Give crisp and concise answer from latest edition of bailey and love of surgery

Reading File

Finding Sources

Reading File

Finding Sources

Reading File

Finding Sources

Here are crisp, concise answers from Bailey & Love's Short Practice of Surgery, 28th Edition:

SECTION A - MCQ ANSWERS

Q	Answer	Key Point
1	(b) Post-operative adhesions	In western countries, adhesions/bands are the most common cause of intestinal obstruction (hernia is #1 worldwide)
2	(a) Palpation of left iliac fossa causing pain in right iliac fossa	Rovsing's sign = pressure on left iliac fossa reproduces RIF pain due to peritoneal stretch
3	(c) Ultrasonography (USG)	USG is the first-line gold standard for cholelithiasis (cheap, non-invasive, >95% sensitivity)
4	(b) Lesser curvature (Incisura angularis)	Most gastric ulcers occur on the lesser curvature, especially at the incisura
5	(b) Hernia where only part of the circumference of the bowel wall is trapped	Richter's hernia - only anti-mesenteric wall is caught; no obstruction, but risk of strangulation
6	(a) Acute Pancreatitis	Sentinel loop = localised ileus of jejunum near pancreas, seen in acute pancreatitis
7	(c) Heller's Myotomy	Treatment of choice for achalasia; laparoscopic Heller's myotomy +/- partial fundoplication
8	(b) Hypochloremic Hypokalemic Metabolic Alkalosis	Classic electrolyte abnormality in HPS due to loss of HCl and K+ from vomiting
9	(c) Duodenal Atresia	Double bubble sign = gas in stomach + dilated duodenum, diagnostic of duodenal atresia
10	(d) Hypoglycemic symptoms during fasting	Whipple's Triad: (i) symptoms of hypoglycaemia during fasting, (ii) blood glucose <2.5 mmol/L, (iii) relief with glucose
11	(c) End-tidal CO₂ (EtCO₂) detection	Most reliable clinical indicator of correct ET tube placement
12	(a) Carcinoma Colon	Apple-core/napkin-ring appearance on barium enema = carcinoma of the colon
13	(d) Ketamine	Ketamine causes dissociative anaesthesia (NMDA receptor antagonist)
14	(b) Small bowel obstruction	Step-ladder pattern (valvulae conniventes) = small bowel obstruction
15	(a) Acute Necrotizing Ulcerative Gingivitis	Vincent's Angina = ANUG caused by fusospirochaetal infection
16	(a) Colles' Fracture	Dinner fork deformity = dorsal displacement + dorsal angulation of distal radius
17	(d) Posterior	Most common hip dislocation is posterior (90%) - occurs with knee hitting dashboard
18	(a) Ewing's Sarcoma	Sunray/sunburst appearance on X-ray is classically Ewing's sarcoma (onion-peel periosteal reaction also classic)
19	(a) Radial Nerve	Radial nerve runs in spiral groove; injured in fracture of surgical neck/mid-shaft humerus
20	(a) Gluteus Medius and Minimus	Positive Trendelenburg = weakness of abductor muscles (gluteus medius & minimus) on weight-bearing side

SECTION B

Q1 - Acute Appendicitis

(a) Most Likely Diagnosis: Acute Appendicitis

Periumbilical pain shifting to RIF (McBurney's point) + vomiting + low-grade fever = classic presentation. Visceral pain from distension (periumbilical) shifts to somatic pain in RIF as parietal peritoneum is involved.

(b) Clinical Signs + Alvarado Score

Clinical Signs:

Tenderness at McBurney's point (2/3 from umbilicus to ASIS)
Rebound tenderness (Blumberg's sign)
Rovsing's sign (pressure on LIF → pain in RIF)
Psoas sign (pain on hip extension - retrocaecal appendix)
Obturator sign (pain on internal rotation of flexed right hip - pelvic appendix)
Guarding and rigidity

Alvarado (MANTRELS) Score (Bailey & Love, Table 76.2):

Feature	Score
Migratory RIF pain	1
Anorexia	1
Nausea/vomiting	1
Tenderness RIF	2
Rebound tenderness	1
Elevated temperature	1
Leukocytosis	2
Shift to left (neutrophilia)	1
Total	10

