General Surgery Principles Practice Questions

Q: A 43-year-old window cleaner fell off a scaffold. He sustained an open wound on the right leg. Debridement was carried out in the emergency department, and the edges of the wound were left open. Which factor is least likely to inhibit wound contraction?

Transforming growth factor β. ***Transforming growth factor β*** - **TGF-β** is a potent **pro-fibrotic cytokine** that plays a crucial role in promoting wound contraction and fibrosis by stimulating **fibroblast proliferation**, **myofibroblast differentiation**, and **collagen synthesis**. - Its presence and activity would *enhance* rather than inhibit wound contraction, making it the **least likely factor to inhibit** this process. - In wound healing, TGF-β is essential for the contraction phase and tissue remodeling. *Radiation* - **Ionizing radiation** can damage cells, including **fibroblasts** and **myofibroblasts**, which are essential for wound contraction. - This cellular damage and reduction in viable cells can significantly **impair** the contractile forces within the wound. - Radiation therapy is a known factor that inhibits wound healing and contraction. *Full-thickness skin graft* - A **full-thickness skin graft** introduces a complete layer of skin, including the dermis, into the wound. - The presence of the **dermis** within the graft provides a structural barrier and helps to **anchor the wound edges**, thereby reducing the tendency for contraction. - In contrast, **split-thickness grafts** allow more wound contraction due to less dermal tissue. *Cytolytic drug* - **Cytolytic drugs** are designed to kill cells, and if applied to a wound, they would destroy **fibroblasts** and **myofibroblasts**. - The destruction of these critical cells would directly **inhibit** the cellular machinery responsible for pulling the wound edges together, hence preventing contraction. - These drugs impair the proliferative phase of wound healing.

Q: For a lacerated wound, delayed primary suturing is done within:

48 hr. ***48 hr*** - **Delayed primary closure (DPC)** is typically performed **between 48 hours and 7 days** after the initial injury, with **48 hours representing the earliest threshold** for this technique. - At 48 hours, the wound has passed the acute inflammatory phase, bacterial load has been reduced through initial wound care, and the tissue can be assessed for readiness to close. - This method is used for **contaminated or potentially infected wounds** where immediate closure would risk infection, allowing time for wound cleaning and monitoring. - While optimal DPC is often performed at **3-5 days**, 48 hours marks the transition from primary to delayed primary closure. *24 hr* - This timeframe represents **primary closure**, where clean, uncontaminated wounds are sutured immediately or within the first 24 hours of injury. - At 24 hours, contaminated wounds have not had sufficient time for bacterial load reduction and inflammatory response assessment. *36 hr* - While 36 hours represents a delay from immediate closure, it falls short of the **minimum 48-hour threshold** typically required for delayed primary closure. - This intermediate timeframe does not allow adequate wound assessment and bacterial load reduction. *50 hr* - Although 50 hours falls within the DPC window (48 hours to 7 days), the question asks for the timeframe within which DPC is done, and **48 hours is the established earliest/minimum threshold**. - While DPC can certainly be performed at 50 hours, 48 hours is the standard benchmark cited in surgical literature as the beginning of the DPC window.

Q: Which of the following muscles is cut in posterolateral thoracotomy?

Latissimus dorsi. ***Latissimus dorsi*** - The **latissimus dorsi** is the **largest muscle divided** during a standard posterolateral thoracotomy incision. - It is the **most superficial** of the divided muscles and is routinely cut to allow access to the deeper structures and ribs required for entry into the thoracic cavity. - This is the **primary muscle** identified with this surgical approach. *Serratus anterior* - The **serratus anterior** is also typically **divided** (along with latissimus dorsi) in a posterolateral thoracotomy. - However, latissimus dorsi is considered the **more characteristic** muscle of this approach due to its larger size and more superficial position. - Preservation when possible is important for shoulder function (scapular protraction and superior rotation). *Rhomboids* - The **rhomboid muscles** (major and minor) lie deeper, beneath the trapezius, and are **not typically cut** in a standard posterolateral thoracotomy. - They remain protected and are involved in **scapular retraction** and downward rotation. *Pectoralis major* - The **pectoralis major** muscle is a large chest muscle located **anteriorly** and is **not involved** in a posterolateral thoracotomy approach. - This muscle is relevant in anterior thoracotomy approaches, where it's involved in **adduction, medial rotation**, and flexion of the humerus.

Q: Which of the following is a PRIMARY indication for negative pressure wound therapy (NPWT)?

