CHAPTER 09: LOWER LIMB Flashcards

Question 1

Q

What are the contents of the anterior compartment of the leg?

Answer

A

Muscles - EHL, EDL, Tib Ant, Peron Tertius,
Nerve → Deep peroneal
Artery→ Ant tibial
Main function→ Dorsiflexion

Question 2

Q

What are the contents of the lateral compartment of the leg?

Answer

A

Muscles - Peroneus Longus, Peroneus Brevis
Nerve → Superficial peroneal
Artery → peroneal
Function→ eversion

Question 3

Q

What are the contents of the posterior compartment of the leg?

Answer

A

Muscles - Deep → FHL, FDL, Tib Post
Muscles - Superficial → Gastrocnemius, Soleus, Plantaris
Nerve → Tibial
Artery → Post tibial
Main function→ plantar flexion

Question 4

Q

What is the nerve supply to the lower leg?

Answer

A

Posterior thigh = post fem cut n
Lateral thigh = lat fem cut n
Anterior thigh = int & med fem cut n
Medial upper thigh = cut br of obturator n
Lateral calf = sural n
Medial calf = saphenous n
Dorsum of foot = superficial peroneal n
1st web = deep peroneal n
Sole of foot = medial and lateral plantar ns from post tib

Question 5

Q

What is the Gustilo and Anderson classification?

Answer

A

Gustilo & Anderson (1976) 1025 patients

Grade I - clean puncture, 1cm, no traumatic flaps, no extensive soft tissue damage, or avulsions, simple#
Grade III - Extensive soft tissue inc skin, muscle and neurovascular, high energy, severe crush, comminuted #, segmental #, bone loss, GSW, traumatic amputation.

Question 6

Q

Grade 2

Answer

A

Grade II - >1cm, no traumatic flaps, no extensive soft tissue damage, or avulsions, simple#

Question 7

Q

How was it modified?

Answer

A

Gustilo & Mendoza (1984) subdivided grade III:
Grade IIIa = high energy regardless of wound size, adequate soft tissue – rare, often posterior wounds
Grade IIIb = Extensive soft tissue with periosteal stripping and bone exposure, major wound contamination, bone loss – most common – half get infected
Grade IIIc = arterial injury requiring repair

Criticism - most injuries lumped into IIIb

Question 8

Q

Name another classification for lower limb trauma

Answer

A

Byrd and Spicer
Type I – Low Energy
o spiral or oblique fracture,
o with skin laceration less than 2cm,
o clean wound
Type II – Moderate Energy
o comminuted or displaced fracture,
o skin laceration more than 2cm,
o moderate adjacent skin and muscle contusion,
o without devitalised soft tissue
Type III – High Energy
o significantly displaced / severe comminution / segmental fracture, or
o bone defect with extensive associated skin loss and devitalised muscle
o Type IIIa – Extreme Energy
o As in III, but
o with extreme forces such as in gunshot, crush, degloving or
o associated vascular injury needing repair
Criticism - high inter-observer variability

Question 9

Q

What is the Mangled Extremity Severity Score?

Answer

A

MESS = Mangled extremity severity score - Seattle Trauma Centre - Is limb salvageable?
Score/22
If >7/22 = 100% amputation
4 variables SAVE (shock, age, vasc, energy)
o Energy → Low =1, Medium = 2, High = 3, Very High = 4
o Ischaemia (double over 6hrs) ↓pulse normal perfusion = 1, no pulse, paraesthesia ↓cap refill = 2, Cool paralysed insensate or numb = 3.
o Shock → Systolic BP always ↑90 = 1, transient ↓BP = 2, Persistent ↓BP = 3
o Age → <30yrs = 1, 30-50yrs =2, over 50 yrs = 3
Criticism - Did not mention sensate vs insensate, salvageable ones have to fit into 0-7- once again, lumped together, how relevant are parameters?

Question 10

Q

Who classified degloving injuries of the lower limb?

Answer

A

Arnez and Tyler. (BJPS 1999)
I - IV based on energy transfer and circumferential vs non-circumferential
Type 1 → non-circumferential degloving
Type 2 → abrasion but no degloving
Type 3 → circumferential degloving
Type 4 → circumferential degloving with avulsion between deep tissue planes (IM, Muscle - periosteum)
Types 3 & 4 paradoxically need serial conservative debridements and delayed recon. Early radical debridement → functionless limb.

Question 11

Q

What other classifications are there for lower limb trauma?

Answer

A

Limb Salvage Index - 7 components (injury to an artery, deep vein, nerve, bone, skin, muscle & warm ischaemia time. Criticism - predictive results have not been reproduced.
Hanover Fracture Scale-13 weighted variables
AO, Hidalgo, Harold Ellis JBJS 1958

Question 12

Q

What is the most commonly quoted document for lower limb management?

Answer

A

Lower Limb Trauma Standards

Joint BOA / BAPRAS

Question 13

Q

Who should be referred to specialist centres?

