Surgery PACES Flashcards
List some different types of myocutaneous flap.
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
Which special test should you be careful about performing in a patient with a hip replacement?
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
List some complications of hernia repair surgery.
EARLY
- urinary retention
- haematoma
- infection
- intra-abdominal injury (laparoscopy)
LATE
- recurrence
- ischaemic orchitis (due to thrombosis of pampiniform plexus)
- chronic groin pain
What are sebaceous cysts and what are the two histological subtypes?
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
What are the two ways in which a dislocated shoulder can be reduced?
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
What are the main things you need to elicit in a patient with a hernia?
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?
EPONYMOUS OPERATIONS: lower oesophageal cancer
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
How is inflammatory bowel disease investigated?
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
What are the advantages and disadvantages of EVAR?
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)
What is the ulnar paradox?
Closer to the paw the worse the claw
Proximal lesions cause paralysis of flexor digitorum profundus which causes less clawing of the hand
What is a major complication of pelvic fractures?
Urethral injury leading to urinary retention
What are the X-ray features of osteoarthritis?
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
What is a cystic hygroma?
Congenital multicystic lymphatic malformation usually seen in the posterior triangle of infants
NOTE: it transilluminated brilliantly and is soft and fluctuant
How are paraumbilical hernias managed?
Surgery is advised due to high risk of strangulation
Mayo repair (mobilise sac and reduce contents)
List some abdominal wall or soft tissue masses that can affect any part of the abdomen.
Sebaceous cyst
Lipoma
Sarcoma
What is myositis ossificans?
Ossification of muscles at sites of haematoma formation leading to restricted painful movement (usually affects elbows and quads) and requires excision
What are the main motor and sensory areas supplied by the radial nerve?
Motor: metacarpophalangeal joint extension
Sensory: 1st dorsal web space
What are the layers of tissue that are cut in an abdominal incision?
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
List some differentials for anterior neck lumps.
Lymphnodes
Chemodectoma
Goitre
Parotid tumour (e.g. mumps)
Branchial cyst
Laryngocele
What is the first-line investigation for suspected prostate cancer?
Multiparametric MRI
This has superseded TRUS biopsy
What is a radical cystectomy?
Men: bladder, prostate and iliac lymph nodes
Women: bladder, ovaries, uterus, cervix and anterior wall of vagina
What is a Monteggia fracture?
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)
EPONYMOUS OPERATIONS: rectal prolapse
Delorme procedure - perineal approach with mucosal excision
List some complications of thyroid surgery.
Haemorrhage
Recurrent laryngeal nerve palsy
Hypocalcaemia (parathyroid damage)
Thyroid storm
Hypothyroidism and hypoparathyroidism
Recurrence
Keloid
List some peripheral stigmata of thyroid disease.
Agitated or lethargic
Body habitus
Sweating
Skin and hair (loss suggests hypothyroidism)
Thyroid acropachy
Palmar erythema
Tremor
AF
What are the key aspects of a history you need to focus on in a patient with suspected osteoarthritis?
Pain - exertional, rest, night
Disability - walking distance, stairs, giving way
Deformity
What are the four types of thyroid cancer and which is most common?
Papillary (80%)
Follicular
Medullary
Anaplastic
(Lymphoma)
What are the advantages and disadvantages of braided sutures?
ADVANTAGES: easier to handle, knots slip less, greater tensile strength
DISADVANTAGES: increased risk of infection, increased friction on tissues
What are the three main reasons for having vascular bypass surgery?
Trauma
Aneurysm
Occlusion
How do you test the reaction of a hernia to raised intra-abdominal pressure in a patient with a tracheostomy?
Lie them flat and ask them to lift their legs up
List some reasons for having vascular access scars in the groin.
Bypass
Embolectomy
Endovascular aneurysm repair
Stent insertion
Femoral endarterectomy
Angioplasty
List some key differences between ileostomy and colostomy.
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)
Describe the classification of operative haemorrhages.
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)
Describe an antalgic gait.
Shortened stance-phase on the affected side
What is the difference between a total and subtotal gastrectomy?
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
Outline the management of hydroceles.
Non-Surgical: watch and wait, aspiration for symptomatic relief
Surgical
- Lord’s repair (plication of tunica vaginalis)
- Jaboulay’s repair (eversion of the sac)
If you hear a bruit over a varicosity what does that suggest?
AV malformation
What are some causes of subcutaneous lumps?
Lipoma
Ganglion
Lymph nodes
NOTE: can move the skin over the lump
What is the Monroe-Kelly doctrine?
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
What is the point of tunnelling a central line?
Cuffs promote tissue reaction which creates a better seal
The tunnel helps keep the catheter in place and reduces the risk of infection
Why is acute on chronic limb ischaemia less time urgent than acute limb ischaemia?
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)
Which investigations are used for patients with intermittent claudication?
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)
During an operation, how can a direct inguinal hernia be distinguished from an indirect inguinal hernia?
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
List some forms of definitive airway.
Orotracheal airway
Nasotracheal airway
Tracheostomy
Cricothyroidotomy
List some indications for using a disposable rigid sigmoidoscope.
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
List some complication of using a shouldered syringe to inject haemorrhoids.
IMMEDIATE: pain if injected below the dentate line, damage to nearby structures, primary haemorrhage
LATE: prostatitis, impotence
List some causes of knee locking.
Meniscal tear
Cruciate ligament injury
Osteochondritis dissecans
Loose body
How are thyroglossal cysts treated?
Sistrunk operation - removal of thyroglossal tract through transverse incision just above thyroid cartilage
What is a triple phase CT scan and what is its purpose?
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
What should be offered to patients with chronic urinary retention who want to avoid surgery?
Intermittent self-catheterisation
NOTE: if this fails, a long-term catheter can be offered
What is the benefit of using an uncuffed ET tube?
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
What are the clinical features of radial nerve palsy?
Wrist drop
Loss of sensation over the first dorsal interosseous (webbing)
May have sensory loss over dorsal forearm
Why does an anterior resection require a loop ileostomy?
Rectal blood supply is poor so the colorectal anastomosis must be rested and, hence, covered by a loop ileostomy
What rehabilitation support should be offered to patients with a stoma?
Aim for normal diet
Good skin care and hygiene
Psychosexual support
What is a subtotal colectomy?
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
Other than the carpal tunnel, where else can the median nerve get trapped?
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)
Describe the management of ileus.
Correct underlying abnormalities (electrolytes and drugS)
Consider the need for parenteral nutrition
What are the main indications for doing a total hip replacement as opposed to a hemiarthroplasty?
Mobilises with no more than 1 walking stick
Not cognitively impaired
Medically fit for anaesthesia and surgery (minimal comorbidities)
Outline how to examine a stoma.
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
What does Thomas’ test look for?
Fixed flexion deformity in the knee
Causes: osteoarthritis, ACL injury, bucket handle meniscal tear, iliopsoas tightness
Outline the management of popliteal aneurysms and its indications.
Surgical Indications: symptomatic, aneurysms containing thrombus, aneurysms > 2 cm
ACUTE Rx: embolectomy, femoral-distal bypass
STABLE: excision bypass
What are some causes of intradermal lumps?
Sebaceous cyst
Neurofibroma
Dermatofibroma
NOTE: the skin cannot be drawn over the lump
What is the investigation of choice for suspected chronic pancreatitis?
CT scan with IV contrast (to look for pancreatic calcification)
What is the difference between a true and false aneurysm?
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)
List some associations of Terry’s nails.
Chronic liver failure
Diabetes mellitus
Congestive heart failure
Hyperthyroidism
Malnutrition
Describe how the location of varicose veins relates to the veins involved.
Medial and above or below the knee - great saphenous
Posterior and below the knee - short saphenous
Few varicosities with prominent skin changes - calf perforators
How should a breast lump be investigated further?
< 35 years: US
> 35 years: US + mammogram (oblique and craniocaudal)
MRI if multifocal disease or cosmetic implants present
Outline the management principles of claudication.
CONSERVATIVE: structured exercise programme, stop smoking, weight loss, foot care
MEDICAL: RF modification (BP, BM, lipids) , antiplatelets (clopidogrel), analgesia
INTERVENTIONAL: angioplasty, stenting
Under what circumstance is steroid injections for join pain contraindicated?
If they already have some form of join replacement (risks introducing infection)
What is the main indication for a loin incision?
Nephrectomy
How can you clear the C spine in a trauma patient?
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)
List some differentials for epigastric masses.
