Dave Practice Q's Flashcards
Superficial Fascia contents
cutaneous nerves and superficial venous system
Deep Fascia contents
muscles/tendons, arteries, deep veins, and nerves
periosteum (3rd dissection interval)
cartilage
Target tissue in surgery is what?
Bone (5th surgical layer)
Exception with Digital Anatomy (concerning surgical layers)
All neurovascular elements are in the superficial fascia
Target tissue in HAV surgery
1st MT head and Proximal phalanx base
Incision for HAV surgery
Dorsomedial incision centered over shafts of 1st MT and Hallux proximal phalanx, between medial eminence and EHL tendon
Target tissue in digital procedure
Head of the proximal phalanx
Joint capsule closure
Absorbable suture, interrupted cruciate 2-0 or 3-0 Vicryl
Which suture technique offers the most eversion of the skin edges?
Vertical Mattress interrupted suture
Deep fascia closure
2-0 or 3-0 Vicryl cruciate
Superficial fascia closure
buried interrupted (3-0 ir 4-0 Vicryl)
What is the hyponychium?
distal free edge of the nail
eponychium
aka cuticle, proximal skin fold on nail
Nail Matrix Borders
- Distal= lunula
- proximal= distal portion of the extensor ridge
- med/lat= lateral condyles of distal phalanx
When would a total nail avulsion procedure be appropriate?
nail pathology greater than 50% of the nail
When is phenol contraindicated in nail surgery? what is the alternative?
During acute infection, dont use phenol–> do a cold steel matrixectomy (15 blade)
Acisional nail procedures
- Partial nail avulsion
- Bottlecap nail avulsion
Incisional nail procedures
- Winograd
- Frost
- Zadik
When is the Winograd procedure used?
In pediatric patients or if there is hypergranular tissue
What is the advantage of the Frost procedure?
allows visualization of the nail matrix via proximal incision
When is a Zadik procedure appropriate?
For better matrix visualization during a permanent total nail avulsion
Post-Op for partial nail avulsion
1st day post-op, start soaking in epsom salt and warm water for 20min 3x a day
Post-op for total nail avulsion
NO SOAKING! Keep bandage clean/dry/intact
Overdrill
same size as the screw thread diameter, thru proximal cortex only Glide Hole
Underdrill
Thread Hole smaller than screw diameter, thru the near and far cortices **Use a drill guide to stay coaxial to the glide hole**
Countersinking
increases the surface contact area for the screw head, and makes the head less prominent (which would cause soft tissue irritation)
Measure
Using a depth gauge to determine screw length for drill hole ALWAYS after countersinking, because that step will remove some bone
Tapping
cuts the thread pattern for the screw, use the 2 forward 1 back technique
Screw
Always the last step, tighten to 2 finger tightness only
What are the 4 AO principles?
- Fracture reduction and fixation to restore anatomical relationships
- Stability by fixation or splintage, as the personality of the fracture or injury requires
- Preservation of the blood supply to soft tissue and bone by careful handling and gentle reduction techniques
- Early and safe mobilization of the part and the patient
Why do we fixate fractures/osteotomies?
Lack of motion is osteogenic, not compression!
What are the 2 components of interfragmentary compression?
- holding the near fragment with the screw head
- grabbing and pulling the far fragment with the screw threads
Screw sizes in mini-frag set
1.5, 2.0, 2.7
Screw sizes in small frag set
3.5 and 4.0
Screw sizes in large frag set
4.5 and 6.0
What are the 3 stabilization rules?
- Screw fixation
- Plate stability
- Vassals Rule
Screw fixation
Resistance of screws to tear-out depends on screw diameter, length of screw thread gripping bone, and bone strength At least 3 active screw threads are needed to maintain resistance to dislodgment
Plate stability
3 or 4 cortical threads in each main fragment distally, and 5-6 cortical threads proximally
Vassal’s Rule
Reduce/fixate the dominant fracture first
What is the pitch of a cortical screw?
1.25 mm
What is the pitch on a cancellous screw?
1.75 mm
AO interfrag technique order
- overdrill
- underdrill
- countersink
- measure
- tap
- screw
Reasons for post-op bandaging
- Maintain a sterile OR environment
- Protect the surgical site from contamination
- Hold reconstructive positioning
- Compression against edema and inflammation
- Cushioning and protecting bony prominences
- Wick moisture and drainage
- remind patient that they just had surgery, and to take care of the area
- only thing the patient sees post-op, so make it pretty
what are the 3 non-adherent bandaging materials?
- Xeroform
- Adaptic
- Mepitel
Xeroform details
occlusive petroleum gauze,
active ingredient is Bismuth
Adaptic details
knitted cellulose acetate mesh,
impregnated with petrolatum emulsion
Hammertoe surgery,
post-op bandaging
- MPJ in PF
- 1st PIPJ and DIPJ held in neutral/extended positions
HAV positioning with bandaging
- 1st MPJ PF and Adducted,
- IPJ neutral/extended
5th digit surgery positioning/bandaging
move toe out of varus (nail facing straight up) and level with 4th toe in the sagittal plane
Suture for joint capsule closure
2-0 or 3-0 Vicryl
Suture for Subcutaneous closure
3-0 or 4-0 vicryl
Skin closure
4-0 Nylon or Prolene
Surgical instruments are made of what material?
