Urology:

1. A 65-year male comes to Emergency with history that he is unable to

pass urine for the last 12 hours.
a. Enlist two major causes?
● Benign prostatic hyperplasia (BPH)
● Prostate carcinoma
● Urethritis

b. What further points in history can differentiate between these

two conditions?
In case of BPH:
● Patient will have lower urinary tract symptoms (LUTS)
○ Increased frequency
○ Nocturia
○ Urgency
○ Reduced urinary stream/ incomplete emptying
In case of CA prostate:
● Patient will complain of weight loss
● Hematuria
● Bladder outflow obstruction
● Pelvic and bone pain
In case of Urethritis:
● Burning or itching of the urethral meatus
● Urethral discharge
● Fever and chills
● Myalgia

c. What are the examination findings that can lead to these reasons?
BPH:
● On DRE the prostate will be symmetrically enlarged, smooth
(no nodules), non-tender and firm with rubbery and elastic
texture.
CA Prostate:
● On DRE palpable lesions which will be hard and lumpy
Urethritis:
 ● Examination of distal meatus may show skin lesions,
strictures and obvious urethral discharge
● Examination of testis may show signs of inflammation,
warmth and tenderness.

d. How will you investigate this patient?

BPH:
● Labs:
○ Urine RE
○ Serum PSA (over 1.5 ng/mL)
○ RFTs
○ CBC
● Flow rate measurement/ uroflowmetry (＜10 ml/s)
● Pressure flow urodynamic studies
● Radiology:
○ X-ray KUB (kidney, ureter, bladder)
○ USG (abdomen)
○ Transrectal ultrasound scan (TRUS)
○ MRI or CT pelvis
● Cystourethroscopy
● IPSS scoring
○ Mild 0-7
○ Moderate 8-19
○ Severe 20-35
● Postvoidal residual volume

CA prostate:
● Prostate biopsy:
○ Microscopy/cytology and histology: GLEASON grading
● Serum PSA is markedly raised
○ >10 ng/ml suggestive of cancer
○ >35 ng/ml advanced CA prostate
● Raised Alk Phosphatase (indicative of metastatic disease)
● Radiology:
○ USG (TRUS or transabdominal)
○ CT and MRI (for staging by determining local spread
and lymph node involvement)
 ○ X-ray bone scan ( for bony metastasis)
● LFTs
● CBC

Urethritis:
● Urine dipstick test
● Pyuria
● Urethral smear
● Gram stain of urethral swab or discharge
● NAAT

2. A 30-year male comes to you in outdoor with history of marriage for 3

years but his wife couldn't conceive
a. How do you define infertility?
Failure of conception after at least 12 months of regular
unprotected intercourse.

b. What are important points in history that you will ask related to
male infertility?
● If the couple has conceived a child before (primary or
secondary subfertility)
● Smoking, alcohol
● Childhood illnesses like
○ Mumps
○ Testicular torsion
○ Developmental delay
○ Precocious puberty
● STIs
● UTIs
● Bladder neck surgery
● Use of steroids, recreational drugs (marijuana)
● Previous Chemotherapy
● Erectile dysfunction

c. What positive findings in the abdomen and genitalia examination

can lead you to diagnosis?
 Abdomen:
● Palpable masses in lower abdomen or scrotal area
● Hernia
● Scars from prior surgery
● Abnormal hair distribution (indicative of endocrine
disorder)
Genitalia:
● Testicular abnormalities
○ Torsion
○ Mass
○ Presence and size
○ Tenderness
● Varicocele
● Absent vasa
● Scrotal abnormalities
● Epididymal abnormalities
○ Signs of infection

d. What two major investigations you will not miss?

● Semen Analysis:
○ Sperm count, motility, morphology, volume, pH and
viscosity.
● Hormonal profile:
○ Testosterone ↓
○ FSH LH and prolactin ↑
○ Thyroid

3. A 70 year old gentleman presents to a clinic with LUTS. He doesn’t have

any comorbidity, nor taking any medications.
a. Name the questionnaire used to assess his symptoms?
● International Prostate Scoring System (IPSS)
○ Mild 0-7
○ Moderate 8-19
○ Severe 20-35

b. What baseline investigations will you advise? (Q1 D BPH)

● Urinalysis
 ● Urine Culture
● Serum PSA
● RFTs
● Transrectal USG
● Postvoidal residual volume
● Uroflowmetry
● MRI or CT pelvis
● Cystourethroscopy

c. He has severe, bothersome, voiding LUTS. What firstline

medicine would you like to start and what is the main side effect
of this medicine?
● Alpha adrenergic blocking agents ( ɑ blockers)
○ Tamsulosin
● Side effects:
○ Retrograde ejaculation
○ Postural hypotension/ Orthostatic hypotension
○ Floppy iris
○ Dizziness, nasal congestion and headache.

d. If his prostate volume is 45cc(normal is 20cc), What other

medicine would you like to add, and what’s the main side effect?
● In addition to tamsulosin, 5-alpha reductase inhibitors can
be given:
○ Finasteride
○ Dutasteride
● Side effects of 5 alpha reductase
○ Sexual dysfunction
○ Gynecomastia
○ Mood disorders

e. After 1 year he presented to the emergency with a painful inability

to pass urine with no other symptoms. What is the diagnosis?
How will you relieve his symptoms?
Acute Urinary Retention:
● Urethral catheterization
● Suprapubic puncture
 ● Bladder decompression
● Surgical intervention (TURP)

4. A 30 years old gentleman presented with acute onset of right sided loin
to groin pain which is colicky, in nature. He doesn’t have any other
symptoms. He is otherwise fit and well.

A 40-year-old lady presented with acute onset of right sided loin to

groin pain which is colicky in nature. She doesn't have any other
symptoms. She is otherwise fit and well

A 45-year-old male presents with Right flank pain for the last 2
months. The pain is dull and Intermittent. He needs analgesics off & on.

A 50-year-old male presents with left sided acute onset of severe loin
to groin pain. He has a previous history of renal stones. There are no
other symptoms

A 25-year-old female presents with Rt-sided abdominal pain and

dysuria for the past 2 days. The pain is dull and intermittent. She needs
analgesics off and on

a. Name the differential diagnosis?

Ureteric Stones
b. What is the first line of treatment that you will advise in an
emergency to relieve his pain?
● NSAIDs (first line)
○ Diclofenac 75 mg IV or IM
● Opioids (second line; in severe cases or in patients with
contraindications to NSAIDs)

c. How will you investigate this patient?

● Urine RE & dipstick
○ Gross and microscopic hematuria
○ Crystalluria
● Urine & blood culture
● CT KUB (without contrast is golden standard for diagnosis)
● X-ray KUB (radio-opaque mass)
● USS KUB
● IV urogram
● MR urogram
● CT urogram
● For females:
 ○ Per Speculum examination
○ Culture of vaginal discharge
○ Pregnancy test
○ Doppler for ovarian torsion
○ Baseline tests: CBC, ESR, CRP

d. Name treatment options available for ureteric stones.

