SURGERY CASES MADE EASY-final

SURGERY CASES MADE EASY
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Copyrights Â© 2018 Dr. Rajith Eranga.

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Copyrights © 2018 Rajith Eranga
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
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photocopying, recording or otherwise without the prior permission from the author.
ISBN - 978-9553-558701
Chapter: SURGERY CASES MADE EASY
Dr. Rajith Eranga

MBBS (Sri Lanka)
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2
PREFACE
This book is designed to provide a concise yet comprehensive study guide to short
cases (OSCE) for undergraduate clinical examinations in the field of surgery. It covers
most of the surgical short cases commonly given at the final MBBS examination. Hence
medical students and ERPM candidates will be highly benefited referring to this book.
Carefully selected 32 common cases are included in the first edition of the book and
the distinctive feature of this book is that it offers a stepwise sequence of examination
which appears to be lacking in most of study materials. It also provides a sample
presentation, probable questions you might be asked as well as their answers along
with relevant images for each of the cases. There is a separate chapter consisting of
quick-review flash cards which would be perfect for a last minute revision before the
exam.
Nevertheless nothing is a substitute for clinical practice. Acquisition of correct

examination techniques and confidence takes time as well as experience. But this book
will be a handy tool to help you in mastering your skills in a confident manner with less
confusion, especially in a busy clinical setting.
I would like to thank Dr. Gathika Kodithuwakku for providing invaluable specialist
inputs to the book.
Dr. Rajith Eranga Rathnayake

MBBS (Sri Lanka)
2018 April
Chapter:
3
TABLE OF CONTENTS
CASE 01 - Examination of a Lump …………………………………………………………………….. 04-05
CASE 02 – Lipoma …………………………………………………………………………………………….. 06-07
CASE 03 - Sebaceous Cyst ………………………………………………………………………………… 08-09
CASE 04 - Dermoid Cyst ……………………………………………………………………………………. 10-11
CASE 05 - Ganglion …………………………………………………………………………………………… 12-13
CASE 06 - Ulcer Examination .…………………………………………………………………………… 14-16
CASE 07- Malignant Melanoma ……………………………………………………………………….. 17-19
CASE 08 - Thyroid Examination………………………………………………………………………….. 20-23
CASE 09 - Thyroidectomy Post-operative………………………………………………………….. 24-25
CASE 10 - Breast Examination ………………………………………………………………………….. 26-29
CASE 11 - Mastectomy Post-operative.……………………………………………………………… 30-31
CASE 12 - Post Mastectomy …………………………………………………………………………….. 32-34
CASE 13 - Gynaecomastia …………………………………………………………………………..……. 35-36
CASE 14 - Inguinal Hernia …………………………………………………………………………………. 37-39
CASE 15 - Femoral Hernia …………………………………………………………………………………. 40-41
CASE 16 - Paraumbilical Hernia ………………………………………………………………………… 42-44
CASE 17 - Parotid Tumours ………………………………………………………………………………. 45-46
CASE 18 - Submandibular Tumours ………………………………………………………………….. 47-48
CASE 19 - Vericose Veins ………………………………………………………………………………….. 49-51
CASE 20 - Scrotal Lumps …………………………………………………………………………………… 51-54
CASE 21 - Carpal Tunnel Syndrome ………………………………………………………………….. 55-57
CASE 22 - Radial Nerve Palsy ……………………………………………………………………………. 58-59
CASE 23 - Ulnar Nerve Palsy …………………………………………………………………………….. 60-62
CASE 24 - Trigger Finger …………………………………………………………………………………… 63-64
CASE 25 - Baker’s Cyst ……………………………………………………………………………………… 65-66
CASE 26 - Amputated Stump …………………………………………………………………………… 67-70
CASE 27 - Cellulitis ………………….……………………………………………………………………….. 71-73
Chapter: TABLE OF CONTENTS
CASE 28 - Stomas …………………………………………………………………………………………….. 74-76

CASE 29 - Upper Limb POP Casts ………………………………………………………………………. 77-80
CASE 30 - Lower Limb POP Casts ………………………………………………………………………. 81-84
CASE 31 - External Fixators ………………………………………………………………………………. 85-87
CASE 32 - Intercostal Tube ……………………………………………………………………………….. 88-90
QUICK REVIEW FLASH CARDS ………………………………………………………………………….. 91-105
4
EXAMINATION OF A LUMP CASE 01
Examination of a lump is a component in almost every surgical clinical examination. Sometimes you
may be asked to spot diagnose a lump with just inspection. Given below is a rough guide to
examination of a lump.
EXAMINATION
Inspection
1. Site, Size and Shape (SSS).
2. Skin overlying the lump (Scars, Signs of Inflammation, Punctum).
Palpation
1. Surface (Smooth/ Irregular).
CASE 01
2. Edge (Well or poorly defined).
3. Tissue Plane/ Mobility /Fixity – Skin attachment and attachment to underlying structures.
4. Consistency (Soft, Firm or Hard).
5. Cross Fluctuation (Only if soft to firm).
6. Transillumination (Only if fluctuant).
7. Temperature and Tenderness.
8. Reducibility.
9. Pulsatility.
10. Palpable lymphnodes.
PRESENTATION
There is a hemispherical shaped lump, over the left lateral aspect of the neck, measuring 5cm x
5cm in size. The overlying skin looks normal. Its surface is smooth and the edge is well defined. It is
Chapter: EXAMINATION OF A LUMP
mobile and not attached to skin or the underlying structures. It is soft in consistency, fluctuant and
transilluminant. It is not reducible or pulsatile and there is no associated lymphadenopathy.
Tip: If you are confident enough, make sure that you give a rational presentation, excluding the
possibilities one by one for more marks.
5
Fig 1.1 - A Lump in the scalp Fig 1.2 - A cystic hygroma in a child
CASE 01
QUESTION AND ANSWERS
1. How do you elicit the skin attachment of a lump?
Using the thumb of the examining hand, the skin over the lump is stretched in two directions
perpendicular to each other. If the skin is freely movable over the lump, the lump is not
attached to the skin.
2. Why “pinching” the skin over the lump is not the ideal way?
This method is not accurate as the lump may be attached to the skin in a point other than the
site of pinching.
3. How do you elicit fluctuations?

First the lump should be fixed between the two feeling fingers (the index finger and the thumb)
of one hand and press on the lump using the index finger of the other hand. If you can see the
feeling fingers moving apart with each press, it is fluctuant. The same technique of
examination should be carried out twice in two directions perpendicular to each other, “Cross
Fluctuations”.
Chapter: EXAMINATION OF A LUMP
4. If it is fluctuant, what does that mean?

That means the lump is cystic; in other words it contains fluid. But lipomas (fat cells) can show
pseudofluctuations.
5. If it is trasilluminant, what does that mean?

That means the fluid inside is clear and does not absorb light. Some lumps are brilliantly
transilluminant.
6
LIPOMA CASE 02
EXAMINATION
1. Site - Commonly over the front and back of the chest.

2. Size -Medium to large.
3. Shape - Hemispherical.
4. Skin - Scar? (Recurrence?)
5. Surface - Lobulated.
6. Edge - Well defined.
7. Tissue plane - Freely mobile (Slipping sign). Not attached to skin or underlying muscle.
Try to elicit the tissue plane of the lipoma by contracting the underlying muscle. When the
muscle is contracted,
CASE 02
 If the lump becomes prominent - a subcutaneous lipoma.
 If the lump becomes less prominent - an intramural lipoma.
8. Consistency - Soft to firm depending on the nature of fat within it.
9. Fluctuance - Fluctuant (Pseudofluctuant).
10. Transillumination - May be transilluminant.
PRESENTATION
There is a hemispherical shaped lump, measuring 5 cm in diameter, over the right scapula. It is
not tender, the surface is lobulated and the edge is well defined. It is freely mobile and not attached
to skin or the underlying muscle. It is soft in consistency, fluctuant and transilluminant.
So my probable diagnosis is a lipoma and I would like to offer him surgical excision under LA if
it is cosmetically unacceptable.
Chapter: LIPOMA
7
CASE 02
Fig 2.1 - A lipoma on the back of the chest

1. What is a lipoma?
It is a benign tumour that consists of mature fat cells.
2. What is Dercum’s disease?

It is characterized by multiple painful lipomas.
3. Can they undergo malignant transformation?

No. But liposarcoma can occur de novo.
4. What is the treatment for lipoma?

Usually by reassurance.
But surgery is offered if the patient complains of pain or if it is cosmetically unacceptable. It is
removed by either simple surgical excision under LA or suction lipolysis after obtaining the
Chapter: LIPOMA
consent.
8
SEBACEOUS CYST CASE 03
EXAMINATION
1. Site - Commonly over the scalp and hairy areas, NOT in palms and soles.
2. Size -Medium to large.
4. Skin - Punctum (50%)? Infected (Erythema, Tenderness, Warmth)?
5. Surface -Smooth.
7. Tissue plane -Always attached to skin. Not attached to underlying structures.
8. Consistency - Soft to firm.
9. Fluctuance - Fluctuant.
10. Transillumination - Not transilluminant (Thick sebum).
CASE 03
11. Lymph nodes (Infected?)
Fig 3.1 - Uncomplicated sebaceous cyst

Chapter: SEBACEOUS CYST
9
PRESENTATION
There is an oval shaped lump, measuring 5cm x 4cm in size, over the right side of the forehead
2 cm above the eyebrow. There is a punctum on the overlying skin and there is no surrounding
erythema or warmth. Its surface is smooth and edge is well defined. It is attached to the skin and
not attached to the underlying muscle. It is firm in consistency, fluctuant and not transilluminant.
So my diagnosis is an uncomplicated sebaceous cyst and I would like to offer him surgical
excision under Local anesthesia (LA). But if it is infected patient may need to undergo general
anesthesia (GA).
CASE 03
1. What are the histological types of sebaceous cysts?
1. Epidermal cysts.
2. Trichilemmal cysts.
2. What is “Cock’s peculiar tumour”?

When a sebaceous cyst is left untreated, it grows bigger and gets infected and ulcerated. This is
known as Cock’s peculiar tumour and it clinically and histologically resembles a squamous cell
carcinoma.
3. Can they undergo malignant transformation?

Yes, but very rare.
4. What are the complications that can occur?

1. Infection.
2. Ulceration.
3. Sebaceous horn formation.
4. Calcification.
5. Malignant transformation.
5. What is the treatment for a sebaceous cyst?

If not infected, simple excision under LA is done.
Chapter: SEBACEOUS CYST
If infected, incision and drainage is done ideally under GA (But some surgeons prefer local
anesthesia for small ones).
An elliptical incision is used encircling the punctum.
10
DERMOID CYST CASE 04
EXAMINATION
1. Site - Commonly over the midline (forehead, neck, trunk), behind the ear (Posterior auricular
dermoid), over the lateral eye brow (External angular dermoid).
2. Size - Small to medium.
4. Skin - Overlying scar (Implanted dermoid), no punctum (Not a sebaceous cyst).
5. Surface - Smooth.
7. Tissue plane - Not attached to underlying structures. Congenital or inclusion dermoid cysts do
not attach to the skin. But acquired or implanted dermoid cysts are attached to the skin.
8. Consistency - Soft, indentable.
CASE 04
9. Fluctuance - May be fluctuant.
10. Transillumination- Not transilluminant.
Tip: If you are given an external angular dermoid, at the end of your examination, ask the
patient to blow forcefully while his mouth is sealed and nostrils are pinched and palpate the
lump for expansility. If it is expansile, it might indicate intracranial communication of the
dermoid cyst.
Chapter: DERMOID CYST
Fig 4.1 - Posterior auricular dermoid Fig 4.2 - External angular dermoid
11
PRESENTATION
There is a hemispherical shaped lump, measuring 3cm x 3cm in size, bisecting lateral side of the
right eyebrow. There is no punctum or scars on overlying skin. Its surface is smooth and edge is well
defined. It is not attached to the skin or underlying muscle. It is soft in consistency, indentable,
fluctuant and not transilluminant. Clinically it does not increase in size with manoeuvres which
increase the intracranial pressure.
So my probable diagnosis is external angular dermoid and I would like to offer him surgical
excision under local anaesthesia (LA) after exclusion of intracranial extension with skull x-ray and CT
brain.
CASE 04
1. What is a dermoid cyst?
It is a skin lined cyst deep to the skin in the subcutaneous tissue.
2. What are the two types of dermoid cysts?

1. Congenital dermoid (Inclusion dermoid) - due to failure of fusion of skin dermatomes.
2. Acquired dermoid (Implanted dermoid) - due to forced implantation of skin in the
subcutaneous tissue following injuries.
3. Where do inclusion dermoids occur?

Along the lines of fusion of skin dermatomes. They can occur anywhere along the midline,
commonly over the forehead, neck and trunk. Other specific sites are lateral eyebrow (External
angular dermoid) and behind the ear (Posterior auricular dermoid).
4. Where do implanted dermoids occur?

In areas prone to get injured such as palms and fingers.
5. How would you differentiate it from a sebaceous cyst?

No punctum.
Not attached to the skin (inclusion dermoids).
Chapter: DERMOID CYST
6. How would you treat?

Complete surgical excision under LA after excluding intracranial extension in suspected cases
(by skull X-rays and CT brain).
12
GANGLION CASE 05
EXAMINATION
1. Site - Commonly over the dorsum of the hand and foot near joints.
2. Size - Small.
4. Skin - Scar? (Recurrence?)
7. Tissue plane - Not attached to skin.
Check the mobility by contracting the underlying tendon (i.e. if the ganglion is on the dorsum of
the hand, ask the patient to maintain the fingers in extension while you are applying resistance
by downward pressure on extended fingers. Meanwhile assess the mobility of the lump both
CASE 05
vertically and horizontally).
Ganglion’s horizontal mobility (sideways movement to the tendon) is reduced when the muscle
of the relevant tendon is contracted.
8. Consistency - Soft to firm depending on the tension of fluid within it.
9. Fluctuance - Fluctuant (May be difficult elicit due to its size).
10. Transillumination - Brilliantly transilluminant (clear fluid).
Chapter: GANGLION
Fig 5.1 - Ganglion in an extensor tendon Fig 5.2 - Ganglion in a flexor tendon
13
PRESENTATION
There is a hemispherical shaped lump, measuring 1cm in diameter, over the dorsum of the
right hand. Its surface is smooth and edge is well defined. It is not attached to the skin but to the
underlying extensor digitorum tendon. Its horizontal mobility is restricted when the tendon is
contracted. It is soft in consistency, fluctuant and brilliantly transilluminant.
So my diagnosis is a ganglion of extensor digitorum tendon and I would like to offer him
surgical excision under general anesthesia (GA) in a bloodless field.

1. What is a ganglion?
CASE 05
It is a cystic swelling related to the synovial lining of the tendon sheath and it is believed to
occur due to myxomatous degeneration of the synovial sheath.
2. What are the differential diagnosis?

1. Bursae.
2. Protrusion of synovial cavity of arthritic joints.
3. Other skin lumps - Lipomas, Dermoids.
3. Where do ganglions occur?

Commonly over the dorsum of the hand and foot as well as in the palmar aspect related to the
flexor tendons.
4. How would you treat?

Complete surgical excision under GA in a
bloodless field.
5. How would you create a bloodless field?

With a pneumatic tourniquet.
6. What are the complications of the surgery?

