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Toronto Notes: Plastic Surgery > All Sections > Flashcards

All Sections Flashcards

1
Q

What are the layers of the skin?

A

Epidermis

  • “Come Let’s Get Some Beer”
    • Stratum corneum
    • Stratum lucidum
    • Stratum Granulosum
    • Stratum Spinosum
    • Stratum Basale

Dermis

  • Upper (papillary)
  • Lower (reticular)

Subcutaneous tissue

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2
Q

Compare full-thickness vs split-thickness skin grafts.

A

Full-thickness includes all of the dermis down to subcutaneous tissue.

Split-thickness can be thin (epidermis), medium (papillary dermis), thick (reticular dermis).

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3
Q

How thick are different types of STSG?

A

Thin: 0.005 - 0.012 in (0.2 - 0.3 mm)

Medium: 0.012 - 0.018 in (0.3 - 0.45 mm)

Thick: 0.018 - 0.030 in (0.45 - 0.75 mm)

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4
Q

Describe the blood supply to the hand.

A

Source arteries

  • Radial artery (b/w FCR/brachioradialis)
  • Ulnar artery (lateral to ulnar nerve)
  • Supplemental arteries
    • anterior interosseus artery
    • posterior interosseus artery
    • median artery (occassionally)

(A) Superficial arch

  • predominant supply is ulnar artery
  • main supplier to the digits (except thumb and radial D2)
  • digital arteries run volar to nerves in palm, dorsal in digits

(B) Deep arch

  • predominant supply is radial artery
  • supplies thumb and radial D2

(C) Dorsal arteries

  • PI artery and dorsal perforating branch of AI artery form dorsal carpal arch –> dorsal MC arteries

(D) Veins

  • Deep veins follow deep arterial system as venae comintantes
  • Superficial veins on dorsal surface contribute to basilic (ulnar) and cephalic (radial) vein system
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5
Q

Name the carpal bones.

A

“She Looks Too Pretty, Try To Call Her”

Scaphoid

Lunate

Triquetrum

Pisiform

Trapezium

Trapezoid

Capitate

Hamate

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6
Q

Describe sensory distribution in the hand.

A

Median

  • volar D1, D2, D3, radial side of D4
  • dorsal D1, D2, D3, radial D4 (distal to PIPJ)

Ulnar

  • volar and dorsal D5, ulnar side of D4

Radial

  • dorsal hand excluding areas described above
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7
Q

Describe the flexor mechanism.

A
  • FDS inserts at proximal middle phalanx
    • splits midway along proximal phalanx at Camper’s chiasm
  • FDP inserts at proximal distal phalanx
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8
Q

Describe the extensor mechanism.

A
  • Extensor tendon runs midline, inserting as the central slip at the proximal middle phalanx
  • Lateral bands branch off of central slip, just proximal to PIPJ, inserting into proximal distal phalanx at terminal insertion
  • Triangular ligament runs within lateral bands near the terminal insertion
  • Lumbricals and interossei insert into the extensor hood
  • Extensor hood is made up of proximal sagittal fibres and distal oblique fibres, covering the proximal phalanx
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9
Q

Label the following nail anatomy:

A
  1. Hyponychium
  2. Sterile matrix
  3. Germinal matrix
  4. Ventral floor
  5. Lunula
  6. Eponychium
  7. Dorsal root
  8. Distal phalanx
  9. Extensor tendon
  10. Flexor tendon
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10
Q

Which type of tendons require operative repair?

A

Flexor tendons - all require OR repair.

Extensor = ER repair (unless proximal/multiple tendons).

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11
Q

Label the following cross-section of the carpal tunnel:

A
  • FCU tendon, ulnar nerve, ulnar artery
  • Palmaris longus tendon, median nerve
  • FPL, FCR, Radial artery
  • Carpal bones: hamate, capitate, trapezoid, trapezium
  • Carpal tunnel: transverse carpal ligament (flexor retinaculum), FDS x 4, FDP x 4, median nerve, FPL
  • Note:
    • FDS to long and ring are superficial, index and small are deep (think “34 is higher than 25”)
    • FDP has one muscle belly (think one “profound” belly), whereas FDS divides into four bundles
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12
Q

Name the six extensor compartments of the wrist.

A

Compartments lie under the extensor retinaculum.

Radial to medial:

  1. APL; EPB
  2. ECRL; ECRB
  3. EPL (passes around Lister’s tubercle)
  4. EDC (superficial); EIP (deep)
  5. EDM
  6. ECU

Note:

  • EIP & EDC both supply the index finger, EDM & EDC both supply the small finger
  • In both cases, EDC is radial and other extensor is ulnar
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13
Q

Name the components of the brachial plexus (think of the acronym).

