FAB Applied

from Combined Handbook

Langer’s lines (AKA tension/cleavage lines)

follow orientation of collagen fibres in the dermis → incisions made parallel to these lines heal more rapidly + neater scars

Venepuncture + venous cannulation

venepuncture → use median cubital vein

venous cannulation → use cephalic vein (fairly large + constant position)

Popeye muscle

ruptured biceps tendon (proximal)

usually the long head → retracted muscle bunches up in arm, leads to bulge → short head intact so functional loss is minimal → seen in 40 - 60 yr old patients with previous shoulder problems (secondary to chronic wear + tear of tendon)

younger patients may rupture biceps tendon after a fall

distal biceps ruptures

often at the insertion into the radial tuberosity → followed by reduced strength in forearm supination + elbow flexion (requires surgery)

Humeral shaft fractures

can lead to complications like radial nerve injury (recall its location in spiral groove) → so may result in wrist drop due to compromised wrist and finger extension

90% of radial nerve palsy (associated with these fractures) recover spontaneously

supracondylar fractures

common childhood fracture

fracture of distal humerus (proximal to epicondyles)

associated with FOOSH

serious complications involve rupture/compression of brachial artery + median nerve injury (these lie anteriorly)

if pulseless hand (due to brachial artery compression) → this is an emergency

elbow dislocation

most common fracture in children → FOOSH

second most common dislocation (after shoulder) in adults

posterior dislocation is most common form of elbow dislocation

ulnar nerve runs posterior to medial epicondyle → so risk of ulnar nerve entrapment (if posterior dislocation)

brachial artery + median nerve may also be injured (but less common)

carpal tunnel syndrome

median nerve entrapment (via compression) in carpal tunnel

presents with pain and paresthesia in distribution of median nerve

thenar eminence muscle weakness

management → night splints to prevent wrist flexion, steroid injections + (extreme) surgery to remove flexor retinaculum

rupture of extensor pollicis longus tendon

fractures of distal radius can cause this (due to association with dorsal Lister’s tubercle)

unable to extend interphalangeal joint of the thumb

scaphoid fracture

commonly caused by FOOSH

scaphoid is palpable on floor of anatomical snuffbox → so presents with snuffbox tenderness (treat with applying a plaster cast + X-ray in 4 weeks)

undisplaced fracture may not be visible at first so follow up X-ray will reveal a fracture as it is healing or no fracture (so cast can then be removed)

if fracture left untreated, can lead to avascular necrosis of proximal fragment

tennis elbow

lateral epicondylitis caused by repetitive wrist extension + gripping activities → leading to pain over the lateral elbow (common extensor origin) → leads to degenerative tear

resisted wrist extension aggravates the pain

rest/steroid injections

golfer’s elbow

medial epicondylitis caused by repetitive wrist flexion + gripping activities → resulting in pain over the medial elbow (common flexor origin)

rest/physical therapy

erb’s palsy

injury to brachial plexus upper trunk (C5, C6) → from excessive downward traction on upper limb (e.g during difficult delivery/motorcycle accident)

shoulder abduction + elbow flexion + supination affected → leads to waiter’s tip

klumpke’s palsy

injury to lower trunk of the brachial plexus (C8, T1) → often due to hyperabduction of shoulder (typically during childbirth)

weakness/wasting in the hand's intrinsic muscles leading to a claw hand deformity

median nerve injury

distal lesions → carpal tunnel syndrome

proximal lesions → inability to flex index + middle fingers + distal thumb phalanx → weakness/wasting of thenar eminence → inability to oppose + abduct thumb → impairment of precision grip → ulnar deviation at wrist

ulnar nerve injury

distal ulnar lesion → claw hand (extension of metacarpophalangeal joints + flexion of interphalangeal joints of ring and little fingers → due to paralysis of interossei and lumbrical muscles

proximal ulnar lesion → weakness in wrist flexion and adduction, impaired grip strength, sensory loss in the little finger + half of the ring finger → greater functional disability as flexor digitorum profundus branches lost but less deformity (ulnar paradox)

radial nerve injury

wrist drop (inability to extend wrist + fingers + thumb)

weakness of power grip (this depends on synergistic contraction of both flexors and extensors)

wrist drop and loss of active elbow extension suggest more proximal injury (axilla?)