1. Recurrance.
2. Damage to the adjacent nerves and vessels.
3. Wound related complications.
Fig 5.3 - Removal of a ganglion

7. What is the risk of recurrence?
Chapter: GANGLION
Around 5% to 20% (Fairly high).
14
ULCER EXAMINATION CASE 06
EXAMINATION
Examination of an ulcer is more or less similar to an examination of a lump. But some additional
features have to be kept in mind.
Inspection
1. Site.
2. Size (Extent).
3. Margin (Shape) - Regular? Irregular?
4. Edge - Sloping? Punched-out? Undermined? Rolled-out? Everted?
5. Floor - Healthy? Granulation tissue? Slough?
6. Discharge? - Serous? Serosanguinous? Purulent? Amount and smell?
Palpation (With a gloved hand)

1. Palpate the margin and edge.
2. Palpate the base - Muscle? Bone?
Palpation (Without gloves) - depending on the type of suspected ulcer from above
1. Temperature of the surrounding skin.
2. Regional lymphadenopathy.
3. Peripheral pulses.
4. Peripheral sensation and joint position sensations (JPS).
PRESENTATION
CASE 06
1) Venous Ulcer
There is an ulcer over the right ankle just
above the medial malleolus (Gaiter’s area). It is
oval in shape, approximately 2cm x 3cm in size.
Its margin is irregular, edge is sloping and floor
contains healthy granulation tissue. There is a
serous discharge from the ulcer. The ulcer is
Chapter: ULCER EXAMINATION
superficial and the base contains subcutaneous

tissue. The surrounding skin is warmer,
pigmented and thickened. There are
associated varicose veins. Peripheral pulses
and sensation are normal and there is no
inguinal lymphadenopathy.
15
PRESENTATION
2) Neuropathic Ulcer
There is an ulcer over the sole of right foot which
is oval in shape, approximately 3cm x 4cm in size.
Its margin is regular, edge is punched-out and
floor contains healthy granulation tissue. There is
no discharge from the ulcer. Ulcer is painless, base
contains flexor tendons of toes, surrounding skin
and peripheral pulses are normal. Peripheral
sensation to pain is absent up to ankles and joint
position sensation is impaired.
PRESENTATION
3) Ischemic Ulcer
There is an ulcer over the tip of the 2nd toe of right
foot which is round in shape, approximately 1cm x
1cm in size. Its margin is irregular, edge is punched-
out and floor contains slough. There is a purulent
discharge from the ulcer. The base contains bone of
the distal phalanx. The surrounding skin is colder and
blackish in colour. Dorsalis pedis and posterior tibial
pulses are absent and the femoral pulse is weak on
the right side. The peripheral sensations are normal
and there is no inguinal lymphadenopathy.
CASE 06
PRESENTATION
4) Malignant Ulcer
There is an ulcer over the dorsum of the right foot
which is irregular in shape, with a maximum diameter

of 6cm. There is a purulent discharge from the ulcer. Its
margin is irregular, edge is raised & everted. Floor is
reddish-brown and contains slough. There is hard
inguinal lymphadenopathy on the right side. Peripheral
pulses and sensation are normal.
16

1. What is an ulcer?
It is a break in the continuity of an epithelial surface.
2. Explain the terms margin, floor, edge and base of an ulcer.

1. Margin - The line of demarcation between normal and affected tissue.
2. Floor - Exposed bottom of the ulcer.
3. Edge - It connects the margin to the floor.
4. Base - The area in which the ulcer rests.
3. What are the types of edges and examples for each one?
1. Sloping - Venous ulcer.
2. Punched-out - Ischemic ulcer.
3. Undermined - Tuberculous ulcer.
4. Rolled-out - Basal cell CA.
5. Everted - Squamous cell CA.
4. What are the common causes for leg ulceration?

1. Peripheral vascular disase.
2. Varicose veins.
3. Peripheral neuropathy.
4. Squamous cell carcinoma.
5. Sickle cell disease.
6. Syphilis.
7. Tuberculosis.
5. What are the causes for neuropathic ulcers?

1. Uncontrolled diabetes.
2. Chronic alcoholism.
CASE 06
3. Vitamin B12 deficinecy.
4. Leprosy.
5. Vasculitis.
6. How do you differentiate a neuropathic ulcer from an ischemic ulcer?

1. Painless ulcers.
2. Associated glove & stocking type of sensory loss.
3. Normal surrounding skin.
7. What are the risk factors in diabetics for foot ulceration?

1. Peripheral neuropathy.
2. Peripheral vascular disease.
3. Immunodeficinecy.
17
MALIGNANT MELANOMA CASE 07
EXAMINATION
Malignant Melanoma are usually found on the legs of young adults (more commonly in females).
But the site of the lesion and its characteristics may vary depending on the type of Melanoma.
Inspection is the most vital part of the examination.
1. Inspect carefully the lesion which is characteristically brownish or blackish in colour. They
are usually found on the legs and soles of young women and the back of the trunk in men.
Look for,
a. Marked variation of the colour within the lesion
b. Surface ulceration
c. A halo of brown pigment in the skin around the lesion
2. Palpate the lesion. They are usually palpable and have irregular margins.
CASE 07
3. Examine the draining lymphnodes. Look for inguinal lymphadenopathy (If positive - Stage III
disease).
4. Inspect carefully for “Satellite lesions” - along the pathway of lymphatic drainage for tumour
nodules.
5. Look for hepatomegally (If positive - Stage IV disease).
6. If you are given a chance to talk with the patient, ask for,
III. Smptoms that may indicative of malignancy
a. Rapid increase in size recently
b. Change in colour or shape of the lesion recently
c. Itching
d. Bleeding
II. Predisposing factors

a. Previous Melanoma
b. Family history
c. Large congenital Navei Chapter: MALIGNANT MELANOMA
PRESENTATION
I examined this 30 year old women who is having a brownish skin lesion on her left sole which
is 2 cm x 2 cm in size. There is marked variation in colour within the lesion and there is brownish
halo in the skin surrounding it. Its surface is ulcerated. It is palpable and has an irregualar margin.
There is left inguinal lymphadenopathy and I could notice satellite lesions along the lymph draining
pathway. So my probable diagnosis is a malignant melanoma.
18
Fig 7.1 - Malignant Melanoma Fig 7.1 - Melanoma (Closer view)
CASE 07
1. What is the most common type of malignant melanoma?
Superficial spreading melanoma.
2. What are the other rarer types?

1. Nodular melanoma.
2. Lentigo maligna melanoma.
3. Arcal lentiginous melanoma.
4. Intracranial melanoma.
3. Are they always pigmented?

No. There are amelanocytic melanoma with no pigmentation.
4. What are the predisposing factors?

Congenital
1. Large congenital navei.
2. Familty history in first degree relatives.
Acquired
1. UV light (Sunlight).
Chapter: MALIGNANT MELANOMA
2. Lentigo maligna.
3. Previous melanoma.

1. Freckles - Normal melanocytes count, producing high amount of melanin
2. Lentigo - Increased melanocytes count, producing normal amount of melanin
3. Moles (Pigmented naveus) - Increased melanocytes count, producing high amount of
melanin.
19
6. What are the features favoring a malignancy?

1. Recent rapid enlargement of the lesion.
2. Recent change in colour or shape of the lesion.
3. Marked variation in colour within the lesion.
4. Bleeding.
5. Ulceration.
7. How do you stage malignant melanoma?

1. Based on depth of invasion - Clark’s levels of invasion
2. Four stage Beahrs & Myers classification - Clinically useful
eg: Stage III - Lymphnode metastasis
Stage IV - Distant metastasis
8. What are the treatment options?

Wide local excision of the lesion down to deep fascia.
CASE 07
FNAC of suspicious nodes and inguinal block dissection is done if node positive disease.
9. What are the poor prognostic factors?

1. Male gender.
2. Increase in age.
3. Ulceration.
4. Amelanocytic melanoma.
Fig 7.1 - Satellite lesions

Chapter: MALIGNANT MELANOMA
20
THYROID EXAMINATION CASE 08
EXAMINATION
Greet the patient and take consent. Make sure you have enough space behind the patient’s chair
before proceeding with the examination.
Examine from front,
1. Inspect – Offer a glass of water and ask to swallow on command & look for the lump moving
upwards with deglutition. Observe from the side.
2. Only if the lump is small and in the midline, ask the patient to put the tongue out while
stabilizing the jaw and look for the lump moving upwards.
3. Look for scars (previous lobectomy scar) and dialated neck veins.
4. Only if the lump is a large one, elicit Pemberton’s sign.
Then go to back of the patient,
CASE 08
1. Palpate the thyroid gland from behind. Examine using one hand at a time while stabilizing the
gland from the other. Feel for the consistency and nodularity of the gland.
2. Examine for cervical lymphadenopathy.
Come back to front of the patient and look for,

1. Tracheal deviation - Feel along the trachea downwards.
2. Retrosternal extension - Check whether you can feel the lower border of the gland while the
patient is asked to swallow. If cannot percuss to elicit retrosternal dullness.
3. Displaced carotid pulsation – Check both carotid pulses, one at a time.
4. Bruit – Auscultate over the right upper lobe.
Examine for thyroid eye signs and hands.

1. Look for Exophthalmos (See from behind), Lid retraction, Lid lag and Opthalmoplegia.
2. Look for sweaty hands, tachycardia (radial pulse), fine tremors.
PRESENTATION
This patient is having a lump in the antero-inferior aspect of the neck which moves up with
deglutition. There are no visible surgical scars in the neck or dilated neck veins and Pemberton’s sign
Chapter: THYROID EXAMINATION
is negative. Lump is firm in consistency and its surface is nodular with a prominent nodule in the
right upper lobe. There is no cervical lymphadenopathy. Its lower border can be felt, trachea is
deviated to the left side and the right carotid pulse is deviated posterolaterally. There is no bruit. She
is clinically euthyroid and there are no thyroid eye signs.
So my probable diagnosis is a clinically euthyroid longstanding multinodular goiter (MNG)

without retrosternal extension. I would like to investigate her with a thyroid profile, USS neck and
FNAC of the prominent nodule to decide on further management.
21
CASE 08
Fig 8.1 - Diffuse goiter
(Grave’s disease)
Fig 8.2 - Multinodular goiter (MNG)

1. What are the causes for diffuse thyroid enlargement?
1. Simple colloid goiter.
2. Thyroditis.
3. Grave’s disease.
2. What are the differential diagnosis for a solitary nodule of thyroid (SNT)?
1. Prominent nodule of a MNG.
2. Hemorrhage into a colloid cyst.
3. Thyroid adenoma.
4. Thyroid carcinoma.
5. Foci of thyroiditis.
22
3. What would be the next management option, if the histology of a SNT comes as follicular
neoplasm?
Thyroid lobectomy and look for the histology to decide on further management. If the histology
is malignant, other lobe is also removed later.
4. Where would you auscultate for a bruit?

Over the right upper lobe laterally while patient is holding the breath.
5. What is the significance of a thyroid bruit?

It indicates the increased vascularity of the gland (hyperdynamic circulation) - seen in Grave’s
disease.
6. What are the compressive features?

1. Nocturnal dyspnea and cough.
2. Recent onset dysphagia.
CASE 08
3. Deviated trachea.
4. Displaced carotid pulse.
7. What are the features of retrosternal extension?

1. Distended neck veins.
2. Positive Pemberton’s sign.
3. Lower border of the goiter cannot be felt.
4. Retrosternal dullness.
8. What are the malignant features?

1. Recent rapid enlargement.
2. Recent voice change (Hoarseness).
3. Hard in consistency.
4. Cervical lymphadenopathy.
5. Irregular margins.
6. Multiple attachments.
9. What are thyroid eye signs?

1. Lid lag.
2. Lid retraction.
3. Exophthalmos..
4. Proptosis.
5. Opthalmoplegia.
10. How do you identify a thyroglossal cyst?

It moves upward with deglutition as well as with the protrusion of the tongue when the jaw is fixed.
Being in midline differentiates it from goiters.
23
11. Why do we have to excise thyroglossal cysts?

1. Cosmetically unacceptable.
2. Prone to get infected.
3. May undergo malignant transformation.
12. What is the surgical procedure for a thyroglossal cyst?

Sistrunk procedure (Complete excision of the cyst and its tract together with the middle part of the
body of the hyoid bone).
13. What are the indications for thyroidectomy for a multinodular goiter (MNG)?
1. Cosmetically unacceptable (Patient’s wish).
2. Compressive symptoms.
3. Secondary thyrotoxicosis.
4. Suspected or proven malignancy.
CASE 08
Fig 8.3 - Solitary thyroid nodule (STN)
Fig 8.4 - Thyroglossal cyst
24
THYROIDECTOMY POST-OPERATIVE CASE 09
EXAMINATION
1. Look for stridor.
2. Talk to the patient and ask how she feels now and look for horseness of voice.
3. Ask the patient when the drainage was last emptied and comment on its colour and volume
and check whether it is functioning.
4. Inspect / Offer to inspect the scar.
5. Elicit Chvostek’s sign to detect hypoglycemia.
PRESENTATION
I examined this patient who had undergone a thyroidetomy one day before. Her general
condition is good and has no stridor or hoarseness of voice. The drain has been last emptied eight
hours before and it has about 2ml of drainage and is functioning. Chvostek’s sign is negative. I would
like to remove the dressing to inspect the surgical scar.
Chapter: THYROIDECTOMY POST-OPERATIVE CASE 09
Fig 9.1 - Drain inserted after Fig 9.2 - Scar of collar incision
thyroidectomy
25

1. What are the specific complications of thyroidectomy?
1. Hemorrhage - primary & reactionary.
2. Nerve injuries - recurrent laryngeal & external branch of
the superior laryngeal nerves.
3. Hypocalcaemia.
4. Thyrotoxic crisis.
5. Hypothyrodism.
2. What are the causes for stridor?

1. Bilateral partial recurrent laryngeal nerve injury.
2. Tracheomalasia.
3. Reactionary hemorrhage.
4. Hypocalcaemia. Fig 9.3 - Chvostek’s sign
3. How does a reactionary hemorrhage cause stridor?

Haematoma compresses veins leading to laryngeal oedema secondarily.
4. What are the effects of different types of recurrent laryngeal nerves injuries?
1. Unilateral partial - Asymptomatic.
2. Unilateral complete - Hoarseness of voice.
3. Bilateral partial - Severe stridor.
4. Bilateral complete - Aphonia.
5. How do you clinically detect hypocalcaemia?

1. Circumoral paresthesia.
2. Trosseau’s sign.
3. Chvostek’s sign.
4. Late - Carpo-pedal spasms, tetany, laryngeal oedema.
Chapter: THYROIDECTOMY POST-OPERATIVE CASE 09

6. What is the treatment?
IV 10% Calcium Gluconaten 10ml over 10 mins. Fig 9.4 - Trousseau’s sign
26
BREAST EXAMINATION CASE 10
EXAMINATION
Take consent. Provide adequate Privacy.
Ask her to be seated first.
1. Expose up to the waist. Use a cloth to cover the lower torso and a chaperon.
2. Ask the patient on which side the lump is and whether it is tender before you touch.
3. Look for breast asymmetry, skin changes (erythema, ulceration, peaud’orange appearance)
and nipple changes (deviation, retraction, destruction).
4. Ask to raise both upper limbs and look for skin tethering. Don’t forget to inspect the sub-
mammary area.
5. Ask the patient herself to squeeze her nipple if she complains of a nipple discharge and check
CASE 10
whether it is blood stained.
Then ask her to lie down and put her both arms behind her head.
1. First palpate the normal breast using the flat of the fingers. Then palpate “6 areas”; namely the
four quadrants, subarealoar area and axillary tail in order.
2. Then palpate the contralateral breast. Determine the site, size, shape, consistency, surface,
regularity and the margins of the lump (if the lump is not palpable, ask the patient herself to
locate it for you).
3. Check the skin attachment of the lump while in the supine position.
Then ask her to be seated again.
1. Look for deep structure attachment. Ask her to keep her ipsilateral hand on the hip and press
against waist when she is asked to. Check whether there is a reduction in mobility when the
Pectoralis Major muscle is contracted. Proper contraction of the muscle is confirmed by
palpating the anterior axillary fold by the other hand of the examiner simultaneously.
2. Assess both axillae. Ask the patient to rest her arm relaxed on top of yours as shown in the
picture (Fig-9.1). Palpate all the axillary lymph node groups - anterior, lateral, medial,
posterior, central and apical. Assess their consistency and mobility if palpable.
3. Finally palpate for supraclavicular lymphadenopathy.