Acute Management:
● Analgesia for pain (NSAIDs or opioids)
● Antibiotics (piperacillin or tazobactam)
● Observe and monitor patient (BP, temperature, pulse, WBC
count and eGFR for renal function)
● 90% of kidney stones pass by themselves without
intervention.
● Medical expulsive therapy:
○ Alpha blockers: tamsulosin
○ Calcium channel blockers: nifedipine
● Insertion of ureteric stent
● Insertion of percutaneous nephrostomy (PCN)

Definitive Treatment:
● Extracorporeal shockwave lithotripsy (ESWL)
● Flexible ureteroscopy (FURS)
● Laser lithotripsy
● Percutaneous nephrolithotomy (PCNL)
● Rarely open stone surgery
○ Pyelolithotomy
○ Ureterolithotomy
○ Nephrolithotomy

Adjust diet and increase hydration

e. Which stones are amenable to medical dissolution therapy?

● Uric acid stones
○ Allopurinol
○ Bicarbonate
● Cysteine stones
 ○ Potassium citrate
f. What are possible complications of ureteral stones?
● Urinary tract infection
● Hydronephrosis
● Ureteral stricture
● Urinary Obstruction
● Pyelonephritis
● Renal impairment
● CKD
● Sepsis

g. What are the contraindications for conservative treatment of

ureteric stones?
● Sepsis or signs of infection
● Deteriorating renal function
● Large stones >10mm
● Complete urinary obstruction
● Solitary kidney

5. A 66 years old male smoker presented with painless gross hematuria.

Ultrasound shows mass in the right kidney.
a. What is the most probable diagnosis?
Renal Cell Carcinoma

b. Which radiological investigation will almost confirm the

diagnosis?
● CT scan with contrast (gold standard)
○ Local extension
○ Extension into renal vein and inferior vena cava
○ Distant mets
● USG
○ Solid mass
○ Size
○ Contralateral kidney
● MRI
○ Vascular extension
● Bone scan
 ○ To check for bony metastasis
○ NEEDED if the patient has increased alk phosphatase
● DTPA scan
○ If renal function is compromised
● X-ray Chest
○ To check for lung mets
● FNAC/ TRUCUT biopsy
● IVP
○ Rarely done
○ Increased renal shadow
○ Distortion of calyces

c. What is the most common histopathology in such masses?

Clear Cell Carcinoma:
● Clear cytoplasm, rich vascular network, glycogen lipids
● Foci of high grade malignant spindle cells

d. What is the gold standard treatment for a and localized disease?

Nephrectomy
● Partial
○ largest amount of healthy renal parenchyma is
preserved
○ It is done in case of
■ T1 tumor
■ Normal contralateral kidney
■ Solitary kidney
● Radical
○ Removal of the kidney, perirenal fat, adrenal gland
and regional lymph nodes.
○ If tumor is present at inferior pole then adrenal gland
is spared

6. A 55-year old male presented with LUTS. On DRE there is a smooth &
enlarged prostate.

A 60 year old male presents to urology outdoor with a history of weak

and Intermittent urine stream and nocturia for 1 уear.
A 65 year male presented with nocturia and poor stream at urination for
the last 01 years. DRE shows enlarged firm prostate. His father died of
prostate cancer. His serum PSA is 3ng/dI.

A 60 year old male presents to Urology outdoor with a history of

hesitancy, weak stream, and intermittent urination for last year. His
IPSS is 16.

a. What is the most probable diagnosis?

Benign Prostatic Hyperplasia

b. Write the most important radiology Investigation for diagnosis.

● Transrectal ultrasound TRUS
● X-ray KUB
● USG

c. Write two important groups of medicines used for this condition.

● Alpha adrenergic blockers (tamsulosin)
● 5 Alpha reductase inhibitors (finasteride, dutasteride)

d. Name two Important surgeries for this condition.

● Endoscopic
○ Transurethral resection of prostate (TURP)is the gold
standard
○ Transurethral vaporization of prostate holmium or
KTP (potassium titanyl phosphate)
○ Transurethral needle ablation (TUNA)
● Open
○ Transvesical prostatectomy
○ Transpubic prostatectomy

e. What are the management options for mild severity

Conservative treatment given above

f. Symptoms to assess the severity of the disease.

Based on IPSS
g. Write down emergency and definitive plan
● Emergent:
○ Bladder decompression
○ Catheterization
● Definitive:
○ TURP

h. Name 4 complications of this disease.

● Recurrent UTI
● Pyelonephritis
● Bladder diverticula
● Renal calculi
● Hydronephrosis
 ● CKD
● Renal failure

7. A 45years old lady presented with leaking of urine

a. How do you define urinary Incontinence?
Any involuntary leakage of urine which results from failure of
bladder to store urine due to dysfunction of bladder muscle or
sphincter or any anatomical abnormality.

b. What are different types of urinary Incontinence?

c. What are important Investigations for urinary Incontinence?

In complicated cases:
● CBC
● Cystoscopy
○ To evaluate for tumors or fistulae
● Radioimaging
○ USG KUB
○ MRI for pelvic floor defects
○ CT with contrast for masses or bladder wall thickening
● Urodynamic studies
 ○ To determine detrusor and sphincter function

Basic tests: (PVR: post-void residual volume)

d. What is the difference between nocturia and nocturnal enuresis

on the basis of history?
Nocturia:
● Nocturia refers to the need to wake up at night, often
multiple times to urinate.In the history of a person with
nocturia, there may be a pattern of waking up one or more
times at night to urinate, with a sense of urgency, and
sometimes discomfort or pain during urination.

Nocturnal Enuresis:
● Nocturnal enuresis refers to involuntary release of urine
during sleep. In the history of a person, there's a description
of bed wetting during sleep and the person may not wake up
during the episode.

8. A 22 years old sexually active male presented with acute unilateral

painful testicular swelling, urethral discharge and fever
a. What is the most likely diagnosis?
Epididymo-orchitis

b. What is differential diagnosis?

● Testicular torsion
● Hydrocele
● Varicocele
● Epididymitis
● Inguinal hernia
● Testicular tumor
● Teratoma
● Syphilitic gumma

c. What Investigations would you advise?

● It is a clinical diagnosis
● Urinalysis
○ Increased leukocytes
● Blood tests (CBC ,ESR, CRP)
● Nucleic acid amplification testing (NAAT)
○ To identity gonococcal or chlamydial urethritis
● Ultrasound
○ To identify epididymitis
○ To identify abscess formation
● Urethral swab or culture
● Tests for HIV and STI (chlamydia commonly)
● Scrotal USG
○ To rule out testicular torsion

d. How would you treat him?

