Surgical Reconstruction After Tumor Resection — MCQs
Which of the following is the POOREST recipient bed for a skin graft?
Contraindications for skin traction: a) Dermatitis b) Vascularly compromised status of limb c) Abrasions d) Hypopigmentation (vitiligo) e) Bony deformity
Best procedure for an injury to the leg with exposed bone and skin loss:
What is a late complication of elbow dislocation?
Healing by Haversian remodeling is a type of:
In which of the following situations is breast conservation surgery not indicated?
Which of the following tumors is known for its potential for spontaneous regression?
Surgery was performed as shown in the image below. What is the name of the procedure?
A patient presents with upper limb swelling after undergoing a modified radical mastectomy (MRM). What is the most likely cause?
What is the treatment of choice in desmoid tumors?
Surgical Reconstruction After Tumor Resection Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is the POOREST recipient bed for a skin graft?
- A. Fat (Correct Answer)
- B. Muscle
- C. Deep fascia
- D. Skull bone
Explanation: ***Fat*** - **Fat** is a poor recipient for a skin graft due to its **limited vascularity**, which hinders the necessary process of revascularization for graft survival. - The high metabolic demand of a graft cannot be adequately met by the relatively avascular subcutaneous fat, leading to graft failure. *Muscle* - **Muscle tissue** is an excellent recipient bed for skin grafts due to its **rich blood supply**. - Its robust vascularity effectively supports the revascularization and survival of the grafted tissue. *Deep fascia* - **Deep fascia** provides a good vascularized bed for skin grafts, as it has a reasonable blood supply from underlying muscles and surrounding tissues. - This vascularization is sufficient to nourish and ensure the take of a skin graft. *Skull bone* - **Skull bone** (specifically the periosteum covering it) can serve as an adequate graft bed due to its vascular supply. - If the **periosteum** is intact and healthy, it offers sufficient blood flow for graft survival.
Question 2: Contraindications for skin traction: a) Dermatitis b) Vascularly compromised status of limb c) Abrasions d) Hypopigmentation (vitiligo) e) Bony deformity
- A. ab
- B. abc (Correct Answer)
- C. acd
- D. bcd
Explanation: ***ab*** - All conditions listed under 'a' and 'b' (Dermatitis, Vascularly compromised status of limb, Abrasions) are **absolute contraindications** for skin traction as they directly compromise skin integrity or circulation. - Applying skin traction in these situations can lead to **skin breakdown**, infection, or further **ischemic damage**, worsening the patient's condition. *ab* - While **dermatitis**, **vascular compromise**, and **abrasions** are indeed contraindications, the option for 'abc' implies there might be other correct choices included, which is not the case for this option. - This option is incomplete as it misses 'c' (Abrasions) which is also a significant contraindication. *acd* - This option incorrectly includes **hypopigmentation (vitiligo)** as a contraindication, which does not inherently prevent skin traction. - It also omits **vascularly compromised status of limb**, a critical contraindication, while including 'a', 'c', and 'd'. *bcd* - This option incorrectly includes **hypopigmentation (vitiligo)** as a contraindication for skin traction. - It also omits **dermatitis**, a key contraindication, while including 'b', 'c', and 'd'.
Question 3: Best procedure for an injury to the leg with exposed bone and skin loss:
- A. Full thickness grafting
- B. Skin flap
- C. Split skin grafting
- D. Pedicle flap (Correct Answer)
Explanation: ***Pedicle flap*** - A pedicle flap provides **vascularized tissue** that can cover exposed bone, which requires a robust blood supply for healing and protection. - This method ensures good **tissue viability** and bulk, crucial for areas with high functional demands and potential for infection like the lower leg. *Full thickness grafting* - **Full-thickness skin grafts** are generally too thin to adequately cover exposed bone and do not provide sufficient vascularity or padding. - They rely entirely on the recipient bed for vascularization, which is poor over exposed bone, leading to a high risk of **graft failure**. *Skin flap* - While a generic "skin flap" implies a vascularized tissue transfer, it is less specific than a pedicle flap, which ensures continuous blood supply from the donor site until full integration. - The term "skin flap" alone doesn't specify if it's a local, regional, or free flap, and **pedicle flaps** are often the most direct and reliable solution for lower leg bone exposure. *Split skin grafting* - **Split-thickness skin grafts** are very thin and contain only a portion of the dermis, making them unsuitable for covering exposed bone or tendons. - They would likely **fail to take** due to lack of a vascular bed and offer no padding or protection against further injury.