Answer

A

tib+fib, 
comminuted, 
segmental, bone loss
skin loss, 
degloving, 
devitalised muscle, 
damaged artery

Question 14

Q

What are the recommended antibiotic regime?

Answer

A

Start Abx asap, within 3hrs
- Augmentin / cefuroxime (or clindamycin)
At 1st debridement (until (3) or 72hrs)
- Augmentin + gentamicin (1.5mg/kg)
At skeletal stabilisation & definitive closure
- Gent + vancomycin / teicoplanin

Question 15

Q

What is the recommended time for debridement?

What is the recommended time for achieving wound closure?

Answer

A

Immediate exploration only if

gross contamination (agricultural, marine, sewage)
compartment syndrome
devascularised limb
multiply injured patient

Definitive wound closure - within 1wk

Question 16

Q

What are the indications for amputation?

Answer

A

damage control
warm ischaemia time >6hrs
3 incomplete traumatic amputation, severe damage to distal remnant

Amputation considered if

avascular limb >4hrs
segmental muscle loss >2compartments
segmental bone loss >1/3 tibia

reduced plantar sensation is not an indication

Question 17

Q

What should the A&E do before referral?

Answer

A

Initial assessment & Rx according to ATLS
Haemorrhage control - direct pressure
Limb assessment - document & repeated after manipulation
Wound - remove gross contaminants, photo, dress
Antibiotics, anti-tetanus
X ray 2 views tibia & ankle

Question 18

Q

What are the different types of fixation?

Answer

A

Spanning external fixator (quad frame)
Internal fixation - only if definitive closure can be performed at the same time
- intramedullary nailing - reamed / unreamed avoids disruption of endosteal blood supply
- plating, exacerbates periosteal stripping and infection risk
Multiplanar and circular fixators (Ilizarov, Taylors spacial frame with computer program)
Avoid nails in children (disrupt growth plates)

Question 19

Q

What evidence is there for muscle vs fasciocutaneous flaps in lower limb?

Answer

A

diaphyseal tib fractures w periosteal stripping -muscle flaps better
metaphyseal fractures esp ankle - FC flaps best (free / local)

Question 20

Q

How is compartment syndrome diagnosed?

Answer

A

Pain on palp.
Pain on passive stretch (Homans’ sign)
Swelling/turgor
Sensory deficit (1st Webspace)
Muscle weakness
6% of Gustillo IIIB
Loss of pulses = too late

Intra-compartment pressure = diastolic BP - compartment pressure
Decompress if
- Compartment pressure >30mmHg, or
- <30mmHg below diastolic pressure.

Measure using Whiteside’s Infusion technique (3-way tap/syringe etc) or Stryker STIC device.
Rest 5mmHg, Exercised 20 - 30mmHg, within 30 of diastolic
Danger if delta-P 10-30
Most imp measure in anterior comp at fracture level

Question 21

Q

In compartment syndrome, what is the injury sequence?

Answer

A

Nerve
Muscle (deep ones first)
Arteries
Veins
Skin

Upper limb

FDP FPL and Median n. first affected - i.e deep structures
Ellipsoid necrosis

Question 22

Q

Where are the fasciotomy incisions situated?

Answer

A

Anterolateral incision
2 cm lateral to sc tibial border
divide lateral intermuscular septum to enter peroneal compartment
releases anterior and lateral compartments

Posteromedial incision
1cm medial to sc tibial border
at ankle, identify fascia over post tibial NV bundle, split fascia upwards detaching soleus from tibia
releases superficial and deep post comps

Question 23

Q

Principles of Rx - Vascular injuries of lower limb

Answer

A

compare with normal leg - if compromised explore without delay (<4hrs)
pulse present does not equal intact artery- angiography may influence surgery
shunting will reduce ischaemia time, reduce fracture then revasc w reversed vein grafts
1 single patent vessel is not contraindication to free flap recon w end to side anastomosis, but aim to repair injured vessels

Question 24

Q

How do you deal with degloved plantar skin?

Answer

A

a. If suprafascial, is defatted and replaced as full-thickness graft
b. If subfascial and proximally based, is sutured back without tension
c. If subfascial and distally based, is considered for revascularisation

Question 25

Q

What outcome measures are useful for lower limb trauma pts?

Answer

A

Pt health status questionnaires
Enneking Score (compares with contralateral uninjured limb)
Union time of fracture

Question 26

Q

What is the surgical plan for lower limb trauma?

Answer

A

Debridement of all non-viable tissue, excise wound. Lavage 6L
Fasciotomy → crush / reperfusion
Restore perfusion by arterial repair (temp shunts if needed while bone fixed)
Reduce and stabilise fracture
Soft tissue cover

Question 27

Q

What are the timings and advantages of early cover of open fracture?

Answer

A

Advantages of early or emergency cover of the open fracture
o Less infection
o Fewer operations
o Shorter hospital time
o Earlier mobilisation
o Lower treatment costs

Emergency free flap → at the time of first debridement < 24hrs
Early – 24-72hrs
Delayed 72hrs – 3mths
Late > 3 months

Question 28

Q

What are the options for soft tissue cover?