Gastric cancer
Hepatomegaly
Pancreatic cancer
Pancreatic pseudocyst
AAA
Which investigations are used for achalasia?
Barium swallow
CXR - wide mediastinum, double right heart border
Manometry - failure of relaxation
OGD - exclude cancer
Outline the management of wound dehiscence.
Cover in steril soaked gauze
IV antibiotics
Repair in theatre
What operation might require a transverse muscle splitting incision?
Right hemicolectomy (along with a midline laparotomy and laparoscopic ports)
What are the indications for operating on an AAA?
Symptomatic
Asymptomatic but > 5.5 cm or expanding > 1 cm/year
What is the first-line investigation for diverticulitis?
CT scan
Other investigations for diverticulosis include gastrograffin enema/swallow and colonoscopy
List some conditions that are associated with carpal tunnel syndrome.
Hypothyroidism
Pregnancy
Rheumatoid arthritis
Pregnancy
Amyloidosis
Diabetes mellitus
List some complications of urinary catheterisation.
Creation of false tract
Urethral rupture
Paraphimosis
Haematuria
Infection
Blockage
NOTE: urethral injury is a major contraindication for urinary catheterisation
List the degrees of haemorrhoids.
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
What is the main indication for a shouldered/Gabriel syringe?
Injection of haemorrhoids with 5% phenol in almond oil (sclerosant)
Used with a proctoscope to allow visualisation of the haemorrhoids
List some complications of laparoscopic cholecystectomy.
Conversion to open procedure
Common bile duct injury
Bile leak
Retained stones
Intra-abdominal haemorrhage
If you see a stoma on examination, what else should you examine?
Perineum - do see if it is a permanent stoma or a temporary stoma or if the anus has been excised.
What are the features of acute limb ischaemia and which features are indications for immediate revascularisation?
Painful
Pulseless
Pale
Perishingly cold
Indications for immediate revascularisation: paralysis, paraesthesia
What classification system is used for peripheral nerve injury?
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)
What is refeeding syndrome?
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
What are the advantages and disadvantages of the use of myocutaneous flaps for breast reconstruction?
ADVANTAGES: useful when little muscle/skin remaining, good cosmetic result
DISADVANTAGES: increased blood loss, increased operation time, late complications (e.g. flap necrosis)
What are the ways in which fractured can be held?
Closed –> plaster or traction (skin or skeletal)
Fixation
Which investigation would provide a definitive diagnosis of small bowel obstruction?
Abdominal CT
NOTE: AXR is first-line but not definitive
List some causes of gangrene.
Diabetes (most common)
Embolism and thrombosis
Raynaud’s phenomenon
Thrombangiitis obliterans
Injury (e.g. extreme cold, trauma)
What is the main indication for hip resurfacing?
Young, active people who are expected to outlive the replacement
Why are varicoceles much more likely on the left side?
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
What are the most common causes of epigastric hernias?
Lipoma
Incisional hernia where you can’t see the incision (most commonly port site from lap chole)
Which classification system is used for intracapsular neck of femur fractures?
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
How should an NG tube be sized?
Measure from the tip of the nose to the epigastrium, going around the ear
List some indications for total parenteral nutrition.
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
List some complications of using ET tubes.
EARLY: oropharyngeal and laryngeal trauma, C-spine injury (atlanto-axial instability), oesophageal intubation, bronchial intubation
DELAYED: sore throat, tracheal stenosis, difficult wean
What do you ‘feel’ for when examining a joint?
Tenderness
Effusion
Temperature
NOTE: the joint should be moved in every direction possible, first actively then passively
Outline the conservative management of inguinal hernias.
Manage risk factors (e.g. chronic cough, constipation)
Weight loss
Hernia truss
How can the integrity of a surgical bowel anastomosis be checked?
Intra-operative: fill pelvic cavity with saline, insufflate rectum with air and look for bubbles in the saline
Post-operative: water-soluble contrast enema
Which special test can be done to further assess a patient with suspected ulnar nerve injury?
Froment’s sign - flexion of thumb at interphalangeal joint due to weak adductor policis brevis
Describe the main physical characteristics of the spleen.
Located below ribs 9-11
Usually 9-11 cm in length
Weighs 150 g
Not usually palpable
List some causes of splenomegaly.
Infection (EBV, CMV, cat scratch disease)
Haemolytic disease (sickle cell, thalassemia, spherocytosis)
Malignancy (lymphoma, leukaemia)
Portal hypertension (cirrhosis)
Other (sarcoidosis, Felty syndrome)
List some types of absorbable suture.
Catgut (natural)
Monocryl (used for subcuticular skin closure)
Vicryl (subcutaneous closure, bowel anastomosis)
PDS (closing abdominal wall)
What should be done in the run up to thyroid surgery?
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
List some complications of chest drains.
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
List some general surgical complications that can occur with most operations.
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
Outline the surgical options in the management of osteoarthritis.
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
Describe a Trendelenburg gait.
Sideways lurch of trunk to bring body weight over limb
List some surgical management options for varicose veins.
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)
What are the three phases of venous gangrene?
Phlegmasia alba dolens (white leg)
Phlegmasia cerulea dolens (blue leg)
Gangrene secondary to acute ischaemia
Outline how you would do a vascular examination.
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
List some indications for using a Swan Ganz catheter.
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)
How long can a central line (e.g. PICC, Hickman or portacath) stay in place?
Until the end of treatment (this can be months to years)
What is an Ivor-Lewis oesophagectomy?
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
How are oropharyngeal and nasopharyngeal tubes sized?
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)
What are the borders of the femoral canal?
Lateral: femoral vein
Medial: lacunar ligament
Anterior: inguinal ligament
Posterior: pectineal ligament
Define stridor and list the different types.
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
List some complications of EVAR.
MI
Spinal or mesenteric ischaemia
Renal failure
Graft migration of stenosis
Leakage
Which classification system is used for distal fibula fractures?
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
What are the main motor and sensory areas supplied by the ulnar nerve?
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
What flow rate and percentage of oxygen can be administered through a non-rebreathe mask?
10-15 L/min
60-90% oxygen
List some differentials for subacromial impingment.
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
In what scenario will it be difficult to both actively and passively move a joint?
Osteoarthritis
Outline the management of varicoceles.
Non-Surgical: scrotal support, radiological embolisation
Surgical: generally recommended because of risk of infertility
- Palomo operation (vein exposed and ligated)
- Laparoscopic is possible
Which test can be done when palpating a varicose vein?
Tap test (Chevrier’s test) - tap proximally and feel for an impulse distally
List some operations that may require a Kocher’s incision?
Right: open cholecystectomy
Left: splenectomy
What are the main motor and sensory areas supplied by the median nerve?
Motor: abductor policis brevis
Sensory: pulps of index and middle finger
Describe the anatomy of Bouttoniere and Swan neck deformity.
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
How is a patient with suspected testicular cancer worked up?
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)
List some complications of AAA.
Rupture
Embolisation (trash foot, missing pulses in popliteal aneurysms)
Thrombosis (acutely ischaemic leg)
Pressure (DVT)
Fistulation
NOTE: trash foot usually happens after AAA surgery
What are the borders of the inguinal canal?
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
Outline the treatment of nasal fractures.
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
What are the three compartments of the knee?
Medial
Lateral
Patellofemoral
Outline the surgical management of intracapsular neck of femur fractures.
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
How should patients be prepared before a mastectomy?
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)
What is the order of size of peripheral venous cannulas?
Yellow (SMALLEST - 24 gauge)
Blue
Pink
Green
Grey
Brown (BIGGEST - 14 gauge)
NOTE: flow rate is proportional to r^4 (Poiseuille’s law)
List some indications for long-term catheterisation.
Chronic bladder outlet obstruction
Neurogenic bladder (e.g. MS, DM) with chronic retention
Alternative: clean intermittent self-catheterisation
What is the technical term used to describe chronic neuropathic pain that occurs after an injury or fracture?
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
List some complications of central venous catheter insertion.
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
Which follow-up treatment should be recommended for women who have had breast cancer treatment by wide local excision?
Whole breast radiotherapy
IMPORTANT: wide local excision should only be offered for DCIS < 4 cm
What is a neobladder?
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
List some indications for a stoma.
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)
Outline the management of high risk superficial transitional cell carcinoma of the bladder.
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
What is a pyogenic granuloma?
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
List some features you may notice on examination of an osteoarthritic hip.
