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
Ilioinguinal nerve
Genital branch of the genitofemoral nerve
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
