---

DEPARTMENT OF SURGERY - SAMC & PGI INDORE

2nd Sessional Exam 2021 (July 2026) - Model Answers

---

LONG QUESTIONS (Any 2) [2 x 15 = 30]

---

Q1. Enumerate Etiologies of Perforation Peritonitis. Discuss Clinical Features & Management of Peptic Perforation.

Etiologies of Perforation Peritonitis

Peptic Ulcer Perforation

• Sudden onset, severe, constant "board-like" epigastric pain - the pain is instantaneous and catastrophic
• Pain may radiate to right shoulder (referred diaphragmatic irritation)
• Nausea and vomiting
• History of peptic ulcer disease in ~50% of patients

1. Peritoneal shock (0-2 hrs): Severe epigastric pain, board-like rigidity, absent bowel sounds, patient lies still
2. Reaction stage (2-12 hrs): Temporary improvement (gut bacteria haven't infected yet), patient appears slightly better - can be misleading
3. Bacterial peritonitis (>12 hrs): Fever, sepsis, distension, toxemia, paralytic ileus

• Board-like abdominal rigidity
• Guarding and tenderness
• Loss of liver dullness on percussion (Traube's space - free gas under diaphragm)
• Obliteration of psoas shadow on X-ray

• X-ray erect abdomen: Free gas under diaphragm in 70-80% (pneumoperitoneum)
• CT abdomen (gold standard): Free air, fluid collection, perforation site
• Serum amylase (may be mildly raised)
• FBC, LFTs, urea/creatinine

• IV access, aggressive fluid resuscitation (crystalloids)
• Nasogastric tube on free drainage (decompress stomach)
• Urinary catheter to monitor output
• IV broad-spectrum antibiotics (e.g., cefuroxime + metronidazole)
• Analgesia (IV opioids)
• NBM, PPI (proton pump inhibitor) IV infusion

• Laparoscopic or open
• The perforation is closed with 2-3 absorbable sutures + a pedicle of omentum tied over the defect (Graham's patch)
• Peritoneal lavage with warm saline

• Continue antibiotics
• H. pylori testing and eradication (triple therapy: PPI + clarithromycin + amoxicillin x 7 days)
• Long-term PPI
• Avoid NSAIDs, smoking, alcohol

---

Q2. Describe with Schematic Diagram: Anatomy of Venous System of Lower Limb. Discuss Etiopathogenesis & Management of Venous Ulcer.

Anatomy of Venous System of Lower Limb

• Great Saphenous Vein (GSV): Longest vein in body. Arises from medial end of dorsal venous arch, ascends anteromedially to enter femoral vein at saphenofemoral junction (SFJ) - 4 cm below and lateral to pubic tubercle. It has 6 tributaries entering at the SFJ ("the six sisters").
• Small Saphenous Vein (SSV): Arises from lateral dorsal arch, runs posterolateral up the calf, enters popliteal vein at saphenopopliteal junction (SPJ) in popliteal fossa.

• Runs alongside named arteries: Anterior tibial, posterior tibial, peroneal veins → popliteal vein → femoral vein → external iliac vein

• Connect superficial to deep at 3 levels: ankle (Cockett's perforators), mid-calf (Boyd's), thigh (Dodd's/Hunterian)
• Normal flow is from superficial → deep
• Valves prevent reflux from deep → superficial

External iliac vein
        |
Femoral vein ←── GSV (SFJ)
        |
  Popliteal vein ←── SSV (SPJ)
        |
 Anterior/Posterior tibial
 and Peroneal veins
        |
 Plantar venous plexus

Etiopathogenesis of Venous Ulcer

• Valvular incompetence (superficial or deep)
• Deep vein obstruction (post-thrombotic syndrome)
• Perforator incompetence (reflux from deep to superficial)

1. Incompetent valves → venous reflux → ambulatory venous hypertension
2. Increased venous pressure transmitted to capillaries
3. Capillary leak of fibrin and proteins → pericapillary fibrin cuffs form
4. White cell trapping → leukocytes adhere to endothelium, release proteolytic enzymes and free radicals
5. Tissue hypoxia + chronic inflammation → lipodermatosclerosis → skin breakdown → ulcer