May be Trendelenburg positive
Pain
Stiffness
Reduce range of motion (especially internal rotation)
Fixed flexion deformity
What are some complications of shoulder dislocation?
Recurrent dislocation
Axillary nerve injury
Avulsion injury/rotator cuff tear
List some complications of knee replacement.
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
How can inguinal and femoral hernias be distinguished on the basis of their location?
Inguinal: above and medial to pubic tubercle
Femoral: below and lateral to pubic tubercle
List some causes of lymphoedema.
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)
What are the advantages and disadvantages of monofilament sutures?
ADVANTAGES: reduced risk of infection, less friction against tissues
DISADVANTAGES: harder to handle, knots may slip, less tensile strength
What might require a thoracoabdominal incision?
Oesophagogastrectomy
List some anatomical structures that are found at the transpyloric plane of Addison.
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
Outline the screening programme for AAA.
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
EPONYMOUS OPERATIONS: hydrocele
Lord’s repair - plication of tunica vaginalis
Jaboulay’s repair - eversion of tunica vaginalis
List some complications of surgical drains.
Infection
Damage caused by mechanical pressure or suction
Limit patient mobility
List some causes of varicose veins.
Primary (95%): prolonged standing, pregnancy, obesity
Secondary (5%): valve destruction (DVT), obstruction (pelvic mass), AV malformation, syndromes (Klippel-Trenaunay, Parkes-Weber)
Outline the management of chronic limb ischaemia.
CONSERVATIVE: optimise risk factors, clopidogrel and statin, foot care
INTERVENTIONAL: angioplasty, stenting, chemical sympathectomy
SURGICAL: endarterectomy, bypass grafting, amputation
List some complications of feeding NG tubes.
Nasal trauma
Malposition (cranium)
Blockage
Electrolyte imbalance (refeeding syndrome)
List some complications of gastrectomy.
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
What specific type of X-ray should be taken in orthopaedic patients with hip and knee problems?
Weight-bearing X-ray
NOTE: for knee, also take lateral and skyline X-rays to look for patelofemoral joint osteoarthritis
How does the angle of shoulder abduction at which pain is elicited relate to the cause of the pain?
60-120 degrees: impingement or rotator cuff tendonitis
140-180 degrees: acromioclavicular osteoarthritis
What are the contents of the inguinal canal in females?
Round ligament (Spermatic cord in males)
Ilioinguinal nerve
Genital branch of the genitofemoral nerve
Blood and lymphatic vessels
What is swinging of the chest drain?
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
What is the investigation of choice for hydroceles?
Ultrasound
What demarcates the 9 quadrants of the abdomen?
Transpyloric plane: across L1 from the tip of the 9th costal cartilage
Supracristal plane: across L4 at the highest point of the iliac crest
What are the three compartments of the abdomen in which you may feel for masses?
Subcutaneous
Visceral
Retroperitoneal
List some causes of salivary gland swelling.
DIFFUSE
- infection (parotitis)
- Sjogren’ syndrome
- sarcoidosis
- systemic (bulimia, anorexia, chronic liver disease)
LOCALSED
- calculus
- lipoma
- salivary gland neoplasm
- lymphoma/leukaemia
What urine dipstick results would you expect to see in post-hepatic jaundice?
High bilirubin
No urobilinogen
What bony and soft tissue lesions may be seen on an X-ray in shoulder dislocation?
Bankart lesion: damage to glenoid labrum
Hill-Sachs lesion: cortical depression in posterolateral part of humeral head
What is gangrene and what are the different types?
Definition: irreversible tissue death from poor vascular supply
Wet: tissue death + infection
Dry: tissue death only
List some complications of using a laryngoscope.
Laryngeal and oropharyngeal trauma
C-spine injury (e.g. in atlanto-axial instability)
What is a dermatofibroma?
Benign neoplasm of dermal fibroblasts
Usually seen on the legs of women, firm, woody feel may look like malignancy
What is Admirand’s triangle?
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
What is the main benefit of a port a cath?
Very low risk of infection as skin breech is minimal
Typically used for long-term administration of chemotherapy/antibiotics
EPONYMOUS OPERATIONS: refractory GORD
Nissen fundoplication - wrapping the fundus around the lower oesophageal sphincter
List some causes of problems with fracture union.
Infection
Ischaemia
Interfragmentary movement
Interposition of soft tissue
Intercurrent illness
What is a Ryles nasogastric tube used for?
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)
How can you check for correct positioning of an ET tube?
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)
List some causes of radial nerve palsy.
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
What signs in the hand would you see in ulnar nerve palsy?
Partial claw hand (little and ring fingers)
Wasting of hypothenar eminence and dorsal interossei
Loss of sensation in ulnar distribution
What are the principles of dealing with any fracture?
Reduce (closed or open)
Hold (no metal or metal)
Rehabilitate (move, physiotherapy and use)
Outline the post-operative advice given to patients undergoing surgical hernia repair.
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)
What electrolyte is an indicator of pancreatitis severity?
Hypocalcaemia
NOTE: hypercalcaemia causes pancreatitis
Why might the pedal pulses of a patient with diabetes be preserved until late in the disease?
Calcification in the walls of the vessel
NOTE: this also causes an abnormally high ABPI
Outline the surgical approaches to managing femoral hernias.
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)
What are the two different techniques of breast reconstruction?
Implants
Myocutaneous flap
List some operations that may require a midline laparotomy.
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
List some indications for using a disposable proctoscope.
Investigation of perianal pathology (e.g. haemorrhoids, low rectal cancer)
Examination or biopsy of anal canal and lower rectum
Therapeutic (banding or sclerotherapy)
List some complications of cannulation.
Haematoma
Malplacement
Blockage
Superficial thrombophlebitis
What is the upper limit of a post-void residual volume in patients under 65 yrs and over 65 yrs?
< 65 yrs = < 50 mL
> 65 yrs = < 100 mL
What are the roles of nerves L4, L5 and S1?
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
Outline the management principles of osteoarthritis.
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)
What are the consequences of depressed fractures of the zygoma?
Binocular vision post-facial trauma and pain on opening the jaw
Which veins can be used as access for central venous catheters?
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.
EPONYMOUS OPERATIONS: Pharyngeal pouch repair
Dohlman procedure - minimally invasive endoscopic stapling
What is a PICC line?
Peripherally inserted central catheter
Inserted into a peripheral vein (e.g. cephalic vein) and it is advanced until the tip is in the SVC
List some indications for partial nephrectomy.
Solitary kidney
Bilateral renal masses
Renal impairment
NOTE: radiofrequency ablation and cryotherapy are minimally invasive way of treating small renal cancers
What are the main radiological features of rheumatoid arthritis?
Soft tissue swelling
Periarticular osteopaenia and erosions
Severe deformity
NOTE: fewer patients have deformities now because of adequate treatment
Outline the national bowel cancer screening programme.
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)
What is enhanced recovery after surgery (ERAS) and how is it achieved?
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
Outline the management of meniscal tears.
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
Which changes in the skin give rise to a seborrhoeic keratosis?
Hyperkeratosis - thickening of corneum
Acanthosis - thickening of spinosum
Hyperplasia of basal cells
List the special tests used in a shoulder exam and state the anatomical structure that is being tested.
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
Which investigation should be requested in suspected renal tract cancer?
Renal tract ultrasound
List some differentials for RIF masses.
Transplanted kidney
Caecal cancer
Appendix mass
Incisional hernia
Ovarian tumour/fibroid uterus
Ectopic kidney
Iliac artery aneurysm
What adjacent structures can be damaged during a fracture?
Nerves
Vessels
Ligaments
Tendons
List some different types of bypass surgery for chronic limb ischaemia.
Anatomical: femoral-popliteal, femoral-distal, aorto-bifemoral
Extra-Anatomical: axillo-fem, fem-fem crossover
What are the two main techniques used for hip replacement? Describe them.
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)
What features of a fracture can be described from a plain X-ray?
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)
What are the boundaries of Hesselbach’s triangle?
Medial: rectus abdominis muscle
Lateral: inferior epigastric artery
Inferior: inguinal ligament
List some types of non-absorbable suture.
Silk (used to secure drains)
Prolene (skin wounds and arterial anastomosis)
Ethilon (skin wounds)
Metal (skin wounds, sternotomy closure)
What does limited active movement but normal passive movement suggest?
Either a muscular problem (e.g. tendon rupture) or an innervation issue
List some contraindications for IV urography.
