NEET MDS Lessons
General Surgery
An ulcer is a break in the continuity of the skin or the mucous membrane.
Mode of onset: Traumatic ulcers heal when the traumatic agent is removed., If it persists it becomes chronic as in the case of dental ulcer of the tongue. Ulcers may develop spontaneously as in the case of gumma (syphilitic ulcer). It may develop with varicose veins called varicose ulcer, which develops in the lower third of the leg.
Sometimes a malignant ulcer develops in a scar called Marjolin’s ulcer. Special features are:
No pain - as there are no nerves. It does not spread - as there is scar tissue. No metastases - as there are no lymphatics Treatment:- Wide excision.
Classification of Ulcer
A) Pathologically
I. Non-specific ulcers:
a. Due to infected wound after trauma, that is physical or chemical agents.
b. Due to local infection example dental ulcer, pressure sore
Specific ulcers: Caused by specific infection
a. Syphilitic ulcers (Hunterian chancre)
b. Tubercular ulcers, actinomycosis
Trophic ulcer:- Caused by two factors:
Diminished nutrition due to inadequate blood supply to the tissues
Eg. Ulcers in Buerger’s Disease, Artherosclerosis
b. Diminished or absence of sensation of the skin leading to perforating ulcer of the foot
iv. Malignant ulcer: Due to squamous cell carcinoma, rodent ulcers and melanoma.
B) Clinical classification of ulcers
1. Acute Ulcer: The edge is inflamed oedematous and painful with slough in the floor and n o granulation tissue. Profuse purulent Discgarge seen
2. Healing ulcers: edge sloping with bluish margin The floor is covered with a red, healthy granulation tissue.
3. Chronic or callous ulcer (non- healing) There is no tendency to heal by itself, the base is jndurated unhealthy granulation tissue is present in the floor The edge is rounded and thickened.
Chronic ulcer occur due to:
Chronic infection , Defective circulation , Foreign body, Persistent local oedema , Malignancy , Diabetes , Malnutrition (loss of proteins), Gout
Specific Ulcers
Tubeculous Ulcer
Edge Undermined, floor contains granulation tissue a watery discharge is present. Caseous material is found in the floor of the ulcer. It usually occurs in tubercular lymphadenitis in the neck, axilla or groin.
Syphilitic Ulcer
a) Huntarian Chancre or primary sore or hard chancre: usuaIly occurs over the genitalia especially on penis. Occurs in the primary stage of syphilis Ulcer is round or oval, it is hard,indurated, elevated and painless It feels like a button, discharges serum containing spirochetes (cork screw) which is highly infective.
b) In the Secondary stage mucous patches and condylomata occurs The ulcers are shallow white patches, of sodden thickness which occur in the mouth and tongue. Condyloma are hypertrophied epithelium with serous discharge occurring in mucocutaneous junction around the anus. The regional lymphnod (inguinal transverse chain) are enlarged.
c) In tertiary stage of syphilis gummatous ulcers occur They have a punched out edge and wash Ieather floor. They occur on the subcutaneous bones like sternum and tibia. They are painless and refuse to heal.
Soft Sore (chanchroid)
They are painful muitiple ulcers, with copious discharge. They are caused by Bacillus Ducrey lncubation time is 3 to 4 days. located on glans penis and prepuce is due to venereal infection. They are associated with enlarged called bilateral inguinal lymphnodes
Tropical ulcer:
a) Oriental Sore - due to L. Tropica (lieshmaniasis)
b) Ulcers and sinuses are due to guinea worm abscess
c) Histoplasmosis with multiple ulcers on the tibia.
d) Chronic ulcers due to yaws
e) Amoebic ulcers occur in colon_and rectum , flask shaped ulcers , undermined edge , caused by Entamoeba Histolytica
Varicose Ulcer:
Associated with varicose veins. Occurs on the inner aspect of the lower third of leg , chronic ulcer The surrounding area is pigmented and eczema is present. The sore is longitudinally oval It does not penetrate the deep fascia and is painless The base is adherent to the periosteum of the tibia
Rodent ulcer
Usually Occurs on the face above a line joining the lobule of the ear to the angle of the mouth. Usually occurs at the inner canthous of the eye . Edge is raised and rolled, Erodes the deeper structures and the bone, the lyrnph nodes are not involved.
Treatment: If small wide excision is done with skin grafting, If large, radiotherapy is given.