• Site: Gaiter area (medial malleolus - area of Cockett's perforators)
• Shallow, irregular edges, sloping edges
• Wet, granulating base
• Surrounding skin: lipodermatosclerosis, varicose eczema, haemosiderin pigmentation
• Relatively painless unless infected
• ABPI (Ankle-Brachial Pressure Index) > 0.8 (unlike arterial ulcers)

Management of Venous Ulcer

• Compression therapy: Mainstay. 4-layer graduated compression bandaging achieves 30-40 mmHg. Reduces venous hypertension and promotes healing
• Leg elevation
• Wound care: debridement, appropriate dressings (hydrocolloid, foam)
• Treat infection with antibiotics only if clinical signs present (not routine)
• Pentoxifylline (improves microcirculation)

• Early endovenous ablation of superficial venous reflux (EVLA - endovenous laser ablation, or RFA - radiofrequency ablation) almost halves the time to healing and reduces recurrence
• Foam sclerotherapy for small varices
• SEPS (subfascial endoscopic perforator surgery) for incompetent perforators

---

Q3. Enumerate Classification of Breast Lump. Discuss Clinical Features & Management of T2N1M0 Carcinoma Breast.

Classification of Breast Lump

T2N1M0 Carcinoma Breast

• T2: Primary tumor 2-5 cm in greatest dimension
• N1: Movable ipsilateral axillary lymph nodes involved (1-3 nodes)
• M0: No distant metastasis
• Stage: IIIA → actually this is Stage IIB

• Lump 2-5 cm, hard, irregular, non-tender
• May have skin attachment, tethering to deep structures
• Peau d'orange (skin dimpling/orange peel appearance due to lymphatic obstruction)
• Nipple retraction, nipple discharge (blood-stained)
• Palpable ipsilateral mobile axillary nodes

• No hepatomegaly, no bone pain, no lung symptoms in M0 disease

• Mammography: Spiculate opacity, microcalcifications
• USS breast: Solid irregular hypoechoic mass
• Core needle biopsy: Gold standard for tissue diagnosis; provides ER, PR, HER2 receptor status
• Staging CT chest/abdomen/pelvis: For M0 confirmation
• Bone scan if symptomatic
• Sentinel lymph node biopsy assessment

• Modified Radical Mastectomy (MRM) = total mastectomy + level I-III axillary clearance - OR -
• Breast conserving surgery (BCS) = wide local excision + axillary node clearance + mandatory adjuvant radiotherapy (both options have equal survival)

• Chemotherapy: Anthracycline-based (FAC/FEC) or Taxane regimens. May be neoadjuvant (to downstage) or adjuvant
• Radiotherapy: Mandatory after BCS; also to chest wall after MRM if high-risk features
• Reconstruction (if mastectomy): Immediate or delayed, implant or autologous (TRAM, DIEP flap, LD flap)

---

SHORT QUESTIONS (Any 4) [4 x 5 = 20]

---

1. Hypertrophic Pyloric Stenosis (HPS)

• Incidence: 1 in 300-900 live births
• Most common: 2-8 weeks of age
• Male: Female = 4:1; first-born males most at risk
• Cause: Unknown; deficiency of nitric oxide synthase in pyloric tissue implicated

• Progressively worsening, projectile, non-bilious vomiting (bile is produced distally - NOT bile-stained is key)
• Baby remains hungry after vomiting ("hungry vomiter")
• Visible gastric peristalsis (left upper quadrant to epigastrium)
• Palpable pyloric "olive" in epigastrium (pathognomonic - no further imaging needed)
• Signs of dehydration
• Metabolic derangement: Hypokalaemic, hypochloraemic metabolic alkalosis

• USS (ultrasound) first line: pyloric muscle thickness >3-4 mm, length >15-18 mm
• Electrolytes: hypokalemia, hypochloremia, raised bicarbonate
• Upper GI contrast if equivocal (shows "string sign" or "double track sign")

• NOT a surgical emergency - resuscitate first
• IV fluids: Normal saline bolus 20 mL/kg then D5 ½ NS + 20 mEq/L KCl
• Correct to serum bicarbonate <30 mEq/L, chloride >95 mEq/L before surgery
• Ramstedt's Pyloromyotomy (Fredet-Ramstedt procedure): Longitudinal incision through the hypertrophied pyloric muscle down to intact mucosa. Can be laparoscopic or open.