● Doxycycline (100–200 mg daily) or a quinolone for two
weeks (in young men)
● Quinolones (in older men)
● In case of sepsis IV antibiotics (adjust after culture reports)
● Analgesia to relieve pain
● Contact tracing of partener
● Increased fluid intake
● In case of abscess incision and drainage is necessary
 e. What are the possible complications of this condition?
● Abscess formation
● Chronic epididymitis
● Reduced fertility/ infertility
● Testicular atrophy
● Testicular rupture

9. A Young male of 45, presented to emergency with spreading fasciitis in

right groin and scrotal skin. On examination, he is toxic looking,
having tachycardia and fever. There is a necrotic patch of skin with foul
smelling discharge.
a. Name the disease condition.
Fournier’s Gangrene

b. What are the causative organisms?

● B-hemolytic Streptococci
● S.Aureus
● E.coli
● Enterococci
● Klebsiella
● Proteus, Pseudomonas

c. Write down predisposing factors.

● Diabetes Mellitus
● Alcoholism

d. How will you manage this case?

● ICU admission
● IV access
● Resuscitation (careful monitoring of volume and cardiac
status)
● Start IV fluids, administer O2, check and control blood sugar
in diabetics
● High dose penicillin G + Broad spectrum (metronidazole)
antibiotics IV, given immediately
 ● Patient transferred to OT for debridement (surgical excision
of tissue is cornerstone of tx)
● If excessive perineal/perianal involvement, fecal diversion
with colostomy
● Wound irrigation w/ hydrogen peroxide at the end
● Catheterization for urine monitoring
● Repeat examination under anesthetic, further debridement
of residual necrotic tissue at 24hrs
● If available, Hyperbaric O2 (HB)use can be beneficial
● Treat underlying comorbid
● Vacuum assisted closure of wounds
● Reconstruction when the wound is healed by means of skin
graft.

10. A 35 years married female came to you with a history of fever,

frequency of urination burning, painful micturition, and suprapubic
discomfort for the last week
a. Name 02 differential diagnoses.
● UTI
● Cystitis
● Pelvic inflammatory disease

b. Write 3 important investigations to reach the diagnosis.

● Urine dipstick (WBCs)/ urinalysis/ nitrite testing
● Urine culture and sensitivity
● Imaging:
○ USS and CT scan
○ Cystoscopy to rule out malignancy

c. Name 3 important components of treatment.

● Antimicrobial drug therapy (empirical antibiotics)
○ Fluoroquinolones
○ Co-amoxiclav
○ Cephalosporins
○ Aminoglycoside
● Mild to moderate infection: oral antibiotics
 ● Severe: hospital admission and IV antibiotics
● Definitive treatment is correction of the underlying
abnormality
● NSAIDs for pain management
● OTHER:

11. A 45 year female presents with right flank pain with shivering and
chills. TLC Is raised. Ultrasound Is suggesting Pyonephrosis Right.
a. Name 3 possible causes of this condition.
● Ureteric obstruction by kidney stones
● Pelvic ureteric tract obstruction (PUJO)
● UTI

b. Name 3 important lab investigations.

● CBC
● Urine R/E
● Urine C/S
● Imaging:
○ USG pelvis:
■ Evidence of obstruction
■ Fluid-debris level
■ Air in collecting system
○ CT pelvis:
■ Hydronephrosis
 ■ Stranding of perinephric fat
■ Thickening of the renal pelvis

c. Name 2 Initial interventions for drainage.

● PCN (percutaneous nephrostomy)
● Ureteric stent (DJ-Stent)

d. What are possible organisms involved?

● E Coli (most common)
● Staphylococci
● Enterococci
● Proteus

12. A 33 Year male came to urology outdoor with a history of swelling of

right testis for 2 months. On examination there is painless hard
swelling within the right testis.
a. What is the most probable diagnosis?
Seminoma

b. What is the first imaging investigation for diagnosis and what are
blood investigations?
● USG (gold standard)
○ differentiates between other cystic swelling
● Others: CT/MRI
● Blood: ESR, CRP
● Tumor Markers:
○ B-HCG: increased
○ Alpha fetoprotein: pure seminomas don't secrete AFP
○ PLAP
○ OCT3/4
○ Placental Alkaline Phosphatase
○ LDH
 ● Biopsy (Cytology):
○ fried egg looking like cells

c. What is the basic surgery procedure for diagnosis and staging?

● Radical orchiectomy: removes testis and spermatic cord.
○ Used to diagnose and stage testicular tumors
especially when the diagnosis is uncertain.
● Contrast enhanced CT can also be used for staging

d. What are important risk factors for this disease?

● Undescended testis
● Smoking
● Family history
● Klinefelter syndrome
● Chromosomal abnormalities (loss of ch11,13,18)
● Infertility

13. A 35 year old male presents in emergency with a history of RTA

followed by visible hematuria. He Is vitally stable but there is bruise and
tenderness in left flank.
a. What is the most probable cause of hematuria?
● Traumatic injury to the kidney or urinary tract
● Internal bleed due to hip fracture
● Injury to bladder

b. Name 3 important steps in management.

● Classification of grades based on CT findings:
○ Grade I: Contusion, No laceration
○ Grade II: Laceration <1cm
○ Grade III: Laceration >1cm
○ Grade IV: Injury involving collecting system
○ Grade V: Shattered kidney or hilum avulsion
c. What imaging investigation is required for grading the injury for
management?
● CT scan with contrast is the investigation of choice in stable
patients

● Others:
○ In unstable patients one shot Intravenous Pyelography
(IVP)
○ FAST

d. What grades of the injury are managed conservatively?

14.A 6 weeks old baby boy is brought by her mother to you. The mother
thinks there is something wrong "down there". On examination there
is a rounded swelling in the left groin. There is no impulse on crying.
Also, there is an empty ipsilateral side of scrotum.
a. What is the most likely diagnosis of this condition?
Cryptorchidism/inguinal hernia

b. At what age the surgery should be done?

c. Why is it not done at this age?
d. If not done what complications can occur?

15. A 32 year old male with a history of surgery for the right undescended
testis in childhood presented with a painless lump in the right testis.
a. What is the most probable diagnosis?
Testicular Carcinoma

b. What is diagnostic imaging investigation?

● USG
● Testicular ultrasound

c. Name three treatment modalities for this disease?

 ● Chemotherapy: platinum based (cisplatin)
● Radiotherapy
● Surgery: orchiectomy

Orthopedic:
1. A 55-year-old male presented to the Accident and Emergency
department with a history of RTA. At the time of presentation, he was
conscious and oriented with GCS 15/15. He is complaining of low back
pain. On examination, the log roll test of both lower limbs is negative.
There is a left foot drop.
a. How will you clinically assess this patient?
● Advanced trauma life support protocol (ATLS)
○ Immobilize the spine using full spinal precautions
until proven otherwise
● Primary survey:
○ Systemic examination, particular attention to
abdomen and chest, spinal injury masks as
intra-abdominal injury.
● Spinal examination
● Neurological examination (ASIA neurological impairment
scale)

● Lower limb neurological assessment (motor + sensory)

using MRC grading (0-5)
● Palpate the entire spine after spinal log roll
● Leg signs:
 ○ common peroneal nerve stress test (Foot drop is
typically common peroneal nerve injury)
● SLR (straight leg raise test)
● Femoral stretch test
● Gait assessment
● Rectal exam

b. What investigations are required to assess spinal injuries?

