Janis Notes

Question 1

Define Maffucci’s syndrome.

Answer 1

Enchondromatosis associated with multiple cutaneous hemangiomas.

Question 2

Indications for Mohs micrographic surgery (5).

Answer 2

1. Recurrent
2. Cosmetically sensitive (periorbital, periauricular, perinasal)
3. Morpheaform and sclerosing or aggressive features
4. Poorly delineated margins in scar tissue
5. Other tumor types: SCC with perineural involvement, dermatofibrosarcoma protuberans, microcystic adnexal carcinoma.

Question 3

Define Nevus of Ota.

Answer 3

Nevus of Ota: Onset at birth or less than 1 year and around puberty. Found more commonly in blacks and Asians. Blue-brown, unilatreal, periocular macula. Size varies from few cm to covering half the face. Areas follow distribution of V1 and V2.

Question 4

Describe Tessier Cleft Number 5.

Answer 4

Tessier Cleft Number 5.

One liner: Cleft begins lateral to the canine and courses lateral to infraorbital foramen terminating in the lateral aspect of lower eyelid and orbital floor.

Soft tissue:

• Begins medial to oral commisure and courses along the cheek lateral to the nasal ala
• Terminates in the lateral half of the lower eyelid

Skeletal involvement:

• Begins lateral to the canine.
• Courses lateral to infraorbital forarmen
• Terminates in the lateral aspect of the orbital floor and rim.
• Lateral orbital wall possibly thickened and greater wing of sphenoid abnormal.

Question 5

Risk of malignant transformation with congenitcal nevocytic nevi.

Answer 5

• Small (<1.5 cm^2): 1-5% lifetime risk (rarely before puberty).
• Medium (1.5 - 20 cm^2): uncertain (rarely before puberty).
• Giant (> 20 cm^2): 5-10% result in melanoma with 50% arising between the age of 3-5 years old.

Question 6

Risk factors (11) for recurrence of BCC and SCC.

Answer 6

• Location/size: >20 mm on trunk/extremities; >10mm cheek, forehead, scalp, neck; >6mm central face, genitalia, hands, feet.
• Poorly defined borders.
• Recurrent lesion.
• Immunopsuppresion
• Previous radiotherapy.
• Pathology: morpheaform, sclerosing, micronodular, mixed infiltrative, adenoid, desmoplastic
• Perineural involvement
• Lymphovascular invasion
• Radpidly growing
• Depth: >2mm, Clark IV and V
• Poorly differentiated

Question 7

Timing of normal suture fusion.

Answer 7

• Metopic: 6-8 months.
• Sagittal: 22 years.
• Coronal: 24 years.
• Lambdoidal: 26 years.

Question 8

Risk factors for tetanus (5).

Answer 8

1. Time since injury (>6 hours)
2. Depth of injury (>1 cm)
3. Mechanism of injury (crush, burn, GSW, puncture)
4. Presence of devitalized tissue
5. Contamination (grass, soil, saliva, retained foreign body)

Question 9

Treatment of phenol burns.

Answer 9

Irrigate and treat with polyethylene glycol.

Question 10

Define Parkes Weber syndrome.

Answer 10

• Similar to Klippel-Trénaunay syndrome (patchy port-win stain on an extremity overlying a deeper venous and lymphatic malformation with associated skeletal hypertrophy).
• Distinguished by the prescence of an arteriovenous fistula.

Question 11

Steps to PIP contracture release after Dupuytren’s disease excision and continued stiffness.

Answer 11

1. Chein rein ligament release.
2. Volar capsulomtomy.
3. Collateral ligament release.

Question 12

Name two otoplasty techniques for addressing lower third prominence.

Answer 12

• Modified fishtail excision of lobule (Wood-Smith)
• Inferior conchal mastoid sutures

Question 13

Horizontal (5) and vertical buttresses (4) of the face.

Answer 13

HORIZONTAL BUTRESSES

1. Frontal bar
2. Inferior orbital rim / upper transverse maxillary
3. Maxillary alveolar and hard palate / lower transverse maxillary
4. Mandibular alveolar / upper transverse mandibular
5. Inferior border of mandible / lower transverse mandibular

VERTICAL BUTTRESSES

1. Zygomaticomaxillary / lateral maxillary / lateral buttress
2. Nasomaxillary / medial maxillary / medial buttress
3. Pterygomaxillary / posterior maxillary / deep buttress
4. Vertical mandible / posterior verticle

Question 14

Describe ‘Stahl’s ear’.

Answer 14

The presence of the third and/or horizontal superior crus with a pointed upper helix. Results in upper and middle third prominence.

Question 15

Describe the intracranial, cranial, orbit, midface, and extremity findings in Apert syndrome.

Answer 15

• Intracranial: elevated ICP.
• Cranial: bicoronal synostoses with turribrachycephaly, enlarged anterior fontanel, bitemporal widening, occipital flattening.
• Orbits: exorbitism, downslanting palpebral fissures, and mild hypertelorism.
• Midface: hypoplasia, parrot beak deformity, high arch or cleft palate, anterior open bite, class III malocclusion.
• Extremity: Complex syndactyly of hands and feet.

Question 16

Treatment of hydroflouric acid burns.

Answer 16

Calcium gluconate.

Question 17

Surgical management of trigonocephaly (metopic synostosis).

Answer 17

Overcorrection of frontal dysmorphology and bitemporal contriction with bifrontal craniotomy, frontal reshaping and expansion of frontoorbital bar and frontal bone flaps with interpositional bone graft, wedge osteotomies, bone grafting.

Question 18

Alkali burns cause what time of injury.

Answer 18

Liquefactive necrosis.

Question 19

Where is Stenson’s duct located intraorally?

Answer 19

Opposite the second maxillary molar.

Question 20

Describe the cranial, extremity, and other findings of Muenke syndrome.

Answer 20

• Cranial: uni or bicoronal synostosis.
• Midface: typically no hypoplasia.
• Extremities: Thimble like hypoplasia.
• Other: sensorineural hearing loss.

Question 21

Describe Tessier Cleft Number 30.

Answer 21

Tessier Cleft Number 30

One liner: Mandibular cleft originating between the central incisors and extending inferiorly, yielding notching of the lower lip and a bifid tongue.

Soft tissue:

• Notch in lower lip
• Bifid anterior tongue with attachment to mandible by dense fibrous band.

Skeletal involvement:

• Cleft between central incisors extending into mandibular synthesis
• Hyoid bone may be absent
• Thyroid cartilage incompletely formed

Question 22

Surgical management of lambdoid synostosis.

Answer 22

Biparietal-occipital craniotomies, occipital switch, and contouring.

Question 23

Formula to estimate caloric needs in burns.

Answer 23

Curreri formula.

Caloric needs = [25 kcal/kg/day] + [40 kcal/%TBSA/day]

Caloric needs per day = [25 kcal]*[weight in kg] + [40 kcal]*[%TBSA]

Question 24

Compared with nasal ideals for whites, describe the characteristic differences of black and middle eastern noses?

Answer 24

Blacks

• Wide, low nasal dorsum
• Descreased nasal length and tip projection
• Poor nasal tip definition
• Acute columellar-labial angle
• Alar flaring

Middle Eastern

• Wide nasal bones
• Thick, sebaceous skin
• Ill-defined bulbous tip
• High dorsum and over projecting radix
• Acute columellar-labial angle
• Slight alar flaring

Question 25

Histological zones of distraction osteogenesis (5).

Answer 25

1. Central zone: cellular proliferation.
2. Transitional zone of vasculogenesis
3. Paracentral zone: Parallel orientation of collagen fibers with osteoid production.
4. Transitional mineralization front: Primary mineralization found with bone spicule formation.
5. Mature bone zone: Progressive calcification of primary mineralization front with formation of cortical and cancellous elements.

Question 26

Natural history and malignant degeneration of Nevus sebaceus of Jadassohn.

Answer 26

• Present at birth on scalp or face.
• Well-circumscribed, hairless, yellowish plagque that becomes verrucous and nodular at puberty.
• 10-15% malignant degeneration to BCC.

Question 27

Cells of the epidermis and their function.

Answer 27

• Keratinocyte: Major cell type. Protective barrier.
• Melanocyte: Neural crest origin. Pigmentation. UV protection.
• Merkel cells: Neural crest origin. Constant pressure and touch. Static two-point discrimination.
• Langerhands cells: Mesenchymal origin (from precursor cells of bone marrow). Antigen presenting cells.

Question 28

Ratio of Type I:III collagen in mature skin, hypertrophic scars, and keloid scars.

Answer 28

• Mature skin = 4:1
• Hypertrophic = 2:1
• Keloid = 3:1

Question 29

Options for surgical access to the orbital floor.

Answer 29

1. Subciliary (‘lower bleph’)
2. Subtarsal (‘mid lid’)
3. Infraorbital (‘inferior orbital rim’)
4. Tranconjunctival

Question 30

TIming of normal fontanelle closure.

Answer 30

• Posterior fontanelle: 3-6 months.
• Anterior fontanelle: 9-12 months.

Question 31

Options for recipient veins in breast reconstruction.

Answer 31

1. Thoracoacromial.
2. Lateral thoracic.
3. Axillary.
4. Retrograde flow in IM vein.
5. Cephalic turned down.
6. External jugular turned down.

Question 32

Describe Tessier Cleft Number 8.

Answer 32

Tessier Cleft Number 8

One liner: Largely isolated to the orbit with the cleft affecting the frontozygomatic suture with a hypoplastic or absent zygoma with coloboma of the lateral commisure.

Soft tissue:

• Largely isolated to the orbit.
• Coloboma of the lateral commissure with abscence of the lateral canthus.

Skeletal involvement:

• Involves frontozygomatic suture.
• Zygoma hypoplastic or absent with lateral orbital wall missing.
• Continuit of orbital and temporal fossa.

Other:

• Almost always concurrent with another rare cleft
• Associated with Goldenhar’s syndrome

Question 33

Optimal centrifuge for fat grafting.

Answer 33

3 minutes at 3000 rpm.

Question 34

Describe the correct placement of the ear (height, width, angulation)?

Answer 34

Question 35

Define Sturge-Weber syndrome.

Answer 35

• Large facial port-wine stain with V1 and commonly V2 trigeminal nerve distribution.
• Associated with leptomeningeal venous malformations and frequent mental retardation.

Question 36

Define Riley-Smith syndrome.

Answer 36

Pseudopapilledema, microcephaly, vascular malformations.

Question 37

Prognostic signs of hemangiomas (7).

Answer 37

1. Size of hemangioma or sex of patient has no influence on the speed or completeness of resolution.
2. Site of hemangioma has minimal effect on final result.
3. Multiple hemangiomas may resolve at different rates.
4. Presence of subcutaneous tumor elements has no effect on final outcome.
5. Early dramatic growth is not a prognostic sign of resolution.
6. Time of involution is indicative of outcome.
7. Prescence of ulceration has no prognostic significance except for scar consequences.

Question 38

Advantages and disadvantages of alloplastic breast reconstruction.

Answer 38

Advantages:

1. Lower initial costs compared with autologous reconstruction.
2. Technical ease.
3. No donor site morbidity.
4. Shorter operative time and recovery time compared with autologous.

Disadvantages:

1. Early cost advantage disappears over time as revisions surgeries are required.
2. Potential capsular contracture.
3. Potential implant rupture / failure.
4. Potential infection requiring removal.
5. Increased probability for future surgery.
6. Difficult to acheive symmetry with unilateral reconstruction.

Question 39

List the basic goals of otoplasty (10)?

Answer 39

1. Correction of upper-third protrusion.
2. Visibility of the helix beyond the anithelix when viewed from the front.
3. Smooth and regular helix.
4. No marked distortion or decrease in the depth of the postauricular sulcus.
5. Correct placement of the ear; helix-to-mastoid distance falls in the normal range of 10-12mm at the top, 16-18mm in the middle, and 20-22 in the lower third.
6. Bilateral symmetry to within 3mm at any given point.
7. Smooth, rounded, and well-define antihelical fold.
8. Concoscaphal angle of 90 degree.
9. Conchal reduction or reduction of the conchomastoidal angle.
10. Helical rim that projects laterally farther than the lobule.

Question 40

Describe the Mustarde otoplasty technique.

Answer 40

Question 41

Name the most common anatomical deformities yielding a prominent ear (3).

Answer 41

1. Poorly defined antihelical fold.
2. Conchoscaphal angle >90 degrees.
3. Conchal excess.

Question 42

Describe Tessier Cleft Number 4.

Answer 42

Tessier Cleft Number 4

One liner: Cleft begins between lateral incisor and canine teeth extending superiorly lateral to the piriform and medial to the infraorbital foramen into the lower eyelid.

Soft tissue:

• Begins lateral to Cupid’s bow between commisure of mouth and philtral crest -> passes onto cheek lateral to nasal alar -> curves into lower eyelid to terminate medial to the punctum
• Lower canniculus disrupted along with most of the inferior supporting structures of the eye.
• Colobomas.
• Medial canthal ligament and lacrimal aparatus usually intact.

Skeletal involvement:

• Begins between lateral incisor and canine teeth
• Extends onto anterior surface of maxilla, lateral to piriform aperature, medial to infraorbital foramen
• Medial and inferior portions of orbital disrupted
• Nose displaced superiorly (especially in bilateral cases)

Question 43

List the contents of the superior orbital fissure and explain the presentation and pathophysiology of superior orbital fissue syndrome (SOFS). Differentiate with orbital apex syndrome.

Answer 43

Contents of superior orbital fissure:

The order of the nerves passing through the superior orbital fissure from superior to inferior (Lazy French Tarts Sit Nakedly In Anticipation):

• L: lacrimal nerve (branch of CN V1)
• F: frontal nerve (branch of CN V1)
• T: trochlear nerve (CN IV)
• S: superior division of the oculomotor nerve (CN III)
• N: nasociliary nerve (branch of CN V1)
• I: inferior division of the oculomotor nerve (CN III)
• A: abducens nerve (CN VI)

Presentation of superior orbital fissue syndrome (SOFS):

• Ophthalmoplegia: due to compression or damage to oculomotor, trochlear and abducens nerves
• Ptosis: due to loss of oculomotor motor supply to the levator palpebrae superioris and loss of sympathetic input (third order postganglionic) to Muller’s muscle
• Proptosis: due to decreased tension in the extraocular muscles with loss of innervation
• Fixed dilated pupil: due to loss of parasympathetic supply to the pupil by the oculomotor nerve
• Lacrimal hyposecretion and eyelid or forehead anaesthesia: due to damage to branches of the ophthalmic division of the trigeminal nerve
• Loss of corneal reflex: due to loss of afferent input from the ophthalmic division of the trigeminal nerve.

Orbital apex syndrome presents the same but also has loss of vision because of involvement of the optic nerve at the orbital apex.

Question 44

Three predictors of mortality in burns (Baux score).

Answer 44

1. Age
2. % TBSA
3. Inhalational injury

Question 45

Two mechanisms of skull growth.

Answer 45

• Sutural growth: perpendicular to sutures.
• Appositional growth: Bone resoprtion on the inner surgace and deposition on the outer surface of the skull.

Question 46

Options for burn wound coverage.

Answer 46

Temporary

• Allograft
• Xenograft
• Biobrane (nylon fabric coated with porcine dermal collagen with silicone membrane)
• TransCyte (biobrane and cultured human neonate fibroblasts)

Permanent

• FTSG / STSG
• Integra (bovine collagen, shark chondroitin-6-sulfate, silicone layer)
• AlloDerm
• Cultured epithelial autograft

Question 47

Keen approach to the zygomatic arch.

Answer 47

1-2cm incision made laterally in the buccal sulcus. Subperiosteal elevation allows the eleator to be placed behind the arch.

Question 48

Define PHACE syndrome.

Answer 48

• Posterior fossa malformations
• Hemangiomas (large facial hemangiomas)
• Arterial anomalies
• Coarctation of the aorta and other cardiac anomalies
• Eye abnormalities

Question 49

Treatment algorithm of ZMC fractures based on energy.

