Yr4 Surgery - Short Cases

Question 1

• What are the classics signs of a fracture?
• Plastering tips – how to apply a plaster?

Answer 1

What are the classics signs of a fracture?
1. Pain
2. Tenderness
3. Loss of function
4. Deformity

Question 2

• What are the complications of a plaster cast? (3)
• Which X-rays should be ordered? (Rule of 2s)

Answer 2

Complications of a Plaster Cast
1. Development of pressure ulcers
2. Thermal burns during plaster hardening
3. Thrombophlebitis.

The AO ASIF group commented on prolonged cast immobilization, or cast disease, as being responsible for circulatory disturbances, inflammation, and bone disease resulting in osteoporosis, chronic oedema, soft tissue atrophy, and joint stiffness. These problems may be avoided by providing functional aftercare.

Question 3

• How long do fractures take to heal?
• 5 Phases of fracture healing?
• Patient factors influencing healing?
• What are delayed union, non-union and malunion?

Answer 3

Five phases of fracture:
1. Fracture and inflammatory phase - 7days
2. Granulation tissue formation - 2 weeks
3. Callus formation - 14-16 weeks
4. Lamellar bone deposition
5. Remodelling 1-4 years

• Patient factors influencing fracture healing: age, degree of trauma, patient co-morbidities, medication use, social factors, type of fracture, systemic and local disease, infection, and nutrition.
• Patients who have poor prognostic factors in terms of fracture healing are at increased risk for complications of fracture healing such as non-union, malunion, osteomyelitis, and chronic pain.

Question 4

• What 3 soft tissue injuries may occur in conjunction with a fracture?
• What other imaging may be ordered for a fracture and why?

Answer 4

What soft tissue injuries may occur in conjunction with a fracture?
1. Neurologic injury
2. Muscle compartment syndromes
3. Vascular injuries.

Question 5

• What factors cause young men to be reticent about seeking early medical help?

Answer 5

Question 6

What are the causes of scrotal swelling in young men? How common is cancer of the
testis? How do this cancer present?

Answer 6

Question 7

• Does the positioning of the testes in the scrotum outside the abdominal cavity have any inherent risks?
• What investigations would you consider a first priority in this case?

Answer 7

Does the positioning of the testes in the scrotum outside the abdominal cavity have any inherent risks?
- Trauma to the testis is probably the greatest risk. It is commonest among younger males
eg sporting injuries and physical assault.

Question 8

How aggressive should modern treatment of testicular tumours be?

Answer 8

Question 9

Case scenario: A 33 year old woman had a routine Caesarean 2 days ago. Today there has been loss of fluid from the wound and on examination the skin has parted over 5 cm. There is yellow, fat like material protruding through the wound. She does not look unwell. There is no fever.

• What needs to be done?
• What factors interfere with wound healing?

Answer 9

What to do?
- Superficial (outside the abdomen).
- If a wound has opened superficially then it might be resutured; but generally it is allowed to heal from its base, as there is often infection which will be likely to drain again and cause breakdown again.
- This is the most common scenario – wound breaks down by itself or a collection of haemo serous fluid becomes infected and drains through the wound (like a boil draining); full wound dehiscence as in this case is rare.

Question 10

Why does wound breakdown happen?

Answer 10

Question 11

• How do you know if you (or your team or a doctor you refer to) has an acceptable post surgery complication rate?
• What audit mechanisms are useful?

Answer 11