Bed sore in sacrum after debridement. ***Bed sore in sacrum after debridement*** - **Negative pressure wound therapy (NPWT)** is a **primary, well-established indication** for pressure ulcers (bedsores) after debridement. - NPWT promotes **granulation tissue formation**, **wound contraction**, and prepares the wound bed for closure. - It effectively reduces **exudate** and bacterial load, making it a **first-line adjunctive therapy** for clean pressure ulcers. - **Strong evidence base** supports its use in this indication, particularly for Stage III-IV pressure ulcers post-debridement. *After amputation* - NPWT can be used in selected post-amputation cases to manage residual limb wounds or surgical site complications. - However, it is **not a primary or routine indication** but rather a **secondary/adjunctive option** for specific complications. - The main post-amputation focus is limb shaping, prosthetic preparation, and infection prevention. *Chronic osteomyelitis wound* - NPWT serves as **adjunctive therapy** for osteomyelitis wounds after surgical debridement to manage exudate. - The **primary treatment** for chronic osteomyelitis is aggressive **surgical debridement** and prolonged **antibiotic therapy**. - NPWT is supportive but **not the primary therapeutic modality** for this condition. *After split skin graft* - NPWT can be used post-grafting as a **graft bolster** to ensure adherence and optimal take. - While effective, this is a **specialized application** rather than a primary indication. - Traditional tie-over dressings remain standard in many settings, with NPWT reserved for complex cases.

Q: In flap method of amputation, which structure is kept shorter than the level of amputation?

Bone. ***Bone*** - In the **flap method of amputation**, the bone is intentionally cut **shorter** than the soft tissue flaps (typically 2-3 cm proximal to the planned skin closure level). - This allows the **muscle and skin flaps** to be closed over the end of the bone without tension, providing good padding and a well-contoured stump for prosthesis fitting. - This is the **primary structural principle** of flap amputation technique. *Nerves* - **Nerves** are typically cut sharply under gentle traction and allowed to retract proximally (usually 5-10 cm proximal to bone level) to prevent **neuroma formation** and phantom limb pain. - While nerves are indeed cut shorter, the **bone** is the structure specifically beveled shorter **for the purpose of flap closure**, which is what the question asks. *Vessels* - **Vessels** (arteries and veins) are ligated and divided at a level that ensures **hemostasis** and allows for proper flap closure. - They are handled for vascular control, not specifically kept shorter than the bone for shaping the stump. *Muscles* - **Muscles** are usually beveled and sewn to each other (myoplasty) or to the periosteum (myodesis) over the bone end to provide a well-padded, functional stump. - Muscles form the **flap itself** and are **longer than the bone**, not shorter, as they must cover and cushion it.

Q: During hysterectomy, dissection through the broad ligament most commonly risks injury to which structure?

Ureter. ***Ureter*** - During a hysterectomy, especially when dissecting deeply within the **broad ligament** to ligate the uterine artery, the **ureter** is at high risk of injury due to its close anatomical proximity. - The ureter passes just **inferior to the uterine artery** (water under the bridge), making it vulnerable during clamping and ligation of the uterine vessels. *Transverse colon* - The transverse colon is located much higher in the abdomen and is not typically within the surgical field of a hysterectomy unless there is **extensive adhesion formation** or a very unusual approach. - Injury to the transverse colon is highly **unlikely** during an uncomplicated hysterectomy through the broad ligament. *Bladder* - The bladder is anterior to the uterus and is more commonly at risk of injury when dissecting the **vesicouterine fold** or during mobilization of the anterior vaginal wall. - While a common site of injury in hysterectomy, it is less directly related to dissection within the **broad ligament** itself, which is more lateral to the bladder's dome. *Urethra* - The urethra is the terminal portion of the urinary tract and is located much more **inferiorly and anteriorly**, within the pelvic floor and distal to the surgical field for uterine removal. - Injury to the urethra is extremely rare during a routine hysterectomy and would imply a significant **surgical misadventure** far from the broad ligament.

Q: In the acute management of ecchymosis and hematoma, which thermal modality is most appropriate?