Answer 49

Low-energy injuries:

• ZM exposed with with upper buccal sulcus incision
• ZF and ZS exposed with upper bleph incision
• ZS articulation best to assess reduction
• Stabilize ZF and then ZM; if needed ZS fixation can be performed as well
• Lower lid incision not required unless floor exploration or reconstruction desired

High-energy injuries:

• Require wide exposure with coronal approach to visualize temporal articulation
• Will likely require exploration and fixation of the floor

Question 50

Prevalance of concurrent injuries in panfacial fractures (top 5).

Answer 50

1. Intracranial injury / hemmorrhage (18%).
2. Abdominal organ injury (16%).
3. Pneumothorax (13%).
4. Pulmonary contusion (13%).
5. Cervical spine fracture (13%).

Question 51

Features consistent with metopic synostosis (4).

Answer 51

Collectively referred to as trigonocephaly (‘keel shaped, triangular’).

1. Keel-shaped forehead
2. Bitemporal narrowing
3. Hypotelorism
4. Bilateral supraorbital retrusion

Question 52

Describe Tessier Cleft Number 1.

Answer 52

Tessier Cleft Number 1.

One liner: Cleft begins between the lateral and central incisor moving superiorly through the margin of cupid bow and up between the nasal bones and the frontal process of the maxilla.

*Can continue as cleft number 13*

Soft tissue:

• Pattern similar to cleft lip and palate.
• Cleft through lateral margin of Cupid’s bow progresses into nose, causing notching of the dome and soft triangle but may travel medially to a malpositioned medial canthus.

Skeletal involvement:

• Cleft between central and lateral incisor.
• Cleft separates nasal floor from piriform and the nasal bone from the frontal process of the maxilla.

Question 53

Predisposing conditions / lesions for melanoma (7).

Answer 53

1. Familial Atypical Multiple-Mole Melanoma (FAMMM Syndrome)
   
   • >100 melanocytic nevi measuring 6-15mm
   • one or more measuring > 8mm
   • 10% risk of melanoma
2. Dysplastic nevus (6-10% risk of melanoma).
3. Congenital nevus (6% lifetime risk of melanoma).
4. Typical moles (risk if >50)
5. Melanoma in situ
6. Xeroderma pigmentosum
7. Lentigo maligna (Hutchinson freckle)

Question 54

Describe the embrology of the face and its prominences.

Answer 54

• Face develops from five prominences:
  
  • Frontonasal prominence (1) which is composed of bilateral medial and lateral nasal prominences.
  • Paired maxillary prominences (2)
  • Paired mandibular promincens (2)
• Frontonasal prominence:
  
  • Pulled ventrally and caudally to form the forehead, nasal dorsum, and medial and lateral nasal prominences.
  • Outpouchings of the lateral nasal walls form the sinsuses (maxillary at 3 months gestations, ethmoid at 5 months gestation, sphenoid 5 months postnatally, and frontal 2-6 years postnatally).
  • Medial nasal prominence forms the primary palate, midmaxilla, midlip, philtrum, central nose, and septum.
  • Lateral nasal prominence forms the nasal alae.
• Maxillary prominences:
  
  • Migrate medially to form the secondary palate, lateral maxilla, and lateral lip.
  • Junction with the lateral nasal prominences forms the nasolacrimal groove and nasolacrimal duct system.
• Mandibular prominences:
  
  • Form the mandible, lower lip, and lower face.

Question 55

Features consistent with sagittal synostosis (3).

Answer 55

Collectively referred to as scaphocephaly or dolichocephaly (“boat shaped”)

1. Elongated anteroposterior head.
2. Frontal and occipital prominence.
3. Biparietal narrowness

Question 56

Define Nevus of Ito.

Answer 56

Nevus of Ito: Usually appears at birth. Typically found in Asians and blacks. Large, blue-brown macula located on the posterior shoulder, areas innervated by the posterior supraclavicular and lateral cutaneous brachial nerves.

Question 57

Decribe Tessier Cleft Number 12.

Answer 57

Tessier Cleft Number 12

One-liner: Cleft lies medial to the medial canthus extending upward and coming out lateral to the cribriform plate, yielding hypertelorism.

Soft tissue:

• Cleft lies medial the medial canthus, which is displaced laterally.
• Colobomas extend to the root of the eyebrow.
• Paramedian frontal hairline projects downward.

Skeletal involvement:

• Orbital hypertelorism and telecanthus from increased dimension of ethmoid air cells.
• Frontal and sphenoid sinuses pneumatized.
• Lies lateral to cribriform plate, which remains normal.
• Anterior and middle cranial fossa enlarged.

Question 58

Timing and indications for surgery (3).

Answer 58

Surgery typically delayed until school age when child may beging to have psychological consequences.

Indications for urgent surgery in proliferative phase:

1. Visual obstruction
   
   • During first year of life, visual obstruction for 1 week can result in deprivation amblyopia or anisometropia.
2. Nasolaryngeal obstruction
   
   • Hemangiomas in “beard distribution’ proliferating in subglottic airway = potentially life threatening. Requires aggressive treatment with beta-blockers, surgery, and potentially LASER.
3. Auditory canal obstruction
   
   • Can result in conductive hearing loss.

Question 59

Describe the ossification of the cranium, including the neurocranium and the viscerocranium.

Answer 59

Neurocranium is the portion of the skull encasing and protecting the brain. It develops from both intramembranous ossification and endochondral ossification.

• Membranous neurocranium
  
  • Forms via intramemranous ossification of neural crest origin.
  • Includes the paired frontal, squamosal, and parietal bones, and upper occipital bones.
• Cartilaginous neurocranium (ie basicranium)
  
  • ​Forms via endochondral ossification of mesodermal origin.
  • Includes sphenoid and ethmoid bones, mastoid and petrous temporal bone, and the base of the occipital bone.

Viscerocranium is the bones of the facial skeleton and forms primarily via intramembranous ossification of pharyngeal arch I, except for Meckel’s cartilage (which forms the malleus and the mandibular condyles)

Question 60

Describe Tessier Cleft Number 2.

Answer 60

Tessier Cleft Number 2

One liner: Cleft originates at lateral incisor and margin of cupid bow and extends superiorly through the alar rim.

*Can extend as cleft number 12*

Soft tissue:

• Originates at the lateral margin of cupids bow and extends into the lateral alar rim lateral to dome.
• Ala typically hypoplastic.
• Medial canthus displace but lacrimal duct not involved

Skeletal involvement:

• Cleft through lateral incisor extends into piriform aperature.

Question 61

Define Klippel-Trénaunay syndrome.

Answer 61

Pathy port-win stain on an extremity overlying a deeper venous and lymphatic malformation with associated skeletal hypertrophy.

Question 62

Features (7) of Nevoid basal cell syndrome (Gorlin’s syndrome).

Answer 62

1. Multiple basal cells
2. Odontogenic keratocysts
3. Palmar and plantar pits
4. Calcification of falx cerebri
5. Bifid ribs
6. Hypertelorism
7. Broad nasal root

Question 63

Describe the intracranial, cranial, orbit, and midface features of Crouzon syndrome.

Answer 63

• Intracranial: hydrocephalus, ICP elevation, Chiari malformation.
• Cranial: bicoronal most common; usually brachycephalic, but scaphocephally, trigonocephaly, cloverleaf deformity, and normocephalic described.
• Orbit: Exorbitism.
• Midface: hypoplasia with anterior open bite, class III occlusion, narrow and high arched palate.

Question 64

Ratios to assess on a lateral view facial analysis (3).

Answer 64

Question 65

Indications for distraction osteogenesis.

Answer 65

1. Mandibular lengthening.
   
   • Hemifacial microsomia, micrognathia
2. Le Fort I adavanacement
   
   • For large anterior movements > 1cm
   • Particularly helpful for significant class III occlusion in clefts secondary to maxllary hypoplasia.
3. Le Fort III / monobloc
   
   • Syndromic craniosynostosis with severe midface hypoplasia and exorbitism.
4. Posterior cranial vault reconstruction.
   
   • Can be used in some craniosynostosis.

Question 66

Mutations associated with craniosynostosis (4).

Answer 66

1. FGFR2
2. FGFR3
3. TWIST1
4. EFNB1

Question 67

Describe Tessier Cleft Number 10.

Answer 67

Tessier Cleft Number 10.

One liner: Cleft lateral to the supraorbital foramen, yielding encephaloceles and hypertelorism from inferolateral orbital rotation.

Soft tissue:

• Begins at middle third of upper eyelid and eyebrow.
• Coloboma in mid-upper lid and irregular retraced brow.

Skeletal involvement:

• Cleft at middle orbital rim just lateral to supraorbital foramen.
• Encephalocele common
• Hypertelorism from inferolateral rotation of orbit
• Anterior cranial base distortion

Question 68

Describe the Furnas otoplasty technique.

Answer 68

Question 69

Topical antimicrobial for burn wounds along with their antimicrobial coverage, notable clinical properties and side effects (4).

Answer 69

• Silver sulfadiazine (silvadene)
  
  • Gram positive and gram negative coverage.
  • Transient leucopenia.
  • Penetrates eschar poorly.
• Mafenide acetate (sulfamylon)
  
  • Gram positive.
  • Potent carbonic anyhydrase inhibitor.
  • Hyperchloremic metabolic acidosis.
  • Compensatory hyperventilation.
  • Penetrates deeply.
• Silver nitrate (0.5% solution)
  
  • Staphylococcus species and gram negative (pseudomonas).
  • Hyponatremia and hypokalemia.
• Sodium hypochlorite
  
  • Broad spectrum.
  • at 0.025% is bactericidal without inhibiting fibroblasts or keratinocytes.

Question 70

Treatment options for SCC.

Answer 70

• Medical
  
  • Topical 5-FU for premalignant lesions
  • Chemotherapy for adjuvant therapy
• Radiation (adjuvant or primary treatment; 90% cure)
• Destructive
  
  • Curettage and electrodessication
  • Photodynamic therapy
• Surgery
  
  • WLE (95% cure; 4-6 mm margins)
  • Mohs (95% cure)

Question 71

Describe the features of Treacher Collins Syndrome.

Answer 71

Bilateral Tessier cleft 6, 7, and 8.

• Coloboma and retraction of the lower lid
• Upper lid redundancy in lateral half gives impression of ptosis
• Lateral canthus displaced inferiorly
• Absence of zygomatic arch
• Hypoplasia of temporalis
• Ear malformations
• Hairline abnormalities
• Abscence of lateral inferior orital rim
• Hypoplasia of malar ones and mandible

Question 72

Ratios to assess in the frontal view facial analysis (8).

Answer 72

Question 73

Cords in Dupuytren’s disease.

Answer 73

1. Pretendinous cord: in the palm.

2. Spiral cord: composed of pretendinous, spiral band, lateral digital sheet, and Graysons (can displace NVB centrally and superficially).

3. Central cord: continuation of pretendinous.

4. Lateral cord: runs from the natatory to the lateral digital sheet.

5. Natatory cord: natatory band.

6. Retrovascular cord.

Question 74

Risk factors for Dupuytren’s diathesis.

Answer 74

1. Male gender.
2. Earlier disease onset.
3. Family history.
4. Bilateral involvement.
5. Ectopic involvement (Peyronies, Ledderhose, Garrods).

Question 75

Landmarks for Gillies approach.

Answer 75

Incision made 2cm anterior and superior to the helix.

Dissection carried down to and through the deep temporal fascia (overlying temporalis muscle). Elevator placed beneath the deep temporal fascia but superficial to temporalis allowing access to the medial aspect of the zygoma while protecting the facial nerve.

Question 76

Describe Tessier Cleft Number 7.

Answer 76

Tessier Cleft Number 7

One liner: Cleft begins at the oral commissure and extends outward affect the ramus/condyle/coronoid of the mandible and include the ear.

Soft tissue:

• Begins at oral commissure and varies from mild broadening to complete fissure.
• Extends toward the ear, ceasing at the anterior border of the masseter.
• Ear involvement varies from a skin tag to microtic ear.
• Paralysis of CN V and CN VII common.

Skeletal:

• Cleft passes through pterygomaxillary junction.
• Posterior maxilla and ramus (condyle and coronoid) are hypoplastic.
• Zygomatic body is also severely hypoplastic and displaced.
• Cranial base asymmetrical.
• Open bite or cross bite seen.

Other:

• Often accompanies crnaiofacial microsomia.

Question 77

Management algorithm for anterior table fracture of frontal sinus.

Answer 77

Depends on degree of displacement and involvement of nasofrontal duct.

Question 78

When does the the size of the ear mature (width, length)?

Answer 78

• By the third year of life the ear has reached 85% of adult size.
• Ear WIDTH reaches mature size by 6-7 years of age (girls-boys)
• Ear LENGTH reaches mature size by 12-13 years of age (girls-boys).

Question 79

Risk of metastasis from primary SCC (trunk vs. face/extremity).

Answer 79

• Trunk: 2-5%
• Face / extremity: 10-20%

Question 80

Differential diagnosis for congenital nevocytic nevus (13).

Answer 80

1. Café au lait spot
2. Nevus spilus
3. Epidermal nevus
4. Acquired nevus
5. Dysplastic nevus
6. Blue nevus
7. Becker’s nevus
8. Halo nevus
9. Mongolian spot
10. Nevus of Ota
11. Nevus of Ito
12. Spitz nevus
13. Nevus sebaceus

Question 81

Describe the intracranial, cranial, orbit, and other features of Saethre-Chotzen syndrome.

Answer 81

• Intracranial: mental status usually normal.
• Cranial: bi or uni-coronal synostosis.
• Orbits: Ptosis.
• Ears: Prominent crus helicis extending through the conchal bowl.
• Midface: deviated nasal septum, narrow palate.
• Extremities: Patrial syndactyly with short stature.

Question 82

Collagenase clostridium histolyticum injection protocol.

Answer 82

1. Inject 0.58mg into a given cord (each vial contains 0.9mg).
2. Up to TWO cords or TWO joints in the same hand can be treated each visit.
3. A cord can be treated up to THREE times at 4 week intervals.

Question 83

Draw the anatomy of the ear.

Answer 83

Question 84

Define Bannayan-Zonana syndrome.

Answer 84

Microcephaly, multiple lipomas, multiple vascular malformations.

Question 85

Describe Goldenhar’s Syndrome.

Answer 85

• Prominent frontal bossing.
• Low hairline.
• Mandibular hypoplasia.
• Low set ears
• Colobomas of the UPPER eyelid
• Epibulbar dermoids
• Bilateral anterior accessory auricular appendages
• Vertebral abnormalities

Question 86

List the nervous, arterial, bony, and muscular elements of the pharyngeal arches.

Answer 86

Question 87

Three pathophysiological stages of Dupuytren’s Disease?

Answer 87

1. Nodule formation: type III collagen, disorganized, high cellular density, myofribroblasts.

2. Cord formation without contracture: decreasing cellularity, more organization to collagen.

3. Mature cords with finger contracture: organized collagen, hypocellularity.

Question 88

Types of SCC (4).

Answer 88

1. Verrucous
2. Ulcerative
3. Marjolin
4. Subungual

Question 89

Advantages and disadvantages of IMMEDIATE breast reconstruction.

Answer 89

Advantages:

1. Superior cosmetic result previous of preservation of skin envelope and anatomic landmarks.
2. Psychological benefit from immediate return of body image.
3. Single-stage procedure with lower overall socioeconomic cost.
4. Best for stage I/II breast cancer not expected to receive post-operative radiotherapy.

Disadvantages:

1. Difficult to assess mastectomy flap viability.
2. Risk of post-operative radiotherapy could jeopradize reconstruction.
3. Increased risk of post-operative complications.
4. Post-operative complications can delay adjuvant thereapy.

Question 90

Reasons for failure of Dupuytren’s release.

Answer 90

1. Inadequate resection of fascia.
2. Failure to address joint contracture.
3. Failure to address central slip attenuation.
4. Poor hand therapy compliance.
5. Contraction of digital vessels over time.

Question 91

Define Spitz nevus and outline management.

Answer 91

Spitz nevus: Usually appears at birth. Also called juvenile melanoma. REd or pigmented smooth, dome-shaped papule. Telangiectasia is a frequent finding. Average diameter is 8mm. Most commonly found on head and neck. Recommend excision for both therapeutic and diagnostic reasons.

Question 92

Indications for transfer to a burn center (10).