---

2. Phyllodes Tumor of Breast

• Benign (60-75%)
• Borderline (15-20%)
• Malignant (10-15%)

• Age: Usually 35-55 years (10-20 years older than fibroadenoma)
• Large, rapidly growing breast lump
• Smooth, lobulated, firm-to-rubbery mass
• Skin stretched, shiny, prominent veins visible
• Rarely: skin ulceration (from pressure necrosis, not malignant invasion)
• Axillary nodes NOT typically involved (unlike carcinoma)
• Lung most common site for metastasis (hematogenous, not lymphatic)

• Core needle biopsy preferred (FNAC insufficient to distinguish from fibroadenoma)
• Histology: leaf-like intracanalicular growth pattern, hypercellular stroma

• Wide local excision with at least 1 cm clear margins (even for benign - higher recurrence if margins inadequate)
• Simple mastectomy for large tumors or if clear margins not achievable
• Axillary dissection NOT required (lymphatic spread is rare)
• No role for radiotherapy or chemotherapy in benign/borderline
• Malignant: chemotherapy (ifosfamide + doxorubicin) for metastatic disease

---

3. Ventricular Septal Defect (VSD)

1. Perimembranous/Membranous (80%) - most common, near aortic valve
2. Muscular (5-20%)
3. Inlet/AV canal type (8%)
4. Outlet/Supracristal/Conal (5-7%) - associated with aortic regurgitation

• Left-to-right shunt (systemic pressure > pulmonary pressure)
• Shunt magnitude depends on defect size and pulmonary vascular resistance (PVR)
• Increased pulmonary blood flow → pulmonary hypertension → Eisenmenger syndrome (reversal to R→L shunt, cyanosis) if untreated

• Loud pansystolic murmur at left lower sternal edge (LLSE), 4th intercostal space
• Thrill palpable
• Signs of heart failure if large: tachycardia, hepatomegaly, recurrent LRTI

• CXR: Cardiomegaly, increased pulmonary vascularity
• ECG: Biventricular hypertrophy
• Echo (2D + Doppler): Gold standard - confirms defect, quantifies shunt (Qp:Qs)
• Cardiac catheterization (if surgical planning)

• Small VSD: Conservative. 50% close spontaneously by age 3; SBE prophylaxis
• Large/symptomatic: Diuretics + digoxin + ACE inhibitors to control heart failure, then surgery
• Surgical: Patch closure (Dacron/pericardial patch) via median sternotomy on cardiopulmonary bypass; or transcatheter device closure (Amplatzer occluder) for suitable anatomy
• Eisenmenger syndrome: Contraindication to surgical repair; managed with pulmonary vasodilators (sildenafil, bosentan)

---

4. DVT Prophylaxis

1. Stasis of blood flow
2. Endothelial injury
3. Hypercoagulable state

• Early ambulation (most effective simple measure)
• Graduated compression stockings (TED stockings) - class II, 18-23 mmHg
• Intermittent pneumatic compression (IPC) devices - preferred intraoperatively
• Foot pumps

• LMWH (Low Molecular Weight Heparin): Enoxaparin 40 mg SC OD or Dalteparin 5000 units SC OD - first choice. Start 12 hours pre-op or 6-12 hours post-op
• Unfractionated heparin (UFH): 5000 units SC BD/TDS - used when eGFR <30
• Fondaparinux: 2.5 mg SC OD - especially for hip/knee surgery
• DOACs (Direct Oral Anticoagulants): Rivaroxaban, Apixaban - for elective hip/knee arthroplasty

• General surgery: until fully mobile (5-7 days minimum)
• Orthopedic (hip/knee): 28-35 days extended prophylaxis
• Cancer surgery: Extended (28 days) LMWH recommended

---

5. Flail Chest

• High-velocity blunt trauma to the chest (RTA, crush injury)
• The flail segment moves INWARD on inspiration and OUTWARD on expiration (paradoxical movement) - opposite to the rest of the chest wall

• Paradoxical movement reduces effective tidal volume
• Underlying pulmonary contusion is almost always present and contributes significantly to hypoxia
• Mediastinal shift ("pendelluft" phenomenon) - outdated concept

