Trendelenburg test:

-Patient in standing position and asked to lift one leg; the pelvis should remain level but if falls or dips inferiorly on the side of the raised leg, this is indicative of abductor muscle weakness on side of standing leg.

#Surgery

Legg- Calve- Perthes disease:

-Unknown pathophysiology
-It's idiopathic osteonecrosis of femoral head; typically presents at age 4–8 years.

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Developmental dysplasia of the hip;:

-Abnormal hip development resulting in laxity, subluxation, or dislocation of the. hip; initial instability/laxity of the. hip results in malposition-ing of the femoral head in the developing acetabulum and incomplete formation of the hip socket; dysplasia can lead to gradual dislocation, difficulty with ambulation, degenerative arthritis, and pain.

#Surgery

Developmental dysplasia of the hip X-ray:

- Subluxation or dislocation of the femoral head from the acetabulum;. difficult to assess on x-ray in infants, for which ultrasound is typically used.

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Types of thyroiditis.

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Spread of HCC:

-Lymphatic spread: It can spread to other part of liver through lymphatics within the liver, to the lymph nodes in the porta hepatis and other abdominal lymph nodes later. Often spread occurs directly to cisterna chyli.

-Blood spread: To lungs, bones and adrenals often can occur.

-Direct infiltration: To diaphragm and neighbouring structures.

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What's difference between gatroschisis and omphalocele ?


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Latent tetany:
-With serum calcium 7 – 9 mg/dl; signs:
1)Chevostek sign:
Tapping the facial nerve in front of the ear → twitch of the mouth.

2)Trouseau sign:
Inflation of sphygmomanometer cuff over the arm above systolic pressure for 3 min → carpal spasm.

3)Peroneal sign:
Tapping of the peroneal nerve o dorsiflexion + abduction of the foot.

4)Erb’s sign:
Motor nerve can be stimulated by low current.

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Manifest Tetany:
-With serum calcium < 7 mg/dl ; manifested by :

1. Carpo pedal spasm:
- Flexion of the wrist & metacarpophalangeal joints
- Extended interphalangeal joints
- Flexed adducted thumb.
- Plantar flexion & inversion of the feet

2. Laryngeal spasm (laryngismus stridulous): stridor is afebrile & recurrent.
3. Convulsions.

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Radiologic X-ray findings in Rickets:

Active rickets:
The lower ends show:
- Broadening ; widening of the distal end of the metaphysis
-Cupping or concavity ; metaphysis changes from a convex or flat surface to a more concave surface
- Metaphysis loses its sharp border ( Fraying )
-Wide joint space.

The shaft shows:
-Rarefaction o p bone density
-May be green stick fracture.
-May be deformities.

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b. Healing rickets:
-Usually seen 2 weeks of vitamin D therapy
-The lower ends shows white concave continuous line at ZPC
- Less evident features of rickets

c. Healed rickets:
-Usually seen 4-6 weeks of vitamin D therapy
- The lower ends show straight continuous line at ZPC.
- No features of active rickets.

#Surgery

- Choledochal cyst:(types)
type I: dilatation of CBD
Ia-->cystic.
Ib-->saccular.
Ic-->fusiform.
type II: Choledochal diverticle.
type III: Choledochocele.
type IVa: Dilatation of extra & intra hepatic biliary ducts.
type IVb: Dilatation of multiple sections of extrahepatic duct.
type V: Caroli's syndrome.

- Congenital extrahepatic biliary atresia (types):
type I: atretic CBD.
type IIA: atretic CHD.
type IIB: atretic CBD and CHD.
type III: atretic CBD, CHD, RHD&LHD

Klatskin tumour is classified as 4 types—
I: Just at or below the confluence;
II: At the confluence.
III: at the confluence extending
along the RHD.
IV: at the confluence extending along the LHD.

