Professional and Linguistic Assessments Board (PLAB) Surgery, Trauma and Perioperative Care Syllabus

State the Parkland formula for fluid resuscitation in burns and how it is administered.

$\text{Volume} = 4 \,\text{mL} \times \text{weight (kg)} \times \%\,\text{TBSA burned}$, using Hartmann's solution over 24 hours. Half is given in the first 8 hours from the time of injury and the remainder over the next 16 hours.

What features distinguish a superficial partial-thickness burn from a full-thickness burn?

Superficial partial-thickness: painful, red/pink, blisters, blanches, moist. Full-thickness: painless (nerves destroyed), white/leathery/charred, dry, non-blanching, may need excision and grafting.

Describe the typical claudication distance relationship and the ankle-brachial pressure index (ABPI) ranges in peripheral arterial disease.

Pain on walking relieved by rest; shorter claudication distance indicates more severe disease. ABPI: $>0.9$ normal, $0.5\text{–}0.9$ intermittent claudication, $<0.5$ critical limb ischaemia. ABPI $>1.3$ suggests calcified/incompressible vessels (e.g. diabetes).

List the '6 Ps' of acute limb ischaemia.

Pain, Pallor, Pulselessness, Perishingly cold (Poikilothermia), Paraesthesia, and Paralysis. Paraesthesia and paralysis are late signs indicating threatened limb viability requiring urgent revascularisation.

At what diameter is elective repair of an abdominal aortic aneurysm (AAA) generally indicated, and what is the UK screening programme?

Elective repair when the AAA is $\geq 5.5$ cm, symptomatic, or expanding $>1$ cm/year. The NHS screens men in the year they turn 65 with a single abdominal ultrasound.

What is the classic triad of a ruptured abdominal aortic aneurysm?

Sudden severe abdominal/flank/back pain, hypotension (shock), and a pulsatile expansile abdominal mass. A ruptured AAA in a haemodynamically unstable patient warrants immediate surgery without delay for imaging.

Describe the typical presentation and management of testicular torsion.

Sudden severe unilateral testicular pain (often in adolescents), high-riding testis with horizontal lie, absent cremasteric reflex, negative Prehn's sign (pain not relieved by elevation). Requires surgical exploration and bilateral orchidopexy within 6 hours to save the testis.

What is the management of acute urinary retention with a tender suprapubic mass?

Immediate urethral (or suprapubic if contraindicated) catheterisation to decompress the bladder; record residual volume. Monitor for post-obstructive diuresis. Investigate and treat the cause (e.g. BPH, constipation, drugs).

Compare the typical features of renal (ureteric) colic with pyelonephritis.

Renal colic: severe loin-to-groin colicky pain, patient restless/writhing, haematuria, usually afebrile. Pyelonephritis: loin pain, high fever with rigors, dysuria/frequency, costovertebral angle tenderness, systemically unwell.

What is the most common type of renal cell carcinoma and its classic (though rare) triad?

Clear cell carcinoma is the most common subtype. Classic triad (present in $<10\%$): haematuria, loin pain, and a palpable flank mass. May cause a left-sided varicocele and paraneoplastic syndromes.

What is the most common type of bladder cancer in the UK and its main risk factors?

Transitional cell (urothelial) carcinoma. Risk factors: smoking, occupational exposure to aromatic amines (rubber, dye, paint industries), and cyclophosphamide. Presents typically with painless visible haematuria.

Describe the Salter-Harris classification of paediatric physeal (growth plate) fractures.

Type I – through the physis (Slipped); II – through physis and metaphysis (Above); III – through physis and epiphysis (Lower); IV – through metaphysis, physis, and epiphysis (Through); V – crush of the physis. (Mnemonic SALTR.)

What is the difference between a Colles' fracture and a Smith's fracture?

Colles': distal radius fracture with dorsal (posterior) displacement, producing a 'dinner fork' deformity, typically from a fall on an outstretched hand. Smith's: distal radius fracture with volar (anterior) displacement ('reverse Colles').

Define compartment syndrome and its hallmark clinical sign.

Raised pressure within a closed fascial compartment compromising perfusion. The hallmark is pain out of proportion to the injury, worsened by passive stretching of the muscles. Treatment is urgent fasciotomy; do not wait for pulselessness (a late sign).

Differentiate osteoarthritis from rheumatoid arthritis in terms of joint involvement and morning stiffness.

Osteoarthritis: asymmetrical, weight-bearing/DIP joints (Heberden's nodes), brief morning stiffness $<30$ minutes, worse with activity. Rheumatoid: symmetrical, MCP/PIP joints, morning stiffness $>1$ hour, improves with activity, systemic features.

List the classic X-ray features of rheumatoid arthritis.

Loss of joint space, juxta-articular (periarticular) osteopenia, bony erosions, and soft tissue swelling. (Mnemonic LESS.) Contrast with osteoarthritis: Loss of joint space, Osteophytes, Subchondral cysts, Subchondral Sclerosis (LOSS).

