Board Review part II Flashcards
Dupuytrens cords that cause contractures at the PIP joint
Central cord, Spiral cord, Lateral cord
Dupuytrens cords that cause contractures at the DIP joint
Lateral cord, retrovascular cord
Dupuytrens cords that cause contractures at the MCP joint
Preteninous cord
Dupuytrens cord that prevents abduction of fingers
Natatory cord
The nerve bifucates ____ to the artery in the palm
distal
The digital nerve is ____ to the artery in the finger and ___ to the artery in the palm
volar to the artery in the palm and dorsal to the artery in the palm
In the proximal forearm, the radial artery runs between the ___ and ___ muscles
brachioradialis and pronator teres
At the wrist crease, the radial artery lies superficially between tendons ___ and ___
APL and FCR
Thenar muscles
Median nerve innervated
Opponens pollicis
Abduction pollicis brevis
Flexor pollicis longus (deep is ulnar innervated)
Methods for maintaining elbow extension in quadriplegia
- deltoid to triceps transfer with free graft
2. Biceps to triceps for C5-6 tetraplegia
Treatment of thumb in palm deformity
associated with cerebral palsy: release spastic muscles and stabilization of the joint
- FPL abductoplasty (FPL to APB + fusion/tenodesis thumb IP)
- Flexor/pronator slide
Treatment of wrist flexion contracture and clenched fist deformity in cerebral palsy and stroke
- botox injections
- Surgery if that doesn’t work- transfer flexors to different levels of forearm, fractional lengthening, FDS to FDP transfer
Restore thumb key pinch in low level quads
thumb IP fusion with release of pulley and tenodesis of FPL to volar radius, tenodesis of EPL to dorsum of thumb metacarpal
Where is parona’s space?
deep flexor compartment of the forearm - PQ, FPL, FDP
AIN innervated hand
FPL, PQ, 2/3 FDP
Median innervated hand
LOAF
Ulnar innervated hand
- all intrinsics except radial 2 lumbricals
- deep head of FPB, hypothenars
- 4/5 FDP
Radial innervated hand
ECRB/ECRL
PIN innervated hand
All extensors except ECRB/ECRL
what are the deep forearm extensors?
anconeus, supinator, EIP, EPL, EPB, APL
compartments 1, 3, 4
What are the superficial forearm extensors?
ECU, EDM, EDC, ECRB, ECRL, BR
compartments 2, 4, 5, 6
Treatment for volkmann’s contracture
- mild: FDP 3/4
- moderate: FDP and FPL
- severe: all flexors
Mild: excision of scar cord on muscle bellies
Moderate: decompress median and ulnar nerves, excision of cords, flexor-pronator slide, then tendon transfers (ECRB to FDP) (BR or ECU to FPL)
Severe: innervated gracilis free flap
Proximodistal limb growth controlled by
AER (apical ectodermal ridge)
- dyfunction = short limb
Radio-Ulnar limb growth controlled by
Zone of polarizing activity (sonic hedgehog protein)
Dorsal-ventral limb growth is controlled by
WNT7 signaling pathway which produces LMX1 (dorsal), EN1 blocks wnt (ventral)
Innervation to the lateral lower fat pad of the eye?
Zygomaticofacial nerve
Innervation to the upper lateral eyelid?
Lacrimal nerve via lateral palpebral branch
Innervation to the medial upper and lower eyelid
Infratrochlear nerve
4 stages of perilunate instability pattern
- Scapholunate disruption (DISI)
- Dorsal dislocation of capitate
- Lunotriquetral disruption (VISI)
- Volar dislocation of lunate
Normal scapholunate angle?
DISI?
VISI?
Normal is 30-60 degrees
DISI < 30 degrees
VISI > 60 degrees
Lateral calcaneal artery is the terminal branch of what artery?
lateral calcaneal artery is usually the terminal branch of the peroneal artery but occasionally may arise from the posterior tibial artery
Tendon transfer for foot drop
posterior tibial tendon to anterior tendon transfer
Genitofemoral nerve
proximal portion of the thigh about the femoral triangle just lateral to the skin that is innervated by the ilioinguinal nerve. Nerve injury may result from hernia repair, but injury to this nerve is rare
Ilioinguinal nerve
from the fusion of T12 and L1 nerve roots and pierces the transversus abdominis and internal oblique muscles.
- sensory to the pubic symphysis, the femoral triangle, and either the root of the penis and anterior scrotum in the male or the mons pubis and labia majora in the female
- Symptoms include paresthesia of the skin along the inguinal ligament. The sensation may radiate to the lower abdomen. Pain may be localized to the medial groin, the labia majora or scrotum, and the inner thigh.
iliohypogastric
small region just superior to the pubis. Symptoms include burning pain into the inguinal and suprapubic region
Lateral femoral cutaneous nerve
anterior and lateral thigh burning, tingling, and/or numbness that increase with standing, walking, or hip extension.