Intermittent ice pack. ***Intermittent ice pack*** - An **intermittent ice pack** is the cornerstone of acute thermal management for ecchymosis and hematoma, reducing **swelling** and **inflammation**. - Cold application causes **vasoconstriction**, minimizing further bleeding into tissues and providing **analgesia** by numbing the affected area. - Intermittent application (15-20 minutes on, 20-30 minutes off) prevents tissue damage while maximizing therapeutic benefit. - Part of the **RICE protocol** (Rest, Ice, Compression, Elevation) for acute soft tissue injuries. *Continuous ice pack* - **Continuous ice pack** application can cause **tissue damage**, including frostbite, nerve injury, and skin necrosis. - Prolonged vasoconstriction impairs tissue perfusion and delays healing by limiting oxygen and nutrient delivery. - Should be avoided in favor of intermittent application. *Pressure and pack* - While **compression/pressure** is indeed an important component of acute hematoma management, this option refers to the mechanical intervention rather than the thermal modality asked in the question. - Pressure dressings are used **in conjunction with** ice application, not as an alternative thermal treatment. - The question specifically asks about thermal modality, making ice the correct answer. *Intermittent hot pack* - **Heat application** in the acute phase causes **vasodilation**, which would increase blood flow and exacerbate bleeding. - This would worsen swelling and hematoma formation in the initial 24-48 hours post-injury. - Heat therapy is reserved for the later stages (after 48-72 hours) to promote healing and reduce chronic inflammation.

Q: Neurofibromatosis presents as all of the following except -

Lymphadenovarix. ***Lymphadenovarix*** - **Lymphadenovarix** is a rare condition characterized by the abnormal dilation of lymphatic vessels, forming a varicose appearance, and is not a feature of neurofibromatosis. - It is often associated with lymphatic obstruction or congenital lymphatic malformations, unrelated to neural crest cell anomalies. *Von Recklinghausen's disease* - This is an older name for **Neurofibromatosis type 1 (NF1)**, which is the most common form of neurofibromatosis. - NF1 is a **genetic disorder** that causes tumors to grow on nerve tissue, as well as various skin and bone abnormalities. *Elephantiasis neuromatodes* - This term refers to a severe form of **plexiform neurofibroma** that causes extensive overgrowth of skin and subcutaneous tissues, leading to a thickened, elephant-like appearance. - It is a significant and disfiguring manifestation of **Neurofibromatosis Type 1**. *Plexiform neuroma* - A **plexiform neuroma** is a pathognomonic feature of **Neurofibromatosis Type 1 (NF1)**, consisting of a diffuse neurofibroma that involves multiple nerve fascicles. - These tumors can be extensive, involve deep tissues, and are associated with a risk of **malignant transformation** to malignant peripheral nerve sheath tumors (MPNST). [1]

Question 1

A 43-year-old window cleaner fell off a scaffold. He sustained an open wound on the right leg. Debridement was carried out in the emergency department, and the edges of the wound were left open. Which factor is least likely to inhibit wound contraction?

Accepted Answer

Transforming growth factor β

Answer

Radiation

Answer

Full-thickness skin graft

Answer

Cytolytic drug

Question 2

For a lacerated wound, delayed primary suturing is done within:

Accepted Answer

48 hr

Answer

24 hr

Answer

36 hr

Answer

50 hr

Question 3

A patient with grossly contaminated wound presents 12 hours after an accident. His wound should be managed by -

Accepted Answer

Thorough cleaning with debridement of all dead and devitalised tissue without primary closure

Answer

Primary closure over a drain

Answer

Covering the defect with split skin graft after cleaning

Answer

Thorough cleaning and primary repair

Question 4

Which of the following muscles is cut in posterolateral thoracotomy?

Accepted Answer

Latissimus dorsi

Answer

Serratus anterior

Answer

Rhomboids

Answer

Pectoralis major

Question 5

Which of the following is a PRIMARY indication for negative pressure wound therapy (NPWT)?

Accepted Answer

Bed sore in sacrum after debridement

Answer

After amputation

Answer

Chronic osteomyelitis wound

Answer

After split skin graft

Question 6

In flap method of amputation, which structure is kept shorter than the level of amputation?

Accepted Answer

Bone

Answer

Nerves

Answer

Vessels

Answer

Muscles

Question 7

During hysterectomy, dissection through the broad ligament most commonly risks injury to which structure?

Accepted Answer

Ureter

Answer

Transverse colon

Answer

Bladder

Answer

Urethra

Question 8

In the acute management of ecchymosis and hematoma, which thermal modality is most appropriate?

Accepted Answer

Intermittent ice pack

Answer

Continuous ice pack

Answer

Pressure and pack

Answer

Intermittent hot pack

Question 9

A patient has a lacerated, untidy wound of the leg and attended the casualty department after 2 hours. His wound should be:

Accepted Answer

Debrided and sutured secondarily

Answer

Debrided and sutured immediately

Answer

Sutured immediately

Answer

Cleaned and dressed

Question 10

Neurofibromatosis presents as all of the following except -

Accepted Answer

Lymphadenovarix

Answer

Von Recklinghausen's disease

Answer

Elephantiasis neuromatodes

Answer

Plexiform neuroma

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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