Saturday night palsy shown →

breast cancer

most common cancer for women

axillary palpation crucial to understand lymphatic drainage of breast → for surgery

sentinel node = first lymph node/group of nodes that drain the cancer → biopsy here determines stage of cancer

axillary clearance = surgical removal of axillary nodes (but may result in long thoracic nerve injury → serratus anterior paralysis + winged scapula) → can also lead to lymphoedema (especially when combined with radiotherapy)

remember “APICAL” pneumonic for lymph nodes

clavicular fractures

common in young active males/elderly individuals

direct trauma to shoulder

force transmitted from acromioclavicular → sternoclavicular

acromioclavicular dislocation

direct trauma

little disability (yay!)

palpable + visible swelling over joint

glenohumeral dislocation

most common dislocated large joint

anteroinferior dislocations → most common

head of humerus lies anteriorly under coracoid process → recurrent dislocation is common here

damage to axillary nerve possible → deltoid paralysis → loss of sensation in arm’s “regimental badge” area

rotator cuff rupture

difficulty initiating abduction

patient may compensate by leaning over to the affected side → allows gravity to assist abduction before deltoid kicks in

scapular fractures + scapulothoracic disorders

rare → result of high energy, blunt force trauma

glenohumeral joint function impaired → posterior shoulder pain → rotator cuff bursitis/tendinitis

degenerative changes in the spine

vertical forces thru the spine → with rotational flexion/extension movements in upright posture → produce arthritic degenerative changes in facet joints + intervertebral diswcs

more likely to occur in lumbar spine

abnormal lateral curve = scoliosis

prolapsed intervertebral disc

if anulus fibrosus degenerates + ruptures → nucleus pulposus protrudes through it and puts pressure on cord/nerve roots

most common in lower lumbar region

developmental spine defects

spina bifida → incomplete fusion of posterior elements of vertebra (common in lumbar region)

meninges/spinal cord/roots may herniate thru the defect → several neurological deficits

pulled elbow

subluxation of the radius head out of the anular ligament

occurs when the hand of a child is suddenly pulled with force

subluxation = partial dislocation, where two bones that form a joint are still partially in contact but are not in their normal alignment

Colles’ fracture

non-articular fracture of distal radius → from FOOSH

common in patients over 50 yrs old

distal fragment is driven posteriorly + superiorly → dinner-fork deformity

reduction is necessary

Dupuytren’s contracture

(contracture = permanent tightening/shortening)

contracture of the palmar fascia → fixed deformities in the hand + finger joints

surgical treatment → removing strands of contracted fascia without damaging the interwoven digital nerves

tenosynovitis

inflammation of flexor tendons + synovial sheaths (from chronic repetitive use/trauma/arthritis)

symptoms → pain, swelling, difficulty moving the inflamed joints

trigger finger → finger remains in flexed position

metacarpal fracture

boxer’s fracture → resultant transverse/short oblique fracture at neck of 5th metacarpal

Guyon’s canal

fibro-osseous tunnel between pisiform + hook of hamate

site of ulnar nerve compression

(but less common than median nerve carpal tunnel compression)

Allen’s test

assess collateral circulation to hand

most people should have dual blood supply via anastomoses between deep and superficial arches

puncture + cannulation of radial artery can lead to injury + ischaemia in subjects without dual blood supply

internal jugular vein surface marking

runs from lobe of ear to → sternoclavicular joint

access from triangular space between sternal + clavicular heads of sternocleidomastoid/ deep to posterolateral border of SCM

important for insertion of central venous lines → closely related to lung apices so care must be taken to avoid puncturing pleura (take a chest radiograph after procedure)

external jugular vein surface marking

runs from lobe of ear to → midpoint of clavicle

important for insertion of central venous lines → closely related to lung apices so care must be taken to avoid puncturing pleura (take a chest radiograph after procedure)

torticollis/wryneck

spinal accessory nerve irritation (as lies next to lymph nodes so these can irritate spinal nerve if inflamed)