Mirizzi syndrome:-
Type I : Compression of CBD without lumen narrowing.
Type II : Compression causing CBD lumen narrowing.
Type III : Compression causing CBD wall necrosis.
Type IV : Cholecysto-choledochal fistula.

Pancreatic pseudocyst

◼️This refer to the collection of pancreatic secretions in a well defined wall of granulation tissue or fibrous tissue.

◼️It forms after trauma, acute pancreatitis or chronic pancreatitis, basically anything that lead to duct disruption and escape of pancreatic secretions, it requires 4 weeks or more from the index event for the wall to fully mature.

◼️Most pseudocysts are located in the lesser sac, unusual locations do occur however like in the spleen or even the chest, but this is rare, most do go away on their own, but those over 6 cm, lasting over 12 weeks or occur due to chronic pancreatitis are unlikely to resolve spontaneously.

◼️When appropriate drainage should be done, this can be done by simple percutaneous aspiration or by cystogastrostomy which are nowadays usually done by endoscopy.

◼️Above table lists possible complications of pseudocysts.

#Surgery

Nomenclature

◼️Halsted mastectomy = involve removal of breast, pectoralis major and minor, with axillary nodes fascia and fat. No longer done.

◼️Modified 'patey' mastectomy = en bloc removal of breast, skin (centre of which overlies the tumor but always includes the nipple), axillary dissection.

◼️Wide local excision = removal of the tumor with a rim of healthy tissue of atleast 1 cm.

◼️Quadrantectomy = removal of the segment containing the tumor.

◼️QUART = combination of quadrantectomy, axillary dissection and radiotherapy.

#Breast

Indications for mastectomy

Recently there has been a gradual shift towards more conservative techniques, clinical trials has shown that mastectomy has equal efficacy to local excision and radiotherapy, therefore nowadays mastectomy is strictly indicated only in the following conditions:

◼️Large tumor in relation to the size of the breast (small breast).

◼️Central tumor beneath or involving the nipple.

◼️Multifocal especially seen in lobular carcinoma.

◼️Local recurrence.

◼️Patient preference.

#Breast

Paget disease of the nipple

◼️This is an eczema like condition of the nipple and areola.

◼️It is indicative of an underlying breast carcinoma.

◼️The nipple becomes slowly eroded until its completely obsecured (see image above black arrow) , if left, the underlying carcinoma will sooner or later become clinically evident.

◼️The pathophysiology is uncertain, according to the migratory theory, malignant cells travel along the duct system and eventually reach the nipple and areola, the motility of these cells being induced by motility factors acting through HER2/NEU receptors.

◼️Microscopic picture include presence of large ovoid malignant cells with abundant pale cytoplasm in the malpighian layer of epidermis.

◼️It should be suspected strongly when a presumed eczema of the nipple fails to respond to local treatment, whenever in doubt, biopsy of the nipple should be obtained to confirm the diagnosis.

#Breast

Aetiologic factors in breast cancer

◼️Geographic

Breast cancer is more common in developed western counteries, it account for 3-5% of all deaths, whereas in developing counteries the incidence is lower and account for 1-3% of all deaths. It was found to be rare in japan.

◼️Age

Breast cancer is extremely rare below the age of 20 years, but thereafter, the risk steadily increasea until it becomes 20% at 90 years.

◼️Gender

Males represent less than 0.5% of all cases of breast cancer.

◼️Genetic

Breast cancer is more common in women with a family history of breast cancer,, breast cancers that are due to a specific mutation represent about 5% of all cases, and they will be discussed later in details.

◼️Diet

It was found that there is a link to diets with low phytoestrogens, also high alcohol consumption increase the risk.

◼️Endocrine

Estrogenic drive seems to increase the risk of breast cancer, it was found that nulliparous women are more likely to have breast cancer, also having the first child at an early age is protective, breastfeeding in protective, also late menarche and early menopause seem to be protective.
The role of oral contraceptive pills and hormonal replacement therapy is controversial, it seems that the benefits from these treatments outweight the small putative risk.

#Breast