MRCS Part A_ Essential Revision Notes_ Book 1

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Nigel W GummersonChapter 10 Paediatric surgeryStuart J O’Toole, Juliette Murray, Susan Picton and David CrabbeChapter 11 Plastic Surgery
Stuart W WaterstonList of AbbreviationsBibliographyIndex
Page 4 and 5: © 2012 PASTEST LTDEgerton CourtPar
Page 6 and 7: Tristan E McMillanChapter 2 Surgica
Page 8 and 9: Claire Ritchie ChalmersChapter 5 Pr
Page 10 and 11: George Hondag Tse
Page 12 and 13: Nigel W GummersonChapter 7 Evidence
Page 16 and 17: AcknowledgementsI would like to tha
Page 18 and 19: Picture PermissionsThe following fi
Page 20 and 21: copyright material. However, if any
Page 22 and 23: General Infirmary, Leeds Orthopaedi
Page 24 and 25: Consultant Clinical Oncologist, Ken
Page 26 and 27: A Tension pneumothoraxB Aortic rupt
Page 28 and 29: Emergency medicine 9Oncology 8Surgi
Page 30 and 31: The MRCS exam and syllabus is being
Page 32 and 33: 3.1 Local anaesthesia3.2 Regional a
Page 34 and 35: In 2011 NCEPOD published Knowing th
Page 36 and 37: history of problems under anaesthet
Page 38 and 39: cardiovascular system • All patie
Page 40 and 41: orthopaedics, spinal cord compressi
Page 42 and 43: General concerns of the surgical pa
Page 44 and 45: Documentation often starts with cle
Page 46 and 47: SECTION 2Preoperative management of
Page 48 and 49: Indications for perioperative corti
Page 50 and 51: Heparinucopolysaccharide purified f
Page 52 and 53: FBCorrection of anaemia is essentia
Page 54 and 55: Assessing myocardial ischaemiaECG:
Page 56 and 57: HypertensionCauses of hypertensionE
Page 58 and 59: Patients should have the pacemaker
Page 60 and 61: arbon monoxide reduces oxygen deliv
Page 62 and 63: advance - can predispose to lactic
Page 64 and 65:
Preoperative management of epilepsy
Page 66 and 67:
Preoperative management of cholesta
Page 68 and 69:
C-spine: 15% of RA patients have at
Page 70 and 71:
20-27Malnourished
Page 72 and 73:
30-35Overweight
Page 74 and 75:
Morbidly obese50-60 Super-obese }60
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Catabolic states40-45 1.5-2.5
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Increasingly catabolic stateDue to
Page 80 and 81:
Aspirationncreased gastric volume a
Page 82 and 83:
Technical problemsurgery takes long
Page 84 and 85:
Metabolic complicationsyperglycaemi
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Upper GI surgeryOesophageal and gas
Page 88 and 89:
Dosage of local anaesthetic agents:
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3.2 Regional anaesthesiaField block
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The sciatic nerve block can be perf
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nguinal ligament T12High block may
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cause seizures) • All patients ha
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Inhalational anaesthetics may also
Page 100 and 101:
Contraindications of depolarising m
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No IV access required
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Dose titratableUpper oesophageal to
Page 106 and 107:
DisadvantagesRespiration maintained
Page 108 and 109:
Loss of airway controlIrritantMay c
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Apnoea commonPatient monitoring dur
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cardiovascular collapse • Managem
Page 114 and 115:
Treatment of malignant hyperpyrexia
Page 116 and 117:
Risk factors for aspiration• Rais
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Muscle injuriesPressure-area injury
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CHAPTER 2Surgical Technique and Tec
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SECTION 1Surgical wounds1.1 Skin an
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Depth of woundSuperficial woundsSup
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1.4 Pathophysiology of wound healin
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Neutrophils1-2 days
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Fibroblasts2-4 days
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Endothelial cellsFigure 2.3 Wound h
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and growth factors that activate fi
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LiverThe liver has remarkable regen
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Nutritional factorsroteins are esse
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perpendicular to the skin, avoids a
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SECTION 2Surgical technique2.1 Prin
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Scalpel blades should be changed us
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Abdominal incisionsFigure 2.6 Commo
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reat vessels (especially ascending
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Thoracic closure is covered in the
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Bipolarower power unit (50 W)urrent
Page 154 and 155:
Choose your suture with regard to:S
Page 156 and 157:
Polyglycolic acidynthetic homopolym
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Staples for skin closureThe teeth o
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infectionExamples of surgical drain
Page 162 and 163:
packingxamples: Kaltostat, SorbsanF
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Uses of biopsyBiopsy is used specif
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Advantages of core biopsyimple, eas
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Advantages of endoscopic biopsyvoid
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Advantages and usesssessment of ope
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Figure 2.10 Incisions for benign le
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upuytren’s contracture surgeryngr
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Hollow organs: GI and genitourinary
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General factorsoor tissue perfusion
Page 180 and 181:
each consultant’s preference, and
Page 182 and 183:
• Fundoplication• Gastric bypas
Page 184 and 185:
photographic images or video. A sec
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Physiological changes include:or ch
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variety of operations using multich
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Disadvantagesecurity of access site
Page 192 and 193:
3.8 Managing the surgical listThere