SCM + trapezius excessive contraction → head pulled down to affected shoulder, face rotated in opposite direction

in babies → SCM may tear during childbirth → can cause this

lymph node biopsy can also cause this

complete loss of function? → droopy shoulder (trapezius paralysis + unopposed SCM action)

acute tonsillitis

jugulodigsatric lymph nodes (in triangles of neck) → enlarged

wounds in posterior triangle

can damage brachial plexus on its way to upper limb

thoracic outlet/inlet syndrome

compression of neurovascular structures in thoracic inlet/outlet (just above 1st rib but behind clavicle)

affected structures → brachial plexus lower trunk, subclavian vein, subclavian artery

symptoms → ischaemia, swelling, pain, paraesthesia of hand, wasting of muscles supplied by C8 + T1 roots

cervical rib from C7 can be a possible cause

tracheostomy (in children)

tracheostomy = surgical procedure creating an opening (stoma) in the front of the neck to access the windpipe (trachea)

left brachiocephalic vein crosses to the right behind the manubrium

may lie above suprasternal notch in children

at risk during a tracheostomy

referred phrenic nerve pain

inflammation of subphrenic organs (e.g gallbladder) → can involve peritoneum → cause referred pain to C3, C4, C5 dermatomes → shoulder tip

pneumothorax

entry of air into pleural cavity (either from penetrating wound of parietal pleura/rupture of pulmonary lesion into the pleural cavity) → leads to lung collapse

with a chest wound, blood may enter pleural cavity → haemothorax

inhaled foreign bodies (lungs)

right main bronchus is wider + shorter + more vertical

so inhaled foreign bodies more likely to pass down right bronchial tree

supine position → likely to pass to the apical lower lobe segment (1st lobe to arise posteriorly) → risk of pneumonia

standing/sitting position → likely to pass to one of the basal bronchi

carcinoma of bronchus

primary lung cancer (AKA bronchogenic carcinoma) → most arise in mucosa of large bronchi + produce a persistent/productive cough or haemoptysis (coughing up blood)

lung tumours metastasise early to bronchopulmonary lymph nodes → to other thoracic nodes

common metastases → brain, bones, other parts of lung, liver, adrenal glands

other cancers often commonly metastasise to the lungs

pericardiocentesis

fluid aspiration (removal) from the pericardium → needle inserted immediately left of xiphisternum + directed upwards to tip of left scapula → allows aspiration without lung puncture

relief of cardiac tamponade (emergency situation, no time for ultrasound)

heart surface markings

vertical line of valves (superior to inferior) → “PAMT”

right: 3 - 6 costal cartilages

left: 2nd costal cartilage → 5th intercostal space

auscultation points:

Pulmonary valve → 2nd and 3rd left intercostal spaces

Aortic valve → 2nd right intercostal space radiating up to the neck

Mitral valve → apex, 5th intercostal space, mid-clavicular line

Tricuspid valve → lower left sternal edge, may also be heard on the right

coronary artery disease

stenosis/occlusion of coronary arteries (from atherosclerosis due to lipid deposition)

anastomoses between coronary arteries not very effective → myocardial infarction is a common consequence

treatment → angioplasty (radiologically controlled balloon dilatation) / coronary bypass grafting (using great saphenous vein/internal thoracic artery/radial artery)

conduction defects (heart)

often cause by ischaemia (coronary artery disease)

damage to heart’s conducting system

disturbances of cardiac muscle contraction

occlusion of nodal branches of right coronary artery → may result in heart block (to different degrees)

pacemaker may need to be implanted → to maintain appropriate ventricular contraction rate

congenital heart defects

septal defects → differential pressures between 2 sides of heart → blood flow from left to right → no cyanosis → surgical repair

persistent ductus arteriosus → blood passes from left to right → initially no cyanosis but right heart is strained → right heart pressure may rise until shunt reversal so cyanosis

tetralogy of Fallot → pulmonary outflow stenosis, interventricular septal defect, right ventricular hypertrophy, over-riding aorta

right heart pressure rises → blood shunted from right to left → cyanosis

oesophageal varices

portal hypertension → dilatation of lower oesophageal submucous veins

can rupture → severe haemorrhage

treatment: endoscopic band ligation (stops acute bleeding + prevents recurrent bleeding)

chylothorax

presence of lymphatic fluid in pleural space

secondary to leakage from thoracic duct

malignancy (e.g lymphoma) or trauma can cause this

referred pain (from splanchnic nerves)

pain from foregut structures → referred to epigastric region (general viscerals with greater splanchnic nerve)

pain from midgut structures → referred to umbilical region (general viscerals with lesser splanchnic nerve)

pain from hindgut structures → referred to suprapubic region (general viscerals with least splanchnic nerve)

intercostal nerve block

injection of local anaesthetic directed towards the costal groove in upper part of intercostal space → to directly reach intercostal nerve