● Full cervical spine series
○ Anteroposterior view and Lateral view of the whole
cervical spine
○ Open mouth views.
● Computed tomography (CT) scanning with
two-dimensional (2D) reconstruction remains the gold
standard
● MRI
○ In cases of neurological deficits
○ To check ligaments
● Myelography
● EMG(electromyography)
● NCS (nerve conduction studies)
● Evoked Potentials
● Bone Scan
● Angiography
● Dynamic imaging:
○ Lateral flexion–extension radiographs of the cervical
spine for assessing long term stability of spine.

c. How will you manage the patient?

● The likely cause of this patients foot drop and lower back
pain is:
○ Lumbar Nerve Root Compression: as lower back pain
and negative log roll test
○ Common Peroneal Nerve Injury (causes foot drop) : At
Knee or thigh level.
● Stabilization:
 ○ Ensure that the patient's vital signs are stable and that
there are no other life-threatening injuries. In this
case, the GCS score of 15/15 is reassuring.
● Pain Management:
○ Address the patient's pain with appropriate pain
management techniques, while maintaining their
level of consciousness.
● Immobilization:
○ Immobilize the spine and pelvis to prevent further
injury. This may include applying a cervical collar and
a rigid backboard.
● Treat the underlying cause:
○ After results of imaging determine appropriate
treatment options such as physical therapy,
medication or surgical decompression at appropriate
lumbar levels.
● Rehabilitation:
○ If the foot drop is due to nerve compression or injury,
rehabilitation may be necessary to regain strength and
function in the affected leg.

2. A 26-year-old male had a motorcycle accident an hour ago. He

complains of severe pain and inability to use his right shoulder. He also
has numbness over the shoulder. Clinically, he has loss of shoulder
contour & blunted sensations over the deltoid region. His radial pulse is
well felt. There is no open wound or any other injuries.
a. Diagnosis?
Anterior Shoulder Dislocation

b. Write down clinical tests to help in its diagnosis?

● Shoulder apprehension test.
○ the shoulder has a full range of motion, but with
forced abduction and external rotation the patient
experiences apprehension
● Loss of shoulder contour
● Humeral head may be palpable below the coracoid or in the
axilla
 ● Hamilton ruler test
● Duga’s test (inability to touch opposite shoulder)
● Callaways test

c. How will you confirm your diagnosis?

● CT or MR Arthrography
○ detachment of the anteroinferior labrum (Bankart’s
lesion)
○ damage to the humeral head (Hill–Sachs lesion)
● X-ray AP view:
○ To determine type of dislocation
○ To determine if there is a fracture or not

d. Enumerate two complications

● Axillary nerve damage/ axillary nerve palsy
● Injury to axillary artery
● Unreduced dislocation
● Recurrent dislocation
● Traumatic osteoarthritis
● Shoulder stiffness

e. How will you manage this patient?

● An emergency, the dislocation will be reduced under
analgesia or sometime under anesthesia
● Conservative management: reduction with following
methods:
○ Kocher's method
○ Hippocratic method
○ Stimson's maneuver
3. A young enthusiastic athlete has reported with agonizing pain in his
right leg which particularly comes during physical exertion . On clinical
examination, the consultant has a suspicion of stress fracture of tibia.
a. What is a stress fracture?
A stress fracture is a small crack or hairline fracture in a bone that
occurs due to repetitive stress or overuse rather than a single
traumatic event.

b. What is the etiology of a stress fracture?

● Repetitive Overloading:
○ Running
○ Jumping
○ Dancing
● Training Errors
● Muscular Fatigue
● Poor Biomechanics:
 ○ Abnormalities in foot arches, leg alignment, or gait
mechanics
● Inadequate Bone Strength:
○ Osteoporosis
○ Vitamin D or calcium deficiency
● Environmental Factors:
○ Training on hard or uneven surfaces
○ Inadequate footwear
● Poor recovery:
○ Inadequate rest, recovery and nutrition

c. Write the radiological findings of a stress fracture?

● X-ray:
○ Fracture line
○ Increased cortical density
○ Callus formation
○ Sclerosis
○ Periosteal thickening
● MRI:
○ Soft tissue edema
○ Inflammation
○ Fracture line
● Bone Scans:
○ Hot spots due to increased bone turnover

d. How will you treat this condition?

● Low risk stress fractures:
○ Decrease physical activity
○ Splinting
○ Pain control (acetaminophen, ice packs)
○ Risk modification (improved nutrition, calcium and
vitamin D supplementation)
● High risk stress fractures:
○ Closed reduction
○ Immobilization (with cast or splint)
○ Avoid weight bearing activities
○ Risk factor modifications
4. A 45-year-old air combat fighter pilot presented to the OPD with a
complaint of low back pain for the last two weeks. The pain is radiating
to the right lower leg. There is no paresthesia in lower limbs. There is
no bladder or bowel complaint. On examination he has limited forward
flexion of spine. There is decreased sensation on the dorsum of the
right foot as compared to the left side and there is decreased
dorsiflexion or right big toe. The deep tendon reflexes are intact on
both sides.
a. What is the most likely diagnosis? give 2 other possible
diagnoses?
● Most likely diagnosis: Herniated Lumbar Disc (sciatica)
● Differentials:
○ Lumbar disc degeneration
○ Spinal stenosis
○ Lumbar Spondylosis
b. How will you investigate to confirm the diagnosis?
● MRI of the Lumbar spine is diagnostic. Will show herniation
at L4-L5
● CT to visualize spinal stenosis
● Straight Leg Raise (for L5-S1 root) pain at 30-70 degrees
● Diagnostic Injections: Lumbar Transforaminal ESI (selective
nerve root block)
● Electrodiagnostic test: EMG and NCS

c. How will you manage the patient?

● Conservative:
○ Rest
○ Physical Therapy
○ Pain Management:
■ NSAIDs
■ Acetaminophen
■ Trial of pregabalin (GABA analogue)
■ Transforaminal epidural steroid injection
■ Activity Modification (avoid changes that can
exacerbate or cause pain)
● Surgical:
 ○ Microdiscectomy
○ Laminectomy
○ Foraminotomy
○ Fusion

5. You have received a 25 year old male patient in emergency, with a

history of road traffic accident, He has an isolated open fracture of right
tibia & fibula.