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SECTION 4Diagnostic and interventio
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Occasionally patients can have true
Page 198 and 199:
levels on the screen as different l
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ExpenseClaustrophobiaContraindicate
Page 202 and 203:
CHAPTER 3Postoperative Management a
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• Endoplasmic reticulum• Golgi
Page 206 and 207:
Transport across membranesGeneratio
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Energy from lipidsThe basic compone
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channels open and sodium ions flood
Page 212 and 213:
muscle therefore travel in both dir
Page 214 and 215:
Figure 3.6 The structure of the myo
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Thrombocytes (platelets)The haemato
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ncrease in allergic states (eg hayf
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• Ileal resection• Crohn’s di
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aemoglobinopathyInappropriate incre
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Inflammationurnsrauma (eg postopera
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LymphocytosisLymphocytosis is used
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latelet count of >1000 × 10 9 /lli
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kidney, liver and penis (priapism)I
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Nitric oxideTissueplasminogenactiva
Page 234 and 235:
It is often expressed as the intern
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Acquired bleeding disordersThromboc
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giving advice about minimising othe
Page 240 and 241:
Clots usually start in the deep vei
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No risk factors other than age with
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Scores ≥3Moderate probability of
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Complications of pulmonary embolism
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INR of 0.8-1.2 Normal coagulationIN
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Blood compatibility testingDonor an
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significant haemorrhage) • Prophy
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Early complications:Immunological c
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administration of donated blood (wh
Page 258 and 259:
Chronic Group characterised by an u
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Lymphoma is a cancer of the reticul
Page 262 and 263:
Multiple myeloma is a neoplastic pr
Page 264 and 265:
1.3 Fluid balance and fluid replace
Page 266 and 267:
ATPase pump which was discussed ear
Page 268 and 269:
Figure 3.14 The movement of fluids
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In general, fluid maintenance needs
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• Small risk of anaphylaxis• Li
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In a nutshell ...The products of me
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Respiratory acidosisRespiratory aci
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normal (ie if there was no respirat
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Metabolism = anabolism + catabolism
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Energy supplied by different food t
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This is achieved by:utaneous vasoco
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SECTION 2Critical care2.1 The struc
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Admission to ITUor elective, emerge
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Medical staffTU director: should ha
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Improvement in survivalThis is poss
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Systemic vascular resistanceSystemi
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Regulation of stroke volumeStroke v
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Arterial BP sensorsMean arterial pr
Page 300 and 301:
ChemoreceptorsChemoreceptors found
Page 302 and 303:
Natriuretic peptidesBlood volume ch
Page 304 and 305:
wide QRS (>0.12) occurs when depola
Page 306 and 307:
Catheterisation and hourly urine me
Page 308 and 309:
Fluid challenge using CVP monitorin
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Figure 3.22 Pressure waves as cathe
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SternumThis consists of three parts
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Costal cartilages-7 articulate dire
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Innermost intercostalsross more tha
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Lung rootsulmonary artery lies supe
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The mechanics of breathingThe funct
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The work of breathingThe work of br
Page 324 and 325:
Respiratory rateThe amount of air b
Page 326 and 327:
ChemoreceptorsChemoreceptors detect
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Binds four molecules of O 2 per mol
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Increased carboxyhaemoglobinIncreas
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CvO 2 is measured by substituting m
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urrent management depends on what i
Page 336 and 337:
Chest traumaHypovolaemia
Page 338 and 339:
Burns
Page 340 and 341:
Fat embolism
Page 342 and 343:
DIC
Page 344 and 345:
haemoglobin, and combined this beco
Page 346 and 347:
Early (see ‘Hazards’ above): da
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Mini-tracheostomyA small tracheosto
Page 350 and 351:
Continuous positive airway pressure
Page 352 and 353:
ExtubationThe patient must:e able t
Page 354 and 355:
fibres terminate in lamina 2 and la
Page 356 and 357:
Spinal mechanismsOpioids act direct
Page 358 and 359:
Referred painThis is when pain is p
Page 360 and 361:
Methods of assessing acute painSubj
Page 362 and 363:
reventing the development of pain i
Page 364 and 365:
Aetiology of chronic painNeural sys
Page 366 and 367:
Assessment of chronic painistory of
Page 368 and 369:
Pain in malignancyPain from maligna
Page 370 and 371:
OralSublingual
Page 372 and 373:
IntravenousInhalational
Page 374 and 375:
Transdermal SpinalParacetamolildly
Page 376 and 377:
Management of analgesiaRemember to
Page 378 and 379:
Disadvantages of PCAechnical error
