FMGE 2025 - Surgery Practice Questions

Q: During an explosion, a patient sustains a crushed lower limb injury by collapse of a building. What type of blast injury does this represent?

Quaternary. ***Quaternary*** - This category includes all injuries not caused by primary, secondary, or tertiary mechanisms, such as **crush injuries**, burns, and toxic exposures. - The patient's crushed lower limb from a collapsing building is a classic example of a **quaternary blast injury**. *Primary* - Primary blast injuries are caused by the direct effect of the **blast wave overpressure** on the body. - They typically affect gas-containing organs, leading to conditions like **tympanic membrane rupture** or **blast lung**, which are not described here. *Secondary* - Secondary blast injuries result from being struck by **flying debris or fragments** (shrapnel) propelled by the explosion. - This mechanism causes penetrating or blunt trauma from projectiles, not crush injuries from a structural collapse. *Tertiary* - Tertiary blast injuries occur when the victim is thrown by the **blast wind** and impacts a solid object like a wall or the ground. - This results in blunt force trauma and fractures from the impact, which is different from being crushed by a falling structure.

Q: In the given image, which vein is mainly affected?

Great saphenous vein. ***Great saphenous vein*** - The image displays prominent varicose veins along the **medial aspect of the leg**, which corresponds to the anatomical path of the **great saphenous vein (GSV)**. - The GSV is the most frequently affected vein in varicose vein disease due to valvular incompetence, leading to venous reflux and the characteristic tortuous dilatation seen in the picture. *Short saphenous vein* - The **short saphenous vein (SSV)** ascends along the **posterior aspect of the calf**. Varicosities primarily from the SSV would be most visible on the back of the leg. - While some posterior varicosities may be present, the predominant involvement shown is medial, making the GSV the main affected vessel. *Femoral vein* - The **femoral vein** is a major vessel of the **deep venous system**, not the superficial system. - Varicose veins are a disease of **superficial veins**; deep veins like the femoral vein do not become varicose. *Perforator veins* - **Perforator veins** connect the superficial venous system to the deep system. Their incompetence is a crucial factor in the development of venous hypertension and varicosities. - However, the large, dilated vessels visible on the skin are part of a major superficial trunk (the GSV in this case), not the perforators themselves, which are much smaller connecting vessels.

Q: After the parotidectomy operation, a patient presents with excessive sweating and redness over the parotid region. What is the diagnosis?

Frey’s Syndrome. ***Frey’s Syndrome***- It is a common post-parotidectomy complication resulting from **aberrant regeneration** of the severed **auriculotemporal nerve**.- The parasympathetic secretomotor fibers meant for the parotid gland mistakenly reinnervate the overlying cutaneous sweat glands and blood vessels, causing **gustatory sweating** and **flushing (redness)** in the parotid region upon chewing or eating.*Horner’s syndrome*- This syndrome results from interruption of the **cervical sympathetic trunk** and presents with the classic triad of **ptosis** (droopy eyelid), **miosis** (constricted pupil), and **anhidrosis** (lack of sweating) on the affected side of the face.- It is unrelated to the auriculotemporal nerve damage common after parotidectomy and involves *lack* of sweating, contrary to the patient's complaint of *excessive* sweating.*Bell’s Palsy*- This is an **idiopathic acute peripheral facial nerve palsy**, leading to unilateral weakness or paralysis of the muscles of facial expression (e.g., inability to close the eye or raise the eyebrow).- While the facial nerve (CN VII) is at risk during parotidectomy, Bell's Palsy itself does not account for the specific symptoms of post-operative gustatory sweating and redness.*Glossopharyngeal neuralgia*- This condition involves brief, severe episodes of stabbing pain in the throat, tonsillar area, back of the tongue, or ear due to irritation of the **glossopharyngeal nerve (CN IX)**.- It is a disorder characterized purely by pain, often triggered by **swallowing** or **talking**, and is not associated with post-operative salivary gland complication symptoms like gustatory sweating.

Q: A professional singer presents with difficulty in raising the pitch of her voice following thyroid surgery. There is no hoarseness, but high-pitched voice production is impaired. Which nerve is most likely injured?

