Board Cases Flashcards
CTS (+advanced)
Tinel/phalens/dirkens
EMG: 3.5 ms sensory, 4.5 ms motor
**decreased amplitude with prolonged latency +/- fibrillations –> means denervation
- Opponensplasty: FDS RF thru hemi FCU loop into AbdP
Pressure Sore
Hx:
Continent?
PMH: DM / PVD?
Spinal cord injury / ambulatory / sensation / spasticity?
Current wound care regimen
W/U:
Imaging - MRI
Bx - tissue path (marjolins
ulcer / micro / bone bx)
Consults: IM, PT, SW, ID (+/- ortho /gen surg /uro)
______
1. educate
2. spasticity (baclofen/diazepam)
3. prevent contractures (PT/tenotomy)
4. Stage 3/4 –> debride /changes. Close only if social fixed, Bx negative
Ischial - inf glut rot (FC or MC- IGA), Hamstring V-Y (MC-profunda),Post thigh V-Y (based medially - profunda)
Sacral - Sup glut rot (FC or MC - SGA), BL V-Y (SGA), SGAP (FC)
Troch - TFL (MC - transv LFCA), ALT (Desc LFCA), girdlestone (with vastus lateralis interpsoition)
**Bx for Marjolins
Lip
BB is also “BB webster”
Hx: XP, Gorlin syn, rads, organ transplant
PE: full skin exam, LN
Dx: Bx (not shave)
Palpable LN –> medical oncology / CT / PET
Nose
Subunits (dorsum,sidewall,tip,ala, soft triangle,columella)
Layers (mucosa,cartilage,skin)
**2 stages: 1st is FRF with extra fascia extension, fascia is lining. 2nd stage rib cartilage is used as cantilever dorsal nasal graft and BL conchal alar batten grafts for alar support, then fold flap (with skin paddle over cartilage. 2nd stage remove majority of skin paddle but leave lining and add cartilage and cover with forehead flap.
Eyelid
Ear
TPF based on STA
ZMC fx
Burn
*escharotomy / fasciotomy if electrical
Parkland: 4 x kg x tbsa (goal 30cc/hr adult, 1cc/kg/hr kids)
OT / splinting / ROM
Max 30% tbsa excision at once, 10U pRBC, 2-3 hrs
Lower lid ectropion
Types:
- senile: laxity of muscle –> tarsal strip
- paralytic
- cicatricial: scar/injury –> release scar and FTSG then tarsal strip
Microtia
Complication:
Eyelid ptosis
Acquired - 2/2 disinsertion of levator aponeurosis
Congenital - nonfunctional levator
PE: Bells, EOM, Herrings law (cover that eye up)
**wake them up, 4:1 correction to ptosis (ie 2mm ptosis is 8mm correction)
Mild: 2mm droop, 10-15mm excursion - FS
clamp conjunctiva at superior edge of tarsus with mueller muscle, suture with runnnig chromic then resect tissue. excise 8mm tissue.
Mod: 3mm droop, 5-10mm excursion- LA transcutaneous, suture levator aponeurosis back into tarsus
Severe: 4mm droop, 5mm excursion -FA
use synthetic or TFL graft to thread thru anterior lamella then subQ up to above brow, knot and tied to subQ tissue.
Comp:
Cheimosis: tobradex, patch, tape
Frontal sinus fx
Ant table –> displaced / non –> NFOT?
Post table –> displaced / non –> CSF leak?
-Coronal incision approach
-pericrainal flap through a window
Mandible fx
Complications:
infection: washout and keep HW if early, remove and ex fix / bone graft later if late
malocclusion: guiding elastics vs revise later
malunion: revise
nonuion: revise with bone graft
plate exposure: remove plate
nerve injury: marge, watchful waiting unless certain you injured it
Condylar head: Dislocation out of glenoid fossa, foreign body, BL condylar
VPI
PE: submucous cleft
W/U: speech eval via nasoendoscopy, video flouroscopy to evaluate closure
Tx:
-Furlow (small midline gap)
-posterior pharyngeal flap (Poor velar or posterior wall motion)
-sphincter pharyngoplasty (Poor lateral wall motion)
Posterior pharyngealwall augmentation
Poland Syndrome
PE: palpate lack of sternal head of pec, back for scars,
- brachysyndactyly, facial palsy
-Counsell: ALCL / BII / CC
Tx:
-Teen –> TE initially, implant + FG as adult
-Adult –> implant
-Male –> LD
Cleft lip
https://journals.lww.com/plasreconsurg/pages/video.aspx?v=157&autoPlay=false
Hx: Feeding and breathing issues
Counsel: palate at 1 year
NAM immediately
Fisher anatomic subunit repair
Comp:
Nerve Lac
Radial N –> TT (PT - ECRB, FCR - EDC, PL - EIP)
N growth: 1mm/day or 1 inch/mo
EMG: takes 1 month to show injury
Tendon Transfer
RN: Brand
MN: pinch (BR –> FPL)
IP flexion (FDP 4/5 –> 2/3)
opposition (FDS 4 –> APB)
UN:
How to tension: 50/50 → tight as you can, then no tension and do middle between those. Confirm with tenodesis.
Postop: splint 4 weeks, AROM after
Sagital band injury
partial just treat with relative motion extension splint
Complete → repair or use PL graft tendon loop thru MC head
Boutenierre
Swan Neck
2 difficult ones:
Boutenneire → chronic central slip
** is this passively correctable. If no → OT, if yes → surgery
Lateral band centralization, take medial half LB and centralize it and anchor to p2
Swan neck → Chronic terminal tendon injury
** is this passively correctable. If no → OT, if yes → surgery
FDS tenodesis → 1 slip FDS into P2 in slight flexion
**Bunnell intrinsic tightness test, if present do release over P1, excise triangle of extensor hood
Meningocele
- recommend VP shunt, neurosurgery (reduce, repair dura), operate within 1d
- Tx;
1) rhomboid flap going vertically up back OR ying yang flaps
2) primary closure with lateral relaxing incisions
3) SGAP flap (lateral edge of sacrum (medially), iliac crest (superior), ischial protuberance (inferior) — perfs 2/3 way from greater troch –> PSIS)
4) paraspinal advancement and STSG
5) LD release origin and insertion and slide whole muscle down
Lymphedema
Dx: lymphoscintigraphy via ICG
Tx:
Conservative → complete decongestive therapy via lymphedema therapist (massage, compression dressings, skin care)
Surgical:
-Charles procedure → circumferential subfascial excision with STSG after (modified charles is where you VAC it after then STSG 1 week later)
-Vascularized LN transfer:
Donor options: supraclavicular (transverse cervical vessels), **superficial inguinal nodes (superficial circumflex vessels → can take skin paddle which is essentially a SCIP flap)
Lymphovenous anastomosis : superficial lymphatics and superficial veins.
AV malformation / Hemangioma
Facial Palsy
** upper eyelid closure, lower lid laxity, smile
upper lid - gold weight, pre tarsal
Smile:
Tuberous Breast
Stage: TE first, 2nd stage 3 mo later - subfascial implant with PA lift
Complication:
Double bubble –> release bands at IMF, ensure no bottoming out, fat graft
Perineal wound
VRAM -
Gracilis musculocutaneous - MFCA
Singapore - internal pudendal off of internal iliac
Chest wall wound
<4 ribs or <5cm - dont need rigid fixation
ADM lining + rib plating + flap OR
PTFE goretex mesh + flap
Flaps:
pedicled:
LD, VRAM/TRAM pec, serratus** ( Lat thoraciac and thoracodorsal), omentum**
Free: ALT, DIEP
