk (cholangitis)

Question 442

How should anticoagulated patients with a low VTE risk be managed before an elective operation?

Answer 442

Stop warfarin 5 days pre-op (aim for INR < 1.5) | Restart warfarin the day after operation

Question 443

How should anticoagulated patients with a high risk of VTE be managed before an elecive operation?

Answer 443

``` Stop warfarin 5 days pre-op and start LMWH Stop LMWH 12-18 hours pre-op Restart LMWH 6 hours post-op Restart warfarin the next day Stop LMWH when INR > 2 ``` NOTE: high VTE risk includes valves and recurrent VTE

Question 444

Outline the main principals of general anaesthesia.

Answer 444

Induction - e.g. propofol Muscle relaxation - e.g. suxamethonium, rocuronium Airway control - e.g. ET tube, LMA Maintenance - e.g. halothane, enflurane End of Anaesthesia - change inspired gas to 100% oxygen, reverse paralysis with neostigmine/atropine

Question 445

List some complications of general anaesthesia.

Answer 445

``` Cardiorespiratory depression (propofol) Intubation injury (oropharyngeal) Loss of pain sensation (urinary retention, nerve palsies) Loss of muscle power (atelectasis) Malignant hyperthermia Anaphylaxis (colloid, antibiotics) ```

Question 446

List some complications of inadequate analgesia for surgery.

Answer 446

``` Wound hypoperfusion (impaired wound healing) Reduced mobilisation (VTE, deconditioning) Reduced coughing (atelectasis, pneumonia) ```

Question 447

List some causes of post-operative urinary retention.

Answer 447

Drugs (opioids, epidural/spinal anaesthesia, anticholinergics) Pain Psychogenic (hospital environment)

Question 448

Describe the presentation of post-operative atelectasis.

Answer 448

Within 48 hours of operation Mild pyrexia Dyspnoea Dull bases with reduced air entry

Question 449

List some complications of breast surgery.

Answer 449

Arm lymphoedema Seroma Skin necrosis

Question 450

List some causes of post-operative pyrexia.

Answer 450

EARLY: blood transfusion, physiological, atelectasis, infection DELAYED: pneumonia, VTE, wound infection, anastomotic leak, collection

Question 451

List some aspects of assessing the fluid status of a patient.

Answer 451

``` Capillary refill Heart rate BP lying/standing JVP Skin turgor Mucus membranes Urine output (and U&E) Consciousness ```

Question 452

Which type of fluid should be used in patients with cardiac or renal failure?

Answer 452

5% dextrose AVOID fluids with sodium because these patients will be retaining sodium

Question 453

What is the normal output you would expect to see from an ileostomy?

Answer 453

10-15 mL/kg/day = 700 mL/day NOTE: high output is > 1000 mL/day

Question 454

List some different types of enteral nutrition.

Answer 454

Polymeric (e.g. osmolite) - intact proteins, starches, long-chain free fatty acids Disease-specific - branched chain AAs in hepatic encephalopathy Elemental - simple AAs and oligo/monosaccharides (requires minimal absorption so used in abnormal GIT (e.g. CD))

Question 455

What are the components of a secondary survey?

Answer 455

``` Allergies Medications PMH Last ate/drank Events ```

Question 456

What are the different types of burn and how do they present?

Answer 456

Superficial (first degree, epidermis) - red without blisters, dry and painful Superficial partial thickness (second degree, involves dermis) - red with blisters, moist, very painful Deep partial thickness (second degree, involves dermis) - yellow/white, may be blistering, feels like pressure Full thickness (third degree, through dermis) - stiff, white/brown, no blanching, painless Fourth-degree (into fat, muscle, bone) - black, eschars, dry and painless

Question 457

What are the phases of fracture healing?

Answer 457

Bleeding into fracture site (haematoma) Inflammation (cytokine and growth factor release leading to formation of granulation tissue) Proliferation (of osteoblasts and fibroblasts, laying down cartilage and bone to form soft callus) Consolidation (endochondrial ossification of woven bone to lamellar bone) Remodelling (based on mechanical forces - Wolff's law)

Question 458

What are the three types of fracture based on aetiology?

Answer 458

Traumatic Stress (bone fatigue due to repetitive strain) Pathological (normal forces on diseased bone)

Question 459

What are the main methods of reducing a fracture?

Answer 459

Manipulation/closed reduction Traction (not used now) Open reduction (accurate reduction in surgery)

Question 460

What are the main methods of holding a fracture?

Answer 460

Non-rigid (slings, elastic support) Plaster External fixation (fragments held in position by pins/wires connected to external frame) Internal fixation (pins, plates, screws, IM nails)

Question 461

List some causes of reflex sympathetic dystrophy.

Answer 461

Fractures Carpal tunnel disease Operations for Dupuytren's contracture Presentation: hyperalgesia, allodynia, vasomotor symptoms, weakness, dystonia (NOT traumatised area affected - usually neighbouring area)

Question 462

What is Shenton's line?

Answer 462

Curved line from the inferior border of superior pubic ramus and along the inferomedial border of the neck of the femur Should be continuous and smooth Irregularity suggests fracture or dislocation NOTE: Klein's line is the line going along the superior surface of the neck of the femur (it should bisect the head of the femur)

Question 463

What is a Barton fracture?

Answer 463

Oblique intra-articular fracture involving the dorsal aspect of the distal radius with dislocation of the radio-carpal joint

Question 464

Outline the management of a suspected scaphoid fracture.

Answer 464