Answer

A

Depends on defect, pt, surgeon

Secondary intention
- VAC, Papineau technique (drill holes, moist)
Primary closure: Gustillo I+II
SSG: Gustillo IIIA

FC flap
prox / distally based ( distal = PT perforators)
5 or 10cm above medial malleolus, intermuscular septum b/t FHL & soleus

Cross leg flap - immobilisation main problem

Free flap - Gustillo IIIB

Question 29

Q

What are the recipient vessels for free flaps?

Answer

A

Post Tibial → usu well protected, best option (end to side)
Ant Tib A → usu compromised by trauma
Geniculate vessels in pop fossa
Vein grafts to the femoral canal → proximal vein graft first before detaching the flap, leave the vein graft as a loop then divide and anastomose to the donor vessels.

Question 30

Q

What local / pedicled flap options are there for lower leg recon?

Answer

A

Upper 1/3
- proximally based FC (peroneal / post tib a)
- gastrocnemius
Middle 1/3
- prox / distally based FC
- soleus
- bipedicled tibialis ant turnover flap
Lower 1/3
- distally based FC 
- adipofascial turnover flap
- sural artery flap (based on A&V of sural nerve: small & unreliable, sacrifice nerve)

Question 31

Q

What local / pedicled flap options are there for ankle / heel recon?

Answer

A

Ankle / heel

distally based islanded FC flap
medial plantar island flap (can be sensate, based on medial plantar artery)
dorsalis pedis flap

Question 32

Q

What paper do you know about definitive cover for lower limb?

Answer

A

Early microsurgical reconstruction of complex trauma of the extremities (GODINA 1986 PRS)

 Early 3 months (to 12yrs) – 9.5% failure, longest hospital stay, slowest to heal, most anaesthetics

o 26% of 1st 100 free flaps failed, 4% of last
o But
 Injuries not described – old ladies with pre-tib lacerations were lumped in with severest injuries.
 Infections not described
 62/532 cases in Kuwait
 Return to weight bearing not mentioned
 Published posthumously

Question 33

Q

Early, late and delayed wound closure

Answer

A

Early <72hrs – 0.75% failure, lowest infection (even lower under free flaps), quickest bone healing, shortest hospital stay, fewest anaesthetics, fewest free flap failures

Late 72hrs – 3 months – 12% failure, highest infection

Delayed >3 months (to 12yrs) – 9.5% failure, longest hospital stay, slowest to heal, most anaesthetics

o 26% of 1st 100 free flaps failed, 4% of last

Question 34

Q

What did Gopal’s paper in 2000 show about fix & flap?

Answer

A

debride, ORIF & flap within 72hrs (33/80)

flap failure rate 3.5%
deep infection rate 9.5%
bone union 39wks
retrospective study, no functional outcome assessment

Question 35

Q

How are bone defects managed?

Answer

A

Primary bone shortening
o Segmental defects < 5cm (>5cm → kinking of vessels & ischaemia)
Temporary Spacer - Masquelet technique
o Gentamicin-impregnated methylmethacrylate spacers bridge bony defect and keep limb length. Later removed and defect reconstructed
Bone Grafting
o Small defect + well vascularised bed
o Delayed cancellous bone grafting usually performed about 6 – 12 weeks after the injury when soft tissues are healed
Ilizarov Techniques
o 5-8cm bone gaps
Vascularised bone
o >8cm bone gaps

Question 36

Q

How do you reconstruct bone defects with Ilizarov technique?

Answer

A

Ilizarov Techniques
o 5-8cm bone gaps
o Limb SHORTENING followed by DISTRACTION OSTEOGENESIS
o Limb HELD TO LENGTH followed by BONE TRANSPORT → corticotomy to develop the mobile segment (preserving medullary and periosteal supply), Need adequate soft tissue/ free flap, avoids soft tissue contracture of shortened limb (muscle atrophy, joint contractures, stiffness, disuse osteoporosis)
o Latent period ~ 5 days then 1mm/day
o Bone must be healthy
o Monitor distraction by serial x-rays → avoid too slow = premature fusion or too fast = lucency
o When at required length, leave frame for 2 months → consolidate
o Complications → length discrepancy, refracture, pin infections, incomplete docking/non-union (req 2ry bone graft).

Question 37

Q

How do you reconstruct bone defects with vascularised bone graft?

Answer

A

Reconstruction with vascularised bone
o Complex reconstruction performed in early post trauma phase
o Vascularised bone good for segmental defects > 8cm
o Free fibula or DCIA
o Bone and soft tissue free flap together usually required.
o Takes a long time to hypertrophy and strengthen → strict non wt bearing or will #.

Question 38

Q

How is chronic osteomyelitis managed?