Location of the medial plantar artery
between flexor digitorum brevis and abductor hallucis
Location of the lateral plantar artery
lateral plantar artery runs between the flexor digitorum brevis and abductor digiti minimi
Location of the dorsalis pedis
dorsalis pedis artery runs between the extensor hallucis longus and extensor digitorum longus tendons
Medial plantar artery comes off the … artery
posterior tibial artery. Innervation through the medial plantar nerve
Margins for excision of high-risk SCC?
What is a high-risk SCC?
- 6mm to 10mm
- larger than 2 cm, invasive to fat, or in high-risk locations (i.e., central face, ears, scalp, genitalia, hands, feet).
- 4-mm margin of healthy tissue is recommended for lower-risk lesions
- Frozen sections of margins are recommended for high-risk squamous cell carcinoma and basal cell carcinoma in high-risk areas, lesions more than 2 cm, and any morpheaform basal cell carcinoma.
areas of thickened skin involving the forearms and hands. Telangiectasias are seen on the face and oral cavity. A review of systems discloses symptoms of heartburn and dysphagia.
CREST
- calcinosis, raynaud’s, esophageal dysmotility, sclerodactyly, telangiectasias
- ok to debride if needed (different from calciphylaxis)
Treatment of angiosarcoma (purple plaque) on the forehead
wide local excision with reconstruction
Treatment of kid with purpura fulminans with DIC
activated protein C
Treatment of Merkel cell carcinoma
WLE and radiation (it is a radio-sensitive tumor)
multiple ulcerative, nonhealing wounds on the left shoulder after MRM and radiation for breast cancer
Stewart treaves
wide local excision with reconstruction
Indications for MOHS surgery for BCC?
- Recurrent or incompletely excised BCC or squamous cell carcinoma (SCC)
- Primary BCC or SCC with indistinct borders
- Lesions located in high-risk areas (ie, eyelids, nose, ear, nasolabial folds, upper lip, vermillion border, columella, periorbital, temples, preauricular and postauricular areas, scalp)
- Cosmetically and functionally important areas, including genital, anal, perianal, hand, foot, and nail units
- Tumors with aggressive clinical behavior (ie, rapidly growing, greater than 2 cm in diameter)
- Tumors with an aggressive histologic subtype (ie, morpheaform BCC) and/or those with perivascular invasion
- SCCs ranging from undifferentiated to poorly differentiated, and SCCs that are adenoid (acantholytic), adenosquamous, desmoplastic, infiltrative, perineural, periadnexal, or perivascular
- Tumors arising in sites of previous radiation therapy
- Tumors arising in immunosuppressed patients
- Basal cell nevus syndrome patients
Mechanism of topical 5-FU
topical chemotherapeutic agent that directly inhibits DNA synthesis
MOA of imiquod
stimulates host cytokine production and induces apoptosis of tumor cells. It has been used to treat actinic keratoses, viral warts, and nonmelanoma skin malignancy
Bazex syndrome
multiple BCCs of the face, follicular atrophoderma of the extremities, localized or generalized hypohidrosis, and hypotrichosis,
-like gorlin but no hand pits or molar pain
Erythroplasia of Queyrat
arises from the squamous epithelial cells of the glans penis. It is synonymous with Bowen disease of the glans penis, is seen mostly in uncircumcised men, and represents an in situ form of squamous cell carcinoma
excision margin for lentigo maligna
1cm
Melanoma excision based on depth
In situ = 0.5cm
<1mm = 1cm
1-4mm = 2cm
>4mm = 3cm
Treatment for radiation dermatitis
hydrocortisone
What is Type 1 hypersensitivity?
Type 1 (allergy) refers to immediate release of IgE, mediated release of histamine, and other vasoactive mediators resulting in manifestation within minutes. Examples include asthma or anaphylaxis.
What is Type 2 hypersensitivity?
Type 2 (cytotoxic-antibody dependent) refers to binding of IgM or IgG to the target cell, which in this case is a host cell. This results in the membrane attack complex (MAC) destruction of the targeted cell. Examples include thrombocytopenia, Goodpasture, and membranous nephropathy.
What is Type 3 hypersensitivity?
Type 3 (immune complex–mediated reaction) refers to IgG binding to circulating antigen resulting in formation of an immune complex. These complexes can end up collecting in the vasculature, joints, and kidneys resulting in local destruction. Examples include rheumatoid arthritis, systemic lupus erythematosus, and serum sickness.
What is Type 4 hypersensistivity?
