Surgery B Flashcards

Question

When should range of neck movement be assessed?

Answer 1

1. Was involved in a simple rear-end motor vehicle collision 2. Comfortable in a sitting position in the emergency department 3. Has been ambulatory at any time since injury 4. Has no cervical spine tenderness 5. Presents with delayed onset of neck pain

Answer 2

Management options should be described as operative vs non operative. Operative management can be divided into anterior fixation or posterior fusion and halo immobilisation. These are all unsuitable for this patient especially the halo, which has a high mortality/morbidity rate. This patient is therefore not a candidate for surgery and should be treated with a hard cervical collar These injuries should all be discussed with the local spinal/neurosurgical department

Answer 3

Discussion with spinal unit - mention any changes in neurology Eradication of infection with 6-12 weeks of antibiotics sensitive to a positive culture Preservation or restoration of spinal structure, stability and neurological deficits Analgesia

Answer 4

Staphylococcus aureus – Gram +ve cocci most likely Pseudomonas in IV drug abuse and Streptococcus in chest infection.

Answer 5

Over 50s with a 2:1 male to female ratio Increasing age More common with increased use of interventional techniques (angiography, surgical etc) IVDU (hospital and illicit) T2DM Smoking

Answer 6

Bilateral sciatica Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion Difficulty initiating micturition or impaired sensation of urinary flow, if untreated this may lead to irreversible urinary retention with overflow urinary incontinence Loss of sensation of rectal fullness, if untreated this may lead to irreversible faecal incontinence Perianal, perineal or genital sensory loss (saddle anaesthesia or paraesthesia) Laxity of the anal sphincter

Answer 7

Loss of proteoglycan and collagen, and degradation Fall in osmotic pressure of disc matrix No longer behaves hydrostatically under pressure Loose height and weight rapidly Stress concentration along end plates and annulus

Answer 8

Decompressive Laminectomy 20% of all CES patients will have a poor outcome usually with the need for ongoing treatment e.g. management of sexual dysfunction, self-catheterisation, colostomy, urological and gynaecological surgery, spinal injuries rehabilitation and psycho-social support

Answer 9

At age of 6-7 yrs, supracondylar area is remodelling, and is thinner than at other ages and the elbow can hyperextend in this age group  Extension type injury in 98% of cases  Extension Type Injury: Fall onto outstretched hand and the elbow becomes locked in hyperextension Tension forces anteriorly and the olecranon is forced into the olecranon fossa The triceps cause posterior and proximal migration of the distal fracture fragment 

Answer 10

Neuropraxia (nearly all resolve) Anterior interosseous nerve (AIN) neuropraxia (branch of median) is the most common Can also see radial nerve palsy (close second) and ulnar nerve palsy in a flexion type injury  Vascular compromise (~10%) - although rich collateral circulation can maintain supply 

Answer 11

Gartland Classification (all based on lateral elbow radiograph)  Type 1 - non displaced - treated with cast immobilisation for 3-4 weeks with radiographs at 1 week  Type 2 - displaced (posterior cortex and posterior periosteal hinge are intact) - deformity only in the sagittal plane and typically treated with CRPP or open reduction 2a is not rotated and 2b is rotated  Type 3 - displaced, often in 2/3 planes - treated with CRPP or open reduction  Type 4 - complete periosteal disruption with instability in flexion and extension - diagnosed during surgery and treated with CRPP or open reduction  Medial communition - collapse of the medial column, loss of Baumann angle - leads to a virus malunion (gunstock deformity) - treated with CRPP and often requires significant values force to reduce  Flexion type injury - generally due to fall on the olecranon, treated with CRPP, more likely to require open reduction 

Answer 12

Presentation  Symptoms - pain and refusal to move the elbow  Physical exam Inspection - gross deformity, swelling, ecchymosis in antecubital fossa  Motion - limited  Neuro - may show AIN neuropraxia (ok sign), median nerve injury or radial nerve injury Also vascular exam to assess perfusion  S-Shape Deformity  and Puckering of the Skin

Answer 13

AP and lateral x-rays of the elbow  Posterior fat pad sign - lucent on a lateral view along poster distal humerus and olecranon fossa suggestive if occult fracture around the elbow  Displacement of the anterior humeral line  and alteration of Baumann’s angle  Angiography indicated if vascular compromise 

