Surgery Flashcards
Terminal ileum resection is associated with what kind of malabsorption?
Bile acids because they are resorbed in the terminal ileum.
Note that fats are resorbed in the jejunum. ***
Mobile, firm, smooth and rubbery breast lump in a young woman
Fibroadenoma ***
Do what with a solid testicular mass or acute hydrocele in a young patient?
Exclude malignancy
Diagnosis of testicular cancer
Diagnosis is established by pathological evaluation of specimen obtained by radical inguinal orchidectomy
Does orchiopexy reduce the risk of testicular carcinoma?
Surgical descent (orchiopexy) of undescended testis does not eliminate the risk of malignancy, but allows for earlier detection by self-examination and reduces the risk of infertility
Risk factors testicular cancer
- Cryptorchidism
- Atrophy
- Sex hormones
- HIV infection
- Infertility
- Family Hx
- Past Hx of testicular cancer
Tumour markers testicular ca
Beta-hCG, LDH, AFP
Risk factors for achilles tendon rupture
- Longstanding tendonitis
- Fluoroquinolones (famously ciprofloxacin)
- Rheumatoid arthritis
- Gout
- Corticosteroid use
What is Simmond’s Test?
Simmonds’ test (also called the Thompson test or Simmonds-Thompson test) is used in lower limb examination to test for the rupture of the Achilles tendon.
The patient lies face down with feet hanging off the edge of the bed. If the test is positive, there is no movement of the foot (normally plantarflexion) on squeezing the corresponding calf, signifying likely rupture of the Achilles tendon
Complications of achilles tendon rupture
- Sural nerve injury
- Re-rupture
- Infection
- Note the most common site of Achilles tendon rupture is 2-6 cm from its insertion where the blood supply is the poorest
Management achilles tendon rupture
- Athletic- surgical repair
- Non-athletic - cast in plantarflexion 8-12 weeks
Clinical features of scaphoid fracture
- pain with resisted pronation
- tenderness in the anatomical “snuff box”, over scaphoid tubercle, and pain with long axis compression into scaphoid
- usually nondisplaced
Management of anatomical snuff box tenderness with normal X-Ray
- A fracture may not be radiologically evident up to 2 wk after acute injury, so if a patient complains of wrist pain and has anatomical snuff box tenderness but a negative x-ray, treat as if positive for a scaphoid fracture and repeat x-ray 2 wk later to rule out a fracture;
- if x-ray still negative, order CT or MRI
Riskiest part of the scaphoid to fracture
The proximal pole of the scaphoid receives as much as 100% of its arterial blood supply from the radial artery that enters at the distal pole. A fracture through the proximal third disrupts this blood supply and results in a high incidence of AVN/nonunion
Brachial plexus injuries accompany clavicular fractures in which area?
Proximal third
The major risk factor for slipped capital femoral epiphysis
Obesity
Management of slipped capital femoral epiphysis
Once SCFE is suspected, the patient should be non-weight bearing + remain on strict bed rest.
In severe cases, after enough rest the patient may require physical therapy to regain strength and movement back to the leg. SCFE is an orthopaedic emergency, as further slippage may result in occlusion of the blood supply and avascular necrosis (25%). Almost all cases require surgery, which usually involves the placement of one or two pins into the femoral head to prevent further slippage
Which fracture is typically characterized by numbness and weakness of the pinkie finger with partial involvement of the ring finger as well, the “ulnar 1½ fingers”?
hamate bone
DVT Prophylaxis in Hip Fractures
LMWH (i.e. enoxaparin 40 mg SC bid), fondaparinux, low dose heparin on admission, do not give <12 h before surgery
High-voltage pulsed galvanic stimulation (HGVS) can be used to prevent what?
