Surgery and Musculoskeletal Medicine
This domain tests surgical triage - which abdomen, joint or injury needs same-day referral - plus competent conservative management of the common musculoskeletal complaints that fill clinics.
Core rules
- Acute abdomen: rigidity, guarding and rebound indicate peritonitis and require immediate surgical referral. Adequate analgesia does not mask the diagnosis and should not be withheld.
- Appendicitis typically migrates from periumbilical pain to the right iliac fossa with anorexia and low-grade fever; use Alvarado or similar scoring and image when the diagnosis is unclear, especially in women of childbearing age.
- Testicular torsion is a clinical diagnosis within a 6-hour window: do not delay exploration for Doppler imaging.
- Hernias: irreducibility, exquisite pain, overlying skin change or obstruction suggest strangulation - emergency referral.
- Low back pain red flags: age over 50 with new pain, fever, night pain, weight loss, cancer history, progressive neurological deficit, or cauda equina features (saddle anaesthesia, urinary retention, bilateral sciatica). Cauda equina needs urgent MRI and surgical referral.
- Fractures: document neurovascular status before and after splinting, use the Ottawa ankle and knee rules to avoid unnecessary imaging, and give antibiotics early for open fractures.
- Osteoarthritis: exercise, weight management, topical NSAIDs; use oral NSAIDs at the lowest dose for the shortest time and avoid them in CKD or frailty.
Worked example
A 62-year-old presents with 2 weeks of back pain, urinary retention and numbness around the perineum. Reasoning: saddle anaesthesia plus retention is cauda equina syndrome. Emergency MRI and neurosurgical or orthopaedic referral the same day, with catheterisation and documentation of neurology.
Traps that cost marks
Missing compartment syndrome (pain out of proportion, pain on passive stretch); attributing night pain to strain; prescribing NSAIDs in CKD; dismissing torsion as epididymitis.