Solve as you are MBBS final year student giving professional exam.

Reading File

This is a comprehensive Surgery Paper II exam. I'll answer all sections systematically as an MBBS final year student.

M.B.B.S. 3rd Professional (Part-2) — Surgery Paper II

MBT-404 | Paper Code: 4004 | Max Marks: 100

SECTION A — MCQs (20 Marks)

Q	Answer	Key Reasoning
1	(b) Post-operative adhesions	Most common cause of mechanical SBO worldwide; hernias are #1 in developing countries but adhesions dominate globally
2	(a) Palpation of the left iliac fossa causing pain in the right iliac fossa	Rovsing's sign: pressure in LIF transmits gas across colon → pain at McBurney's point
3	(c) Ultrasonography (USG)	Gold standard for cholelithiasis — cheap, no radiation, >95% sensitivity for gallstones
4	(b) Lesser curvature (Incisura angularis)	Most gastric ulcers occur at the incisura angularis on the lesser curvature (Type I)
5	(b) Hernia where only a part of the circumference of the bowel wall is trapped	Richter's hernia = partial enterocele (knuckle of bowel wall); can strangulate without obstruction
6	(a) Acute Pancreatitis	Sentinel loop = localized ileus of a single loop of jejunum adjacent to inflamed pancreas
7	(c) Heller's Myotomy	Treatment of choice for Achalasia Cardia; laparoscopic Heller's myotomy ± Dor fundoplication
8	(b) Hypochloremic Hypokalemic Metabolic Alkalosis	HPS → projectile non-bilious vomiting → loss of HCl → hypochloremia, hypokalemia, metabolic alkalosis ("paradoxical aciduria")
9	(c) Duodenal Atresia	Double bubble sign = gas in stomach + dilated duodenum; associated with Down syndrome
10	(d) Hypoglycemic symptoms during fasting	Whipple's Triad: (1) symptoms during fasting, (2) blood glucose <2.8 mmol/L, (3) relief with glucose
11	(c) End-tidal CO₂ (EtCO₂) detection	Most reliable confirmation of ETT placement; waveform capnography is gold standard
12	(a) Carcinoma Colon	Apple core/napkin ring appearance on barium enema = annular carcinoma of colon
13	(d) Ketamine	Dissociative anesthesia — NMDA receptor antagonist; causes analgesia + amnesia + catalepsy
14	(b) Small bowel obstruction	Step-ladder pattern (multiple air-fluid levels in a staircase pattern) = SBO
15	(c) Ludwig's Angina	Vincent's Angina = acute necrotizing ulcerative gingivitis (ANUG); Ludwig's = floor of mouth cellulitis
16	(b) Smith's Fracture	Dinner fork deformity (volar displacement) = Smith's fracture (reverse Colles')
17	(d) Posterior	Most common hip dislocation is posterior (~90%); caused by dashboard injury
18	(b) Osteosarcoma	"Sunburst" (sunray) periosteal reaction on X-ray is classic for osteosarcoma
19	(a) Radial Nerve	Surgical neck of humerus fracture → axillary nerve; Shaft fracture → Radial nerve (spiral groove). Question says "surgical neck" → (d) Axillary Nerve
20	(a) Gluteus Medius and Minimus	Trendelenburg sign = weakness of hip abductors (gluteus medius + minimus) on the stance side

Note on Q19: If the question reads "surgical neck of humerus" → Axillary nerve (d). If "shaft/mid-shaft" → Radial nerve. Most exam papers intend Radial nerve for mid-shaft fractures.

SECTION B (40 Marks)

Q1. 25-year-old male: periumbilical pain shifting to right iliac fossa + vomiting + low-grade fever

(a) Most Likely Diagnosis — 1 mark

Acute Appendicitis

Classic triad: periumbilical pain shifting to RIF (Cockade migration), anorexia, fever, and vomiting. The sequence (pain → vomiting, unlike intestinal obstruction where vomiting precedes pain) is characteristic.