Contrast allergy
Renal impairment
Pregnancy
Severe asthma
Metformin
List some causes of thoracic outflow obstruction.
Cervical rib
Clavicle fracture
Pathological enlargement of 1st rib
NOTE: DDx - Raynaud’s, axillary vein thrombosis, cervical spondylosis, Pancoast tumour
Describe the examination features of a sebaceous cyst.
Occur at sites of hair growth (e.g. scalp, face, neck, chest)
Central punctum
Firm, smooth and intradermal
List some differentials for RUQ masses.
Hepatomegaly
Hepatic mass (e.g. cyst)
Gallbladder
Right kidney
When should the COCP be stopped prior to elective surgery?
4 weeks
What is a trigger finger?
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
At what vertebral levels do the coeliac trunk, SMA and IMA branch off the aorta?
Coeliac trunk: L1
SMA: L1
Renal arteries: L2
IMA: L3
Bifurcation of aorta: L4/L5
List some gastrointestinal causes of clubbing.
Cirrhosis
Crohn’s disease
Coeliac disease
GI lymphoma
Describe two types of urostomy.
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)
Outline the management of arterial ulcers.
Pain management
Risk factor modification
Clopidogrel
IV prostaglandins
Chemical lumbar sympathectomy
How can you confirm the location of an NG tube?
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
List some indications for using an oropharyngeal or nasopharyngeal airway.
Airway adjunct in patients with impaired consciousness
EPONYMOUS OPERATIONS: varicose veins
Trendelenberg - saphenofemoral junction ligation
Cockett - perforator ligation
List some complications of surgical management of varicose veins.
EARLY: haematoma, wound sepsis, nerve damage (long saphenous)
LATE: superficial thrombophlebitis, DVT, recurrence
List some complications of pancreatitis.
EARLY: hypovolaemia (shock), SIRS, hyperglycaemia, hypocalcaemia
LATE: pseudocyst, pancreatic necrosis, infection, abscess, bleeding, thrombosis, fistula
How can varicose veins be treated?
CONSERVATIVE: weight loss, avoid prolonged standing, compression stockings, emollients
Injection sclerotherapy
Endovernous laser or radiofrequency ablation
Surgery
Which operations are likely to require an end colostomy?
Permanent: AP resection (colon cancer)
Temporary: Hartmann’s (diverticulitis)
How can a seminoma be distinguished from a teratoma?
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
What causes Trendelenburg sign?
Weakness of hip abductors (mainly gluteus medius)
May be caused by superior gluteal nerve injury
List some causes of spider naevi.
More than 3 is abnormal
Chronic liver disease
Pregnancy
COCP
Which Foley catheters tend to be used in men and women?
Male: 16-18 French
Female: 12-14 French
NOTE: French is the diameter of the catheter in mm
What is the main reason for using external fixation?
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
What are the pros and cons of an anterolateral approach to hip replacement as opposed to a posterior approach?
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
Outline the management of compartment syndrome.
Elevate and remove any bandages/cast
Fasciotomy
Describe the tourniquet test/Trendelenberg test for venous insufficiency.
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
List some differentials for posterior neck lumps.
Lymph nodes
Cervical rib
Cystic hygroma
Pharyngeal pouch
What are the main indications for adenoidectomy?
OSA in children
Glue ear with failed grommets
Malignancy
What is a Galeazzi fracture?
Fracture of radial shaft between middle and distal 1/3 + dislocation of distal radio-ulnar joint
What is the Parkland formula for fluid resuscitation in burns?
Fluid resuscitation in the first 24 hours = % surface area x weight x 4 mL
List some complications of Nissen fundoplication.
Gas-bloat syndrome (can’t belch or vomit)
Dysphagia (if wrap around is too tight)
What are the features of critical limb ischaemia?
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)
What are some key differences between hypertrophic scars and keloids?
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
Outline the criteria for having a tonsillectomy.
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
What are the surgical management options for BPH?
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
Outline the management of Raynaud’s phenomenon.
Wear gloves and avoid cold
Stop smoking
CCBs (e.g. nifedipine)
IV prostacyclin
What is the normal range of flexion in a knee joint?
0-140 degree
List some complications of stomas.
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
List some causes of jaundice after cholecystectomy.
Gallstone retention
Biliary sepsis
Thermal injury
Ligation of common hepatic or common bile duct
Haemolysis after transfusion
Halogenated anaesthetics
List some complications of joint prosthesis.
Cement reaction
Deep infection
Fracture
Dislocation
Loosening
Failure
What is a major issue with the use of fine needle aspiration to investigate a thyroid lump?
Cannot distinguish between adenoma and follicular cancer
NOTE: before thyroid surgery, patients need to have their vocal cords assessed
What are the contents of the spermatic cord?
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
What are the indications for an urgent CT head scan (within 8 hours) in patients who have had a head injury?
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
List some indications for surgical treatment of CD.
ACUTE
- obstruction secondary to stenosis
- perforation
- severe GI bleed
CHRONIC
- perianal disease (e.g. fistula, abscess)
- failure of medical treatment
- entero-cutaneous fistulae
What are the three main sites at which valvular incompetence occurs?
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)
Define herniorrhaphy and herniotomy.
Herniotomy (removal of the hernial sac only). Herniorrhaphy (herniotomy plus repair of the posterior wall of the inguinal canal)
Herniotomy - ligation and excision of hernial sac
Herniorrhaphy - repair of abdominal wall defect
List some indications for using a circular bowel stapler.
Rectal anastomosis
Gastrectomy
Haemorrhoids
Rectal prolapse
List some features of chronic venous insufficiency.
Haemosiderosis
Atrophie blanche
Lipodermatosclerosis
Venous eczema
Venous ulcers
Which types of grafts can be used for bypass surgery in patients with peripheral vascular disease?
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
List some causes of smooth and irregular hepatomegaly.
Smooth: CCF, cirrhosis, lymphoreticular disease, Budd-Chiari syndrome, amyloidosis
Irregular: secondary mets, macronodular cirrhosis, polycystic disease, primary HCC
What is a post-phlebitic limb?
A limb which has features of chronic venous insufficiency due to previous deep vein thrombosis
What are the indications for carotid endarterectomy?
SYMPTOMATIC (ECST or NASCET guidelines)
Usually > 70% stenosis
Some recommend > 50% stenosis
Perform within 2 weeks of presentation
ASYMPTOMATIC: patients with stenosis >60% benefit
List some indications for using colloids.
Fluid challenge
Hypovolaemic shock
Burns
Complications: anaphylaxis, volume overload
What ABPI is required for the use of compression bandages?
ABPI > 0.8
NOTE: other treatment options include oral pentoxyfylline, topical antiseptics and split-thickness skin grafts
List some complications of varicose veins.
Itching (venous eczema)
Bleeding
Swelling
Skin changes (haemosiderin deposition, lipodermatosclerosis, venous ulcers)
How is thyroid cancer managed?
Total thyroidectomy
T4 to suppress TSH
With or without radioiodine
NOTE: thyroglobulin is used as a tumour marker (and calcitonin in medullar thyroid cancer)
What is the normal range for central venous pressure?
0-6 mm Hg
NOTE: fluid overload is associated with a high CVP
List some secondary causes of Raynaud’s phenomenon.
Blood: polycythaemia, cryoglobulinaemia, cold agglutinins
Arterial: atherosclerosis, thrombangiitis obliterans
Drugs: beta-blockers, OCP
Cervical rib: thoracic outlet obstruction
Autoimmune: SLE, RA, SS
What is Saint’s triad?
A condition in which diverticular disease, hiatus hernia and cholelithiasis occur at the same time
List some complications of using proctoscopes.
Haemorrhage
Perforation
List some differentials for exophthalmos.
Graves’ disease
Orbital cellulitis
Trauma
Masses (meningioma, glioma)
Cavernous sinus thrombosis
Describe the national AAA screening programme.
Men aged 65 years offered a one-time ultrasound scan
What is a Fogarty embolectomy catheter used for?
Management of an acutely ischaemic limb
NOTE: insert into femoral artery at groin, pass catheter distal to embolus, inflate balloon and withdraw
List some complications of tracheostomy.
IMMEDIATE: haemorrhage, trauma, pneumothorax
EARLY: tracheal erosion, tube displacement/obstruction, surgical emphysema, aspiration pneumonia
LATE: tracheomalacia, tracheo-oesophageal fistula, tracheal stenosis
Describe the typical presentation of ACL injury.
