Surgical shorts Flashcards
Features of a malignant breast lump: (6)
Features of a Malignant Lump
- Irregular, nodular surface
- Poorly defined edge
- Hard / scirrhous consistency
- Painless
- Fixation to skin or chest wall
- Nipple involvement
Types of malignant breast lumps (6)
- Ductal carcinoma NOS: ~70% of cancers
- Lobular carcinoma: ~20% of cancers
- Other: mucinous,
- other: medullary,
- other: papillary
- other: Phylloides tumours
What do you see: examine
-
Inspection
- General
- Note asymmetry
- Descr scar
- Arm lymphoedema
- Evidence of radiotherapy
- Evidence of axillary clearance / radiotherapy
- Ask patient to press hips: pec major present?
- nipple tattoo
- Flap Reconstruction
- Scars extend over back or abdominal wall
- Recess:
- On back where lat dorsi has been removed
- In the rectus muscle; ask pt. to lift head of bead (when lying supine) to see recess
- Implant Reconstruction
- Rounder shape than normal breast
- Breast usually lies higher
- Becker implant may have palpable SC filling port in the axilla
- General
Types of breast reconstruction flaps:
- Implants:
- Myocutaneous:
- Latissimus dorsi myocutaneous flap
- transverse rectus abdominis myocutaneous (TRAM) flap
- Deeper inferior epigastric perforator (DIEP) flap
Transverse Rectus Abdominis Myocutaneous (TRAM) Flap
- Pedicled: inf. epigastric A.
- Or free: attached to internal thoracic A
- No implant necessary and combined tummy tuck
- CI if poor circulation: smokers, obese, PVD, DM
- Risk of abdominal hernia
Deep Inferior Epigastric Perforator (DIEP) Flap
- Evolution of the TRAM flap
- Free: skin and fat only, no muscle
- Spares the rectus: ↓ pain and ↓ risk of hernia
- May not be possible if small perforators
Latissimus Dorsi myocutaneous flap
- Pedicled: skin, fat, muscle and blood supply
- LD mobilised and tunnelled medially to form neo-breast
- Supplied by thoracodorsal A. via subscapular A.
- Often augmented c¯ an implant
Advantages and disadvantages of implants
- advantages:
- simpler technique
- primary or delayed
- disadvantage:
- cosmetic result not as good
- requires plenty of available skin
- lies higher than other breast
- late comp:
- capsilar contracture
- implant leakage
- infection req removal
myocutaneous flaps advantages and disadvantages
- advantages:
- useful when little remaining skin or muscle
- good cosmetic result
- primary or delayed
- Disadvantages:
- increased blood loss
- increased time of op and complication rate
- use of rectus impossible if pt has had abdo surgery
- late complications: flap necrosis and infection
What scar do you see?
Dermofasciectomy with FTSG (full thickness skin graft)
What scar do you see?
Well healed 7cm midline scar on the palmar surface of the right hand vertically over the carpal tunnel consistent with open carpal tunnel release surgery
nb ultra minimally invasive (Ultra-MIS) carpal tunnel release (CTR) through 1mm incision is possible
What scar do you see?
Partial fasciectomy-Z plasty
(Causes of;abcdef+T)
AIDS/Age
Booze
Cirrhosis
Diabetes
Epileptics (anti)
Familial/Fibromatoses
& trauma
Where else would you look? (nb. shorts Q)
x2
- Feet: for plantar fascia thickening in Ledderhose disease
- Penis: Peyronie’s disease - scar tissue in tunica albuginea apparently affects 5% of men
What is the pathophysiology of dupuytren’s contracture
Palmar fascia becomes abnormally thick due to change from type 1 to type 3 collagen, which is significantly thicker
(microvascular ischaemia -> increased xanthine oxidase activity-free radicals-myofibroblast proliferation)
How would you manage Dupuytren’t
C/M/S
- Conservative: splint
- Medical: radiation, collagenase
- Surgical: fasciotomy
What are your differentials
(2)
Ulnar claw; ulnar nerve palsy/volkmann’s ischaemic contracture
What is the ulnar paradox
The ulnar nerve also innervates the ulnar (medial) half of the flexor digitorum profundus muscle (FDP). If the ulnar nerve lesion occurs more proximally (closer to the elbow), the flexor digitorum profundus muscle may also be denervated. As a result, flexion of the IP joints is weakened, which reduces the claw-like appearance of the hand.[3] This is called the “ulnar paradox” because one would normally expect a more proximal and thus debilitating injury to result in a more deformed appearance.
‘the closer to the Paw, the worse the Claw’.
Decreased sensation
What is volkmann’s ischaemic contracture
aetiology
result
What do you see?
Wasting of the thenar eminence on the left hand
seen in carpal tunnel syndrome due to median nerve palsy
Pathophysiology of CTS
Flexor retinaculum strong fibrous band covering carpal bones on palmar side of hand Attaches to pisiform and hamate on ulnar side and scaphoid and trapezoid on radial side Ulnar artery, nerve and cutaneous branches of median and ulnar nerves pass on top Median nerve and tendons of muscles that flex the hand run through the carpal tunnel
Causes of CTS
(IWRIST)
I WRIST
- Idiopathic
- Water: pregnancy, hypothyroid
- Radial fracture
- Inflammation: RA, gout
- Soft tissue swelling: lipomas, acromegaly, amyloidosis
- Toxic: DM, EtOH
Management of CTS
(CMS)
- Conservative
- Splinting
- Manage underlying cause
- Medical
- Steroid injections
- Surgical
- Division of flexor retinaculum
What is this
Split thickness skin graft
Key descriptives when describing a lump
(3+4+4+3=14)
- Site
- Size
- Shape
- Colour
- Consistency
- Contour
- cough impulse
- Tenderness
- Temperature
- Transilluminance
- Tethering
- Fluctuance
- pulsatility
- spread: LN!
Lipoma
- Benign, soft, subcutaneous
- Sarcomatous change in 0.1%
- Anywhere fat can expand
- Dercum’s disease
- Familial Multiple Lipomatosis
- Madelung’s disease
-
Bannayan Zonana Syndrome
- Macrocephaly
- Haemangiomas
Sebaceous cysts
- Epidermal cyst
- Trichilemmal cyst
- Firm, smooth, intradermal
- Gardener’s syndrome:
- FAP
- Thyroid tumours
- Osteomas
- Dental abnormalities
- Epidermal cysts
What could this scar be from
parotidectomy
What are the indications for a parotidectomy?
- Parotid cancer: most primary parotid tumours benign (80%) but 20% are malignant.
- Benign tumour: pleomorphic adenoma
- Parotitis or abscess
- Calculi
- Sialorrhea: drooling too much
What is the main concerning complication with a parotidectomy?
injury to the facial never