Answer 14

Non-Operative Treatment : Long arm casting with less than 30% of elbow flexion  Indications - warm perfused hand with no neuro deficit in type 1 fractures and type 2 fractures where the anterior humeral line intersects the capitellum, minimal swelling and no medial communities  3 weeks and repeat radiographs at 1 week to assess for interval displacement  Operative Treatment : Closed reduction and percutaneous pinning (CRPP) Indications - type 2 and 3 supracondylar fractures, flexion type and medial column collapse  Non urgent (can wait overnight) - warm perfused hand with no neuro deficits - splint overnight 30-40° elbow flexion and elevate in preparation for surgery  Urgent (same day) - pulseless, well perfused hand, sensory nerve deficit, XS swelling, brachialis sign and floating elbow - check vascular status after reduction  Emergent (within hours) - pulseless, poorly perfused hand - check vascular after reduction Open Reduction, Percutaneous Pinning +/- Vascular Exploration Indications - open fracture, failed closed reduction (more frequently flexion fracture), pulseless white that is unable to be reduced and remains a gap (gap may represent entrapped vasculature)

Answer 15

High energy is usually from MVC, crush injury, fall from a height, or dashboard injury resulting in axial load to a flexed knee Low energy may be from an athletic injury or routine walking  Hyperextension injury leads to anterior dislocations  Posteriorly directed force across the proximal tibia (dashboard injuries) leads to posterior dislocations

Answer 16

Vascular injury  Nervous injury - usually common peroneal (25% incidence) and tibial is much less common  Fractures - present in 60% dislocations  Soft tissue injury - patellar tendon rupture, periarticular avulsion and displaced menisci 

Answer 17

Kennedy Classification (based on direction of tibial displacement( Anterior (most common) - due to hyperextension, usually involves PCL tear, highest rate of peroneal injury  Posterior - due to axial load of flexed knee (dashboard injury) - highest rate of vascular injury - highest incidence of popliteal artery tear Lateral - due to varus or valgus forces, usually involves ACL and PCL Medial - due to varus or values forces - usually disrupted PLC and PCL  Rotational - posterolateral is most common rotational dislocation, usually irreducible and may present with buttoning of femoral condyle through the capsule 

Answer 18

Symptoms - trauma history, knee pain, instability  Inspection No obvious deformity - 50% reduced before ED arrival and may present with subtle signs of the trauma (swelling, effusions, abrasions, ecchymosis) Obvious deformity - reduce immediately (especially if absent pulses), dimple sign (buttonholing of medial femoral condyles through the medial capsules - indicative of an irreducible posterolateral dislocation - contraindication to closed reduction due to risks of skin necrosis  Vascular exam - rule out injury before and after reduction If pulses present and normal - measure ABPI - if abnormal - arterial duplex USS or CT angiography If pulses are absent and diminished - immediate surgical exploration - ischaemia time >8 hours is 86% amputation rate - imaging contraindicated if surgery delayed  Neurological exam - assess sensory and motor function of peroneal and tibial nerves  Stability - diagnosis based on instability on physical exam, may see recurvatum when in extension, assess ACL, PCL, MCL, LCL and PLC

Answer 19

Imaging  Radiographs Pre-reduction AP and lateral of the knee - look for asymmetric or irregular joint space, avulsion fractures, osteochondral defects  Post reduction AP and lateral of the knee Optional - 45 degree oblique if fracture suspected  CT - indicated if fracture identified on post reduction plain films, obtain post reduction CT for characterisation of fractures  MRI - obtain MRI after acute reduction but prior to hardware placement - required to evaluated soft tissue injury and for surgical planning

Answer 20

Nonoperative Treatment Emergent closed reduction followed by vascular assessment - considered in an orthopaedic emergency and consider vascular input if pulses diminished post reduction  Immobilisation as definitive  Operative Treatment  Open reduction - indications include irreducible knee, posterolateral dislocation, open fracture dislocation,  obesity, vascular injury External fixation - indications include vascular repair (takes precedence), open fracture dislocation, compartment syndrome, obese (if difficult to maintain reduction) or poly trauma patient  Delayed ligamentous reconstruction - indications include instability - patients can be placed in a knee immobiliser for 3 weeks until treated operatively 

Answer 21

Acute limb ischaemia is defined as the sudden decrease in limb perfusion that threatens the viability of the limb 

Answer 22

Thrombus in situ - (60%) whereby an atheroma plaque in the artery ruptures and a thrombus forms on the plaque’s cap; can present acutely or acute-on-chronic  Embolisation - (30%) whereby a thrombus from a proximal source travels distally to occlude the artery; original thrombus may be due to AF, post MI mural thrombus, AAA or prosthetic heart valves  Trauma - long bone fractures and dislocations