A

“Real Teens Drink Cold Beer”

  • Roots (C5, C6, C7, C8, T1)
  • Trunks (Superior, Middle, Inferior)
  • Divisions (Anterior, Posterior)
  • Cords (Lateral, Posterior, Medial)
  • Branches (“MARMU” - musculocutaneous, axillary, radial, median, ulnar)
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14
Q

What are causes of saddlenose deformity?

A
  1. Granulomatous disorders
    1. Granulomatosis with polyangiitis
    2. Infection (mycobacterial - leprosy [Hansen’s])
    3. Sarcoidosis
  2. Neoplastic conditions
    1. EBV-associated nasal lymphomas
  3. Relapsing polychondritis
  4. Primary atrophic rhinosinusitis
  5. Congenital syphilis
  6. Iatrogenic
    1. Trauma (most common cause)
    2. Cocaine
    3. Surgery
    4. Radiations
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15
Q

Draw/label the brachial plexus.

A
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16
Q

Label the bones/landmarks of the face and skull.

A
  1. temporal
  2. ethmoid
  3. lacrimal
  4. maxilla
  5. nasal
  6. zygoma
  7. zygomatic process of temporal bone (zygomatic arch)
  8. alveolar process of maxilla
  9. mental foramen
  10. mandibular symphisis
  11. mastoid process
  12. sphenoid bone
  13. body of the mandible
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17
Q

Name the craniofacial buttresses.

A

Horizontal buttresses

  1. Frontal bar
  2. Upper transverse maxillary (inferior orbital rim)
  3. Lower transverse maxillary (hard palate)
  4. Upper transverse mandibular
  5. Lower transverse mandibular

Vertical buttresses

  1. Medial maxillary (nasomaxillary)
  2. Lateral maxillary (zygomaticomaxillary)
  3. Posterior maxillary (pterygomaxillary)
  4. Posterior vertical (vertical mandible)
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18
Q

What are the factors that determine lesion excision margins?

A
  1. Type of lesion
  2. Lesion diameter
  3. Lesion depth (for melanoma)
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19
Q

List the precursors of BCC, SCC, and malignant melanoma.

A

BCC

  • Nevus sebaceous of Jadassohn

SCC

  • Actinic keratosis
  • Bowen’s disease (SCC in situ)
  • Bowenoid papulosis (genitals)
  • Paget’s disease
  • Leukoplakia (mouth)
  • Erythroplasia (Bowen’s of the penis)

Malignant melanoma

  • Lentigo maligna (in situ)
  • Giant congenital nevus
  • Dysplastic nevus
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20
Q

Label the ear.

A

A. Crura of antihelix

B. Crus of helix

C. Anterior notch

D. Supratragal tubercle

E. Tragus

F. Intertragal notch

G. Lobule

H. External auditory meatus

I. Antitragus

J. Posterior auricular sulcus

K. Antihelix

L. Cavum conchae

M. Cymba conchae

N. Concha

O. Scaphoid fossa

P1. Helix

P2. Darwinian tubercle

Q. Triangular fossa

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21
Q

What are the surgical margins for BCC, SCC, and melanoma?

A

BCC

  • 3 mm for nonaggressive BCC subtypes (i.e., nodular and superficial) < 2 cm
  • 5-mm margin for larger BCCs or BCCs with an aggressive histological subtype (i.e., infiltrative or micronodular)

SCC

  • 4 mm margin for lower-risk lesions (well-differentiated, <2 cm, not on the scalp, ears, eyelids, lips, or nose, and do not involve subcutaneous fat)
  • 6 mm margin for lesions that are larger than 2 cm, invasive to fat, or in high-risk locations (ie, central face, ears, scalp, genitalia, hands, feet)

Melanoma

  • pTis melanoma (in situ): 5 mm margin
  • pT1 melanoma (<1.0 mm): 1 cm margin
  • pT2 melanoma (1.0–2.0 mm): 1–2 cm margin
  • pT3 melanoma (2.0–4.0 mm): 1–2 cm margin
    • A wider margin (2 cm) is optimal, where possible, depending on tumour site and surgeon/patient preference.
  • pT4 melanoma (>4.0 mm): 2 cm margin
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22
Q

What are the different subtypes of BCC?

A
  1. Noduloulcerative (typical)
  2. Pigmented variant
  3. Superifical variant
  4. Sclerosing (morpheaform) variant
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23
Q

What are the subtypes of malignant melanoma?

