Surgery

Question 1

What are the 6 Ps of Acute Limb Ischaemia?

Answer 1

1. Pain
2. Pulseless
3. Pallor
4. Perishingly cold
5. Parasthesia (which supersedes pain)
6. Paralysis

N.o. 5,6 distinguish it from partial limb ischaemia (which can be treated medically first. Complete ischaemia needs revascularisation within 6 hours.

Question 2

What is reperfusion injury?

Answer 2

Tissue damage as a result of reperfusion (vs ischaemia), due to production of free radicals

Question 3

Complications of reperfusion (other than reperfusion injury)?

Answer 3

Reperfusion washes out byproducts of anaerobic metabolism - e.g. lactic acid - and cell lysis - e.g. K+, myoglobin. This can cause arrythmias, ARDS and acute renal failure (see below)

Cardiac arrythmias - because metabolic acidosis and hyperkalaemia

Acute renal failure: Rhabdomyolysis -> myoglobin -> acute tubular necrosis

Acute respiratory distress syndrome

Compartment syndrome - increased cap permeability + oedema = muscle swelling. Fascia restrict -> muscle necrosis. Treat with fasciotomy.

Question 4

Open # Rx

Answer 4

6 A’s

1) Analgesia - M+M
2) Assess NV status, soft tissue, photo. Likely high energy injury, consider [head] CT.
3) Antisepsis - Wound swab, saline sterile gauze to cover
4) Alignment - reduce/splint. Reassess N+V, imaging - orthogonal, + joint above/below.
5) Antitetanus status
6) Abx - Co-amoxiclav

In theatre, debride, clean with wash-out and fixate externally.

When swelling reduced, fixate internally

Question 5

Complication of an open #

Answer 5

Clostridium perfringens - gas gangrene + Sepsis

Debridement
Clindamycin

Open fractures are associated with high rates of morbidity and mortality
The most common fractures that are open are tibial, phalangeal, forearm, ankle, and metacarpal
Check the overlying area for skin breakdown or tissue loss
All patients with open fractures need antibiotic cover and up-to-date tetanus vaccination
Timely surgical management, with input from plastic and vascular surgery as required, will ensure optimal outcomes

Question 6

Classification of an open #

Answer 6

Gustillo-Anderson

1. <1 cm and clean
2. 1-10cm and clean
   3a. >10cm but high energy, but soft tissue coverage (Ortho can manage)
   3b. ^ but not adequate soft tissue coverage (Need plastics)
   3c. All injuries with vascular injury (Need Vascular team as well).

Question 7

What is compartment syndrome?

Answer 7

inc. pressure in a fascial compartment

due to oedema/bleeding

can lead to muscle necrosis

Rhabdomyolysis -> Acute Tubular Necrosis

Question 8

Symptoms of Compartment syndrome

Answer 8

Pain - even passive stretch

Parasthesia

Question 9

Why is it important to remove pus from septic joint?

Answer 9

Pus - neutrophils
Destroy cartilage
Arthritis don’t want

Question 10

Why intracapsular # matter?

Answer 10

Callus formation in joint not ideal

post-trauma arthritis

Question 11

Types

Answer 11

Transverse

Oblique

Spiral

Comminuted

Avulsion

Question 12

Don’t aspirate prosthetic knee joint that looks septic

Answer 12

no idea why

Question 13

How to distinguish between transient synovitis vs septic arthritis

Answer 13

Kocher’s criteria

Non WB
Febrile
ESR raised >40
WBC raised >12000

Question 14

Chorda equina red flags

Answer 14

Back pain
Saddle anaesthesia
Faecal incontinence/loss of anal tone
Urinary retention and subsequent stress incontinence

Question 15

Shoulder trauma types

Answer 15

# Clavicle, prox humeral/humeral shaft # 
Dislocations - humeral and AC joint

Question 16

Clavicle important points

Answer 16

FOOSH. Middle 3rd common site. Rx: Broad arm sling 3 weeks

Question 17

Humeral shaft

Answer 17

Usually FOOSH, oblique and displaced….

Worry about radial nerve damage.

Rx: Collar/cuff

Question 18

Definition of open #

Answer 18

A fracture is ‘open’ when there is a direct communication between the fracture site and the external environment. This is most often through the skin – however, pelvic fractures may be internally open, having penetrated in to the vagina or rectum.