External branch of the superior laryngeal nerve (EBSLN). ***Correct: External branch of the superior laryngeal nerve (EBSLN)*** - The EBSLN innervates the **cricothyroid muscle**, which is responsible for increasing **vocal cord tension** - Injury results in inability to tense the vocal cords, causing **loss of high-pitched voice** production - Crucially, there is **NO hoarseness** because vocal cord adduction (brought together by other muscles) remains intact - Classic presentation: Professional singers or teachers notice difficulty hitting high notes after thyroid surgery *Incorrect: Recurrent laryngeal nerve (RLN)* - RLN innervates all intrinsic laryngeal muscles **except** the cricothyroid - Injury causes **hoarseness** due to impaired vocal cord adduction - This patient has no hoarseness, making RLN injury unlikely *Incorrect: Internal branch of the superior laryngeal nerve (IBSLN)* - IBSLN is purely **sensory** to the supraglottic larynx - Injury causes loss of sensation above the vocal cords, leading to **aspiration risk** - Does not affect voice pitch or motor function *Incorrect: Glossopharyngeal nerve* - Provides motor innervation to stylopharyngeus and sensory to pharynx/posterior tongue - **Not involved in laryngeal function** or voice production - Injury would cause dysphagia and loss of gag reflex, not voice changes

Q: A patient presents with enophthalmos and periorbital ecchymosis after being hit by a ball. What is the most likely diagnosis?

Orbital blowout fracture. ***Orbital blowout fracture*** - The clinical presentation of **periorbital ecchymosis** (bruising around the eye) and **enophthalmos** (posterior displacement of the eyeball) following blunt trauma from an object like a ball is classic for an orbital blowout fracture. - This injury often involves the thin orbital floor, leading to herniation of orbital contents into the maxillary sinus and potential entrapment of the **inferior rectus muscle**, which can cause **diplopia** (double vision) on upward gaze. *Zygomatic fracture* - A zygomatic (cheekbone) fracture typically causes facial flattening, a palpable **step-off deformity** along the orbital rim, and numbness over the cheek due to **infraorbital nerve** injury. - While it can be associated with an orbital floor fracture, isolated **enophthalmos** is not its primary presenting sign; facial asymmetry is more prominent. *Nasal bone fracture* - This is the most common facial fracture and presents with localized pain, swelling, deformity of the nasal bridge, and **epistaxis** (nosebleed). - **Enophthalmos** is not a feature of an isolated nasal bone fracture, although periorbital ecchymosis can be present. *Le Fort I fracture* - This is a horizontal fracture of the maxilla, resulting in a **"floating palate"** where the entire upper dental arch is mobile. - It is characterized by **dental malocclusion** and does not typically cause the isolated orbital signs of **enophthalmos** seen in this case.

Question 1

During an explosion, a patient sustains a crushed lower limb injury by collapse of a building. What type of blast injury does this represent?

Accepted Answer

Quaternary

Answer

Tertiary

Answer

Primary

Answer

Secondary

Question 2

In the given image, which vein is mainly affected?

Accepted Answer

Great saphenous vein

Answer

Perforator veins

Answer

Femoral vein

Answer

Short saphenous vein

Question 3

After the parotidectomy operation, a patient presents with excessive sweating and redness over the parotid region. What is the diagnosis?

Accepted Answer

Frey’s Syndrome

Answer

Bell’s Palsy

Answer

Glossopharyngeal neuralgia

Answer

Horner’s syndrome

Question 4

A professional singer presents with difficulty in raising the pitch of her voice following thyroid surgery. There is no hoarseness, but high-pitched voice production is impaired. Which nerve is most likely injured?

Accepted Answer

External branch of the superior laryngeal nerve (EBSLN)

Answer

Glossopharyngeal nerve

Answer

Internal branch of the superior laryngeal nerve (IBSLN)

Answer

Recurrent laryngeal nerve (RLN)

Question 5

A patient presents with enophthalmos and periorbital ecchymosis after being hit by a ball. What is the most likely diagnosis?

Accepted Answer

Orbital blowout fracture

Answer

Le Fort I fracture

Answer

Zygomatic fracture

Answer

Nasal bone fracture

FMGE 2025 — Surgery