``` Scaphoid plaster (beer glass position) Re-X ray after 10 days to decide how long the plaster should stay there for ```

Question 465

What is impingement syndrome?

Answer 465

Entrapment of supraspinatus tendon and subacromial bursa between the acromion and greater tuberosity of the humerus I.e. either due to subacromial bursitis or supraspinatus tendonitis DDx: supraspinatus tear, acromioclavicular joint OA

Question 466

Outline the management of impingement syndrome.

Answer 466

Conservative: rest and physiotherapy Medical: NSAIDs, subacromial bursa steroid injection Surgical: arthroscopic acromioplasty

Question 467

Describe the examination findings of a complete rotator cuff tear.

Answer 467

Shoulder tip pain Full range of passive motion Inability to abduct the arm Active abduction possible after passive abduction to 90 degrees

Question 468

Outline the Ottawa rules regarding ankle fractures.

Answer 468

Ankle X-ray should only be requested if there is pain in the malleolar zone + any of: - tenderness along distal 6 cm of posterior tib/fib including posterior tip of malleoli - inability to bear weight both immediately and in ED

Question 469

How are ankle fractures managed?

Answer 469

Weber A - boot or below knee PoP Non-displaced B/C - below-knee PoP Displaced B/C - closed reduction and PoP, ORIF if closed reduction fails

Question 470

What is the 'unhappy triad' in orthopaedics?

Answer 470

ACL MCL Medial meniscus NOTE: sometimes referred to as a blown knee

Question 471

List some different types of osteochondrosis. NOTE: osteochondrosis is when interruption of a blood supply to a bone is interrupted leading to osteonecrosis followed by later regrowth of the bone resulting in deformity (usually affects children and adolescents)

Answer 471

Scheuermann's disease - wedge-shaped vertebrae causing exaggerated thoracic kyphosis Kohler's disease - navicular bone, limp Kienboch's disease - lunate bones, impaired grip Friedberg disease - 2nd and 3rd metatarsal heads (pain) Panner's disease - capitulum of humerus

Question 472

List some causes of avascular necrosis of bone.

Answer 472

``` Fracture Dislocation Sickle cell disease SLE Drugs (e.g. steroids) ```

Question 473

What are the contents of the carpal tunnel?

Answer 473

FDS - 4 tendons FDP - 4 tendons Flexor Pollicis Longus - 1 tendon Median nerve NOTE: palmar cutaneous branch of median nerve travels superficial to the flexor retinaculum so CTS will spare sensation over the thenar eminence

Question 474

List some causes of Dupuytren's contracture.

Answer 474

``` Alcoholism Idiopathic (most common) Epilepsy and medications (phenytoin) Diabetes mellitus Smoking Peyronie's disease ```

Question 475

What is Chilaiditi sign?

Answer 475

A loop of bowel between the liver and the diaphragm gives the impression of pneumoperitoneum

Question 476

How are perforated peptic ulcers repaired?

Answer 476

Duodenal - abdominal washout and omental patch repair Gastric - excise ulcer and repair defect Partial gastrectomy is sometimes requires NOTE: the omentum may seal the perforation spontaneously in some cases

Question 477

List some causes of obstructive jaundice.