Answer 23

Pain, pallor, pulselessness, paraesthesia, perishingly cold, paralysis  Sudden onset, Hx of cause of potential embolisation 

Answer 24

Rest pain, gangrene, ulcers and erythema

Answer 25

Serum lactate (asses level of ischaemia), a thrombophilia screen and group and save  ECG CT angiography  Duplex ultrasound (if available)

Answer 26

Initial Management  Complete arterial occlusion will lead to irreversible tissue damage within 6 hours  Start the patient on high flow oxygen and ensure adequate IV access  A heparin bolus doe then heparin infusion should be initiated  Conservative Management  Considered in Rutherford 1 and 2a - consider a prolonged course of heparin may be effective - but will require regular assessment  Surgical Intervention Mandatory for Rutherford 2b  If embolic cause - embolectomy via a Fogerty catheter, local intra-arterial thrombolysis or bypass surgery  If thrombotic cause - local intra-arterial thrombolysis in combination with angioplasty or bypass surgery  Angioplasty 

Answer 27

Dilatation of the aorta greater than 3cm.

Answer 28

Main cause is atherosclerosis Other causes include trauma, infections connective tissue disease (Marfan’s, Ehler’s Danlos, Loey Gietz) or inflammatory disease (Takayasu’s disease) Risk factors for AAA include smoking, hypertension, hyperlipidaemia, family history, male gender, and increasing age  Diabetes mellitus is considered a negative risk factor - mechanism unknown

Answer 29

Many abdominal aortic aneurysms are asymptomatic and are simply detected on incidental finding or screening  Symptomatic patients present with abdominal pain, back/loin pain, distal embolisation producing limb ischaemia and/or aortoenteric fistula (rare cause of GI bleed) On examination, pulsatile mass in the abdomen (above umbilical level) and rarely, signs of retroperitoneal haemorrhage may be evident  A ruptured AAA presents with pain (abdominal/back/loin), a degree of shock or syncope and pulsatile mass 

Answer 30

Men aged 65 receive a one-off USS

Answer 31

Medical Management Any AAA < 5.5cm can be monitored via Duplex USS, as surgery prior to this diameter provides no survival benefit  3. 0-4.4 cm = yearly USS 4. 5-4.9 cm = 6 monthly USS 5. 0-5.4 cm = 3 monthly USS Any small (3.0-5.5 cm) have a 3% / year mortality, and should reduced CVS risk factors: smoking cessation, improve BP control, commence statin and aspirin therapy and weight loss

Answer 32

Surgery should be considered for an AAA >5.5 cm in diameter, AAA expanding at >1 cm per year or a symptomatic AAA in a patient who is otherwise fit If patient less fit for surgery - then can be left to until 6 cm Open repair - involves a midline laparotomy or long transverse incision, exposing the aorta, and clamping the aorta proximally and the iliac arteries distally, before the segment is then removed and replaced with a prosthetic graft  Endovascular repair (EVAR) - involves introducing a graft via the femoral arteries and fixing the stent across the aneurysm  Both have the same outcomes at 2 years +, but EVAR has an improved short term outcome but higher rate of reintervention

Answer 33

Important complication of EVAR, whereby an incomplete seal forms around the aneurysm resulting in the blood leaking around the graft  Usually asymptomatic hence regular surveillance (usually ultrasound unless a complication is noted) is needed 

Answer 34

AAA rupture increases exponentially with aneurysmal diameter - and risk increased by smoking, hypertension and female gender An AAA rupture can present with abdominal/groin pain, back pain or syncope  On examination they will typically be haemodynamically compromised, with a pulsatile abdominal mass and tenderness  Classic triad (50% of rAAA cases) - flank/back pain, hypotension, pulsatile abdominal mass

Answer 35

Immediate high flow oxygen, IV access (2x large bore cannula) and urgent bloods (FBC, U&Es, clotting) with crossmatch for minimum 6U units  Treat shock with care - fluids may dislodge clots precipitating further bleeding so aim for BP<100mmHg (permissive hyptension) Unstable patient - immediate transfer to local vascular unit  Stable patient - CT angiogram to determine whether the aneurysm is suitable for EVAR

Answer 36

This generally occurs in younger patients (30-60) and the differential diagnosis is frozen shoulder and AC joint arthritis. Shoulder impingement occurs when the supraspinatus tendon catches on the acromion as the shoulder elevates. Primary impingement is caused by collagen degeneration, vascular damage or subacromial spurs. Secondary shoulder instability is the cause of secondary impingement syndrome.

