USMLE Surgery
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| tx of dev hip dysplasia based on age | <6wks Pavlik harness 2-3mos, 6-15mos Spica cast, >15mos need open reduction and cast 2-3mos
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| what's Galeazzi's sign? Another name for the sign? | knee of dislocate hip is lower when hips and knees are both flexed
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| which ethnicities at risk for dev hip dysplasia | white (>AA) and Navajao (chinese are less)
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| describe Ortolani and Barlow's manuveurs | Ortolanis –start w legs together, then thighs abducted w pressure on greater trochanter (reduces posteriorly dislocated hip); Barlow-pressure placed on inner part of abducted thighs and then hip adducted (dislocates hip, pushing back)
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| describe physical exam of SCFE hip | as sit affected leg's foot faces other leg; as hip flexed it ext rotates; can't rotate internally also decrsd flexion and abd
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| describe physical exam of Legg Calves hip | Decrsd internal rotation and abduction [same as SCFE]
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| how does a toddler hold a septic hip | flexed, sl abd w external rotation (hip fx in adults also ext rotated)
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| what is dx sign on XR for SCFE? Which directions is the fem head displaced | Kleins line doesn't cross epiphysis; medial and posterior displacement of fem head
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| little kid w severe localized pain in bone, diagnosis? How confirm? Tx? | acute hematogenous osteo, dx w bone scan, IV Abx
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| describe how Blount presents, who see it in, how tx | bow legs (genus varum--nml <3yo) in obese AA boy who started to walk early; brace if >16 degrees or >2-3yo; surgery if bracing doesn't work, severe dz, or >4yo
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| when is genus varum nml? Genus valgum? Describe leg angulation | varum-bow legs () like a Ring, nml <2-3yo; valgum=knock knees, legs like X, nml 4-8yo
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| if pain at patella but more lateral what's the problem? Who see in? how tx? | patellofemoral syn, often adolescent girls, rest and strengthen
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| describe the angulations in club foot | inversion of foot at heel; adduction forefoot, equinus/inversion at ankle w plantar flex of ankle and internal rotation of tibia=InAdEquate
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| progression of tx for club foot | adducted forefoot, then hindfoot varus, then equinus of ankle
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| how often club foot bilateral? Assoc w (2)? | 1/2 are bilateral, assoc w develop hip dysplasia (10%) and spina bifida
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| describe metatarsus adductus and how difft from club foot | pigeon toed (aka metatarsus varus)-forefoot is adducted as in clubfoot, but hindfoot is nml
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| tx options for difft severity of metatarsus adductus | if can passively overcorrect just observe, if can only passively correct do stretching exercises, if stiff may need 3-6wks; surgery if not corrected by 4yo
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| name for clubfoot | talipes equinovarus
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| tx for difft degrees of scolsiosis | brace for prevention when still growing (before menarche); 10-20degrees f/u4mos, 20-40 degrees brace; >45degrees surgery
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| how is the angle of scolios determined, name assoc? | XR, called Cobbs angle
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| screening test for scoliosis name | Adams test
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| how does nursemaids elbow occur, how does child hold arm, w/u and tx | sublux radial head from pulling up on arm, toddle holds elbow flexed w nml hand fxn; dx: don't need XR, tx: reduction
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| tx of compression (buckle or torus) fx | splint 3-4wks
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| tx incomplete/greenstick | may need to break other side of bone for good alignment
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| classif of fx wrt grwth plate (Salter Harris) | SALTR=I=same within physis, II=above, into metaphysis; III=beLOW, into epiphysis; IV=through and through, into both metaphysis and epiphysis; IV=R=crush/compression
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| wich SALTR fx need surgical repair | III and IV, if epiphysis and grwth plate are displaced wrt metpahysis can just do closed reduction
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| what include in w/u path fx | suspect malig, not only do XR, do bone scan for other mets and look for primary
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| patholphysiol of compartment syndrome, Pressure | , 5Ps
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| most sensitive test compartment syndrome of arm | pain on passive extenson of fingers, **note nml pulses does not r/o
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| tx gas gangrene, often occurs (incl timing) | IV PCN and emergent debridement and hyperbaric O2; often occurs s/p deep penetrating injury (ie stepping on nail) 3d later look for very sick and crepitations on exam
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| when is radial n at risk | distal 1/3 humeral fx
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| when is ulnar n at risk | medial epicondyle fx
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| when is axillary n at risk | prox humerus fx, shoulder dislocate
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| which injuries most as risk for vascular injury, how long isch time before amputation likely | distal femur, prox tibia, and supracondylar fx + knee dislocation; amputation 100% if isch time >6hrs
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| how pt hold arm s/p anterior shoulder dislocation? Nerves/arteries at risk? | arm close to body w outward rotation like going to shake hands, high risk recurrence, axillary artery and nerve at risk (ie dumbness over deltoid, can't abd to horiz)
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| how pt hold arm s/p anterior shoulder dislocation? Imaging | arm close to body w internal rotation, need axillary or scapular lateral XR to see. Commonly s/p sz or electrical burn
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| describe how Colles fx occurs and physical exam. Tx | old osteoporotic women (or child) fall on outstretched hand; fx of distal radius. Dinner fork shape w dorsal displacement and angulation. Closed reduction as long as not intrarticular (but maybe need splint 5-7d until swelling comes down)
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| describe Boxer's fx, how occurs, tx | Fx of 5th metacarpal neck. Fwd trauma on closed fist (ie punching wall). closed reduction and ulnar gutter splint, may need perQ pinning “Kirschner-wire” very angulated. Skin broken assume oral pathogen-> surgical debride, irrigat, IV Abx cover Eikenella
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| describe management of wrist drop in humerus shaft fx | if present w palsy may recover, just prevent contracture until then. If palsy develops s/p closed reduction the n could be trapped, need to explore
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| describe nightstick/Monteggia fx. Tx? | Ulnar shaft fx from self defense ag a blunt object (ie night stick of policeman), w dislocation of radial head. Tx: ORIF if significantly displaced and closed reduction of radial head dislocation.