Chapter: BREAST EXAMINATION
4. Dress her up and thank her.
27
PRESENTATION
At the end of the examination, come to a clinical staging depending on your findings.
On inspection there is no breast asymmetry, tethering, any skin or nipple changes. She is
having a lump in the upper outer quadrant of her right breast measuring about 3cm x 4cm x 4cm in
size. It is hard in consistency, irregular in shape and margins are ill defined. It is not attached to the
skin or the underlying muscles. There is a hard mobile solitary lymph node in right axilla in the
anterior group. Left breast and left axilla is clinically normal.
My clinical staging is T2N1Mx and I would like to complete the triple assessment and proceed.
CASE 10
Fig 10.1 - Examination of axilla Fig 10.2 - Peaudo’range appearance
Fig 10.3 - Nipple retraction Fig 10.4 - Paget’s disease of breast
28

1. What are the differential diagnosis for a breast lump?
1. Breast Carcinoma.
2. Fibroadenoma.
3. Fibroadenosis.
4. Fat necrosis.
5. Breast abscess.
6. Breast cyst.
2. How would you investigate this patient?

Triple assessment should be done. To complete it,
1. FNAC/True cut biopsy.uhuhuh
2. USS/Mammography of both breasts.
3. If FNAC confirms it is a malignancy, do you still want to do imaging?
CASE 10
Yes. It must be done to exclude multifocality and to detect impalpable lesions in the
contralateral breast.
4. What are the mammographic features of a breast CA?

1. Structural distortion.
2. Spiculated lesions.
3. Microcalcifications.
Fig 10.5 - Mammogram of breast carcinoma
29
5. How do you stage breast CA?

TNM staging.
1. T staging
1. <2cm.
2. 2-5cm.
3. >5cm.
4. Any size lump,
a. Attached to chest wall.
b. Attached to skin.
c. Attached to both.
d. Inflammatory breast CA.
2. N staging
0. No Lymph nodes.
1. Mobile ipsilateral axillary nodes.
2. Fixed ipsilateral axillary nodes.
CASE 10
3. Ipsilateral supraclavicular/ internal mammary nodes.
3. M staging
MX – Unknown Mets.
M0 – No Mets.
M1 – Metastatic Breast CA.
6. What are the contraindications for breast conservative therapy?

1. Multifocality.
2. Pregnancy.
3. Extensive diffuse microcalcifications.
4. >5 cm or large relative to the breast size.
5. Poorly differentiated CA.
6. Any contraindications to radiotherapy.
7. How do you manage the breast CA?

1. Surgery (Conservative / simple mastectomy).
2. Radiotherapy.
3. Chemotherapy (Doxyrubicin).
4. Hormonal (Tamoxifen in young, Aromatase inhibitors in elderly).
5. Biologics (Tratuzumab for HeR2+ breast CA).
8. How do you manage the axilla?

1. Sentinal node biopsy.
2. Axillary node sampling.
3. Axillary clearance (Level of axillary clearance depends on the extent of the tumor
spread. E.g: Level II or Level III axillary clearance - usually level II).
30
MASTECTOMY POST-OPERATIVE CASE 11
EXAMINATION
Talk to the patient and ask how she is feeling now and get an idea of her general condition.
1. Examine (or offer to examine if covered), the scar for early wound related complications. Look
for the degree of healing, wound dehiscence, seroma formation, infection and flap necrosis.
2. If there is a drain, check whether it is functioning. Comment on the volume & colour and ask
when it was last emptied.
3. Examine the contralateral breast and both axillae and comment on any palpable lump or
lymphnodes.
4. Clinically exclude any intraoperative nerve injuries.
a. Intercostobrachial nerve - An area of sensory loss over the medial aspect of upper
arm.
b. Long Thoracic nerve - Check for winged scapula (Ask the patient to push against a wall/
CASE 11
against resistance and look for elevation of the medial border of the scapula).
c. Thoracodorsal nerve - Assess Latissimusdorsi (Instruct the patient to cough while
feeling the posterior axillary fold).
PRESENTATION
I examined this patient who has undergone a right sided simple mastectomy recently. The
wound is still covered with a plaster and I would like to remove it to examine for early wound
related complications. The drain has red/pink colour drainage of 50ml and it is functioning. There are
no palpable lumps in the contralateral breast or axilla. Intercostobrachial nerve, Longthoracic nerve
and Thoracodorsal nerve on the right side is clinically intact.
Chapter: MASTECTOMY POST-OPERATIVE
Fig 11.1 - Bilateral mastectomy with Fig 11.2 - Flap of breast

breast reconstruction
31

1. What are the different types of mastectomies?
1. Simple Mastectomy (Commonest - Except this one, others are hardly practiced now).
2. Radical Mastectomy.
3. Modified Radical Mastectomy.
4. Extended Radical Mastectomy.
2. How do you prepare a patient for mastectomy?

1. Informed consent (Tell about drains, possible complications, risk of recurrence and
breast reconstructive options).
2. Anaesthetic evaluation & optimization prior to the surgery.
3. Mark the side with permanent ink.
4. Psychological support.
3. How do you put the first incision?
CASE 11
An elliptical insicion is made around the nipple and areola, not extending beyond the midline or
midaxillary line.
4. What are the lymphnodes removed in level II axillary clearance?

Lymphnodes which are lateral and posterior to Pectoralis Minor.
5. What are the complications of axillary clearance?

1. Lymphoedma of ipsilateral upper limb.
2. Winged scapula.
3. Sensory loss over the medial aspect of upper arm.
4. Axillary vein thrombosis.
5. Frozen shoulder.
6. How many drains are inserted?

Depends on the operating surgeon’s preference. Usually two. One in the lower down in the cavity
of the mastectomized breast and one in the axilla.
7. When the drains are removed?

Chapter: MASTECTOMY POST-OPERATIVE
They are usually left for few days or until the drainage is less than 20ml per day. Usually it will
take around 7-8 days for a mastectomy as the removed bulk is of vascular tissue.
32
POST MASTECTOMY CASE 12
EXAMINATION
Examination of a patient who had undergone a mastectomy some time ago is quite different from a
patient who had a mastectomy in the same hospital admission. Although some of the steps are
common for both cases, there are slight differences.
1. Examine the scar for late wound related complications. Look for hypertrophic scar or keloid
formation.
2. Comment on radiotherapy (RT) marks.
3. Examine both breasts and axillae and comment on any palpable lumps or lymphnodes. (Local
recurrence?).
4. Ask the patient to straighten both upper limbs and look for lymphoedma of the ipsilateral one.
5. Clinically exclude any intraoperative nerve injuries.
a. Intercostobrachial nerve - An area of sensory loss over the medial aspect of upper arm.
b. Long Thoracic nerve - Check for winged scapula (Ask the patient push against a wall/
against resistance and look for elevation of the medial border of the scapula).
c. Thoracodorsal nerve - Assess Latissimus dorsi (Instruct the patient to cough while
feeling the posterior axillary fold).
6. Look for features of metastatic disease.
a. Palpable scalp lump?
b. Jaundice?
c. Enlarged Virchow’s node?
d. Spinal tenderness?
e. Pleural effusion?
f. Enlarged liver?
CASE 12
Chapter: POST MASTECTOMY
Fig 12.1- Lymphoedmea of ipsilateral Fig 12.2 - Winged scapula (due to

upper limb after mastectomy damage of long thoracic nerve)
33
PRESENTATION
I examined this lady who has undergone a right sided mastectomy 6 months ago. The scar is
completely healed and there is no hypertrophic scar or keloid formation. There are no visible
radiotherapy marks. There are no palpable lumps or lymphnodes in contralateral breast and axilla.
There is no lymphoedma of the ipsilateral upper limb and the right intercostobrachial nerve, long
thoracic nerve and thoracodorsal nerve are clinically intact. There are no clinical features suggestive
of the metastatic disease.

1. What is the difference between a hypertrophic scar and keloid?
Hypertrophic scars are confined to wound margins where as Keloid scars extend beyond wound
margins.
2. How do you manage lymphoedema?

1. Limb elevation.
2. Massaging.
3. Compressive stockings.
4. Prophylactic antibiotics (Penicillin).
3. What are the dugs commonly used for adjuant chemotherapy?

1. Cyclophosphomide (CYC).
2. Methotrexate (MTX).
3. 5-Flurouracil (5FU).
4. What are the side effects of chemotherapy?

1. General - Anorexia, Nausea & Vomiting, Metallic taste.
2. Skin - Hair loss, Rashes.
CASE 12
3. BM - Bone marrow suppression.
4. Renal - Cystitis.
5. GIT - Oral ulcerations, Diarrhoea.
6. Reproductive - Sterility, Mutations.
7. Oncogenicity - 20-fold increase of other malignancies!
5. What are the side effects of radiotherapy?

1. General - Tiredness.
2. Skin - Desquamation.
3. Vessels - Endarteritis obliterans.
4. Renal - Cystitis.
5. GIT - Radiatio proctitis.
34
6. What are the methods available for breast reconstruction?

1. Tissue flaps.
i. Latissimus dorsi flap.
ii. Transverse Rectus Abdomins Musculocutaneous (TRAM) flap.
iii. Inner thigh / Buttok.
2. Oncoplastic techniques.
i. Bilateral breast reduction.
ii. Fat injection.
3. Silicon Prosthesis.
CASE 12
Fig 12.3 - Keloid formation
Fig 12.4 - Hypertrophic scar
35
GYNAECOMASTIA CASE 13
EXAMINATION
Gynaecomastia is benign hypertrophy of male breast and the examination of such a patient should
aim to find a probable cause and to exclude breast carcinoma (rare). Hence the sequence of
examination should follow that of the female breast.
1. Expose the patient up to the waist.

2. Note whether it is unilateral or bilateral gynaecomastia ( If unilateral - exclude CA breast).
3. Look for changes of the overlying skin and nipple.
4. Check whether it is painful or painless gynaecomastia.
5. Palpate all four quadrants of both breasts & axillae and check for any palpable lumps.
6. Look for a probable cause,
a. Signs of alcoholic liver disease - Parotid enlagement, Loss of body hair, Ascites, Spider
naevi.
CASE 13
b. Examine testis - Orchidectomized? Atrophied? Tumours?
c. Klinefelter’s syndrome -Tall?
d. Examine signs of hypo/hyperthyroidism.
e. Offer to take a brief drug history - Cimetidine, Spiranolactone, Digoxin.
Fig 13.1 - Unilateral gynaecomastia Fig 13.2 - Unilateral gynaecomastia

(mild case)
Chapter: GYNAECOMASTIA
PRESENTATION
This patient has painless bilateral enlargement of breasts. There are no nipple changes or
palpable lumps and the overlying skin is normal. There are no signs of alcoholic liver disease or
thyroid dysfunction. External genitalia are clinically normal with no evidence of testicular atrophy or
testicular tumours. I would like to take a brief drug history to find out a probable aetiology for
gynaecomastia.
36

1. What are the age groups for physiological gynaecomastia?
1. Newborns.
2. Puberty.
3. Old age.
2. What are the pathological causes for gynaecomastia?

1. Endocrinopathies.
2. Testicular causes.
3. Chronic liver disease.
4. Klinefelter’s syndrome.
5. Drugs.
3. What are the endocrinopathies causing gynaecomastia?

1. Hypothyrodism.
2. Hyperthyrodism
CASE 13
3. Hyperprolactineamia.
4. Acromegally.
Fig 13.3 - Bilateral gynaecomastia
4. What are the drugs causing gynaecomastia?

1. Cimetidine / Ranitidine.
2. Digoxin.
3. Spiranolactone.
4. Angiotensin Converting Enzyme Inhibitors (ACEI).
5. Methyldopa.
6. Metranidazole.
7. Ketaconazole.
5. What are the testicular causes for gynaecomastia?

1. Testicular atrophy.
2. Testicular tumours.
3.
4. Bilateral orchidectomy.
6. What is the prevalence of male breast cancer?

1 %.
7. What are the investigations you would do?

Chapter: GYNAECOMASTIA
It depends on the clinical scenario. Some patients require none. But serum Alfa Feto Proteins
(AFP), serum beta hCG level, thyroid function tests may be useful as well as serum FHS, LH and
testosterone levels.
But if a lump is palpable patient should undergo triple assessment including FNAC of the lump.
37
INGUINAL HERNIA CASE 14
EXAMINATION
You will be asked to examine the groin area of a patient who is lying supine, but always remember to
examine the patient in the erect position as well, at some point of your examination.
1. Get the Consent, cover the area and expose adequately.

2. Look carefully for surgical scars in the groin (Recurrent hernia?).
3. See the shape of the lump in the groin. A direct inguinal hernia is usually globular in shape and
an indirect one may be sausage shaped (inguino-scrotal swellings).
4. Ask the patient to cough,
a. To elicit expansile cough impulse.
b. To visualize a hernia that cannot be seen.
c. To see the full extent of an already visible hernia.
CASE 14
5. ONLY IF the hernia still cannot be seen, ask the patient where the lump is (It may be a scrotal
swelling!!) and ask him to stand up at this point & look for a bulge appearing on the groin area
on coughing (Very rare to give invisible ones in an exam setting).
6. Once the hernia is visible, demonstrate the palpable expansile cough impulse.
7. ONLY IF there is no past surgical scar indicating a previous repair, differentiate whether it is
direct or indirect hernia.
a. Ask the patient himself to reduce the hernia fully for you.
b. If the patient is unable to do so, ask the examiner whether you may try to reduce it
(DO NOT try to reduce without the consent of the examiner)
c. ONLY IF the hernia is reduced,
i. Locate the deep inguinal ring (2methods can be used).
1. 1 cm above the femoral pulse (Easy way).
2. 1 cm above the mid inguinal point (midpoint between the anterior
superior iliac sine and pubic tubercle).
ii. Ask to cough while you are applying firm pressure on deep inguinal ring with
your index finger.
iii. If the lump can be controlled by digital pressure over the deep ring, it is an
“Indirect inguinal hernia”, if not it is a“Direct inguinal hernia”.
8. Examine the external genitalia to exclude phimosis and coexisting scrotal lump which is very
common.
9. If the patient was supine throughout your examination, ask him to stand up before you finish
and look for,
Chapter: INGUINAL HERNIA
a. A coexisting small hernia on the other groin.

b. A coexisting vericocele.
38
PRESENTATION
This patient has got a globular shaped lump in the right groin region. It has visible and
expansile cough impulse. The hernia can be completely reduced and cannot be controlled by
applying firm pressure over the deep inguinal ring. He has got no phimosis and there are no
coexisting scrotal lumps. The contralateral groin is normal. So my probable diagnosis is
uncomplicated right sided direct inguinal hernia and I would like to offer him inguinal hernia repair
under spinal anaesthesia.

1. How do you locate the deep inguinal ring?
1. 1 cm above the femoral pulse (Easy way).
2. 1 cm above the mid inguinal point (midpoint between the anterior superior iliac sine and
pubic tubercle).
CASE 14
2. If you see a scar of a previous repair, do you still want to locate the deep inguinal ring?
No. Once a hernia is repaired, its anatomy is disturbed. So a recurrence of a hernia arises from
the weakest part of it. Hence it is neither direct nor indirect.
3. If you cannot control the hernia by applying firm pressure over the deep inguinal ring, can
it still be an indirect hernia? Why?
Yes it can be.
1. Not enough pressure applied.
2. Finger is not on the deep inguinal ring.
Any way this method is just for crude assessment. The

direct or indirect nature of a hernia is best identified
during the surgery.
4. From where does an indirect inguinal hernia appear?

It comes from deep inguinal ring, passes obliquely through
the inguinal canal and may continue through the
superficial inguinal ring to the scrotum. It arise lateral to
the inferior epigastric artery. Commonly due persistent
processes vaginalis. Fig 14.1 - Inguinal hernia A
5. From where does a direct inguinal hernia appear?

It occurs as a result of weakened posterior wall of the inguinal canal and arise medial to the
inferior epigastric artery. So a direct inguinal hernia is not within the spermatic code. It may
descend to the scrotum though.
6. What is the importance of differentiating direct and indirect inguinal hernia?

No importance! Management is same for both.
39
7. What is the landmark to differentiate direct from indirect inguinal hernia during the surgery?
Inferior epigastric artery.
8. At what age inguinal hernia are operated on children?