Question 4: What is a late complication of elbow dislocation?
- A. Median nerve injury
- B. Brachial artery injury
- C. Myositis ossificans (Correct Answer)
- D. None of the options
Explanation: **Myositis ossificans** - **Myositis ossificans** is the abnormal formation of **heterotopic bone** within muscle or other soft tissues, often developing weeks to months after joint trauma such as an elbow dislocation. - It typically presents as a painful, firm mass with restricted joint movement, especially **flexion** and **extension** at the elbow. *Median nerve injury* - **Median nerve injury** can occur at the time of the initial elbow dislocation (an **acute complication**), but it is not typically considered a late complication that develops over weeks or months. - Symptoms include numbness in the thumb, index, and middle fingers, as well as weakness in **thumb opposition** and **flexion** of the index finger. *Brachial artery injury* - **Brachial artery injury** is an **acute complication** of severe elbow dislocation, leading to compromise of distal blood flow. - Signs include absence of pulses, pallor, paresthesia, and pain in the forearm and hand, requiring immediate surgical intervention. *None of the options* - This option is incorrect because **myositis ossificans** is a well-recognized late complication of elbow dislocation.
Question 5: Healing by Haversian remodeling is a type of:
- A. Tertiary healing.
- B. Secondary healing.
- C. Primary healing. (Correct Answer)
- D. Intermediate healing.
Explanation: ***Primary healing*** - This term refers to **direct healing**, where bone fragments are in contact and movement is minimized, leading to direct bone formation without significant callus. - **Haversian remodeling**, common in rigid internal fixation, is the hallmark of primary bone healing, involving direct osteon formation across the fracture site. *Tertiary healing* - This is **not a recognized term** in the classification of bone healing processes. - Bone healing is generally categorized as primary (direct) or secondary (indirect). *Secondary healing* - This involves the formation of a **soft and then hard callus** in cases of unreduced or mobile fractures. - It is characterized by three overlapping phases: **inflammation, repair**, and **remodeling**, and does not primarily rely on Haversian remodeling. *Intermediate healing* - This is **not a formal classification** of bone healing. - Bone healing is typically dichotomized into primary and secondary healing, depending on the stability and reduction of the fracture.
Question 6: In which of the following situations is breast conservation surgery not indicated?
- A. SLE
- B. Large pendular breast
- C. Diffuse microcalcification
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - All listed scenarios—**large pendular breast**, **SLE**, and **diffuse microcalcification**—represent situations where breast conservation surgery is generally contraindicated or challenging. - Their presence often necessitates alternative treatment approaches, such as mastectomy, to achieve optimal oncologic and cosmetic outcomes. *Large pendular breast* - While not an absolute contraindication, a **very large or pendulous breast** can make it difficult to achieve a satisfactory cosmetic outcome after breast conservation surgery. - The disproportionate breast size post-lumpectomy may lead to significant **asymmetry**, requiring further reconstructive procedures. *SLE* - Patients with **Systemic Lupus Erythematosus (SLE)** are at an increased risk of complications from radiation therapy, a mandatory component of breast conservation surgery. - They tend to experience more severe and prolonged **acute and chronic skin reactions** to radiation, which can significantly impair healing and quality of life. *Diffuse microcalcification* - **Diffuse microcalcification** within the breast can indicate widespread in situ carcinoma (e.g., DCIS) or an invasive carcinoma with extensive intraductal component. - In such cases, achieving **clear surgical margins** with breast conservation surgery can be challenging and often leads to multiple re-excisions or an increased risk of local recurrence.
Question 7: Which of the following tumors is known for its potential for spontaneous regression?
- A. Osteogenic sarcoma
- B. Malignant melanoma (Correct Answer)
- C. Retinoblastoma
- D. Cholangiocarcinoma
Explanation: ***Osteogenic sarcoma*** - Osteogenic sarcoma, or **osteosarcoma**, is a **malignant bone tumor** that typically does not resolve spontaneously and often requires aggressive treatment [1]. - It commonly presents with **pain and swelling** in long bones, and its prognosis is poor without intervention. *Retinoblastoma* - Retinoblastoma can exhibit **spontaneous regression**, especially in bilateral cases, where the tumor may shrink without treatment over time. - It primarily affects the **retina** in children, ideally diagnosed early to preserve vision and life. *Cholangio carcinoma* - Cholangio carcinoma is an aggressive form of **bile duct cancer** that does not resolve spontaneously and usually has a poor prognosis. - Symptoms typically include **jaundice** and bile duct obstruction, requiring surgical intervention. *Malignant melanoma* - Malignant melanoma is a highly aggressive skin cancer that does not undergo spontaneous resolution and often metastasizes quickly. - Early recognition is crucial for treatment, as it is associated with significant **morbidity and mortality**. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 673-674.