Type 4 (delayed type hypersensitivity) refers to the activation of TH1 helper T cells by an antigen-presenting cell. This establishes an immune response memory and when activated again, the TH1 cells activate a macrophage-mediated response resulting in cellular damage. Examples include chronic transplant rejection, contact dermatitis, and multiple sclerosis.
What type of hypersensitivity is immunosuppression of transplant patients trying to prevent?
Transplant patients require immunosuppression to avoid a type 4 hypersensitivity.
Briefly describe the 4 types of hypersensitivity:
Type 1: immediate release of IgE, mediated release of histamine, and other vasoactive mediators resulting in manifestation within minutes (asthma or anaphylaxis)
Type 2: IgM or IgM bind to host cell, cytotoxic antibody dependent
Type 3: immune complex-mediated reaction - IgG binding to circulating antigen (RA, SLE)
Type 4: delayed type; activation of Th1 helper T cells
order that cells show up in a wound
platelets, neutrophils, macrophages, lymphocytes, and fibroblasts
Describe the wound healing process
The appearance of cell types in an acute wound occurs in the following order: platelets, neutrophils, macrophages, lymphocytes, and fibroblasts, during the inflammatory phase.
- The ensuing phases of wound healing consist of inflammation, collagen synthesis, angiogenesis, epithelialization, and remodeling.
- after platelet aggregation and degranulation, chemoattractants, activation factors, and vasoconstrictors are released. An efflux of neutrophils occurs at the wound site to primarily sterilize the wound. Within 2 to 3 days, the inflammatory cell population shifts to monocytes that differentiate into macrophages, which orchestrate the repair process. Collagen synthesis occurs as circulating bone marrow-derived cells migrate into the wound and develop a fibroblastic cell function. These cells and local, activated fibroblasts synthesize and secrete the replacement collagen scar. Fibroblasts become the predominant cell type by 3 to 5 days in clean, noninfected wounds. As fibroplasia progresses, granulation tissue forms as a consequence of neoangiogenesis and the directed growth of vascular endothelial cells stimulated by platelet and activated macrophage and fibroblast products. Wound reepithelialization occurs as keratinocytes at the wound margins migrate and proliferate once epidermal continuity is reestablished. Remodeling of the resultant scar is a dynamic process that occurs slowly over months to years. Collagen deposition and degradation occur to yield a mature scar; however, maximum tensile strength of a wound reaches only approximately 80% of noninjured skin.
Tx bulbous tip
cephalic trim, transdomal sutures, lateral crural sutures
Tx boxy tip
Transdomal sutures
How long after isotretinoin treatment before pursuing cosmetic procedures?
6 months to 1 year
Mechanism of retinoids
- decrease corneocyte adhesion in the stratum corneum, resulting in reduced follicular occlusion and comedone formation.
- increases dermal collagen production and decreases degradation over 6 to 12 months of treatment.
Mechanism of hydroquinone
Suppresses metabolic processes of the melanocyte, specifically the inhibition of the oxidation of tyrosine to 3,4-dihydroxyphenylalanine (DOPA)
When to give radiation to epithelioid sarcoma of the forearm
Preoperative radiation should be administered for epithelioid sarcomas, as it will help decrease tumor size and local recurrence rates.
- Postoperative chemotherapy is appropriate for tumors that are high grade, greater than 10 cm in diameter, involve the lymph node, or are metastatic.
- Epithelioid sarcomas are usually high grade, so excisional biopsy would not be appropriate. Forearm amputation should be considered if negative margins cannot be achieved. Wide excision with negative margins is a mainstay of surgical treatment.
Mechanism of action of Botox
inhibits release of acetylcholine at the neuromuscular junction. may inhibit neuropeptide neurotransmitter release
Describe the depressor muscles of the brow
- corrugator supercilii
- Procerus
- orbital portion of the orbicularis oculi
- depressor supercilii
Elevator muscles of the eyelid
- levator palpebrae muscle (parasympathetic)
- Mueller’s muscle (sympathetic)
both insert onto the tarsal plate
What muscles are responsible for bunny lines?
- Levator labii superioris alaeque nasi
2. Nasalis
What are the retaining ligaments of the brow and temple?
- Supraorbital ligamentous adhesions
- temporal ligamentous adhesion
- Superior temporal septum
- interior temporal septum
What are the layers of the temple?
- scalp
- Superficial temporal fascia AKA TPF
- Superficial DTF
- Deep DTF
- Temporalis
What structure in the temple is contiguous with the galea and the SMAS?
Superficial temporal fascia
What nerves supply sensation to the ear?
- Auriculotemporal nerve (V3)
- Great auricular nerve
- Lesser occipital nerve
- vagus nerve
- Glossopharyngeal nerve
What is the vascular supply of the ear
- Posterior auricular (dominant)
2. Superficial temporal