Answer

A

Incidence - 4.5% in Gustillo III

Investigations
o X-rays
o Bone scan
o Wound swab/culture
o Arteriography

Treatment
o Radical wound debridement → soft tissue and sequestrum
o Bone graft to defect → free or vascularised
o Rigid immobilisation
o Free muscle flap → brings good blood
o Antibiotics → local delivery systems / systemic 2-6/52

Question 39

Q

What are the causes of leg ulcers?

Answer

A

VATIMAN
Venous disease (85%)
Arterial disease
Trauma → insect bites, trophic ulcers, DSH, Frostbite, Radiation
Infection → bacterial, fungal, TB, syphilis
Metabolic→ Diabetes, Necrobiosis lipoidica diabeticorum, pyoderma gangrenosum, porphyria, gout
Autoimmune→ Lupus, RhA, Polyarteritis Nodosa
Neoplasia → SCC (Marjolin’s Ulcer), BCC, Kaposi’s sarcoma, lymphoma

Question 40

Q

What causes venous ulceration?

Answer

A

varicose veins, DVT, chronic venous insufficiency, poor calf muscle func, AV fistulae, obesity, prev leg fracture
thrombophlebitis -> valve incompetence
Lipodermatosclerosis = scarred, fibrotic hyperpigmented skin 2dry to venous hyperten

Question 41

Q

What is important in history of leg ulcers?

Answer

A

Time (Marjolins), how it started ? trauma
Previous trauma, mobility, check footwear
Claudication?
Conditions predisposing to poor wound healing - diabetes, inflammatory disease, smoking?

Question 42

Q

Examination of leg ulcers

Answer

A

Ulcer → characteristics, shape, size edge etc, signs of malignancy
Circulation → Temp of leg, cap refill, pulses, Buergers angle
Sensation→ presence and pattern, glove and stocking - ?diabetes.

Question 43

Q

Investigations for leg ulcers

Answer

A

Wound swab for micro
Measure ABPI normally 1.2, ↓ in arterial disease
Vascular studies → venous duplex for clots, angio for ischaemia
Radiology → X-ray and bone scans for bony involvement
Biopsy → exclude malignancy

Question 44

Q

Management of leg ulcers

Answer

A

Non – op
o Elevation, meticulous hygiene, elastic compression
Op
o failed conservative, if ↑↑↑ pain
o Rx → subfascial ligation of the perforating vessels
o SSG → high recurrence rate if not Rx cause
o Local or free flaps → very rarely indicated

Question 45

Q

How do you prepare a patient for compression bandaging? What does it involve?

Answer

A

Limb assessment including ABPI (less than 0.8 not indicated)
Wound assessment, size and photograph
Dressings 
Pain assessment
Pt understanding and commitment

4 layer bandaging
Orthopaedic wool
Cotton crepe
Elastic extensible bandaging 17mmHg
Cohesive bandage 23mmHg

Question 46

Q

What is the pathophysiology of diabetic foot ulcers?

Answer

A

Sensory neuropathy → loss of protective sensation
Motor neuropathy → derangement of joints → pressure sores over metatarsal heads
Autonomic neuropathy → dry, cracked skin → infection
Peripheral vascular disease → tissue hypoxia → infection
↓ cellular and humeral immunity → infection

Question 47

Q

How do you manage diabetic foot ulcers?

Answer

A

Prevention & Non-surgical

Effective gylcaemic control
Chiropody, DM foot care regimes, shoes
Systemic antibiotics
Hyperbaric Oxygen

Question 48

Q

What are the surgical options?

Answer

A

Surgical
1. Wound debridement 
2. Revascularisation 
3. Amputation / arthrodesis
Amputation at level of 
- toes
- TMT joints → Lisfranc
- talonavicular joint → Chopart
- just above ankle → Syme’s
- MTP joint arthrodesis for dorsal ulceration as a result of motor imbalance
Soft tissue
- dressings, granulation, SSG
- local flap - medial plantar, distally based FC
- free flap

Question 49

Q

Lower limb amputations

Answer

A

Hindquarter
Transfemoral - must do adductor magnus myodesis and myoplasty of flexors to extensors, 11-13cm
Knee disarticulation (better in kids)
Transtibial
- 10 - 14cm – ant/post tib nerves and peroneal nerves divided. Smooth, bevelled end to tibia, fib cut 1cm shorter. Myoplasty (stitch muscle ends together vs myodesis - drill into bone) usually enough.
- Burgess - Long post flap
- Robinson - Skew flap
- Sagittal Flap
- End myodesis important says Umraz
Symes

Osteointegration

Question 50

Q

What is lymphoedema?

Answer

A

Abnormal collection of protein-rich interstitial fluid in subcutaneous tissues.
May be caused by a maldevelopment of the lymphatics or an acquired obstruction. Lymphoedema is confined to subcut tissues and skin

Question 51

Q

What is the anatomy of the lymphatic system?