(b) Clinical Signs & Alvarado Scoring System — 5 marks

Clinical Signs of Acute Appendicitis:

Sign	Description
McBurney's point tenderness	Maximum tenderness at junction of lateral 1/3 and medial 2/3 of line from ASIS to umbilicus
Rovsing's sign	Pressure in LIF → pain in RIF (peritoneal irritation)
Psoas sign	Pain on extension of right hip — retrocaecal appendix lies on psoas
Obturator sign	Pain on internal rotation of flexed right hip — pelvic appendix irritates obturator internus
Guarding & Rigidity	Involuntary muscle spasm over RIF in peritonitis
Rebound tenderness	Blumberg's sign — sudden release of pressure causes severe pain
Dunphy's sign	Increased pain on coughing

Alvarado Score (MANTRELS):

Feature	Score
M — Migration of pain to RIF	1
A — Anorexia	1
N — Nausea/Vomiting	1
T — Tenderness in RIF	2
R — Rebound tenderness	1
E — Elevated temperature (>37.3°C)	1
L — Leucocytosis (>10,000/mm³)	2
S — Shift of WBC to left	1
Total	10

Interpretation:

1–4: Appendicitis unlikely
5–6: Possible appendicitis — observe
7–8: Probable appendicitis — operate
9–10: Definite appendicitis — operate immediately

This patient: Migration (1) + Nausea/vomiting (1) + Tenderness RIF (2) + Fever (1) + likely leucocytosis (2) = Score ≥7 → Operate

(c) Surgical Management & Complications if Left Untreated — 4 marks

Surgical Management:

Pre-operative:

IV fluid resuscitation, NPO
IV antibiotics (metronidazole + cefuroxime)
Urinalysis, USS RIF, CBC, CRP

Operative:

Laparoscopic appendicectomy — gold standard (cosmesis, reduced wound infection, shorter stay)
Open appendicectomy (Lanz/McBurney incision) — if laparoscopy unavailable or perforated with abscess

Surgical steps (open): Grid iron/Lanz incision → identify caecum → trace taenia coli to base of appendix → ligate and divide mesoappendix → double ligation of appendix base → excise appendix → bury stump (optional)

Post-operative: Continue antibiotics 24–48 hrs (extend if perforated)

Complications if Left Untreated:

Early	Late
Perforation (24–72 hrs)	Portal pyaemia (suppurative pylephlebitis)
Appendicular abscess (pericaecal)	Liver abscess
Appendicular mass/phlegmon	Intestinal obstruction (adhesions)
Generalized peritonitis	Infertility in females (pelvic adhesions)
Septicaemia/septic shock	Pylephlebitis

Q2. Short Notes (4×5 = 20 marks)

(a) Classification of Inguinal Hernias + Anatomy of Inguinal Canal

Classification of Inguinal Hernias:

1. Indirect Inguinal Hernia (Lateral/Oblique)

Passes through the deep inguinal ring, traverses the inguinal canal, exits through superficial ring
Follows the course of the spermatic cord — congenital (patent processus vaginalis)
Lies lateral to inferior epigastric vessels
More common in young males; most common hernia overall

2. Direct Inguinal Hernia (Medial)

Protrudes directly through the posterior wall of inguinal canal (Hesselbach's triangle)
Lies medial to inferior epigastric vessels
Due to weakness of transversalis fascia — acquired
More common in elderly males; rarely strangulates

Hasselbach's Triangle boundaries:

Medial: Lateral border of rectus abdominis
Lateral: Inferior epigastric vessels
Inferior: Inguinal ligament

Anatomy of Inguinal Canal:

Length: 4 cm in adults
Direction: Downward, medially, forward
Location: Runs above the medial half of inguinal ligament

Feature	Description
Deep ring	Opening in transversalis fascia; lies at midpoint of inguinal ligament
Superficial ring	V-shaped opening in external oblique aponeurosis; above pubic tubercle
Anterior wall	External oblique aponeurosis (entire); internal oblique (lateral 1/3)
Posterior wall	Transversalis fascia (entire); conjoint tendon (medial 1/3)
Roof	Arching fibers of internal oblique and transversus abdominis
Floor	Inguinal ligament + lacunar ligament medially