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| describe Galeazzi's fx. Tx? | Diaphyseal fx of radius w dislocation of distal radioulnar joint (pretty much opposite of Monteggia).Tx: ORIF of radius and casting of forearm in supination to reduce distal radioulnar joint
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| how hold leg s/p hip dislocation? Mc occurs when? Neurovasc risks? Tx | shortened leg, adducted and internal rotat; s/p MVA and dashboard injury; AVN and sciatic injury; tx=closed reduction w abduction pillow/bracing and evaluate w CT after reduction
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| how hold leg s/p hip fx? Neurovasc risks/cxns? Tx | shortened leg, externally rotated, at risk for AVN if fem neck fx (consider just replacing); also immobil and DVT risk; tx: ORIF v hip replacement, anticoag
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| describe fat emboli syndrome, at risk w which fx, how present and tx | at risk w femoral shaft fx esp if mltpl; key is respir compromise (dyspnea, hypoxia) + F, AMS, petichae, decrsd plts; tx=respiratory support
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| what at risk w knee dislocation | popliteal artery/vein, peroneal n
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| what testing need for knee dislocation | angio to check for popliteal artery and vein damge
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| how ACL injury occur, dx, tx | forced hyperflexion, + anterior drawer and Lachman **be sure r/o meniscal and MCL injury. Tx=surgical w graft from parellar or hamstring tendons (but maybe just hinged cast for sedentary ppl)
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| how PCL injury occur, dx, tx | forced hyperflexion, + posterior drawer, tx=hinged cast unless highly competitive athlete
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| how MCL injury occur, dx, tx | lateral impact, dx w abduction or valgus test; tx=conservative unless several lig torn
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| describe Lachman's test, used to dx what? | hold thigh w knee at 20 degrees and pull leg, for dx of ACL
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| which more common, ACL or PCL | ACL
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| how LCL injury occur, dx, tx | medial impact, dx w adduction or varus test; tx=conservative unless several lig torn
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| clinical presentation or meniscal tear, dx, tx? | pt reports clicking or locking, have joint line tenderness and + McMurrays, dx w MRI; tx=arhtroscopic try to save as much meniscus as possible
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| describe McMurray's test, used to dx what? | start w knee 90, w hand on heel extend leg and rotate external, + if a click or pain (a tag from the tear is getting stuck)
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| presentation tx of tibial fx | often young men on long marches, point tenderness but XR often neg, tx=casting and repeat XR in 2wks (watch for compression syndrome!)