Caused by deceleration and rotational movements
Hear a pop
Inability to continue activity
Haemarthrosis within 4-6 hours
Instability/giving way following injury
What are the two different types of prosthesis that can be used for hip arthoplasty?
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)
Outline the measures taken to prevent DVT in orthopaedic patients.
TED stockings
Hydration
Minimise length of surgery
Intermittent pneumatic compression devices
LMWH (also DOACs)
Early mobilisation
Good analgesia
Physiotherapy
List some complications of appendicectomy.
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)
What are the advantages of tracheostomy over ET tubes?
Easier to wean patients
No need for sedation
Reduced discomfort
Reduced risk of glottis trauma
Reduced dead space (reduced work of breathing)
Which special tests can be used to elicit symptoms in patients with suspected carpal tunnel syndrome?
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
Which operations would require a Pfannenstiel incision?
Caesarean section
Gynaecological surgery
Lower urinary tract surgery
Extraction of excised organs (along with laparoscopic port sites)
List some risk factors of incisional hernias.
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
Which nerve roots are responsible for the following reflexes?
Ankle
Knee
Triceps
Biceps
Ankle: S1-S2
Knee: L3-L4
Biceps: C5-C6
Triceps: C7-C8
Which two types of incision are used for appendicectomy and how are they different?
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)
What are the main indications for amputation of a leg?
Dead (peripheral vascular disease, thrombangiitis obliterans)
Dangerous (sepsis, malignancy)
Damaged (trauma, burns, frostbite)
Damned nuisance (pain, neurological damage)
Define varus and valgus.
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
List some complications of Colles fracture.
Median nerve injury
Frozen shoulder
Tendon rupture (especially EPL)
Mal-/non-union
What is Calot’s triangle and what are its borders?
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
What are the advantages and disadvantages of the use of implants for breast reconstruction?
ADVANTAGES: simpler technique
DISADVANTAGES: worse cosmetic results, requires lots of available skin, risk of complications (capsular contracture, infection, implant leakage)
What is a branchial cyst?
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
Outline the management of carpal tunnel syndrome.
NON-SURGICAL: treat underlying cause, wrist splints (hold it in extension), local steroid injections
SURGICAL: carpal tunnel decompression by dividing the flexor retinaculum
What are the general recommendations on how to prepare for surgery regarding oral intake?
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
List some complications of hip arthroplasty.
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)
Where can the ulnar nerve be compressed?
Elbow: cubital tunnel
Wrist: Guyon’s canal
NOTE: other causes of ulnar nerve palsy include supracondylar fractures of the humerus and elbow dislocation
Outline the ASA classification system.
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
List some risk factors for wound infections.
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
List some causes of unilateral leg swelling.
DVT
Trauma (e.g. compartment syndrome, muscle rupture)
Venous disease
Lymphoedema (Milroy syndrome, surgery, radiotherapy, TB, filariasis)
Malignancy (sarcoma)
What is the most common type of salivary gland neoplasm?
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
List two major complications of acute sinusitis.
Periorbital cellulitis
Brain abscess
Describe Perthes test.
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
What flow rate and percentage of oxygen can be administered through nasal prongs?
1-4 L/min
24-40% oxygen
List some indications for surgical treatment of UC.
ACUTE
- Toxic megacolon
- Perforation
- Severe GI bleeding
CHRONIC
- Failure of medical management
- Malignancy
- Failure of maturation in children
List some causes of knee effusions.
Synovial fluid: synovitis
Blood: ACL rupture, intrarticular fracture, meniscal tear, bleeding diathesis
Pus: septic arthritis
What is a dominant peroneal artery?
Present in 5% of the population
Dorsalis pedis pulse is absent but a pulse can be felt just anterior to the lateral malleolus
What is the most appropriate surgical management option for most rectal tumours?
Anterior resection
NOTE: low rectal tumours should be managed with abdominoperineal resection
NOTE: Hartmann’s procedure is used for sigmoid tumours
What operations are likely to require a loop ileostomy?
Anterior resection (colon cancer)
Bowel rest (Crohn’s disease)
NOTE: this stoma is used to rest the bowel distal to the stoma
How should patients be positioned when examining their hernial orifices?
Start with them standing
Then repeat the examination with them lying down
Which investigations are usually requested for patients attending a rapid access clinic for haematuria?
MSU
Renal/bladder ultrasound
CT urogram (all > 50 yrs + all with frank haematuria)
Flexible cystoscopy
What is a bunion?
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
Outline the management of gangrene.
Take cultures
Debridement
Antibiotics (e.g. vancomycin, cephalosporins)
EPONYMOUS OPERATIONS: umbilical hernia
Mayo repair: double-breast the linea alba +/- sublay mesh
List some complications of open repair of AAA.
Mortality (elective: 5%; emergency: 50%)
MI
Renal failure
Anastomotic bleeding
Graft infection
Spinal or mesenteric ischaemia
Distal trash from thromboembolisation
Aortoenteric fistula
EPONYMOUS OPERATIONS: femoral hernia
Lockwood approach - low incision over hernia with herniotomy and herniorrhaphy (ELECTIVE)
McEvedy approach - high approach in inguinal region with herniotomy and herniorrhaphy (EMERGENCY)
Describe how neck of femur fractures are defined based on their anatomical location.
INTRAcapsular: subcapital, transcervical, basicervical
EXTRAcapsular: intertrochanteric, subtrochanteric, reverse oblique intertrochanteric
What do you ‘look’ for when examining a joint?
Scars
Swelling
Deformity
Redness
What are the ways in which you can reduce closed and open fractures?
Closed –> manipulation or traction (skin or skeletal pins in bone)
Open –> mini-incision or full exposure
What operations would require a Mercedez-Benz/Rooftop incision?
Hepatobiliary surgery (e.g. liver transplant, Whipple’s, liver resection, gastric surgery)
What is the normal range of motion for a hip joint?
Abduction: 45
Adduction: 30
Flexion: 130
Internal rotation: 20
External rotation: 45
What is mallet finger?
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
EPONYMOUS OPERATIONS: chronic venous insufficiency
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
Outline bladder tumour staging.
Ta - within mucosa
T1 - into submucosa
T2 - into muscularis propria
T3 - into perivesical fat
EPONYMOUS OPERATIONS: undescended testicle
Dartos Pouch Procedure - mobilisation of testis and placement in a pouch via a hole in the dartos muscle
What is a major contraindication for TED stockings?
Arterial disease (e.g. peripheral vascular disease)
Severe skin breakdown (ulceration/infection)
List some causes of haematuria.
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
What are the four stages of clubbing?
1) bogginess of nail bed
2) loss of nail angle
3) increased curvature
4) expansion of distal phalanx
Which layers are cut in a midline laparotomy incision?
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
List some specific complications of colonic surgery.
EARLY: ileus, acute acalculous cholecystitis, anastomotic leak, enterocutaneous fistulae, abdominal abscess
LATE: adhesions (obstruction), incisional hernia
List the different colours of vacutainer and their uses.
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
Define aneurysm.
Abnormal dilatation of a blood vessels to > 50% of its normal diameter
What are ganglion cysts?
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
After how long is a surgical drain usually removed?
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
List some complications of ERCP.
Pancreatitis (5%)
Bleeding (check clotting beforehand)
Bowel perforation
Contrast allergy
What are the different types of internal fixation?
Intramedullary –> pins or nails
Extramedullary –> plate/screws or pins
List some differentials for knee osteoarthritis.
Septic arthritis
Medial meniscus tear
Gout
Rheumatoid arthritis
How are pharyngeal pouches treated?
Dohlman’s procedure - minimally invasive endoscopic stapling
What is a neurofibroma?
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
EPONYMOUS OPERATIONS: cancer of the head of the pancreas
Whipple’s - removal of head of pancreas
Also removes gastric antrum, gallbladder, proximal duodenum and regional lymph nodes
Where are port sites usually found for a laparoscopic cholecystectomy?
Umbilicus
Epigastrium
Right costal margin
Right flank
Outline the management of lumbar disc herniation.
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
List some complications of fractures.
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
EPONYMOUS OPERATIONS: varicocele
Palomo operation - high retroperitoneal approach for ligation of testicular veins, transverse incision at midinguinal point on level of ASIS
List some indications for surgical thyroidectomy.
Mechanical obstruction
Malignancy
Cosmetic
Failure of medical treatment
Mediastinal extension
What are some causes of hip pain after a hip arthroplasty?