Question 19

Painful arch

Answer 19

Subacromial impingement syndrome refers to the inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space
Presents with progressive pain in the anterior superior shoulder, typically worsening by abduction and relieved by rest
Diagnosis is a clinical one however MRI imaging can be useful to confirm the diagnosis and assess for further complications of the condition
Mainstay of management is conservative, with limited evidence advocating surgical intervention

Question 20

Olecranon

Answer 20

Fractures of the olecranon process are relatively common fractures of the upper limb
Will often follow falling on an outstretched hand, with tenderness over the posterior aspect of the elbow and a potential palpable defect
Lateral and AP radiographs remain the mainstay of initial investigations
Management can be either operative or non-operative, heavily influenced by degree of displacement

Question 21

What leads to mal/non-union

Answer 21

Fragments may have moved
Soft tissue got in the way
Too much movement
Poor blood supply
Infection

Question 22

Rx Compartment Syndrome

Answer 22

Remove all bandages/splints

Lie limb flat (don’t elevate as decreases blood flow)

Monitor pressure in compartment using cathether - if difference between diastolic pressure and osteofacial compartment is less than 30mmHg, immediate decompression.

If you don’t have ^ equipment, then monitor symptoms after removal of bandaging, and if not improved 2 hours, immediate decompression

Fasciotomy. Open and leave for 2 days.

If muscle necrosis, debride
If none, then suture/skin graft

Question 23

How long does it take for ischaemia to kill off muscle tissue?

Answer 23

4-6 hours

Question 24

Why can compartment syndrome lead to renal problems?

Answer 24

Muscle death
Rhabdomyolysis
Acute Tubular Necrosis

Question 25

Proximal humeral # | What nerve are you worried about?

Answer 25

TWO - Radial and (more commonly) Axillary The axillary nerve is most commonly damaged by trauma to the shoulder or proximal humerus – such as a fracture of the humerus surgical neck. Motor functions: Paralysis of the deltoid and teres minor muscles. This renders the patient unable to abduct the affected limb. Sensory functions: The upper lateral cutaneous nerve of arm will be affected, resulting in loss of sensation over the regimental badge area. Characteristic clinical signs: In long standing cases, the paralysed deltoid muscle rapidly atrophies, and the greater tuberosity can be palpated in that area. _____________________________________________________ The radial nerve can be damaged in the axilla region by a dislocation at the shoulder joint, or a fracture of the proximal humerus. Occasionally, it is injured via excessive pressure on the nerve within the axilla (e.g. a badly fitting crutch). Motor functions – the triceps brachii and muscles in posterior compartment are affected. The patient is unable to extend at the forearm, wrist and fingers. Unopposed flexion of wrist occurs, known as wrist-drop. Sensory functions – all four cutaneous branches of the radial nerve are affected. There will be a loss of sensation over the lateral and posterior arm, posterior forearm, and dorsal surface of the lateral three and a half digits.

Question 26

Complications of #s

Answer 26

CNS 'n' VIV ``` Compartment Syndrome Nerve damage Sores - pressure and plaster Non-union Vascular injury Infection Visceral injury ```

Question 27

Rx of anteromedial shoulder dislocation

Answer 27

! Axillary N injury ``` Analgesia Assess Radiograph Reduce Reassess Radiograph ``` Reduction is either traction/countertraction or modified kocker's (ext. rota, adducted)

Question 28

What are the types of non-union, and what can be done to treat?

Answer 28

Hypertrophic - Bone ends enlarged, so osteogenesis IS taking place, but not enough. Functional bracing, Pulsed EM fields, Pulsed USS to stimulate along with rigid fixation OR Atrophic - Bone ends rounded and sclerosis present. No more osteogenesis will take place without intervention. Need to excise fibrous tissue and sclerotic edge of the bone + bone graft.

Question 29

Clostridium perfringens infection symptoms

Answer 29

Pain Brown discharge Tachycardia SMELL Rx: Fluid resuscitation, decompress wound/debride +/- hyperbaric O2 chambers

Question 30

At what point after a fracture and delayed reunion would you intervene ?