A young motorcyclist has sustained a compound fracture of his right

tibia and fibula and has been brought to the emergency department in a
state of shock. A loose cotton dressing is seen around his wound which
is soaked in blood.
a. Give an overview of his acute care in the emergency department.
● ABCDE
● Control the hypotension by adding IV fluids (crystalloids).
● Give universal donor blood products (o neg). Order specific
packed red cells for transfusion.
● Apply pressure to the wound to prevent leakage of blood and
icing to vasoconstrict the local area.
● Give antifibrinolytics such as aminocaproic acid.

b. Define an open fracture?

● Any fracture with an overlying wound should be considered
an open fracture
● Fracture communicates with the exterior

c. How will you manage his fractured limb in the ER ? What is his
definitive treatment?
● Presurgical Phase:
○ Follow ATLS protocol guidelines (ABCDE)
○ Remove Macroscopic Dirt
○ reduce the fracture/dislocation
○ Once overall alignment is achieved, splint the affected
limb
○ Apply a moist saline dressing to the wound
○ Administer intravenous antibiotics (Broad spectrum)
 ○ Tetanus prophylaxis
○ Document and inform Surgical Team
● Surgical Phase:
○ Fracture stabilization:
■ External fixation
■ Internal fixation with
screws/plates/intramedullary nails
○ Management of the soft tissues:
■ Debridement

6. A 70 year old patient was brought to emergency with a history of fall in

home. He is vitally stable and conscious. His X-ray shows
intertrochanteric fracture of the left side.
a. How will you manage him?
● Treatment:
● Conservative treatment has very little role, only considered
for those patients who are very ill and unfit for any kind of
anesthesia.
● Surgical Treatment:
○ ORIF (Open reduction and internal fixation) is done
using plates, screws or nails (for this patient
cephalomedullary nails are used)
● Manage any complications that may arise:
○ Malunion
 ○ Thromboembolic complication Bed sore
○ Pneumonia

b. What is the choice of implant?

● Two types:
○ Cephalomedullary nails: (in older patients with
unstable fractures)
○ Sliding hip screws and plate (in younger patients with
good bone quality and stable fractures)

c. Types of fractures?
● Types fracture
○ Stable (broken ends of bones not out of place)
○ Unstable (needs aggressive treatment and surgery)

7. A 6 year old boy presented with a history of fever and pain at right distal
femur for two weeks. You are suspecting acute osteomyelitis.
a. What are the investigations required to support your diagnosis?
How will you interpret it?
● Blood Tests:
○ CBC: WBC, ESR and CRP Raised
● Early phase: (2-3 Days)
○ Normal Radiograph
○ MRI:
■ Bone edema
■ Periosteal elevation
● 5-7 days:
○ Osteopenia
○ Periosteal new bone formation
● Isotope bone scan:
○ T99 bone scan
○ shows areas of increased bone activity indicating
infection
● CT Scan:
○ Bone erosion
○ Fluid collection
● MRI:
 ○ investigation of choice showing edema of the marrow
and collection of pus.
● Blood culture
○ To isolate organism
● Microbiology:
○ Gram stain

b. Management.

● Resuscitation
● Antibiotics (after C/S) IV antibiotics for 2 weeks followed by
oral for 4-6
● Splintage of affected limb to prevent soft tissue contracture
● Radiology guided aspiration of pus
● Cortex of involved bone may be drilled at 2 or 3 sites
 ● to decompress the underlying pus

c. Complications.
● Recurrence
● Chronic Osteomyelitis
● Septic Arthritis
● Pathological Fracture
● Damage to growth plate
● Bone necrosis
● Septicemia

8. A 22 year old footballer had trauma to his left knee while tackling the
opponent. He heard a pop in his knee and fell down. He immediately
developed a swelling in the knee and was unable to continue the rest of
the game. At the time of presentation in the A & E department he had
left knee swelling and movements were painful and restricted.
a. What can be the possible injuries?
● Left ACL tear,
○ Unhappy Triad
■ Lateral meniscus tear
■ ACL injury
■ MCL injury
● PCL
● Collateral ligament injury
● Meniscus injury
● Dislocation of Patella

b. What Investigation will you advise that will help in diagnosis?

EXAMINATION:

● Anterior Cruciate Ligament:

○ Lackmans test
○ Anterior Draw test
● Posterior Cruciate Ligament:
○ Posterior draw test
○ Posterior sag sign
 ● Collateral Ligaments:
○ Lateral collateral ligament:
■ Varus stress test at 10 degree flexion
○ Medial collateral ligament:
■ Valgus stress test at 30 degree flexion
● Mensici:
○ McMurray’s Test
○ Appleys test
○ Valgus stress test
● Patellofemoral joint:
○ Patellar tracking
○ Patellar apprehension (fairbank’s test)

IMAGING:

● MRI is investigation of choice: will show tears in ligaments

along with meniscal damage
● X-Ray:
○ Full series; AP, lateral, inferior-superior axial views
○ Will not show soft tissue but other causes of knee pain
e.g fractures or osteoarthritis
● Arthroscopy: direct visualization of internal structures.
● Arthrography
● CT scan

c. How will you treat this patient?

● Initial Acute Phase:

○ Analgesia for pain relief

■ Paracetamol
■ Codeine
 ○ Aspiration of hemarthrosis
○ Temporary knee brace or crutches
○ Physiotherapy before and after surgery to strengthen
quadriceps and hamstrings.
○ For Menisci: plaster backslab for 3-4 weeks after acute
injury
● Surgical Intervention:
○ Surgical repair, augmentation and reconstruction are
considered in multiligament injuries
○ ACL
■ Isolated ACL injury is most commonly treated
with an arthroscopic intra-articular
reconstruction using allograft.
■ In case of avulsion arthroscopy is required
○ Menisci:
■ Arthroscopy with meniscal debridement for
central tears.
■ Meniscus repair for peripheral tears
■ Corticosteroid injection into joint (partial,
subtotal, total)
■ Meniscectomy
○ Collateral Ligaments:
■ Exploration and reconstruction
■ Protection from further injury using a brace that
allows motion and protects from valgus injury.
○ Post Surgical Rehab: intense rehab and physiotherapy
with focus on regaining range of motion and working
on strengthening the quadriceps and hamstrings to
stabilize the knee.

9. A 30 year old male presented with a history of a road side accident 1

hour ago. He landed in Emergency with an 08 cm bleeding laceration
over his right tibia. X-ray shows an oblique fracture of the shaft of
Tibia.
a. What is an open fracture?
Any fracture with an overlying wound should be considered
an open fracture.
 OR
The fracture communicates with the exterior. i.e. the skin over the
fracture site is breached (the broken bone penetrates through skin
and is exposed to the outside environment)

b. How will you evaluate him?