Post-operative abductor weakness/rupture
Leg length discrepancy
Loosened prosthesis
Prosthesis infection
Radiating back pain
List some complications of carotid endarterectomy.
Stroke or death
Haematoma
MI
Nerve injury (hypoglossal, great auricular (numb ear lobe), recurrent laryngeal nerve)
What is the main indication for using a three-way urinary catheter?
Irrigate the bladder in patients at risk of clot retention (e.g. after TURP or patients with haematuria)
List some causes of salivary gland swelling.
Duct strictures
Calculi
Sialadenitis
Inflammatory (Sjogrens, sarcoid)
Tumours (80% in parotid)
NOTE: three main pairs of salivary glands - submandibular, sublingual and parotid
List some differentials for LIF masses.
Faecal mass
Colon cancer
Diverticular mass
Transplanted kidney
Ovarian tumour/fibroid
Ectopic kidney
Iliac artery aneurysm
What test is used when assessing a patient with suspected de Quervain’s tenosynovitis?
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
What are the benefits of Hickman lines over PICC lines?
PICC lines are not suitable for all medications
PICC lines block more easily
PICC lines may cause clots in your arm
What are the features of Leriche syndrome?
Buttock claudication and wasting
Erectile dysfunction
Absent femoral pulses
NOTE: caused by aorto-iliac insufficiency
List some complications of TURP.
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
What are the advantages and disadvantages of suprapubic catheterisation?
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)
What are the main types of testicular tumour?
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)
Outline the surgical management of inguinal hernias.
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
List some conditions that cause lipomas.
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
What is a cholesteatoma?
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
What are the borders of the femoral canal?
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)
What are the indications for immediate CT head scan (within 1 hour) in patients who have had a head injury?
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
List some causes of shoulder pain with or without reduced range of motion.
Rotator cuff tear/tendonitis
Subacromial bursitis
Adhesive capsulitis (frozen shoulder)
Synovitis
Osteoarthritis
Dislocation
Fracture of the humeral head
Referred pain from the diaphragm
Which operations are likely to require a loop colostomy?
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
List some differentials for midline neck masses.
Thyroid isthmus mass
Inclusion dermoid cyst
Thyroglossal cyst
What is a dermoid cyst?
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
What does the McMurray test look for?
Meniscal tears
EPONYMOUS OPERATIONS: pyloric stenosis
Ramstedt pyloromyotomy - longitudinal incision through muscularis propria at pylorus
What is the main indication for abdomino-perineal resection?
Tumours lying within 4-5 cm of the anal verge
List some complications of mechanical ventilation.
Pneumothorax
Fluid retention
Ventilator-induced lung injury
Ventilator-associated pneumonia
Outline the management of Dupuytren’s contractures.
Non-Surgical: physiotherapy, steroid injections, allopurinol
Surgical: fasciotomy, partial fasciectomy (Z-plasty), arthrodesis
List some complications of carpal tunnel decompression surgery.
Hypertrophic and keloid scars
Scar tenderness
Nerve injury (palmar cutaneous branch of median nerve, motor branch to thenar muscles)
Failure to relieve symptoms
What causes winging of the scapula?
Serratus anterior weakness
May be due to long thoracic nerve injury, upper brachial plexus injury and muscular dystrophy (fascio-scapulo-humeral)
Outline the surgical management of extracapulsar neck of femur fractures.
ORIF with dynamic hip screw
What are the different types of external fixation?
Monoplanar
Multiplanar
What are the advantages and disadvantages of minimal access surgery?
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
What are the main approaches to preventing problems with fracture union?
Optimise physiology: treat/prevent infection, bone graft, ensure adequate blood supply, bone morphogenetic protein
Optimise mechanics: external fixation, internal fixation
List some complications of surgical management of NOF fractures.
Avascular necrosis of femoral head (if displaced fracture)
Non/malunion
Infection
Osteoarthritis
What does pain on straight leg raise suggest?
Lumbosacral nerve root irritation
NOTE: Lesague sign is worsening pain on dorsiflexion of the foot
Which ducts connect the submandibular and parotid glands to the oral cavity?
Submandibular - submandibular duct (Wharton’s duct) - adjacent to frenulum
Parotid - parotid duct (Stensen’s duct) - opposite 2nd maxillary molar
Which operations are likely to require an end ileostomy?
Permanent: panproctocolectomy (e.g. UC)
Temporary: total colectomy with later ileal pouch-anal anastomosis (e.g. FAP)
EPONYMOUS OPERATIONS: Achalasia
Heller’s cardiomyotomy - longitudinal incision through muscularis propria at lower oesophageal sphincter
What are some major contraindications for using a nasopharyngeal tube?
Facial injuries
Basal skull fracture (Raccoon eyes, Battle sign, haemotympanum, CSF rhinorrhoea/otorrhoea)
Which surgical treatment options are considered in UC patients?
Subtotal colectomy with end ileostomy +/- mucus fistula (can be followed with ileorectal anastamosis, IPAA or permanent end ileostomy)
Proctocolectomy and end ileostomy
Describe Buerger’s test.
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
What is thoracic outlet syndrome?
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
List some indications for using a larngeal mask airway.
Non-definitive airway for short day-case surgery
Emergency situations if unable to insert ET tube
List some causes of gynaecomastia.
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)
Which classification system is used for diverticulitis?
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
Which classification system is used for pelvic fractures?
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
What is Goodsall’s law?
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.
What is the difference between an open and a closed surgical drain?
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)
What are the contents of the inguinal canal in males?
Spermatic cord
Ilioinguinal nerve
Outline the staging of prostate cancer.
Stage 1 and 2 - can’t be palpated on DRE
Stage 3 - can palpate on DRE
Stage 4 - metastasised
List some indications for bypass grafting in chronic limb ischaemia.
Very short claudication distance
Symptoms greatly affecting patient
Rest pain
What is the main purpose of a CT urogram?
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
List some causes of a persistent hoarse voice.
Nodules
Polyps
Reinke’s oedema
Granuloma
Laryngeal cancer
Which classification system is used for fractures of the growth plate?
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
Outline the management of incisional hernias.
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
List some indications for central venous catheters.
Central venous pressure measurement (for fluid balance)
Drug administration (amiodarone, mannitol, potassium)
Total parenteral nutrition
How can direct and indirect inguinal hernias be distinguished on examination?
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
What is the main indication for a urostomy?
Total cystectomy
Which nerves may be damaged in a carotid endarterectomy?
Recurrent laryngeal nerve
Hypoglossal nerve
What is the difference between true leg length and apparent leg length?
True: ASIS to medial malleolus
Apparent: umbilicus to medial malleolus
NOTE: Galeazzi test checks whether the shortening is due to tibial or femoral shortening
List some causes of true leg shortening.
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
List some causes of small bowel obstruction
Adhesions
Hernia
Paralytic ileus
Faeces
Foreign body
Gallstone ileus
Benign stricture
Malignant stricture
Drugs (e.g. TCA)
Outline the management of ACL rupture.
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
List some complications of open fractures.
Clostridium perfringens (gas gangrene)
Hypovolaemic shock
Neurovascular compromise
Compartment syndrome
Fat embolism
Which classification system is used for open fractures?
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
List some complications of total parenteral nutrition.
Line-related: pneumothorax, arrhythmia, line sepsis, thrombosis
Feed-related: villous atrophy, electrolyte disturbance (refeeding syndrome), hyperglycaemia, vitamin and mineral deficiencies
In general terms, how does the management of intracapsular fractures differ from extracapsular fractures?
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
Outline the post-operative VTE prophylaxis that is offered for patients undergoing hip and knee replacements.
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
Which arteries supply blood to the head of the femur?
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
List some differentials for monoarthritis.
Septic arthritis
Crystal (gout, pseudogout)
Trauma
Haemarthrosis
Reactive
Psoriatic arthritis
List some indications for using a central line.
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.
List some interventions that use Seldinger technique.
Central venous access
Arterial access (angiography)
Intra-abdominal/biliary/ureteric drainage
PEG insertion
List some indications for a chest drain.
Pneumothorax
Pleural effusion
Haemothorax
Post-surgical (cardiac, thoracic, oesophageal)
NOTE: in pneumothorax the tube should point upwards, in pleural effusion it should point downwards
List some indications for using surgical drains.
Drain potential space post-surgery
Removal of harmful fluid (blood, pus, bile)
Detection of bleeding or leakage (anastomosis)
List some complications associated with surgical drains.