A
  1. Lentigo maligna (in situ)
  2. Lentigo meligna melanoma (invading into dermis)
  3. Superficial spreading (most common)
  4. Nodular
  5. Acrolentiginous (palmar, plantar, subungual, mucous membranes)
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24
Q

What are the 5-year survival rates for different Breslow depths/cancer stages of melanoma?

A

<1.0 mm (Stage I): 90%

  1. 0-2.0 mm (Stage II): 70%
  2. 0-4.0 mm (Stage III): 45%

>4.0 mm (Stage IV): 10%

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25
Q

What is a traumatic tattoo?

A

Traumatic tattos are permanent discolourations resulting from new skin growth over foreign material or dirt left in the dermis.

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26
Q

What is the toxic limit for lidocaine (Xylocaine)?

A

5 mg/kg without epinephrine (45-60 min)

7 mg/kg with epinephrine (2-6 h)

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27
Q

What is the toxic limit for bupivicaine (Marcaine)?

A

2 mg/kg without epinephrine (2-4 h)

3 mg/kg with epinephrine (3-7 h)

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28
Q

What are symptoms of lidocaine toxicity (local anaesthetic toxicity)?

A

Initial signs:

  • circumoral numbness
  • light-headedness
  • drowsiness

Later signs:

  • tremors
  • seizures

Late signs:

  • cardiac
  • respiratory
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29
Q

Calculate the toxic limit and max bolus injection for a 70 kg patient, using 1% lidocaine without epinephrine.

A

Lidocaine w/o epi = 5 mg/kg

5 mg/kg X 70 kg = 350 mg

1% lidocaine = 10 mg/1000 mg = 10 mg/g = 10 mg/cc

350 mg / (10 mg/cc) = 35 cc

Therefore, toxic limit is 350 mg and max bolus is 35 cc.

More lidocaine can be added after 30 mins.

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30
Q

What can you do to ensure good suturing cosmesis?

A
  • Make incisions along relaxed skin tension lines (Langer’s lines)
  • Attain close apposition of wound edges
  • Minimise tension on skin by closing in layers
  • Every wound edges
  • Use appropriately size sutures
    • 5-0, 6-0 on face
    • 3-0, 4-0 elsewhere
  • Ensure equal width and depth of tissue on both sides
  • Remove sutures in a timely manner
    • 5-7 d from face
    • 10-14 d from scalp/extremities
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31
Q

What are the two important first steps to perform with a wound (besides asking about tetanus status)?

A

Irrigation & debridement

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32
Q

What does irrigating do?

A

Removes bacteria; removes nidi of infection from foreign material, surface clots, devitalised tissue.

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33
Q

What needle gauge and syringe size should be used for irrigation? What pound-force per square inch (psi) does this generate?

A

19-gauge needle

35 cc syringe

~ 18 psi

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34
Q

What must be done to ragged wound edges?

A

Irregular or ragged wound edges must be excised to produce sharp wound edges that will assist with healing when approximated.

Wounds left unapproximated >8h should be debrided to ensure wound edges are optimised for healing.

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35
Q

List the following:

  • absorbable monofilament sutures
  • non-absorbable monofilament sutures
  • absorbable multifilament sutures
  • non-absorbable multifilament sutures
A
  • absorbable monofilament sutures
    • Monocryl
    • PDS II (polydioxanone)
    • Plain gut / fast absorbing gut
  • non-absorbable monofilament sutures
    • Prolene (polypropylene)
    • Nylon (Ethilon)
  • absorbable multifilament sutures
    • Vicryl
  • non-absorbable multifilament sutures
    • Ethibond
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36
Q

List the uses of absorbable vs non-absorbable sutures, and monofilament vs multifilament sutures.

A

Absorbable

  • Deep sutures under short-term tension
  • Skin closure in children
  • At least 50% of strength lost in 4 weeks

Non-absorbable

  • Skin closure
  • Sites of long-term tension
  • Lower likelihood of wound dehiscence
  • More difficult to tie
  • Makes track marks

Monofilament

  • Optimal for contaminated and infected wounds (lower likelihood of bacterial trapping)
  • Slides through tissue w/ less friction
  • More memory/stiffness

Multifilament

  • AVOID in contaminated wounds
  • Less memory/stiffness therefore easier to work with
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37
Q

List the different types of suturing methods and their benefits.

A
  • simple interrupted: can almost always be used
  • subcuticular: good cosmetic result but weak; used w/ deep sutures; not used in trauma
  • vertical mattress: for areas difficult to evert (e.g. volar palm of hand)
  • horizontal mattress: everting; time saving
  • running “baseball stitch”: time saving; good for haemostasis
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38
Q

List three other types of skin closure methods (not sutures).