What are the red flag features of back pain suggesting cauda equina syndrome?

Bilateral sciatica, saddle (perineal) anaesthesia, bladder/bowel dysfunction (urinary retention then overflow incontinence), reduced anal tone, and erectile dysfunction. Requires urgent MRI and surgical decompression.

Describe the typical presentation of slipped upper femoral epiphysis (SUFE).

An obese adolescent (commonly 10–16 years, often male) with hip, groin, or referred knee pain and a limp; the leg is externally rotated. Diagnosed on frog-leg lateral X-ray (Trethowan's sign); managed with surgical pinning in situ.

What is the typical age and presentation of Perthes' disease?

Avascular necrosis of the femoral head in children aged about 4–8 years (more common in boys), presenting with a painless limp and hip/knee pain, with reduced internal rotation and abduction. Self-limiting but may need bracing or surgery.

What is developmental dysplasia of the hip (DDH) and which clinical tests screen for it in neonates?

Abnormal development of the hip joint with instability/dislocation. Screened with the Barlow test (dislocates an unstable hip by posterior pressure) and the Ortolani test (relocates a dislocated hip with abduction). Ultrasound confirms in infants $<6$ months.

What does the ASA physical status classification grade, and what is ASA III?

It grades a patient's preoperative physical fitness/perioperative risk. ASA I: healthy; II: mild systemic disease; III: severe systemic disease (substantive functional limitation but not incapacitating); IV: severe disease that is a constant threat to life; V: moribund, not expected to survive without surgery.

Which patients require preoperative fasting, and what are the standard '6-2' fasting rules?

No solid food (or milk-containing drinks) for 6 hours before surgery, and no clear fluids for 2 hours before. This reduces the risk of aspiration of gastric contents during anaesthesia.

How is postoperative pyrexia timed to its likely causes (the '5 Ws')?

Wind (atelectasis/pneumonia, days 1–2), Water (urinary tract infection, days 3–5), Wound (infection, days 5–7), Walking (DVT/PE, days 5+), Wonder drugs (drug reaction or anastomotic leak, any time).

What are the classic features and management of postoperative atelectasis?

Occurs typically within 24–48 hours; presents with mild fever, dyspnoea, and reduced basal air entry. Managed with chest physiotherapy, deep breathing exercises/incentive spirometry, adequate analgesia, and early mobilisation.

Outline the WHO analgesic ladder for pain management.

Step 1: non-opioids (paracetamol, NSAIDs) $\pm$ adjuvants. Step 2: weak opioids (codeine, tramadol) $\pm$ non-opioids $\pm$ adjuvants. Step 3: strong opioids (morphine) $\pm$ non-opioids $\pm$ adjuvants. Climb the ladder if pain persists or increases.

What is the recommended maintenance IV fluid prescription for a 70 kg adult per NICE (water, sodium, potassium)?

Approximately $25\text{–}30\,\text{mL/kg/day}$ of water, $1\,\text{mmol/kg/day}$ of sodium, potassium and chloride, and $50\text{–}100\,\text{g/day}$ of glucose to limit ketosis. For 70 kg, roughly 1.75–2.1 L of water per day.

How do you estimate the maintenance fluid rate for a child using the 4-2-1 rule?

$4\,\text{mL/kg/hr}$ for the first 10 kg, plus $2\,\text{mL/kg/hr}$ for the next 10 kg, plus $1\,\text{mL/kg/hr}$ for each kg above 20 kg. E.g. a 25 kg child: $40 + 20 + 5 = 65\,\text{mL/hr}$.

What two components make up combined mechanical and pharmacological VTE prophylaxis in surgical inpatients?

Mechanical: anti-embolism (graduated compression) stockings and/or intermittent pneumatic compression devices. Pharmacological: low molecular weight heparin (e.g. enoxaparin/dalteparin), or a DOAC where appropriate, given when bleeding risk is acceptable.

Which scoring tools assess VTE and bleeding risk, and when should pharmacological VTE prophylaxis be withheld?

VTE risk is assessed by a risk assessment tool (e.g. the Department of Health/NICE tool); bleeding risk may use ORBIT/HAS-BLED in some contexts. Pharmacological prophylaxis is withheld when bleeding risk outweighs benefit (e.g. active bleeding, acute stroke, thrombocytopenia, or recent neurosurgery).

What are the well-recognised signs of pulmonary embolism postoperatively and the first-line imaging?

Sudden dyspnoea, pleuritic chest pain, tachycardia, hypoxia, and haemoptysis. First-line imaging is a CT pulmonary angiogram (CTPA); a V/Q scan is an alternative in renal impairment or contrast allergy. Wells score guides the pathway.

Differentiate the bleeding pattern and typical cause of upper versus lower GI haemorrhage in the acute abdomen.

Upper GI bleed (proximal to ligament of Treitz): haematemesis and/or melaena (black tarry stool), often peptic ulcer or varices, raised urea. Lower GI bleed: fresh red blood per rectum (haematochezia), often diverticular disease or angiodysplasia.