Page 380 and 381:
Routes for sedationolus dosing: pre
Page 382 and 383:
Indications for peripheral venous a
Page 384 and 385:
Complications of peripheral venous
Page 386 and 387:
introduced into the vein:eedle intr
Page 388 and 389:
Ultrasonography for identification
Page 390 and 391:
Infuse and pumpIn a nutshell ...The
Page 392 and 393:
Blood pressureim for MAP >60 mmHg o
Page 394 and 395:
SECTION 3Postoperative complication
Page 396 and 397:
Postoperative pyrexiaPyrexia is a c
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Prophylaxis for wound infectionsden
Page 400 and 401:
eriprosthetic fracturealunionon-uni
Page 402 and 403:
In a nutshell ...Respiratory proble
Page 404 and 405:
cascade).Factors influencing renal
Page 406 and 407:
There are two types of nephrons wit
Page 408 and 409:
Measurement of GFRThere are a numbe
Page 410 and 411:
Oliguria is defined as a urine outp
Page 412 and 413:
Measurement Prerenal RenalUrinary s
Page 414 and 415:
Indications for renal replacement t
Page 416 and 417:
SIRS is a disseminated inflammatory
Page 418 and 419:
3.5 Sepsis and septic shockDefiniti
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Management of sepsis-induced shock,
Page 422 and 423:
Neurological failureCS <6 in the ab
Page 424 and 425:
CHAPTER 4Infection and Inflammation
Page 426 and 427:
SECTION 1Inflammatory processesIn a
Page 428 and 429:
Due to three different responseshe
Page 430 and 431:
Mediators of the inflammatory respo
Page 432 and 433:
Kinin systemLysosomal enzymes
Page 434 and 435:
Fibrinolytic system
Page 436 and 437:
Complement systemThe complement sys
Page 438 and 439:
Coagulation and fibrinolysisThe clo
Page 440 and 441:
Lysosomal enzymesLeucocytes degranu
Page 442 and 443:
pyrogen (see Section 2, The immune
Page 444 and 445:
Infiltration of tissue with mononuc
Page 446 and 447:
OrganismMycobacterium tuberculosis
Page 448 and 449:
Treatment of TBultiple drug therapy
Page 450 and 451:
Symptoms of syphilisThese are divid
Page 452 and 453:
Treatment of syphilisntravenous (IV
Page 454 and 455:
Demographics of leprosyHO data show
Page 456 and 457:
Classification of leprosyaucibacill
Page 458 and 459:
Asbestosissbestosis results from pr
Page 460 and 461:
Immune reactions and granulomasGran
Page 462 and 463:
FibrinogenComponent of the clotting
Page 464 and 465:
(eg rofecoxib, celecoxib, valdecoxi
Page 466 and 467:
Commensal organismsNormal commensal
Page 468 and 469:
roliferation of T lymphocytesntibod
Page 470 and 471:
Figure 4.5 Activation of CD8 + T ly
Page 472 and 473:
proliferations: uncontrolled produc
Page 474 and 475:
Monozygotic twins of patients are a
Page 476 and 477:
Group of autosomal or X-linked rece
Page 478 and 479:
are some reports that the risk of i
Page 480 and 481:
Endotoxinsipopolysaccharide molecul
Page 482 and 483:
Gram-negative bacteriaStain pink/re
Page 484 and 485:
eath of the host cell by lysis to r
Page 486 and 487:
Figure 4.12 The virionaccine includ
Page 488 and 489:
Human immunodeficiency viruses (HIV
Page 490 and 491:
ring-enhancing lesions on CT/MRI
Page 492 and 493:
immunodeficiency. Progressive deple
Page 494 and 495:
(systemic; often fatal in immunosup
Page 496 and 497:
lagellate parasitesesponsible for A
Page 498 and 499:
Examination for sepsisPossible foci
Page 500 and 501:
Acute phase proteinsCRP is commonly
Page 502 and 503:
Clotting screenThere may also be a
Page 504 and 505:
MicrobiologySee section 4.6, Specim
Page 506 and 507:
Organism related to wound typelean
Page 508 and 509:
4.3 Abscess managementIn a nutshell
Page 510 and 511:
ontaminated needlePathology of necr
Page 512 and 513:
If considering endocarditis, three
Page 514 and 515:
Growth in both bottlestaphylococci:
Page 516 and 517:
SECTION 5Prevention and control of
Page 518 and 519:
wound sepsis • Therefore shave im
Page 520 and 521:
SterilisationSterilisation methods
Page 522 and 523:
Dry heat sterilisationot-air ovenso
Page 524 and 525:
Irradiation sterilisationse of gamm
Page 526 and 527:
Hydrogen peroxidenly weak bacterici
Page 528 and 529:
Patient preparationSkin disinfectio
Page 530 and 531:
Dirty woundsross pus, perforated vi
Page 532 and 533:
tudents (medical and nursing)aborat
Page 534 and 535:
SECTION 6Antibiotic control of infe
Page 536 and 537:
Bacteriostatic antibioticsnclude te
Page 538 and 539:
ttachment of mRNA to ribosome (eg b
Page 540 and 541:
Alteration of cell membrane functio
Page 542 and 543:
Aminoglycosidesxamples: gentamicin,
Page 544 and 545:
Sulfonamidesxamples: co-trimoxazole
Page 546 and 547:
Quinolonesxamples: ciprofloxacin, n
Page 548 and 549:
CellulitisMost likely organisms are
Page 550 and 551:
Complicated UTIUTI involving urosep
Page 552 and 553:
Diarrhoea after food poisoningMay n
Page 554 and 555:
infection and antibiotic resistance
Page 556 and 557:
Systemic MRSA infectionsMay require
Page 558 and 559:
5.2 Radiotherapy5.3 Chemotherapy5.4
Page 560 and 561:
Information from death certificates
Page 562 and 563:
reast cancer: much less common in t
Page 564 and 565:
Environmental exposuresbestos: the
Page 566 and 567:
Screeningnitial increase in inciden
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differentiation:Labile cells: const
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tem cell: a cell from an embryo, fe
Page 572 and 573:
HypertrophyIncrease in cell size bu
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Chemical carcinogensChemical carcin
Page 576 and 577:
are damaged or missing).Examples of
Page 578 and 579:
Familial cancers - congenital mutat
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• Surgical prophylaxis (eg mastec
Page 582 and 583:
Homeostasis: eg loss of the uterine
Page 584 and 585:
Inhibitors of angiogenesisNaturally
Page 586 and 587:
in the filtering lymph nodes draini
Page 588 and 589:
components and the abnormal cells a
Page 590 and 591:
e simple and cheap/cost-effective
Page 592 and 593:
SECTION 4Clinical and pathological
Page 594 and 595:
in guiding treatment.4.3 Tumour mar
Page 596 and 597:
SECTION 5Principles of cancer treat
Page 598 and 599:
Sentinel nodes can then be identifi
Page 600 and 601:
Administration of radiotherapyocall
Page 602 and 603:
Alkylating agentsAntimetabolitesAnt
Page 604 and 605:
ChlorambucilCLLNon-Hodgkin’s lymp
Page 606 and 607:
Bladder cancerOvary cancerWilms’
Page 608 and 609:
Acute complicationsausea and vomiti
Page 610 and 611:
ncreasing use in primary treatment
Page 612 and 613:
Dry mouthAppetite loss, nausea, vom
Page 614 and 615:
Colic
Page 616 and 617:
Muscle spasmNerve pain-compression
Page 618 and 619:
Nerve irritationLiver pain (capsula
Page 620 and 621:
Dyspnoea
Page 622 and 623:
CoughGIAntacid, metoclopramide, chl
