Case 1
An otherwise healthy 20-year-old woman presents to your office with concerns regarding her breasts.
Breast reduction
Objective 1: To identify surgical options for breast reduction
- Question 1: What surgical options would you offer to this patient for breast reduction?
Key Answers 1:
- Wise pattern
- Superior pedicle
- Superomedial pedicle
- Inferior pedicle
- Bipedicle
- Free nipple graft
Objective 2: The candidate can draw markings for a Wise pattern breast reduction
- Question 2: You decide to proceed with a Wise pattern breast reduction – please draw your surgical markings?
Key Answers 2:
- Draws sternal notch to nipple distance
- Draws nipple to IMF distance
- Draws pedicle of appropriate width
- Draws vertical limbs of appropriate length
- Draws horizontal limbs of appropriate length
- Comments on length of the pedicle
Objective 3: The candidate can manage nipple necrosis
- Question 3: Following the procedure the patient experiences necrosis of the left nipple. How would you manage this complication?
Key Answers 3:
- Allow healing by secondary intention
- Secondary nipple reconstruction
- Secondary tattooing of nipple and areola
- Tell the patient that this is a complication
Case 2
A 25-year-old woman sustained a puncture while gardening. She presented to the emergency room 48 h after the injury with a painful and swollen finger.
Flexor tenosynovitis
Objective 1: To assess the candidate’s ability to diagnose flexor tenosynovitis
- Question 1: What specific features would you examine for in this patient on physical examination?
Key Answers 1:
- Kanavel’s 4 signs
- Pain on passive extension
- Finger held in flexion
- Pain on palpation of the anatomic flexor tendon sheath
- Fusiform swelling of the digit
Objective 2: To assess the candidate’s ability to manage flexor tenosynovitis
- Question 2: You decide to manage the patient nonoperatively. What is your initial management?
Key Answers 2:
- Intravenous antibiotics
- Limb elevation
- Splint
- Hospital admission or outpatient re-evaluation within 24 h
- Question 3: What antibiotics would you choose
Key Answers 3:
- Combination coverage for Gram-positive and Gram-negative organisms
- Gram positive: One of – ancef, vancomycin, penicillin, cloxacillin, moxifloxacin
- Gram negative – One of – ciprofloxacin, gentamicin, ceftriaxone, Consider flagyl
- Could consider broad spectrum piperacillin/tazobactam or ticarcillin/ clavulin pending cultures
Objective 3: To assess the candidate’s operative management of flexor tenosynovitis
- Question 4: After 24 h, you re-assess the patient and her pain has increased, as has the swelling. What is your management now?
Key Answers 4:
- I&D
Question 5: Please draw your incisions
- Please give Transparency to draw on the photo
Key Answers 5:
- Draw lines for Bruner inicision
- Initially makes incision over the A1 pulley proximally and the A5 pulley distally
- Describes irrigation of the tendon sheath
Objective 4: To demonstrate recognition of the complications of untreated tenosynovitis
- Question 6: What is a common adverse consequence of untreated flexor tenosynovitis?
Key Answers 4:
- Flexor tendon rupture
- Tendon adhesion