Score ≥7: Strongly predictive - operate
Score 5-6: Equivocal - USS or CT
Score <5: Appendicitis unlikely

(c) Surgical Management:

Appendicectomy (laparoscopic preferred): diagnostic + therapeutic advantage; faster recovery, less wound infection
Open approach (grid-iron/Lanz incision) if laparoscopic unavailable
Interval appendicectomy after 6-8 weeks if appendix mass is present

Complications if Left Untreated:

Appendix mass / phlegmon
Appendix abscess
Perforation → generalised peritonitis
Portal pyaemia (rare but fatal - septic thrombosis of portal vein)
Septicaemia and death

Q2 Short Notes

(a) Inguinal Hernias - Classification & Anatomy of Inguinal Canal

Classification:

Indirect (lateral to inferior epigastric vessels) - most common; congenital/patent processus vaginalis; enters deep ring, travels through canal
Direct (medial to inferior epigastric vessels) - acquired; weakness of posterior wall (Hasselbach's triangle); does not enter deep ring

Anatomy of Inguinal Canal:

Length: 4 cm, runs obliquely from deep to superficial ring
Anterior wall: External oblique aponeurosis (whole length) + internal oblique (lateral 1/3)
Posterior wall: Transversalis fascia (whole length) + conjoint tendon (medial 1/3)
Roof: Arching fibres of internal oblique + transversus abdominis
Floor: Inguinal ligament + lacunar ligament medially
Deep ring: Defect in transversalis fascia, lateral to inferior epigastric vessels
Superficial ring: Defect in external oblique aponeurosis, above pubic tubercle
Contents (male): spermatic cord (vas deferens, testicular artery, pampiniform plexus, genital branch of genitofemoral nerve, cremasteric artery, ilioinguinal nerve lies on top)

(b) Acute Pancreatitis - Clinical Features & Management

Clinical Features:

Severe epigastric pain radiating to back, relieved by leaning forward
Nausea/vomiting
Grey-Turner sign (flank bruising) and Cullen's sign (periumbilical bruising) - late, severe disease
Tenderness, guarding in epigastrium

Management:

Aggressive IV fluid resuscitation (Hartmann's)
NBM + analgesia (IV morphine)
NG tube if vomiting
Monitor urine output
CT scan (CECT) if severe or no improvement - assess necrosis
ERCP + sphincterotomy within 72 hrs if biliary pancreatitis with cholangitis
Prophylactic antibiotics in infected necrosis (meropenem)
Necrosectomy for infected pancreatic necrosis failing conservative treatment

(c) FAST - Focused Assessment with Sonography for Trauma

Definition: Bedside USS to detect free fluid (blood) in abdomen/pericardium in trauma.

Four Windows Examined:

Pericardial (subxiphoid) - haemopericardium
Morrison's pouch (right upper quadrant) - hepatorenal recess - most sensitive
Splenorenal recess (left upper quadrant)
Pelvis (pouch of Douglas / rectovesical)

Extended FAST (eFAST): Also examines bilateral pleural spaces for pneumothorax.

Advantages: Rapid, bedside, repeatable, no radiation, cost-effective Limitations: Operator dependent; cannot detect retroperitoneal bleeding; misses bowel/diaphragm injuries

(d) Spinal Anaesthesia

Definition: Injection of local anaesthetic into the subarachnoid space (intrathecal space), below L1/L2 (conus medullaris).

Indications:

Lower limb surgery
Hip/knee replacement
Caesarean section
Hernia repair
Cystoscopy/transurethral procedures
Perineal/anal procedures

Two Common Complications:

Hypotension - due to sympathetic blockade → vasodilation; treated with IV fluids + vasopressors
Post-dural puncture headache (PDPH) - CSF leak through dural hole; positional (worse upright); treated with bed rest, hydration, caffeine; refractory cases: epidural blood patch

Q3 - Very Short Notes

(a) Two Causes of Pneumoperitoneum

Perforated peptic ulcer (most common cause of surgical pneumoperitoneum)
Perforated hollow viscus (e.g., perforated diverticulitis, perforated carcinoma colon) Others: post-laparoscopy (physiological), post-ERCP, spontaneous in neonates

(b) Child-Pugh Score

Assesses severity of cirrhosis and surgical risk.