Contents:

Male: Spermatic cord (3 arteries, 3 veins, 3 nerves, vas deferens, lymphatics, processus vaginalis remnant)
Female: Round ligament of uterus + ilioinguinal nerve

(b) Clinical Features & Management of Acute Pancreatitis

Clinical Features:

Symptoms:

Severe epigastric pain radiating to back ("boring"), relieved by leaning forward
Nausea, vomiting (does not relieve pain)
Abdominal distension
Low-grade fever

Signs:

Epigastric tenderness, guarding
Cullen's sign — periumbilical bruising (haemoperitoneum)
Grey Turner's sign — flank bruising (retroperitoneal haemorrhage)
Fox's sign — bruising at inguinal ligament
Tachycardia, hypotension (hypovolaemia)
Absent bowel sounds (ileus)
Jaundice (biliary obstruction)

Investigations:

Serum amylase >3× normal (rises within 2–12 hrs) — not specific
Serum lipase — more sensitive and specific, stays elevated longer
USS abdomen (gallstones), CECT abdomen (gold standard for severity/necrosis — Balthazar Score)
CBC, LFTs, RFTs, blood glucose, calcium, CRP

Severity Assessment — Modified Glasgow (IMRIE) Criteria: (PaO₂ <8 kPa, Age >55, Neutrophils >15×10⁹, Calcium <2 mmol/L, Renal urea >16 mmol/L, Enzymes LDH>600, Albumin <32 g/L, Sugar/Glucose >10 mmol/L) — Score ≥3 = severe

Management:

Conservative ("Drip and Suck"):

Aggressive IV fluid resuscitation (Hartmann's/Ringer's lactate, 250–500 mL/hr)
Analgesia — IV morphine/pethidine (despite old myths, opioids are safe)
NBM (nil by mouth), NG suction if vomiting
Urinary catheter — monitor UO (>0.5 mL/kg/hr)
O₂ supplementation, ICU monitoring if severe
Early enteral feeding (nasojejunal) — reduces infectious complications, better than TPN
IV antibiotics only if infected necrosis (not prophylactic)

Specific:

Gallstone pancreatitis → ERCP + sphincterotomy within 72 hrs if cholangitis/obstruction; cholecystectomy same admission
Infected pancreatic necrosis → CT-guided drainage or necrosectomy ("step-up" approach)

(c) Role of FAST (Focused Assessment with Sonography for Trauma) in Abdominal Emergencies

Definition: FAST is a rapid, bedside, point-of-care ultrasound exam performed in trauma patients to detect free intraperitoneal fluid (blood) and pericardial effusion.

Extended FAST (eFAST): Includes thoracic windows to detect pneumothorax/haemothorax.

Four Standard Windows:

Window	Detects
Perihepatic (Morison's pouch)	RUQ haemoperitoneum — hepatorenal space
Perisplenic (Koller's pouch)	LUQ haemoperitoneum — splenorenal space
Pelvic (Pouch of Douglas/retrovesical)	Pelvic free fluid
Pericardial (Subxiphoid)	Haemopericardium, tamponade

Indications:

Blunt abdominal trauma (BAT)
Penetrating trauma
Hypotensive trauma patients
Suspected haemopericardium
Monitoring after trauma

Advantages:

Rapid (<3 minutes)
Non-invasive, no radiation
Bedside — does not interrupt resuscitation
Repeatable
Sensitivity 79–95% for significant haemoperitoneum

Interpretation:

FAST positive (free fluid visible) + haemodynamically unstable → Emergency exploratory laparotomy
FAST positive + haemodynamically stable → CT abdomen for further evaluation
FAST negative + unstable → Repeated FAST or diagnostic peritoneal lavage (DPL)

Limitations:

Operator-dependent
Cannot detect retroperitoneal injuries
Misses <250–500 mL of free fluid
Poor in obese patients, bowel gas interference

(d) Spinal Anaesthesia — Definition, Indications & Complications

Definition: Spinal anaesthesia (subarachnoid block/intrathecal block) is the injection of local anaesthetic (± adjuvants) into the subarachnoid space (cerebrospinal fluid) at the lumbar level (usually L3/L4 or L4/L5 — below the conus medullaris at L1/L2), producing segmental blockade of spinal nerve roots.