Answer 92

1. Partial thickness burns greater than 10% total body surface area (TBSA).
2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints.
3. Third degree burns in any age group.
4. Electrical burns, including lightning injury.
5. Chemical burns.
6. Inhalation injury.
7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.
8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality.
9. Burned children in hospitals without qualified personnel or equipment for the care of children.
10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention.

Question 93

Predictors of recurrence with SCC (4).

Answer 93

1. Degree of differentiation (well differentiated = 7%, moderately differentiated = 23%, poorly differentiated = 28%)
2. Depth of tumour invasion
3. Perineural invasion
4. Desmoplastic SCC

Question 94

Treatment options for Dupuytren’s disease.

Answer 94

1. Collagenase (Clostridium histolyticum)
2. Needle fasciotomy.
3. Open fasciotomy.
4. Limited fasciectomy.
5. Radial fasciectomy.
6. Dermatofasciectomy.

Question 95

Melanoma types (8).

Answer 95

1. Superficial spreading
2. Nodular
3. Lentigo maligna
4. Acral-lentiginous
5. Desmoplasic
6. Amelanotic
7. Noncutaneous
8. Ocular

Question 96

What is traumatic carotid-cavernous sinus fistula.

Answer 96

Traumatic carotid-cavernous sinus fistula arises when a fracture results in a laceration or tear in the arterial wall allowing blood to shunt fron the internal carotid artery to the cavernous sinus.

Signs:

• Proptosis
• Ocular bruit
• Injection and chemosis (edema of the conjunctiva)
• Ophthalmoplegia of CNs II, IV, VI
• Dilated ophthalmic vein on CT of orbit

Management: Surgical ligation of carotid artery or interventional placement of coild to obliterate fistula.

Question 97

Describe Tessier Cleft Number 0.

Answer 97

Tessier Cleft Number 0

One liner: Like cleft number 14, can yield absent or excess midline skeletal and soft tissue involvement. Cleft begins between the upper incisors, extending through premaxilla, secondary palate (cleft), and nasal bones (potential absence OR potential bifid nose).

* Can continue as cleft number 14*

Deficient midline structures:

• Soft tissue deficiency: Midline facial cleft includes upper lip/nose, leading to hypotelorism (holoprosencephaly).
• Skeletal deficiency: Premaxilla is absent, secondary palate cleft, partial / total absence of nasal bones.

Excess midline structures:

• Soft tissue excess: Duplicated frenulum, bifid nose, middorsal furrow. Hypertelorism.
• Skeletal involvement: Diastema of the upper incisors, keel shaped maxillary alveolus, nasal maxillary process, nasal bones, septum broadened.

Question 98

Differentiate synostotic and deformational plagiocephaly.

Answer 98

Deformational plagiocephaly is often mistaken for either unilateral lambdoidal or coronal plagiocephaly.

In deformational plagiocephaly, the following changes are expected:

1. Head assumes parallelogram configuration.
2. Ipsilateral occipital flattening and frontal bossing.
3. Ear displaced anteriorly.

Question 99

Describe Tessier Cleft Number 6.

Answer 99

Tessier Cleft Number 6

One liner: Cleft extends from the oral commissure along the junction of the maxilla and zygoma into the lower eyelid and inferior orbital fissure.

Soft tissue:

• Cleft is a vertical furrow extending from the oral commissure to the lateral lower eyelid.
• Lateral palpebral fissure is pulled downward and lateral canthus follows, causing antimongoloid slant.
• Creates appearance of ectropion and colobomas and of the lower eyelid.

Skeletal involvement:

• Essentially a cleft at the zygomaxillary junction.
• Choanal atresia is common (blocking of the posterior aspect of the nasal passages).
• Cleft connected to the inferior orbital fissure.
• Zygoma is hypoplastic.
• Anterior cranial fossa narrowed.

Question 100

Risk factors for melanoma (7).

Answer 100

1. UV exposure
2. Age
3. Prior melanoma
4. Family history
5. Fitzpatrick skin type (I, II)
6. Sex (male > female)
7. Race (white > black)

Question 101

Describe the embryology of the palate.

Answer 101

• Primary palate:
  
  • Develops at 5-6 weeks.
  • Medial and lateral palatine processes of the medial nasal prominences come together to form the primary palate.
  • Clefts of primary palate result from failure of fusion of he medial and lateral palatine processes.
• Secondary palate:
  
  • Develops weeks 9-12 weeks.
  • Lateral palatine shelves of the maxillary prominences form the secondary palate.
  • Palatine shelves are initially vertical but migrate horizontally as the tongue drops with mandibular growth.
  • Right palate drops first, explaining the higher incidence of left sided clefts.
  • Clefts of the secondary palate result from the failure of fusion of the lateral palatine process with the nasal septum.

Question 102

Histological effects of aging within the EPIDERMIS and DERMIS.

Answer 102

EPIDERMIS

• Compact laminated stratum corneum.
• Flattened dermal-epidermal junction.
• Fewer layers of keratinocytes.
• Melanocyte density decreases.
• Langerhans cells decrease.

DERMIS

• Dermal atrophy.
• Fribroblasts enlarge and decrease mitotic activity.
• Pacini’s and Meissner’s corpuscles decrease in density.
• Decreased elastic fibers.
• Increased ground substance.
• Increased Type III collagen.

Question 103

Indications for tracheotomy (4).

Answer 103

1. Acute airway obstruction and failed endotracheal intubation.
2. Expected prolonged mechanical ventilation.
3. Multiple facial fractures associated with basilar skull fractures.
4. Destruction of nasal anatomy associated with facial fractures.

Question 104

Principles of operative management of NOE fractures.

Answer 104

• Treatment directed at reconstituting the intercanthal relationship, nasal projection, and internal orbital structures.
• Broad exposure with coronal flap.
• Bony fragments reduced and fixated with miniplates.
• Cranial bone grafts may be required to reestablish nasal projection.
• Canthal tendons reconstructed with transnasal wiring.
• Soft tissues of nasoorbital valley redraped with bolsters.

Question 105

Describe the lacrimal apparatus.

Answer 105

The lacrimal system is made up of the superior and inferior canaliculi that coalesce into the common canaluculus. This empties into the lacrimal sac, which drains into the nose (inferior meatus) through the lacrimal duct.

Question 106

Describe Tessier Cleft Number 9.

Answer 106

Tessier Cleft Number 9

One liner: Cleft involves the lateral third of the upper eyelid and brow with a hypoplastic greater wing of the sphenoid; can have encephaloceles.

Soft tissue:

• Hallmarks are lateral third of the upper eyelid and brow abnormalities
• Micropthalmia.
• CN VII palsy of the forehead and upper eyelid.

Skeletal involvement:

• Hypoplastic greater wing of sphenoid causes lateral displacement of orbital rim.
• Anterior cranial fossa reduced.
• Can have encephaloceles.

Question 107

Surgical management of anterior plagiocephaly (unicoronal synostosis) or brachycephaly (bicoronal synostosis).

Answer 107

Bifrontal craniotomy, fronto-orbital advanacement, repositioning of the frontal bar, recontouring frontal bone, barrel staves.

Question 108

Name the sutures of the cranium and what implication synostosis has on growth.

Answer 108

Question 109

Features of lambdoid synostosis (5).

Answer 109

Collectively referred to as posterior plagiocephaly or occipital plagiocephaly.

1. Ipsilateral occipital flattening
2. Ipsilateral mastoid bulge
3. Ipsilateral downward cant of the posterior skull base
4. Ipsilateral ear inferior
5. Contralateral large middle cranial fossa

Question 110

Types of BCC.

Answer 110

1. Nodular.
2. Micronodular.
3. Superficial spreading.
4. Infiltrative.
5. Pigmented.
6. Morpheaform (sclerosing or fibrosing).

Question 111

Surgical management options for nonsyndromic scaphocephaly (sagittal synostosis).

Answer 111

1. Extended strip craniectomy (open vs. endoscopic) with helmet.
2. Spring assisted cranioplasty.
3. Open vault
   
   • Anterior and posterior in 2 stages (total cault in 1 stage rarely done).
   • Posterior reconstruction only: patients shown to normalize their forehead shape if an isolated posterior-middle vault expansion peformed.

Question 112

Acids cause what type of injury.

Answer 112

Coagulative necrosis.

Question 113

Name otoplasty techniques for addressing upper third prominence (3)?

Answer 113

1. Mustarde (scaphaconchal sutures)
2. Furnas (conchal mastoid sutures)
3. Converse-Wood-Smith (cartilage breaking)

Question 114

What are the elements of an aesthetic nasal assessment made on the AP (6), lateral, and basal view?

Answer 114

AP

1. Facial symmetry and nasal deviation: line drawn through the midglabella to the menton should bisect the nasal bridge, nasal tip, and cupids bow.
2. Nasal length: Nasal length should be ~ 2/3 of the middle third of the face and/or roughly the distance from the stomion to the menton.
3. Width of the nose and degree of alar flare: Alar base should be the same as the intercanthal distance and the width of an eye. Normal alar flaring is 2mm wider than alar base (caucasian females).
4. Dorsal aesthetic lines: Lines should extend from the medial supraciliary ridges to the tip-defining points on the dorsum.
5. Nasal tip evaluation: Tip-defining points bilaterally, supra-tip break superiorly, and columellar-lobular angle inferiorly should form 2 equilateral triangles.
6. Columella evaluation: Columella should hang just inferior to alar rims, giving a gentle gull wing.

LATERAL VIEW

1. Projection: Tip projection (from the alar base to the nasal tip) should be the same as the alar base width. Put differentialy, tip projection should be 2/3 of nasal length. Also, 50-60% of this projection should line anterior to a line drawn vertically from the most projecting portion of the upper lip.
   
   • If >60% is anterior to the vertical line, tip is overprojected and should be reduced.
   • If <50% is anteriot to the vertical line, tip is underprojected and should be augmented.
2. Dorsum: Connect a line from the nasofrontal angle to the tip. In women the dorsum should lie 2mm behind this line with a slight supratip break. In men, the dorsum should lie slightly more anterior.
3. Tip Rotation: Nasolabial angle is formed by a line through the most anterior and posterior elements of the nostril and a perpindicular line through the natural horizontal facial plane. In women 95-100 is preferred. In men, 90-95 is preferred.
4. Tip: Columellar-lobule angle is the angle between the columella and the infra-tip lobule. It is typically 30-45 degrees.

BASAL VIEW

• Nostrils: Should be tear drop shape.
• Columella to lobule ratio: 2:1 ratio of the columella to lobule on basal view.

Question 115

Indications for SLNB in melanoma.

Answer 115

Both the ASCO-SSO and the National Comprehensive Cancer Network (NCCN) guidelines state that for patients with T1b (<0.8 mm with ulceration or 0.8-1.0 mm with or without ulceration) melanomas, SLNB may be considered and discussed with the patient.

Question 116

Treatment options for BCC.

Answer 116

• Medical
  
  • Imiquimod 5% or 5-flurouracil (can be used for low risk superficial BCC and SCC in situ)
  • Vismodegib (adjuvant therapy when surgical and radiation options exhausted)
• Radiation (92% cure)
• Destructive
  
  • Curettage and electrodessication (96-100% cure for tumours <2mm)
  • Cryotherapy
  • LASER phototherapy (CO2)
  • Photodynamic therapy
• Surgical excision
  
  • WLE (4mm for small primary BCC on face, 10mm for high risk larger tumors on trunk / extremities)
  • Mohs

Question 117

Qualities of a youthfull neck (5).

Answer 117

• Distint inferior mandibular border.
• Subhyoid depression.
• Visible thyroid cartilage bulge.
• Visible anterior border of sternocleidomastoid
• Cervicomental angle of 105-120 degrees.

Question 118

Define Osler-Weber-Rendu disease (hereditary hemorrhagic telangiectasia).

Answer 118

Multiple malformed ecstatic vessels in the sin, mucous mebranes, viscera.

Question 119

Describe Tessier Cleft Number 3.

Answer 119

Tessier Cleft Number 3

One liner: Cleft begins between lateral incisor and canine and extends superiroly to create communication between oral, nasal, and orbital cavities with disruption of lacrimal system.

*Can continue as cleft number 10 or 11*

Soft tissue:

• Originates from lateral margin of Cupid’s bow and extends across ala through the frontal process of maxilla.
• Extends through the nasolacrimal duct and into lacrimal groove.
• Alar base usually superioly displaced and the nose foreshortened.
• Lacrimal system usually blocked with anomalous drainage into cheek.
• Colobomas of the lower eyelid.
• Globe positioned inferiorly and laterally.

Skeletal involvement:

• Between lateral incisor and canine.
• Direct communication between oral, nasal, and orbital cavities.

Question 120

Three zones of transplanted fat.

Answer 120

1. Surviving area: adipocytes survived.

2. Regeneration area: adipocytes died and adipose-derived stromal cells survived to replace dead adipocytes.

3. Necrotic area: adipocytes and adipose-dervied stromal cells died.

Question 121

Management approach for life threatening hemorrhage from internal maxillary artery with associated factial fractures.

Answer 121

1. Secure airway.
2. Posterior nasal and oropharyngeal packing.
3. Immediate reduction of fractures.
4. Selective embolization for stable patients or ligation of external carotid for hemodynamically unstable patients.

Question 122

Function of the face (5).

Answer 122

1. Protect central nervous system.
2. House specialized sensory organs (olfaction, gustation, vision, balance, hearing, touch).
3. Initiate digestions.
4. Facilitate respiration.
5. Express emotion.

Question 123

Describe the intracranial, cranial, orbit, midface, and extremity findings in Pfeiffer syndrome.

Answer 123

• Intracranial: hydrocephalus, potential chiari malformaiton. Usually normal mental status.
• Cranial: bicoronal synostoses with turribrachycephaly.
• Orbits: shallow exorbitism, downslanting palpebral fissures, strabismus.
• Midface: hypoplasia, parrot beak, class III malocclusion, anterior open bite.
• Extremity: Broad thumbs and halluces, mild cutaneous syndactyly.

Question 124

Which patients should get a tetanus toxoid vaccination and which patients also require tetanus immune globulin.

Answer 124

NON-TETANUS PRONE WOUND

1. In a non-tetanus prone wound, a patient requires a tetanus booster (0.5 mL) if:
   
   • They have an unknown or incomplete tetanus vaccination series.
   • They received their booster >10 years ago.
2. In a non-tetanus prone wound, a patient does not need tetanus immune globulin regardless of their tetanus vaccination status.

TETANUS PRONE WOUND

1. In a tetanus prone wound, a patient requires a tetanus booster if:
   
   • They have an unknown or incomplete tetanus vaccination series.
   • They received their booster >5 years ago.
2. In a tetanus prone wound, a patient requires tetanus immune globulin (250 units) if:
   
   • They have an unknown or incomplete tetanus vaccination series.
   • They received their booster >10 years ago.

Question 125

Risk factors for SCC (8).

Answer 125

1. Fitzpatrick skin type (type I and II)
2. Sun
3. Carcinogen (pesticides, arsenic, hydrocarbons)
4. Viral infection (HPV, herpes simplex)
5. Radiation
6. Immunopsupression
7. Chronic wound
8. Premalignant lesions (actinic keratosis, bowen’s, leuoplakia, keratoacanthoma)

Question 126

What are the main considerations in the timing of otoplasty?

Answer 126

1. Ear development: ear is nearly fully developed at 6-7, so it is reasonable to proceed with surgery at this time.
2. Child maturity and preferences: Decision should ideally be driven by child’s desire to fix the ear deformity.

Question 127

Contraindications to breast conservation therapy.

Answer 127

1. Previous radiation
2. Multifocial disease
3. Serious connective tissue disorder
4. Pregnancy
5. Large tumours (>5cm)
6. Inflammatory breast cancer
7. Large cancer in a small breast

Question 128

Fascial structures affected in Dupuytren’s.

Answer 128

1. Spiral bands.
2. Lateral digital sheets.
3. Natatory ligaments.
4. Pretendinous bands.
5. Grayson’s ligaments (NOT Cleland’s ligaments)

Question 129

Zones of injury in burns.

Answer 129

1. Zone of coagulation (necrosis): Non-viable necrotic tissue in the center of the wound.
2. Zone of stasis (edema): Surrounds zone of coagulation, initially viable.
3. Zone of hyperemia (inflammation): Outermost zone, viable.