Malignant Ulcer
Occurs due to chronic irritation as in the case of malignant ulcer of the tongue. The edge is everted. The floor is covered with slough and tumor tissue The regional lymph nodes are hard.
Initially mobile later becomes hard
Treatment: Wide excision is done.
Marjolin ulcer: Malignant Ulcer occurring on scar of Burns
Zygomatic Bone Reduction
When performing a reduction of the zygomatic bone, particularly in the context of maxillary arch fractures, several key checkpoints are used to assess the success of the procedure. Here’s a detailed overview of the important checkpoints for both zygomatic bone and zygomatic arch reduction.
Zygomatic Bone Reduction
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Alignment at the Sphenozygomatic Suture:
- While this is considered the best checkpoint for assessing the reduction of the zygomatic bone, it may not always be the most practical or available option in certain clinical scenarios.
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Symmetry of the Zygomatic Arch:
- Importance: This is the second-best checkpoint and
serves multiple purposes:
- Maintains Interzygomatic Distance: Ensures that the distance between the zygomatic bones is preserved, which is crucial for facial symmetry.
- Maintains Facial Symmetry and Aesthetic Balance: A symmetrical zygomatic arch contributes to the overall aesthetic appearance of the face.
- Preserves the Dome Effect: The prominence of the zygomatic arch creates a natural contour that is important for facial aesthetics.
- Importance: This is the second-best checkpoint and
serves multiple purposes:
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Continuity of the Infraorbital Rim:
- A critical checkpoint indicating that the reduction is complete. The infraorbital rim should show no step-off, indicating proper alignment and continuity.
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Continuity at the Frontozygomatic Suture:
- Ensures that the junction between the frontal bone and the zygomatic bone is intact and properly aligned.
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Continuity at the Zygomatic Buttress Region:
- The zygomatic buttress is an important structural component that provides support and stability to the zygomatic bone.
Zygomatic Arch Reduction
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Click Sound:
- The presence of a click sound during manipulation can indicate proper alignment and reduction of the zygomatic arch.
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Symmetry of the Arches:
- Assessing the symmetry of the zygomatic arches on both sides of the face is crucial for ensuring that the reduction has been successful and that the facial aesthetics are preserved.
Dautrey Procedure
The Dautrey procedure is a surgical intervention aimed at preventing dislocation of the temporomandibular joint (TMJ) by creating a mechanical obstacle that restricts abnormal forward translation of the condylar head. This technique is particularly beneficial for patients who experience recurrent TMJ dislocations or subluxations, especially when conservative management strategies have proven ineffective.
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Indications:
- The Dautrey procedure is indicated for patients with a history of recurrent TMJ dislocations. It is particularly useful when conservative treatments, such as physical therapy or splint therapy, have failed to provide adequate stabilization of the joint.
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Surgical Technique:
- Osteotomy of the Zygomatic Arch: The procedure begins with an osteotomy, which involves surgically cutting the zygomatic arch, the bony structure that forms the prominence of the cheek.
- Depressing the Zygomatic Arch: After the osteotomy, the zygomatic arch is depressed in front of the condylar head. This depression creates a physical barrier that acts as an obstacle to the forward movement of the condylar head during jaw opening or excessive movement.
- Stabilization: The newly positioned zygomatic arch limits the range of motion of the condylar head, thereby reducing the risk of dislocation during functional activities such as chewing or speaking.
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Mechanism of Action:
- By altering the position of the zygomatic arch, the Dautrey procedure effectively changes the biomechanics of the TMJ. The new position of the zygomatic arch prevents the condylar head from translating too far forward, which is a common cause of dislocation.
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Postoperative Care:
- Following the procedure, patients may require a period of recovery
and rehabilitation. This may include:
- Dietary Modifications: Soft diet to minimize stress on the TMJ during the healing process.
- Pain Management: Use of analgesics to manage postoperative discomfort.
- Physical Therapy: Exercises to restore normal function and range of motion in the jaw.
- Following the procedure, patients may require a period of recovery
and rehabilitation. This may include:
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Outcomes:
- The Dautrey procedure has been shown to be effective in preventing recurrent TMJ dislocations. Patients often experience improved joint stability and a better quality of life following the surgery. Successful outcomes can lead to reduced pain, improved jaw function, and enhanced overall satisfaction with treatment.