Common Agents: Hyperbaric bupivacaine 0.5% (heavy) ± fentanyl/morphine/clonidine

Indications:

Lower abdominal surgeries (appendicectomy, herniorrhaphy)
Urological procedures (TURP, cystoscopy)
Gynaecological procedures (hysterectomy)
Lower limb orthopedic surgeries (hip/knee replacement, # fixation)
Perineal and perianal surgeries (haemorrhoidectomy, fistula)
Caesarean section (obstetric)
Peripheral vascular surgeries below umbilicus

Two Common Complications:

1. Post-Dural Puncture Headache (PDPH):

Incidence: 1–5% with 25G Quincke needle
Mechanism: CSF leak through dural hole → reduced CSF pressure → traction on meninges
Character: Postural — worse sitting/standing, relieved lying flat
Treatment: Bed rest, hydration, caffeine, analgesics; Epidural blood patch (gold standard if persistent)

2. Hypotension:

Most common immediate complication (~30%)
Mechanism: Sympathetic blockade → vasodilation → reduced venous return → reduced cardiac output
Treatment: IV fluid pre-loading (500–1000 mL crystalloid), IV ephedrine (vasopressor of choice in obstetrics), IV phenylephrine, leg elevation

Other notable complications: Total spinal (high block), urinary retention, backache, neurological injury (rare), meningitis

Q3. Very Short Notes (5×2 = 10 marks)

(a) Two Causes of Pneumoperitoneum

Free gas under diaphragm on erect CXR/AXR:

Perforated peptic ulcer (most common — anterior duodenal ulcer)
Perforated hollow viscus (e.g., perforated diverticulitis, perforated carcinoma colon, typhoid perforation)

Other causes: Post-laparotomy/laparoscopy, pneumatosis intestinalis, post-ERCP, Boerhaave syndrome

(b) Child-Pugh Score

Used to assess severity of chronic liver disease and prognosis in cirrhosis.

Parameter	1 Point	2 Points	3 Points
Bilirubin (µmol/L)	<34	34–50	>50
Albumin (g/L)	>35	28–35	<28
PT prolongation (sec)	<4	4–6	>6
Ascites	None	Mild/controlled	Severe/refractory
Hepatic encephalopathy	None	Grade I–II	Grade III–IV

Classification:

Class A (5–6): Well-compensated — 1-year survival 100%, operative mortality 5%
Class B (7–9): Significant functional compromise — operative mortality 10%
Class C (10–15): Decompensated — operative mortality >25%

(c) Courvoisier's Law

"In a patient with obstructive jaundice, if the gallbladder is palpable and non-tender, the obstruction is unlikely to be due to gallstones."

Gallstones → chronic cholecystitis → fibrotic, thickened, non-distensible gallbladder → cannot dilate
Malignant obstruction (carcinoma head of pancreas, cholangiocarcinoma, periampullary carcinoma) → slow, progressive → gallbladder dilates without inflammation → palpable, non-tender
A palpable gallbladder with painless obstructive jaundice strongly suggests periampullary/pancreatic malignancy

(d) Two Indications for Bariatric Surgery

Criteria (NIH guidelines — BMI-based):

BMI ≥40 kg/m² without comorbidities (morbid obesity)
BMI ≥35 kg/m² with significant obesity-related comorbidities (Type 2 DM, HTN, obstructive sleep apnoea, GERD, dyslipidemia)

Types: Roux-en-Y gastric bypass, sleeve gastrectomy, adjustable gastric band

(e) Two Common Causes of Leukoplakia

Leukoplakia = white patch on mucous membrane that cannot be rubbed off and cannot be attributed to any other definable disease (precancerous lesion).