(different concept to triangle of safety)

diaphragmatic paralysis

injury to phrenic nerve

bilateral damage → can lead to rapid ventilatory failure

trachea-oesophageal fistula

congenital abnormality

connection between trachea and oesophagus

other congenital issues → blind-ending oesophagus/atresia

abdominal incisions

longitudinal incisions → exploratory operations (along midline or paramedian)

muscle-splitting incisions → McBurney incision for appendicectomy

subcostal incisions → access to liver, biliary tract + spleen

suprapubic (Pfannenstiel) incisions → gynaecological/obstetric operations

acute appendicitis referred pain

(midgut)

referred to periumbilical region → as inflammation profresses, parietal peritoneum is involved so pain is localised to right iliac fossa

inguinal hernia

inguinal canal → site of weakness

direct hernia → protrudes thru weakend conjoint tendon, medial to inferior epigastric artery

indirect hernia → passes thru deep ring, initially lateral to inferior epigastric artery but then down to canal → can reach scrotum

femoral hernia

thru femoral canal (below + lateral to pubic tubercle)

more frequent in women

prone to strangulation (requires emergency surgery)

exomphalos (congenital abdominal)

defect in abdominal wall

herniation of intra-abdominal contents into base of umbilical cord

omphalocele can form (can range from an umbilical hernia to a large mass containing most of the visceral organs)

ectopia vesicae AKA exstrophy (congenital abdominal)

defect of anterior wall of the bladder + anterior abdominal wall → results in exposed, everted posterior bladder wall

umbilical hernia

common in neonates, particularly premature births

usually herniation of small bowel → neck of hernia is wide so strangulation is rare

close spontaneously within first few years

peritanitis (abdomen)

bacterial contamination during surgery/gut rupture post-infection or inflammation

allows gas + gastric contents + bile + faecal matter to enter peritoneal cavity

pain in overlying dermatome + rigidity in anterior abdominal muscles

ascites (abdomen)

excess fluid in peritoneal cavity

caused by secondary carcinoma, cirrhosis or other things

gastro-oesophageal reflux disease (GORD)

reflux of gastric contents into oesophagus → heartburn + acid regurgitation

incompetent lower oesophageal sphincter can be a cause

associated with hiatus hernia → portion of stomach prolapses thru oesophageal opening in diaphragm

peptic ulceration (abdomen)

posterior gastric ulcers can erode into the splenic artery → causes torrential haemorrhage

gastric contents can enter lesser sac

pyloric stenosis can be congenital or acquired → congenital most common in boys in first few weeks (presents with projectile vomiting) → acquired cases from peptic ulceration

carcinoma of the stomach

poor prognosis

because impossible to ensure complete removal of involve lymphatics due to extensive drainage

appendicitis

inflammation

→ leads to thrombosis of appendicular artery → then necrosis → then perforation

pain referred to T10 dermatome (around umbilicus) → as inflammation progresses, will irritate parietal peritoneum → somatic innervation so pain felt in right iliac fossa

appendix on a mesentery → mobile so may be difficult to diagnose

differential diagnoses include Meckel’s diverticulum (which lies on antimesenteric border of ileum) or ectopic pregnancy (where the fetus embeds NOT in the uterus, often in the ampulla of fallopian tubes → erodes away that area)

Meckel’s diverticulum

embryological remnant of vitellointestinal duct (connects gut tube to yolk sac)

typically 3 - 5cm long → found within 60-100cm of ileocaecal valve

can become inflammed

differential diagnosis for appendicitis

situs inversus (congenital abdominal)

all organs are transposed to opposite side

appendix is therefore in the left iliac fossa → clinical signs/symptoms may be confusing

congenital malrotation of the gut → normal rotation of bowel does not occur fully → appendix may be in an abnormal position

colicky pain

comes and goes in waves

hernia language (reducible - irreducible - strangulated - obstructed)