Answer 477

``` Gallstones Pancreatic cancer Cholangiocarcinoma PSC/PBC Drugs (co-amoxiclav, OCP) ```

Question 478

Describe the anatomy of the anal canal.

Answer 478

4 cm long from levator ani to anal verge Upper 2/3 - columnar, insensate, internal iliac nodes, superior rectal artery and vein Lower 1/3 - squamous, sensate, middle and inferior rectal arteries and veins, superficial inguinal nodes NOTE: dentate line is the squamomucosal junction; white line is where anal canal becomes normal skin

Question 479

What are haemorrhoids?

Answer 479

Dilated anal cushions arising above the dentate line (not painful) Positioned at 3, 7 and 11 o'clock (position of three major arteries feeding the venous plexus) May become strangulated by the anal sphincter

Question 480

Define fistula.

Answer 480

An abnormal tract between two epithelial surfaces NOTE: a sinus is a blind-ending tract lined by epithelial or granulation tissue, opening onto an epithelial surface

Question 481

What are the two types of rectal prolapse?

Answer 481

Type 1: Mucosal Prolapse - partial prolapse of redundant mucosa Type 2: Full Thickness Prolapse - more common, elderly females with poor O&G history

Question 482

What are the boundaries of the anterior and posterior triangles of the neck?

Answer 482

Anterior: anterior margin of SCM, midline, ramus of the mandible Posterior: posterior margin of SCM, anterior margin of trapezius, middle 1/3 of clavicle

Question 483

Outline the national breast cancer screening programme.

Answer 483

Every 3 years from 47-73 years | Mammography (craniocaudal and oblique)

Question 484

List some complications of mastectomy.

Answer 484

Haematoma Seroma Long-thoracic nerve damage (winging) Lymphoedema

Question 485

Which classification system is used for limb ischaemia?

Answer 485

``` Fontaine 1 - asymptomatic 2 - intermittent claudication 3 - ischaemic rest pain 4 - ulceration/gangrene ``` NOTE: Rutherford is another classification system

Question 486

List some sources of emboli that could cause acute limb ischaemia.

Answer 486

AF Valve disease Iatrogenic (surgery, angioplasty) Paradoxical (via PFO)

Question 487

Outline the management of acute limb ischaemia.

Answer 487

``` NBM IV UFH (prevent clot propagation) Embolectomy (if failed, try thrombolysis and consider reconstruction/amputation) ``` NOTE: once the acute situation has been dealt with, investigate to find a source of the embolus (ECG, echo, aorta ultrasound)

Question 488

List some causes of aneurysms.

Answer 488

CONGENITAL: ADPKD, Marfan's, Ehlers-Danlos ACQUIRED: atherosclerosis, trauma, inflammatory (takayasu's aortitis), syphilis

Question 489

What are the different types of skin graft?

Answer 489

Split Thickness: includes epidermis and part of dermis Full Thickness: includes epidermis and entire dermis Composite: contains skin and underlying cartilage or other tissues NOTE: they can also be classified based on the donor (autograft - same individual, allogeneic - same species, xenogeneic - different species, prosthetic - synthetic material)

Question 490

List some differentials for bilateral leg swelling.

Answer 490

Increased venous pressure: RHF, venous insufficiency, drugs (CCB) Decreased oncotic pressure: nephrotic syndrome, HF, protein losing enteropathy Lymphoedema Myxoedema (pretibial)

Question 491

List some causes of urinary tract obstruction.

Answer 491

LUMINAL: stones, blood clots MURAL: tumour, neuromuscular dysfunction EXTRAMURAL: prostate enlargement, abdominal mass, retroperitoneal fibrosis

Question 492

List the main subtypes of renal adenocarcinoma.

Answer 492

Clear cell carcinoma (MOST COMMON) Papillary Chromophobe Collecting duct

Question 493

Outline the management of bladder cancer based on stage.

Answer 493

Tis, Ta, T1 = superficial --> intravesical mitomycin and BCG, diathermy via TURBT T2, T3 = invasive --> radical cystectomy + ileal conduit T4 = palliative --> chemotherapy, long-term catheterisation

Question 494

Outline the management options for prostate cancer.

Answer 494

Conservative: active monitoring Medical: LHRH analogues (goserelin), anti-androgens (cyproterone acetate) Radical prostatectomy Brachytherapy

Question 495

Outline the management of otitis externa.

Answer 495

Ear drops containing steroid and antibiotic NOTE: malignant otitis media can lead to osteomyelitis so requires surgical debridement and IV antibiotics

Question 496

What are the different types of otitis media?

Answer 496

Acute Otitis Media with effusion (glue ear) - effusion after symptom regression Chronic - effusion lasting > 3 months (if bilateral) or > 6 months (if unilateral) Chronic suppurative otitis media - ear discharge with hearing loss and evidence of drum perforation

Question 497

List some causes of tinnitus.

Answer 497

``` Meniere's disease Acoustic neuroma Otosclerosis Noise-induced Head injury Drugs (aspirin, loop diuretics) ``` NOTE: all patients with unilateral tinnitus should have an MRI

Question 498

List some causes of vertigo.