A
  1. Tapes
    • ​​may work for superficial wounds with opposable edges
    • cannot be applied to actively bleeding wound
    • will prevent surface marks
    • can be applied primarily or after suture sutures have been removed
  2. Skin adhesives
    • ​​e.g. Dermabond (2-octylcyanoacrylate)
    • works well on small areas w/o much tension or shearing
    • may cause irreversible tattooing
  3. Staples
    • ​​steel-titanium alloys that incite minimal tissue reaction
    • healing comparable to wounds closed by sutures
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39
Q

What are some tips for proper lesion excision?

A
  • run incision along relaxed skin tension lines (minimises scar)
  • use elliptical incision (prevents dog ears)
    • length of ellipse will be approx. 3x width
  • undermine wound edges to release tension (if needed)
  • use layered closure, including dermal sutures, when wound is deeper than superficial (decreases tension)
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40
Q

Do relaxed skin tension lines (Langer’s lines) run parallel or perpendicular to muscle fibres?

A
  • Perpendicular to muscle fibres
  • Parallel to existing wrinkle lines
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41
Q

Name the four types of skin biopsy.

A
  1. Shave biopsy
    • superficial lesions (non-pigmented)
  2. Needle biopsy
    • ​​breast masses / LNs
  3. Incisional biopsy
    • ​​punch or ellipse within lesion
    • take biopsy along border with normal skin
    • punch knives range from 2-10 mm diameter
    • punches >3mm best to be closed w/ sutures to prevent scarring
  4. Excisional biopsy
    • ​​complete removal for diagnostic and/or therapeutic purposes
    • best for small lesions that are easily removed and closed
    • always requires suture closure
42
Q

What are the risks and benefits of adding epinephrine to local anaesthetic?

A

Risks

  • avoid in patients with vascular compromise
  • can be used anywhere except significantly injured digits (e.g. saw injury)
  • mantra of “fingers nose penis toes” no longer followed

Benefits

  • constrict blood vessels which:
    • decreases bleeding
    • prolongs anaesthesia
    • limits lidocaine toxicity
43
Q

Which antiseptics can be used on the face?

A

Chlorhexidine

  • comes in [c] 0.5-4% – only use lower [c] on the face otherwise risk of burning mucous membranes
  • flammable – dry completely before cautery

Betadine

  • 7.5% povidone-iodine safer around eyes/ears/mucous membranes

Both solutions are bacteriostatis and bactericidal.

44
Q

Distinguish between laceration, abrasion, contusion, avulsion, puncture wound, and crush injury.

A

Laceration

  • cut or torn tissue

Abrasion

  • superficial skin layer removed; variable depth

Contusion

  • injury caused by forceful blow; entire outer layer of skin is intact but injured

Avulsion

  • tissue/limb forcefully separated from surrounding tissue, either partially or fully; “de-gloving”

Puncture wound

  • cutaneous opening relatively small as compared with depth (e.g. needle)
  • includes bite wounds

Crush injury

  • caused by compression

Also: Thermal and chemical wounds

45
Q

Define “wound”.

A

Disruption of the normal anatomical relationships of tissue as a result of injury.

46
Q

List local and general factors influencing wound healing.

A

Local (reversible/controllable)

  • mechanical (local trauma, significant crush, avulsion, tension)
  • blood supply (ischaemia/circulation)
  • temperature
  • technique and suture materials
  • retained foreign body
  • infection
  • venous hypertension
  • peripheral vascular disease
  • haematoma/seroma (also increases infection rate)

General (often irreversible)

  • age
  • nutrition (protein, vitamin C, O2)
  • smoking
  • chronic illness (e.g. DM, cancer, CVD)
  • immunosuppression (steroids, chemo)
  • collagen vascular disease
  • tissue irradiation
47
Q

Name the layers of the upper eyelid (remember the 4-5-7 rule).

A

Lower 5 mm: 4 layers

  1. skin (anterior lamella)
  2. orbicularis oculi (anterior lamella)
  3. tarsus (posterior lamella)
  4. conjunctiva (posterior lamella)

Middle 5 mm: 5 layers

  1. skin
  2. orbicularis oculi
  3. levator aponeurosis
  4. tarsus
  5. conjunctiva

Upper 10 mm: 7 layers

  1. skin
  2. orbicularis oculi
  3. septum
  4. preaponeurotic fat
  5. levator aponeurosis
  6. Müller’s muscle (inserts into tarsus)
  7. conjunctiva
48
Q

Name the layers of the lower eyelid (4-7).