Tobacco use (smoking and smokeless tobacco/gutka) — most common cause
Chronic alcohol consumption (synergistic with tobacco)

Other causes: Chronic irritation (ill-fitting dentures), HPV infection, candidiasis (pseudomembranous — but this can be wiped off), Betel nut chewing

SECTION C (40 Marks)

C-Q1. Gustilo-Anderson Classification of Compound (Open) Fractures + Emergency Management + Debridement (10 marks)

Gustilo-Anderson Classification

Definition: Open/compound fracture = fracture with communication of the fracture site with the external environment through a wound.

Grade	Wound Size	Contamination	Soft Tissue	Bone
Type I	<1 cm	Minimal/clean	Minimal stripping	Simple, comminution <50%
Type II	1–10 cm	Moderate	Moderate stripping	Moderate comminution
Type IIIA	>10 cm	Heavy	Severe stripping but adequate soft tissue coverage	Comminuted; coverage possible
Type IIIB	>10 cm	Heavy	Extensive periosteal stripping; inadequate coverage	Exposed bone; requires local/free flap
Type IIIC	Any	Any	Any	Associated arterial injury requiring repair

Mnemonic: "Open fractures get worse with bigger wounds, more contamination, less soft tissue, and vessel injury."

Infection rates: Type I: ~2%; Type II: ~5–10%; Type IIIA: ~10–25%; Type IIIB/C: up to 50%

Emergency Management of Open Fractures

"ABCDE + wound care + stabilization"

1. Primary Survey (ATLS): Airway, Breathing, Circulation — control haemorrhage with direct pressure

2. Wound Assessment:

Note wound size, contamination, degree of soft tissue loss, neurovascular status
Photograph wound — do NOT probe repeatedly

3. Tetanus Prophylaxis:

Tetanus toxoid if not immunized
Tetanus immunoglobulin (TIG) if heavily contaminated wound

4. IV Antibiotics:

Type I/II: IV Cefazolin (1st generation cephalosporin) — started within 1–3 hrs (ideally in ED)
Type III: Add metronidazole + aminoglycoside (gentamicin) for gram-negative and anaerobic cover
Farm injuries/soil contamination: Add Penicillin G (Clostridium coverage)
Duration: 24–72 hrs post-debridement

5. Wound Irrigation and Temporary Coverage:

Saline-soaked sterile dressing — do NOT pack with iodine gauze
Do NOT close wound primarily in emergency department

6. Fracture Stabilization:

Reduce and splint in ED
External fixation — preferred for Type III open fractures (allows wound access, stable)
Intramedullary nailing for Type I/II (after thorough debridement)

7. Neurovascular assessment: Document distal pulses, capillary refill, sensation, motor function

8. Operative debridement: Within 6 hours traditionally (now evidence suggests within 24 hrs if antibiotics given and appropriate debridement performed — but early is safer)

Principles of Debridement in Open Fractures

Definition: Debridement = surgical removal of all devitalized, contaminated, and foreign tissue from a wound to create a clean biological environment for healing.

Steps of Debridement:

1. Excision of wound edges: Elliptical excision of skin margins (~2–5 mm)

2. Fasciotomy if indicated: Release compartment pressure (compartment syndrome); prophylactic in Type III injuries

3. Wound extension: Extend wound proximally and distally to adequately expose all devitalized tissue; never cross flexion creases transversely

4. Systematic layered removal:

Skin: Remove only frankly devitalized skin (pinch test — blanching = viable)
Subcutaneous fat: Freely remove devitalized fat
Fascia: Remove devitalized fascia
Muscle: 4 C's — Colour (pink), Contractility (contracts to stimulation), Consistency (firm), Capacity to bleed. Remove any muscle failing these criteria
Bone: Remove only small, completely detached, non-cortical fragments; large cortical fragments with periosteal attachments are preserved (necessary for healing)
Foreign bodies: Complete removal

5. Copious irrigation: 6–9 litres of normal saline by pulsed lavage (9L for Type III); reduces bacterial load by 100-fold; do NOT use hydrogen peroxide or Betadine (cytotoxic)