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| MC ligament in ankle sprain, 2nd | MC lateral side=anterior talofibular ligament, also calcaneofibular liag (posterior talofibular lig); Medial lig=deltoid lig
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| grading of ankle sprain | 1=partial rupture ATF (a talofibular lateral side); 2=complete rupture ATF + partial CF (calcaneofibular); 3=complete rupture of ATF and CF
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| when get XR | don't need XR if able to walk 4 steps at time of injury and time of eval, no bony tenderness over either malleolus
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| dx and tx of ankle fx | Dx by AP, lateral, and mortise XR; tx: ORIF if displaced
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| 2 named signs for carpal tunnel | tinels=tap median n causes paresthesia, phalen=flex wrist (let hang) reproduces
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| 3 illnesses that have carpal tunnel assoc | hypothyroid, DM, diffuse scleroderma
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| describe trigger finger, tx | usu women wake up in middle of night w finger acutely flexed and they have to pull it--painful snap; tx w injxn of steroid
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| describe de quervain tenosynovitis, test to dx; tx | wrist flexed and thumb extended to cradle baby's head, pain is along radial side; test dx: hold thumb in fist and deviate wrist ulna side; tx=steroid injxn
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| describe felon, tx | abscess in pulp of finger 2/2 penetrating trauma; throbbing pain, F; tx=surgical drainage (build up of fluid can cause tissue necrosis)
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| describe gamekeeper finger, physical exam, tx | Hyperextension of thumb seen often when thumb gets stuck in snow or ski trap when fall. Collateral laxity in thumb MCP joint, tx=casting
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| describe jersey finger, physical exam | When flexed finger is extended (trying to grab someone’s jersey). When they make a fist the distal phalanx of the finger doesn’t fle
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| describe mallet finger, physical exam | Opposite of Jersey finger, an extended finger is forcibly flexed and extensor tendon is ruptured—often volleyball. The tip of the finger is flexed while the rest of the hand is extended (looks like mallet)
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| key findings of cauda equina | saddle anesthesia, flaccid rectal sphincter, distended bladder, low back pain wknss (have h/o bowel/bladder incontinence)
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| progression of herniated lumbar disc | start w vague discogenic pain, then sudden onset of extreme pain after a forced mvmt (neurogenic)
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| pathophysiol of herniated lumbar disk, 2MC locations and how differentiate | nucleus pulposus extrudes thru annulus fibrosis and impinges nerve roots; L4-5 (pain goes to big toes), L5-S1 (little toe)
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| key aspects physical finding herniated lumbar disk | fwd flexion/straight leg reproduces pain; pain worse w coughing/straining
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| how differentiate lumbar spine stenosis (degen changes) from lumbar herniated disk | spine stenosis is worse when extended and relieved sitting (opposite), also pain worse w activity and relieved by rest
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| tx herniated lumbar disk | bed rest 3wks, surgery if neurologic changes are progressing or cauda equina
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| MC lytic bone mets in men? Women? | men=lung (prostate is osteoblastic), women=breast
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| describe tennis elbow, tx | lateral epicondylitis, inflamm of extensors from supinating/pronating; tx=splint forearm, PT (no injxns needed)
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| describe golfer's elbow | medial epicondylitis, exacerbated by wrist flexion
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| palpable tender spot bw 3and 4th toe, what is it? Tx? | morton neuroma from inflamm of c digital n, wear better shoes
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| describe marjolin's ulcer | SCC from a chronic wound
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| absolute cardiac contraindication for non cardiac surgery, 2 most impt risk predictors | EF<35%; JVD is worst predictor, recent MI is 2nd…if severe angina w/u for possible revascularization
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| biggest cause of pulmonary risk in surgery, pathopysiol, what do | smoking, due to decrsd ventilation; have them quit smoking 8 wks before surgery and undergo intensive PT
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| key factors of hepatic risk for surgery and % mortality | 40% mortality if any of: bili >2, albumin <3, PT>16, encephalopathy. 80% if 3 present.
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| 4 key values/indications for nutritional risk before surgery, how tx | alb<3 or 20% loss body wgt, transferrin <200, anergy to skin allergens, try >5d good nutrition by gut
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| what in a DM pt would be abs contraindication to surgery | DM coma (although if 2/2 sepsis, won't be able to resolve until sepsis taken care of)
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| 5 things that prevent a fistula to heal | FETID=foreign body, epithelialization, tumor, infxn, irradiated tissue/IBD, distal obstruction
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| 3 key features of malignant hyperthermia, tx | T>104, metabolic acidosis, hyper Ca++, tx dantrolene, 100% O2, correct acidosis, cooling blankets and watch for myoglobinuria
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| when does bacteremia post op come, common scenario and presentation | 30-45min, instrumentation of urinary, show chills, T spikes to 104
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| what days POD see: PNA, wound infxn, DVT, UTI, atelectasis, dehiscence | POD1=atelectasis, POD3=PNA, UTI, POD5=DVT, dehiscence, POD7=wound infxn
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| tx of no urine output post op | in and out cath if no UOP 6hrs, repeat and insert Foley at 2nd or 3rd
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| proportion of GI bleeds upper v lower, what abt age | 3/4 upper, 1/4 colon (but majority of those older…so reallly in elderly it could be anywhere)