A

Upper 5mm: 4 layers

  1. skin
  2. orbicularis oculi
  3. tarsus
  4. conjunctiva

Lower 5mm: 7 layers

  1. skin
  2. orbicularis oculi
  3. septum
  4. pre-capsulopalpebral fascia fat
  5. inferior sympathetic muscle (equivalent to Müller’s in upper lid)
  6. CPF (equivalent to levator aponeurosis)
  7. conjunctiva
49
Q

What is the distinction between canthopexy and canthoplasty?

A

Canthopexy: lateral canthal tendon of the eye is not cut, but is fixated to the orbital rim.

Canthoplasty: lateral canthal tendon is cut and then secured to lateral orbital rim (at Whitnall’s tubercle).

50
Q

Define ectropion and entropion.

A

Entropion: eyelid inverted.

Ectropion: eyelid everted.

51
Q

How long does it take a scar to fully mature?

A

1 to 2 years

52
Q

What are the three phases of wound healing?

A
  1. Inflammatory (Days 1-6)
    • ​​limits damage, prevents further injury
      1. ​​Haemostasis
        • ​vasoconstriction + platelet plug
      2. Chemotaxis
        • _​​_migration of macrophages and PMN
        • neutrophils (24-48 h); macrophages (48-96 h); lymphocytes (5-7 d)
  2. Proliferative (Day 4 - Week 3)
    • ​​fibroblasts attracted and activated by macrophage growth factors
      1. ​Collagen synthesis (mainly type III)
        • tensile strength begins to increase at 4-5 days_​_
      2. Angiogenesis
        • relieves ischaemia
      3. Epithelialization
  3. Remodelling (Week 3 - 1 year)
    • ​​increasing collagen organisation and stronger crosslinks
      1. ​Contraction
      2. Scarring
      3. Remodelling of scar
        • _​​_type I replaces type III collagen until normal 4:1 ratio achieved
        • peak tensile strength at 60 d – 80% of pre-injury strength
53
Q

Contrast hypertrophic and keloid scars.

A

Type

Hypertrophic

Keloid

Definition

Scar within original boundaries

Scar outside original boundaries

Location

Any location; often on extensor surfaces of joints

Commonly on sternal skin, shoulders, upper arms, earlobes, cheeks

Change in size

Regress with time

Grow for years

Collagen

Fewer thick collagen fibres

Thick collagen

Mucoid matrix

Scanty matrix

Mucoid matrix

Elevation

Flatten over time

Remain elevated >4mm

Initiation

Appear within one month

Appear at 3 months or later

Skin type

Less association with pigmentation

More common in darker skin types (genetic component)

Appearance

Red, raised, widened, pruritic

Red, raised, widened beyond scar borders, pruritic (constant collagen deposition and growth)

Treatment

Massage, pressure garment, silicone sheeting, corticosteroid injection (Kenalog – triamcinolone), surgical excision (may recur)

Multimodal: pressure garments, silicone sheeting, steroid injection, fractional carbon dioxide ablative laser, radiation (sometimes with excision – high risk of recurrence)

54
Q

What are the three causes of keloid scars?

A
  1. Genetic factors (highest rates in African/Asian ethnicity)
  2. Endocrine factors
  3. Excess tension on wound or delayed closure (e.g. burn wounds)
55
Q

Define “spread scar”.

A

A spread scar is characterised by having the exactly same order of collagen fibres as normal scars. It is typically flat, wide, and often dented. Treatment is with surgical excision and closure.

56
Q

Define “chronic wound”.

A

A chronic wound fails to achieve primary wound healing within 4 to 6 weeks. Common chronic wounds include diabetic, pressure, and venous stasis ulcers. Chronic wounds are treated with meticulous wound care +/- surgery.

57
Q

What is the name of SCC arising in a chronic wound?

A

Marjolin’s ulcer.

Arises secondary to genetic changes caused by chonic inflammation. Always consider a biopsy of a chronic wound.

58
Q

What are the three types of wound healing?

A

Primary intention

  • Definition: wound closure by direct approximation of wound edges within hours of wound creation.
  • Indication: recent (<6 h); clean wound.
  • Contraindications: bites (except on face); crush injury; infection; >6-8 h since injury; retained FB

Secondary intention (spontaneous)

  • Definition: wound left open to heal spontaneously
  • epithelialisation 1 mm/d from wound margins
  • contraction by myofibroblasts at <0.75 mm/d
  • granulation
  • maintained in inflammatory phase until wound closed
  • requires dressing changes
  • inferior cosmetic result
  • Indication: when primary closure not possible or indicated

Third intention (delayed primary)

  • Definition: intentionally interrupt healing process, then close wound 4-10 d post-injury after granulation tissue has formed and <105 bacteria/gram of tissue
  • Indication: contaminated; long time since injury; severe crush; significant tissue devitalisation; closure of fasciotomy wounds
  • prolongation of inflammatory phase decreases bacterial count and lessens chance of infection after closure
59
Q

Contrast contamination, colonisation, and infection.