As early as possible due to high risk of strangulation.

1. Mesh repair (Gold standard).
2. Darning repair.
3. Bassini repair.
4. Shouldice repair.
10. What is the difference in surgical steps of managing inguinal herniae?

Indirect inguinal herniae require both herniotomy (excision of the hernia sac) & hernioraphy
(hernial repair) while direct inguinal herniae usually only necessitate hernioraphy.
CASE 14
11. What are the aetiological factors?
1. Chronic cough.
2. Constipation.
3. Cigarette smoking.
4. Bladder outflow obstruction (BOO).
12. What are the complications of inguinal herniae?

1. Irreducibility.
2. Obstruction.
3. Strangulation.
4. Incarceration
13. What are the complications of the surgery?

1. Acute urine retention.
2. Hematoma formation.
3. Pain. Fig 14.2 - Inguinal hernia B
4. Infection.
5. Ischemic orchitis.
6. Recurrence.
14. What is the risk of recurrence after a Mesh repair?

Less than 1%.
40
FEMORAL HERNIA CASE 15
EXAMINATION
The probability of getting a femoral hernia is uncommon at exam setting than its counterpart;
inguinal hernia. It’s because they are rarer as well as they are operated shortly after the
presentation due to higher incidence of strangulation.
Sometimes it will be difficult to differentiate it from inguinal hernia for an inexperienced candidate.
The technique of examination is almost the same as for an inguinal hernia.
1. Get the Consent, cover the area and expose adequately.

2. Look carefully for surgical scars in the groin.
3. Comment on the shape and size of the lump if it is obvious.
4. Ask the patient to cough (femoral herniae usually do not have cough impulse).
CASE 15
5. Ask the patient himself to reduce the hernia fully for you - femoral herniae are more often
than not irreducible.
6. Locate the exact anatomical location of the hernia neck.
a. To do that, locate the pubic tubercle which is about 1 cm lateral to the pubic symphisis in
the midline.
b. The neck of a femoral hernia always lies below and lateral to the public tubercle (where
as that of an inguinal hernia lies above and medial to it).
7. Examine the contralateral groin for a coexsisting hernia.
Chapter: FEMORAL HERNIA
Fig 15.1 - Femoral hernia (Diagram) Fig 15.2 - Femoral Henia
41
PRESENTATION
There is a hemispherical lump over the left inguinal region which is approximately 2 cm in
diameter. It has no expansile cough reflex and it is irreducible. It is neck is located below and lateral
to the pubic tubercle. So my probable diagnosis is obstructed femoral hernia.

1. Skin lumps - Lipoma/ sebaceous cyst/ dermoid cyst.
2. Femoral aneurysm.
3. Saphena varix.
4. Inguinal hernia.
CASE 15
5. Inguinal lymphadenopathy.
6. Undecended testis.
2. How to differentiate it from inguinal hernia?

1. Below the inguinal ligament.
2. Lateral to pubic tubercle.
3. Usually no cough impulse and irreducible.
3. Can there be congenital femoral hernia?

No, it is always acquired. Thus never seen in newborns.
4. What are the principle steps of surgical management?

1. Reduction of the contents of hernia sac.
2. Herniotomy.
3. Repair of the defect.
5. What are techniques of surgical repair for femoral herniae?

1. Lockwood repair .
2. McEvedy repair (Abdominal repair).
3. Lotheissen repair.
6. What are the contents of femoral canal from lateral to medial?

Chapter: FEMORAL HERNIA
1. Femoral Nerve.
2. Femoral Artery.
3. Femoral Vein.
4. Hernial sac (through the saphenous opening).
42
PARAUMBILICAL HERNIA CASE 16
EXAMINATION
You may be directed to the case with the commanding line of “Do an abdominal examination
of this patient”. The patient is usually a middle aged overweight female.
1. Expose the abdomen fully from the xiphisternum to the pubic symphisis.
2. Notice any lump around the umbilicus which bulges out beside it. In a paraumbilical hernia,
the umbilicus is pushed to a side and stretched forming a crescent shaped crest, giving the
appearance of a “Smiling Umbilicus”.
3. Note the presence of any overlying scar (recurrent hernia?).
4. Inspect the crest carefully. It may go deep and there may be foul smelling discharge, even
an “Ompholith” (dried up sebaceous secretions).
CASE 16
5. Ask the patient to cough to visualize non-apparent hernia and to elicit expansile cough
impulse.
6. Ask the patient to reduce the lump herself for you (Do not try to do this by yourself
without the consent of the examiner).
7. ONLY IF the lump is fully reducible, try to determine the size of the neck of the hernial sac.
a. Once the lump is fully reduced, insert a finger through the defect.
b. EITHER ask the patient to lift the head against resistance & look at her abdomen
OR raise straightened both lower limbs together to contract Rectus Abdominis
muscle.
c. Feel the hardened edge of the defect (of fibrous linea alba) with the finger and
assess the approximate size of it.
8. Always exclude coexisting herniae (Eg: inguinal hernia) and divarication (diastasis) of recti.
9. If the initial command is to do an abdominal examination, continue with the rest of the
examination unless the examiner intervenes.
PRESENTATION
Chapter: PARAUMBILICAL HERNIA
I examined the abdomen of this middle aged overweight female who is having a lump at the
umbilicus. There is a globular shaped lump measuring 2 cm in diameter near the superior edge of
the umbilicus and the umbilicus is pushed aside forming a crescent shaped pit below it. There are no
overlying scars and the pit is deep but clean, with no foul smelling discharge. Patient cannot reduce
the lump and there is no expansile cough impulse. But it is not tender to touch. There are no
coexisting inguinal herniae or divarication of recti and the rest of the abdominal examination is
unremarkable.
So my probable diagnosis is irreducible paraumbilical hernia.
43
Fig 16.1 - Paraumbilical hernia Fig 16.2 - Umbilical hernia
CASE 16
Fig 16.3 - Divarication (diastasis) of Fig 16.4 - Diagram showing diastasis
recti of recti Chapter: PARAUMBILICAL HERNIA
Fig 16.6 - Incisional hernia

Fig 16.5 - Epigastric hernia
44

1. What is an “Umbilical hernia”?
A true umbilical hernia comes through the umbilical scar and has the umbilical skin tethered to
it. They are most common in infants, especially evident when the infant cries and they occur
following failed fusion of the anterior abdominal wall muscles. But They can occur in adults
secondary to raised intra-abdomial pressure.
2. What is a “paraumbilical hernia”?

It is a form of acquired hernia in adults (middle aged females), which comes through a defect
adjacent to the umbilicus, hence beside it (usually above or below the umbilicus) rather than
coming through it. They are associated with obesity and weak abdominal muscles.
3. What is “diverication or diastasis of recti”?
CASE 16
It is a condition where the right and left sides of the Rectus Abdominis muscles spread apart in
the midline (Linear Alba). It is common in pregnancy and postpartum.
4. When an umbilical herniar is operated in a child?

Only after completion of one year of age, if not resolved spontaneously.
5. What are the complications of paraumbilical hernia?

1. Irreducibility.
2. Strangulation.
6. Why intestinal obstruction is uncommon in paraumbilical hernia?

Because usually it contains the omentum, not the intestine.
7. Why they are usually irreducible?

Because they often have a narrow neck.
8. What will happen to the patient if the hernia is strangulated?

She will complain of severe pain, but still the features of bowel obstruction are very rare. Since
the sac usually contains the omentum, what gets strangulated is extraperitoneal fat.
Chapter: PARAUMBILICAL HERNIA
9. What are the treatment options for paraumbilical hernia?

1. Mesh repair (Gold standard).
2. Simple approximation.
3. Mayo’s repair.
10. What is “Mayo’s repair”?

It is double breasting of the anterior rectus sheath.
45
PAROTID LUMP CASE 17
EXAMINATION
1. Examine the lump as usual (Site, Size, Shape, Surface, Consistency, Margins).
2. Look for skin attachment.
3. Look for muscle attachment (Masseter) – Ask the patient to clench the teeth to contract
Masseter.
4. Instruct to open the mouth and look for,
a. Opening of the parotid duct (opposite the 2nd upper molar) - Inflammation or pus?
b. Bulging of the tonsil of the affected side (Deep lobe of the gland).
5. Assess the integrity of facial nerve (Ask to wrinkle the forehead, close the eyes tightly,
blowout the cheeks, and show the teeth).
6. Look for cervical Lymphadenopathy.
CASE 17
7. Offer to palpate the parotid duct for a stone wearing a pair of gloves.
PRESENTATION
There is a hemispherical lump in the right preauricular area which is 2.5 cm in diameter. It is of
firm consistency with regular surface and distinct margins. The lump is not attached to skin or
underlying Masseter. Facial Nerve is intact and there is no cervical lymphadenopathy. So my clinical
diagnosis is a benign parotid tumour most probably a pleomorphic adenoma.
Fig 17.1 - Parotid tumour

Chapter: PAROTID LUMP
46

1) What are the differential diagnoses for unilateral parotid lump?
1. Benign parotid neoplasm.
2. Malignant parotid neoplasm.
3. Parotid lymph node.
4. Sialolithiasis.
5. Sialadenitis.
6. Sarcoidosis.
7. Facial nerve neuroma.
8. Outside – Lipoma / Sabaseaus cyst / Hypertrophied masseter.
2) What are the types of benign parotid tumours?

1. Pleomorphic adenoma.
2. Monomorphic adenoma.
3. Adenolymphoma (Warthin’s tumour).
CASE 17
3) What are the types of malignant parotid tumours?
1. Mucoepidermoid carcinoma.
2. Adenocystic carcinoma.
3. Oncocytoma.
4) What do you know about epidemiology of parotid tumours?

1. 80% salivary neoplasms affect the parotid gland.
2. 80% of them are benign.
3. 80% of the benign parotid neoplasms are pleomorphic adenomas.
5) What are the clinical features of a malignant lump?

1. Pain and recent rapid growth.
2. Hard in consistency.
3. Irregular surface and ill defined edge.
4. Fixed to skin and underlying muscle.
5. Facial nerve involvement.
6) What is the operation for pleomorphic adenoma?

Conservative superficial parotidectomy.
7) What are the specific complications of parotidectomy?

1. Facial nerve palsy.
Chapter: PAROTID LUMP
2. Salivary fistula.
3. Frey’s syndrome (Gustatory sweating).
47
SUBMANDIBULAR LUMP CASE 18
EXAMINATION
1. Examine the lump as usual (Site, Size, Shape, Surface, Consistency, Margins).
2. Look for skin attachment.
3. Look for muscle attachment (Myelohyoid) – Ask the patient to press the tongue against the
hard palate to contract Myelohyoid and look for reduction in mobility of the lump.
4. Instruct to open the mouth and look for the opening of the Submandibular duct (either side of
the frenulum lingulae) - Inflammation or pus?
5. Look for cervical Lymphadenopathy.
6. Wear gloves & palpate bimanually- If it is submandibular gland it is bimanually palpable.
7. Palpate along the submandibular duct for a stone.
CASE 18
PRESENTATION
There is an oval shaped lump in the right submandibular fossa which is 2 cm x 3 cm in size. It is
of firm consistency with regular surface and distinct margins. The lump is not attached to skin, but to
the underlying Myelohyoid. There is no cervical lymphadenopathy. The lump is bimanually palpable
and I could not feel any stone along the submandibular duct. So my clinical diagnosis is a
submandibular gland tumour.
Fig 18.1 - Submandibular tumour

Chapter: SUBMANDIBULAR LUMP
48

1. What are your main differential diagnosis for a lump in the submandibular area?
1. Submandibular lymphnode.
2. Palpable enlarged submandibular gland.
3. Other skin lumps (lipomas, sebaceous cysts, dermoids).
2. What are the common reasons for a palpable enlarged submandibular gland?
1. Submandibular sialedenitis and sialectasis.
2. Submandibular tumours.
3. How would you differentiate a submandibular lymphnode from a submandibular gland

tumour?
1. Not bimanually palpable.
2. Not attached to Myelohyoid.
3. Can be delivered to cheek, past the lower border of the jaw!
CASE 18
4. What is sialectasis?
Irregular dialatation and stenosis of the intraductular duct system due to recurrent infection.
5. What is the presentation of submandibular calculi?

1. Pain while seeing or thinking of food.
2. Referred pain in the tongue (Lingual colic).
3. Lump increases in size during meals.
4. Duct is inflamed & swollen.
6. Why submandibular gland is commonly affected by calculi in contrast to Parotid?

1. Longer duct.
2. Thick secretions.
3. Drains upwards (Against gravity).
7. What are the radiological investigations done to visualize submandibular calculi?

1. Intraoral plain X-ray.
2. Submandibular sialogram.

Chapter: SUBMANDIBULAR LUMP
1. If the stone is within the intraglandular ducts - Submandibular sialadenectomy.

2. If the stone can be felt - Stone is removed under LA & the duct is kept open.
9. What are the nerves that can be damaged during submandibular sialadenectomy?
1. Marginal mandibular branch of the facial nerve.
2. Lingual nerve.
3. Hypoglossal nerve.
10. How many salivary calculi are radio-opaque? 80%.
49
VERICOSE VEINS CASE 19
EXAMINATION
Ask the patient to stand up and inspect the anterior and posterior surfaces of both lower limbs from
below upwards. (You may have to kneel down by the side). If the both lower limbs are affected, you
will be asked to examine one leg only. You will need a tourniquet (a urinary foleycatheter would do)
during the examination.
1. Identify the affected territory (If anteromedial – Long saphenous territory and If posterior -
Short saphenous territory).
2. Look for “Saphenavarix”.
3. Look for “Blow-outs”.
4. Carry out “Tap test”.
CASE 19
Ask the patient to lie down on the bed,
1. Inspect the lower limb for pigmentation, ezema, venous ulcerations, lipodermatosclerosis and
superficial thromboblephitis.
2. Lift the lower limb up and empty all the dialated veins.
3. Apply the tourniquet as high as possible just below the saphenofemoral junction (SFJ).
Get the patient out of the bed quickly,
1. Look for reappearance of vericosities (indicates perforator incompetence).

2. Remove the tourniquet and look for appearance of vericosities which was not there before
(Pure Saphenofemoral incompetence) or increase in already appeared vericosities (Both).
Offer to do the Perthe’s Test to check the integrity of the deep veins. (Apply a tourniquet just below
SFJ and ask the patient to walk/ tip toe for about 10-15 min. A Cramping leg pain is indicative of
affected deep veins.
PRESENTATION
He is having dilated torturous veins involving the antero-medial aspect of his right lower limb
and there is lump in the right femoral triangle with a cough impulse and fluid thrill most probably a
Chapter: VERICOSE VEINS
saphinavarix. I did not notice any blow-outs and the tap test is positive. There is pigmentation,
lipodermatosclerosis and a superficial ulcer on the Gaiter’s area. He has got both saphenofemoral
and perforator incompetence. I would like to do Perthe’s test to assess the intergrity of the deep
veins.
50
Fig 19.1 - Vericose veins affecting Fig 19.2 - Vericose veins affecting
greater saphenous system lesser saphenous system
CASE 19
Fig 19.3 - Saphenavarix Fig 19.4 - Blow-outs (perforator
incompetence)
Fig 19.5 - Lipodermatosclerosis Fig 19.6 - Venous ulceration over the

Gaiter’s area
1. What are varicose veins?
The presence of dilated, elongated, tortuous superficial veins.
51
2. How do you clinically classify it? (American Venous Forum classification)

C0 -No visible or palpable signs of venous disease.
C1 -Telengectasiaes or reticular veins.
C2 - Varicose veins.
C3 - Oedema.
C4a - Pigmentation.
C4b -Lipodermatosclerosis.
C5- Healed venous ulcer.
C6 - Active venous ulcer.
3. How would you investigate?