Page 624 and 625:
AnorexiaLactulose, co-danthrusate
Page 626 and 627:
Nausea and vomitingSkin/mucous memb
Page 628 and 629:
Dry mouthNeurological
Page 630 and 631:
HypoxiaConfusion/sedationConfusion/
Page 632 and 633:
Key features of using the LCPNon-es
Page 634 and 635:
Management of spinal cord compressi
Page 636 and 637:
leep disturbance and loss of diurna
Page 638 and 639:
Planning and follow-upPlanning for
Page 640 and 641:
CHAPTER 6TraumaPart 1: Head, Abdome
Page 642 and 643:
SECTION 1Overview of trauma1.1 Hist
Page 644 and 645:
servicesrimary care: general practi
Page 646 and 647:
LaryngoscopeRapid communication lin
Page 648 and 649:
Fully stocked anaesthetictrolleyDes
Page 650 and 651:
OxygenBlood sampling equipment1.4 T
Page 652 and 653:
SECTION 2Injury and shock2.1 The bi
Page 654 and 655:
HypothermiaHypothermia may be accid
Page 656 and 657:
Hypovolaemic shockPathophysiology o
Page 658 and 659:
sign of ongoing blood loss.Fluid re
Page 660 and 661:
Expect the following values for uri
Page 662 and 663:
Contraindicationsulmonary oedemausp
Page 664 and 665:
SECTION 3Resuscitation: the primary
Page 666 and 667:
Recognition of a compromised airway
Page 668 and 669:
Chest wall movementAdminister suppl
Page 670 and 671:
Surgical cricothyroidotomyThis tech
Page 672 and 673:
Spontaneous breathing may resume wh
Page 674 and 675:
Establish IV accessEstablish IV acc
Page 676 and 677:
HistoryIt is important to take a me
Page 678 and 679:
ThoraxAbdomenPelvisExtremitiesSpine
Page 680 and 681:
DocumentationDocument ABCDE status,
Page 682 and 683:
Moderate Coma lasting >24 hours No
Page 684 and 685:
Obstruction of CSF flow (rarely an
Page 686 and 687:
Burr holesA burr hole is a small ho
Page 688 and 689:
Best eye-opening response 4 Open sp
Page 690 and 691:
blood supply and nerve supply of th
Page 692 and 693:
This consists of:asal bones (right
Page 694 and 695:
The inferior alveolar nerve provide
Page 696 and 697:
Figure 6.17 Le Fort injuryZygomatic
Page 698 and 699:
Types of traumalunt chest trauma as
Page 700 and 701:
Figure 6.18 Tension pneumothoraxrai
Page 702 and 703:
If there are any signs of penetrati
Page 704 and 705:
Procedure box: PericardiocentesisIn
Page 706 and 707:
Confirmation of oesophageal trauma
Page 708 and 709:
Contraindications to DPLbsolute - d
Page 710 and 711:
Management includes simultaneous as
Page 712 and 713:
4Grade5A completely shattered kidne
Page 714 and 715:
bladder. If this is unsuccessful, p
Page 716 and 717:
If there is blood at the urethral m
Page 718 and 719:
RadiotherapyStructure of peripheral
Page 720 and 721:
In a nutshell ...The major trauma p
Page 722 and 723:
Figure 6.21 The peripheral and cent
Page 724 and 725:
system can manifest as priapism and
Page 726 and 727:
These usually result in wedge fract
Page 728 and 729:
aematomaseudo-aneurysm occurs when
Page 730 and 731:
SECTION 5Special cases in trauma5.1
Page 732 and 733:
Pathophysiology of burnsBurn injuri
Page 734 and 735:
Primary surveyAirway + C-spineEnsur
Page 736 and 737:
DeathCO poisoning must be excluded
Page 738 and 739:
Fluid resuscitationFluid resuscitat
Page 740 and 741:
Assessment of the burn woundIn addi
Page 742 and 743:
Management of special areasFaceSign
Page 744 and 745:
Figure 6.24 Causes of death (A) and
Page 746 and 747:
BreathingNote these differences whe
Page 748 and 749:
n children aged <6 years: intraosse
Page 750 and 751:
ExposureRemember that the relativel
Page 752 and 753:
Abdominal trauma in childrenecompre
Page 754 and 755:
lunt/penetrating uterine traumalace
Page 756 and 757:
The diagnosis of brainstem deathDef
Page 758 and 759:
neither revascularization nor amput
Page 760 and 761:
Nigel W GummersonPathophysiology of
Page 762 and 763:
SECTION 1Pathophysiology of fractur
Page 764 and 765:
Reparative phaseFibroblasts, recrui
Page 766 and 767:
Factors that delay bone healingSyst
Page 768 and 769:
A fall on the outstretched hand the
Page 770 and 771:
SECTION 3Principles of management o
Page 772 and 773:
Complications of internal fixationn
Page 774 and 775:
1-3 Limb ischaemia (double score if
Page 776 and 777:
Complications of fracturesComplicat
Page 778 and 779:
Fractures and fat embolism syndrome
Page 780 and 781:
Radial nerveRadial nerve (most comm
Page 782 and 783:
Distal radial fractureLumbar-sacral
Page 784 and 785:
Sciatic nervePopliteal artery and c
Page 786 and 787:
Open tibial fracturePriorities in m
Page 788 and 789:
Features of cellulitishere is infec
Page 790 and 791:
Risk factors for cellulitisymphoede
Page 792 and 793:
Features of gas gangrenehock and se
Page 794 and 795:
Risk factors for gas gangrenefter a
Page 796 and 797:
Features of tetanusSymptoms begin 3
Page 798 and 799:
Risk factors for tetanusounds that
Page 800 and 801:
Treatment of tetanususcle relaxants
Page 802 and 803:
increase the risk of AVN. Early and
Page 804 and 805:
Features of AVNainhondrolysis and c
Page 806 and 807:
Fractures and myositis ossificansMy
Page 808 and 809:
Treatment of myositis ossificansiff
Page 810 and 811:
Treatment of CRPS type IUsually thi
Page 812 and 813:
Mechanics of anterior shoulder disl
Page 814 and 815:
Radiographs of anterior shoulder di
Page 816 and 817:
Proximal humerus fracturesThese fra
Page 818 and 819:
GroupIISurgical neck fracture with
Page 820 and 821:
GroupIV
Page 822 and 823:
Group Fracture dislocationsVIGroups
Page 824 and 825:
Fractures around the elbowAdult sup
Page 826 and 827:
Complications of fractures around t
Page 828 and 829:
Complications of forearm shaft frac
Page 830 and 831:
Scaphoid fractureThe most commonly
Page 832 and 833:
Intracapsular fracture of the proxi
Page 834 and 835:
Management of intracapsular fractur
Page 836 and 837:
Postoperative complications of intr
Page 838 and 839:
Complications of proximal femur fra
Page 840 and 841:
Complications associated with tibia
Page 842 and 843:
The pelvic ring comprises the sacru
Page 844 and 845:
Investigating pelvic fracturesA pla
Page 846 and 847:
Acetabular fracturesAcetabular frac
Page 848 and 849:
Classification of spinal injuriesSp
Page 850 and 851:
Treatment of cervical spine injurie
Page 852 and 853:
Type Iistraction injury of growth p
Page 854 and 855:
Complete, greenstick and torus frac
Page 856 and 857:
SECTION 7Soft-tissue injuries and d
Page 858 and 859:
pathology at presentation or pathol
Page 860 and 861:
of patella (patella tendon rupture)
Page 862 and 863:
Forced dorsiflexionWhen the foot is
Page 864 and 865:
SECTION 8Compartment syndromeIn a n
Page 866 and 867:
Management of compartment syndromeI
Page 868 and 869:
Nerys ForesterSurgical research and
Page 870 and 871:
There are advantages and disadvanta
Page 872 and 873:
ControlsA control group is a group
