CHAPTER 09: LOWER LIMB Flashcards

Question

What outcome measures are useful for lower limb trauma pts?

Answer 1

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

Answer 2

1. Debridement of all non-viable tissue, excise wound. Lavage 6L 2. Fasciotomy → crush / reperfusion 3. Restore perfusion by arterial repair (temp shunts if needed while bone fixed) 4. Reduce and stabilise fracture 5. Soft tissue cover

Answer 3

``` 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

Answer 4

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

Answer 5

1. Post Tibial → usu well protected, best option (end to side) 2. Ant Tib A → usu compromised by trauma 3. Geniculate vessels in pop fossa 4. 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.

Answer 6

``` 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) ```

Answer 7

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

Answer 8

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

Answer 9

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

Answer 10

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

Answer 11

1. Primary bone shortening o Segmental defects < 5cm (>5cm → kinking of vessels & ischaemia) 2. Temporary Spacer - Masquelet technique o Gentamicin-impregnated methylmethacrylate spacers bridge bony defect and keep limb length. Later removed and defect reconstructed 3. 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 4. Ilizarov Techniques o 5-8cm bone gaps 5. Vascularised bone o >8cm bone gaps

Answer 12

4. 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).

Answer 13

5. 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 #.

Answer 14

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

Answer 15

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

Answer 16

- 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

Answer 17

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

Answer 18

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.

Answer 19

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

Answer 20

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

Answer 21

``` 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 ```

Answer 22

1. Sensory neuropathy → loss of protective sensation 2. Motor neuropathy → derangement of joints → pressure sores over metatarsal heads 3. Autonomic neuropathy → dry, cracked skin → infection 4. Peripheral vascular disease → tissue hypoxia → infection 5. ↓ cellular and humeral immunity → infection

Answer 23

Prevention & Non-surgical 1. Effective gylcaemic control 2. Chiropody, DM foot care regimes, shoes 3. Systemic antibiotics 4. Hyperbaric Oxygen

Answer 24

``` 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 ```

Answer 25

1. Hindquarter 2. Transfemoral - must do adductor magnus myodesis and myoplasty of flexors to extensors, 11-13cm 3. Knee disarticulation (better in kids) 4. 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 5. Symes Osteointegration

Answer 26

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

Answer 27

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.

Answer 28

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

Answer 29

1. Returns protein and lipid from interstitial space to vascular system 2. 50% of body's albumin processed each 24hrs 3. Humoral immune system → Carries foreign particles or proteins to LNs 4. Fat transport pathway from GI tract to vascular system.

Answer 30

``` 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 ```

Answer 31

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

Answer 32

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

Answer 33

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

Answer 34

Lymphangiosarcoma in 10% of severe cases after 10yrs. | Stewart-Treves syndrome → malignant change in postmastectomy lymphoedema → high mortality

Answer 35

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

Answer 36

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

Answer 37

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)

Answer 38

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

Answer 39

- 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

Answer 40

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

Answer 41

Can and should this foot be saved? | How can the best functional and morphologic recovery be achieved?

Answer 42

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 43

Skin graft or local flap is indicated 1. < 3cm2 limited - traumatic or neoplastic 2. Small (< 3 cm2) involving aponeurosis or muscular layers or even more superficial but resistant to medical therapy 3. Limited* > 3 cm2 of NWB areas Free flap is indicated 1. > 3 cm2 of WB areas 2. Bone loss of WB areas *Limited = skin & sub cut tissue only

Answer 44

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

Answer 45

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

Answer 46

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 47

< 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 48

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 2. Transposition, rotation, and V-Y skin flaps Sensitive fasciocutaneous or cutaneous flaps to cover WB areas Defects less than 3 cm2, with random vascularisation 3. 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 49

1. 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 2. 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 50

1. 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 2. Medial pedis flap

Answer 51

1. 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 2. 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 3. 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 52

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 53

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

Answer 54

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

Answer 55

- 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 56

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 57

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

Answer 58

- 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 59

- 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 60

``` 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 61

1. Plan biopsy site so that it will be excised subsequently 2. Avoid transverse incisions 3. Same surgeon performing biopsy and subsequent excision 4. Avoid contamination of adjacent structures 5. Good tissue handling 6. Consider referral before biopsying

Answer 62

 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 63

 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 64

 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 65

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 66

1. Manual lymphatic drainage 2. Multilayer lymphoedema bandaging 3. Remedial exercises (active muscles in limb to improve drainage) 4. Skin care Intensive phase - daily for up to 6wks Maintenance phase, 6mthly reviews

Answer 67

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 68

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 69

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 70

- 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 71

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

Answer 72

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 73

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 74

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 75