Answer

A

Embryonically develops from venous system
Superficial (follows veins) and deep lymphatic vessels (follows arteries in deep fascia). None in muscles.
Superficial joins deep system at cubital fossa, popliteal fossa & inguinal region
Lower limb → Cisterna chyli (thin walled sac at L1-2) → thoracic duct at T12 → int jug vein and left subclavian vein at their confluence. Can be damaged in Level IV LND
Lymph from right arm → right subclavian trunk
Right side of head → into right jugular lymph trunk.

Question 52

Q

What is the pathophysiology of lymphoedema?

Answer

A

Abnormal flow / obstruction → stasis → valvular mechanism disrupted → interstitial fluid cannot return to vasc system → raised oncotic pressure in tissues → oedema
Protein triggers inflammatory response → collagen deposition and fibroplasia → stasis predisposes to infection, oedema reduces oxygen transport to cells → hypoxia → more inflammation

Question 53

Q

What is the function of the lymphatic system?

Answer

A

Returns protein and lipid from interstitial space to vascular system
50% of body’s albumin processed each 24hrs
Humoral immune system → Carries foreign particles or proteins to LNs
Fat transport pathway from GI tract to vascular system.

Question 54

Q

How do you classify lymphoedema?

Answer

A

Primary vs Secondary
Primary
1. Lymphoedema Congenita
15-20%, FHx Milroy's disease (sex linked)
usu anaplastic
2. Lymphoedema praecox (puberty)
70-80% primary cases
usu hypoplastic
3. Lymphoedema tarda (after 35)
10%
Meige disease
usu hyperplastic

Question 55

Q

What are the secondary causes of lymphoedema?

Answer

A

Mechanical obstruction of a normal lymphatic system.
o Invasion by Tumour →1ry or 2ry
o Infection → Filariasis from Wuchereria bancrofti (elephantiasis of legs and genitalia, commonest lymphoedema in world), TB, lymphogranuloma and recurrent infection.
o Inflammation → snake bites, insect bites
o Irradiation
o Iatrogenic → ELND, v vein stripping

Question 56

Q

What is important in history and examination?

Answer

A

onset, inciting factors, symptoms, prev Rx
skin - thick brawny, fissures, ulceration
neurovascular status

Question 57

Q

What are the differential diagnoses?

Answer

A

Lipodystrophy, Myxoedema and Oedema
Venous thrombosis, Venous stasis, 
Klippel-Trenaunay syndrome, 
Congestive heart failure, 
Low protein state, 
Factitious use of tourniquets

Question 58

Q

What malignant changes may occur?

Answer

A

Lymphangiosarcoma in 10% of severe cases after 10yrs.

Stewart-Treves syndrome → malignant change in postmastectomy lymphoedema → high mortality

Question 59

Q

What imaging may be used?

Answer

A

Doppler USS (venous obstruction)
CT scan, MRI, lymphoscinitigraphy

Question 60

Q

How is treatment classified?

What excisional treatments are available?

Answer

A

Non-surgical (90%)

elevation, compression, exercise, meticulous hygiene, treat inf, lose weight
NO diuretics
Complex decongestive physiotherapy

Surgical 10% (Excisional & Physiological)

Excisional
Charles technique - resurfacing
- Circumferential excision of lymphoedematous tissue + SSG to fascia

Homans technique - debulking
- Longitudinal segment of skin and subcut tissue removed. Edges sewn together. Medially then laterally later.

Thompson technique
-Segment of s/c tissue excised. Dermal flap tunnelled through fascia into muscular compartment

Liposuction
- may worsen fibrosis

Question 61

Q

What physiological treatments are there?

Answer

A

Lymphangioplasty

Omental transfer (pedicled → affected limb)
Enteromesenteric flap (transected iliac / inguinal nodes covered w segment of ilium)

Lymphovenous shunts (Koshima 2000 J Recon Micro)

Lympholymphatic anastomosis

Free vascularised LN transfers (Becker 2000)

Question 62

Q

Name the layers in the sole of the foot

Answer

A

Layer 1 = Abductor Hall, Flex Dig Brevis, Abductor Dig Minimi
Layer 2 = FHL, FDL, Lumbricals, Flexor accessorius
Layer 3 = FHB, Add Hall, Flex Dig Min Brevis
Layer 4 = Interosseii

Question 63

Q

What are the risks of chronic lymphoedema?

Answer

A

Recurrent cellulitis → 30% of cases of primary and assoc with ↑ disease
Ulceration
Verrucous skin changes
↑ risk if SCC
Lymphangiosarcoma → Rare less than 1 % but has poor prognosis
Kaposi’s sarcoma → rare but reported

Question 64

Q

Causes of foot defects

Answer

A

Vascular - arterial or venous
Metabolic - diabetes (microangiopathy, neuropathy), alcoholism, gout
Tumour - melanoma, epithelioma, sarcoma of bone, soft tissue
Infection
Trauma
Malformation (club foot)

Answer 65

A

Can and should this foot be saved?

How can the best functional and morphologic recovery be achieved?