Ascending infection
Foreign body reaction (fibrosis/granulation)
Migration
Obstruction/kinking
Fistulation
What CXR features would suggest that an NG tube is sited correctly?
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?
What is the main indication for using a feeding NG tube?
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
List some complications of NG tubes.
Aspiration pneumonia (due to incorrect position)
Pneumothorax
Malposition in GI tract
Obstruction/knotting/kinking
Reflux oesophagitis
Gastritis
Visceral perforation
List some indications for post-pyloric feeding.
Gastroparesis (DM, critical illness, neurological (MS, PD), scleroderma)
Gastric outlet obstruction (PUD, malignancy)
Recurrent aspiration
Pancreatitis (less stimulation of pancreas)
What are the two materials that urinary catheters can be made of?
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
List some indications for using a urinary catheter.
Urinary retention
Measurement of urine output
During abdominal/pelvic surgery
Neurogenic bladder
Immobility (e.g. stroke)
End of life care
Urinary incontinence
What are the three main types of scalpels?
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)
Outline the general rules for using absorbable, non-absorbable and monofilament sutures.
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)
Why is CO2 used to insufflate the abdomen in laparoscopic surgery?
It is inert, highly soluble and rapidly cleared by expiration
NOTE: techniques for laparoscopic trocar insertion include Veress needle and Hasson technique
What are the two forms of diathermy?
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
What are some risks of using an oropharyngeal airway?
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)
List some indications for using a laryngeal mask airway.
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)
What is a definitive airway?
Infraglottic
Secure (cuffed)
Prevents aspiration of gastric contents
Can deliver maximum concentrations of oxygen
List some indications for tracheostomy.
Weaning off mechanical ventilation
Severe maxillofacial trauma
List some indications for intubation.
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)
Outline the management options for hypertrophic and keloid scars.
Topical silicone gel sheets
Intralesional steroid and local anaesthetic injections
Antihistamines
Surgery: revision of scar
List some differentials for a groin lump.
Inguinal hernia
Femoral hernia
Saphena varix
Undescended testicle
Femoral artery aneurysm
Lymph node
Lipoma/sebaceous cyst
Which hand muscles are innervated by the median nerve?
Lateral two lumbricals
Opponens policis
Abductor policis brevis
Flexor policis brevis
LLOAF
List some causes of a positive Trendelenburg test.
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
What are the main stages of wound healing?
Haemostasis (vasospasm, platelet plug formation)
Inflammation (neutrophils migrate to wound and release growth factors)
Regeneration (fibroblasts produce collagen network)
Remodelling (collagen fibres remodelled)
Which routine bloods are one before any operation?
FBC
U&E
Group and Save
Clotting
Glucose
How should insulin-dependent diabetic patients be managed around an elective operation?
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
How should non-insulin dependent diabetic patients be managed around an elective operation?
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)
What are the risks of operating on a jaundiced patient?
Obstructive jaundice –> increased risk of renal failure
Coagulopathy
Increased infection risk (cholangitis)
How should anticoagulated patients with a low VTE risk be managed before an elective operation?
Stop warfarin 5 days pre-op (aim for INR < 1.5)
Restart warfarin the day after operation
How should anticoagulated patients with a high risk of VTE be managed before an elecive operation?
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
Outline the main principals of general anaesthesia.
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
List some complications of general anaesthesia.
Cardiorespiratory depression (propofol)
Intubation injury (oropharyngeal)
Loss of pain sensation (urinary retention, nerve palsies)
Loss of muscle power (atelectasis)
Malignant hyperthermia
Anaphylaxis (colloid, antibiotics)
List some complications of inadequate analgesia for surgery.
Wound hypoperfusion (impaired wound healing)
Reduced mobilisation (VTE, deconditioning)
Reduced coughing (atelectasis, pneumonia)
List some causes of post-operative urinary retention.
Drugs (opioids, epidural/spinal anaesthesia, anticholinergics)
Pain
Psychogenic (hospital environment)
Describe the presentation of post-operative atelectasis.
Within 48 hours of operation
Mild pyrexia
Dyspnoea
Dull bases with reduced air entry
List some complications of breast surgery.
Arm lymphoedema
Seroma
Skin necrosis
List some causes of post-operative pyrexia.
EARLY: blood transfusion, physiological, atelectasis, infection
DELAYED: pneumonia, VTE, wound infection, anastomotic leak, collection
List some aspects of assessing the fluid status of a patient.
Capillary refill
Heart rate
BP lying/standing
JVP
Skin turgor
Mucus membranes
Urine output (and U&E)
Consciousness
Which type of fluid should be used in patients with cardiac or renal failure?
5% dextrose
AVOID fluids with sodium because these patients will be retaining sodium
What is the normal output you would expect to see from an ileostomy?
10-15 mL/kg/day = 700 mL/day
NOTE: high output is > 1000 mL/day
List some different types of enteral nutrition.
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))
What are the components of a secondary survey?
Allergies
Medications
PMH
Last ate/drank
Events
What are the different types of burn and how do they present?
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
What are the phases of fracture healing?
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)
What are the three types of fracture based on aetiology?
Traumatic
Stress (bone fatigue due to repetitive strain)
Pathological (normal forces on diseased bone)
What are the main methods of reducing a fracture?
Manipulation/closed reduction
Traction (not used now)
Open reduction (accurate reduction in surgery)
What are the main methods of holding a fracture?
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)
List some causes of reflex sympathetic dystrophy.
Fractures
Carpal tunnel disease
Operations for Dupuytren’s contracture
Presentation: hyperalgesia, allodynia, vasomotor symptoms, weakness, dystonia (NOT traumatised area affected - usually neighbouring area)
What is Shenton’s line?
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)
What is a Barton fracture?
Oblique intra-articular fracture involving the dorsal aspect of the distal radius with dislocation of the radio-carpal joint
Outline the management of a suspected scaphoid fracture.
Scaphoid plaster (beer glass position)
Re-X ray after 10 days to decide how long the plaster should stay there for
What is impingement syndrome?
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
Outline the management of impingement syndrome.
Conservative: rest and physiotherapy
Medical: NSAIDs, subacromial bursa steroid injection
Surgical: arthroscopic acromioplasty
Describe the examination findings of a complete rotator cuff tear.
Shoulder tip pain
Full range of passive motion
Inability to abduct the arm
Active abduction possible after passive abduction to 90 degrees
Outline the Ottawa rules regarding ankle fractures.
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
How are ankle fractures managed?
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
What is the ‘unhappy triad’ in orthopaedics?
ACL
MCL
Medial meniscus
NOTE: sometimes referred to as a blown knee
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)
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
List some causes of avascular necrosis of bone.
Fracture
Dislocation
Sickle cell disease
SLE
Drugs (e.g. steroids)
What are the contents of the carpal tunnel?
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
List some causes of Dupuytren’s contracture.
Alcoholism
Idiopathic (most common)
Epilepsy and medications (phenytoin)
Diabetes mellitus
Smoking
Peyronie’s disease
What is Chilaiditi sign?
A loop of bowel between the liver and the diaphragm gives the impression of pneumoperitoneum
How are perforated peptic ulcers repaired?
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
List some causes of obstructive jaundice.
Gallstones
Pancreatic cancer
Cholangiocarcinoma
PSC/PBC
Drugs (co-amoxiclav, OCP)
Describe the anatomy of the anal canal.
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
What are haemorrhoids?
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
Define fistula.
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
What are the two types of rectal prolapse?
Type 1: Mucosal Prolapse - partial prolapse of redundant mucosa
Type 2: Full Thickness Prolapse - more common, elderly females with poor O&G history
What are the boundaries of the anterior and posterior triangles of the neck?
Anterior: anterior margin of SCM, midline, ramus of the mandible
Posterior: posterior margin of SCM, anterior margin of trapezius, middle 1/3 of clavicle
Outline the national breast cancer screening programme.
Every 3 years from 47-73 years
Mammography (craniocaudal and oblique)
List some complications of mastectomy.
Haematoma
Seroma
Long-thoracic nerve damage (winging)
Lymphoedema
Which classification system is used for limb ischaemia?
Fontaine
1 - asymptomatic
2 - intermittent claudication
3 - ischaemic rest pain
4 - ulceration/gangrene
NOTE: Rutherford is another classification system
List some sources of emboli that could cause acute limb ischaemia.
AF
Valve disease
Iatrogenic (surgery, angioplasty)
Paradoxical (via PFO)
Outline the management of acute limb ischaemia.