1. Hand held Dopplar scan.
2. Duplex scan.
CASE 19
1. Conservative management (Reassurance, Lifestyle modification, Stockings).
2. Sclerotherapy (For below knee varicosities with Sodium tetradecyl sulfate).
3. Surgery.
a. Saphenofemoral junction ligation and greater saphenous stripling.
b. Saphenopopliteal junction ligation and lesser saphenous stripling.
c. Stab avulsion of the perforators.
4. Endovascular ablation (Induce permanent endothelial damage by heat).
5. What are the complications?

1. Pigmentation.
2. Eczema.
3. Lipodermatosclerosis.
4. Thromboplebitis.
5. Bleeding.
6. Ulceration (Commonly over the Gaiter’s area).
6. What are the measures that are taken to reduce the risk of postoperative DVT?
1. Ensure hydration.
2. Adequate mobilization.
3. Limb physiotherapy.
4. Tight fitting stockings for 4 weeks.
5. Low molecular weight heparin (LMWH) to high risk patients.
7. What is the risk of recurrence?

20% risk at 5 years.
52
SCROTAL LUMPS CASE 20
EXAMINATION
Take consent. Expose well. Remember to examine the contralateral hemiscrotum and for a
coexsisting inguinal hernia which is not uncommon.
1. Palpate the Spermatic cord to differentiate a scrotal lump from an inguino-scrotal lump.
 Scrotal lumps- Hydroceles, Epididymal cysts, Cysts of the cord.
 Inguino-scrotal lumps - Inguinal hernia (usually indirect).
2. Check whether you can feel the testis separately from the lump.
a. If yes, check whether there is a distinct gap between the testis and lump (Cyst of the
cord) or not (Epididymal cyst).
b. If no, it’s a hydrocele (But in “Lax hydrocele” testis can be palpable due to small amount
of fluid).
CASE 20
3. Stabilize the lump (against the thigh using your fingers of both hands) and elicit cross
fluctuations.
4. Stretch the scrotal skin and keep a pen light away from the testis to look for transillumination
(Transillumination will not be elicited across the testis).
5. Examine the contralateral hemiscrotum as well.
6. Get the patient out of the bed and look for coexisting inguinal hernia and vericocele.
Chapter: SCROTAL LUMPS
Fig 20.1 - Hydrocele Fig 20.2 - Transillumiation of a

hydrocele
53
PRESENTATION
Hydrocele - He is having a lump confined to the right hemiscrotum which is fluctuant and
transilluminant. The right testis cannot be separately palpable (The Left hemiscrotum and testis is
normal and he does not have coexsisting inguinal hernia or vericocle).
Epididymal Cyst - This patient is having a lump confined to right hemiscrotum which is fluctuant
and brilliantly transilluminant. The right testis is separately palpable and there is no distinct gap
between the lump and testis.
Cyst of the Cord - He is having a lump confined to the right hemiscrotum which is fluctuant and
brilliantly transilluminant. The right testis is separately palpable and there is a distinct gap
between the lump and testis.
CASE 20
1. What are the types of hydroceles?
1. Primary Hydrocele (Idiopathic Hydrocele).
2. Secondary Hydrocele (Lax Hydrocele) - Due to testicular tumours, torsion, infection, trauma
or following inguinal hernia repair.
2. Do all hydroceles transilluminate?

No. Chronic hydroceles are not transilluminant due to calcified sac wall.
3. Why do we operate on hydroceles?

1. Cosmetically unacceptable and interfere with intercourse.
2. Liable to trauma and infection.
4. What are the surgical procedures?

1. Jaboulay’s procedure – Sac is everted.
2. Lord’s procedure – Sac is plicated.
5. What is the management of an epididymal cyst?

1. Reassurance is the choice in young due to risk of post-operative subfertility.
2. Surgery may be indicated in elderly in the presence of large or painful cysts.
6. What are the main types of testicular malignancies?

1. Teratoma – young (< 30 years).
2. Seminoma – older (> 30 years).
54
7. What is the management of them?

High ligation orchidectomy using a transinguinal approach.
Transscrotal approach is avoided due to risk of skin contamination.
8. What are the causes for painful scrotal swellings?

1. Testicular torsion.
2. Epididymo-orchitis.
CASE 20
Fig 20.3 - Epididymal cyst being
operated
Fig 20.4 - Transillumination of an

epididymal cyst
55
CARPAL TUNNEL SYNDROME CASE 21
EXAMINATION
Usually the command is to examine the hands of the patient, but sometimes you might be given a
clue like “This lady presented with tingling sensation in her hands”. The disease is often bilateral.
1. Ask the patient to spread out the hands for you.

2. Look for,
a. Wasting of thenar muscles.
b. Scar of a previous carpal tunnel decompression surgery.
3. Examine functions of the muscles supplied by the Median nerve.
a. Abductor Pollicis Brevis - Ask the patient to place the dorsum of the hand on a flat
surface and lift the thumb towards the ceiling against resistance (Pen touch test).
b. Opponens Pollicis - This muscle is usually not tested as it may also be supplied by the
ulnar nerve ( an anatomical variation).
4. Examine the sensory distribution.
a. There is an area of sensory loss over the palmar aspect of the lateral three and half
fingers.
b. However the sensation over the thenar eminence is preserved.
5. Special Signs to elicit,
a. Tinel’s Test - Tap over the flexor aspect of the wrist over the midline. If the patient
feels a tingling sensation over the distribution of the median nerve, the test is positive.
b. Phalen’s Test - Ask the patient to flex the wrists maximally and keep for one minute. If
the patient feels pain in the hands, the test is considered positive.
6. Try to identify a probable aetiology.
a. Obesity.
b. Hypothyrodism - Goiter? Facial puffiness? Loss of lateral third of eye brows?
c. Rheumatoid arthritis - Shawn neck deformity? Boutnier’s deformity? Z thumb?
CASE 21
7. Offer assessment of the patient’s quality of life (QOL).
a. Nocturnal and early morning worsening of symptoms.
b. Effects on occupation or activities of daily living (eg: Washing clothes).
Chapter: CARPAL TUNNEL SYNDROME
PRESENTATION
This patient who presented with tingling sensation of hands, has bilateral thenar muscle
wasting but there is no wasting of hypothenar eminence or dorsal guttering. There are no visible
surgical scars, suggestive of previous carpal tunnel decompression surgery. Her opposition of the
thumbs is weak and the pen touch test is positive, but there is no weakness in finger adduction or
extension. There is an area of sensory loss over the palmar aspect of the lateral three and half
fingers and no other areas of sensory loss. Tinel’s test and Phalen’s test are positive. So my tentative
diagnosis is bilateral Carpal Tunnel Syndrome (CTS) and I would like to assess her functional
disability and probable aetiology.
56
Fig 21.1 - Wasting of thenar eminence Fig 21.1 - Severe wasting of bilateral
thenar muscles
Fig 21.3 - Phalen’s test Fig 21.4 - Tinel’s test
CASE 21

1. What is Carpal Tunnel Syndrome?

It is the symptomatic compression of the median nerve at the carpal tunnel where it runs deep to
the flexor retinaculum (Commonest entrapment neuropathy).
2. What are the boundaries of carpal tunnel?

Roof - Flexor retinaculum.
Medial (Ulnar) - Pisiform & Hook of Hamate.
Lateral (Radial) - Scaphoid and Trapezius .
Palmar aspect - Transverse carpal ligament.
57
3. What are the structures that pass through the carpal tunnel?
1. Median nerve.
2. Four tendons of Flexor Digitorum Superficialis.
3. Four tendons of Flexor Digitorum Profundus.
4. Tendon of Flexor Pollicis Longus.
5. Tendon of Flexor Carpi Ulnaris (in a separate compartment).
4. What are the structures that pass over the carpal tunnel?
1. Palmar cutaneous branch of the Median nerve.
2. Ulnar nerve.
3. Ulnar artery.
4. Tendon of Palmaris Longus.
5. Why not the sensation over the radial aspect of the palm is affected?
Because the palmar cutaneous branch of the Median nerve is given away proximal to the flexor
retinaculum and which passes over it.
6. What are the muscles in hand which are innervated by the Median nerve?
1. All thenar muscles except Adductor Pollicis.
2. Radial two Lumbricals.
7. Name one investigationto confirm your clinical diagnosis?

Nerve conduction studies (NCS).
8. What are the known causes for carpal tunnel

syndrome?
1. Obesity.
2. Pregnancy.
3. Hypothyroidism.
4. Diabetes Mellitus.
CASE 21
5. Rheumatoid Arthritis.

1. Cervical rib.
2. Cervical spondylosis.
3. Pancoast’s syndrome. Fig 21.5 - Carpal tunnel

decompression surgery
10. What is the surgery?
Carpal tunnel decompression by longitudinally dividing the flexor retinaculum in full length in a
bloodless field under local anesthesia.
11. What are other non surgical treatment options?

1. Local steroid injection.
2. Splinting of the wrist at night.
3. Treating the underlying cause.
58
RADIAL NERVE PALSY CASE 22
EXAMINATION
1. Ask the patient to spread out the arms for you and look for a “Wrist drop” (flexion of wrist and
fingers of the affected hand).
2. Examine the functions of the muscles supplied by the Radial nerve.
a. Long extensors in forearm (wrist and MCPJ extensors) - Ask the patient to extend the
wrist & fingers against resistance.
b. Triceps - Ask the patient to extend the elbow against resistance.
c. Brachioradialis - Ask to flex the elbow in the semipronated position against resistance.
d. Supinator - Ask to supinate the forearm with extended elbow against resistance.
a. There is an area of sensory loss over the 1stinterdigital space on the dorsum of the hand.
Fig 22.1 - Wrist drop
CASE 22
Chapter: RADIAL NERVE PALSY
PRESENTATION
There is a wrist drop in the right side compared to the left side and he cannot extend
the wrist or fingers at metacarphalangeal joints against resistance. Extension of the elbow is
weak as well as the flexion of elbow in the semipronated position compared to the other side.
Supination is also impaired with extended elbow against resistance. There is an area of sensory
loss over the dorsal aspect of the 1st web space. Opposition of thumb, adduction and abduction
of the fingers are intact. So my probable diagnosis is right sided radial nerve palsy.
59

1. What are the muscles innervated by the Radial nerve?
1. Triceps.
2. Brachioradialis.
3. All the muscles in the extensor compartment of forearm.
2. What are the muscles in hand supplied by Radial nerve?

None.
3. Why the extension of proximal interphalangeal joints (PIPJ) are preserved?

Due to intact Lubricals and Interossei which are
supplied by the Ulnar nerve and Median nerve.
4. What is the area of sensory loss in Radial nerve

palsy?
Over the dorsal aspect of the 1stinterdigital
space.
5. What are the causes for Radial nerve palsy?

1. Compression at axilla - Crutch palsy
(Saturday night Palsy).
2. Fracture shaft of humerus.
3. Tight tourniquet.
4. Supracondylar fracture of humerus.
5. Dislocation of elbow. Fig 22.2 - Splinting for wrist drop
6. Fracture head of the radius.

Immediate nerve suturing and tendon transfer using the Palmaris Longus tendon followed by
CASE 22
physiotherapy.
Chapter: RADIAL NERVE PALSY
60
ULNAR NERVE PALSY CASE 23
EXAMINATION
Given below is a targeted examination for Ulnar nerve palsy. But remember to examine other
nerves (Median & Radial) to exclude multiple nerve involvement.
1. Ask the patient to spread out the hands for you and try to spot diagnose the “Ulnar claw hand”
(Clawing of the medial two fingers of the hand).
2. Inspect carefully both the palmar and dorsal aspect of the hands and look for,
a. Wasting of hypothenar eminence (compare with the other side).
b. Dorsal guttering (due to wasted Interossei muscles) - Palpate the 1st finger web where
the wasting is often obvious.
3. Examine the functions of the muscles supplied by the Ulnar nerve.
a. Palmar Interossei - Ask the patient hold a card between two fingers while you attempt
pull it away using the same two fingers.
b. Dosrsal Interossei - Ask the patient to keep the hand on a flat surface and spread out
the fingers against resistance.
c. Adductor Pollicis - Ask the patient hold a paper between the thumb and the radial
aspect of the index fingers while you attempting to pull it away. Flexion of the terminal
phalanx of the thumb to hold the paper indicates a positive Froment’s sign.
a. High lesions - There is an area of sensory loss over the both palmar & dorsal aspects of
the medial side of the hand and medial one and half fingers.
b. Low lesions - There is an area of sensory loss only over the palmar aspect of the medial
side of the hand and medial one and half fingers.
a. Look for depigemented anaesthetic patches and Ulnar nerve thickening at elbow
(Leprosy).
CASE 23
b. Look for scars on the forearm (trauma).
6. Offer to assess the patient’s quality of life.
PRESENTATION
Chapter: ULNAR NERVE PALSY
There is marked clawing of the ring and little fingers of the right hand and there is wasting of
hypothenar eminence with dorsal guttering, but the thenar eminence is not affected. The actions of
palmar and dorsal interossei are impaired and Froment’s sign is positive. Opposition of the thumb
and finger extension is intact. There is an area of sensory loss over the palmar aspect of the medial
side of the hand and medial one and half fingers. There is no hypopigmented patches or ulnar nerve
thickening and there is no visible scars on the forearm. So my tentative diagnosis is right sided Ulnar
nerve palsy, probably a lower lesion.
61
Fig 23.1 - Ulnar claw hand Fig 23.2 - Ulnar claw hand
(Dorsal view) (Palmar view)

1. What is “Clawing”?
It is the hyperextension of the metacarpophalangeal joints and flexion of proximal and distal
interphalangeal joints.
2. Why does it occur?

It is due to paralyzed Interossei and Lumbricals with unopposed action of long flexors and
extensors.
3. What is “Ulnar claw hand”?

The clawing is only obvious in medial two fingers (Because lateral two Lumbricals which are
CASE 23
supplied by the median nerve are spared).
4. What is “Ulnar paradox”?

Surprisingly, high division of the ulnar nerve (anywhere hand’s breadth above the wrist) causes
less clawing than the lower lesions.
5. Why does it occur?

In higher lesions the innervation to medial half of Flexor Digitorum Profundus is also lost, causing
less intense flexion of the fingers.
6. How do you differentiate?

From the degree of clawing and the area of sensory involvement (see examination).
62
7. What are the muscles that are innervated by the Ulnar nerve?
1. Flexor Carpi Ulnaris.
2. Medial half of Flexor Digitorum Profundus.
3. All Palmar Interossei.
4. All dorsal Interossei.
5. 3rd & 4th Lumbricals.
6. Adductor Pollicis.
8. What is the basis of Forment's sign?

Patient tries to compensate the ‘lost’ adduction of the thumb by flexion of it (with Flexor Pollicis
Longus which is supplied by the Median nerve).
9. What are the causes for Ulnar nerve palsy?

1. Leprosy (often bilateral).
2. Laceration over the wrist or anywhere along its course.
3. Fracture medial epicodyle.
4. Dislocation of elbow.
5. Cubital tunnel syndrome.
6. Degenerative arthritis.
7. Malunion of fractures of the lower end of humerus (Tardae Ulna nerve palsy).
10. What are the surgical options for Ulnar nerve palsy you know of?
1. Ulnar nerve decompression.
2. Ulnar nerve anterior transposition.
3. Medial epicondylectomy.
CASE 23
Fig 23.3 -Traumatic ulnar neve injury
63
TRIGGER FINGER CASE 24
EXAMINATION
1. Ask the patient to spread out the hands with palmar surface facing upwards as for any hand
examination. Note any degree of flexion in ring (and middle) fingers.
2. Then ask the patient to flex and extend the fingers.
3. After flexion of the fingers, extension will be painful and there will be an obvious rapid phase
(triggering) in finger extension.
4. Then palpate gently over the palmar surface, proximal to the finger affected and feel for a
small tender nodule along the tendon (commonly found over the metacarpal heads).
CASE 24
Fig 24.1 - Trigger finger
PRESENTATION
Chapter: TRIGGER FINGER
This patient is having difficulty in extending the ring finger of the right hand after flexion and
there is a sudden extension when attempting to do so. There is a small tender nodule over the 4 th
metacarpal head of the right hand. So my probable diagnosis is stenosing tenosinovitis in the right
ring finger.
64

1. What is the scientific name for “trigger finger”?
Stenosing tenosinovitis.
2. What is the pathophysiology?

It is caused by the fibrosis and thickening of flexor tendon sheaths as the tendons enters the digit.
3. What are the causes?