Answer 37

The symptoms are pain in the shoulder when lifting the arms above the head, they will have the palm sign where they localise pain to the deltoid because they cannot localise the pain. They may also have a mid range painful arc between 60-120 degrees. The Hawkins test is where the arm is taken to 90 degrees and internally rotated to see if it causes pain. Steroids can be used to confirm diagnosis as this will remove the pain.

Answer 38

The rotator cuff includes the subscapulairis (internal rotation), supraspinatus, infraspinatus and teres minor. The rotator cuff’s function is to balance the deltoid action to permit shoulder movement that is stable and concentric.

Answer 39

Rotator cuff tears: Present in the over 60s, history of impingement pain, affects dominant arm more commonly, pain with overhead activities and pain at night and weakness. Acute large tears following dislocation in patients over 40s need urgent care because they will have a complete tear. Strength testing all 4 muscles is vital. The empty can test is used for supraspinatus which will be painful and weak if positive.The lift off test is used for subscapularis tears. Most tears are chronic and can be managed non-operatively with physiotherapy, NSAIDs, rest and possibly steroid injections.

Answer 40

Symptoms are well localised AC joint region pain. They will have a high painful arc to elevation with pain at the top of the arc. Pain can be elicited by stressing the AC joint with the cross shoulder adduction test. Investigation are with X-Ray, MRI and steroid injections. Steroid injections will almost certainly abolish OA pain so can be a positive diagnostic test. Non-operative treatment is with rest, NSAIDs and up to 3 injections. Operative is with resection of the lateral end clavicle arthroscopically and should be done if non-operative treatment only provides transient relief.

Answer 41

Symptoms include pain with lifting or tendon rupture. They will be tender of the bicep groove, speeds test and yergason test. Long head biceps rupture can be assessed with Popeye’s sign where the tone is lost so the muscle belly bunches up. A distal rupture can be assessed with hook test where the muscle belly moves proximally and there is a distal defect associated with bruising, the hook test is where the tendon cannot be felt at the distal end.

Answer 42

Investigations are with USS, MRI or diagnostic USS guided injection for localising pain. Management depends on the pathology as secondary tendonitis needs to treat the rotator cuff pathology, beginning conservatively. Proximal ruptures do not need surgery but distal biceps rupture will need acute surgical repair within 3 weeks.

Answer 43

Definition is symptoms of median nerve compression within the carpal tunnel. The carpal tunnel is enclosed radially by the scaphoid, trapezium and fascial septum overlying the flexor carpi radialis. The ulnar border consists of the hook of the hamate, triquetrum and pisiform. The median nerve is the most superficial part of the carpal tunnel and so is susceptible to damage. The recurrent branch of the median nerve supplies the abductor pollices brevis, opponens pollices and superficial part of the flexor pollices brevis. Pathology is caused by inability of the carpal tunnel to expand which causes increased pressure. This leads to the cessation of blood flow and oedematous changes.

Answer 44

Acute carpal tunnel may require immediate surgical intervention of decompression. This is seen in wrist trauma and infection. Chronic carpal tunnel can be subdivided into: Idiopathic (most common) with women more affected than men Anatomic - persistent medial artery, infection, ganglion cyst or tumours Systemic - obesity, drug toxicity, alcoholism, diabetes, hypothyroidism, rheumatoid arthritis, primary amyloidosis and renal failure Exertional - repeated impact on the palm or vibratory tools

Answer 45

Diagnosis is based on the history of nocturnal pain, tingling in the thumb and on or more radial fingers. Shaking and wringing of hands may improve symptoms and in chronic median nerve compression there may be motor symptoms. On examination there may be thenar atrophy, sensory testing and physical examination of the cervical spine and entire upper extremities. Phalen’s test is where the patient places their hands back to back pointing downwards for 60 seconds. This is positive if the patient experiences paraesthesia. Durken’s test involves direct compression of the median nerve at the carpal tunnel for 30 seconds. Electrodiagnostic nerve studies can be done to exclude other pathologies. Management is with splinting and immobilisation of the wrist at night and intermittently during the day. Steroids injections can be beneficial conservatively and surgically. Surgical interventions include open release, endoscopic carpal tunnel release and limited open carpal tunnel release.