A

Contamination: presence of nonreplicating organisms within a wound.

Colonisation: presence of replicating organisms within a wound.

Infection: greater than 105 microorganisms in a wound without intact epithelium; may also be infected with small amounts of a very virulent organism (e.g. GBS).

60
Q

Which organism is the most common cause of necrotising fasciitis?

A

Group A Strep

61
Q

What are three overarching risk factors for infection?

A
  1. Virulence of infecting organism.
  2. Amount of bacteria present.
  3. Host resistance (host defenses).
62
Q

A patient presents with an acute (<24 h) contaminated wound. Describe the steps of treatment.

A
  1. Cleanse and irrigate with NS or RL w/ pressure.
  2. Evaluate for injury to underlying structures.
  3. Control active bleeding.
  4. Debride FB, devitalised tissue, old blood. Surgical debridement as needed.
  5. Rx systemic antibiotics for obvious infection. Particularly: wound >8 h; severely contaminated; bites; immunocompromised; involvement of deeper structures (e.g. joints, fractures).
  6. +/- Tetanus.
  7. +/- post-exposure tx of hep B, HIV, hep C (if titres confirmed at 6 mo).
  8. Re-evaluate in 24-48 h for signs of superficial or deep infection.
    • If evidence of infection, remove sutures to open infected portion, swab for c&s, irrigate, allow healing by 2ndary intention.
63
Q

A patient comes in with a contaminated wound that has been present for >24 h. How would you manage it?

A
  1. Irrigate and debride.
    • Remove particles that could cause traumatic tattooing.
  2. Systemic abx if concern for worsening infxn (e.g. redness, welling, pain, clinically unwell).
  3. Topical antimicrobials: beneficial for minor wounds, but doesn not add to systemic abx; may help with chronic wound healing.
  4. Closure via secondary intention (most common), tertiary closure, skin graft, or skin flap.
    • Successful closure depends on bacterial count <105/cm3 prior to closure and frequent dressing changes.
64
Q

What is a “biofilm”?

A

A biofilm is defined as “an assemblage of microbial cells that is irreversibly associated with a surface and enclosed in a matrix of primarily polysaccharide material”.

65
Q

What factors increase the risk of contracting tetanus?

A

Wound characteristics

Tetanus-Prone

Not Tetanus-Prone

Time since injury

>6 h

<6 h

Depth of injury

>1 cm

<1 cm

Mechanism of injury

Crush, burn, gunshot, frostbite, puncture through clothing, farming injury

Sharp cut (e.g. clean knife, clean glass)

Devitalised tissue

Present

Not present

Contamination (e.g. soil, dirt, saliva, grass

Yes

No

Retained foreign body

Yes

No

66
Q

When is tetanus required for clean, minor wounds? When is it required for all other wounds?

A

Clean, minor wounds

History of tetanus immunization

Td or Tdap*

Tig**

Uncertain, <3 doses, or 10 y since booster

Yes

No

3 doses

No

No

*0.5 mL combined tetanus and diphtheria toxoids +/- acellular pertussis

**Tetanus immune globulin, 250 U given at separate site from Td/Tdap

All other wounds

History of tetanus immunization

Td or Tdap

Tig

Uncertain, <3 doses, or >5 y since booster

Yes

Yes

3 doses

No

No^

^ Yes, if immunocompromised

67
Q

What are the risks with more frequent dressing changes?

A
  1. Decreased body temp
  2. Cost
  3. Outpatient inconvenience
  4. Contamination
  5. Pain
  6. Trauma to wound
68
Q

What are the common pathogens of dog and cat bites?

A
  • Pasteurella multocida
  • Staph aureus
  • Strep viridans
69
Q

What two investigations must be carried out when a patient presents with a bite injury?

A
  1. Radiographs to r/o FB or fracture.
  2. Wound swab - culture for aerobic and anaerobic organisms, gram stain.
70
Q

What antibiotic & dose is used to treat dog and cat bites?

A

Clavulin (amoxicillin + clavulanic acid)

500 mg PO q8h started immediately

71
Q

What is an important question to ask someone who comes in with an animal bite?

A

Could the animal have rabies?

Consider prophylaxis if unknown animal or animal showing symptoms of rabies.