● ABCDE: Airway and cervical spine, Breathing, Circulation,
Disability, Exposure.
● Secondary survey
○ Examination once patient is stable
● Neuro-vascular examination
● Look for compartment syndrome
● Assess fracture according to Gustilo-Anderson
Classification:
○ Grade I. wound less than 1 cm, minimal soft tissue
injury and simple fracture.
○ Grade II. wound more than 1 and less than 10 cm,
moderate tissue trauma moderately comminuted
fracture.
○ Grade III A. wound more than 10 cm severe tissue
injury. Bone is coverable. Comminution high.
○ III B wound more than 10 cm. severe contamination
highly comminuted fracture, soft tissue coverage for
bone is required.
○ III C irrespective of size of the wound there is vascular
injury which needs repair.
● Wound assessment
● Imaging (X-ray and CT)
● Assessment of vascular injury and status.

c. What emergency treatment is required in the ER.

● ATLS protocol
● Assess neurovascular status and if compromised and the
fracture displaced, quickly remove any macroscopic dirt and
reduce the fracture/dislocation.
● Splint limb
● Blood grouping and crossmatch
 ● IV fluids
● Debridement and irrigate with 0.9% saline
● Administer intravenous antibiotics (broad spectrum)
according to local protocols.
● Analgesics
● Tetanus prophylaxis
● Inform an orthopedic surgeon and prepare for the surgical
phase.

10.A six-year-old child presented with a history of fever for 1 week. He has
a swollen erythematous right knee. He is unable to move his knee and
complaining of severe pain.

A 35-year-old lady presented to OPD with complaints of pain and

swelling left knee for the last 02 months. There is no history of trauma.
She has lost her appetite. There is no significant history of weight loss,
however she has on and off fever which settles with taking antipyretics
from local GP. On examination there is effusion in the knee joint along
with generalized boggy swelling, mildly tender, soft in consistency.

a. What is the most likely diagnosis?

Septic Arthritis

b. What is the differential diagnosis?

● Inflammatory arthritis (rheumatoid, psoriatic)
● Crystal Arthropathy
● Traumatic Arthritis
● Hemarthrosis

c. What investigation do you want to do for confirmation of

diagnosis?
● Arthrocentesis (gold standard)
● Lab Tests:
○ FBC, ESR, CRP and blood cultures .
○ High WBC count in joint fluid with neutrophil
predominance.
 ○ Gram Stain and C/S (S. aureus is the most common
organism.)
● Imaging:
○ X-ray:
■ To exclude other diagnosis
■ To identify osteomyelitis
○ Ultrasound:
■ To identify joint effusion
○ MRI

d. How do you want to treat him?

● Surgical Drainage
○ Open washout is preferred over an arthroscopic wash.
○ Repeated aspiration/irrigation via large bore cannula
or small arthroscope of all joints except hip joint.
● Antibiotics:
○ 2 weeks IV antibiotics followed by 2-4 weeks oral
○ According to hospital guidelines
○ Gram stain and culture reports
● Splint the joint in reduced position till inflammation
subsides
● Monitor inflammatory markers as more than one washout
may be required if the child fails to improve.

11. Patient had an RTA, Eye opening on a painful stimulus. He was

confused and moving all four limbs when asked. His CT scan shows an
extradural hematoma.
a. What is his Glasgow coma score?
His GCS is 12/15.
(Eyes 2/4, Verbal 4/5, Motor 6/6)

b. How does an extradural hematoma show on CT scan?

● On CT, extradural haematomas appear as a lentiform
(lens-shaped or biconvex) hyperdense lesion between skull
and brain.
 ● Mass effect may be evident, with compression of
surrounding brain and midline shift.

c. Briefly describe burr hole surgery.

● After patient prep an incision is made in the scalp and bone
is exposed.
● A small hole, typically about 1 to 2 centimeters in diameter,
is created in the skull bone using a burr drill. If large area,
craniotomy is performed and bone flap is removed.
● After the necessary procedures are completed,(evacuation of
hematoma), the bone flap is usually repositioned and
secured in place using sutures, plates, or other fixation
techniques

12. A 33-year-old lady presented to the OPD with a complaint of low back
pain for the last 05 months. The pain is moderate in intensity and is
radiating to the left lower leg up to the dorsum of the foot. She is also
complaining of off-and-on numbness. She is also complaining of
anorexia and weight loss for the last 03 months. X-rays of the
LUMBOSACRAL spine show destruction of the lower end of the L-4
vertebra with decreased disc space at the L4-L5 level.
a. Diagnosis.
Spinal tuberculosis (TB) or Pott’s Spine

b. What are the different modes of spread of this disease?

● Hematogenous
● Lymphatics
● Contiguous
● Direct extension
● Reactivation of latent TB

c. Enlist the radiological and serological investigations with

expected results to be observed.
● Serological:
○ ELISPOT (Enzyme- linked immunospot)
○ IgM & IgG antibodies: High sensitivity, low specificity
○ PCR: Tissue /Pus PCR more sensitive
 ● Radiological:
○ X-Ray:
■ Reduced disc space
■ Blurred paradiscal margins
■ Destruction of bodies
■ Loss of trabecular pattern
■ Increased prevertebral soft tissue shadow
■ Subluxation /dislocation
■ Decreased lordosis/Kyphosis
○ MRI:
■ Detect marrow infiltration in vertebral bodies,
leading to early diagnosis
■ Changes of discitis
■ Assessment of extradural abscesses/
subligamentous spread.
■ Skip lesions
○ Radionucleotide Scan T 99m:
■ Avascular segments and abscesses show a cold
spot due to decreased uptake.
■ Highly sensitive but nonspecific.
■ Localize the site of active disease
■ Detect multi level involvement

d. How will you treat this patient?

● Anti Tuberculous Drugs:
 ● Supportive treatment:
○ High protein diet
○ Multivitamins
○ Chest/Urinary tract care
○ Improve immune status
○ Hematinics
● Monitoring:
○ Radiographs and ESR at 3-6 months interval
○ MRI at 6 months interval for 2 years
● Abscess drainage
● Surgery:
○ Decompression(+/- fusion)
○ Debridement +/- decompression +/- fusion
○ Anterior transposition of cord (Extrapleural
anterolateral approach)
○ Laminectomy

13. A 30-year-old biker fell from bike after striking the roadside pavement.
He fell from the bike in an outstretched hand with abducted and
externally rotated. At the time of presentation, he had a swollen left
elbow with bruising. The patient was holding his injured limb with his
right hand and elbow was in slight flexion.
a. What is the most likely injury?
Posterior Elbow Dislocation

b. What can be other possible injuries to the elbow?

● Brachial artery injury
● Ulnar nerve injury
● Median nerve injury
 ● Olecranon fracture
● Supracondylar fracture of humerus

c. How will you confirm your diagnosis?

d. How will you manage this patient in the Accident and Emergency
Department?

14.A 30 years old male presented with a history of pain over the right tibia.
Pain is more at night and responds to analgesia. There is mild swelling
as well. There is no history of fever and weight loss
a. What is the most likely diagnosis?
 Osteoid Osteoma

b. What investigations are required?