• History of significant chest trauma
• Dyspnea, tachypnea, hypoxia
• Paradoxical chest wall movement (visible)
• Chest wall tenderness, crepitus
• Signs of respiratory failure: cyanosis, accessory muscle use
• Associated injuries: pneumothorax, haemothorax, cardiac contusion

• Clinical primarily
• CXR: Multiple rib fractures (may underestimate number)
• CT chest: Accurately defines fractures, pulmonary contusion, pneumo/haemothorax

• High-flow O2
• Pain control: Epidural analgesia is GOLD STANDARD (allows deep breathing without splinting)
• IV analgesia (opioids, NSAIDs, intercostal nerve blocks)

• If tolerated: Supplemental oxygen, physio, incentive spirometry
• Mechanical ventilation (IPPV): Gold standard for internal pneumatic stabilization - indicated if: SpO2 <90%, RR >30, hypercapnia, associated injuries, pre-existing lung disease. Continue for up to 3 weeks while ribs heal
• Surgical rib fixation (ORIF): Increasingly used; plates/screws to stabilize the flail segment; reduces ICU/ventilator time

---

VERY SHORT QUESTIONS (Any 10) [10 x 2 = 20]

---

1. Trendelenburg Test

1. Patient supine, elevate leg to empty superficial veins
2. Apply tourniquet to upper thigh (to occlude GSV)
3. Ask patient to stand

• Negative (normal): Veins fill slowly from below (through perforators) over 30 seconds; on tourniquet release, no sudden further filling
• Tourniquet test positive (SFJ incompetent): On releasing tourniquet, sudden rush of blood fills the veins from above = SFJ incompetence
• Double-positive (perforator + SFJ incompetence): Veins fill rapidly even with tourniquet on, and further fill on release
• Tourniquet can be applied at different levels to locate incompetent perforators

---

2. Critical Limb Ischemia (CLI)

• Rest pain persisting for >2 weeks, requiring analgesia AND ankle systolic pressure <50 mmHg or toe pressure <30 mmHg, OR
• Tissue loss (ulceration or gangrene) with ankle systolic pressure <50 mmHg or toe pressure <30 mmHg

• Severe rest pain (especially at night, relieved by hanging leg down)
• Non-healing ulcers or frank gangrene
• ABI typically <0.4

---

3. Lipodermatosclerosis

• Affects gaiter area (lower third of leg, medial aspect)
• Skin becomes thickened, indurated, brown (haemosiderin deposition)
• Fibrosis of skin and subcutaneous tissue
• "Inverted champagne bottle" or "inverted wine bottle" appearance - lower calf narrow, upper calf normal
• Precedes venous ulcer formation
• Painful when acute; chronic form is firm and non-tender

---

4. Rest Pain in PAD (Peripheral Arterial Disease)

• Affects toes and forefoot (distal most territory)
• Worse at night (cardiac output falls, gravity no longer assists)
• Relieved by hanging the leg down or sleeping in a chair (hence "dependency")
• ABI typically <0.4 (<50 mmHg ankle pressure)

---

5. Line of Demarcation in Ischemic Limb

• Appears after several days to weeks of arterial occlusion
• The ischemic tissue mummifies (dry gangrene) due to the drying effect of air
• The line represents where inflammatory reaction meets dead tissue
• Proximal side: hyperaemic, inflamed skin
• Distal side: black, shrunken, mummified tissue

• Amputation should be performed at or just proximal to the line of demarcation (where healing can occur)
• Never amputate through wet gangrene (infected) - risk of spreading infection; control sepsis first

---

6. Indications for Intercostal Drain (ICD)

1. Pneumothorax:
   • Tension pneumothorax (emergency needle decompression first, then ICD)
   • Large spontaneous pneumothorax (>2 cm rim) not responding to aspiration
   • Traumatic pneumothorax
   • Any pneumothorax in ventilated patient
2. Haemothorax: Traumatic or spontaneous
3. Pleural effusion: Large symptomatic, empyema thoracis, malignant effusion
4. Empyema thoracis
5. Chylothorax
6. Post-operative: After thoracic surgery (thoracotomy, cardiac surgery)
7. Haemo-pneumothorax