1. Mostly idiopathic.
2. Trauma.
3. Congenital.
4. What are the non-surgical treatment options?
CASE 24
1. Heat fomentation.
2. A short course of analgesics.
5. What is the surgical treatment?

Tendon release surgery.
A longitudinal incision over the tendon sheath is made under local anesthesia in a bloodless field.
Fig 24.2 - Tendon release surgery Fig 24.3 - Trigger finger (operated)
Chapter: TRIGGER FINGER
65
BAKER’S CYST CASE 25
EXAMINATION
The principle steps of an examination of a lump should be followed as outlined below.
Remember to examine both knees.
1. Site - Over the popliteal fossa, in the midline below the joint line of the knee.
2. Size - Medium to large.
3. Shape - Hemispherical / oval.
4. Skin - No punctum.
6. Tissue plane - Not attached to skin or underlying muscle.
7. Consistency - Soft.
8. Pulsatility - Not Pulsatile.
9. Compressibility - Can be emptied to the knee joint.
10. Fluctuance - Fluctuant.
11. Transillumination - Transilluminant.
12. Examine the knee for Osteoarthritis - Swollen knee/ Patellar tap/ Crepitus.
PRESENTATION
This patient has a hemispherical shaped lump
CASE 25
measuring 4 cm in diameter, over the left popliteal fossa in
the midline below the line of the knee joint. Surface is
smooth, edge is well defined and it is not attached to the skin
or the underlying muscle. It is soft in consistency, fluctuant
and trasilluminant. It can be emptied to the knee joint and it
is not pulsatile. There is no lump over the right side and both
of the knee joints show degenerative features like crepitus.
So my probable diagnosis is a Baker’s cyst in a background of

Chapter: BAKER’S CYST
osteoarthritis.
Fig 25.1 - Baker’s cyst
66
1. What are the boundries of popliteal fossa?

1. Superomedially - Semimembranosus & Semitendinosus tendons.
2. Superolaterally - Biceps Femoris tendon.
3. Inferomedially - Medial head of Gastrcnemius.
4. Inferolaterally - Lateral head of Gastracnemius.
5. Roof - Fascia Lata.
2. What are the differential diagnosis for a lump in popliteal fossa?

1. Baker’s cyst.
2. Semimembranoses bursa (Popliteal cyst).
3. Popliteal aneurysm.
4. Saphena varix at sapheno-popliteal junction.
5. Lipoma / Sabeceous cyst.
3. What is the critical condition that you should rule out first?
Deep vein thrombosis (DVT).
4. What is a Baker’s cyst?

Baker’s cyst is a posterior herniation of the capsule of the knee joint which occurs secondary to
osteoarthritis of the knee.
5. How do you differentiate a Popliteal cyst from a Baker’s cyst ?

1. Above the joint line of knee, NOT below it.
2. Towards the medial side, NOT in the midline.
3. Occurs in young adults, NOT common in elderly.
6. How do you confirm your diagnosis of Baker’s cyst?
CASE 25
By an ultrasound scan.
7. What is the treatment for a Baker’s cyst?

Aspiration is possible, but recurrence rate is high.
If the lump is large, excision under a bloodless field is done.
8. What are the radiological features of Osteoarthritis?

1. Joint space narrowing.
2. Osteophytes formation.
3. Sclerotic articulate surfaces.
Chapter: BAKER’S CYST
67
AMPUTATED STUMP CASE 26
EXAMINATION
You may be given a patient with peripheral vascular disease (PVD) who is having an
amputated limb, with or without gangrenous toes. Remember to examine the both lower limbs,
especially assess the peripheral pulses of the non-amputated limb which could be vital, but easily
forgotten.
01. Examine the amputation stump first.

a. Describe the anatomical level of amputation.
b. Comment on the skin wound. Healed completely?
c. Ask the patient to flex and extend the knee in a below knee amputation ( to exclude
fixed flexion deformity)
d. Move the skin over the stump and check whether it is freely movable.
02. Look for the scars of previous vascular bypass surgeries. Scars may be in the abdomen!
03. Examine the peripheral pulses of the affected limb. Comment on the presence or absence of
pulse and the pulse volume.
04. Examine the contralateral limb.
a. Carefully examine toes (Toe amputations, Gangrenous toes, Ischemic Ulcers).
b. Feel the skin temperature.
c. Check the capillary refilling time (CRFT).
d. Examine all peripheral pulses (femoral, popliteal, posterior tibial & dorsalis pedis) and
comment on pulse volume.
e. Perform Buerger’s test. (Lift the straightened leg up while patient is lying flat on the
bed, and look for colour
change in the leg to white as
the perfusion drops. Then ask
to lower the leg over the side
CASE 26
of the bed and look for
reactive hyperaemia).
f. Auscultate for a femoral
bruit.
05. Look for nicotin stains in the right
hand.
06. Examine/ Offer to examine
Chapter: AMPUTATED STUMP
comorbiditiesassociated with PVD.

a. Carotid bruit.
b. Deviated heaving apex.
c. Pulsatile epigastric lump
(Abdominal Aortic Aneurism)
Fig 26.1 - Below knee amputation
68
PRESENTATION
The left lower limb of the patient is amputated at below knee level and the skin wound is
completely healed. The skin over the amputation stump is freely movable and there is no fixed
flexion deformity.
There are no scars suggestive of previous vascular bypass surgeries. Both femoral pulses are
felt and good in volume, but distal pulses are weak in the contralateral limb. There are no partial
amupatations, gangrenous toes or ischemic ulcerations of the right lower limb. The peripheries are
warm and capillary refilling time is less than 2 seconds. Beurger’s test is negative. There are no
femoral or carotid bruits, no nicotin stains, pulsatile epigastric lumps and the apex beat in the
normal position and it is normal in character.
Fig 26.2 - Dry gangrene Fig 26.3 - Wet gangrene
CASE 26
1. What are the Indications for amputation?
1. Dead - Dry gangrene.
2. Deadly - Wet gangrene, Spreading celluilitis, Osteomelitis, Trauma.
3. Dead loss - Paralyisis.
2. What are the levels of amputation of lower limb?

1. Partial toe amputation.

2. Toe disarticulation.
3. Partial foot (Ray) amputation.
4. Trans-metatarsal amputation.
5. Ankle disarticulation (Syme’s).
6. Trans-tibial (Bleow knee) amputation.
7. Trans-femoral (Above knee) amputation.
8. Hip disarticulation.
69
3. What are the specific complications of amputation?

1. Haematoma formation & wound dehiscence.
2. Phantom Limb Pain.
3. Osteomyelitis.
4. Stump ulceration.
5. Stump neuroma & osteophytes formation.
6. Psychological disturbances.
4. What is “Gangrene”?
It is the tissue death due to persistent ischemia.
5. What is “Dry gangrene”?

It is a hard, shrunken, non-infected patch of gangrene with a clear line of demarcation.
6. What is “Wet gangrene”?

It is a soft, swollen, infected patch of gangrene without a clear line of demarcation.
7. What is “Fournier’s gangrene”?

A necrotizing subcutaneous infection of the scrotum and perineal skin.
8. What are the causes for gangrene?

1. Diabetes Mellitus.
2. Thrombosis & Embolism.
3. Raynaud’s syndrome.
4. Thomboangitis Obliterans.
5. Trauma.
9. What is critical limb ischemia?

It is the advanced form of peripheral vascular disease (PVD) where the patient has rest pain
CASE 26
and tissue loss (gangrene & ischemic ulceration).
10. What is Fontaine classification?

I. Asymptomatic
II. Intermitant Claudication
IIa. Claudication distance > 200m
IIb. Claudication distance< 200m
III. Rest pain
IV. Tissue loss
11. What is “Buerger’s angle”?

The angle which the leg should be raised before it becomes white in a patient with PVD is
known as the Buerger’s angle or vascular angle. In a normal person, even if the straightened
leg raised to 90 degrees, the toes will stay pink.
70
12. How do you measure Ankle Brachial Pulse Index (ABPI)?

It is measured by placing a cuff just above the patient’s ankle and using a hand held Doppler
probe, Dorsalis pedis or Posterior tibial pulses are detected. The cuff is then inflated above the
systolic pressure and deflated until the signal returns. Brachial artery pressure is then
measured and the ratio is taken as the ABPI.
13. What are the main two aetological entities of PVD?

1. Heavy cigarette smoking.
2. Thromboangitis Obliterans (Berger’s disease).
14. What are the treatment options available for Peripheral Vascular Disease (PVD)?
1. Conservative management
i. Risk factor modification.
ii. Graded exercise.
iii. Foot care.
iv. Medications (Statins, Aspirin).
2. Percutaneous Transluminal Angioplasty (PTA)
3. Surgery
i. Vascular bypass.
ii. Endarterectomy.
iii. Profundaplasty.
iv. Sympathetectomy.
v. Limb Amputation.
15. What are the indications for angiography?

1. Disabling claudications.
2. Critical limb ischemia.
3. Refractory to medical treatment.
16. When do you do angiography?
CASE 26
Only when an intervention is planned (due to its own risks like anaphylaxis and acute renal
failure).
Fig 26.4 - Ray ressection Fig 26.5 - Wound dehiscence in an

amputated stump
71
CELLULITIS CASE 27
EXAMINATION
Consider yourself lucky if you are given a patient with cellulites as one of your exam cases. But
always remember that the easier cases may get tricky. Often the diagnosis is evident, but still the
methodical examination and the presentation may carry the bulk of the marks.
1. Comment on the area affected and up to which level. Lower limbs are the most affected.
2. Examine for cardinal signs of local inflammation.

a. Redness (Erythema) - Look for area of redness and especially comment on the line of
demarcation (whether it is distinct or not). In Erysipelas there is sharp line of
demarcation between reddened skin and the normal skin. Red streaks indicates
lymphangitis.
b. Warmth - First feel the temperature of the contralateral lower limb with the dorsum
of the hand Then compare it with the affected limb.
c. Tenderness - Elicit the tenderness gently by applying firm pressure (This may be
evident while you are eliciting pitting oedema).
d. Oedema - Look for ankle or pedal pitting oedema. If the oedma is non-pitting, there
may be underlying chronic lymphoedema.
3. Look for regional lymphadenopathy - Check for enlarged tender inguinal lymphnodes.
4. Look for systemic signs of inflammation.

a. Fever - Check whether patient is febrile or just look at the QHT chart at bedside.
b. Tachycardia
5. Look for local complications

a. Blisters
CASE 27
b. Necrosis of skin
6. Try to find an aeitiological cause.

a. Source of infection - Look for wound in the foot especially in interdigital spaces.
b. Chronic lymphoedma - Look for non-pitting oedema, thickened dark skin, ulceration.
c. Immunodeficiency - Look for signs of steroid excess, Diabetes Mellitus.
PRESENTATION
Chapter: CELLULITIS
This patient is having swelling and erythema of right leg with indistinct demarcation. The
affected limb is warmer, tender and there is pitting ankle oedema. There is tender right inguinal
lymphadenopathy. She is febrile to touch and having a pulse rate of 110bpm. So she is having right
leg cellulitis and there is no blister formation.
72
Fig 27.1 - Upper limb cellulitis Fig 27.2 - Lower limb cellulitis

1. What is cellulitis?
Spreading inflammation of skin and subcutaneous connective tissue due to non suppurative
bacterial invasion
2. What are the causative organisms?

Streptococcus pyogens
Staphylococcus aureus
3. What are the cardinal signs of acute inflammation?

1. Erythema
2. Warmth
3. Oedema
4. Tenderness
CASE 27
5. Loss of function

1. Erysipelas
2. Deep vein thrombosis (DVT)
3. Dermatitis
4. Superficial thrombophlebitis
5. Paniculitis
5. How do you diagnose “Erysipelas”?

Chapter: CELLULITIS
There is an erythematous patch with a sharp line of demarcation commonly due to

streptococcal infection. Treatment is the same as for cellulitis.
73
6. What is the treatment for cellulitis?

1. Limb elevation
2. Oral Paracetamol
3. Oral Diclofenac Sodium
4. IV Benzylpenicillin is the gold standard choice of empirical antibiotic.
But recently antibiotic resistant has been reported. Hence IV Augmentin, IV Clindamycin
are frequently been used. Oral Roxithromycin is a good alternative for patients with
multiple drug allergies.
5. If there is evidenceof suppuration, IV Cloxacillin is indicated.
7. What are the complications of cellulitis?

1. Suppuration and abscess formation
2. Blister formation
3. Skin necrosis
4. Septicemia & septic shock
8. What are the predisposing factors?

a. Immunodeficinecy - Diabetes Mellitus, Steroid therapy
b. Chronic lymphoedema
9. What is “Necrotizing Fascitis”?
Typically caused by a mixture of aerobic and anaerobic organisms that cause necrosis of
subcutaneous tissue usually including the deep fascia. Without timely treatment (broad spectrum
antibiotics, surgical debridement, amputation if nessasary) the area becomes gangrenous.
CASE 27
Chapter: CELLULITIS
Fig 27.3 - Blister formation Fig 27.4 - Erysipelas
74
STOMAS CASE 28
EXAMINATION
1. Look at the site and morphology of the stoma and try to identify it.
2. Check whether it is functioning or not (presence of effluent or gas).
3. Comment on the effluent (consistency, colour and amount).
4. Look for possible complication of the stoma (offer the removal of colostomy bag with gloved
hands).
5. Try to figure out the possible surgery patient might have undergone (look at the abdominal
scar/ perineal scar).
CASE 28
Fig 28.1 - End ileostomy Fig 28.2 - Loop ileostomy
PRESENTATION
This patient is having an end colostomy at Right Illiac Fossa (RIF). The Mucosa appears pink
Chapter: STOMAS
and healthy. It is functioning and contains moderate amount of faeculent effluent with gas. There is
no evidences of bleeding or necrosis. There is a midline laparatomy scar evidencing pervious
Hartman’s procedure or Abdominoperineal Resection (APR). I would like to inspect for a perineal
scar to differentiate it.
75
CASE 28
Fig 28.3 - Colostomy bag

1. What are the types of stomas?
1. Input and Output stomas.
2. Temporary and Permanent stomas.
3. According to the site.
a. Gastrostomy.
b. Jejunostomy.
c. Ileostomy.
d. Ceacostomy.
e. Colostomy.
i. Ascending colostomy.
ii. Transverse colostomy.
Chapter: STOMAS
iii. Descending colostomy.

iv. Sigmoid colostomy.
f. Urostomy.
76
2. What are the morphological types of colostomies?

1. End colostomy.
2. Loop colostomy.
3. Double barrel colostomy.
3. What are the indications for colostomy/ ileostomy?

1. Permanent, End colostomy – in Abdomino-perineal resection (APR).
2. Temporary, End colostomy – in Hartman’s proceure.
3. Permanent, End ileostomy – in Panproctocolectomy in ulcerative colitis (UC) or FAP.
4. Loop ileostomy (Defunctioning ileostomy) – to protect a distal anastamosis (eg: AR).
4. How do you differentiate a colostomy from an ileostomy?

1. Colostomy is flushed with skin whereas ileostomy is a spout.
2. Colostomy is usually located in LIF whereas ileostomy is in RIF.
3. Colostomy effluent is faeculent whereas in ileostomy effluent is liquid.
CASE 28
5. What are the factors to consider when selecting the stoma site?
1. Easily accessible.
2. At least 5 cm away from the umbilicus.
3. Should not overlie the skin creases and waist line of clothes.
4. Should not overlie past surgical scars.
5. In a place where the stoma bag does not come in contact
with anterior superior iliac spine.
6. What are the complications of colostomy?
Early
1. Bleeding.
2. Necrosis.
3. Suture detachment. Fig 28.5 - Fecal excoriation
Late
1. Stenosis.
2. Retraction.
3. Prolapse.
4. Parastormal Fig 28.4 - Stomal prolapse
herniation.
5. Fistula formation.
6. Skin excoriation.
Chapter: STOMAS
7. Stoma diarrhea.
Fig 28.6 - Mucocutaneous
seperation
77
POP CASTS - UPPER LIMB CASE 29
EXAMINATION
You may be shown a patient who is having a POP cast and asked to comment. Be prepared to
discuss the indications, advantages and complications of POP casts.
1. First identify whether it is a complete POP cast or an incomplete one (Backslab).