Three types of rabies vaccines: 1.0 mL IM in deltoid, repeated on days 3, 7, 14, 28.

+/- Rabies Ig: 20 IU/kg around wound, or IM.

72
Q

How are bite wounds treated?

A
  1. Aggressive irrigation and debridement, with urgent surgical exploration of joint (if involved).
  2. Healing by secondary intention is mainstay of treatment.
    • Only consider primary closure for bite wounds on the face.
  3. Amox-clav 500 mg PO q8h
    • clinda 300 mg PO q6h + cipro 500 mg PO q12h if penicillin allergy
  4. Splint in functional position (for hand wounds).
  5. For animal bites: consider rabies and call Public Health if animal status is unknown.
73
Q

What is the position of safe immobilisation (“intrinsic plus”) of the hand? Why is it used?

A

Wrist extended 20-30 degrees

MCP flexed 60-70 degrees

IPs fully extended

Thumb mid-abduction/extension

The position of safety helps prevent contracture of the joints by:

  • extending the wrist takes tension off extensors and keeps them from pulling MCPJ into extension
  • stretching out the MCP collaterals in flexion
  • stretching out the IP collaterals in extension
74
Q

What is tenodesis function?

A

Tenodesis function: when the wrist is extended the fingers and thumb flex into the palm and when the wrist is flexed the fingers and thumb open.

75
Q

What are the benefits of negative-pressure wound therapy?

A

Promotes healing through the following:

  • removes exudate
  • reduces bacterial count
  • reduces edema
  • promotes granulation
  • increases perfusion (blood flow)
76
Q

List nine components of the reconstruction ladder (or elevator).

A
  1. Healing by secondary intention
  2. Primary closure
  3. Delayed closure
  4. STSG
  5. FTSG
  6. Random pattern flap
  7. Pedicle flap
  8. Tissue expansion
  9. Free flap

NPWT can go on different levels of the “elevator”.

77
Q

What are two causes of hypoalbuminaemia?

A
  1. Inflammation
  2. Inadequate nutritional intake
78
Q

What antibiotic do patients have to be on when they are receiving leech treatment? What organism is the antibiotic covering in particular?

A

Aeromonas bacteria (gram neg anaerobe)

Ciprofloxacin 100% effective in studies

79
Q

How does leeching word to decrease venous congestion?

A

Leeches release a polypeptide called hirudin that inhibits the thrombin-catalysed conversion of fibrinogen to fibrin.

Hirudin also blocks platelet aggregation in response to thrombin and may inhibit Factor X.

80
Q

Define “skin graft”.

A

Skin that is harvested from a donor site and transferred to the recipient site and does not carry its own blood supply.

81
Q

What pressure is a VAC usually set at for a SG? What about for other wounds?

A

SG: -75 mmHg

Other wounds: -125 mmHg

Intermittent VAC = ?improved granulation

82
Q

What is a sign of pseudomonas infection in a wound? Which two topical therapies can be used to treat it?

A

Greenish discolouration.

Acetic acid or silver.

83
Q

What is an important concept when deciding on the layers in a wound dressing?

A

Wet-to-dry - keeps wound moisturised and allows some mechanical debridement.

84
Q

What are important considerations for skin graft donor site selection?

A
  • size
  • hair pattern
  • texture
  • thickness of skin
  • colour
    • facial grafts best taken from “blush zones” above clavicle, such as pre/post auricular or neck
  • STSG usually taken from inconspicuous areas such as the buttocks or lateral thigh
85
Q

What are the three phases of skin graft “take”?

A
  1. Imbibition (first 48 h)
    • ​​diffusion of nutrients from recipient site
  2. Inosculation (days 2-3)
    • ​​vessels in graft connect with those in recipient bed
  3. Revascularisation (days 3-5)​​
86
Q

What factors threaten the survival of a skin graft?

A
  • poorly vascularised bed (bone, tendon, irradiated tissue, infected wounds)
  • haematoma/seroma (staples, sutures, splinting, pressure dressings, bolster dressing all used to prevent movement)
  • shearing
  • bacterial count >105
87
Q

Distinguish autograft vs allograft vs xenograft.

A
  • autograft: from same individual
  • allograft: from same species, different individual
  • xenograft: from different species
88
Q

What is the purpose of Scarpa fascia?

A

No purpose; it is a vestigial structure of the panniculus carnosus (animals such as horses and dogs can use it still to twitch).

Vestigial mucles of panniculus carnosus: platysma, palmaris brevis, dartos muscle (scrotum), some muscles of facial expression.

89
Q

Compare STSG and FTSG.