---

7. Peau d'Orange

• Lymphatic obstruction by tumor cells in subdermal lymphatics
• Causes skin and subcutaneous tissue to become edematous
• Hair follicles and sweat gland orifices are tethered to dermis and cannot swell, while surrounding skin does
• Result: dimpled, pitted appearance resembling orange skin

• Indicates advanced local disease (T4b)
• Associated with inflammatory carcinoma (which shows peau d'orange over >1/3 of breast)
• May also occur in severe breast infections (mastitis)

---

8. Saphena Varix

• Appears as a soft, compressible swelling in the groin (upper medial thigh)
• Classically disappears on lying down (empties when recumbent)
• Shows a transmitted cough impulse (communicates with the venous system)
• Associated with varicose veins of the great saphenous system
• Saphena varix in the groin is a SOFT, COMPRESSIBLE, REDUCIBLE lump that has a COUGH IMPULSE - can be confused with femoral hernia

• Saphena varix: disappears on lying down, no bowel sounds, soft, associated varicosities
• Femoral hernia: does not fully disappear, may be irreducible

---

9. Transmitted Pulsations

1. Expansile pulsation: The lump expands in all directions with each cardiac pulsation = lump is PULSATILE = the lump itself is pulsating (e.g., true arterial aneurysm, AV fistula). Test: place two index fingers on either side of the lump - if they are pushed apart = expansile.
2. Transmitted pulsation: The lump merely rocks back and forth with cardiac contraction = pulsation is transmitted to the lump from an adjacent artery (e.g., a lymph node overlying the aorta). The fingers are NOT pushed apart.

• Expansile pulsation = arterial/vascular lesion (requires vascular surgery evaluation)
• Transmitted = benign characteristic (the lump is simply adjacent to an artery)

---

10. Compressible Swelling

---

11. Intermittent Claudication

• Stage I: Asymptomatic
• Stage IIa: Claudication >200 m
• Stage IIb: Claudication <200 m
• Stage III: Rest pain
• Stage IV: Ulcer/gangrene

• Risk factor modification: Stop smoking (#1), control diabetes, hypertension, hyperlipidemia
• Supervised exercise programme (gold standard conservative treatment - improves walking distance)
• Antiplatelet therapy: Aspirin 75 mg or clopidogrel
• Statin therapy
• Revascularization (angioplasty/bypass) for severe or disabling claudication

---

12. Duplex Scan (Duplex Ultrasonography)

1. B-mode USS: Real-time anatomical imaging - shows vessel lumen, wall, plaque, thrombus
2. Color Doppler: Color codes blood flow direction (red = toward probe, blue = away)
3. Pulse-wave Doppler: Gives flow velocity waveform; can measure peak systolic velocity (PSV) ratio to grade stenosis

• Varicose veins/venous disease: Locate incompetent SFJ, SPJ, perforators; map venous reflux (key pre-surgical planning)
• DVT diagnosis: Shows non-compressible vein, absent flow, thrombus
• Peripheral arterial disease: Grades stenosis, plans revascularization
• Carotid artery disease: Screens for carotid stenosis before endarterectomy
• AAA (aortic aneurysm): Surveillance
• Renal artery stenosis

---

ORTHOPEDIC SECTION [2 Questions] [2 x 10 = 20]

---

Q1. Describe Types & Pathology of Osteomyelitis. Discuss Its Treatment.

Definition

Types of Osteomyelitis

1. Acute Osteomyelitis (<2-3 weeks)
2. Subacute Osteomyelitis (Brodie's abscess)
3. Chronic Osteomyelitis (>6 weeks, or recurrent)

1. Hematogenous: Most common in children; affects metaphysis of long bones (rich blood supply, sluggish flow, lack of phagocytes)
2. Contiguous spread: From adjacent infection (diabetic foot, decubitus ulcer, sinusitis)
3. Direct inoculation: Post-trauma (open fracture), post-surgical

• Pyogenic (bacterial) - most common
• Tuberculous osteomyelitis (Pott's disease - spine)
• Fungal (immunocompromised)
• Viral

Pathology

• Staphylococcus aureus - most common at all ages (binds to bone collagen)
• Neonates: Group B Streptococcus, E. coli
• Sickle cell disease: Salmonella species
• Diabetic foot: Polymicrobial