2. Then identify whether it is an above elbow POP cast or a below elbow cast.
3. If it is a below elbow POP cast, there are two main possibilities,
a. Colles’ POP cast
i. Ball of the thumb is not incorporated.
ii. Forearm is pronated and the wrist is semiflexed & ulnar deviated.
b. Scaphoid POP cast
i. Ball of the thumb is incorporated.
CASE 29
ii. The hand is held in “Glass holding
position”.
4. If it is an above elbow POP cast, it usually indicates a

fracture in radius or ulnar (forearm is semipronated
and elbow is flexed to 90 degrees).
5. Exclude compartment syndrome
i. Check for active finger movements.
ii. Check for pain in passive finger extension.
iii. Check whether fingers are pink in colour and
warm.
iv. Check capillary refilling time (CRFT). Fig 29.1 - Plaster of paris (POP)
PRESENTATION
Chapter: POP CASTS - UPPER LIMB
Patient is having a below elbow complete POP cast down to midpalm without incorporating
the heads of metacarpals of the fingers or the ball of the thumb. The forearm is held in semiprone
position and the wrist is semiflexed and ulnar deviated. So this is a Colles’ POP.
He can move the fingers actively without any pain and there is no pain to passive extension of
fingers. Tips of the fingers are pink in colour and capillary refilling time is less than two seconds.
78
Fig 29.2 - Above elbow POP cast Fig 29.3 - Colle’s POP cast
CASE 29
Fig 29.4 - Scaphoid POP cast Fig 29.5 - U slab for humeral
shaft fracture

1. What is Colles’ fracture?
It is an extra-articular transverse fracture involving the distal end of the radius within 2.5cm
from the distal articular surface with distal segment is displaced & angulated posterolaterally,
driven proximally and supinated.

It usually occurs in elderly postmenopausal women when falling on out-stretched hand.
2. What is Smith’s fracture?

It is a reversed Colles’ fracture. In contrast to Colles’ fracture, the distal fragment gets
displaced anteriorly.
79
3. How do you reduce Colles’ fracture before applying the POP cast?
Displaced fracture segment is manipulated under anesthesia (GA or Hematoma block). Distal
fragment is disimpacted, palmarflexed and ulnar deviated. Then the forearm is kept
semipronated and a POP cast is applied from below elbow down to midpalm without
incorporating the ball of the thumb or the metacarpal heads of the fingers.
4. Does it comply with the law of fracture immbolization?

No. As a rule when immobilizing fractures the two adjacent joints should be immobilized. But
the Colles’ fracture is an exception in which the proximal joint (elbow) is not immobilized.
5. What are the complications of Colles’ fracture?
Early
1. Vascular damage (Volkman’s ischemic contracture).
2. Nerve damage (Median nerve).
CASE 29
Late
1. Malunion.
2. Carpal Tunnel Syndrome (CTS).
3. Rupture of Extensor Pollicis Longus tendon.
4. Joint stiffness.
5. Reflex sympathetic dystrophy (Sudeck’s atrophy).
6. How do you clinically detect a fracture scaphoid?

Wrist is swollen & painful and the patient has a severe tenderness on applying deep pressure
over the anatomical snuffbox.
7. What are the important concepts in scaphoid fracture imaging?

The fracture line may not be visible in early stages. So the fracture should be re-radiographed
in two weeks and treatment should be commenced if clinically suspected.
8. What is the specific complication of scaphoid fracture?

Avascular necrosis of the proximal fragment.
9. What is Monteggia fracture?

It is a fracture involving distal shaft of the Ulnar associated with dislocation of superior
radioulnar joint.
10. What is Galeazzi fracture?

It is a fracture involving proximal shaft of the Radius associated with dislocation of inferior
radioulnar joint.
80
11. What is POP stands for?

Plaster of Paris which consists of muslin strip impregnated with anhydrous Calcium Sulphate.
On addition of water an exothermic reaction occurs and Calcium Sulphate becomes hydrated
& rapidly sets.
12. What are the complications of POP?

1. Compartment syndrome & vascular compression due to tight cast.
2. Pressure sores.
3. Abrasions on removal.
4. Allergy reaction.
13. What are the advantages of newer cast materials?

1. Lighter.
2. Stronger.
3. Waterproof.
CASE 29
4. More radiolucent.
14. What is “Compartment syndrome”?

It is defined as elevated pressure within a closed fascial compartment which in turn results in
vascular compromise and tissue ischemia.
15. What is the treatment for compartment syndrome?

Immediate fasciotomy to decompress the compartment is the choice. If having a POP cast
bivalve the cast in full length distal to proximal using an oscillatory saw.
Fig 29.6 - Colle’s fracture X-ray
81
POP CASTS - LOWER LIMB CASE 30
EXAMINATION
You may be shown a patient who is having a POP cast and asked to comment. Be prepared to
discuss the indications, advantages and complications of POP casts.
1. First identify whether it is a complete POP cast or an incomplete one (Backslab).

2. Then identify whether it is an above knee POP cast, a POP cylinder or a POP boot.
3. Following features may help you identifying it.
a. Above Knee POP (# Tibia & Fibula)

i. It involves from groin to heads of metatarsals of toes.
ii. Knee is kept slightly flexed (300) and the ankle is held in flexed to 900.
iii. Look for a window in that POP cast which will usually indicate an open fracture
CASE 30
tibia.
b. POP Cylinder (# Patella)

i. It extends from mid-thigh downwards and involves only the knee joint, not the
ankle joint.
ii. It is indicated in fractured patella and patellar ligament injury.
c. POP Boot (# Ankle)

i. Runs from tibial tuberosity to heads of metatarsals.
ii. Ankle is flexed to 900 (But held in planter flexion when Achilis tendon is damaged).
iii. Indicated in malleoli fracture and collateral ligament injury of ankle.
d. Non rotator POP Boot (# Neck of Femur)

This is indicated in conservative management of fracture neck of femur with tibial
skeletal traction.
Chapter: POP CASTS - LOWER LIMB

i. Check active toe movements.
ii. Check pain in passive toe extension.
iii. Check whether toes are pink in colour and warm.
iv. Check capillary refilling time.
82
CASE 30
Fig 30.1 - POP casts of fractures of lower limb
PRESENTATION
` Patient is having an above ankle complete POP cast from groin down to the heads of
metatarsals of toes on left lower limb. Metatarso-phalangeal joints are not incorporated. Knee is
kept slightly flexed and ankle is held in 900 of flexion. There is a window over the anterior aspect of
the left tibia.
He can move the toes actively without any pain and there is no pain to passive extension of
toes. Tips of the toes are pink in colour and capillary refilling time is less than two seconds. So my
probable diagnosis is he has had an open fracture tibia.
Fig 30.2 - POP boot
83

1. What are the three steps in fracture management?
1. Reduction when necessary.
2. Immobilization when necessary.
3. Rehabilitation always.
2. How do you classify open fractures?

Using the Gustilo Classification.
 Gustilo I - Skin defect less than 1cm.
 Gustilo II - Skin defect between 1-10cm.
 Gustilo IIIa -Skin defect > 10cm & Primary approximation is feasible.
 Gustilo IIIb -Skin defect > 10cm & Primary approximation is not feasible.
 Gustilo IIIc -Any open fracture associated with a major vascular injury.
3. How do you manage an open tibial fracture?
CASE 30
1. Wound is kept covered with sterile dressing until the patient is transferred to the OT.
2. Skin wound is explored to see the full extent.
3. Wound is thoroughly washed with large amounts of Normal Saline.
4. Wound is cleaned with Povidone iodine.
5. All the devitalized tissue is excised (thorough debridement).
6. Apply an external fixator or an above knee POP cast with a window.
7. Do not suture the skin of wound and allow it to heal by secondary intention.
8. Later close the wound with skin grafts/ flaps.
4. How do you apply the POP for open tibial fracture?

POP is applied extending from the groin to metatarsal heads without incorporating
metatarsophalangeal joints. Anterior superior iliac spine, Patella and the tip of the second
toe should be in one straight line. To achieve that knee is slightly flexed and the ankle is
flexed to 90 degrees. A window is cut over the wound of the open fracture to allow cleaning
and dressing.
5. What are the advantages of external fixator over above knee POP in the management of an
open tibial fracture?
1. Allow early mobilization.
2. Allow skin grafting.
6. What are the types of patella fractures?

1. Undisplaced linear fracture.
2. Comminuted fracture.
3. Displaced transverse fracture.
84
7. How do you manage each of them?

1. Undisplaced linear fracture - POP cylinder for 6 weeks.
2. Comminuted fracture - Patellectomy.
3. Displaced transverse fracture - Open reduction and internal fixation with tension band
wiring.
8. What is the use of non rotating boot?

It is used in the conservative management of extracapsular fractures of neck of the femur.
9. What are the other methods of managing fracture neck of femur?

Intracapsular fractures
1. Lag screws (Young).
2. Austin Moor Hemiarthroplasty (Elderly).
Extracapsular fractures
3. Dynamic Hip Screws (DHS).
CASE 30
4. Non rotator boot with sliding skeletal traction using a tibial pin.
10. What is the classification used to describe the types of ankle fractures?
Weber’s classification.
85
EXTERNAL FIXATORS CASE 31
EXAMINATION
You may be shown a patient who is having an external fixator in situ and asked to comment.
Be prepared to discuss the indications, advantages and complications of external fixators.
1. Identify the type of external fixator.

2. Comment on the bones involved and the probable fracture site.
3. Look for shortening of the affected limb, areas of bony loss, wounds and skin grafted sites.
4. Look for pin site infection.
5. Offer to assess the joint stiffness.
CASE 31
Fig 31.1 - Types of external fixator systems
PRESENTATION
Chapter: EXTERNAL FIXATORS
This patient is having a unilateral frame type external fixator on the left lower limb probably
due to underlying fracture shaft of the tibia. There is an area of bony loss in the middle of the shaft
of the left tibia but no apparent shortening of the left leg. There is a superficial ulcer with healthy
granulation tissue over the fracture site which is ready for skin grafting. No sign of pin site infection
and he can move the affected lower limb without any pain.
86
Fig 31.2 - Open fracture tibia Fig 31.3 - External fixator for a
compound fracture tibia
Fig 31.4 - Skin grafted wound with EF Fig 31.5 - X-ray view of an external
fixator
CASE 31
1. What are the main two types of external fixators (EF)?
1. Unilateral frame.
2. Cylindrical frame (Llizarov).
2. What is unilateral frame?

Screw threaded half pins are inserted from one side of the bone and they are anchored to a
rigid external bar.
87
3. What is Llizarov frame?

Thin transfixation wires are inserted through the bone and they are attached to fixator rings
which are interconnected by longitudinal metal rods.
4. What are the types of internal fixators (IF) you know of?
1. Plate & Screws.
2. Intramedullary nails (K nails).
3. Compression screw plates.
5. What are the indications for external fixators?

1. For severe open fractures in tibia (Gustilo 3b ,3c).
2. For open fractures with bony loss.
3. For closed fractures with severe soft tissue injury.
4. For compartment syndrome after
fasciotomy.
5. As an adjunct to internal fixation.
6. For unstable pelvic fractures (in damage
control surgery).
7. For limb lengthening & bone transport.
6. What are the advantages of EF over POP?

1. More comfortable.
2. Early Mobilization possible.
3. Less joint stiffness & DVT risk.
4. Allow management of other injuries/
wounds.
Fig 31.6 - Llizravo type external fixator
5. Allow skin grafting.
7. What are the advantages of EF over IF?

1. Can use in open or infected fractures.
CASE 31
2. Less expensive.
3. Need less expertise.
8. What are the complications of EF?

1. Pin site infection.
2. Pin loosening.
3. Non union.
4. Neurovascular damage.
5. Chronic pain.
6. Joint stiffness.
Fig 31.7 - External fixator for a femoral

fracture
88
INTERCOSTAL TUBE CASE 32
EXAMINATION
You may be shown a patient who is having an IC tube inserted and asked to do relevant
examination & comment. In case of a left sided IC tube, inspect the drain and tube from the left
side and approach the patient from the right side (as usual) for the rest of the examination.
1. Inspect the IC tube & drain carefully and comment on its side, volume and colour of the
drainage.
2. Check whether it is functioning (look for the swinging movements of the fluid column. If
not swinging, ask the patient to cough).
3. Palpate around the site of insertion of the IC tube and look for surgical emphysema.
4. Auscultate the lungs and look for lung re-expansion.
CASE 32
Fig 32.1 - Intercostal (IC) tube Fig 32.2 - Underwater sealed chest drain
Chapter: INTERCOSTAL TUBE
PRESENTATION
This patient is having an IC tube inserted to left side of the chest and it is functioning. The drain
contains 150ml of blood stained fluid. There is subcutaneous emphysema. Breath sounds are
reduced over left lower zone.
89
Fig 32.3 - Safe triangle of IC tube Fig 33.4 - IC tube placement

insertion
Fig 32.5 - IC tube connected to the drain Fig 32.6 - IC tube in situ in chest X-ray
CASE 32
1. What are the Indications to insert an IC tube?
1. Drainage of heamothorax,
2. Drainage of Empyema (Pyothorax).
3. Drainage of large pneumothorax.
4. Drainage of large pleural effusion.

5. Flail chest / pulmonary contusion requiring ventilator support.
6. Prophylactically in a patient with chest trauma before transportation.
2. What are the contraindications to insert an IC tube?

1. Infection over the insertion site.
2. Uncontrolled bleeding diathesis.
90
3. What is the site of insertion?

At the safe triangle (Between the anterior axillary line, mid axillary line and the upper border of
the fifth rib).
4. Briefly describe the procedure of insertion.

1. Take informed consent.
2. Obtain the pre-procedure chest X-ray.
3. Mark the site of insertion in safe triangle.
4. Position the patient-supine with elevated head, and ask the patient to put the arm over the
head to open up the ribs.
5. Clean and drape the patient.
6. Anesthetize with 2% Lignocaine down to the parietal pleura.
7. Make a small incision close to upper border of fifth rib.
8. Extend the tract using an artery forcep and enter the pleural cavity puncturing the parietal
pleura.
9. Insert a finger and confirm the entry to the pleural cavity.
10. Insert the IC tube and connect to the underwater sealed chest drain.
11. Suture the tube with non-absorbable sutures.
12. Obtain the post-procedure Chest X-ray.
5. Briefly describe the after care in the ward.

1. Keep the patient propped up.
2. Keep the bottle at a lower level.
3. Look for fluid swing.
4. Check the amount and colour of the fluid or check for bubbling in case of a pneumothorax.
5. Reassess patient’s clinical state (RR, chest expansion, percussion, air entry)
6. Never clamp the tube.
6. What could be the reasons if the fluid level does not swing with respiration?
CASE 32
1. Malposition of the tube.
2. Obstructed tube – Blood clot.
3. Kinked tube – too long tube.
7. When a thorocotomy is indicated?

1. Initial drainage more than 1000ml (in trauma).
2. Drainage is more than 1500ml in first hour.
3. Drainage is more than 200ml for four consecutive hours.
8. When to remove the IC tube?

1. Hydrothorax - When the drainage is minimal (<20ml/24h).
2. Pneumothorax – When the bubbling is stopped even with coughing.
3. Radiological evidence of fully expanded lungs.
91
QUICK-REVIEW FLASHCARDS
1. EXAMINATION OF A LUMP
1. Site, Size, Shape, Skin & Suface

2. Edge.
3. Tissue plane.
4. Consistency.
5. Fluctuation.
6. Transillumination.
7. Reducibility.
8. Pulsatility.
9. Lymphadenopathy.
2. LIPOMA
1. Commonly over the front & the back of the chest.