Answer 66

A

Size

Small tissue defects less than 3 cm2
Large tissue defects greater than 3 cm2

Depth

Skin
Subcutaneous and aponeurosis systems
Muscle
Bone
skin, subcutaneous fat, plantar fascia, muscles, bone

Localization

Anatomic areas (dorsum, medial, lateral side, sole, heel, toes)
Baropodometric areas (WB or non-weightbearing [NWB])

Answer 67

A

Skin graft or local flap is indicated

< 3cm2 limited - traumatic or neoplastic
Small (< 3 cm2) involving aponeurosis or muscular layers or even more superficial but resistant to medical therapy
Limited* > 3 cm2 of NWB areas

Free flap is indicated

> 3 cm2 of WB areas
Bone loss of WB areas

*Limited = skin & sub cut tissue only

Answer 68

A

<3cm skin and sc defects of vascular, metabolic and infective aetiology

Answer 69

A

Ant tib
→ dorsalis pedis
Post tib
→ medial and lateral plantar arteries
Peroneal
→ branches to posterior ankle and calcaneum

Answer 70

A

Anterior tibial nerve
→ EDB, EHB
→ skin in 1st WS

Posterior tibial nerve →
Medial plantar nerve
→ abductor hallucis, flexor brevis digitorum, flexor brevis hallucis, and the first and second lumbricales
→ sole, 1st - 1/2 of 4th toe

Lateral plantar nerve
→ flexor brevis minimi digiti, all interosseus muscles, lumbricales, adductor obliquus hallucis, adductor transversus hallucis, abductor minimi digiti, and accessorius
→ 1/2 of 4th & 5th toe

Saphenous nerve
→ medial foot

Answer 71

A

< 3 cm2
Soft tissue
WB areas
Local flap

< 3 cm2
Soft tissue
NWB areas
Skin grafts

> 3 cm2
Soft tissue
WB areas
Free flap (free FC, MC, muscle flap + graft)

> 3 cm2
Soft tissue and bone loss
WB areas
Free osteocutaneous flap

Answer 72

A

Sole
1. MEDIAL PLANTAR FLAP (O’Brien and Shanahan, 1979)
Type B fasciocutaneous flap
Maximum dimensions - 10 X 7 cm
Pedicle - Medial plantar artery 12cm long, proximally or distally based
Arc of rotation - calcaneum, medial malleolar area, distal WB areas on heads of metatarsus

Transposition, rotation, and V-Y skin flaps
Sensitive fasciocutaneous or cutaneous flaps to cover WB areas
Defects less than 3 cm2, with random vascularisation
Island flaps of toes based on digital artery (WB areas of MT heads) - difficult dissection

4. 
Flexor brevis digitorum
Abductor brevis hallucis
Abductor brevis minimi
Flexor brevis hallucis

Answer 73

A

Dorsalis pedis flap
Type B fasciocutaneous flap
Sensate FC or MC flap (including the extensor brevis digitorum muscle)
Flap - dorsal skin of the medial two thirds of the foot from ankle to toes
Pedicle - septocutaneous perforators of dorsalis pedis and first dorsal metatarsal arteries, 6-10cm long, 2-3mm diameter
Arc of rotation - Medial or lateral dorsal area, malleolar areas
First webspace flap
Fasciocutaneous sensitive flap harvested from the first web space
Very small dimensions
Pedicle - First web space artery, which is the terminal branch of the dorsalis pedis artery
Arc of rotation - Distal dorsum

Answer 74

A

Lateral calcaneal flap
Cutaneous sensate flap below lateral malleolar area along lateral side of foot
Pedicle - Lateral calcaneal artery, (terminal branch of the peroneal artery)
Innervation - branches from sural nerve
Arc of rotation - Achilles tendon and lateral malleolar area
Medial pedis flap

Answer 75

A

Sural artery flap (Donski 1983)
Type A fasciocutaneous flap
Pedicle - Sural artery, branch of the peroneal artery
Flap - b/t popliteal fossa and midposterior leg b/t medial and lateral heads of gastrocnemius. The flap can measure 15 x 6 cm and may include the sural nerve as a neurosensory flap.
Arc of rotation - Achilles tendon and lateral malleolar area
Perforator flap from posterior tibialis artery
Type B fasciocutaneous flap
Flap - medial aspect of leg along axis from knee to medial malleolus b/t soleus and flexor longus digitorum
Pedicle - Septocutaneous branches from the posterior tibialis artery
Arc of rotation - Medial malleolar area, calcaneum, proximal dorsum of foot
Reverse dermis or fascia flap
Dermal or adipofascial flap harvested from posterior leg, +/- donor skin grafted
Pedicle - Random
Arc of rotation - Calcaneum, Achilles tendon

Answer 76

A

Cutaneous
1. Groin flap (Daniel and Taylor, 1973)
Pedicle - Superficial iliac circumflex artery
2. Scapular
Pedicle - Circumflex artery of the scapula
3. Parascapular
Pedicle - Descending branch of the circumflex artery of the scapula