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| w/u for red blood per rectum | if active bleeding aspirate NG, if blood do upper endo, if white could be duo, if green you know it's not upper GI so r/o hemorrhoids w anoscopy and do colonoscopy/angiography (if >2ml/min angiography, <0.5ml/min wait for stop and do angio)
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| compare pt w acute obstruction v perf | perf=pt isn't moving, mscl guarding and peritoneal signs throughout; obstruction=colicky pain, pt is restless trying to get comfortable, few physical findings just in that position
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| w/u for distended GB | think cancer, get CT then perQ bx of mass; if nothing on CT do ERCP (can see small cancer of ampulla or CBD)
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| w/u for suspeted biliary atresia | 1wk of phenobarb (incrs sxn bile), then HIDA, if no bile reaches duo then surgical exploration. 1/3 get surgical derivation that lasts, 1/3 get surgical derivation but then need liver tx, 1/3 get liver transplant
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| types of anal atresia and management | if fistula it can wait till baby older (but before toilet training); supralevator/higher up need colostomy then repair; infralevator (through puborectalis sling) can do primary repair
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| management congenital diaph hernia | need 3-4d for more lung maturation, put NG suction, TPN, and mech vent w low P
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| how does vascular ring present | stridor/respir distress and trble swallowing, they hyperextend their neck during episodes. Bronch shows external compression and Ba also shows external compression
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| w/u suspected lung cancer | sputum cytology and CT
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| subclavian steal sympt, management, difftl | claudication (coldness, tingling, msl pain)+ ** visual sympt and **equilibrium problems when exercise arm. If only vascular sympt could be thoracic outlet. Tx w bypass
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| AAA w excruciating back pain? That's tender? | suggesting already leaking (retroperitneal hematoma); going to rupture in a few days
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| w/u PVD | doppler to look for gradient, then arteriography (short segments can be stented)
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| distribution of BCC v SCC on face | BCC tend to be upper face, SCC lower lip and lower
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| margins for melanoma | based on depth, <1mm good px and just local excision. Deeper need 2-3cm. Lesions >4mm very poor px. And 1-4mm all should get LN dissection
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| describe cystic hygroma and tx | base of neck, large mushy ill defined mass occupying entire supraclavicular area and often extend into mediastinum. Need CT before attempt resection
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| parotid tumor--benign v malignant | hard parotid mass that is painful or produced paralysis=cancer. Most tumors are pleomorphic adenomas that are benign but have malignant potl and don’t have pain or paralysis
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| new suspicious LN HEENT, what do | have come back 3-4 wks (unless alarming signs). If still there w/u. Remember-never do open bx on neck
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| what's Ludwig angina | abscess in floor of mouth from tooth infxn-an emergency, concern is for airway
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| nose bleed in adolescent that doesn't stop (2), management | cocaine abuse (w septal perf—use posterior packing), or juvenile nasopharyngeal angiofibroma (needs surgical resection, a benign tumor but invades nearby structures)
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| meds for dizziness 3 | if “room is spinning”=inner ear, meclizine (ie Dramamine anti His), phenergen, or diazepam help [otherwise it's brain problem]
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| inappropriate behavior, ipsi optic nerve atrophy, contra papilloedema | Foster-Kennedy syndrome”-a tumor at the base of the frontal lobe
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| describe pituitary apoplexy | bleeding from pit tumor destroying pit. History c/w pit tumor (HA, visual loss, endocrine) -> sudden severe HA, compression by hematoma (deterioration of remaining vision), & destruction of pituitary (stupor and hypotension). Urgently give steroids,
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| describe Parinaud syndrome | pineal gland tumor causing loss of upper gaze (sunset eyes)
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| describe reflex sympathetic dystrophy, aka, tx | aka causalgia-months after crushing injury. Constant, burning, pain aggravated by slightest stimulation&doesn’t respond to analgesics. Extremity is cold, cyanotic. If sympathetic block =diagnostic->tx=surgical sympathectomy
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| key diffs testicular torsion and acute epididymitis | torsion=sudden onset w/o F, pyuria, or mumps. High riding testicle, very swollen w horiz lie. Cord is not tender; Acute epididymitis-young men old enough to be sex active, sudden pain w F, pyuria, swollen testicle but nml position and CORD is painful
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| describe presentation of ureteropelvic conjunction obstruction | appears when body is trying to diurese and the path isn’t big enough. Ie someone on drinking binge for first time develops colicky flank pain
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| describe presentation of low implantation ureter in girl | (in boy usu asympt) urine drips into vagina as well as bladder so although feels need to void and voids nmlly at nml intervals, also is wet all the time from a constant drip
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| presentation and tx acute urinary retention | often BPH after taking cold meds and lots of fluids during a cold. May need indwelling bladder cath for >3d. Use alpha blockers for long term and 5-alpha reductase inhib for glands >40g
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| MC cause pneumaturia | fistulization bw bladder and GI (MC sigmoid colon) usu from diverticulitis. w/u w CT. will need sigmoidoscopy to r/o cancer
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