Parameter	1	2	3
Bilirubin (µmol/L)	<34	34-50	>50
Albumin (g/L)	>35	28-35	<28
PT prolongation (sec)	<4	4-6	>6
Ascites	None	Mild	Severe
Encephalopathy	None	Grade 1-2	Grade 3-4

Class A (5-6): Well-compensated; good surgical risk
Class B (7-9): Significant impairment; moderate risk
Class C (10-15): Decompensated; poor surgical candidate

(c) Courvoisier's Law

"In the presence of obstructive jaundice, if the gallbladder is palpable and non-tender, the cause is unlikely to be gallstones."

Gallstone obstruction: gallbladder chronically inflamed/fibrosed → cannot distend
Carcinoma of pancreatic head / periampullary tumour: gallbladder unaffected → distends and is palpable
Exceptions: double calculi, Mirizzi syndrome, carcinoma in a gallstone patient

(d) Two Indications for Bariatric Surgery

BMI ≥40 kg/m² (morbid obesity) with or without comorbidities
BMI ≥35 kg/m² with significant obesity-related comorbidities (T2DM, hypertension, OSA, GORD)

(NICE criteria: failed at least 6 months supervised non-surgical management)

(e) Two Common Causes of Leukoplakia

Tobacco (smoking/chewing) - most common
Chronic alcohol use Others: chronic friction (ill-fitting dentures), candidiasis, HPV, syphilis

SECTION C

Q1 - Compound (Open) Fractures: Gustilo-Anderson Classification + Emergency Management + Debridement

Gustilo-Anderson Classification (Bailey & Love, Table 32.2):

Type	Description
I	Low-energy; wound <1 cm; clean
II	Wound >1 cm; no extensive soft-tissue damage/flaps/avulsion
IIIA	High-energy; extensive soft-tissue damage; adequate bone cover after stabilisation
IIIB	Inadequate soft-tissue cover; requires flap coverage
IIIC	Associated arterial injury requiring repair

Emergency Management:

ATLS - primary survey, ABC
Wound coverage - saline-soaked gauze, photograph, do not repeatedly remove
IV antibiotics immediately (co-amoxiclav; add metronidazole if contaminated; aminoglycoside for Type III)
Tetanus prophylaxis
Fracture splinting - reduce gross deformity, splint/traction
Neurovascular assessment before and after reduction
Definitive surgery within 6 hours (ideally)

Principles of Debridement:

Excision of contaminated/devitalised tissue
Lavage with copious normal saline (3-9 litres for Type III)
Bone: remove small fragments; preserve large fragments with soft-tissue attachment
Wound left open (delayed primary closure at 48-72 hrs)
Repeat debridement if doubt about viability
Stabilise fracture (external fixator for Type II/III; IM nail for Type I/II)

Q2 Short Notes

(a) Total Hip Replacement - Consent (Risks, Benefits, Right to Refuse)

Benefits:

Pain relief (most significant)
Improved mobility and function
Better quality of life

Risks (must be discussed - Montgomery ruling):

DVT/PE (1-3%)
Infection (1-2%) - may require revision
Dislocation (1-3%)
Leg length discrepancy
Nerve injury (sciatic/femoral)
Periprosthetic fracture
Aseptic loosening (requiring revision ~15 years)
General anaesthetic risks

Right to Refuse:

Under Mental Capacity Act, a competent adult has absolute right to refuse any treatment, even life-saving
Clinician must ensure patient has capacity, is fully informed, and decision is free from coercion
Document clearly in notes
If lacking capacity: act in best interests, involve next of kin/IMCA

(b) Colles' Fracture

Definition: Fracture of distal radius within 2.5 cm of the wrist, with dorsal displacement and dorsal angulation.

Mechanism: FOOSH (fall on outstretched hand) in osteoporotic elderly women.