6. Wound closure:

Type I: Primary closure possible
Type II/IIIA: Delayed primary closure at 48–72 hrs
Type IIIB/C: Soft tissue reconstruction (local/free flap) after clean wound confirmed

7. Reassess at 48–72 hrs ("second look"): Repeat debridement if necessary until wound is clean

C-Q2. Short Notes (4×5 = 20 marks)

(a) Total Hip Replacement — Informed Consent (Right to Refuse)

Scenario: 70-year-old patient requiring THR — explaining risks, benefits, and right to refuse.

Ethical-Legal Framework: The patient's autonomy is paramount. The principle of "Right to Refuse" is enshrined in medical ethics and law — a competent adult has the absolute right to refuse any treatment, even life-saving treatment.

What must be explained (Informed Consent process):

Benefits of THR:

Relief from chronic hip pain (osteoarthritis, AVN)
Restoration of mobility and function
Improved quality of life
90–95% success rate with 15–20 year implant longevity

Risks of THR:

Short-term	Long-term
Anaesthetic risks (cardiac, respiratory)	Aseptic loosening (most common late complication)
DVT/PE — most feared early complication	Periprosthetic fracture
Wound infection (1–2%)	Dislocation (posterior approach ~2%)
Nerve injury (sciatic nerve — foot drop)	Heterotopic ossification
Intraoperative fracture	Wear debris/osteolysis
Leg length discrepancy	Revision surgery needed
Blood loss — transfusion risk

Consequences of Refusal:

Progressive joint destruction, increasing pain
Reduced mobility, risk of falls
Functional dependence
Alternative management: physiotherapy, analgesia, walking aids — discussed

Capacity Assessment:

Patient must demonstrate: understanding, retention, weighing information, communication of decision
If patient lacks capacity (dementia) → best interests decision + family/proxy consultation

Documentation:

Consent form signed by patient + witness
Record in notes that refusal was informed, voluntary, and with capacity
Involve family with patient's permission

(b) Colles' Fracture — Clinical Features & Management

Definition: Colles' fracture is a fracture of the distal radius within 2.5 cm of the articular surface, with:

Dorsal displacement and angulation
Radial shortening
Dorsal comminution
Associated ulnar styloid fracture (in 50–60%)

Mechanism: FOOSH (Fall On Outstretched Hand) in osteoporotic, post-menopausal women

Clinical Features:

Symptoms:

Pain, swelling over distal forearm/wrist
Restricted wrist movements
History of fall on outstretched hand

Signs:

"Dinner Fork" deformity — dorsal displacement of distal fragment (when viewed from side)
"Gun stock" deformity — radial deviation (from front)
Tenderness over distal radius
Swelling, bruising over dorsal aspect of wrist
Radial shortening → ulnar styloid appears prominent

Radiological Features (X-ray wrist AP + lateral):

Dorsal tilt of distal radial articular surface (normal volar tilt 11–12°; Colles' shows dorsal tilt)
Radial shortening (normal ulnar variance neutral; Colles' shows positive variance)
Loss of radial inclination (normal 22–23°; reduced)
Dorsal comminution
Ulnar styloid fracture

Management:

Undisplaced: Below-elbow plaster of Paris (POP) cast — 6 weeks; wrist in slight palmar flexion and ulnar deviation (Cotton-Loder position)

Displaced:

Closed reduction under haematoma block (1% lidocaine) or Bier's block + above-elbow POP × 6 weeks
Check post-reduction X-ray
Reduction technique: Traction + disimpaction → palmar flexion + ulnar deviation

Criteria for ORIF (operative):

Failed closed reduction
Intra-articular involvement with step >2 mm
Radial shortening >5 mm
Dorsal angulation >20°
Young, active patients
Open fracture

Operative: Volar locking plate (ORIF), K-wires (Kapandji technique), external fixation

Complications:

Malunion (most common) — residual deformity
Median nerve injury (carpal tunnel syndrome)
Rupture of EPL tendon (3–6 weeks post-reduction)
Stiffness/shoulder-hand syndrome (Sudeck's atrophy/CRPS Type I)
Carpal tunnel syndrome (late)

(c) Osteosarcoma — Pathology & Radiological Features

Definition: Osteosarcoma (osteogenic sarcoma) is the most common primary malignant bone tumour (excluding myeloma), arising from primitive bone-forming mesenchymal cells that produce osteoid or immature bone.