Question 130

Layers of epidermis and clinical significance.

Answer 130

• Stratum corneum: Composed of non-viable keratinocytes. Responsible for thickness of glaborous skin.
• Stratum lucidum: Composed of non-viable keratinocytes.
• Stratum granulosum: Composed of marginally viable keratinocytes. Thickens most with tissue expansion.
• Stratum spinosum: Composed of viable keratinocytes.
• Stratum basal: Mitotically active keratinocytes, melanocytes, tactile cells, nonpigmented granular dendrocytes. Origin of various skin cancers.

Question 131

Define neuromelanosis and neurocutaneous melanosis.

Answer 131

Neuromelanosis is a melanocytic proliferation (benign or malignant; nodular or diffuse) within the leptomeninges and brain parenchyma.

Neurocutaneous melanosis is neuromelanosis associated with congential nevocytic nevi (CNN).

Question 132

Describe the embroyology of the ear?

Answer 132

• Anterior hillock is derived from the first branchial arch (mandibular), which contributes with upper third of the ear:
  
  • tragus
  • root of helix
  • superior helix
• Posterior hillock is derived from the second branchial arch (hyoid), which contributes the lower two thirds of the ear:
  
  • antihelix
  • antitragus
  • lobule

Question 133

Treatment of phosphorus burns.

Answer 133

Stain with 0.5% copper sulfate and surgically remove.

Question 135

Describe Tessier Cleft Number 14.

Answer 135

Tessier Cleft Number 14

One liner: Midline cleft often with significant CNS abnormalities (including holoproencephaly), midline encephalocele and cyclopia - consequently, limited life expectancy often.

*Can be paired with a Tessier Cleft Number 0*

Soft tissue abundance:

• Hypertelorism
• Midline encephalocele
• Long midline frontal hairline

Soft tissue agenesis:

• Holoproencephaly (forebrain does not develop into two hemispheres), hypotelorism, microcephaly, severe CNS abnormalities
• Cyclopia
• Malformation of forebrain to proportional degree of facial deformity

Skeletal involvement:

• Medial frontal defect with encephalocele
• Midline structure bifidity: crista galli, perpendicular plate of ethmoid.
• Cribriform plate displaced caudally
• Harlequin deformity of orbits from upslanting anterior cranial fossa

Other:

• Accompanying central nervous system abnormalities.
• Life expectancy limited
• Like a cleft 0, can create agenesis or overabundance of tissue

Question 136

Define Kasabach-Merritt syndrome.

Answer 136

Profound thrombocytopenia with kaposiform hemangioendothelioma.

Question 137

Critical factors (3) and the management algorithm for combined anterior and posterior frontal sinus fractures.

Answer 137

Three important factors:

1. Degree of displacement of the posterior table.
2. Presence or absences of CSF leake.
3. Infolvement of the nasofrontal duct.

Management options:

1. ORIF anterior table alone:
   
   • Reserved for isolated anterior table fractures without nasofrontal duct involvement and without CSF leakage.
2. Sinus obliteration:
   
   • Indicated for fractures of anterior table involving nasofrontal ducts.
   • Used when posterior table displacement minimal and no CSF leakage.
3. Cranialization:
   
   • Indicated for fractures of anterior table with involvement of CSF leakage, significant displacement or comminution of posterior table.
   • Posterior table removed, remaining mucosa removed, nasofrontal ducts obliterated, nasal cavity isolated from cranial cavity with pericranial flap along floor of anterior cranial fossa. Anterior table recontructed.

Question 138

Desribe the innervation of the ear?

Answer 138

• Auricular temporal nerve (branch of trigeminal) provides sensation to tragus and crus helicis.
• Great auricular nerve (branch of cervical plexus) divides into anterior and posterior devisions and supplies the rest of the ear.
• Lesser occipital nerve has some contribution.

Question 139

Breast cancer risk factors.

Answer 139

Strong risk factors (RR>4.0)

1. Female.
2. Age (>65)
3. Biopsy confirmed atypical hyperplasia
4. Personal history of breast cancer
5. BRCA1/BRCA2
6. Mammographically dense breasts

Moderate (RR 2.1-4)

1. Two first-degree relatives with breast cancer
2. High dose radiation to chest
3. High endogenous estrogen or testoterone levels
4. High bone density (postmenopausal)

Low (RR 1.1-2.0)

1. EtOH
2. Ashkenazi Jewish heritage
3. Early menarche (<12)
4. Late menopause (>55)
5. Never breast fed child
6. Nulliparity
7. Late age at first full term pregnancy (>30)
8. Hormone replacement therapy
9. Personal history of endometrial, ovarian, or colon cancer
10. Obesity
11. Height (tall)
12. High socieconomic status
13. Jewish heri

Question 140

Options for recipient arteries in breast reconstruction.

Answer 140

1. Internal mammary.
2. Thoracodorsal.
3. Lateral thoracic.
4. Axillary.
5. Retrograde IM artery.
6. Thoracoacromial.

Question 141

Treatment options for infantile hemangiomas.

Answer 141

1. Conservative management.
2. Beta-blockers (propranolol oral, timolol topical).
3. Steroids (oral or intralesional).
4. LASER (pulsed dye and Nd:YAG).
5. Surgery.

Question 142

Describe the development of the frontal sinus.

Answer 142

• Pneumatization begins at age 2.
• Reaches adult size by age 12.
• Not identifiable radiographically until age 8.

Question 143

Describe the embryology of the external ear.

Answer 143

• Arch I form three anterior hillocks, which form essentially the superior half of the ear:
  
  • Tragus
  • Root of helix
  • Superior helix
• Arch II form three posterior hillocks, which form essentially the inferior half of the ear:
  
  • Antitragus
  • Antihelix
  • Lobule

Question 144

Differentiate intramembranous ossification and endochondral ossification.

Answer 144

• Intramembranous ossification: Cartilaginous precursor resorb; mesenchymal cells directly differentiate into osteoblasts without a cartilaginous intermediate.
• Endochondral ossification: A cartilaginous template is directly and gradually replaced with a bony matrix.

Question 145

Dermal appendages and their function.

Answer 145

• Hair follicle: hair growth.
• Sebaceous gland: sebum.
• Eccrine sweat gland: thermoregulation.
• Apocrine sweat gland: sweat.
• Naked nerve fiber: pain, temperature, chemoreceptor.
• Meissner’s corpuscle: light touch, dynamic two-point discrimination.
• Pacinian corpuscle: vibration, deep pressure.
• Bulb of Krause: temperature (cold).
• Ruffini ending: sustained pressure, temperature (hot)

Question 146

Features of bilateral coronal synostosis (3).

Answer 146

Collectively referred to as brachycephaly.

1. Bilateral retruded forehead and supraorbital rims.
2. Increased biparietal diameter.
3. Elevation of height of skull but short in AP direction.

Question 147

Describe Tessier Cleft Number 11.

Answer 147

Tessier Cleft Number 11.

One-liner: Cleft extending upward from the medial third of the eyelid accompanied by hypertelorism and encephaloceles.

Soft tissue:

• Medial third of upper eyelid with coloboma.
• Disruption extends to the hairline.

Skeletal:

• Extensive pneumatization of ethmoid cells produces hypertelorism / enecephalocele.
• Cranial base is normal.

Question 148

Diagnostic tests for CSF (2).

Answer 148

1. Beta-transferrin test.
2. Ring test.

Question 150

Describe the blood supply of the ear (2)?

Answer 150

1. Posterior auricular artery
2. Superficial temporary artery

Question 151

Strategies to prevent intra-arterial injections when fat grafting.

Answer 151

1. Do not use sharp cannulas or needles; instead use larger, blunt cannulas.
2. Use epinephrine; a vasocontricted vessel is much harder to cannulate than a dilated one.
3. Inject small volumes around danger areas.
4. Use small syringes; controlled injected volume is much easier with a 1cc Luer-lock syringe han a 10-20cc syringe.
5. Do not use mechanical devices for injecting that can generated high pressures.

Question 152

Perforator flap options for breast reconstruction.

Answer 152

1. Deep inferior epigastric artery perforator (DIEP)
2. Periumbilical perforator (PUP)
3. Superior gluteal artery perforator (SGAP)
4. Inferior gluteal artery perforator (IGAP)
5. Posterior thigh
6. Anterolateral thigh
7. Thoracodorsal artery perforator (TDAP)
8. Transverse upper gracilis myocutaneous (TUG)
9. Superficial inferior epigastric artery (SIEA)
10. Rubens (based on cutaneous perforators of the deep circumflex iliac artery and vein)

Question 153

Describe Tessier Cleft Number 13.

Answer 153

Tessier Cleft Number 13

One liner: Paramedian cleft with disruption of cribriform plate, hypertelorism, and frontal encephalocele.

Soft tissue:

• Paramedian frontal encephalocele locaed between nasal bone and frontl process of maxilla
• V-shaped frontal hairline projection

Skeletal:

• Hypertelorism from widening of cribriform plate and ethmoid cells
• Cribriform plate displaced inferiorly by frontal encephalocele
• Orbital dystopia

Question 154

In distraction osteogenesis, what is the typical time period form osteomy to distraction.

Answer 154

In neonates range is form 0-72 hours.

Typically initiated after 5-7 days in most patients.

Question 155

Advantages and disadvantages of DELAYED reconstruction.

Answer 155

Advantages:

1. No delay in adjuvant thereapy as a result of reconstructive complications.
2. Allows careful monitoring for advanced malignancy prior to reconstruction.
3. Decreased risk of complications.
4. Skin damage to mastectomy flap can be addressed at time of reconstruction.
5. Improved body image and increase vitality.

Disadvantages:

1. Loss of breast skin envelope and natural landmarks.
2. Recipient vessel dissection more tedious because of scarred / irradiated axilla or chest wall.
3. Flap size requirement usually greater than with immediate reconstruction.
4. Psychological morbidity of living with mastectomy defect.

Question 156

Surgical margins for melanoma.

Answer 156

• In situ: 0.5cm
• <1mm: 1cm margin
• >1mm: 2cm margin

Question 157

Basal cell carcinoma (BCC) risk factors.

Answer 157

• Fitzpatrick skin type
• Sun exposure
• Age
• Immunosuppression
• Carcinogenic exposure (UV, ionizing radiation, arsenic, hydrocarbons)
• Genetic mutuations / syndrome (Albinism, Nevoid basal cell syndrome / Gorlin’s syndrome, Xeroderma pigmentosum)

Question 158

Phases of infantile hemangiomas.

Answer 158

1. Proliferative phase (0-12 months)
   
   • 80% of maximum size at 3-5 months.
2. Involuting phase (12 months to 7-10 years)
   
   • Tumor shrinks, color fades, lesion flattens.
3. Involuted phase (complete at > 10 years)
   
   • 50% of cases will have residual bulk, color, or skin redundancy.

Question 159

Features consistent with unilateral coronal synostosis (7).

Answer 159

Collectively referred to as anterior plagiocephaly.

1. Ipsilateral frontal flattening, retruded forehead and supraorbital rim.
2. Ipsilateral raised eyebrow.
3. Ipsilateral widened palpebral fissure (increased diameter of orbital alters origin of levetor muscle and leads to widened palpebral fissure).
4. Ipsilateral deviated nasal root.
5. Ipsilateral ear anterior and superior.
6. Contralateral frontoparietal bossing.
7. Anteriorly displaced glenoid fossa causes chin to point to the contralateral side.

Question 160

Describe the facial canons of devine proportion (11).

Answer 160

Question 161

Relative frequency of CL/P for the left, right, and bilateral.

Answer 161

6:3:1

Question 162

What the main emobryological event that leads to an isolated cleft lip?

Answer 162

Failure of medial nasal process to contact maxillary process.

Question 163

During what weeks of gestation does the lip form?

Answer 163

Weeks 4-7.

Question 164

Describe the following as they relate to the surface anatomy of the life:

• Philtral column
• Philtral dimple
• White roll
• Vermillion
• Red line
• Cupid’s bow
• Tubercle

Answer 164

• Philtral column: Bilateral verticle buldge created by dermal inseration of the orbicularis rosi fibers.
• Philtral dimple: Concavity between the phitral columns created by a relative paucity of muscle fibers.
• White roll: Prominent ridge just above the cutaneous-vermillion border.
• Vermillion: Red mucosal portion of the lip divided into dry (keratinized) and wet (nonkeratinized); widest at peaks of cupids bow.
• Red line: Line separting wet and dry vermilion.
• Cupid’s bow: Curvature of the central white roll; two lateral peaks are the inferior extension of the philral columns
• Tubercle: Vermillion fullness at central inferior apex of cupid’s bow.

Question 165

Describe the anatomy of a unilateral cleft lip (5).

Answer 165

1. Cleft lip results in projection and outward rotation of the premaxilla and retropositioning of the lateral maxillary segment.
2. Orbicularis oris muscle in lateral lip element ends at the margin of the cleft and inserts into the alar wing.
3. There is hypoplasia and disorientation of the pars marginalis of the orbicularis oris.
4. Philrum is short.
5. Vermillion width is decreased on the cleft side and increased laterally.

Question 166

Describe the anatomy of a bilateral cleft lip.

Answer 166

1. Two deep clefts separate prolabium from paired lateral elements.
2. Prolabium has no cupid’s bow, no philtrum or philtral columns, and no orbicularis.
3. Lateral lip elements muscle fibers run parallel to cleft edges toward alar bases.

Question 167

Describe a Simonart’s band.

Answer 167

Simonart’s band: Residual skin bridge spanning upper portion of cleft lip.

Question 168

Features of cleft nasal deformity (10).

Answer 168

1. Deviated nasal tip.
2. Attenuated lower lateral cartilage (obtuse angle between medial/lateral crura as well as bucklng of lateral crura).
3. Flattened alar/facial angle.
4. Widened nostril floor.
5. Nasal tip and nostrils asymmetrical.
6. Hypertrophic inferior turbinate on cleft side.
7. Alar base displaced latereally, posteriorly, and sometimes inferiorly.
8. Deficient vestibular lining on cleft side.
9. Columella shorter on cleft side.
10. Caudal spetum deviate to noncleft side with posterio septum convex on cleft side.

Question 169

Risk of familial recurence in cleft lip, with or without cleft palate for:

• 1 afffected parent.
• 1 affected child
• Affected parent and affected child

Answer 169

Question 170

Risk factors for cleft lip and palate.

Answer 170

• Family history
• Phenytoin.
• Exposure to anticonvulsants.
• Smoing in first trimester.

Question 171

Elements of microform cleft (forme fruste) (3).

Answer 171

1. Small notch in vermillion.
2. Band of fibrous tissue running from edge of red lip to nostril floor
3. Deformity of the ala on the side of the notch.

Question 172

Describe the timeline for surgery for a patient with CL/P (cleft lip, palate, VPI, alveolar bone grafting, rhinoplasty, orthognathic surgery)?

Answer 172

Question 173

Methods of unilateral cleft lip repair (4).

Answer 173

1. Rose-Thomspon
   
   • Straight line repair
   • May be useful in microform clefts and repair of vermillion notching.
2. Triagnular flap repair
   
   • Uses single z-plasty as vermillion-cutaneous junction.
3. Quadrangular flap repair
4. Rotation-advancement
   
   • Millard
   • Rotates medial lip element downward and fills resulting defect with lateral lip.
   • Places scar along proposed philtral column.
   • Most common method of unilateral repair.

Question 174

Options for bilateral cleft lip repair.

Answer 174

• Mulliken repair
• Millard repair
• Modified Manchester repair

Question 175

Describe the markings and steps for a Mulliken bilateral cleft lip repair.

