Lifting head and flexing the hip simultaneously.
We touched upon it very briefly. What's the
top one? Keloid. And what's the bottom
one? Hypertrophy. That's from CABG and that’s
from an acne. But in your exam they will give
you any sort of trivial surgery or a trivial
trauma to the skin resulting in a keloid scar.
Now, so they'll give you a scenario which
would be something along these lines.
The patient had ear lobe piercing or some form
of surgery a few months ago or a year ago.
On the shoulder or one of the sites they will
give you sternum or shoulder, and they'll
give you a -- African. Same thing, the dark
skin. Same thing, they'll give you, the two
options would be hypertrophic and keloid. Okay.
As I said, these
pathology questions are final medical student
level. Only the anatomy is slightly different,
the physiology, pathology you'll be absolutely
fine with your basic knowledge. There's nothing
really new in these things. Okay. So keloid
outgrows original scar, it can develop up
to a year later, predilection for the sternum,
shoulder and ear lobes. And hypertrophy is
different. Diagnosis? Yes,
What are the associations? What does it
associated with? Von Recklinghausen's.
What else? Multiple endocrine neoplasias.
So, Neurofibromatosis I, Neurofibromatosis II,
and MEN I, MEN II. Now, I really don't
understand how you remember this, but if you
can remember this MEN I, II and IIA. People
have told me different ways to remember, I
still forget it. But you need to know this, part A
and part B, they ask you multiple endocrine
neoplasias. Does anybody know a way
to remember it?
Three Ps, two Ps one M, and then two
Ms, one P. The mnemonic, for instance,
MEN I has got three Ps. MEN IIA has got
two Ps, one M. And then MEN IIB has got,
I don’t know where the third M
come from. But two Ms and one P. Basically,
yeah MEN I is the pancreatic, and then above
in the neckline, parathyroid and pituitary.
MEN IIA and IIB are your pheos, and then it
just depends whether you’ve got, again neck,
so the parathyroid or whether you’ve got
marfanoid. So Marfan’s is MEN IIB, actually.
It’s quite simple when you actually learned
it. If you’ve got a pheo, you’re a II of some form.
Then IIB is your Marfan’s and a pheo.
And IIA is your parathyroid and your pheo.
So remember two Ps, remember
pheo, IIA? I don’t know how to describe it.
No, no. You are right. So three Ps yeah.
So II is your pheos. You know for a fact IIA
has got two Ps and you know it’s got
parathyroid and pheo. And IIB is a pheo but
it’s Marfan’s as well. If there’s no pheo,
it’s MEN I. Okay, correct. You are right.
You know, I
could not really feel how to remember this.
But I suppose, as she said three Ps go for
MEN I. Okay, but you need to know the MEN
Now very quick. What is the diagnosis?
Dupuytren's. This is why, the reason for the
slide; you'll get a -- No, in this question?
Yes, high serum lipids is the wrong answer.
There are all risk factors, all others are
risk factors for Dupuytren's. Okay. And this
is quite important. Commonly quoted but no
evidence. So in your exam, they have taken
this off now. So it's very unlikely they're
going to confuse you with this because I'm
sure some of you may know Professor McRoger.
He's retired now, he was a plastic surgeon
here in Manchester. They did a lot of study and
they clearly identified there is no relation
between any of those. So they wrote to the
college and the old questions have been removed
which said vibrating tools, phenobarbitone,
alcoholic liver disease. There's no evidence.
Even in the Oxford handbook it says, but in
the new guidelines, these are the only four
things, race, male sex, diabetes, positive
family history. Only the four things have
got a clear evidence or a clear correlation.
So be careful when you get in the exam, if
you get alcohol, epilepsy, phenobarbitone,
think well what are they really coming at.
You know this, don't you? What are the
things you will examine in the hands?
What else, plantar fibromatosis, penile fibromatosis,
relation with Duputyren’s. Management. Okay
you know all this. Conservative. What's next?
What is a new -- Yes, this is the one. Clostridial
collagenase. Okay, so this is coming up in
the exam now. What is the most appropriate
treatment in a patient with early stage Dupuytren's?
You can go for clostridial collagenase.
If you have a single digit disease, a little
bit of flexion, you can avoid surgery just
by injecting a little bit of collagenase and
physically pushing it down, breaking the collagen.
So that has become the newer modality and
the more on the first line management.
Yes, because you always have these options,
don't you? You can always do the fasciotomy,
fasciectomy or dermofasciectomy. But this
is a newer one which has been introduced in
the exam now. I think this is still the order.
If you can
avoid the collagenase, you can avoid it. So
if you are able to splint it, and do some
physio and try to straighten the finger, fair
enough. But it doesn’t really work. We always
give them night splintage and all those, but
very little evidence to show it works.
So this is quite accepted in the exam now,
clostridial collagenase. It's licensed as
Xiaflex. Amputation, you can use it as a