• Reducible – can be pushed back into the abdominal cavity with gentle manual pressure.​

• Irreducible – cannot be returned to the abdominal cavity AKA incarcerated​

• Strangulated – a hernia that is so tightly incarcerated outside the abdominal wall that the intestinal or omental blood supply is cut off putting it at risk of ischaemia, followed by necrosis and possible perforation leading to peritonitis.​

• Obstructed – occurs when a part of the intestine (usually small bowel) becomes twisted within the hernia, causing an intestinal obstruction. The hernia can become increasingly painful. Vomiting may also result.​

Note : can be either strangulated, obstructed or both

indirect vs direct inguinal hernias

indirect → passes thru inguinal canal and both rings

direct → does not enter deep ring (but may go thru superficial ring) → thru Hasselbach’s triangle

deep inguinal ring surface marking

midpoint of inguinal ligament

½ between ASIS and pubic tubercle

femoral artery surface marking

midinguinal point

½ between ASIS and pubic symphysis

Hasselbach’s triangle

where direct inguinal hernia protrudes thru

lateral border: inferior epigastric vessels

medial border: rectus abdominis (lateral side)

inferior border: inguinal ligament

why are femoral hernias more prone to strangulation?

narrow femoral canal

rigidity of femoral ring

valvulae conniventes AKA Kerckring folds

circular folds of small intestine

more common in jejunum

tend to be more central than large bowel

hernia management

immediate: decompression + IV fluids + pain relief

if hernia is irreducible → surgery needed

surgical: laparoscopic with a mesh (to strengthen abdominal wall)

abdominal hernia symptoms

abdominal pain

obstruction → constipation → vomiting

bowel hernia complications

spermatic cord layers are continuous with abdominal wall muscles

patent processus vaginalis

failure to obliterate processus vaginalis

→ congenital indirect inguinal hernia

abdominal aorta levels

T12 → coeliac trunk

L1 → superior mesenteric artery

L3 → inferior mesenteric artery

abdominal pain dermatomes (a chunky one, just a heads up)

take a break

lock in mf

imaging for appendicitis

ultrasound → preferable for younger patients (lack of ionising radiation)

CT → highly sensitive + specific (used with an IV contrast)

appendicitis management

RISK? → it could rupture blood vessels → toxic digestive stuff and enzymes spill out into peritoneal cavity

immediate → resuscitation + antibiotics + pain relief

non-surgical → if patient is stable, antibiotics + CT/US-guided drainage of peri-appendiceal abscesses administered

surgical → if patient becomes peritonitic (abdomen becomes swollen and red) → appendectomy (open or laparoscopically)

colorectal carcinoma (differentials)

3rd most common cancer

differential diagnoses → diverticulitis/diverticular mass or stricture → gynaecological mass (uterus or ovary) invading or causing compression of bowel

Diverticular disease vs Diverticulitis

• Diverticulosis = multiple pouches (diverticula) in the colon​

• Diverticular disease = when they are symptomatic – bloating, pain, constipation etc​

• Diverticulitis = clinically inflamed

low fibre diet in West a possible cause?

typically in sigmoid colon

diverticular disease complications

rectal bleeding

diverticular bleeding is the most common cause of acute lower gastrointestinal bleeding

acute inflammation

obstruction

abscess formation

perforation

fistula formation (rare)

sigmoid volvulus

has a relatively narrow mesentery → so quite mobile → prone to twisting

sigmoid volvulus → coffee bean sign

on a radiograph →

Popeye’s muscle radiograph

watershed area (hint: think vascular)

regions of the body, that receive dual blood supply → from the most distal branches of two large arteries

e.g splenic flexure of the large intestine

upper limb pulses

motor median nerve testing

Volkmann’s Ischaemic Contracture

• supracondylar fracture

• brachial artery damage → ischaemia → contracture (permanent shortening + stiffening) of forearm long flexors and extensors

• deformed hand → muscles replaced with fibrous tissue → wrist flexed

• extension of metacarpophalangeal joints + flexion of interphalangeal joints

supracondylar fracture management

varus vs valgus

the example in diagram is a complication of supracondylar fracture

what is an autonomous sensory zone?

part of dermatome that has no overlap from adjacent nerves