Answer 175

Mulliken Repair for Bilateral Cleft Lip

• Markings:
  
  • subnasale (sn), subalaris (sbal), labiale superisu (ls), crista philtri superioris (cphs), and crista philtri inferioris (cphi), red line.
  • Prolabium flap dimenions:
    
    • 2mm wide superiorly (cphs-cphs)
    • 4mm wide inferior (cphi-cphi)
    • 6-7mm in height (sn-ls)
    • Flanking flaps 2-3mm width on each flap to be deepithelialized
  • Noordhoff point marked on lateral labial elements (ensure 3mm of white roll medial to this)
  • Cutaneous advancement flaps drawn just above white roll up to sbal.
• Operative steps:
  
  • Key landmarks tattooed and markings scored with scalpel
  • Local anesthetic infiltration.
  • Deepithelialization of flanking flaps.
  • Discard remaining prolabial skin and vermillion with preservation of prolabial mucosa. Excise prolabial submucosa.
  • Lateral labial flap are incised at the superior aspect and maxilla exposed.
  • Alar base released sharply from piriform rim.
  • Submuscular (supraperiosteal) dissection continued laterally to the level of the malar eminence using Tessier elevator to mobilize the cheek and decrease tension on labial repair.
  • Vermillion / mucosal flap is then divided from the cutaneous portion of the lateral advancement flap.
  • Orbicularis separated from overlying skin and oral mucosa.
  • Mucosal flap secured to the premaxillary periosteum at the anterior nasal spine and gingivoperiosteoplasty is performed.
  • Vestibular mucosa approximated and lateral labial mucosa is closed.
  • Orbicularis muscle is approximated in the midline, secured to anterior nasal spine, and closed.
  • Identify the cphi on each lateral labial flap and mark 3mm medial to cphi. These two points approximated and will later receive the ls of the philtral flap.
  • Prolabial c-flaps approximated to the alar base flaps.
  • Alar cinch stich placed to control alar bases (24-26 mm in infants).
  • Nasal correction (if any).
  • Lateral labial cutaneous advancements trimmed and closed.

Question 177

Long term complications after cleft lip repair.

Answer 177

• Short lip
• Long lip
• Whistling deformity: Central vermillion deformity that presents as notching or inadequate vermillion with exposure of central incisiors in repose.
• Widened scar
• Lip landmark abnormalities

Question 178

Syndromes with variable degrees of auricular malformations (5).

Answer 178

• Branchial arch syndromes
• Goldenhar’s syndrome
• Treacher Collins Syndrome
• Oculoauriculovertebral syndrome
• Hemifacial microsomia

Question 179

What is the typical timing of autologous auricular reconstruction.

Answer 179

• Brent technique
  
  • Wait until age 4-6 years to allow for ear maturity and to reach appropriate school age.
• Nagata technique
  
  • Wait until age 10 OR when chest circumference at xyphoid is 60cm to allow for sufficient cartilage for recontruction.

Question 180

Diagnostic studies to be performed when considering autologous auricular reconstruction.

Answer 180

• Complete audiometric testing to determine conductive vs. sensorineural defect.
• High resolution CT to assess middle ear ossicles.
• MRI to assess course of facial nerve which can be displaced and to assess for presence of cholesteatoma (4-7% of atretic ears)

Question 181

What are options for reonstruction in the context of microtia (4).

Answer 181

• Autogenous costal cartilage.
  
  • Originally described by Tanzer, and revised by Nagata and Brent.
  • Positives: Best long-term recontruction.
  • Negatives: Donor site morbidity, chest wall deformity, multiple stages.
• Silastic Framework
  
  • Positive: Excellent aesthetic appearnce, no donor site.
  • Negatives: extrusion, long-term failure, susceptible to trauma.
• Porous polyethtylene implant
  
  • Positive: good short-term aesthetic results and extrusion rates.
  • Negatives: Limited long term data.
• Posthestic / Osteointegrated Reconstruction
  
  • Positive: good alternative to more invasive options
  • Negatives: limited by anaplastologist
• Tissue engineering
  
  • Still in development

Question 182

Describe the Brent Technique for microtia reconstruction.

Answer 182

Brent Technique for microtia reconstruction.

• Timing: Begining at 4-6 years of age.
• Stage I:
  
  • High-profile ear framework fabricated from contralateral costochondal rib cartilage of synchondrosis of 6th-8th rib. Placed in subcutaneous pocket at posterior/infeior border of ear vestige.
• Stage II:
  
  • Lobule transposition several months after framework.
• Stage III:
  
  • Projection established.
  • Incision along margin of the rim. Posterior capsule elevated. Projection established with wedge of cartilage placed subfascially.
  • Retroauricular skin advanced. STSG + bolster to cover the posterior defect.
• Stage IV:
  
  • Tragus construction, conchal excavation, and symmetry adjustment.
  • Tragus fashioned from composite graft from contralateral conchal cault or anteriorly based conchal flap with cartilage support.

Question 183

Describe the Nagata technique for microtia recontruction.

Answer 183

Nagata technique for microtia recontruction.

• Timing: Involves two stages starting at 10 years old.
• Stage I:
  
  • Ipsilateral rib cartilage from 6th-9th ribs.
  • Perichondrium left in situ to minimize chest well deformity.
  • Framework recontructed with tragal component.
  • Placed subcutaneously through W-shaped flap.
  • Lobule transposed at this stage.
• Stage II:
  
  • Framework elevated 6 months later.
  • Additional cartilage elevated from 5th rib to use as wedge.
  • Temporoparietal fascia flap elevated and tunneled subcutaneously to cover posterior cartilage grafts.
  • Advancement of retroauricular skin and coverage of defect with STSG.

Question 184

What are the optimal angles for fusion of the MCP, PIP, and DIP of the hand?

Answer 184

Question 185

Staging of lymphedema.

Answer 185

International Society of Lymphology staging of lymphedema.

Stage 0: Latent or subclinical. No edema evident, but lymph transport impaired. Can occur months or years before overt edema.

Stage I: Early accumulation of proteinaceous fluid with edema that resolves with limb elevation. Pitting edema can occur.

Stage II: Pitting edema may or may not be present. Tissue fibrosis develops. Does not resolve with limb elevation.

Stage III: Lymphostatic elephantiasis with absent pitting. Acanthosis, fat deposits, warty growth, and other trophic skin changes.

Question 186

Name and describe the three subtypes of PRIMARY lymphedema.

Answer 186

Congenital Lymphedema (Milroy’s Disease)

• Occurs within first 2 years of life.
• Commonly presents as bilateral lower extremity lymphedema but can afect upper extremity as well (3:1, LE:UE incidence).
• Possible associations: lymphangiectasia (pathologic dilation of lymph vessels) and cholestasis

Familial Lymphedema Praecox (Meige’s Disease)

• Presents during puberty.
• Most common form of primary lymphedema.
• Commonly presents unilateral affecting the foot and calf.
• Possible associations: vertebral, cerebrovascular malformation, hearing loss, double row of eyelashes (distichiasis)

Lymphedema Tarda

• Usually occurs after 35 years old.
• Histologically lymphatics are tortuous, hyperplasics and absent competent valves.

Question 187

Describe the pathophysiology and treatment of secondary lymphedema from filariasis.

Answer 187

• Filariasis (parasitic disease caused by an infection with roundworms) is caused by Wuchereria bancrofti. Whereby, the adult forms obstruct the lymphatic sytem.
• Drug of choice for treatment is ivermectin.
• Ciculating filarial antigens are pathognomonic and used to test efficacy of treatment.

Question 188

Complications of lymphedema (3).

Answer 188

1. Erysipelas.
2. Lymphangitis.
3. Lymphangiosarcoma (Stewart-Treves Syndrome)
   
   • Rare malignant tumour associated with chronic lymphedema.
   • Presents with multiple blue/red subcutaneous nodules in the affected extremity.

Question 189

Define Stemmer’s sign.

Answer 189

Stemmer’s sign: inability to grasp the skin of the dorsum of the second digit of the feet.

Question 190

Describe the conservative management of lymphedema.

Answer 190

Conservative management of lymphedema is first line management in all cases, and is called Complete Decongestive Therapy (CDT). It is composed of a REDUCTIVE PHASE followed by a MAINTENANCE PHASE. CDT can yield 40-60% reduction in excess volume in those with pitting edema.

Reductive Phase (3-8 weeks)

• Manual lymphatic drainage
• Compression bandaging
• Therapeutic exercise
• Skin care
• Education in self-management
• Elastic compression garments

Maintenance Phase (ongoing)

• Lifelong self-lymph drainage
• Exercise
• Skin care
• Compressions garments

Question 191

What three prevenative measures have the best evidence in the treatment of lymphedema?

Answer 191

1. Maintence of normal weight
2. Avoidance of weith gain
3. Participation in supervised exercise programs

Question 192

What are the resection and microsurgical options in the management of lymphedema? Please include a differentiation of the Charles, Modified Charles, and Miller procedure.

Answer 192

1. Resection procedures
   
   • Charles procedure: circumferential excision of lymphedematous tissue down to the deep fascia with coverage with STSG.
   • Modified Charles procedure: circumferential excision of lymphedematous tissue down to the deep fascia, with temporary coverage with negative pressure dressing for 5-7 days prior to definitive coverage with STSG.
   • Miller procedure: longitudinal excision of medial tissue (skin and subcutaneous tissue) with a layered closure and placement of drains.
2. Suction assisted-lipectomy
   
   • Circumferential liposuction of affected extremity
3. Microsurgical procedures
   
   • Autologous lymph node transfer: Flap including myphnodes, artery, and vein is harvested from donor site and placed into lymphedematous tissue follow scar release.
   • Interpositional lymph vessel transplation: Healthy lymphatic vessels used as interpositional grafts to bypass non-functioning area of lymphatic system.
   • Lymphovenous bypass: Subdermal lymphatics anastomosed to neighboring venules.

Question 193

What is the name, foramen, innervation, and function of the cranial nerve?

Answer 193

Question 194

What are the boundaries of the oral cavity?

Answer 194

Oral aperature to the palatoglossal fold.

Question 195

What are is the name, function, and location of the ducts within the oral cavity?

Answer 195

Wharton’s ducts: Salivary ducts for the submandibular and sublingual salivary glands on the floor of the mouth.

Stensen’s ducts: Salivary ducts for the parotid gland located on the buccal mucosa across from and at the level of the maxillary second permanent molar.

Question 196

Describe primary dentition (pediatric), including number and name of teeth.

Answer 196

• Total teeth: 20
• 4 incisors, 2 canines, 4 molars per arch
• No premolars
• Numbering begins with the right maxillary second molar and counts maxillary teeth (A-J). Then begins with the left mandibular second molar and counts mandibular teeth (K-T).

Question 197

Describe secondary dentition (adult), including number and name of teeth.

Answer 197

• Total teeth: 32
• 4 incisors, 2 canines, 4 premolars, 6 molars per arch
• Numbering begins with the third maxillary molar on the right and counts all the maxillary teeth (1-16). Then continues with left third mandibular molar adn counts all mandibular teeth (17-32).

Question 198

Define the following terms:

• Occlusal:
• Apical:
• Incisal:
• Medial:
• Distal:
• Buccal:
• Lingual:
• Palatal:
• Overbite:
• Overjet:
• Proclined:
• Retroclined:
• Buccal version:
• Lingual version:
• Centric occlusion:
• Centric relation:
• Crossbite:
• Open bite:

Answer 198

• Occlusal: functional surface of the tooth.
• Apical: toward the root tip.
• Incisal: occlusal surface of anterior teeth.
• Medial: toward midline.
• Distal: away from midline.
• Buccal: toward the cheek.
• Lingual: toward the tongue (mandibular).
• Palatal: toward the palate (maxillary).
• Overbite: amount of vertical overlap of incisal edges.
• Overjet: amount of horizontal overlap of incisal edges.
• Proclined: anterior tooth angled toward the lip.
• Retroclined: anterior tooth angled angulated toward the tongue.
• Buccal version: posterior tooth angulated toward the cheek.
• Lingual version: posterior tooth angulated toward the tongue.
• Centric occlusion: occlusion of teeth in maximal intercuspation.
• Centric relation: occlusion of teeth with condyle in its most anterosuperior position.
• Crossbite: horizontal malrelationship of teeth; may be classified as anterior or posterior.
• Open bite: occlusal surfaces not in contact when in centric occlusion.

Question 199

Describe normal occlusion and the classification of malocclusion.

Answer 199

Occlusion is defined by the relationship of the first maxillary and mandibular molars. Specifically, the normal relationship is that the mesiobuccal cusp of the first maxillary molar occludes in the buccal grove of the first mandibular molar.

Normal occlusion exists when the mesiobuccal cusp of the mandibular first molar occludes in the buccal groove of the first mandibular molar AND there is no malposed or malrotated teeth.

Angle classification of malocclusion

• Class I: mesiobuccal cusp of the first maxillary molar occludes in the mesiobuccal groove of the mandibular first molar (normal), BUT teeth or malposed or malrotated.
  
  • NOTE: Class I is NOT normal occlusion.
• Class II: The mandibular molar is distally positioned relative to the maxillary molar. Two divisions describe the relationship of the incisor.
  
  • Division I: Overjet with normal angulation of incisor.
  • Division II: Incisor retroclined to some degree, resulting in less overbite and increased overjet.
• Class III: The mandibular molar is mesially positioned relative to the maxillary molar.

Question 200

Describe the location of the infraorbital nerve.

Answer 200

4-7mm below the inferior orbital rim along a line dropped from the medial edge of the limbus.

Question 201

Describe the location of the greater palatine nerve and nasopalatine nerve.

Answer 201

Foramen for the greater palatine nerve is located halfway between the teeth and the palatal midline at about the second molar.

Foramen for the nasopalatine nerve is located at the midline 5-7mm behind the maxillary incisors.

Question 202

Describe location of the inferior alveolar and mental nerve.

Answer 202

• Inferior alveolar nerve* enters the mandibular formamen on the medial ramus 5-10mm above the mandibular occlusal plane and 15-20mm posterior to the anterior border of the ramus.
• Mental nerve* exits through its foramen below the second premolar.

Question 203

Describe the soft tissue cephalometric landmarks.

Answer 203

Question 204

Describe the bony cephalometric landmarks.

Answer 204

Question 205

Describe presentation and management of maxillary excess.

Answer 205

Anteroposterior excess characteristically has class II malocclusion with protrusion of maxillary incisors and convex facial profile. Vertical excess can also include elongation of the lower third, narrow nasal base, excessive incisal amd gingival show, and lip incompetence.

Primary surgical correction involves LeFort I osteomtomy.

Question 206

Describe presentation and management of maxillary deficiency.

Answer 206

Features typically include: deficiency of infraorbital / paranasal regions inadequate upper tooth show, short lower third, deficient upper lip.

Primary surgical correction involves LeFort I osteotomy.

Question 207

Describe the presentation and management of mandibular excess (prognathism).

Answer 207

Typically demonstrates class III molar and canine relationship and reverse overjet of the incisors.

Facial features include a prominent lower third.

Primary correction involve maxillary advancement or mandibular setback. Mandibular setback can be accomplished by bilateral saggital split osteotomies (BSSO) or intraoral vertical ramus osteotomies (IVRO). IVRO requires MMF.

Question 208

Describe the presentation and management of mandibular deficiency (retrognathism).

Answer 208

Typically class II molar and canine relationship.

Facial features include: retruded position of chin, acute labiomental fold, abnormal lip posturing, and short thyromental distance.

Primary surgical treatment includes mandibular advancement with BSSO.

Question 209

Classification of mandible fractures.

Answer 209

Anatomic classification of mandible fractures.

• Dentoalveolar: A fracture without disruption of the underlying osseous structures of the mandile and only involving the tooth-bearing area.
• Condyle: Any fracture the affects the condylar process of the mandible, further classified into:
  
  • Intracapsular
  • Extracapsular
  • Neck
• Coronoid: Any fracture that affects the coronoid process.
• Ramus: Superior to the gonial angle to the sigmoid notch.
• Angle: Region of the gonial angle extending to the region of the third molar.
• Body: Any fracture between the mental foramen and the distal aspect of the second molar.
• Parasymphysis: Any between the mental foramen (second premolar) and the distal aspect of the lateral incisor.
• Symphysis: Fracture in the region of the incisors in a vertical or near-vertical orientation.

Question 210

Indications for teeth removal in the context of mandible fractures (5).

Answer 210

1. Grossly mobile teeth showing evience of periapical pathology or advanced periodontal disease.
2. Partially erupted third molars with associated dental pathology (cycsts or periocoronitis).
3. Teeth prevent fracture reduction.
4. Fractured roots.
5. Exposed root apices.