A

STSG

FTSG

Definition

Epidermis + partial dermis

Epidermis + full dermis

Donor site

More sites

Sites limited by ability to close primarily

Healing of donor site

Re-epithelialisation via dermal appendages in graft and wound edges

Primary closure

Re-harvesting

~10 d (faster on scalp)

N/A

Graft take

More reliable, better survival (shorter nutrient diffusion distance)

Lower rate of survival (thicker, slower vascularisation)

Contraction*

Less primary contraction (less dermis); greater secondary contraction (decreased as graft gets thicker)

Greater primary contraction (more dermis); less secondary contracture

Aesthetic

Poor

Good

Advantages

Takes well in less favourable conditions.

Can cover larger area.

Can be meshed for greater area, extravasation of blood/serum, and to prevent covering of contaminated material.

Potential for healing in less favourable environment.

Large number of donor sites.

May use on face and fingers

Resists (secondary) contraction.

Better colour match.

Disadvantages

Contracts significantly (secondarily).

Abnormal pigmentation.

High susceptibility to trauma.

Requires well-vascularised bed.

Must remove fat from graft before application.

Uses

Large areas of skin.

Granulating tissue beds.

Face (colour match).

Site where thick skin or decreased contracture is desired (e.g. finger).

*Primary: immediate upon harvesting (d/t elastin); Secondary: once place on wound bed and healing has occurred (d/t myofibroblasts).

90
Q

How much of an increase in length can you get with a Z-plasty?

A

45 degree angle: 50%

60 degree angle: 75%

91
Q

What is Parkland’s formula?

A

Formula for fluid resuscitation to achieve haemostasis post-burn injury.

4 mL X TBSA (%) X body weight (kg)

50% given in first 8 hours.

50% given in next 16 hours.

92
Q

What is Froment’s sign?

A

Positive test: flexion of IP joint of thumb when grasping paper b/w thumb and index.

Indicates: adductor pollicis paralysis d/t ulnar nerve damage.

Jeanne’s sign occurs when there is simultaneous MCP extension d/t additional ulnar nerve damage.

93
Q

How does an ulnar claw form?

A

Ulnar nerve injury results in weakened medial lumbricals at D4 and D5. Loss of function of the lumbricals results in hyperextension at the MCPJ and flexion at the IP joints (“claw hand”).

94
Q

Which intrinsic hand muscles does the ulnar nerve innervate?

A
  • medial two lumbricals
  • hyopthenar muscles
  • interossei
  • adductor pollicis
  • FPB (deep head)
95
Q

Which instrinsic hand muscles does the median nerve innervate?

A

Think “LOAF”:

Lateral (radial) two lumbricals

Opponens pollicis

Abductor pollicis brevis

Flexor pollicis brevis (superficial head)

96
Q

What causes ulnar paradox?

How does it appear?

A

Ulnar paradox is a lesion of the ulnar nerve at the elbow.

In addition to the intrinsic hand muscles, FCU and the medial two FDP are paralysed.

Still have hyperextension at MCPJ (as with claw hand), but no flexion at IPJ as FDP paralysed.

97
Q

What causes hand of benediction?

Which muscles are paralysed?

How can you test for it? What does it look like?

A

Cause: damage to median nerve.

All hand flexors are paralysed, except medial 2 FDP (innervated by ulnar nerve). Radial 2 lumbricals are also paralysed (as are thenar muscles),

Test: ask patient to make a fist. If present, index and (possibly) middle finger will not flex at IPJs. Middle finger may flex still due to quadriga effect.

98
Q

What is the quadriga effect?

A

The quadriga effect is characterized by an active flexion lag in fingers adjacent to a digit with a previously injured or repaired flexor digitorum profundus tendon.

This can happen in rev amps if the FDP is pulled over the stump.

Named after the four horse-drawn chariot – if one horse has a shortened lead, then the other three horses’ leads will become slack.

99
Q

List the four stages of development of ulcers.

A
  1. Hyperaemia: disappears 1 h after pressure removed.
  2. Ischaemia: follows 2-6 h of pressure.
  3. Necrosis: follows >6 h of pressure.
  4. Ulcer: necrotic area breaks down.
100
Q

What is the medical term for ‘trigger finger’?

What is trigger finger?

A

Stenosing tenosynovitis.

Definition: inflammation of synovium causes size discrepancy between tendon and sheath/pulley (most commonly at A1 pulley), resulting in locking of the thumb or finger in flexion or extension.

101
Q

What are the two common organisms causing cellulitis?

A
  1. Streptococcus pyogenes (GAS)
  2. Staph aureus
102
Q
A

Toronto Notes: Plastic Surgery (1 decks)

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