● X-Ray:
○ Small radiolucent area called nidus
○ Lesions in the diaphysis are surrounded by dense
sclerosis and cortical thickening
● CT scan:
○ Nidus
● Scintigraphy:
○ Double density sign
● Histology:
○ Circumscribed highly vascular, made of
fibroconnective tissue and woven bone

c. What is the treatment?

● NSAIDs
● CT-guided thermocoagulation
● Surgical removal

15. A 47 year old presented to ED with a history of RTA. He sustained injury

to his right lower leg.
a. Name the parameters based on which you can describe a bone
injury.
● Location
○ bone/bones involved
● Type of fracture
○ Transverse, Oblique, Spiral, Comminuted, Butterfly or
wedge, Segmental
○ Open or closed
● Alignment
○ Displaced
○ Not displaced
● Direction of fracture
● Associated soft tissue injury
● Intra or Extra-articular
● Stability
 ● Neuro-vascular status

b. Name any two classification systems used for classification of

fractures.
● Gustilo and Anderson open fracture classification.
● AO/OTA fracture and dislocation classification (muller’s
classification)
● Tscherne Classification for soft tissue injury

c. Enumerate the purpose of classifying fractures.

● Diagnosis
● Planning appropriate treatment according to the type (as
different types have different treatment)
● Standardized classification helps communicate and
collaborate
● Helps in assessing prognosis for injuries
● Accurate documentation
● Research and Epidemiology
● Compare results

16.A middle-aged fatty lady has presented with worsening pain(more at

night) and paresthesia in both hands, more so in the right hand. Pain is
also felt in her arms and she tries to relieve it by shaking the arm or
hanging it over the side of the bed. A recent development in her
symptoms is utensils falling from her right hand while she is working
in the kitchen. Clinical examination reveals hypoesthesia in her right
index and middle finger.

50 yrs diabetic female, history of pain in the radial aspect of the right
hand. She experiences numbness in her right hand at night.
a. What is your clinical diagnosis?
Carpal Tunnel Syndrome

b. Give two differential diagnoses.

● Cervical radiculopathy
● Diabetic neuropathy
● Thoracic outlet syndrome
 ● Pronator syndrome

c. How will you confirm this diagnosis?

Durkin’s compression test: digital pressure over the carpal tunnel

reproduces the symptoms

d. Give an outline of treatment in this case.

● Non-operative:
○ Night splintage of the wrist in extension
○ Steroid injections
○ Analgesia
● Surgical:
○ The median nerve is surgically decompressed by
incising the roof of the tunnel (transverse carpal
ligament), as either an open or an endoscopic
percutaneous procedure.

17. 6 months, breech delivery, mother notices limitation of abduction of

Rt. Thigh. Leg is short and there is clicking on hip abduction.

A newborn baby presented with H/O breech delivery. There is clicking

on the movement of the right hip.
a. Diagnosis.
Developmental dysplasia of the hip (DDH)

b. What is congenital dislocation of the hip?

Also known as Developmental Dysplasia of the Hip (DDH) defines
the spectrum of hip instability, ranging from the
hip that is in joint but has a shallow (dysplastic) acetabulum
and may be ‘pushed out’ to the dislocated hip that is irreducible

c. What are the predisposing factors?

● Family history
● Oligohydramnios
● Breech presentation
● Girls>Boys
● More common in firstborns
● Congenital Muscular Torticollis
● Spina bifida
● Regional and racial variations

d. Investigations.
● Ultrasound
○ hip stability/anatomy
● Radiography

e. What is the Ortolani and Barlow test?

Ortolani test:
● The hips are abducted gently, if abduction is limited the hip
may be dislocated. The examiner’s finger then lifts the
greater trochanter upwards, a soft clunk-the ortolani test-
with improved hip abduction signifies hip reduction.
 Barlow test:
● If the hip does abduct fully, then the leg is brought back up
to neutral and then adducted while downward pressure is
applied to the knee with the examiner's thumb and palm, an
unstable hip may dislocate or subluxate.

18. A 60 years old male presented with a history of bilateral knee pain. He is
diagnosed with osteoarthritis.
a. Define osteoarthritis.
● Osteoarthritis is a non-inflammatory, degenerative
condition of joints.
● Characterized by degeneration of articular cartilage and
formation of new bone i.e. osteophytes

b. Describe the conservative treatment of osteoarthritis.

Conservative treatment:
● Patient education
● Protect joint from overload
● Exercise:
○ Swimming
○ Cycling
● Modify daily activities
● Relieve pain
○ Analgesics (acetaminophen)
○ NSAIDS
○ Intra-articular steroids
○ Chondroprotective agents
Surgical:
● Joint debridement.
○ Open or arthroscopic
● Realignment osteotomy to redistribute the load on the joint.
19. 5 yrs male, presented to OPD with complaints of bowing of legs for the
past 3 months which is progressing gradually. Complaints of
generalized weakness and lethargy. O/E there is inward bowing of legs.
a. What is the diagnosis?
Rickets

b. Describe the Pathophysiology of the Underlying Disease.

In all types of rickets, there is impaired bone mineralization of
new bone formation and therefore only
effects children with open growth plates
● Calcipenic Rickets - decreased amounts of calcium lead to an
increase in PTH levels, resulting in decreased phosphate =
impaired bone mineralization
● Phosphopenic rickets - decreased phosphate = impaired bone
mineralization
● Direct inhibition of mineralization = impaired bone
mineralization

c. How will you investigate the child to reach a diagnosis?

● Labs:
○ Serum Calcium low
○ Serum phosphorus low
○ Serum alkaline phosphatase elevated
● X-ray wrist and knees:
○ Evidence of bone loss (decreased bone mineral
density, thinned cortical bone)
○ Pathological fractures
○ Epiphyseal plate widening
○ Bone bowing

d. What will be the management of the child?

● Correction of electrolyte imbalance
● Vitamin D and calcium supplementation
● Surgery may be necessary for the management of any
residual limb deformity
20. A 30-year-old male has been brought to the emergency room after
sustaining a road traffic accident. He complains of pain left thigh and
inability to move left lower limb. On examination the left lower limb is
short and the thigh is swollen and tender. Pulses in the left foot are not
palpable.
a. What is your diagnosis? (Lt. Femoral Shaft Fracture with vascular
injury)
b. How would you confirm your diagnosis? >1y
c. How will you manage this patient in the emergency room?
d. What is the definitive management for this patient?
e. Name two complications that may result from this injury?

21. A 35 year old male presented in the emergency room with a history of
fall from the second floor. His left thigh is swollen and he is
complaining of severe pain. He is hemodynamically stable. (Lt. Femoral
Shaft Fracture)
a. How will you approach this case in ER?
b. What is the definite treatment?
c. Name three common complications of this case.