Deformity: Dinner fork deformity (lateral view), bayonet deformity (AP view)

Radiology:

Dorsal tilt >10° (normal 10° palmar tilt)
Radial shortening
Dorsal comminution
Associated ulnar styloid fracture (50%)

Management:

Undisplaced: plaster of Paris back-slab in dorsiflexion + ulnar deviation, 6 weeks
Displaced: manipulation under anaesthesia (haematoma block/Bier's block) + plaster
Unstable/comminuted: K-wire fixation or volar locking plate (ORIF)
Complications: malunion (most common), EPL rupture, CRPS, median nerve compression, carpal tunnel syndrome

(c) Osteosarcoma - Pathology & Radiology

Pathology:

Most common primary malignant bone tumour (excluding myeloma)
Peak: 10-25 years (2nd decade), metaphysis of long bones (distal femur > proximal tibia > proximal humerus)
Histology: pleomorphic malignant cells producing osteoid/tumour bone
Codman's triangle: reactive periosteum lifted by tumour (not pathognomonic but characteristic)

Radiology:

Mixed lytic and sclerotic lesion
Sunburst pattern: new bone laid down in spicules perpendicular to cortex
Codman's triangle: periosteal elevation at margins of tumour
Cortical destruction + soft tissue extension
MRI: best for local staging (marrow involvement, skip lesions)
CXR/CT chest: pulmonary metastases (most common site)

Management:

Neoadjuvant chemotherapy (cisplatin + doxorubicin + methotrexate) → limb salvage surgery → adjuvant chemo
Amputation only if neurovascular structures involved
5-year survival: ~65-70% (localised disease)

(d) Chronic Osteomyelitis - Management

Principles:

Sequestrectomy - remove dead bone (sequestrum)
Saucerisation (involucrum opened) to drain cavity
Antibiotics - prolonged (6-12 weeks); guided by culture and sensitivity
Dead space management: muscle flaps, cancellous bone graft, antibiotic beads (gentamicin)
Wound care: regular dressings, VAC therapy
Treat underlying cause: DM control, vascular disease
Hyperbaric oxygen: adjunct in refractory cases

Q3 - Very Short Notes

(a) Thomas Splint

A traction splint used for temporary immobilisation of fractures of femur.

Provides traction through adhesive skin traction/skeletal traction
Ring fits around upper thigh
Reduces blood loss, pain, and fat embolism
Used in pre-hospital and initial hospital management

(b) Collar-button Abscess

An hourglass-shaped abscess of the palm/web space with two components connected by a narrow neck through a defect in the palmar fascia
Superficial component (between skin and deep fascia) + deep component (beneath palmar fascia)
Incision must drain BOTH compartments (through web space + separate dorsal incision if needed)
Most commonly occurs in web spaces of fingers

(c) Two Clinical Signs of DDH (Developmental Dysplasia of Hip)

In Neonate:

Ortolani's test - dislocated hip is reduced with abduction + anterior pressure ("clunk of entry")
Barlow's test - located hip is dislocated with adduction + posterior pressure ("clunk of exit")

In Older Child:

Galeazzi sign - apparent femoral shortening (knee at different levels with hips/knees flexed)
Trendelenburg gait - positive Trendelenburg sign due to abductor weakness

(d) Fat Embolism Syndrome

Definition: Systemic manifestations following release of fat droplets into circulation, typically 24-72 hrs after long bone/pelvic fractures.

Gurd's Criteria (Major):

Respiratory insufficiency (PaO₂ <60 mmHg)
Cerebral dysfunction
Petechial rash (pathognomonic - axillae, conjunctiva, chest)

Management: Supportive - O₂/ventilation, fluid resuscitation, early fracture fixation reduces risk

(e) Greenstick Fracture

An incomplete fracture seen in children where the bone bends and breaks on one cortex (tension side) but the other cortex and periosteum remain intact, like a green stick of wood.

Occurs because children's bones are more flexible (higher collagen content)
Treatment: manipulation to complete the fracture + plaster; tends to heal rapidly
Risk of re-angulation if not properly reduced

All answers sourced from Bailey & Love's Short Practice of Surgery, 28th Edition (ISBN 9780367548117)

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