Pathology:

Epidemiology:

Peak incidence: 2nd decade (10–20 years) — associated with adolescent growth spurt
2nd peak: >65 years (Paget's disease-related)
Male > Female (1.5:1)
Most common site: Distal femur > proximal tibia > proximal humerus (metaphysis of long bones)

Macroscopy:

Arises in metaphysis
Gritty, hard (osteoid-producing) areas
Haemorrhagic, necrotic
Soft tissue extension common
Lifts periosteum → Codman's triangle

Microscopy:

Pleomorphic malignant spindle cells
Production of osteoid (malignant bone) — hallmark
High mitotic rate, atypical mitoses
Subtypes: Osteoblastic (50%), Chondroblastic (25%), Fibroblastic (25%)
Immunohistochemistry: SATB2 positive (osteoblastic marker)

Radiological Features:

X-ray:

Mixed lytic and sclerotic lesion in metaphysis
"Sunburst" (sunray) pattern — perpendicular periosteal new bone formation radiating outward
Codman's triangle — periosteum lifted at edges of tumour forming triangular ossification
Cortical destruction, soft tissue mass
"Moth-eaten" pattern of bone destruction

MRI (gold standard for local staging):

Best for: Extent of medullary involvement, soft tissue spread, skip lesions, neurovascular proximity
T1: Heterogeneous signal; T2: High signal (oedema, necrosis)
Essential pre-operatively for limb salvage planning

CT Chest:

Staging — pulmonary metastases (most common metastatic site — "cannonball" lesions)

Bone Scan (Tc-99m):

Increased uptake — used to detect skip lesions and distant bone metastases

Staging: Musculoskeletal Tumor Society (MSTS) or AJCC system

Treatment (brief):

Neo-adjuvant chemotherapy (MAP: Methotrexate, Adriamycin/doxorubicin, Cisplatin) → Surgery (limb salvage or amputation) → Adjuvant chemotherapy
5-year survival with treatment: ~60–70% (localized); ~20% (metastatic)

(d) Principles of Management of Chronic Osteomyelitis

Definition: Chronic osteomyelitis is a persistent bone infection characterized by avascular necrotic bone (sequestrum), chronic draining sinuses, involucrum formation, and recurrent flares.

Pathological Features:

Sequestrum: Dead avascular bone — nidus of infection (bacteria within biofilm, avascular → antibiotics cannot penetrate)
Involucrum: New bone formation around sequestrum by elevated periosteum
Cloaca: Opening in involucrum through which pus and dead bone fragments drain
Sinus tract: Epithelialized channel to skin surface

Principles of Management:

1. Assessment:

X-ray (sequestrum, involucrum, periosteal reaction)
MRI (extent of medullary involvement, soft tissue abscess)
CT (bony sequestrum detail — best modality)
Wound swab/bone biopsy for culture — identify organism before surgery
ESR, CRP, WBC

2. Medical Treatment:

Prolonged antibiotics (4–6 weeks IV, then oral) — based on culture sensitivity
Common organisms: S. aureus (most common); Pseudomonas (IV drug users, diabetics); Salmonella (sickle cell)
Empirical: Cloxacillin/flucloxacillin ± gentamicin; MRSA → Vancomycin

3. Surgical Treatment (Mainstay):

a) Sequestrectomy: Removal of sequestrum — essential; removes the avascular nidus of infection

b) Saucerisation (Sclerosing Osteomyelitis): Conversion of deep cavity into shallow saucer-shaped defect to allow granulation tissue formation and facilitate dressing

c) Debridement: Thorough curettage of infected, necrotic tissue and biofilm

d) Dead Space Management (after removal of sequestrum/debridement):