Answer 30

If there is point tenderness and pain after 6months, internal fixation and bone grafts

Question 31

Methods to immobilise #s

Answer 31

External and Internal. Non-op and Op. External - Splints (relieve pain + prevent further damage); Slings/Collar and cuff; Casts, Traction (gravity, skin, skeletal); cast bracing (plaster cast on thigh and calf, joined by brace). Operative external: Ring fixators for tibia. Internal - ORIF: Plates and screws (articular/comminuted); IM nails (#s of long bones - femur, tibia, humerus); K-wires (foot, wrist, hand #s)

Question 32

How do bones heal?

Answer 32

1) Inflammatory phase 2) Reparative phase 3) Remodelling Torn tissue + blood vessels = haematoma. Lack of blood supply so bone regresses a bit. Inflammation + soft callus (temporary join + stability, we don't want this in joints (!) and fixation reduces the need for a callous). Consolidation: Soft callus becomes woven bone and is mineralised. This is then replaced with lamellar bone. Over time this is remodelled.

Question 33

Osteoarthritis ttmt

Answer 33

Advice, Exercise, Weight loss, pain relief 1st line: Paracetamol/topical NSAID 2nd Line: Weak opioid 3rd line: Oral NSAIDs + PPi 4th line: Corticosteriod IA Surgery Locking/poor QoL - TKR, THR

Question 34

Septic Arthritis organisms

Answer 34

Staph aureus/Strep epid (prosthetics) Prosthetics Inarticular injection - e.g. for OA IVDUs UTIs

Question 35

Septic Arthritis diagnosis

Answer 35

``` Kocker's Criteria Fever Non-weightbearing ESR WBC ```

Question 36

Septic Arthritis rx

Answer 36

Aspirate under USS - mcs, polarised light microscopy, WCC, gram stain blood culture blood test - esr, wcc, crp, lfts, electrolytes x-ray

Question 37

Pseudogout

Answer 37

Positively bifringent Crystals Calcium pyrophosphate

Question 38

Gout

Answer 38

Negatively bifringent needles | Sodium monourate

Question 39

Septic Arthritis Abx

Answer 39

6 week initially IV Flucloxacillin, then oral

Question 40

Spondyloarthropathies

Answer 40

PAIR Psoriatic Enteropathic Ankylosing spondylitis Reactive arthritis

Question 41

Ank Spond

Answer 41

NSAIDs

Question 42

Reactive Arthritis

Answer 42

Strep A Chlamydia Salmonella, shigella, campylobacter Reiter's syndrome - conjunctivitis, urethritis, and arthritis Can't see, can't pee, can't bend your knee

Question 43

Reactive Arthritis rx

Answer 43

NSAIDs

Question 44

Gout causes

Answer 44

Monoarthritis ``` Diuretics Alcohol Starvation Surgery Infection Trauma ```

Question 45

Gout ttmt

Answer 45

NSAIDs if contraindicated: colchicine Steroids Wait two weeks, then give Allopurinol - inhibits xanthine oxidase. !Caution! Azathioprine interacts because xanthine oxidase is involved in breaking down azathi. Reduce dose.

Question 46

Gout ttmt

Answer 46

NSAIDs if contraindicated: colchicine if not getting better Steroids Wait two weeks, then give Allopurinol - inhibits xanthine oxidase. Titrate to urate levels. !Caution! Azathioprine interacts because xanthine oxidase is involved in breaking down azathi. Reduce dose.

Question 47

Gout extraarticular manifestations

Answer 47

Tophi

Question 48

Pseudogout - calcinosis in tendons in x-ray

Answer 48

Rest, Icepacks, NSAIDs, Colchizine

Question 49

Kocher's criteria for septic arthritis

Answer 49

Non wb temp 38.5 ESR>40 WBC>12000

Question 50

Risks of surgery

Answer 50

Bleeding, infection, DVT/PE, anaesthetic risks, damage to nerves/muscles

Question 51

Where does crohn's start?

Answer 51

Terminal ileum

Question 52

Where does ulcerative colitis start?

Answer 52

Rectum

Question 53

Which has skip lesions Crohns or UC?

Answer 53

Crohn's

Question 54

Crohn's - how deep does it go ?

Answer 54

Transmural - therefore fistulas

Question 55

Types of fistulas in Crohns

Answer 55

Colovesical Enterocutaneous Colovaginal

Question 56

Defnition of fistulas, strictures, adhesions

Answer 56

fistula = abnormal connection between two epithelial surfaces stricture = abnormal luminal narrowing adhesions =

Question 57

Crypt abscesses are a feature of...

Answer 57

Ulcerative colitis

Question 58

UC hx

Answer 58

most common manifestation of ulcerative colitis is proctitis, whereby the inflammation is confined to the rectum. Patients will complain of PR bleeding and mucus discharge, increased frequency, urgency of defecation, and tenesmus.

Question 59

Test to differentiate IBS from IBD

Answer 59

Faecal calprotein

Question 60

Tests if someone presents with IBD symptoms

Answer 60

Routine bloods* (FBC, U&Es, CRP, LFTs, and clotting) are required to examine for anaemia, low albumin (secondary to malabsorption), and raised CRP and WCC. In the UK, NICE guidelines recommend that faecal calprotectin testing is carried out in patents with recent onset lower gastrointestinal symptoms; it is raised in inflammatory bowel disease, but unchanged in irritable bowel syndrome. A stool sample should be sent for microscopy and culture. *Liver function tests may become deranged in patients on medical treatment and clotting can become deranged in severe attacks due to the large inflammatory response affecting the coagulation cascade.

Question 61

Extra-articular manifestations of Crohns

Answer 61

Musculoskeletal Enteropathic arthritis (typically affecting sacroiliac and other large joints) or nail clubbing Metabolic bone disease (secondary to malabsorption) Skin Erythema nodosum – tender red/purple subcutaneous nodules, typically found on the patient’s shins Pyoderma gangrenosum – erythematous papules/pustules that develop into deep ulcers and can occur anywhere (yet typically affect the shins) Eyes – Episcleritis, anterior uvetitis, or iritis Hepatobiliary – Primary sclerosing cholangitis (more associated with UC), cholangiocarcinoma (due to association with primary sclerosing cholangitis), and gallstones Renal: Renal stones (reduced absorption of bile salts which leads to increased free oxalate)

Question 62

Mucus in poop

Answer 62

suspect UC

Question 63

Diarrhoea definition

Answer 63

> 3 loose stool/wk

Question 64