Page 874 and 875:
Asking an answerable questionClinic
Page 876 and 877:
All studies suffer from loss to fol
Page 878 and 879:
Applying evidence to clinical pract
Page 880 and 881:
se and storage of human tissue (if
Page 882 and 883:
Paper contentThe paper should inclu
Page 884 and 885:
ReferencesCross-reference statement
Page 886 and 887:
Experimental studies are the RCTs.S
Page 888 and 889:
Observational studyAccurate and pre
Page 890 and 891:
CrosssectionalExample is Framingham
Page 892 and 893:
RandomisedcontrolledtrialInterventi
Page 894 and 895:
Measures of spreadMeasure of spread
Page 896 and 897:
The normal distributionIf you study
Page 898 and 899:
Types of biasbserver bias: may occu
Page 900 and 901:
Survival analysisSurvival analysis
Page 902 and 903:
5.2 Who can obtain consent?5.3 Who
Page 904 and 905:
interests of their patients.Non-mal
Page 906 and 907:
SECTION 2Clinical governance and ri
Page 908 and 909:
improvements in safety.A patient sa
Page 910 and 911:
This has replaced the Health Care C
Page 912 and 913:
rediction scores (eg ASA)emographic
Page 914 and 915:
Personal knowledgeThis may be subdi
Page 916 and 917:
Referral involves transferring some
Page 918 and 919:
even where there has probably been
Page 920 and 921:
egible handwritingclearly defined p
Page 922 and 923:
complication after surgery, and the
Page 924 and 925:
Permanent incapacityThis is a compl
Page 926 and 927:
atients whose conditions may be rel
Page 928 and 929:
ny financial interest must be openl
Page 930 and 931:
CHAPTER 9Orthopaedic SurgeryNigel W
Page 932 and 933:
Disorders of the hand10.1 Clinical
Page 934 and 935:
SECTION 1Bone, muscle and joint str
Page 936 and 937:
Parathyroid hormoneine regulator of
Page 938 and 939:
Oestrogens and androgensAnabolic ho
Page 940 and 941:
Bone cellsThe osteoblasts and osteo
Page 942 and 943:
load transfer from the articular su
Page 944 and 945:
Synovial jointsSynovial joints are
Page 946 and 947:
muscle occurs. This is called the s
Page 948 and 949:
Type II fibresew mitochondriaich in
Page 950 and 951:
SECTION 2Joint pathologyDifferentia
Page 952 and 953:
Pain in OA is due to:nflamed and th
Page 954 and 955:
flares, 5% per cent show relentless
Page 956 and 957:
chronic renal failurePathological f
Page 958 and 959:
SECTION 3Bone pathology3.1 Osteopor
Page 960 and 961:
skeletal loading.
Page 962 and 963:
supplements should be given first t
Page 964 and 965:
capital epiphysisMain radiological
Page 966 and 967:
aged >90. Most commonly seen in Bri
Page 968 and 969:
SECTION 4The hip and thigh4.1 Anato
Page 970 and 971:
Nerve supply and movement of the hi
Page 972 and 973:
ExtensionGluteus maximus and hamstr
Page 974 and 975:
AbductionPiriformis, obturators, qu
Page 976 and 977:
Medial rotation4.2 Anatomy of the g
Page 978 and 979:
nferior glutealedial femoral circum
Page 980 and 981:
Move:Thomas’ test for fixed flexi
Page 982 and 983:
Signs of osteoarthritis of the hipT
Page 984 and 985:
Rheumatoid arthritis of the hipRheu
Page 986 and 987:
Compartments of the thighFemoral tr
Page 988 and 989:
SECTION 5The knee5.1 Anatomy of the
Page 990 and 991:
Posterior cruciateligamentPosterior
Page 992 and 993:
• Femur• Posterior ligament of
Page 994 and 995:
Clinical examinationStanding, trous
Page 996 and 997:
Joint injectionsSecond-line treatme
Page 998 and 999:
SECTION 6Disorders of the foot and
Page 1000 and 1001:
Classic peroneal nerve injuryoss of
Page 1002 and 1003:
Classic tibial nerve injuryoss of a
Page 1004 and 1005:
The arches of the footMedial longit
Page 1006 and 1007:
Toenails: onchogryphosis, subungal
Page 1008 and 1009:
Pes cavus (claw foot)This is charac
Page 1010 and 1011:
Surgical optionsild to moderate def
Page 1012 and 1013:
SECTION 7The shoulder and humerus7.
Page 1014 and 1015:
the glenoid cavity to the anatomica
Page 1016 and 1017:
Infraspinatuseinforces the posterio
Page 1018 and 1019:
Anterior (deltopectoral) approachAp
Page 1020 and 1021:
translation: fixing humeral head in
Page 1022:
7.5 Anatomy of the upper armIn a nu
Page 1025 and 1026:
ensory braches: posterior cutaneous
Page 1027 and 1028:
ronation is performed by pronator t
Page 1029 and 1030:
8.3 Clinical assessment of the elbo
Page 1031 and 1032:
8.4 Elbow disordersTennis elbowTenn
Page 1033 and 1034:
SECTION 9The forearm and wrist9.1 A
Page 1036 and 1037:
9.2 Bones of the forearmAnatomy of
Page 1038:
Compartment 6 (ulnar)Extensor carpi
Page 1041 and 1042:
Zone5Area of carpal tunnelContains
Page 1043 and 1044:
Approachevelop plane between brachi
Page 1045 and 1046:
Approachevelop plane between extens
Page 1047 and 1048:
SECTION 10Disorders of the hand10.1
Page 1049 and 1050:
Remember to assess any sensory defi
Page 1051 and 1052:
ParonychiaApical infectionsPulp inf
Page 1053 and 1054:
Conservative management of the rheu
Page 1055 and 1056:
•Little
Page 1057 and 1058:
Index• Thumb (least commonly)Cond
Page 1059 and 1060:
skin (unlike sebaceous cysts) nor t
Page 1061 and 1062:
supracondylar fracturesExamination
Page 1063 and 1064:
Palpationalpate the nerve where it
Page 1065 and 1066:
Powerbductor pollicis brevis: this
Page 1067 and 1068:
Treatment of carpal tunnel syndrome
Page 1069 and 1070:
InspectionAsk patient to roll up th
Page 1071 and 1072:
Sensationlnar side of the palm over
Page 1073 and 1074:
InspectionAsk the patient to roll u
Page 1075 and 1076:
Sensationesions distal to the elbow
Page 1077 and 1078:
canals, causing thrombosis of blood
Page 1079 and 1080:
Spread of infectionOsteomyelitis ma
Page 1081 and 1082:
Common organisms. aureus is most co
Page 1083 and 1084:
Clinical features of septic arthrit
Page 1085 and 1086:
pollution is dilution’ashout may
Page 1087 and 1088:
In adultsecondary OAoint stiffnessi
Page 1089 and 1090:
Aetiology of acute osteomyelitisCau
Page 1091 and 1092:
Other causesalmonella spp. in patie
Page 1093 and 1094:
Investigating acute osteomyelitisad
Page 1095 and 1096:
Classification of chronic osteomyel
Page 1097 and 1098:
Management of chronic osteomyelitis
Page 1099 and 1100:
Microbiology of skeletal TBCausativ
Page 1101 and 1102:
Spinal TBSpinal TB typically involv
Page 1103 and 1104:
Management of skeletal TBAnti-TB ch
Page 1105 and 1106:
Microbiology of spinal infectionsCo
Page 1107 and 1108:
Management of spinal infectionsTrea
Page 1109 and 1110:
Pathogenesis of prosthetic joint in
Page 1111 and 1112:
Management of prosthetic joint infe
Page 1113 and 1114:
Swellingleeding into tumours may pr
Page 1115 and 1116:
pen incisional biopsypen excisional
Page 1117 and 1118:
• Second smaller peak in incidenc
Page 1119 and 1120:
definitive investigationresentation
Page 1121 and 1122:
maging: lytic lesion in epiphysis.