Question 8: Surgery was performed as shown in the image below. What is the name of the procedure?
- A. Below knee amputation
- B. Above knee amputation
- C. Lisfranc amputation
- D. Chopart amputation (Correct Answer)
Explanation: ***Chopart amputation*** - The image shows a disarticulation through the **talonavicular and calcaneocuboid joints**, which defines a **Chopart amputation**. - This procedure removes the distal foot while preserving the **calcaneus and talus**, forming a stump that allows for some ankle motion. *Below knee amputation* - A below-knee amputation involves transection of the tibia and fibula, preserving the knee joint, which is much more proximal than shown in the image. - This type of amputation removes a significant portion of the lower leg, with the foot entirely removed, unlike the partial foot amputation depicted. *Above knee amputation* - An above-knee amputation involves disarticulation or transection through the femur, completely removing the lower leg and knee joint. - This is a much more extensive amputation than what is illustrated, which is confined to the foot. *Lisfranc amputation* - A Lisfranc amputation is a disarticulation through the **tarsometatarsal joints**, removing the metatarsals and phalanges but preserving the tarsal bones. - The image clearly shows the incision more proximally, at the midtarsal level, specifically through the talonavicular and calcaneocuboid joints, not the tarsometatarsal joints.
Question 9: A patient presents with upper limb swelling after undergoing a modified radical mastectomy (MRM). What is the most likely cause?
- A. Angiosarcoma
- B. Recurrence
- C. Upper limb Lymphedema (Correct Answer)
- D. Metastasis
Explanation: ***Upper limb Lymphedema*** - **Lymphedema** is a common complication after **modified radical mastectomy (MRM)** due to the removal of axillary lymph nodes and subsequent disruption of lymphatic drainage pathways. - This disruption leads to an accumulation of lymphatic fluid in the interstitial tissues, causing **swelling** in the ipsilateral upper limb. *Angiosarcoma* - **Angiosarcoma** (Stewart-Treves syndrome) is a very rare, aggressive tumor that can occur in the chronic lymphedematous limb after mastectomy. - It presents as multiple **violaceous nodules or plaques** in the affected limb, which is not described as the initial finding. *Recurrence* - **Recurrence** of breast cancer in the axilla or chest wall could cause swelling, but it would typically involve a palpable mass, skin changes, or pain, which are not mentioned as the primary symptom. - While recurrence can lead to lymphatic obstruction, **lymphedema** is a more direct and common post-operative complication. *Metastasis* - **Metastasis** to the axillary or supraclavicular lymph nodes could cause lymphatic obstruction and swelling. - However, lymphedema from direct surgical disruption of lymphatics is a more immediate and common cause of upper limb swelling following MRM, especially without other signs of widespread disease.
Question 10: What is the treatment of choice in desmoid tumors?
- A. Irradiation
- B. Wide excision (Correct Answer)
- C. Local excision
- D. Local excision following radiation
Explanation: ***Wide excision*** - For **desmoid tumors**, **complete surgical resection with clear margins** is the primary treatment of choice due to their infiltrative nature and high recurrence rates. - This approach aims to minimize local recurrence and prevent tumor progression, which can impact adjacent structures. *Irradiation* - **Radiation therapy** is typically reserved as an **adjuvant** treatment after surgery or for unresectable tumors, not as a primary standalone treatment. - While it can help reduce recurrence rates, it carries risks of **secondary malignancies** and local tissue damage. *Local excision* - **Local excision** alone is insufficient for desmoid tumors due to their **infiltrative growth pattern** and high propensity for **local recurrence** if positive margins remain. - It often leads to incomplete removal, necessitating further intervention and increasing the risk of tumor progression. *Local excision following radiation* - Combining local excision with initial radiation is not the preferred sequence; **wide surgical excision** is typically performed first. - Radiation might be considered preoperatively in specific cases to **reduce tumor size** or postoperatively for **positive margins**, but starting with local excision after initial radiation is not the standard primary management.
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