• Bacteria arrive in metaphysis via blood
• Neutrophilic infiltration, edema, suppuration
• Bone cell necrosis within 48 hours
• Pus tracks through Haversian canals to periosteum → subperiosteal abscess
• Periosteal stripping → impairs blood supply → further necrosis

• Necrotic bone = SEQUESTRUM (dead bone fragment; avascular, antibiotic cannot penetrate)
• New bone formation by periosteum surrounds the sequestrum = INVOLUCRUM (living shell of new bone)
• Pus may breach involucrum through openings (cloacae) → tracks to skin surface = sinus tract
• Brodie's abscess: Subacute form - localized intramedullary abscess, typically in proximal or distal tibia, in children

Clinical Features

• Fever, malaise, rigors (systemic)
• Severe local bone pain (constant, throbbing)
• Swelling, redness, warmth, tenderness over affected bone
• Pseudoparalysis (infant refuses to move limb)
• Chronic osteomyelitis: Chronic discharging sinus, pathological fracture

Investigations

• FBC: Leukocytosis, raised ESR, CRP
• Blood cultures (positive in ~50%)
• X-ray: Periosteal reaction, lytic lesion (appears 10-14 days late)
• MRI: Best modality - shows marrow edema within 24-48 hrs (most sensitive)
• Bone scan (Tc-99m): Useful for multifocal disease
• Bone biopsy + culture: Definitive for organism identification

Treatment

• IV antibiotics immediately (after blood cultures and bone biopsy if possible)
• Anti-staphylococcal: Flucloxacillin + Fusidic acid (or clindamycin); MRSA: Vancomycin/Teicoplanin
• Duration: 4-6 weeks total (IV → oral step-down after clinical improvement)
• Splinting for pain relief and to prevent pathological fracture

• Indications: Failure to respond to IV antibiotics after 24-36 hrs, abscess formation, spreading sepsis
• Surgical drainage: Drill holes (Trueta's method) into medulla to decompress and drain pus
• Subperiosteal abscess: Incision and drainage

1. Sequestrectomy: Removal of all dead bone (sequestrum) - key step
2. Saucerisation: Converting the bone cavity to an open saucer to allow drainage and granulation
3. Dead space management: Fill cavity with cancellous bone graft, muscle flap, or antibiotic-impregnated cement beads (Papineau technique)
4. Treatment of sinus tracts: Excision
5. Correction of deformity (Ilizarov technique for limb shortening/deformity)
6. Amputation: For failed treatment, uncontrolled sepsis, malignant change in sinus (Marjolin's ulcer)

• Pathological fracture
• Septic arthritis
• Secondary amyloidosis
• Squamous cell carcinoma in sinus (Marjolin's ulcer)
• Sarcoma

---

Q2. Orthopedic Short Questions

A. Colles' Fracture

• Fall on an outstretched hand (FOOSH) with wrist dorsiflexed
• Common in: Postmenopausal women (osteoporosis), elderly
• "Dinner fork deformity" or "garden spade deformity" - classic description

• Dorsal displacement of distal fragment
• External (radial) deviation
• Supination of fragment
• Shortening of radius

• Ulnar styloid fracture (60%)
• Interosseous membrane injury
• Median nerve injury (most common nerve complication - assess before and after reduction)

• PA and lateral X-ray wrist: Normal volar tilt (~10-11°) is lost/reversed; normal radial inclination (~22°) is reduced

• Closed reduction under local anaesthesia (haematoma block or Bier's block)
• Manipulation: Traction + flexion + ulnar deviation + pronation to restore anatomy
• Immobilization in plaster of Paris (POP) dorsal back slab/below-elbow cast for 4-6 weeks
• Check neurovascular status post-reduction; X-ray to confirm
• Physiotherapy after cast removal

• Comminuted, unstable, or intraarticular fractures
• Failed closed reduction (>20° dorsal angulation, >5 mm shortening)
• Young active patients
• Neurovascular compromise

• Percutaneous K-wire fixation
• Volar locking plate (ORIF) - most common
• External fixation (highly comminuted)

• Malunion (most common)
• Median nerve injury/carpal tunnel syndrome
• Rupture of Extensor Pollicis Longus (EPL) tendon
• Sudeck's atrophy (CRPS - Complex Regional Pain Syndrome)
• Shoulder-hand syndrome
• Stiffness