Question 211

Define the following terms:

• Rigid (absolute) stability
• Functional stability
• Load-sharing stability
• Load-bearing stability

Answer 211

• Rigid (absolute) stability: No movement across the fracture gap.
• Functional stability: Movement is possible across the fracture gap but is balanced by external forces and remains within the limits that allows the fracture to progress to union.
• Load-sharing stability: Functional stability is achieved by the fixation system in conjunction with stablizing forces provided by anatomic abutment of noncomminuted fracture segments.
• Load-bearing stability: Functional stability, provided solely by the fixation system. Accomplished only by reconstruction plates.

Question 212

Management of condyle fractures.

• Condyle fracture without malocclusion:
• Condyle fracture with malocclusion:

Answer 212

Management of condyle fractures.

• Condyle fracture without malocclusion:
  
  • Soft diet and close observation
  • If malocclusion develops (usually deviation to affected side with contralateral posterior open bite) can usually be treated with arch bars and elastics to control occlusion.
• Condyle fracture with malocclusion:
  
  • Closed reduction:
    
    • Arch bars and occlusion controlled with elastics
    • Usually possible with single, class II elastic on the affected side
  • ORIF necessary when:
    
    • Condylar segment displaced and interfers with translation
    • Condyel is displaced into the middle cranial fossa
    • Bilateral mandibular condyle fractures and midface fractures exist – must reestablish posterior verticle height
    • A normal, reproducible occlusion cannot be established

Question 213

Management of angle fractures.

Answer 213

Fractures of mandibular angle have the higher complication rate of any single region of the mandible.

ORIF techniques have similar complication rates to nonrigid technique (requiring MMF).

Question 214

Management of mandibular body fractures.

Answer 214

Mandibular body fractures can be treated with miniplates or recontruction plates.

• Miniplates are easier to adapt and place but are useful only in non-comminuted fractures when accurate abutting of fracture segments provides load-sharing.
• Reconstruction plates are more difficult to adapt and palce but may be used with comminuted fractures when load-bearing fixation is necessary.

Question 215

Management of symphysis fractures.

Answer 215

Symphysis fractures may be treated with miniplates, reconstruction plates, or lag screws.

Because of torsional forces generated at the symphysis, if miniplates are used two points of fixation are required.

Question 216

How does lack of dentition, small bone stock, and poor bone quality impact the management of mandible fractures?

Answer 216

• Lack of dentition, small bone stock, and poor bone quality compromise the accuracy of reduction and healing capacity.
• In the context of the edentulous patient, transfacial approaches with reconstruction plates aid in bony union.
• Use of mini plates or closed reduction with the patient’s dentures are not recommended.
• In severely atrophic mandibles, bone grafting the fracture site may be necessary in the acute setting.

Question 217

What is the standard sequence of treatment of mandible fractures.

Answer 217

1. Exposure of all fractures.
2. Reduction of all fractures.
3. Placement of MMF.
4. Fixation of fractures.

** MMF must be removed and occlusion reassessed after application of hardware. If the patient is to remain in MMF, it may be reapplied after proper reduction is confirmed.

Question 218

Name the layers of the scalp and the neurocranium.

Answer 218

Scalp

• S (skin): Measures 3-8mm thick (3mm at vertex, 8mm at occiput)
• C (subcutnaeous tissue): Vessels, lymphatics, and nerves found in this layer.
• A (aponeurotic layer): Strength layer, continuous with frontalis and occipitalis muscles.
• L (loose areolar tissue): Also known as subgaleal fascia and innominate fascia;provides scalp mobility; contains emissary veins.
• P (pericranium): Tightly aderhent to calvarium.

Neurocranium

• External table
• Diploic space
• Internal table
• Epidural space
• Dura mater
• Subdural space

Question 219

Describe the 4 vascular territories of the scalp.

Answer 219

• Anterior territory
  
  • Supraorbital and supratrochlear arteries (terminal branches of internal carotid system).
  • Supraorbital artery arises through the supraorbital notch, which is in line with the medial limbus
  • Supratrochlear artery arises more medially, in plane with medial canthus.
• Lateral territory (largest territory)
  
  • Superficial temporal artery (terminal branch of external carotid system).
  • Bifurcates at the superior helix of the ear to frontal and parietal branches.
• Posterior territory
  
  • Occipital arteries cephalad to the nuchal line.
  • Perforating branches of trapezius and splenius capitis muscles caudal to the nuchal line.
• Posterolateral territory (smallest territory)
  
  • Posterior auricular artery (branch of external carotid system).

Question 220

Describe the sensory and motor innervation of the scalp.

Answer 220

SENSORY

Sensory innervation supplied by branches of the three divisions of the trigeminal nerve, cervical spinal nerves, and branches from the cervical plexus.

• Supraorbital nerve
  
  • Superficial division: Pieces frontalis and supplies skin of the forehead and anterior hairline.
  • Deep division: Runs superficial to the periosteum to the level of the coronal suture where it pierces the galeal aponeurosis appropximately 0.5-1.5cm medial to the superior temporal line to innervate the frontoparietal scalp.
• Supratrochlear nerve
  
  • Terminal branch of V1 supplies sensation to lower forehead, conjunctiva, upper eyelid skin.
• Zygomaticotemoral nerve
  
  • Branch of the maxillary division of trigeminal nerve that supplies sensation to a small region lateral to the brow up the superficial temporal crest.
• Auriculotemporal nerve
  
  • Branch of the mandibular division of the trigeminal nerve that supplies the lateral scalp.
• Greater and lesser occipital nerves
  
  • Branches from dorsal rami of cervical spinal nerves and cervical plexus respectively which innervate the occipital territory.
  • Greater occiptal nerve emerges from semispinalis muscle approximately 3cm below occipital protuberance and 1.5cm lateral to midline.

MOTOR

• Frontal branch of facial nerve (temporal branch)
  
  • Supplies frontalis
• Poserior auricular branch of facial nerve
  
  • Supplies anterior and posterior auricular muscles and occipitalis muscle.

Question 221

Describe the concepts of stress relaxation and creep.

Answer 221

• Stress relaxation: Property of skin decreases the amount of force necessary to maintain a fixed amount of skin stretch over time.
• Creep: Skin property whereby skin gains surface area when a constant load is applied.
  
  • As force is applied to a leading skin edge, tissue thickness decreases from extrusion of fluid and mucopolysaccharides, realignment of dermal collagen bundles, elastic fiber microfragmentarion, and mechanical stretching of the skin.

Question 222

In scalp reconstruction, what lengthening can you expect with scoring of the galea?

Answer 222

Scoring in 1cm increments will gain 1.67mm for reach relaxing incision.

Question 223

What percent of the scalp can be reconstructed with tissue expansion?

Answer 223

Approximately 50% of the scalp can be reconstructed with tissue expansion before alopecia becomes a significant issue.

Question 224

What are options for scalp reconstruction based on defect size?

Answer 224

• Small defect (<6cm)
  
  • Skin graft
  • Advancement flaps
  • Rotation flaps
  • Bilobed flaps
  • Pinwheel
  • Three adjacent rhomboid flaps
• Medium-sized defects
  
  • Skin graft
  • Large rotation flap +/- back grafting
  • Orticochea three flap reconstruction (three flap reconstruction based on named vessels of the scalp; the two smaller flaps should be at least 50% of the width of the defect so that when they are brought together they cover the defect)
    
    • Not well suited for vertex scalp defects.
  • Tissue expansion
• Large-sized defects (8-10cm)
  
  • Subtotal scalp flap (essentially a large rotation flap based of STA and posterior auricular arteries with backgrafting)
  • Temporparietal fascial flap with skin graft
  • Pericranial flap with skin graft
  • Free tissue transfers

Question 225

What are options for calvarial reconstruction?

Answer 225

Autologous tissue

• Split clavarial bone graft (parietal preferred because of increased thickness and abscence of underlying venous sinuses)
• Split rib graft (if periosteum left intact, rib may regenerate)
• Advantages of autologous: biocompatible, resistance to infection, increased strength.
• Disadvantages of autologous: difficult contouring, resorption, donor site availability, and morbidity.

Alloplastic materials

• Methymethacrylate
• Titanium mesh
• Hydroxyapatite
• Acrylic
• Polyetheretherketone (PEEK)
• Advantages of alloplastic: unlimited supply, lack of donor site morbidity
• Disadvantages of alloplastic: no integration with recipient site, increased infections, costly

Question 226

Describe the two lamellae of the eyelid and their respective contents.

Answer 226

Outer lamella: skin and orbicularis oculi muscle.

Inner lamella: Tarsal plate, medial / lateral canthal tendons, capsulopalpebral fascia, and conjunctiva.

Question 227

Draw a sagital section of the eyelid.

Answer 227

Question 228

Describe the different elements and function of orbicularis oculi (3).

Answer 228

1. Pretarsal fibers
   
   • Lie over the tarsal plate
   • Responsible for involuntary blink, lower lid tone, lacrimal pumping mechanism
2. Preseptal fibers
   
   • Overlie the orbital septum
   • Assist with blink
3. Orbital fibers
   
   • Overlie orbital rims
   • Responsible for eyelid squeezing, forceful closure, and animated eyelid movement.

Question 229

What are is the length, width, and height of the tarsal plates?

Answer 229

• Tarsal plates are 1-2mm thick and ~25mm long
• Laterally they become the medial and lateral canthal tendons
• Upper tarsal plate is 12-15mm in height with the superior margin forming the attachment for Muller’s muscle and levator aponeurosis.
• Lower tarsal plate is 4-10mm in height with the inferior margin continuous with the capsulopalpebral fascia.

Question 230

Describe the upper the lower eyelid retractors.

Answer 230

UPPER LID

• Levator palperae superioris
  
  • Innervated by CN III (superior division)
  • Originates from the lesser wing of the sphenoid, above optic foramen, and extends forward to insert on the edge of the tarsal plate
  • Whitnall’s ligament serves as a fulcrum to redirect the vector of pull from horizontal to superior direction for lid retraction.
• Müller’s muscle
  
  • Innervated by sympathetic nervous system
  • Arises from inferior surface of the levator palpebrae superioris and inserts onto superior edge of the tarsus.
  • Loss of Müller’s muscle results in 2-3mm of ptosis.

LOWER LID

• Capsulopalpebral fascia
  
  • Condensation of fibroelastic tissue anterior to Lockwood’s ligament, which joins the inferior tarsal plate
  • Serves as a lower lid retractor
  • Smooth muscle fibers found at its condensation.

Question 231

Describe the blood supply and innervation of the eyelid.

Answer 231

Blood Supply

• Upper lid is supplied by branches of the ophthalmic artery
  
  • Medial and lateral superior palpebral arteries branch to form both peripheral and superior marginal arcades
• Lower lid is supplied by branches of the facial artery
  
  • Medial and lateral palpebral arteries form inferior marginal artcade

Innervation

• Upper lid supplied by V1
• Lower lid supplied by V2

Question 232

Describe a general algorithm for eyelid reconstruction, indicating the general size of defects that can be closed primarily vs. require more complex reconstructions.

Answer 232

• Defects < 30% of lid: closed primarily
• Defect 30-50% of lid: closed directly with lateral canthotomy + cantholysis.
• Defects of 50-75% of lid: Closed with myocutaneous advancement flaps.
• Defects > 75% of lid: Generally require tissue from opposite lid or adjacent regions (cheekm temporal, forehead)

Question 233

What are options for recontructing eyelid conunctiva?

Answer 233

• Sliding transconjunctival flap (see illustration)
• Buccal or nasal mucosa graft (nasal mucosa [20%]contracts less than buccal [50%])

Question 234

What are options for recontructing the tarsal plate?

Answer 234

• Palatal mucosal graft
• Cartilage graft
• Acellular dermal matrix

Question 235

What are options for reconstruction of FULL THICKNESS defects of the upper lid?

Answer 235

1. Direct closure (+/- lateral canthotomy and cantholysis)
2. Sliding tarsoconunctival flap + FTSG for anterior lamella
3. Cutler-Beard flap + cartilage graft
4. Lid-sharing (Mustarde pedicled flap)
5. Tenzel semicircular flap
6. Temporal forehead flap (Fricke flap) + mucosal graft for conjunctiva + secondary stage for tarsal plate reconstruction with cartilage graft
7. Paramedian forehead flap + mucosal graft for conjunctiva + secondary stage for tarsal plate reconstruction with cartilage graft

Question 236

Describe direct closure of composite defects of the upper lid?

Answer 236

• Defects of 25-30% can be closed primarily (40% if laxity)
• Lateral canthotomy + cantholysis may provide additional laxity for closure.
• Precise approximation of tarsal plate is critical for proper lid support.

Question 237

Describe Tenzel semicircular flap for composite upper lid defects.

Answer 237

• Combines lateral canthotomy and cantholysis with laterally based myocutaneous flap.
• Allows closure of up to 60% of the upper lid.

Question 238

Describe Cutler-Beard flap reconstruction for composite upper eyelid defects.

Answer 238

• Two-stage procedure
• Advancement of a full thickness flap (skin, orbicularis, conjuctiva) from the lower lid (elevated BELOW the tarsal plate, ie. tarsal plate is NOT included in the flap)
• The flap is made biplanar with a cartilage graft inset between the conjunctiva and the skin/orbicularis.
• Flap division performed at 3-6 weeks.

Question 239

Describe the lid-sharing flap (Mustarde pedicled flap) for composite upper lid defects?

Answer 239

• Used for defets of the central upper lid
• Flap divided at 6 weeks and donor site closed primarily.

Question 240

Describe a temporal forehead flap (Fricke flap) for composite upper eyelid defects.

Answer 240

• Transposition flap from the upper eyebrow
• Requires mucosal graft for conjunctiva recon with secondary procedure for cartilage graft OR palatal mucoperiosteal graft which can provide sufficient support.

Question 241

What are options for reconstructing full thickness lower eyelid defects?

Answer 241

1. Direct closure
2. Advancement tarsoconjunctival (modified Hughes) flap
3. Tarsoconjunctival (Hughes) flap
4. Semicircular rotation (Tenzel) flap
5. Vertical myocutaneous cheek lift
6. Tripier flap
7. Rotation cheek (Mustarde) flap
8. Temporal (Fricke) flap

Question 242

Describe the Tripier flap for lower lid recontruction.

Answer 242

• Myocutaneous flap used for partial thickness coverage of lower lid
• Can be bipedicled or single pedicle

Question 243

Describe Hughes tarsoconjunctival flap for lower lid reconstruction.

Answer 243

• Two-stage procedure
• Transfers conjunctival lining and a small portion of the tarsal plate for subtotal or total lower lid reconstruction.
• Skin coverage provided in the first stage with FTSG
• Flap divided at 4-6 weeks.

Question 244

Describe Mustarde flap reconstruction for lower eyelid.

Answer 244

Question 246

Describe the timing of the treatment of syndactyly.

Answer 246

• Early operative intervention at 4-6 months warranted for border digits (to prevent angular growht and deviation of the longer digit) or when complex (e.g. Apert syndrome with transverse bony components that risk worsening the deformity).
• Mostly vommonly waiting until the hand is larger (6-12 months) more appropriate.

Question 247

Define camptodactyly and the proposed etiologies.

Answer 247

• Camptodactyly: congenital flexion contracture of the proximal interphalangeal joint; classically involving the little finger.
• Theories regarding etiology:
  
  • Abnormal lumbrical insertions and morphology.
  • Extra or abnormal slips of FDS.
  • Abnormal extensor or PIP capsular contractures.
  • Bony abnormality of the PIP.

Question 248

Define symphalangism.

Answer 248

Symphalangism: Joint stiffness secondary to the failure of the IP to differentiate.

Question 249

Define arthrogryposis.

Answer 249

• Arthrogryposis: Arthrogryposis, also called arthrogryposis multiplex congenita (AMC), involves a variety of non-progressive conditions that are characterized by multiple joint contractures (stiffness) and involves muscle weakness found throughout the body at birth.

Question 250

What is the indication for operating in camptodactyly and what is the operative approach.

Answer 250

• Operation typically reserved for those when contracture is >60-90 degrees.
• Technique:
  
  • Stepwise evaluation assessing volar skin, FDS, laxity of central slip.
  • Minimalist, stepwise release of tethering structures until satisfactory correction achieved.

Question 251

Define clinodactyly, its etiology, and its management.