Answer 46

The pathophysiology is first there is a reactive phase (mins-days) where there is an increased tenocyte response, large proteoglycans, no vessels but this is reversible. The second phase is disrepair where there is collagen disorganisation with type 3 collagen present (repair collagen), increased chondrocyte activity and some vessels possible. This stage is also reversible. The third stage is degeneration with areas of cell death, minimal fibrillar collagen, Neo-vessels present and this stage is irreversible.

Answer 47

This presents with sudden pain, audible noise, unable to walk afterwards and there was be a genetic association with the O blood group. It is more common in people who have rheumatoid arthritis, gout, ankylosing spondylitis, chronic uraemia, hyperparathyroidism or on medications such as fluroquinolones and phenytoin. On examination there will be a palpable gap where the achilles should be connected. The Simmonds test is where the calf is squeezed which causes the foot to plantar flex, if this does not happen then the test is positive.

Answer 48

Treatment can be conservative as collagen can repair the achilles tendon over a number of months. Immobilisation increases the amount of scar tissue so more movement will improve the quality of the healed tendon. The chronic achilles tendon rupture is rare and is caused by defects in the tendon. They need surgical intervention to replace the tendon from another site, known as a BOX graft.

Answer 49

Defined as a nerve thickening due to perineurial fibrosis. The intermetatarsal space is narrower in the 2nd and 3rd interspace and there are strong intermetatarsal ligaments whereas the 4th and 5th move a lot. The nerve sits underneath these strong metatarsal ligaments so it gets battered. The medial and lateral plantar nerve have a common branch at the third space which is a common area for compression.

Answer 50

It may be associated with high heels or running shoes. It is more common in women and in over 50s. 70% are affected in the third space. They present with burning pain on the plantar aspect of the foot, located between the metatarsal heads and radiating to the two corresponding toes. They may have some numbness and is made worse by wearing heels or tight shoes. They can also have some shock sensation. It can cause a separation of the toes known as collateral ligament injury. Other causes of metatarsalgia include intractable plantar keratoses, RA, DM, OA, neuromuscular, Freiburg’s (avascular necrosis) and plantar plate rupture. On examination, it is important to palpate under the metatarsal heads as pain is unlikely to cause Morton’s neuroma. Mulder’s click test. Investigate with X ray to rule out other diseases and see size of the space. Ultrasound is the main investigation.

Answer 51

OA of the big toe This can be caused by mechanical factors (post trauma, deformity or OA) or chemical (gout, infection to inflammatory such as RA). They may describe pain when barefoot, wearing shoes or at night. They may have stiffness, ulcers and other foot pains. Classification is with the Hattrup and Johnson system which divides it into three grades. Conservative management is with NSAIDs and shoe modification. Cortisone injections may be beneficial. Grade 3 need arthroplasty.

Answer 52

Defined as a progressive foot deformity in which the first metatarsalphalangeal joint is affected and is often accompanied by disability and foot pain. This joint is gradually subluxed (lateral deviation) causing abduction. Soft tissue develops on the bony prominence which is known as a bunion. Caused by genetics, excessive load, silly shoes, age, forefoot overload and metatarsus Primus varus. The second toe may be deformed with the progressive adduction of the head of the big toe. Investigate with a weight bearing X ray. The metatarsal angle should be less than 9 degrees and the hallux valgus angle less than 15 degrees. Severe is over 40 degrees. Operative treatments include scarf osteotomy and the lateral release technique.

Answer 53

Blumensaat's line is a line which corresponds to the roof of the intercondylar fossa of femur as seen on a lateral radiograph of the knee joint. The angle at which this line appears on the radiograph can be used to determine the position of the patella or diagnose an ACL injury

Answer 54

Patella baja is an abnormally low lying patella, which is associated with restricted range of motion, crepitations, and retropatellar pain. If longstanding, extensor dysfunction may ensue with significant morbidity.

Answer 55

The salter Harris classification system is used to determine whether radius fractures in young people will effect the growth plate or cause growth plate arrest. The higher the number the greater the concern. type I: slipped, fracture plane passes all the way through the growth plate, not involving bone cannot occur if the growth plate is fused. This has a good prognosis type II: Fracture passes across most of the growth plate and up through the metaphysis good prognosis type III: Fracture plane passes some distance along with the growth plate and down through the epiphysis poorer prognosis as the proliferative and reserve zones are interrupted type IV: Through or transverse or together intra-articular Fracture plane passes directly through the metaphysis, growth plate and down through the epiphysis poor prognosis as the proliferative and reserve zones are interrupted ``` type V: Ruined or rammed uncommon <1% crushing type injury does not displace the growth plate but damages it by direct compression worst prognosis ```

Surgery B Flashcards

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