Fasciocutaneous
1. Radial (Chang, 1978)
2. Lateral arm
Pedicle - Septocutaneous branches from the brachialis profunda artery
3. Dorsalis pedis

Muscular
1. LD (thoracodorsal)
2. Gracilis (Tamai 1971) 
Pedicle - 
3. Anterior serratus
Pedicle - Branch from thoracodorsal artery

Osteocutaneous
Iliac crest
Pedicle - For the bone, profundus iliac circumflex artery; for the skin paddle, superficial iliac circumflex artery
Fibula
- peroneal artery

Answer 77

A

Sarcomas = 1% of all malignant disease
50% of deep sarcomas are lower limb, most in thigh
1250/yr in UK

Answer 78

A

By:

Tissue of origin
TNMG classification: Stage
Enneking classification (out of date)

Answer 79

A

Smooth muscle → leiomyosarcoma – if truly dermal - good prognosis, don’t metastasise, if subcut - metastasise
Striated muscle → rhabdomyosarcoma
Fat → Liposarcoma
Blood Vessels → angiosarcoma and Kaposi sarcoma
Lymph channels → lymphangiosarcoma
Fibrous tissue → Fibrosarcoma
Nerve → malignant schwannoma
Synovial tissue → synovial sarcoma
Skin → dermatofibrosarcoma protuberans (DFSP), atypical fibroxanthoma (AFX), and malignant fibrous histiocytoma (MFH)

Answer 80

A

TNMG – AJCC ’92, ‘97

T1 (5cm)
T3 (invasion of bone, vascularity or nerve)
N0 or N1(histologically confirmed)
M0 or M1 (distant mets)
G1 low grade tumour
G2 intermediate
G3 high grade
Stage 1 - T1 or T2, G1
Stage 2 - T1 or T2 , G2
Stage 3 - T1 or T2, N1, G3
Stage 4 - T3 M1

Answer 81

A

T1 (<5cm), T2 (>5cm), T3 (invasion of bone, vascularity, or nerve)

Answer 82

A

Primary amputation rare - no survival benefit
Isolated limb perfusion - Melphalan (cytotoxic) and TNF-alpha (biological)
Wide skin margins usually illogical - usually margins are defined by a neurovascular structure - e.g. sciatic nerve

Sarcoma Reconstruction – same principles as for Head & neck
 MDT lead
 Hole filling in 10%
 Know your role as a Plastic Surgeon
 Timing – Radiotherapy

Answer 83

A

Slowly enlarging mass
May also produce pressure on surrounding structures
Systemic symptoms e.g. ↓wt, malaise and rigors

Presenting features of 526 pts with soft tissue sarcomas
(Johnson Ann RCS Eng 2001)
1. Subcutaneous mass >5cm
2. Pain
3. Increase in size
4. Depth beneath deep fascia

Answer 84

A

ASSESS EXTENT OF LESION
1. X-rays
2. MRI → Gadolinium aides resolution
3. CT → assess bony involvement
4. Angiography → if vessel involvement suspected
5. Radionuclide imaging → 3 phases
A. Arterial phase → inflow into tumour
B. Venous phase → venous pooling within tumour
C. Osseous phase → bony invasion

HISTOLOGY

Biopsy → Must be done CORRECTLY
POOR BIOPSY TECHNIQUE = WORSE PROGNOSIS, therefore:
1. Only AFTER radiology complete
2. FNA or Trucut
3. Skin entry must be removed by excision
4. Incision biopsy NOT recommended
5. Should be performed in the unit where definitive surgery is planned (SAME SURGEON)

Answer 85

A

Plan biopsy site so that it will be excised subsequently
Avoid transverse incisions
Same surgeon performing biopsy and subsequent excision
Avoid contamination of adjacent structures
Good tissue handling
Consider referral before biopsying

Answer 86

A

 Large deep sarcomata should be managed in specialised units
 Deeply situated sarcomas are surrounded by pseoudocapsule.
 Enucleation → prohibitively high recurrence rates
 Ideally resect with one uninvolved anatomical plane in each direction.
 Functional compartmentectomy (preserving at least one muscle within compartment) performed whenever possible
 Resection should include both origin and insertion of the muscle in which the tumour occurs. If not possible then at least 10cm of muscle on either side of tumour.
 preserve major nerve in compartment unless directly infiltrated by tumour.
 post op radiotherapy usu indicated

Answer 87

A

 Most sarcomas are radiosensitive to varying degrees.
 Ewing sarcoma → very radiosensitive
 Liposarcoma → relatively radiosensitive
 Post op radiotherapy seems to ↓ risk of local recurrence
 Esp. indicated in → high grade lesions, incomplete excisions, > 5cm lesions, deep sarcomas of head and neck region.