``` Rota virus Norovirus Capylobacter Shigella Salmonella E.coli C dif ```

Answer 64

...

Question 65

Diverticulosis Diverticular disease Diverticulitis

Answer 65

A diverticulum is an outpouching of the bowel wall that is composed of mucosa. The are most commonly found in the sigmoid colon yet can be present throughout the large bowel and (less commonly) small bowel. There are three different manifestations of diverticiulum: Diverticulosis – the presence of diverticulum Diverticular disease – symptomatic diverticulum Diverticulitis – inflammation of the diverticulum Diverticulosis is present in around 50% of >50yrs and 70% of >80yrs, yet only 25% of these cases become symptomatic. The disease affects more men than women (1.6:1) and is most prevalent in developed countries.

Question 66

GI Symptom red flags

Answer 66

ALARM ``` Anaemia Loss of weight Anorexia Recent onset Malaena ```

Question 67

Achalasia

Answer 67

Achalasia is a serious condition that affects your esophagus. The lower esophageal sphincter (LES) is a muscular ring that closes off the esophagus from the stomach. If you have achalasia, your LES fails to open up during swallowing, which it's supposed to do. This leads to a backup of food within your esophagus.

Question 68

What neurological syndrome is associated with lower oesophagel..f.dfmlksnkfsjbgn

Answer 68

CREST ?? ``` Calcinosis Raynauds Esophageal dismotiliy Schlerodactyly Telangictasia?????????????? ```

Question 69

Oropharyngeal dysphagia

Answer 69

Barium swallow | Endoscopy - Abx co-amox prophylaxis

Question 70

Referral for OGD

Answer 70

New-onset dysphagia Aged >55 years with weight loss and either upper abdominal pain, reflux, or dyspepsia New onset dyspepsia not responding to PPI treatment

Question 71

What is whipple's procedure

Answer 71

Remove bile duct gallbladder head of pancreas duodenum anatamose everything rx for pancreatic ca

Question 72

Hartmann's procedure

Answer 72

Hartmann’s Procedure This procedure is used in emergency bowel surgery, such as bowel obstruction or perforation. This involves a complete resection of the recto-sigmoid colon with the formation of an end-colostomy and the closure of the rectal stump.