Page 1123 and 1124:
Fibrous dysplasiapidemiology: major
Page 1125 and 1126:
Imaging of skeletal metastasesPlain
Page 1127 and 1128:
SECTION 13Spine13.1 Development of
Page 1129 and 1130:
Figure 9.18 Formation of the neural
Page 1131 and 1132:
Role of the spineStructuralaintenan
Page 1133 and 1134:
attachment points for the muscles a
Page 1135 and 1136:
Cervical vertebraell have a hole in
Page 1137 and 1138:
Sacrumransmits the weight of the bo
Page 1139 and 1140:
Intervertebral discsThese are the j
Page 1141 and 1142:
Figure 9.24 Some of the extrinsic m
Page 1143:
Posterior longitudinal ligamentimil
Page 1146 and 1147:
Suboccipital triangleThis is a tria
Page 1148 and 1149:
Forces on the spineWhen comparing r
Page 1150 and 1151:
Spinal cord coveringsThe spinal cor
Page 1152 and 1153:
Composition of the spinal cordThe s
Page 1154 and 1155:
Spinal nerve roots and spinal nerve
Page 1156 and 1157:
Spinal nerve leaves the foramen↓D
Page 1158 and 1159:
Figure 9.28 The interrelationships
Page 1160 and 1161:
Sympathetic nervous systemIf you ca
Page 1162 and 1163:
Spinal nerve↓
Page 1164 and 1165:
Postganglionic fibres↓Grey ramus
Page 1166 and 1167:
Radicular arteriesThe radicular art
Page 1168 and 1169:
HistoryWhen taking a history for so
Page 1170 and 1171:
Summary of neurological examination
Page 1172 and 1173:
Elderly; on steroidsSpinal fracture
Page 1174 and 1175:
Night sweatsTumour, infection
Page 1176 and 1177:
Previous cancer historyMetastatic t
Page 1178 and 1179:
Recent bacterial infectionInfection
Page 1180 and 1181:
Saddle anaesthesiaCauda equina synd
Page 1182 and 1183:
Generalised ill health
Page 1184 and 1185:
Examination Bruising/haematomaTumou
Page 1186 and 1187:
Neurological loss with level
Page 1188 and 1189:
Severe pain on palpation
Page 1190 and 1191:
Lax anal sphincterPerianal/perineal
Page 1192 and 1193:
LymphadenopathyTumour
Page 1194 and 1195:
Abnormal chest examinationTumourInv
Page 1196 and 1197:
Disc prolapseProlapse of the interv
Page 1198 and 1199:
spastic paraparesis, and hyper-refl
Page 1200 and 1201:
Inflammation of ligamentous inserti
Page 1202 and 1203:
Replacement by fibrous tissue↓
Page 1204 and 1205:
Wall testIf a healthy person stands
Page 1206 and 1207:
Extraskeletal manifestationsritis (
Page 1208 and 1209:
Spinal infectionsSee also Section 1
Page 1210 and 1211:
Causes of back painAge 0-10Scoliosi
Page 1212 and 1213:
Management of nerve root painOnce s
Page 1214 and 1215:
Cauda equina syndromeIf the narrowi
Page 1216 and 1217:
Microdiscectomyim: to remove hernia
Page 1218 and 1219:
Intradiscal extracanalicular approa
Page 1220 and 1221:
Posterolateral or intertransverse f
Page 1222 and 1223:
Transforaminal lumbar interbody fus
Page 1224 and 1225:
Pathology of neck painAcute cervica
Page 1226 and 1227:
Management of cervical spondylosisO
Page 1228 and 1229:
ortality (5% for transoral odontoid
Page 1230 and 1231:
urgical treatment reserved for larg
Page 1232 and 1233:
Figure 9.33 Cobb’s method for mea
Page 1234 and 1235:
SpondylolisthesisSpondylolisthesis
Page 1236 and 1237:
The most common site is the lumbar
Page 1238 and 1239:
Spinal column reconstructionThe aim
Page 1240 and 1241:
DecompressionDecompression is a gen
Page 1242 and 1243:
spinal surgery). Upper limb procedu
Page 1244 and 1245:
InfectionImplanting prosthetic mate
Page 1246 and 1247:
Skeletal dysplasiaOsteogenesis impe
Page 1248 and 1249:
septic arthritis in cases where sus
Page 1250 and 1251:
Flex the knees.Place hands so that
Page 1252 and 1253:
Perthes’ diseasePerthes’ diseas
Page 1254 and 1255:
Acute-on-chronic presentation is co
Page 1256 and 1257:
15.2 Problems with the foot in chil
Page 1258 and 1259:
varus/valgus malalignment.Pathologi
Page 1260 and 1261:
Discoid lateral meniscusIncidence i
Page 1262 and 1263:
dominant form is often associated w
Page 1264 and 1265:
CHAPTER 10Paediatric surgeryStuart
Page 1266 and 1267:
SECTION 1Children as surgical patie
Page 1268 and 1269:
Abdominal organs in childrenThere a
Page 1270 and 1271:
Maintenance fluid and electrolyte r
Page 1272 and 1273:
Recognising shock in children is mo
Page 1274 and 1275:
9 months Crawls, babbles, eg ‘mam
Page 1276 and 1277:
Give initial bolus of 20 ml/kg flui
Page 1278 and 1279:
Embryology of the GI tractBy the th
Page 1280 and 1281:
The pharyngeal gutThis extends from
Page 1282 and 1283:
The spleen is a foregut derivative
Page 1284 and 1285:
reatment consists of closure of the
Page 1286 and 1287:
Low and intermediate anorectal anom
Page 1288 and 1289:
bowel lumen and its detergent effec
Page 1290 and 1291:
Embryology of the diaphragmFigure 1
Page 1292 and 1293:
week 6.Figure 10.10 Development of