Answer 251

• Clinodactyly: Curvature that results from an abnormal MIDDLE PHALANX.
• Arises from a c-shaped physis which can be present with a ‘delta phalanx’
• Surgical correction indicated with severe shortening and angulation, particularly when pinch impaured.
• Physiolysis: Bracket resection of longitudinal hysis with preservation of growth plate and fat graft. Works well when true delta phalanx is resected.
• Osteotomy: Closing or opening wedge osteomy. Can be done when trapezoidal wedge present.

Question 252

Indications to restore skeletal stability and structure in chest reconstruction.

Answer 252

Indications to restore skeletal stability and structure in chest reconstruction.

1. If > 4 consecutive ribs are resected.
2. If the defect is >5cm.

* May reconstruct smaller defect if underlying pulmonary disease (less tolerance of respiratory mechanical efficiency)

* May not reconstruct larger defect if previous radiotherapy (radiotherapy stiffens chest wall through ischemic fibrosis)

* If defect is located posterior and/or superiorly, then a larger defect is tolerated.

Question 253

Options for ALLOPLASTIC chest wall reconstruction.

Answer 253

Options for ALLOPLASTIC chest wall reconstruction:

• Mesh
  
  • Polypropylene (Marlex)
  • Expanded polytetrafluroethylene (ePTFE)(GORE-TEX)
• Methylmethacrylate
• Acellular dermal matrix
• Titanium plate fixation

Question 254

Options for AUTOGENOUS chest wall reconstruction.

Answer 254

Options for AUTOGENOUS chest wall reconstruction.

• Pectoralis major (advancement, turnover)
• Latissimus dorsi
• Rectus abdominis
• Serratus anterior
• Omentum

Question 255

Reconstructive options for anterior chest wall and mediastinum.

Answer 255

Reconstructive options for anterior chest wall and mediastinum.

• Pectoralis major.
• Latissimus dorsi.
• Omentum.
• Rectus abdominis.

Question 256

Reconstructive options for anterolateral chest wall.

Answer 256

Reconstructive options for anterolateral chest wall.

• Latissimus dorsi
• Omentum
• Rectus abdominis.
• External oblique.
• Serratus anterior.
• Transverse thoracoabdominal flap.

Question 257

Reconstructive options for diaphragmatic defects.

Answer 257

Reconstructive options for diaphragmatic defects.

• Direct suture repair.
• Acellular dermal matric or mesh.
• Deepithelialized transverse rectus abdomninis myocutaneous (TRAM).
• Latissimus dorsi.
• Omentum.

Question 258

Describe the etiology, features, and indications for treatment in Poland Syndrome.

Answer 258

Poland Syndrome

• Etiology: Hypoplasia of subclavian artery secondary to kinking during wee 6 gestation.
• Features:
  
  • Absence of sternal head of pectoralis major muscle
  • Absence of costal cartilages
  • Hypoplasia / aplasia of breast and subcutaneous tissue, including the nipple-areolar complex.
  • Deficiency of subcutaneous fat and axillary hair.
  • Syndactyly or hypoplasia of ipsilateral extremity.
• Potential additional features:
  
  • Absence or hypoplasia of pectoralis major muscle.
  • Shortening / hypoplasia of forearm.
  • Variable deformities of serratus, infraspinatus, latissimus, and external obliques.
  • Total absence of anterolateral ribs with herniation of the lung.
  • Symphalangism with syndactyly and hypplasia or aplasia of middle phalanges.
  • Occaisionallay associated with Mobius syndrome.
• Indications for treatment:
  
  • Patient with absent ribs.
  • Female patients with breast asymmetry (surgery delayed to allow full development of contralateral breast)

Question 259

Describe the path of the median nerve.

Answer 259

• Formed from the medial and lateral cords of the brachial plexus.
• Courses medial to the brachial artery, sitting between brachialis and the medial intermuscular septum.
• Passes under the ligamenta of Struthers at the supracondylar rim (ligament associated with humeral head of PT)
• Crosses the antecubital fossa under the bicipital aponeurosis (lacertus fibrosis).
• Separates from the brachial artery to pass between the two heads of PT.
• Anterior interosseous nerve comes off and descends on the interosseous membrane.
• Median nerve continues deep to the FDS arch and descends between FDS and FDP.
• Palmar cutaneous branch comes off 5cm proximal to wrist crease and median nerve passes under the carpal tunnel into the hand.
• Median recurrent motor nerve branches off beyond, under, or through the carpal tunnel.

Question 260

Describe boundaries of carpal tunnel.

Answer 260

• Radial: Scaphoid, trapezium, fascial septum.
• Ulnar: Hamate hook, trapezium, pisiform.
• Floor: Carpal bones.
• Roof: Transverse carpal ligament from scaphoid tuberosity / trapezium to pisiform an hamate hook.

Question 261

Describe the course of the radial nerve.

Answer 261

• Terminal branch of the posterior cord.
• Run posterior to the axillary / brachial artery.
• Travels posterior to profunda brachii artery between lateral / medial heads of triceps.
• Transect the lateral intermuscular septum with the radial collateral artery (10cm proximal to distal humerus).
• After passing anterior, travels between BR and brachialis, ultimately passing between BR and ECRL.
• Traverses the radial tunnel (bounded by the radiocapitellar joint bursa, BR tendon, ECRL/ECRB, biceps tendon). Sits 1cm lateral to biceps tendon at the elbow.
• Nerve branches at the elbow with PIN travelling under the leading edge of supinator (arcade of Froshe) and the superficial sensory branch travelling on the underside of BR.
• PIN ultimatelly travels on the floor of the 4th dorsal compartment and the superficial sensory branch becomes subcutaneous 9-10cm proximal to the wrist under BR.
  *

Question 262

Describe the path of the ulnar nerve.

Answer 262

• Terminal branch of the medial cord. Travels medial and posterior to the brachial artery.
• Transect medial intermuscular septum in the middle arm 10cm proximal to the medial epicondyle to enter the posterior arm.
• Covered by the arcade of Struthers 8cm proximal to the medial epicondyle.
• Passes medial to the medial head of triceps and posterior to the medial epicondyle.
• Passes through the cubital tunnel where the nerve is covered by the flexor carpi ulnaris tendon / arcuate ligament of osborne. Cubital tunnel is composed of the capsule / medial collateral ligament.
• After passing through two heads of FCU ulnar nerve travels between FDP and FDS.
• The nerve travels radial to FCU and ulnar to hook of hamate to enter Guyon’s canal.
• Guyons canal is bounded by:
  
  • Roof: the volar carpal ligament
  • Ulnar: Pisiform/FCU, pisohamate ligament, abductor digiti minimi
  • Radial: Hook of hamate
  • Floor: Transverse carpal ligament and hypothenar muscles.

Question 263

Describe the branching pattern of the recurrent motor branch of the median nerve and their frequencies.

Answer 263

• Beyond the transverse carpal ligament (50-90%)
• Beneath the transverse carpal ligament (30%)
• Through the transverse carpal ligament (23%)

Question 264

Define pronator syndrome and potential sources of compression.

Answer 264

• Pronator syndrome is proximal median nerve compression typically presenting with numbness and paresthesias but can also have weakness.
• Potential compression points:
  
  • Lacertus fibrosis
  • PT
  • Ligament of struthers
  • Leading edge of FD
  • Anomalies of vascular branches in distal forearm

Question 265

Describe radial tunnel syndrome and differentiate with PIN syndrome.

Answer 265

• Pain during movement at the elbow radiating distally to the dorsal hand, accompanied by tingling of the hand and weakness of grip.
• Typically arises from repetitive elbow extension / rotation.
• Symptoms most effectively elicited by ‘middle finger test’: pain over ECRB during forceful extension of the middle finger with the elbow held in full extension.
• Lidocaine injection into the radial tunnel can be diagnostic and therapeutic.
• PIN syndrome in contrast does not have sensory involvement as the radial sensory nerve has already branched.

Question 266

Describe Wartenberg’s syndrome and its management.

Answer 266

• Compression of superficial radial nerve at point of exit from beneath BR.
• Progress from conservative to surgical decompression.

Question 267

Five sites of surgical compression.

Answer 267

1. Arcade of struthers
2. Ligament of osborne
3. Medial intermuscular septum
4. Proximal fascia between two heads of FCU
5. Fascial bands within FCU tunnel

Question 268

Describe the blood supply to the scaphoid.

Answer 268

• Major blood supply is via the dorsal carpal branch of radial artery.
  
  • Enters scaphoid in a nonarticular ridge on the dorsal surface and supplies proximal 80% of scaphoid via retrograde blood flow.
• Minor blood supply from superficial palmar branch of radial artery.
  
  • Enters distal tubercle and supplies distal 20% of scaphoid.

Question 269

What type of instability can develop in the context of an unstable scaphoid fracture.

Answer 269

• SL ligament is important for coordinating the action of the proximal row.
• In the context of a scaphoid fracture, the PRXOMAL aspect of the scaphoid remains attached via the SL to the lunate. As such these to elements remain coordinated and are able to extend together. But, the DISTAL aspect of the scaphoid in turn FLEXES without normal restraint.
• This creates DORSAL INTERCALATED SEGMENT INSTABILITY (DISI).
• This changes the distribution of force and carpal loading and can yield SCAPHOID NON-UNION ADVANCE COLLAPSE (SNAC).

Question 270

List of the potential CAUSES and RADIOGRAPHIC findings of DORSAL INTERCALATED SEGMENT INSTABILITY.

Answer 270

ETIOLOGY

• Fracture:
  
  • Scaphoid fracture: bony DISI
  • Distal radius fracture: compensatory DISI
  • Radius malunion: adaptive DISI
• Ligamentous injury:
  
  • Scapholunate ligament dissociation

RADIOGRAPHIC FINDINGS

• On a lateral radiograph, with the wrist in neutral, DISI typically shows:
  
  • A dorsal tilt of the lunate.
  • Scapholunate angle >60 degrees (a sign of scapholunate ligament dissociation)
  • Capitolunate angle >30 degrees (the capitate is displaced posteriorly compared to the distal radius).

Question 271

List the five radiographs required for preliminary work-up of a ?scaphoid fracture.

Answer 271

1. AP
2. Lateral
3. Oblique
4. Clenched fist PA: Extends scaphoid and accentuates waist fracture
5. Scaphoid view: Fisted, semipronated, ulnar deviation

Question 272

Explain the role for CT and/or MRI in the context of ?scaphoid fracture.

Answer 272

CT

• Allows more detailed examination of the scaphoid, reliably demonstrates when a fracture is dispalced.
• Preferred over MRI in the nonacute setting to define bony alignment.

MRI

• Can detect presence or abence of fracture
• Preferred over CT in acute setting

Question 273

Describe the management of non-displaced and displaced scaphoid fractures.

Answer 273

Non-displaced fractures

• Immobilize in a long-arm thumb spica for 6 weeeks, followed by 6 weeks in a short arm thumb spica.
• Consider operate management with internal fixation for:
  
  • High demand patients who cannot tolerate 12 weeks immobilization.
  • Proximal pole fractures given high rates of non-union.

Displaced fractures

• All displaced fractures require operative treatment.
• Typically done with 1-2 cannulated screws through an open or percutaneous approach.
  
  • Dorsal approach proxides best access to proximal pole.
  • Volar approach provides best access to reduce / bone graft a hump back or flexion deformity.

Question 274

Describe the humpback deformity.

Answer 274

• Distal pole of scaphoid flexed and proximal pole extended.
• Creates an angulated scaphoid on lateral radiographs and foreshortened scaphoid on AP radiographs.

Question 275

Four vascularized bone graft options for scaphoid non-union.

Answer 275

1. 1,2 intercompartmental supraretinacular artery (1,2-ICSRA)
2. 2,3 ICSRA
3. Free medial femoral condyle vascularized graft
4. Pronator quadratus graft

Question 276

What is the best xray view to assess the triqutrum.

Answer 276

45-degree pronated oblique.

Question 277

Describe the hook of hamate pull test (HHPT).

Answer 277

Wrist is supinated and ulnar deviated.

Force is then applied to the flexor tendons of the small and ring finger.

Causes displacing force on the hook of the hamate.

Used in ?hook of hamate fractures.

Question 278

Describe the treatment of hamate fractures.

Answer 278

• Hamulus (hook) fractures
  
  • Cast immobilization (high non-union rate).
  • ORIF
  • Excision of fragment.
• Body
  
  • Non-displaced fracture can be treated with immoilization
  • Most displaced body fractures require ORIF as it is in the context of other associated wrist injuries.

Question 279

Define and differentiate carpal instability dissociative (CID) and carpal instability nondissociative (CIND).

Answer 279

• Carpal Instabiity Dissociative (CID): Instability between carpal bones within the same row.
• Carpal Instability Nondissociative (CIND): Instability of the entire proximal row relative to the radiocarpal or midcarpal joint.

Question 280

Name the relevant EXTRINSIC CARPAL LIGAMENTS (8 + neurovascular bundle).

Answer 280

• Palmar radiocarpal (4 + neurovascular bundle)
  
  • Radioscaphoid
  • Radioscaphoid-capitate
  • Long radiolunate
  • Short radiolunate
  • Radioscapholunate ligament or ligament of Testut (neurovascular bundle and not a ligament)
• Palmar ulnocarpal (3)
  
  • Ulnar capitate
  • Ulnar triquetral
  • Ulnar lunate
• Dorsal radiocarpal (1)
  
  • ​Radiotriquetral / radiocarpal

Question 281

Describe carpal kinematics with radial deviation and ulnar deviation respectively.

Answer 281

• In radial deviation, the scaphoid flexes. With intact intercarpal ligaments, the lunate and triquetrum follow suit and passively flex.
• In ulnar deviation, the triquetrum is guided into extension by its articulation with the hamate. With intact intercarpal ligaments, the entire proximal row move into extension along with the triquetrum.

Question 282

What is the normal scapholunate angle.

Answer 282

30-60.

Question 283

Describe the dorsal intercalated segment instability deformity (DISI).

Answer 283

• The DORSAL and VOLAR aspect of DISI and VISI refer to the kinematics of the LUNATE.
• In a DISI deformity, the lunate is tipped dorsally (or extended) as the scaphoid is flexed.
• As such the scapholunate angle is >60 degrees.
• This the most common dissociative pattern.

Question 284

Describe volar intercalated segment instability (VISI).

Answer 284

• The DORSAL and VOLAR aspect of DISI and VISI refer to the kinematics of the LUNATE.
• In a VISI deformity, the lunate is tipped volarly (or flexed) and the scaphoid is extended,
• As such the scapholunate angle is <30 degrees.
• This the second most common dissociative pattern.

Question 285

Differentiate greater and lesser arc injuries of the wrist.

Answer 285

• Greater arc injuries: injuries that progress through the carpal bones; typically fractures that involve one or multiple of the radial styloid, scaphoid, capitate, triqutrum, and the ulnar styloid.
• Lesser arc injuries: Pure ligamentous perilunate injuries.

Question 286

Describe the mechanism of SL injury.

Answer 286

• In hyperextension of the wrist with ulnar deviation, the capitate is driven between the scaphoid and the lunate.
• The lunate is pushed ulnarly and volarly and the scaphoid is pushed radially and dorsally.

Question 287

Describe in details the Watson test / scaphoid shift test.

Answer 287

• On the volar aspect of the hand/wrist, the examiner pushes on the distal pole / scaphoid tubercle and exerts a DORSALLY directed force.
• The patient is brought from ulnar deviation and slightly extended into radial deviation and slightly flexed.
• In those with incompetent SL ligaments, as the scaphoid flexes it remains unconstrained and the dorsally direct force subluxates the scaphoid out of the scaphoid fossa relative to the radius.
• The ‘clunk’ is the scaphoid reducing back into its anatomic position in the scaphoid fossa.

Question 288

Describe in detail the radiographic findings of SL injury (three).

Answer 288

• Increased scapholunate gap (3mm) (‘Terry Thomas sign’)
• Cortical ring sign:
  
  • Represents a hyperflexed scaphoid wherein the distal pole is seen on end and appears as a cortical ring within 7mm of the proximal pole.
• DISI deformity (increased scapholunate angle)

Question 289

What are options for surgical repair of scapholunate injuries (8).