Cancellous bone graft (autologous — gold standard)
Antibiotic-impregnated beads (PMMA beads with gentamicin/tobramycin)
Masquelet technique (induced membrane technique) — two-stage reconstruction
Vascularized bone graft (fibula) for large defects

e) Soft tissue coverage:

Local muscle flaps (gastrocnemius for tibia)
Free flaps for large defects

f) Amputation: Last resort — uncontrolled infection, malignant transformation (Marjolin's ulcer), failed reconstruction

4. Adjuncts:

Hyperbaric oxygen therapy (HBO) — enhances phagocytosis in hypoxic tissue
Vacuum-assisted closure (VAC) dressing
Adequate nutritional support

C-Q3. Very Short Notes (5×2 = 10 marks)

(a) Thomas Splint — Uses

The Thomas splint is used for:

Emergency first aid and transportation of fractures of the femoral shaft (traction splint to reduce pain, haemorrhage, and neurovascular injury)
Pre-operative immobilization of femur fractures pending definitive fixation (intramedullary nailing)
Skin/skeletal traction for paediatric femur fractures (gallows traction in children <2 years; balanced skeletal traction in older children)
Old use: Conservative management of femur shaft fractures ("90-90" traction)

(b) Collar-Button Abscess

A collar-button abscess (dumb-bell abscess) is a superficial palmar space infection in the hand where pus collects in two communicating compartments connected by a narrow neck through a defect in the palmar fascia:

Superficial component (dorsal to skin)
Deep component (in the web space/deep plane)
Connected by a narrow isthmus through fascia — resembling a collar button/dumb-bell
Occurs in web spaces of the hand
Treatment: Incision of both compartments (superficial + deep) through two incisions, otherwise recurs

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

Ortolani's test (Reduction test): In a dislocated hip — abduction + gentle forward pressure on greater trochanter produces a "clunk" as the femoral head reduces back into acetabulum (positive = dislocatable hip)
Barlow's test (Dislocation test): Adduction + posterior pressure — a "clunk" as femoral head dislocates posteriorly (positive = dislocatable hip)

Other signs (older infants):

Asymmetrical gluteal/thigh skin folds
Limited hip abduction on the affected side
Galeazzi sign (Allis sign) — apparent shortening of femur with hips/knees flexed
Trendelenburg gait (walking age)

(d) Fat Embolism Syndrome (FES)

Definition: Fat embolism syndrome is a clinical syndrome occurring after embolization of fat globules into the pulmonary and systemic circulation, most commonly following long bone fractures (femur, tibia, pelvis).

Classic Triad (Gurd's criteria):

Respiratory failure (hypoxia, ARDS) — onset 24–72 hrs post-injury
Neurological dysfunction (confusion, restlessness, seizures, coma)
Petechial rash — pathognomonic; non-blanching petechiae on conjunctivae, chest, axillae, neck

Additional features: Fever, tachycardia, fat globules in urine/sputum, retinal changes

Management: Supportive — O₂/ventilation, fluid resuscitation; early fracture stabilization (IMN) reduces incidence; prophylactic corticosteroids (controversial)

(e) Greenstick Fracture

A greenstick fracture is an incomplete fracture unique to children (paediatric bone) in which the bone bends and breaks on the tension (convex) side but remains intact on the compression (concave) side — analogous to breaking a green, flexible twig.

Key features:

Occurs in long bones (radius, ulna, tibia)
Bone is more porous and flexible in children → does not completely fracture
X-ray: Cortical break on one side only, with bowing/angulation
Management: Manipulation under anaesthesia (complete the fracture if >15° angulation), POP immobilization 4–6 weeks; excellent remodeling potential in children
Risk of re-fracture if cast removed early

Completed all sections. Total: 20 MCQs + Section B (Q1 full, Q2 a/b/c/d, Q3 a–e) + Section C (Q1, Q2 a/b/c/d, Q3 a–e).

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