Answer 88

A

 Tumour of musculoaponeurotic system (mesothelium)
 Myofibroblast is main cell
 Commonest in rectus sheath in post partum women
 Although histologically benign, can be locally invasive and also cause morbidity due to pressure effect
 So manage like sarcoma

Answer 89

A

Shah
Tib post via interosseus membrane - inc adhesions
Tib post routed medially to tib ant or peroneus - foot dorsiflexion or eversion
90% get active function range 6-85 degrees
90% functional gait

Answer 90

A

Manual lymphatic drainage
Multilayer lymphoedema bandaging
Remedial exercises (active muscles in limb to improve drainage)
Skin care

Intensive phase - daily for up to 6wks
Maintenance phase, 6mthly reviews

Answer 91

A

In a case series, 35 patients underwent liposuction combined with controlled compression therapy (CCT) and 14 underwent CCT alone.
CCT involves wearing a custom-made sleeve-and-glove garment taken in gradually and replaced with new custom-made garments, usually at 3, 6 and 12 months after the operation.
Compared with baseline, mean reductions in oedema volume at 12 months were 103% and 50%, respectively, for the two groups (p < 0.0001).

All pts had reductions in self-rated pain, swelling and fatigue, and increases in mobility and activities of daily living at 12-month follow-up (p < 0.01 for all outcomes). In the 14 patients treated with CCT alone, only swelling of the arm improved significantly (p < 0.04).

A non-randomised study using matched-pairs analysis (n = 16 in each group) reported that liposuction with CCT was significantly more effective in reducing oedema volume than CCT alone (p < 0.0001).

In the above study and in a further case series of 28 patients, mean pre treatment oedema volumes of 1745 ml and 1845 ml were reduced to 30 ml and –122 ml (that is, the removed oedema volume exceeded the baseline volume), respectively, at 12-month follow-up.

Adverse events include haemorrhage, skin necrosis, infection, bruising, pain, scarring and neurovascular injury

Answer 92

A

Physiologic procedures attempt to improve lymphatic drainage.
- buried dermal flaps
- omental transposition
- enteromesenteric bridging
- lymphangioplasty
- microvascular lympholymphatic anastomosis
None of these techniques has clearly documented favorable long-term results.

Venous-lymphatic anastomosis

performed in patients with severe lymphedema and a functioning venous system
literature suggest this is effective only in secondary lymphedema

Answer 93

A

It is a limb-threatening and potentially life-threatening condition when perfusion pressure falls below tissue pressure / compartment pressure, which will lead to tissue necrosis, renal failure and death if untreated.

Local blood flow = (Pa - Pv) / resistance
Reduced Pa - high elevation, premorbid limb ischaemia
Increased Pv - limb dependency, high interstitial pressure

Tissue perfusion = cap perfusion pressure - interstitial perfusion pressure
CPP = 25mmHg
IPP = 4mmHg (if it rises above 30mmHg, capillaries will collapse)

Anaerobic metabolism, lactic acid accumulation, Na pump fails, further increase in oedema and compression

Reperfusion generates free radicals and causes further injury

Answer 94

A

crush
prolonged extrinsic compression (lying in 1 posn, POP, antishock trousers)
burns
fractures
vascular injury: extravasation, bleeding from fractures, reperfusion
swelling of soft tissue (electrical injury, myositis, nephrotic syndrome, excessive exercise)

Answer 95

A

Diagnosis of clinical suspicion
Compartment pressures
Doppler / arteriography / MRI (usu chronic cases)
Serum potassium, CK, clotting profile
Urine myoglobin

Answer 96

A

Release extrinsic compression
emergent fasciotomy, splint in position of function, elevation
anticipate myoglobinuria - fluid resus, mannitol, dialysis
Wound closure / SSG (shoelace, vessel loop techniques, Sure-Closure device, VAC assisted dermal recruitment, suture tension adjustment reel STAR)
HBO

Answer 97

A

Foot - 2 dorsal incisions in 2nd and 4th interMT spaces (interossei, central lateral and medial comp)

Thigh - medial and lateral incisions (medial and ant/post compartments)

Upper arm - medial and lateral incisions (medial and post compartments) - avoid ulnar and radial nerves

Forearm
Dorsal - epicondyle to middle MC
Volar - CTR, curve ulnarly (avoid exposing FCR) then radially at elbow (avoid ulnar nerve)

Hands
Dorsal - 2nd and 4th interMC spaces (AdP and interossei)
Volar - thenar, hypothenar eminences, CT

Answer 98

A

Posterior tibial artery

end to side
Godina muscle splitting approach: pt in lateral decubitus position, op leg down, split through 2 heads of gastroc and soleus, outside zone of injury, may simultaneously harvest vein (SSV) and nerve (sural) grafts

Geniculate vessels

Vein grafts: Anastomose distal LSV to superficial femoral artery (AV fistula). Divide loop and anstomose to donor vessels

Flow through flaps - ALT, RFFF

Cross leg free flap (anastomose to contralateral leg, inset to injured leg, allow neovascularisation and divide pedicle after 4wks, possibly longer for muscle flaps)

Answer 99

A