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MyPasTest: MRCS A Online - Jan Exam 201531. Surgical specialities; Plastics & Reconstructive Surgery(30Qs).
01. A 25-year-old man is admitted having cut his flexor digitorum profundus on a piece of glass. Which of
the following is the FDP attached to? Select one answer only.
Clelands ligament« YOUR ANSWER
Graysons ligament
The base of the distal phalynx« CORRECT ANSWER Page
The base of the middle phalynx
1689
The base of the proximal phalynx
The FDP originates from the upper ¾ of the anterior and medial surfaces of ulna, interosseous membrane
and deep fascia of the forearm. One tendon is given off to each of the fingers these insert onto the palmar
base of the distal phalynx.
02. Theme: Benign skin and subcutaneous lesions.
A Angioma
B Benign papilloma
C Clear cell acanthoma circumscriptum (viral warts)
D Epidermal cysts
E Ganglion
F Glomus tumour
G Histiocytoma
H Keratoacanthoma
I Lipoma
J Lymphangioma
K Molluscum contagiosum
L Neurofibroma
M Pyogenic granuloma
N Sebaceous cyst
O Seborrhoeic keratosis.
The following scenarios describe patients presenting with benign cutaneous lesions. From the above list
choose the most likely diagnosis. Each item may be used once, more than once, or not at all.
Scenario 1
A 45-year-old carpenter presents with a lump over the dorsum of his right wrist that disappears on extension of
the joint. The overlying skin is normal.
A - Angioma « YOUR ANSWER
E - Ganglion« CORRECT ANSWER.
A ganglion is a cystic, myxomatous degeneration of fibrous tissue. They can occur anywhere but are
commonly found over the dorsum of the hand over the scapholunate ligament. They are most evident
when the wrist is flexed and commonly occur in people handling heavy objects or who traumatise the
hand. Some reduce on movement of the joint but they are not truly emptying into a joint space.
They can be uncomfortable and cosmetically unsightly. Resection of part of the sac can be performed but
recurrence may be as high as 20%. A differential diagnosis includes a bursa or a mucous cyst, the latter
caused by a ‘blow-out’ of an osteoarthritic joint.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
31. Surgical specialities; Plastics & Reconstructive Surgery(30Qs).
Scenario 2
A 65-year-old woman presents with a lesion on her cheek that had rapidly increased in size over the last 6 weeks
but has recently begun to get smaller. On examination she has a 9-mm hemispherical nodule that has a rolled
edge and a central horny plug. There is no local lymphadenopathy.
B - Benign papilloma « YOUR ANSWER
H - Keratocanthoma« CORRECT ANSWER.
Page
This benign lesion is a rapidly growing collection of hair follicle cells, that is self-limiting and often
regresses leaving a small puckered scar. It can be mistaken for a basal cell carcinoma, although it tends 1690
to be perfectly round, and histologically can resemble a small cell carcinoma.
The lesion consists of normal skin with a central necrotic or keratinous core. There is never any
extension into local tissues and local lymph nodes should not be involved. Treatment is usually expectant
for a short time because they can resolve. However, if in doubt then there is case for early removal to
exclude malignancy as well as for cosmetic reasons.
Scenario 3
A 3-year-old child attends after her parents notice a cluster of coloured small lumps in her axilla. She is otherwise
well and her vaccinations are up to date. On examination there are multiple circumscribed 2–3-mm cystic-looking
papules. Some are translucent while others are brown, red, or black in colour. These do not blanch with pressure.
C - Clear cell acanthoma circumscriptum (viral warts)« YOUR ANSWER
J - Lymphangioma« CORRECT ANSWER.
This is a collection of dilated lymph sacs in the skin and subcutaneous tissue that fail to drain into the
normal lymphatic system. Larger cysts found purely in the subcutaneous tissue are known as cystic
hygromas. They are of unknown aetiology but are probably an aberrant developmental condition where
these vesicles fail to connect to draining lymph structures.
They tend to occur at the junction between the limbs and neck with the trunk. Commonly found in
children, they often present because parents notice the vesicles when they become blood-filled,
subsequently causing them to become bloodstained, brown or black in colour as the blood becomes
haemolysed.
Scenario 4
A 35-year-old woman presents with a lump on her lower lip which has appeared rapidly over the last 6 days
following a minor injury to the area. On examination there is a pink hemispherical nodule, 6 mm in diameter, that
appears vascular and friable. There is no local lymphadenopathy.
D - Epidermal cysts « YOUR ANSWER
M - Pyogenic granuloma« CORRECT ANSWER.
This lesion is a benign reactive inflammatory mass produced in response to trauma, composed of
granulation tissue and blood vessels. They erupt rapidly and have a polypoid appearance and a ‘collar’
around the base.
Profuse contact bleeding is often a presenting symptom. They should be differentiated from a squamous
cell carcinoma, amelanotic melanoma and Kaposi’s sarcoma. Treatment involves curettage or excision
followed by histological examination.
03. Theme: Vascular anomalies
A Haemangioma
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
31. Surgical specialities; Plastics & Reconstructive Surgery(30Qs).
B Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
C Klippel-Trenaunay syndrome
D Ataxia telangiectasia
E Port wine stain
F Pyogenic granuloma
G Familial glomangiomatosis
H Sturge-Weber syndrome Page
I Kaposiform haemangioendothelioma. 1691
Select the most likely diagnosis for each of the patients below. Each option may be used once, more than
once, or not at all.
Scenario 1
A 40-day-old baby girl is brought to the general practitioner with a macular, dark red lesion over the right side of
her forehead. The parents say that this lesion has been present since birth. It does not cross the midline. The
baby is well otherwise and general examination is unremarkable.
A - Haemangioma« YOUR ANSWER
E - Port wine stain« CORRECT ANSWER.
Port wine stain is a form of capillary malformation that is present at birth and persists throughout life. It
usually presents as a macular, dark red vascular stain over the face, trunk or limbs. It can be either well
localised or could have an extensive spread. These lesions do not cross the midline. Port wine stain must
be differentiated from the common fading macular stain (naevus flammeus neonatorum ) that occurs in
up to 50% of neonates, commonly over the glabella, eyelids, nose, upper lip (angel kiss), and nuchal area
(stork bite). It should also be differentiated from haemangiomas which are not usually present at birth but
rapidly increase in size before involuting. Most port wine stains are harmless cutaneous birth marks, and
no general or systemic abnormalities are present.
Scenario 2
A 2-year-old boy is brought to the emergency department with seizures, predominantly affecting the left side. On
examination, there is a macular, reddish-brown stain along the left forehead extending up to his eyelids. The
parents say that this discolouration has been present since birth. Magnetic resonance imaging of the brain reveals
a left-sided cortical atrophy.
B - Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)« YOUR ANSWER
H - Sturge-Weber syndrome« CORRECT ANSWER.
Sturge–Weber syndrome is a congenital vascular malformation affecting the head, face and brain,
associated with ipsilateral pial and ocular vascular anomalies. The leptomeningeal vascular abnormalities
can cause seizures, contralateral hemiplegia and variable developmental delay of motor and cognitive
skills.
Seizures usually present within the first two years of life. Development of the brain usually proceeds to a
normal size, but after birth, there is progressive atrophy of the affected hemisphere. The disease is
usually unilateral, but bilateral cases can occur.
The capillary stain involves the ophthalmic trigeminal dermatome. Children who evidence ipsilateral
increased choroidal vascularity are at an increased risk for retinal detachment, glaucoma and blindness,
more likely if the capillary malformation involves both ophthalmic and maxillary neurosensory areas.
Scenario 3
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
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