Stainless steel
what are the components of stainless steel
- Carbon,
- Chromium,
- Tungsten carbide,
- Nickel,
- Molybdenum
what 3 functions do the surgeon’s hands perform when using power instrumentation?
- Control of power,
- Control of direction, and
- Stability between the instrument and the surgical site
What are the natural-absorbable suture materials?
Pig collagen, sheep intestine, cow intestine, and cat gut
What are the synthetic-absorbable suture materials?
“DPM MV” - “DPM Motor Vehicle”
- Dexon
- PDS
- Maxon
- Monocril
- Vicryl
Vicryl specifics
(polyglactin 910)
braided synthetic absorbable suture
65% strength in 14 days
hydrolyzed in 80-120 days
Rapid Vicryl
(polyglactin 910)
hydrolyzed in 42 days
Vicryl Plus
(polyglactin 910)
coated w/ Triclosan, which is a broad-spec antibiotic
Dexon
(Polyglycolic acid)
braided, synthetic absorbable suture
hydrolyzed in 100-200 days
PDS
(Polydiaxonone)
monofilament synthetic absorbable suture
70% strength in 14 days,
hydrolyzed in 90 days
Maxon
(polyglyconate)
monofilament synthetic absorbable suture
Hydrolyzed in 180 days
*LONGEST LASTING SUTURE
Monocril
(Poliglecaprone)
monofilament synthetic absorbable suture
20-30% strength in 14 days,
hydrolyzed in 90-120 days
Non-absorbable suture is for what?
Superficial closure (skin)
Non-absorbable suture (natural)
Silk- low tensile strength
Cotton/Linen= *WEAKEST suture material
Non-absorbable synthetic suture types
- Nylon
- Polypropylene
- Polyester
- Fiberwire
- Stainless steel
Nylon suture (Ethilon, Surgilon)
monofilament non-absorbable synthetic
*HIGHEST KNOT SLIPPAGE
Polypropylene
(Prolene, Surgilene)
Monofilament non-absorbable synthetic
Best suture for infected wound
*Least reactive suture material
Polyester
(Ethibond, Dacron)
braided non-absorbable synthetic
strong suture material, good for tendon repair
can be coated w/ silicone
Fiberwire
(polyethylene)
multifilament non-absorbable synthetic
polyethylene multifilament core with a braided polyester jacket
Commonly used in orthopedics.
Stainless steel suture
(braided is called Flexon)
monofilament or braided, non-absorbable synthetic
**STRONGEST suture w/ longest absorption rate
Used for bone fixation and tendon repair, but may corrode bone at stress points
How do you prevent thermal necrosis during screw insertion?
- Sharp tip
- fast advancement (2-3mm/sec)
- slow drill speed (300-400rpm)
- firm force (20-25 lbs)
What is the weakest portion of a screw?
run-out:
or the region where the threads stop and the shank begins
where are cortical screws used?
hard cortical bone
where are cancellous screws used?
metaphyseal and epiphyseal bone
Surgical layers of dissection
- Skin
- Superficial fascia
- Deep fascia
- Periosteum
- Bone
1st Dissection interval
Between superficial fascia and deep fascia
–cutaneous nerve and superficial venous system
2nd dissection interval
Between deep fascia and periosteum
3rd dissection interval
between periosteum and bone
- raise the deep fascia and periosteum as a single layer to expose the osseous structure of the head of metatarsal
Tips for skin incisions
- Tension on skin on either side of planned incision
- Vertical incision perpendicular to the skin, w/o skiving
- Tip-Belly-Tip Technique
What is the screw-driver handle made of?
PRESSED LINEN
tourniquet materials
- 3-5 layers of Webril
- Tourniquet
- 10-10 Drape
- Esmarch –> exsanguination
- Sterile Blue towel and towel clamp
Tourniquet application tips
- make sure tubes pointing proximally
- pull tight and make sure to tie red ribbon as proximal as possible
- Next place 10-10 drape over tourniquet
- Go and Scrub, come back and ask for a towel and clamp
What are the potential connections between the medial and central plantar compartments?
FHL tendon,
PL tendon,
Adductor Hallucis, and
medial plantar neurovasculature
The lateral extensile approach for ORIF of calcaneal fractures should lie at the junction of which 2 angiosomes?
Peroneal angiosome and posterior tibial angiosome
What knot “locks in tension” when tying the surgeon’s knot?
square knot
Materials needed for injection, besides needle/syringe:
- 4x4 gauze
- Band-aid
- Ethyl Chloride
What makes an injection painful?
- substance being injected
- gauge of the needle
- size of the syringe (back pressure)
- rate of injection
- site of injection
What is the consensus in regard to epinephrine use in digital blocks?
epinephrine is safe in digital block
Useful in causing vasoconstriction to reduce bleeding, and keep the anesthetic localized to region of injection
Lidocaine toxic dose
Plain= 300mg
w/ Epi= 500mg
Marcaine toxic dose
plain= 175mg
w/ epi= 225mg
Patient with a history of allergy to amino amides (Lidocaine),
what do you give them?
Amino-ester such as Procaine, Tetracaine, etc
What gauge needle is used to draw up for an injection?
18 gauge
Hallux block
3-5cc of anesthetic
Digital block
1-3cc of anesthetic
Mayo Block
8-10 cc of anesthetic
Ankle block
10-15cc of anesthetic