Proctalgia fugax
Usual site for diverticulsosis
95% involve sigmoid colon
Clinical features of diverticulosis
- uncomplicated diverticulosis: asymptomatic (70-80%)
- episodic abdominal pain (often LLQ), bloating, flatulence, constipation, diarrhea
- absence of fever/leukocytosis
- no physical exam findings or poorly localized LLQ tenderness
Investigation of choice in acute episodes of diverticulitis
Contrast CT
Colonoscopy 4-6 weeks after acute episode is over
Diverticulitis complications
Complications (25% of cases)
- Abscess: palpable, tender abdominal mass
- Fistula: colovesical (most common), coloenteric, colovaginal, and colocutaneous
- Colonic obstruction: due to scarring from repeated inammation
- Perforation: generalized peritonitis (feculent vs. purulent)
Diverticultis treatment
Medical treatment - NPO, IVF, and IV antibiotics (e.g. IV ceftriaxone + metronidazole)
- Phlegmon/small pericolic abscess - Medical
- Large abscess/fistula - Medical, abscess drainage ± resection with primary anastomosis
- Purulent peritonitis (ruptured abscess) - Resection or Hartmann procedure
- Feculent peritonitis - Hartmann procedure
Risk factors for haemorrhoids
increased intra-abdominal pressure:
- chronic constipation
- pregnancy
- obesity
- portal HTN
- heavy lifting
Definition of an anal fissure
Tear of anal canal below dentate line
(very sensitive squamous epithelium)
Treatment options for chronic anal fissures
- Stool softeners, increased fibre intake, and sitz baths
- topical nitroglycerin or calcium channel blocker (nifedipine or diltiazam): increases local blood flow, promotes healing, and relieves sphincter spasm
- Lateral internal anal sphincterotomy (most effective): relieves sphincter spasm to increase blood flow and promote healing; reserved for medically-refractory cases due to 5% chance of fecal incontinence
- Alternative treatment: botulinum toxin A; inhibits release of acetylcholine (ACh), reducing sphincter spasm
Benefits of laparoscopic vs open appendicectomy
- Wound infection less likely
- Intra-abdominal abscesses 2x more likely
- Reduced pain on POD #1
- Reduced hospital stay by 1.1 d
- Sooner return to normal activity, work, and sport
- Costs outside hospital are reduced
Breast cancer risk factors
- Gender (99% female)
- Age (83% >50 yr)
- Personal history of breast cancer and/or prior breast biopsy (regardless of pathology)
- FH of breast cancer (greater risk if relative was first degree and premenopausal)
- High breast density, nulliparity, first pregnancy >30 yr, menarche <12 yr, or menopause >55 yr
- Decreased risk with lactation, early menopause, and early childbirth
- Radiation exposure (e.g. mantle radiation for Hodgkin’s disease)
- >5 yr HRT use, >10 yr OCP use
- BRCA1 and BRCA2 gene mutations
- Alcohol use, obesity, and sedentary lifestyle
What is the triple test for diagnosis of breast cancer?
- Clinical breast exam
- Imaging (U/S for <30 yr, mammography + U/S for >30 yr)
- Pathology (biopsy)
Bad prognostic indicators breast cancer
- >5cm
- High grade lesion’
- Node positive
- Oestrogen receptor negative
- Inflammatory cancer
- Positive margins
- Lymphovascular invasion
- Epidermal inclusion cyst
- Dermal lymphatics involved
Treatment options for stage I + II breast cancer
For stage I
Breast Conserving Surgery + axillary node dissection + radiotherapy
For stage II
Chemotherapy for premenopausal women or
postmenopausal and ER negative, followed by tamoxifen
if ER+
Mastectomy offers no survival benefit for stage I+II
Women who have received tamoxifen require follow up for which other malignancy?
Endometrial cancer
Antibiotics in the management of appendicitis
- Cefazolin + metronidazole if uncomplicated, peri-operative dose is adequate
- Consider treatment with post-operative antibiotics for perforated appendicitis
- For patients who present with an abscess (palpable mass or phlegmon on imaging and often delayed diagnosis with symptoms for >4-5 d), consider radiologic drainage + antibiotics x 14 d ± interval appendectomy once inflammation has resolved = (controversial)
- Recent research supports antibiotic only treatment as reasonable for uncomplicated appendicitis, with 10-20% recurrence rates
Elderly ppl presenting with appendicitis should have what investigation and why?
Colonoscopy to exclude neoplasm
Management of epidural hematoma
Treatment is generally by urgent surgery in the form of a craniotomy or burr hole. Without treatment, death typically results.
Indications for surgery in a blowout fracture
- Any size defect with enopthalmos or hypoglobus
- Diplopia
- Entrapment of extraocular muscles
- Fracture of orbital floor >50%
Indications for surgical decompression in subdural haematoma
- Unstable vital signs
- Raised intracranial pressure
- Clinical or CT signs of brain herniation (eg midline shift)
Characteristics of lumbar spinal stenosis pain
- Worse on extension of the spine (therefore worse walking downhill)
- Relieved by flexion of the spine
- Relieved by sitting down
Assessment of cruciate ligaments
The drawer test is used in the initial clinical assessment of suspected rupture of the cruciate ligaments. The pt is supine with hips flexed to 45 degrees, knees flexed to 90 degrees and feet flat on table. The examiner sits on the examination table in front of the knee and grasps the tibia just below the joint line of the knee. The thumbs are placed along the joint line on either side of the patellar tendon. The tibia is then drawn forward anteriorly. If the tibia pulls forward or backward more than normal, the test is considered positive. Excessive displacement of the tibia anteriorly suggests ACL injury, and excessive posterior displacement of tibia may indicate injury of posterior cruciate ligament.
Best treatment for a buckle (greenstick) fracture
Removable splint for 3 weeks
What is the system by which toxic levels of thyroid hormone can contribute to premature death?
Via the SERCA-phospholamban system which affects contractility of cadiac muscles leading to potential palpitations, sinus tachcarida and atrial fibrillation.
What’s this and what is it for?
Supination-flexion technique for radial head subluxation
What is this? Which vessel is usually responsible?
Epidural hematoma
Middle meningeal artery
What does the swirl sign indicate?
Active haemorrhage