2. Medium to large.
3. Hemispherical.
4. Scar?
5. Lobulated?
Chapter: QUICK-REVIEW FLASHCARDS
6. Well defined.
7. Not attached to the skin or the underlying muscle.
8. Soft to firm.
9. Pseudofluctuant.
10. May be transilluminant.
92
3. SEBACEOUS CYST
1. Commonly over the scalp and hairy areas, NOT in palms and soles.
2. Medium to large.
3. Hemispherical.
4. Punctum.
5. Infected?
6. Smooth & well defined.
7. Always attached to skin & not to underlying structures.
8. Soft to firm.
9. Fluctuant.
10. Not transilluminant.
4. DERMOID CYST
1. Commonly over the midline, behind the ear, over the lateral eye brow.
2. Small to medium.
3. Hemispherical.
4. Overlying scar (Implanted dermoid).
6. Implanted dermoids are attached to skin but not inclusion dermoids.
7. Not attached to underlying structures.

8. Soft to firm
9. May be fluctuant.
10. Not transilluminant.
93
5. GANGLION
1. Commonly over the dorsum of the hand and foot (near joints).
2. Small.
3. Hemispherical.
4. Scar?
6. Not attached to skin. Horizontal mobility is reduced when the tendon is
contracted.
7. Soft to firm.
8. Fluctuant.
9. Brilliantly transilluminant.
6. ULCER EXAMINATION
1. Site, Size, Margin

2. Discharge?
3. Edge, Floor.
4. Palpate with gloves - Ulcer margin, Edge & Base.
5. Palpate without gloves - Skin temperature, Regional lymphadenopathy,
Peripheral pulses, sensation and JPS.
94
7. MALIGNANT MELANOMA
1. Inspect the pigmented lesion for,

1. Marked variation of the colour within the lesion.
2. Surface ulceration.
3. A surrounding halo of brown pigment.
2. Palpate - irregular margins.
3. Look for inguinal lymphadenopathy (Stage III).
4. “Satellite lesions”
5. Look for hepatomegally (Stage IV)
6. If you are given a chance to talk with the patient, ask for,
a. Rapid increase in size, change in colour or shape recently.
b. Itching or bleeding.
c. Previous Melanoma or family history.
8. THYROID EXAMINATION
Remember 4-2-4 EH (4 from front, 2 from back, 4 from front again)
 F1- moving upwards with deglutition?

 F2 - Put the tongue out while stabilizing the jaw (If small and in midline).
 F3 - Scars & dialated neck veins.
 F4 - Pemberton’s sign (If large).
 B1 - Palpate from behind for consistency and nodularity.
 B2 - Cervical lymphadenopathy.
 F1 - Tracheal deviation.
 F2 - Retrosternal extension .
 F3 - Displaced carotids.
 F4 - Bruit.
 E - Exopthalmous, Lid retraction, Lid lag and Opthalmoplegia.
 H - Sweaty hands, tachycardia, fine tremors.
95
9. THYROIDECTOMY POST-OP
1. Stridor?
2. Horseness of voice?
3. Drainage - When last emptied? Colour? Volume? Functioning?
4. Offer to inspect the scar.
5. Elicit Chvostek’s sign.
10. BREAST CARCINOMA
Consent. Privacy. Expose up to the waist.
 Seated,
 Breast asymmetry, Skin changes and Nipple changes.
 Skin tethering & sub mammary area.
 Nipple discharge?
 Supine & both arms behind the head,

 Normal breast first. Palpate 6 areas.
 Determine the site, size, shape, consistency, surface regularity and the
margins of the lump.
 Skin attachment.
 Seated again,
 Pectoralis Major Attachment.
 Assess both axillae & Supraclavicular lymphadenopathy.
 Dress her up.
96
11. MASTECTOMY POST-OP
1. Examine the scar for early wound related complications.

2. Drain - functioning? Volume? Colour? When last emptied?
3. Examine the contralateral breast and both axillae.
Any lumps or lymphnodes?
4. Nerve injuries?
a. Intercostobrachial nerve.
b. Long Thoracic nerve.
c. Thoracodorsal nerve.
12. POST MASTECTOMY
1. Scar for late wound related complications. Heypertrophic scar? Keloid?

2. Radiotherapy marks?
3. Examine both breasts and axillae. Any palpable lump or lymphnode?
4. Lymphoedma of the ipsilateral upper limb?
5. Nerve injuries?
a. Intercostobrachial nerve.
b. Long Thoracic.
c. Thoracodorsal nerve.
6. Metastatic disease?
a. Palpable scalp lump.

b. Jaundice.
c. Enlarged virchows node.
d. Spinal tenderness.
e. Plueral effusion.
f. Enlarged liver.
97
13. GYNAECOMASTIA
1. Expose.
2. Unilateral or bilateral?
3. Changes of the overlying skin or nipple?
4. Any palpable lump? Axillary nodes?
5. Look for a probable cause (CLCD signs, testicular cause, drug history).
14. INGUINAL HERNIA
1. Past surgical scars?

2. See the shape of the lump; Globular? Sausage shaped?
3. Ask the patient to cough & look for expansile cough impulse.
4. ONLY IF the hernia is still cannot be seen, ask the patient where the lump and
ask him to stand up at this point & look for a bulge appearing on the groin area
on coughing.
5. Once visible, demonstrate the palpable expansile cough impulse.
6. Differentiate whether it is direct or indirect hernia (Not in a recurrent hernia).
7. Examine the external genitalia to exclude phimosis and coexisting scrotal.
8. If the patient was supine throughout your examination, ask him to stand up
before you finish and look for, coexisting small hernia on the other groin&
coexisting varicocele.
98
15. FEMORAL HERNIA
1. Consent and expose adequately.

2. Surgical scars in the groin.
3. Shape and size of the lump .
4. Ask to cough (usually do not have cough impulse).
5. Ask to reduce the hernia fully (often irreducible).
6. Locate the anatomical location of the hernia neck.
(always lies below and lateral to the public tubercle)
7. Examine the contralateral groin.
16. PARAUMBILICAL HERNIA
1. Expose the abdomen fully.

2. Any lump around the umbilicus? “Smiling Umbilicus”?
3. Overlying scar?
4. Inspect the crest carefully. Foul smelling discharge? Ompholith?
5. Ask to cough to visualize non-apparant hernia and to elicit expansile cough
impulse.
6. Ask the patient to reduce the lump herself.
7. ONLY IF the lump is fully reducible; determine the size of the neck of the hernial
sac.
a. Insert a finger through the defect.
b. Ask the patient to lift the head against resistance & look at her abdomen
or raise straightened both lower limbs together.
c. Feel the hardened edge of the defect and assess the size of it.
8. Exclude coexisting herniae) and diverication of recti.
9. If the initial command is to do an abdominal examination, continue with the
rest of the examination.
99
17. PAROTID TUMOUR
1. Lump as usual (Site, Size, Shape, Surface, Consistency, Margins).

2. Skin attachment.
3. Muscle attachment (Masseter) - clench the teeth.
4. Open the mouth,
a. Duct opening - Inflammation or pus?
b. Bulging of the tonsil?
5. Facial nerve affected?
6. Cervical Lymphadenopathy?
7. Offer to palpate the parotid duct for a stone.
18. SUBMANDIBULAR TUMOUR
1. Examine the lump as usual.

2. Skin attachment.
3. Muscle attachment (Myelohyoid)
4. Look for the opening of the Submandibular duct - Inflammation or pus?

5. Cervical Lymphadenopathy.
6. Bimanually palpable?
7. Along the submandibular duct for a stone.
10
0
19. VERICOSE VEINS
1. Scrotal lump or inguinoscrotal lump?

2. Testis separately palpable?
3. Is there a distinct gap between testis and the lump?
4. Cross fluctuation.
5. Transillumination.
6. Contralatearl hemiscrotum.
7. Coexisting inguinal hernia and vericocele?
20. SCROTAL TUMOURS
Erect
1. Identify territory
2. Saphena varix?
3. Blowouts?
4. Tap test
Supine
1. Complications?
2. Lift and empty.
3. Apply Tourniquet.
Erect
1. SF +/- Perforator incompetence?
2. Perthe’s test (Offer)
10
1
21. CARPAL TUNNEL SYNDROME
1. Spread out the hands.

2. Thenar muscles wasted?
3. Scar of a carpal tunnel decompression?
4. Examine functions of the muscles supplied by the median nerve.
a. Opponens Pollicis.
b. Abductor Pollicis Brevis (Pen touch test).
a. Sensory loss over the palmar aspect of the lateral three and half fingers.
b. Sensation over the thenar eminence is preserved.
6. Special Signs,
a. Tinel’s Test.
b. Phalen’s .
7. Probable aetiology?
a. Obesity.
b. Hypothyrodism.
c. Rhematoid arthritis.
d. Diabetes mellitus
8. Offer assessment of QOL.
a. Nocturnal /early morning worsening.
b. Effects on occupation or ADL.
22. RADIAL NERVE PALSY

1. Spread out the arms and look for a wrist drop.

2. Examine the muscles supplied by the radial nerve.
a. Long extensors in forearm - Ask the patient to extend the wrist & fingers.
b. Triceps - Extend the elbow.
c. Brachioradialis - Flex the elbow in the semipronated position.
d. Supinator - Supinate the forearm with extended elbow.
a. Sensory loss over the 1st interdigital space on the dorsum of the hand.
10
2
23. ULNAR NERVE PALSY
1. Spread out the hands.

2. Try to spot diagnose the “Ulnar claw hand”.
3. Look for wasting of hypothenar eminence& dorsal guttering .
4. Palpate the 1st finger web where the wasting is obvious.
5. Examine the functions of the muscles supplied by the ulnar nerve.
a. Palmar interossei .
b. Dosrsal interossei.
c. Adductor Pollicis (Froment’s sign)
a. High lesions - sensory loss over the both palmar & dorsal aspects.
b. Low lesions - sensory loss only over the palmar aspect.
a. Depigemented anesthetic patches? Ulnar nerve thickening?
b. Scars on the forearm (trauma)?
8. Offer to assess the patient’s QOL.
24. TRIGGER FINGER Chapter: QUICK-REVIEW FLASHCARDS
1. Spread out the hands with palmar surface facing upwards.

2. Any degree of flexion in ring (and middle) fingers?
3. Ask the patient to flex and extend the fingers.
4. Note triggering & Extension will be painful.
5. Feel for a small tender nodule along the tendon (over the metacarpal heads).
10
3
25. BAKER’S CYST
1. Site - in the midline & below the joint line.

2. Size, Shape, Surface.
3. Not attached to skin or underlying muscle.
4. Soft.
5. Not Pulsatile.
6. Can be emptied to knee joint.
7. Fluctuant.
8. Transilluminant.
9. Osteoarthritis features?
26. AMPUTATED STUMP
01. Amputation stump.

a. Anatomical level of amputation.
b. Skin wound healed?
c. Exclude fixed flexion deformity (in below knee)
d. Skin freely movable?
02. Scars of previous vascular bypass surgeries?
03. Pulses of affected limb.
04. Contralatreal limb.
a. Toes (Ischemic Ulcers, Gangreneous toes, Toe amputations).
b. Skin temperature.
c. CRFT.
d. Examine all peripheral pulses & comment on pulse volume.

e. Perform Buerger’s test.
f. Auscultate for femoral bruit.
05. Ncotin stains?
06. Cormorbidites associated with PVD.
a. Carotid bruit.
b. Deviated heaving apex.
c. Pulsatile epigastric lump (AAA).
10
4
27. CELLULITIS
1. Area affected? Up to which level?

2. Cardinal signs of local inflammation.
e. Erythema - Area of redness? Distinct line of demarcation?
f. Warmth - Compare temperature of two limbs.
g. Tenderness - Firm pressure.
h. Oedema - Ankle or pedal pitting oedema? Non-pitting?
3. Inguinal lymphadenopathy?
4. Systemic signs of inflammation.
c. Fever - Febrile or QHT.
d. Tachycardia
5. Look for local complications

c. Blisters
d. Necrosis of skin
6. Predisposing cause - chornic lymphoedema, immunodeficiency.
28. STOMAS
1. Identify the site and morphology.

2. Is functioning? (effluent or gas?).
3. Comment on the Effluent (Consistency, Colour, Amount).
4. Complication (Offer removal of the bag).
5. Possible surgery? (Look at the abdominal scar/Perineal scar).
10
5
29. UPPER LIMB POP CASTS
1. Complete POP or a Backslab?

2. Above elbow POP cast or a below elbow cast?
3. If it is a below elbow POP, Colles’ POP cast? Or Scaphoid POP cast?
4. If it is an above elbow POP cast - fracture in radius or Ulnar.
5. Exclude compartment syndrome.
30. LOWER LIMB POP CASTS
1. Complete POP or a Backslab?

2. Above knee POP cast? POP cylinder? POP boot?
3. Or a non rotator POP boot?
31. EXTERNAL FIXATORS
1. Type of EF.
2. Bones involved.
3. Fracture site.
4. Shortening of the affected limb? Bony loss? Skin grafts?
5. Pin site infection?
6. Joint stiffness? Chapter: QUICK-REVIEW FLASHCARDS
32. INTERCOSTAL TUBE

1. Inspect the IC tube & drain.
2. Comment on its side, volume and colour of the drainage.
3. Swinging fluid column? If not ask to cough.
4. Surgical emphysema?
5. Auscultate the lungs.
10
6

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SURGERY CASES MADE EASY

SURGERY CASES MADE EASY

Dr. Rajith Eranga

Download the android app at googleplay - Short Cases in Surgery

Nevertheless nothing is a substitute for clinical practice. Acquisition of correct

Dr. Rajith Eranga Rathnayake

CASE 28 - Stomas …………………………………………………………………………………………….. 74-76

EXAMINATION OF A LUMP CASE 01

3. How do you elicit fluctuations?

4. If it is fluctuant, what does that mean?

5. If it is trasilluminant, what does that mean?

1. Site - Commonly over the front and back of the chest.

QUESTION AND ANSWERS

2. What is Dercum’s disease?

3. Can they undergo malignant transformation?

4. What is the treatment for lipoma?

SEBACEOUS CYST CASE 03

Fig 3.1 - Uncomplicated sebaceous cyst

QUESTION AND ANSWERS

2. What is “Cock’s peculiar tumour”?

3. Can they undergo malignant transformation?

4. What are the complications that can occur?

5. What is the treatment for a sebaceous cyst?

DERMOID CYST CASE 04

Chapter: DERMOID CYST

2. What are the two types of dermoid cysts?

3. Where do inclusion dermoids occur?

4. Where do implanted dermoids occur?

5. How would you differentiate it from a sebaceous cyst?

6. How would you treat?

QUESTION AND ANSWERS

2. What are the differential diagnosis?

3. Where do ganglions occur?

4. How would you treat?

5. How would you create a bloodless field?

6. What are the complications of the surgery?

Fig 5.3 - Removal of a ganglion

Around 5% to 20% (Fairly high).

ULCER EXAMINATION CASE 06

Palpation (With a gloved hand)

superficial and the base contains subcutaneous

which is irregular in shape, with a maximum diameter

QUESTION AND ANSWERS

2. Explain the terms margin, floor, edge and base of an ulcer.

4. What are the common causes for leg ulceration?

5. What are the causes for neuropathic ulcers?

6. How do you differentiate a neuropathic ulcer from an ischemic ulcer?

3. Normal surrounding skin.

7. What are the risk factors in diabetics for foot ulceration?

MALIGNANT MELANOMA CASE 07

II. Predisposing factors

Fig 7.1 - Malignant Melanoma Fig 7.1 - Melanoma (Closer view)

2. What are the other rarer types?

3. Are they always pigmented?

4. What are the predisposing factors?

5. What are the differential diagnosis?

6. What are the features favoring a malignancy?

7. How do you stage malignant melanoma?

8. What are the treatment options?

9. What are the poor prognostic factors?

Fig 7.1 - Satellite lesions

THYROID EXAMINATION CASE 08

Then go to back of the patient,

Come back to front of the patient and look for,