Page 1294 and 1295:
Formation of the definitive kidneyT
Page 1296 and 1297:
Testesf the germ cells carry an XY
Page 1298 and 1299:
Descent of the testesThe testis is
Page 1300 and 1301:
Genital ducts in the malen the pres
Page 1302 and 1303:
External genitalia in the malehe ge
Page 1304 and 1305:
ay be solitary, multiple or bilater
Page 1306 and 1307:
Associationsystic change in other o
Page 1308 and 1309:
Medullary sponge kidneyystic dilata
Page 1310 and 1311:
Management of PUJ obstructionThe in
Page 1312 and 1313:
Surgery is performed between the ag
Page 1314 and 1315:
Figure 10.15 Ectopic positions for
Page 1316 and 1317:
ilms tumourntersex disorders (gonad
Page 1318 and 1319:
3.7 Urinary tract infections in chi
Page 1320 and 1321:
Idiopathic scrotal oedemaHenoch-Sch
Page 1322 and 1323:
SECTION 4Paediatric oncologyIn a nu
Page 1324 and 1325:
are patent and if blood flow is nor
Page 1326 and 1327:
of tumour volume • Given in fract
Page 1328 and 1329:
Rhabdomyosarcoma
Page 1330 and 1331:
Germ cell tumoursLiver tumours (hep
Page 1332 and 1333:
Treatment of liver tumoursurther ch
Page 1334 and 1335:
Investigating rhabdomyosarcomanitia
Page 1336 and 1337:
Investigating neuroblastomat presen
Page 1338 and 1339:
Treatment of Wilms tumourhemotherap
Page 1340 and 1341:
Staging of germ cell tumoursarious
Page 1342 and 1343:
SECTION 5Paediatric general surgery
Page 1344 and 1345:
can be identified by the prepyloric
Page 1346 and 1347:
ust preserve the umbilicus to avoid
Page 1348 and 1349:
engorged (with rectal bleeding) and
Page 1350 and 1351:
Investigating intussusceptionbdomin
Page 1352 and 1353:
Outcome of treatmentRecurrence rate
Page 1354 and 1355:
CHAPTER 11Plastic SurgeryStuart W W
Page 1356 and 1357:
giving ‘granular’ appearance 4.
Page 1358 and 1359:
complete surgical excision of the c
Page 1360 and 1361:
lesion, particularly on the limbs o
Page 1362 and 1363:
SCC commonly presents in older, fai
Page 1364 and 1365:
Aetiology of melanomaMalignant mela
Page 1366 and 1367:
1.01-2.0 1-22.01-4.0 2-3>4 3Managin
Page 1368 and 1369:
IIb T3bN0M0 T4aN0M0 63-67IIc T4bN0M
Page 1370 and 1371:
Avulsion involves tearing or forcib
Page 1372 and 1373:
Wound debridementDebridement is the
Page 1374 and 1375:
Tissue expansionTissue expansion is
Page 1376 and 1377:
FlapsA flap is a vascularised unit
Page 1378 and 1379:
Scapular and parascapular flapsFlap
Page 1380 and 1381:
Gracilis flapGracilis is a long thi
Page 1382 and 1383:
List of Abbreviations5-HIAA 5-hydro
Page 1384 and 1385:
CT computed tomographyCTEV congenit
Page 1386 and 1387:
ITUIVIVUJGAJIAJVPKUBLALDHLFTsLIFLMW
Page 1388 and 1389:
RARBCRIFRTARUQSBPSIMVSIRSSLESMASPEC
Page 1390 and 1391:
BibliographyBooks:nderson ID (1999)
Page 1392 and 1393:
lter RB, Harris WR (1963) ‘Injuri
Page 1394 and 1395:
management ref 1, ref 2specimen col
Page 1396 and 1397:
liver trauma ref 1pre-hospital resu
Page 1398 and 1399:
aplastic ref 1blood transfusion ref
Page 1400 and 1401:
terior white commissure ref 1terola
Page 1402 and 1403:
electrical injuries ref 1hypothermi
Page 1404 and 1405:
cille Calmette-Guérin (BCG) vaccin
Page 1406 and 1407:
opsy ref 1bone infections ref 1, re
Page 1408 and 1409:
infections ref 1island ref 1, ref 2
Page 1410 and 1411:
segmental ref 1traumatic injuries r
Page 1412 and 1413:
hydrostatic pressure ref 1membrane,
Page 1414 and 1415:
rriage, microbial ref 1rtilageartic
Page 1416 and 1417:
fibres ref 1ancre ref 1emical burns
Page 1418 and 1419:
indamycin ref 1inical decision-maki
Page 1420 and 1421:
postoperative see postoperative com
Page 1422 and 1423:
of surgery ref 1st-utility analysis
Page 1424 and 1425:
osteoclast development ref 1SIRS re
Page 1426 and 1427:
ad spacealveolar ref 1anatomical re
Page 1428 and 1429:
hiscenceanastomosis ref 1wound ref
Page 1430 and 1431:
aphragmcongenital herniation ref 1e
Page 1432 and 1433:
sabilityburns ref 1paediatric traum
Page 1434 and 1435:
odenumatresia ref 1development ref
Page 1436 and 1437:
ectrolytescytoplasmic ref 1daily re
Page 1438 and 1439:
dothelial cellsinflammatory respons
Page 1440 and 1441:
ergymetabolism, paediatric patients
Page 1442 and 1443:
aporation, heat loss via ref 1
Page 1444 and 1445:
posureburns ref 1paediatric trauma
Page 1446 and 1447:
ctor VIIIconcentrate ref 1deficienc
Page 1448 and 1449:
sciotomycompartment syndrome in cal
Page 1450 and 1451:
distaladults ref 1children ref 1fat
Page 1452 and 1453:
gersDupuytren’s contracture ref 1
Page 1454 and 1455:
latedeficiency ref 1red cell ref 1l
Page 1456 and 1457:
fracturesadults ref 1children ref 1
Page 1458 and 1459:
ngal infections ref 1ITUs ref 1, re
Page 1460 and 1461:
Duties of a Doctor ref 1Good Medica
Page 1462 and 1463:
nital tractdevelopmental abnormalit
Page 1464 and 1465:
ucoseenergy production from ref 1,
Page 1466 and 1467:
nadsdescent ref 1development ref 1o
Page 1468 and 1469:
emarthrosishaemophilia-related ref
Page 1470 and 1471:
emophiliaA ref 1B (Christmas diseas
Page 1472 and 1473:
alingfracture ref 1wound see wound
Page 1474 and 1475:
artconducting system ref 1trauma se
Page 1476 and 1477:
rpes simplex virus1 (HSV-1) ref 12
Page 1478 and 1479:
merusanatomy ref 1, ref 2fractures
Page 1480 and 1481:
perkalaemiamassive transfusion ref
Page 1482 and 1483:
povolaemiaburn injuries ref 1physio
Page 1484 and 1485:
capacitypermanent ref 1temporary re
Page 1486 and 1487:
formationconfidentiality see confid
Page 1488 and 1489:
sulin therapydiabetes mellitus ref
Page 1490 and 1491:
tracranial haemorrhageburr holes re
Page 1492 and 1493:
nsdistribution in body ref 1see als
Page 1494 and 1495:
aspirationdiagnostic ref 1, ref 2,
Page 1496 and 1497:
dneyaberrant vasculature ref 1bilat
Page 1498 and 1499:
parotomyabdominal trauma ref 1, ref
Page 1500 and 1501:
erdevelopment ref 1immaturity in ne
Page 1502 and 1503:
wer leganatomy ref 1see also ankle;
Page 1504 and 1505:
mbar spinebiomechanics ref 1disc re
Page 1506 and 1507:
acrophagesacute inflammation ref 1,
Page 1508 and 1509:
edian ref 1
Page 1510 and 1511:
embranecell ref 1transport ref 1emb
Page 1512 and 1513:
etastatic diseaseskeletal ref 1surg
Page 1514 and 1515:
otor endplate ref 1, ref 2
Page 1516 and 1517:
ucous membranesbarrier to infection
Page 1518 and 1519:
ckabscesses ref 1burns, management
Page 1520 and 1521:
urological assessmentback/spinal pr
Page 1522 and 1523:
servational studies ref 1server bia
Page 1524 and 1525:
sophagusatresia ref 1cancer ref 1tr
Page 1526 and 1527:
erating theatre staffminimising ris
Page 1528 and 1529:
tcomesresearch study ref 1, ref 2su
Page 1530 and 1531:
ygen contentarterial blood (CaO 2 )
Page 1532 and 1533:
3 protein ref 1, ref 2cemakers ref
Page 1534 and 1535:
in assessmentchronic pain ref 1paed
Page 1536 and 1537:
ncreasdevelopment ref 1secretions r
Page 1538 and 1539:
telladislocation ref 1fractures ref
Page 1540 and 1541:
lvispaediatric patients ref 1second
Page 1542 and 1543:
ysiologycellular ref 1general ref 1
Page 1544 and 1545:
gmented skin lesionsassessment of s
Page 1546 and 1547:
eumothoraxopen ref 1tension ref 1ly
Page 1548 and 1549:
anion gap ref 1daily requirements r
Page 1550 and 1551:
evalence ref 1, ref 2evalence bias
Page 1552 and 1553:
ostate cancerepidemiology ref 1, re
Page 1554 and 1555:
oteinscatabolism after surgery ref
Page 1556 and 1557:
eudoaneurysmsinjecting drug users r
Page 1558 and 1559:
blicationsurgical outcomes ref 1wri
Page 1560 and 1561:
estionsclinical ref 1patient ref 1,
Page 1562 and 1563:
dial neckfractures ref 1posterolate
Page 1564 and 1565:
diationheat loss via ref 1injuries
Page 1566 and 1567:
flexestendon ref 1testing ref 1flex
Page 1568 and 1569:
placement arthroplastyhip ref 1infe
Page 1570 and 1571:
spiratory distresspaediatric patien
Page 1572 and 1573:
suscitationacute renal failure ref
Page 1574 and 1575:
turday night palsy ref 1alds ref 1a
Page 1576 and 1577:
reeningcancer ref 1, ref 2programme
Page 1578 and 1579:
nsory functionperipheral nerve inju
Page 1580 and 1581:
dislocationsanterior ref 1posterior
Page 1582 and 1583:
dium/potassium pump (Na + /K + ATPa
Page 1584 and 1585:
curvatureabnormal ref 1measurement
Page 1586 and 1587:
ffcritical care ref 1theatre see op
Page 1588 and 1589:
pination, forearm ref 1, ref 2, ref
Page 1590 and 1591:
rgical teampreparation ref 1see als
Page 1592 and 1593:
amsconflict within ref 1working in
Page 1594 and 1595:
ighanatomy ref 1compartments ref 1i
Page 1596 and 1597:
oracotomyanterolateral ref 1, ref 2
Page 1598 and 1599:
umbmallet ref 1movement ref 1simian
Page 1600 and 1601:
esclaw ref 1hammer ref 1mallet ref
Page 1602 and 1603:
initial hospital care ref 1limping
Page 1604 and 1605:
atmentoptions, alternative ref 1ref
Page 1606 and 1607:
nar nerveanatomy ref 1, ref 2, ref
Page 1608 and 1609:
per limbarterial injuries ref 1comp
Page 1610 and 1611:
ethracongenital abnormalities ref 1
Page 1612 and 1613:
inary tractcongenital abnormalities
Page 1614 and 1615:
ine outputburns ref 1hypovolaemic s
Page 1616 and 1617:
scular accesschildren ref 1, ref 2c
Page 1618 and 1619:
insanastomoses ref 1injuries ref 1,
Page 1620 and 1621:
ntilatory supportcritical care ref
Page 1622 and 1623:
n Hippel-Lindau syndrome ref 1, ref
Page 1624 and 1625:
ound closureprimary ref 1principles
Page 1627 and 1628:
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