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)
List some causes of aneurysms.
CONGENITAL: ADPKD, Marfan’s, Ehlers-Danlos
ACQUIRED: atherosclerosis, trauma, inflammatory (takayasu’s aortitis), syphilis
What are the different types of skin graft?
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)
List some differentials for bilateral leg swelling.
Increased venous pressure: RHF, venous insufficiency, drugs (CCB)
Decreased oncotic pressure: nephrotic syndrome, HF, protein losing enteropathy
Lymphoedema
Myxoedema (pretibial)
List some causes of urinary tract obstruction.
LUMINAL: stones, blood clots
MURAL: tumour, neuromuscular dysfunction
EXTRAMURAL: prostate enlargement, abdominal mass, retroperitoneal fibrosis
List the main subtypes of renal adenocarcinoma.
Clear cell carcinoma (MOST COMMON)
Papillary
Chromophobe
Collecting duct
Outline the management of bladder cancer based on stage.
Tis, Ta, T1 = superficial –> intravesical mitomycin and BCG, diathermy via TURBT
T2, T3 = invasive –> radical cystectomy + ileal conduit
T4 = palliative –> chemotherapy, long-term catheterisation
Outline the management options for prostate cancer.
Conservative: active monitoring
Medical: LHRH analogues (goserelin), anti-androgens (cyproterone acetate)
Radical prostatectomy
Brachytherapy
Outline the management of otitis externa.
Ear drops containing steroid and antibiotic
NOTE: malignant otitis media can lead to osteomyelitis so requires surgical debridement and IV antibiotics
What are the different types of otitis media?
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
List some causes of tinnitus.
Meniere’s disease
Acoustic neuroma
Otosclerosis
Noise-induced
Head injury
Drugs (aspirin, loop diuretics)
NOTE: all patients with unilateral tinnitus should have an MRI
List some causes of vertigo.
VESTIBULAR: BPPV, Meniere’s, Labyrinthitis
CENTRAL: acoustic neuroma, MS, stroke
DRUGS: gentamicin, loop diuretics
What is Meniere’s disease?
Dilation of the endolymph spaces of the membranous labyrinth
Causes progressive SNHL, vertigo, tinnitus and aural fullness
Which medications are often used to treat vertigo?
Cyclizine
Betahistine
What are the Centor criteria for tonsillitis?
Fever
Tonsillar exudates
Tender anterior cervical lymphoadenopathy
No cough
3 or more = give antibiotics
What is the difference between metachronous and synchronous cancers?
Synchronous - secondaries occurring within 6 months of primary cancer
Metachronous - secondaries occurring over 6 months after primary cancer
List some reasons for enucleation of the eye.
Trauma
Tumour (retinoblastoma)
Infection
Phthisis bulbi (shrunken non-functional eye)
Sympathetic ophthalmia
Why do anastomoses of the sigmoid colon require a defunctioning loop ileostomy?
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
Outline the management of diverticulitis.
Mild - bowel rest at home (fluids only)
Severe - NBM, drip and suck, antibiotics (ceftriaxone and metronidazole), analgesia
Obstruction/Perforation - Hartmann’s resection
What are the main types of perianal fistula and how are they treated?
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
Outline the management of haemorrhoids.
Conservative: fibre
Medical: topical hydrocortisone, laxatives
Surgical: rubber band ligation, injection sclerotherapy, haemorrhoidectomy
What is taken into account by the modified Glasgow score for pancreatitis?
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
List some causes of chronic pancreatitis.
Gallstones
Ethanol
Recurrent acute pancreatitis
Cystic fibrosis
Haemochromatosis
Autoimmune
NOTE: complications include DM, pseudocysts and cancer
Define osteoarthritis.
Degenerative joint disorder characterised by loss of hyaline cartilage and new bone formation at the joint surface.
Which ligaments are sacrificed in total knee replacement?
ACL is usually sacrificed (however newer replacements may spare it)
IMPORTANT: do not do anterior draw on TKR patients
What are the pros and cons of cemented vs uncemented total hip replacement?
Cemented: better for older patients with poor bone quality and turnover
Uncemented: porous and bone in-growth, makes revision of hip more difficult
What are the 6 As of dealing with open fractures?
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)
What is the normal pressure of the lower oesophageal sphincter?
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
What is a paramedian incision used for?
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)
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?
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
List the mechanisms that could cause GORD.
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)
List some risk factors for gastric cancer.
H. pylori
Atrophic gastritis (pernicious anaemia)
Diet (cured meats)
Smoking
Wht are the three points at which the ureter narrows?
Uretopelvic junction
Pelvic rim
Vesicoureteric junction
How can the point during micturition at which blood is seen allude to the location of the pathology?
Beginning of stream = urethral
Throughout = renal
End = bladder
List some indications for 2 week cystoscopic referral.
All frank haematuria
Persistent haematuria + dysuria
Haematuria + lower urinary tract symptoms
Female retention
Outline the staging of renal cell carcinoma.
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
List some investigations for varicose veins.
Duplex ultrasound
MR venography
What are the two types of below knee amputation?
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
What is the pes anserinus?
Conjoined tendons of three muscles entering into the anteromedial surface of the proximal tibia (semitendinosus, gracilis, sartorius)
Which bursae are found around the knee joint?
Suprapatellar
Pre-patellar
Infrapatellar (subcutaneous and deep)
Semimembranosus
Pes anserine
What are the main differences between epidural and spinal anaesthesia?
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)
List some complications of ocular protheses.
Lagophthalmos (incomplete closure of eyelid over eye)
Enophthalmos
Rotating prosthesis
Prosthesis falling out
Exophthalmos
Describe the classification of joints.
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)
List the main indications for operating on varicose veins.
Venous eczema and ulceration
Skin changes including lipodermatosclerosis
Oedema
Describe the management of low-risk and high-risk invasive bladder cancer.
Low-risk: TURBT + intravesical mitomycin
High-risk: TURBT + intravesical BCG
List some risk factors for umbilical and paraumbilical hernias.
Pregnancy
Ascites
Obesity
Which operations may be conducted in patients with Crohn’s disease?
Ileocaecectomy
Abscess drainage
Stricturoplasty
Colectomy
List some causes of leg length discrepancy.
True: congenital, post-traumatic, bone tumours
Apparent: scoliosis
What are the contents of the adductor canal?
Femoral artery
Femoral vein
Femoral nerve
Saphenous nerve
Boundaries: adductor longus and magnus, vastus medialis, sartorius
Which important pre-operative intervention reduces the risk of infection in patients undergoing an appendicectomy?
Single dose IV tazocin 30 mins before the operation
What are the main aspects of conducting a hernia examination?
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
What are the branches of the coeliac trunk?
Left gastric artery
Splenic artery
Common hepatic artery
Describe the main symptoms of ulnar collateral injury of the thumb.
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
What is a Bennett’s fracture?
Intra-articular fracture of the first metacarpal bone (often associated with boxing)
NOTE: usually requires ORIF, high risk of osteoarthritis later in life
Where will you see scars other than in the breast for the different types of myocutaneous flap?
Latissimus dorsi - back over lat dorsi (looks a bit like lateral thoracotomy)
DIEP and TRAM - transverse lower abdominal scar (along the bikini line)
How is a DIEP flap different from a TRAM flap?
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)
What is the most common cause of cubitus varus?
Supracondylar fracture of the humerus
NOTE: can be corrected with osteotomy
List and describe some types of toe deformity.
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
What is the most commonly used management option for Colles fractures?
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
What are the boundaries of the anatomical snuffbox?
Medial: extensor pollicis longus
Lateral: abductor pollicis longus + extensor pollicis brevis
Floor: scaphoid
Crossed by: radial artery
Describe the incisions used in a 4-compartment fasciotomy.
Medial and lateral skin incisions
Through the lateral incision, you divide the fascia of the superficial and deep posterior compartments
What is the difference between tennis elbow and golfer’s elbow?
Tennis: lateral epicondylitis (insertion of extensor carpi radialis brevis)
Golfer: medial epicondylitis
List some risk factors for hernias.
Pregnancy
Obesity
Weight lifting
Chronic cough
Which blood artery is a transplanted kidney usually connected to?
External iliac artery
List some complications of supracondylar humerus fractures.
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
Define compartment syndrome.
An increase in pressure within an osseofascial compartment (usually > 30 mm Hg diastolic)
What operation is used to treat cataracts?
Phacoemulsification - involves emulsifying and aspirating the lens before inserting an implant