Answer 498

VESTIBULAR: BPPV, Meniere's, Labyrinthitis CENTRAL: acoustic neuroma, MS, stroke DRUGS: gentamicin, loop diuretics

Question 499

What is Meniere's disease?

Answer 499

Dilation of the endolymph spaces of the membranous labyrinth Causes progressive SNHL, vertigo, tinnitus and aural fullness

Question 500

Which medications are often used to treat vertigo?

Answer 500

Cyclizine | Betahistine

Question 501

What are the Centor criteria for tonsillitis?

Answer 501

Fever Tonsillar exudates Tender anterior cervical lymphoadenopathy No cough 3 or more = give antibiotics

Question 502

What is the difference between metachronous and synchronous cancers?

Answer 502

Synchronous - secondaries occurring within 6 months of primary cancer Metachronous - secondaries occurring over 6 months after primary cancer

Question 503

List some reasons for enucleation of the eye.

Answer 503

``` Trauma Tumour (retinoblastoma) Infection Phthisis bulbi (shrunken non-functional eye) Sympathetic ophthalmia ```

Question 504

Why do anastomoses of the sigmoid colon require a defunctioning loop ileostomy?

Answer 504

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

Question 505

Outline the management of diverticulitis.

Answer 505

Mild - bowel rest at home (fluids only) Severe - NBM, drip and suck, antibiotics (ceftriaxone and metronidazole), analgesia Obstruction/Perforation - Hartmann's resection

Question 506

What are the main types of perianal fistula and how are they treated?

Answer 506

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

Question 507

Outline the management of haemorrhoids.

Answer 507

Conservative: fibre Medical: topical hydrocortisone, laxatives Surgical: rubber band ligation, injection sclerotherapy, haemorrhoidectomy

Question 508

What is taken into account by the modified Glasgow score for pancreatitis?

Answer 508

``` 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

Question 509

List some causes of chronic pancreatitis.

Answer 509

``` Gallstones Ethanol Recurrent acute pancreatitis Cystic fibrosis Haemochromatosis Autoimmune ``` NOTE: complications include DM, pseudocysts and cancer

Question 510

Define osteoarthritis.

Answer 510

Degenerative joint disorder characterised by loss of hyaline cartilage and new bone formation at the joint surface.

Question 511

Which ligaments are sacrificed in total knee replacement?

Answer 511

ACL is usually sacrificed (however newer replacements may spare it) IMPORTANT: do not do anterior draw on TKR patients

Question 512

What are the pros and cons of cemented vs uncemented total hip replacement?

Answer 512

Cemented: better for older patients with poor bone quality and turnover Uncemented: porous and bone in-growth, makes revision of hip more difficult

Question 513

What are the 6 As of dealing with open fractures?

Answer 513

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)

Question 514

What is the normal pressure of the lower oesophageal sphincter?

Answer 514

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

Question 515

What is a paramedian incision used for?

Answer 515

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)

Question 516

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?

Answer 516

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

Question 517

List the mechanisms that could cause GORD.

Answer 517

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)

Question 518

List some risk factors for gastric cancer.

Answer 518

H. pylori Atrophic gastritis (pernicious anaemia) Diet (cured meats) Smoking

Question 519

Wht are the three points at which the ureter narrows?

Answer 519

Uretopelvic junction Pelvic rim Vesicoureteric junction

Question 520

How can the point during micturition at which blood is seen allude to the location of the pathology?

Answer 520

Beginning of stream = urethral Throughout = renal End = bladder

Question 521

List some indications for 2 week cystoscopic referral.

Answer 521

All frank haematuria Persistent haematuria + dysuria Haematuria + lower urinary tract symptoms Female retention

Question 522

Outline the staging of renal cell carcinoma.

Answer 522

``` 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 ```

Question 523

List some investigations for varicose veins.