22. A 70 year old man had a fall in his washroom and was unable to help
himself to stand and was helped by his servant to carry him to the
hospital on a stretcher. He is feeling severe pain in his right hip, his
Right knee is slightly flexed and his right foot is externally rotated. He
resists passive movement at the hip due to severe pain.
a. What is the most probable clinical diagnosis?
Fracture of neck of femur (intra or extra capsular??)

b. What emergency treatment will you carry out for this case?
c. What are the options for his definitive treatment?

23.A 12-year-old boy presented with a bony swelling over the medial
aspect of the proximal tibia. The swelling has started to increase in size
recently. There is no history of fever or weight loss.
a. What is the diagnosis? (Osteochondroma (Cartilaginous
Exostosis))
b. How will you investigate?
 c. What are the indications of surgical excision?
24. A 30-year-old male presented to OPD with pain and swelling of left
thigh for the last 5 months. There is also a complaint of lethargy and
weakness along with anorexia and weight loss for the last 01 months.
There is no history of trauma. The swelling is on the lateral aspect of
midthigh gradually increasing in size, diffuse, firm in consistency.
Non-fluctuant, irreducible and non-compressible. The
transillumination test is negative. The neuro-vascular status of the
lower limbs is intact and there are enlarged inguinal lymph nodes.
a. What is the most likely diagnosis?
Ewing’s sarcoma/Fibrosarcoma
b. 2 differential diagnoses?
c. How will you investigate this patient?
d. How will you manage this patient?

Hernia:
1. An average built man in early sixties has presented with bilateral hernia
in the inguinal region. He is a chronic smoker. You need to evaluate him
for surgery.
a. What are the predisposing factors for development of hernia?
● Basic design weakness
● Weakness due to structures entering and leaving the
● abdomen
● Developmental failures
● Genetic weakness of collagen
● Sharp and blunt trauma
● Weakness due to aging and pregnancy
● Primary neurological and muscle diseases
● Excessive intra-abdominal pressure

b. What will you specifically evaluate in your clinical workup?

● Lump
● Pain/discomfort
● Reducibility of hernia
 ● Symptoms that might suggest bowel obstruction
● Primary of recurrent hernia
● Cough impulse
● Try to get above the swelling
● Examine scrotal sac to check for extension into the scrotum
● Asses for incarceration or strangulation of hernia
● Bowel sounds may be heard on auscultation

c. What laboratory and imaging investigations will you advise?

d. Write preventive measures for recurrence in this case?

● During Operation:
○ Mesh Repair / Hernioplasty
● Post-Operatively:
○ Maintain ideal body weight
○ Eat proper diet
○ Avoid constipation + straining
○ Avoid heavy lifting
○ Maintain proper glycemic control
○ Quit smoking

2. A 34 yrs old female has presented with multiple bluish swellings over
the medial aspect of her right leg. During examination you find that
cough impulse is positive below and lateral to her ipsilateral pubic
tubercle.
a. What is the most likely diagnosis?
Femoral hernia
b. How will you investigate to confirm diagnosis?
● Ultrasonography
● CT scan
 ● X-ray:
○ Small bowel obstruction
c. Outline the steps of its operation.
● Low Approach (Lockwood):
○ when there is no risk of bowel resection
○ A transverse incision is made over the hernia
○ The sac of the hernia is opened and its contents
reduced
○ The sac is also reduced and non-­absorbable sutures
are placed between the inguinal ligament above and
the fascia overlying the bone below
○ Some surgeons place a mesh plug into the hernia
defect for further reinforcement
● The Inguinal Approach (Lotheissen):
○ The spermatic cord (or round ligament) is mobilized
and the transversalis fascia opened from deep inguinal
ring to the pubic tubercle.
○ A femoral hernia lies immediately below this incision
○ It is reduced by a combination of pulling from above
and pushing from below
○ Once reduced, the neck of the hernia is closed with
sutures or a mesh plug, protecting the iliac vein
● High Approach (McEvedy):
○ Ideal in the emergency situation where the risk of
bowel strangulation is high
○ A horizontal incision (classically vertical) is made in
the lower abdomen centered at the lateral edge of the
rectus muscle
○ The anterior rectus sheath is incised and the rectus
muscle displaced medially
○ Femoral hernia is reduced. If bowel necrosis is visible,
resection of bowel is made right there itself. If the
bowel is still alive, it is placed back into the peritoneal
cavity and a mesh is placed on the femoral defect.

3. 36 yrs laborer, swelling in the right groin for the last 6 months. The
swelling reduces upon lying down and increases upon standing for
 prolonged periods of time. O/E there is a scrotal swelling and one can
not get above the swelling upon examination, ring occlusion test is
positive. (Indirect Inguinal Hernia)

32 yrs male presented with history of surgery for right undescended

testis in childhood, present with painful lump in the right testes
a. What is the diagnosis?
b. Imaging investigations.
c. Treatment modalities.
d. Name the operation performed for the treatment.
e. Enlist immediate early and late complications of the operation.
4. 63 yrs male, presented with complaints of intermittent swelling in the
right groin for the last 5 months, O/E there is a 12 x 6 cm swelling in the
right groin extending into the neck of scrotum.
a. Ddx in order of priority
b. Mention clinical signs to differentiate among ddx.
5. 60 yrs male presented with colicky abdominal pain, related vomiting,
abdominal distention for the last 3 days. He is toxic and febrile. There is
tense tender swelling at the right inguinoscrotal region
a. What is the diagnosis?
Strangulated Inguinal Hernia

b. Pre-operative management for this patient.

● Resuscitate with adequate fluids
● Empty stomach with nasogastric tube
● Give antibiotics to contain infection
● Catheterise to monitor hemodynamic state

6. A 45 yrs old female presented with visible swelling that appears in the
right hypochondrium upon coughing for the last 2 yrs. She was
operated on for open cholecystectomy 3 yrs ago. The swelling appears
while coughing through the scar while the defect is palpable there.
a. What is the diagnosis?
Incisional Hernia

b. Factors for occurrence.

● Patient factors:
 ○ Obesity
○ General poor healing due to malnutrition
○ Immunosuppression or steroid therapy
○ Chronic cough
○ Cancer
○ Pregnancy
○ Vomiting
○ Distention
● Wound factors:
○ Poor quality tissues
○ Wound infection
● Surgical factors:
○ Inappropriate suture material
○ Incorrect suture placement
○ Drainage
○

c. How can the surgeon avoid this while doing cholecystectomy?

● Alternative surgical method:
○ Laparoscopic
○ Robotic
● Proper wound closure technique:
○ Layered closure ensuring each layer is closed
separately and tightly ensuring tension distribution
○ Use of absorbable sutures (slow absorbing)
○ Suture to wound length ratio 4:1. Small bites during
suture
● Minimize tension on wound:
○ Gentle tissue handling while dissecting
○ Proper sizing of incision after accurate imaging
● Effective hemostasis during surgery
● Prevent infections:
○ Aseptic technique
○ Antibiotic prophylaxis