---

B. Indications for Amputation

• Diabetic foot with non-healing ulcer, wet gangrene, spreading infection
• Uncontrolled foot abscess is a surgical emergency

• Critical limb ischemia where revascularization has failed or is not possible
• Dry/wet gangrene, non-viable limb

• Uncontrolled ascending infection/sepsis (life-saving)
• Chronic osteomyelitis unresponsive to treatment
• Gas gangrene (clostridial myonecrosis) - emergency amputation

• Severe Buerger's disease (thromboangiitis obliterans)
• Severe Raynaud's phenomenon

• Mangled extremity (MESS score ≥7 predicts need for amputation)
• Traumatic amputation requiring formal surgical revision
• After crush injury with warm ischemia >6 hours + posterior tibial nerve disruption

• Malignant bone/soft tissue tumors where limb salvage is impossible (Osteosarcoma, Ewing's sarcoma)
• Locally advanced malignancy with intractable pain/infection

• Severe congenital limb anomalies where amputation + prosthesis gives better function

• Intractable pain (rare)
• Complete denervation with insensate, non-functional limb

• Toe / Ray amputation
• Transmetatarsal
• Syme's (ankle disarticulation)
• Below-knee amputation (BKA / transtibial) - preferred; better functional outcome
• Knee disarticulation
• Above-knee amputation (AKA / transfemoral)
• Hip disarticulation

---

---

Summary of What Was Covered

• Q1 - Perforation Peritonitis: Full etiology list + clinical features of peptic perforation (3 stages) + management (Graham's patch, H. pylori eradication)
• Q2 - Venous Ulcer: Venous anatomy with diagram + pathophysiology (fibrin cuffs, white cell trapping) + management (compression + EVLA)
• Q3 - Carcinoma Breast T2N1M0: Breast lump classification + T2N1M0 = Stage IIB features + MRM vs BCS + adjuvant therapy by receptor status

1. HPS: Projectile non-bilious vomiting, olive mass, metabolic alkalosis, Ramstedt's pyloromyotomy
2. Phyllodes Tumor: Rapidly enlarging lump, 3 grades, wide excision with 1 cm margins
3. VSD: Types, L→R shunt, pansystolic murmur at LLSE, patch closure
4. DVT Prophylaxis: Virchow's triad, TED stockings + LMWH, extended duration for ortho/cancer
5. Flail Chest: Paradoxical movement, pulmonary contusion, epidural analgesia + IPPV

---

Already Answered - Full Model Answers Above

LONG QUESTIONS (Any 2)

1. Perforation Peritonitis - Etiologies + Clinical features & Management of Peptic Perforation (Graham's patch, H. pylori eradication)
2. Venous System + Venous Ulcer - Anatomy diagram + Etiopathogenesis + Management (compression + EVLA)
3. Breast Lump + T2N1M0 Carcinoma - Classification + Stage IIB features + MRM/BCS + receptor-based adjuvant therapy

SHORT QUESTIONS (Any 4)

1. Hypertrophic Pyloric Stenosis
2. Phyllodes Tumor Breast
3. VSD
4. DVT Prophylaxis
5. Flail Chest

VERY SHORT QUESTIONS (Any 10) - All 12 answered

ORTHOPAEDIC SECTION

1. Osteomyelitis - Types, Pathology (sequestrum/involucrum), Treatment
2. Colles' Fracture + Indications for Amputation

---

• A specific question number?
• A topic you want more detail on?
• A shorter/simpler version of one of the answers?This is the same exam paper from SAMC & PGI Indore that I already answered in full detail above! All questions have been covered comprehensively. Please scroll up to find the complete answers.

---

QUICK INDEX OF ALL ANSWERS (Scroll Up)

MCQ Section

• 20 MCQs at 0.5 marks each = 10 marks (paper does not list individual MCQs)

LONG QUESTIONS [Any 2] — 02 x 15 = 30

SHORT QUESTIONS [Any 4] — 04 x 05 = 20

VERY SHORT QUESTIONS [Any 10] — 10 x 02 = 20

ORTHOPAEDIC SECTION — 02 x 10 = 20

---