Answer 523

Duplex ultrasound | MR venography

Question 524

What are the two types of below knee amputation?

Answer 524

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

Question 525

What is the pes anserinus?

Answer 525

Conjoined tendons of three muscles entering into the anteromedial surface of the proximal tibia (semitendinosus, gracilis, sartorius)

Question 526

Which bursae are found around the knee joint?

Answer 526

``` Suprapatellar Pre-patellar Infrapatellar (subcutaneous and deep) Semimembranosus Pes anserine ```

Question 527

What are the main differences between epidural and spinal anaesthesia?

Answer 527

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)

Question 528

List some complications of ocular protheses.

Answer 528

``` Lagophthalmos (incomplete closure of eyelid over eye) Enophthalmos Rotating prosthesis Prosthesis falling out Exophthalmos ```

Question 529

Describe the classification of joints.

Answer 529

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)

Question 530

List the main indications for operating on varicose veins.

Answer 530

Venous eczema and ulceration Skin changes including lipodermatosclerosis Oedema

Question 531

Describe the management of low-risk and high-risk invasive bladder cancer.

Answer 531

Low-risk: TURBT + intravesical mitomycin | High-risk: TURBT + intravesical BCG

Question 532

List some risk factors for umbilical and paraumbilical hernias.

Answer 532

Pregnancy Ascites Obesity

Question 533

Which operations may be conducted in patients with Crohn's disease?

Answer 533

Ileocaecectomy Abscess drainage Stricturoplasty Colectomy

Question 534

List some causes of leg length discrepancy.

Answer 534

True: congenital, post-traumatic, bone tumours Apparent: scoliosis

Question 535

What are the contents of the adductor canal?

Answer 535

Femoral artery Femoral vein Femoral nerve Saphenous nerve Boundaries: adductor longus and magnus, vastus medialis, sartorius

Question 536

Which important pre-operative intervention reduces the risk of infection in patients undergoing an appendicectomy?

Answer 536

Single dose IV tazocin 30 mins before the operation

Question 537

What are the main aspects of conducting a hernia examination?

Answer 537

``` 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 ```

Question 538

What are the branches of the coeliac trunk?

Answer 538

Left gastric artery Splenic artery Common hepatic artery

Question 539

Describe the main symptoms of ulnar collateral injury of the thumb.

Answer 539

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

Question 540

What is a Bennett's fracture?

Answer 540

Intra-articular fracture of the first metacarpal bone (often associated with boxing) NOTE: usually requires ORIF, high risk of osteoarthritis later in life

Question 541

Where will you see scars other than in the breast for the different types of myocutaneous flap?

Answer 541

Latissimus dorsi - back over lat dorsi (looks a bit like lateral thoracotomy) DIEP and TRAM - transverse lower abdominal scar (along the bikini line)

Question 542

How is a DIEP flap different from a TRAM flap?

Answer 542

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)

Question 543

What is the most common cause of cubitus varus?

Answer 543

Supracondylar fracture of the humerus NOTE: can be corrected with osteotomy

Question 544

List and describe some types of toe deformity.

Answer 544

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

Question 545

What is the most commonly used management option for Colles fractures?

Answer 545

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

Question 546

What are the boundaries of the anatomical snuffbox?

Answer 546

Medial: extensor pollicis longus Lateral: abductor pollicis longus + extensor pollicis brevis Floor: scaphoid Crossed by: radial artery

Question 547

Describe the incisions used in a 4-compartment fasciotomy.

Answer 547

Medial and lateral skin incisions | Through the lateral incision, you divide the fascia of the superficial and deep posterior compartments

Question 548

What is the difference between tennis elbow and golfer's elbow?

Answer 548

Tennis: lateral epicondylitis (insertion of extensor carpi radialis brevis) Golfer: medial epicondylitis

Question 549

List some risk factors for hernias.

Answer 549

Pregnancy Obesity Weight lifting Chronic cough

Question 550

Which blood artery is a transplanted kidney usually connected to?

Answer 550

External iliac artery

Question 551

List some complications of supracondylar humerus fractures.

Answer 551

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

Question 552

Define compartment syndrome.

Answer 552

An increase in pressure within an osseofascial compartment (usually > 30 mm Hg diastolic)

Question 553

What operation is used to treat cataracts?

Answer 553

Phacoemulsification - involves emulsifying and aspirating the lens before inserting an implant