Answer 289

1. Pimary repair
   
   • May be performed acutely
   • Usually combined with capsulodesis
2. Thermal shinkage (radiofrequency)
   
   • Thermal energy causes shrinkage (70-80 degrees celcius) and tightens supporting ligaments.
3. Percutaneous pinning
   
   • Typically combined as an adjunct to other surgical techniques.
4. Capsulodesis (Blatt)
   
   • Dorsal capsule used as a tether to prevent scaphoid flexion (suture anchor used to secure).
5. Tenodesis
   
   • ECRL (Taleisnik and Linscheid)
     
     • ECRL left attached distally > passed through scaphoid and triquetrum > final attachment to capitate.
   • FCR (Brunelli and Brunelli)
     
     • FCR left attached distally > passed volar to dorsal through scaphoid.
     • As originally described is then secured to the DISTAL RADIUS, but modification is to secure to the lunate.
6. Bone-ligament-bone
   
   • Bone-ligament-bone grafts from various auto or allo sites use to recontruct.
   • Options:
     
     • SL Allograft
     • Tarsometatarsal autograft
     • Capitohamate autograft
     • D2 or D3 CMC
7. Pseudoarthrosis (RASL)
   
   • Reduction association scapholunate (RASL)
   • Dorsal approach > decortication of ulnar side of scaphoid and radial side of lunate > headless compression screw
   • Combined with radial styloidectomy.
8. Intercarpal fusion
   
   • SL fusion
   • Low fusion rates

Question 290

Describe the mechanism of LT injuries.

Answer 290

• Typically occurs as a progressive perilunate instability with loading in a hyperextended / ulnar deviated position.
• Injury CAN occur in isolation with a FOOSH but in EXTENSION, PRONATION, and RADIAL deviation.

Question 291

Describe provocative tests of LT injury (3).

Answer 291

1. Ballottement test: increased anteroposterior laxity, with pain, in lunotriquetral interval.
2. Shear test: Dorsal force directed on triquetrum while stabilizing the lunate demonstrates increased laxity and elicts pain.
3. Lateral compression test: Pressure placed on the medial tubercle of the triquetrum between the FCU and ECU tendons elicits pain.

** Need to compare with contralateral side **

Question 292

Options for management of LT injuries (6).

Answer 292

1. Nonsurgical management
   
   • Immobilization, NSAID
   • Consider arthroscopy if no improvement in 6 weeks
2. Arthroscopic debridement
3. Percutaneous pin fixation
   
   • Only if no VISI deformity
   • Immobilize 8 weeks
4. Ligament reconstruction
   
   • Slip of ECU passed through drill holes and looped around the lunate and triquetrum to reconstruct ligament.
   • Can also use bone-ligament-bone auto/allo grafts as done SL reconstruction
5. Lunotriquetral arthrodesis
6. Salvage procedures
   
   • Long term, static VISI
   • PRC, 4 corner fusion, total wrist

Question 293

What are the boundaries of the Space of Poirier

Answer 293

Between the radioscaphocapitate and the long radiolunate ligament.

Question 294

Describe Tavernier’s method for reduction of perilunate dislocations.

Answer 294

• Full analgesia and relaxation critical.
• Apply manual traction on slightly extended wrist.
• Stablize the lunate volarly with a thumb.
• Slowly flex the wrist without releasing pressure on the lunate.

Question 295

List the components of the TFCC (6).

Answer 295

1. Articular disc
2. Dorsal radioulnar ligament
3. Volar radioulnar ligament
4. Meniscus homolog
5. Ulnar collateral ligamenta
6. ECU sheath

Question 296

Describe an approach to treatment for TFCC injuries.

Answer 296

• Initial treatment nonoperative unless there is DRUJ instability. Immobilize in long arm cast for 4-6 weeks.
• Costisone injections may provide symptomatic relief but may inhibit healing of peripheral tears.
• Arthroscopy is indicated in patients with TFCC tears who have failed 3 months of nonoperative treatment.
• Early arthroscopic treatment may be considered for high level athletes.
• Surgery also indicated for DRUJ instability.
• Surgical treatment of Type I tears:
  
  • Class IA (central tears): debridement
  • Class IB: Repair
  • Class IC: REpair plus extrinsic ligament plication or open repair.
  • Class ID: Repair to sigmoid notch if DRUJ unstable; debride if DRUJ is stable.
  • Traumatic tear with positive ulnar variance may require concominant ulnar shorterning or wafer resection.
• Surgical treatment of type II tears (degenerative, ulnocarpal impaction) usually requires arthorscopic TFCC disc excision and wafer resection and ulnar shortening

Question 297

List the ports of wrist arthroscopy.

Answer 297

Question 298

Describe the following:

Answer 298

Clitoris

• Erectile organ typically 2cm in length and 1cm in diameter
• Attached to the pubic symphysisby the suspensory ligament of the clitoris.
• Consists of root, body, glans.

Prepuce

• Formed from the folds of the labia minora that pass anterior to the glans.

Frenulum

• Extends from the posterior aspect of the glans. Meets with an extension of the hood to form the labia minora.

Clitoral Hood

• Parallel folds that are 2-6cm in length.

Labia Minora

• Also called ‘nymphae’, ‘labium minus’
• Two longitudinal, hairless cutaneous folds situated between the labia majora.
• Core of spongy connective tissue which is erectile tissue; contribute significantly to engorgement and thickening during sexual stimulation.
• Posterior ends join across the midline by a fold of skin called the frenulum, which is also called:
  
  • frenulum labiorum pudendi
  • fourchette
  • posterior commissure of the labia minora
• Anteriorly each labium divides into anterior and posterior parts.
  
  • The anterior part passes above the clitoris to meet the contralateral side to form an overhand called prepuce (preputium clitoridis).
  • The lower part / posterior part passes below the clitoris to meet the contrlateral part and form teh frenulum.

Labia Majora

• Prominent folds of skin surrounding the pudendal cleft that contains loose subcutaneous tissue with smooth muscle.
• The termination of the round ligament of the uterus.

Mons Pubis

• Rounded, fatty prominence, anterior to the pubic symphysis.
• Surface continuous with anterior abdominal wall.

Vestibule

• Space between the labia minora containing openings for the urethera, vagina, and ducts of teh geater and lesser vestibular glands.

Question 300

Describe the treatment for each stage of SL injury.

Answer 300

• Stage I: Partial SL Injury
  
  • PT
  • Percutaneous K-wire fixation of the SL.
  • Thermal shrinkage
• Stage II: Complete SL Injury, Repairable
  
  • ORIF with primary repair of dorsal SL
• Stage III: Complete SL Injury, Nonrepairable, Normally Aligned Scaphoid
  
  • Bone-ligament-bone (auto/allograft)
  • Dorsal capsulodesis (Blatt)
  • SL reconstruction with dorsal ligaments (DIC or dorsal radiocarpal)
• Stage IV: Complete SL injury, Nonrepairable, Reducible Subluxation
  
  • Tendon reconstruction of SL
    
    • ECRB
    • FCR (Modified Brunelli and Brunelli)
  • RASL
• Stage V: Complete SL Injury, Irreducible, Normal Cartilage
  
  • Partial fusion
    
    • STT arthrodesis
    • SL arthrodesis
    • Scaphpcapitate arthrodesis
    • Scaphoid-Lunate-Capitate Arthrodesis
    • Radioscaphoid-Lunate Fusion + Dital Scaphectomy
• Stage VI: Complete SL Injury with Irreducible Malalignment and Cartilage Degeneration
  
  • Scaphoidectomy + four corner fusion (capitate-lunate-triquetrum-hamate)
  • PRC
  • Total wrist arthrodesis
  • Total wrist arthroplasty

Question 301

Describe radiographic findings of lunate-triquetral dissociation.

Answer 301

• Disruption of Gilula’s lines on AP.
• Lunate (triangular) and scaphoid (foreshortend and cortical ring sign) concurrently sitting flexed.
• Wide SL distance may be present with is actually just the SL interface being stressed and relying on the volar fibers as a restraint.
• On lateral, in advanced cases, the wrist can also sit in VISI with a volarly tilted lunate/scaphoid (scapholunate angle <30).

Question 302

Describe a treatment algorithm for LT injury.

Answer 302

• Acute LT injury, repairable, no static deformity / carpal collapse
  
  • Percutaneous pinning and immobilization
  • If immobilization alone, above elbow cast required to limit forces from pronation/supination
• Chronic injury, non-repairable, no static deformity / carpal collapse
  
  • Arthorscopic debridement
  • Thermal shrinkage
  • Tendon reconstruction (ECU to repair PALMAR LT)
  • LT intercarpal arthrodesis
• Chronic injury, non-repairable, static deformity
  
  • Intercarpal arthrodesis, but no good treatment
• Acute LT in the context of perilunate injury (LT + SL)
  
  • Combined dorsal and volar approach for repair of SL and LT
• Chronic LT in the context of perilunate injury
  
  • Limited treatment options, likely salvage

Question 303

Describe the operative approach for a ORIF and ligament repair for a perilunate dislocation.

Answer 303

• Traditional dorsal approach to the wrist; typically capsule avulsed poximally so it can be extended to make a distally based capsular flap so expose midcarpal and radiocarpal joints.
• Volarly, wrist approached with an extended CTR approach. L-shaped rent between the radioscaphoid-capitate and long radiolunate ligaments is identified.
• Lunate reduced under direct visualization.
• Palmar LT ligament repaired with sutures / anchor.
• ** Palmar SL CANNOT be repaired because it is covered by the intact long radiolunate ligament.
• Direct repair of the dorsal SL ligament and LT ligament.
• K-wire immobilization

Question 304

Describe the embryology of the ear.

Answer 304

• First (mandibular) and second (hyoid) branchial arches are responsible for auricular development.
• During the 6th week ear begins to develop and arises from the six buds of mesenchyme known as the six hillocks of His.
  
  • ​Mandibular arch (first): Hillocks 1-3
  • Hyoid arch (second): Hillocks 4-6
• Lobule is the last component of the external ear to form.
• Insults in the 6-8th week can potentially yield microtia.
  
  • Teratogens: accutane, retinoic acid, thalidomide
  • Ischemia: decreased blood supply in utero
  • Genetic: syndromic causes

Question 305

List associations with microtia.

Answer 305

1. Branchial arch syndromes
2. Goldenhar’s syndrome
3. Treacher Collins Syndrome
4. Oculoauriculovertebral dysplasia
5. Facial nerve absnormalities
6. Cleft lip/palate
7. Hemifacial microsomia
8. Facial clefts
9. Cardiac defects
10. Anopthalmia / micropthalmia
11. Limb reudction defects
12. Renal malformations
13. Holoprosencephaly

Question 306

Indications for auricular repair.

Answer 306

Primary goal:

• Improvement of acoustic function (sound localization, speech perception): various options of hearing aids, bone-anchored conductive devices, or canalplasty in conjunction with auricular reconstruction

Secondary goals:

• Speech
• Social acceptance
• Emotional development

Question 307

Discuss the factors influencing the timing of microtia recontruction.

Answer 307

• Age of external ear maturity
  
  • 85% of ear development is attained by age 4
  • Ear width continues to grow until age 10
• Availability of adequate donor rib cartilage
  
  • Usually adeqaute by age 5-6
• School age and psychological factors of peer redicule
• Need for middle ear surgery
  
  • Auricular reconstruction common performed BEFORE middle ear surgery if possible.
  • If otologic surgery performd first, otologist must coordinate with plastic surgeon to establish:
    
    • Canal position
    • Vascular axis of flaps
    • Locations of incisions used in auricular reconstruction
  • Most hearing deficits (especially b/l microtia) are treated with conductiec hearing aids.
• Different techniques are more appropriate for different ages to achieve optimal reconstruction.
  
  • Brent technique: Wait until age 4-6, allowing for ear maturity and appropirate school age.
  • Nagata technique: Wait until age 10, or when chest circumference at Xyphoid is 60cm to allow for additional cartilage for use in integrated tragal reconstruction.
    *

Question 308

What preoperative imaging is required with anotia work-up?

Answer 308

• High resolution CT to assess for middle ear ossicles
• MRI to assess course of the facial nerve which can be displaced, especially in the absence of a pneumatized mastoid.

Question 309

Options for microtia reconstruction (4).

Answer 309

• Autogenous costal cartilage graft
  
  • Best long term reconstructive option
  • Originally by Tanzer and mofified by Brent and Nagata
  • Disadvantages:
    
    • Donor site morbidity and postoperative sequelae
    • Chest wall deformity
    • Number of staged procedures
• Silastic framework
  
  • Excellent appearance
  • No donor site morbidity
  • Discontinued because of:
    
    • Spontaneous extrusion
    • Susceptibility to minor trauma
    • Unacceptable long term failure rates
• Porous polyethylene implant (medpor)
  
  • Good aesthetic results and acceptable extrusion rates
• Prosthetic / osteointegrated reconstruction
  
  • Limited by availability and skill of anaplastologist
  • Excellent alternative for patients with poor local tissue or high operative risk

Question 310

Describe the brent autologous auricular reconstruction for microtia.

Answer 310

Brent Technique

• Four-staged reconstruction begining at age 4-6 years old.
• Stage I: Ear framework less lobule and tragus.
  
  • Ear framework fabricated from contralateral costochondral rib cartilage of synchondrosis of the 6th-8th ribs
  • Placed in a subcutaneous pocket at the posterior/inferior border of the vestige.
  • No lobule reconstruction in stage I.
• Stage II: Lobule reconsturction.
  
  • Lobule transposition occurs several months after framework.
• Stage III: Projection
  
  • Projection of contruct with wedge of banked costal cartilage or polyethylene blocks.
  • Skin graft used to backgraft skin defect.
• Stage IV: Tragus construction
  
  • Tragus construction, conchal excavation and symmetry adjustment.
  • Tragus fashioned from composite graft from the contralateral conchal vault, or in bilateral cases using an anteriorly based conchal flap with cartilage support.

Question 311

Describe the Nagata technique for reconstruction of microtia.

Answer 311

Nagata technique

• Two stages
• Begins at age 10

STAGE I

• IPSILATERAL rib cartilage
• High definition framework created from 6th-9th ribs
• Perichondrium left intact
• Framework includes tragal component
• W-flap created with lobule transposed at this stage.
• Framework inset.

STAGE II

• Peformed 6 months later
• Framework elevation
• Wedge harvested from previous incision from the 5th rib.
• Temporoparietal fascia flap is elevated and tunneled subcutaneously to coverage posterior cartilage grafts.
• Advancement of retroauricular skin and coverage with backgrafting.

Question 312

At what age does ear length and width mature for males and females respectively?

Answer 312

• Male ears:
  
  • Width matures at age 7
  • Length matures at 13
• Female ears:
  
  • Width matures at age 6
  • Length mature at 12

Question 313

Describe the innervation of the ear.

Answer 313

• Auriculotemporal nerve
  
  • Branch of trigeminal nerve
  • Provides sensation to tragus and crus helicis
• Great auricular nerve
  
  • Branch of cervical plexus (C2-3)
  • Supplies rest of the ear
  • Anterior and posterior divisions
• Lesser occipital nerve

Question 314

List the basic goals of otoplaty (12).

Answer 314

1. Correction of all upper-third protrusion.
2. Visibility of the helix beyond the antihelix when viewed from the front.
3. Smooth and regular helix.
4. No distortion or decrease in the depth of the postauricular sulcus.
5. Correct placement of the ear.
6. Helix-to-mastoid distance falls in the normal range of:
   
   • 10-12mm at the top
   • 16-18mm in the middle
   • 20-22mm in the lower third
7. Bilateral symmetry.
8. Position of the lateral border of the ear matches within 3mm at any point between the ears.
9. Smooth, rounded, and well-defined antihelical fold.
10. Concoscaphal angle of 90 degrees.
11. Conchal reduction or reduction of the conchomastoidal angle.
12. Helical rim that projects laterally father than the lobule.

Question 315

Describe the correct placement of the ear, including its angle, height, width, and distance from the lateral orbital rim.

Answer 315

Question 316

Discuss the considerations in the timing of surgery for the prominent ear.

Answer 316

• Timing depends on a rational approach based on auricular growth and age of school matriculation.
• Because the ear is nearly fully developed at 6-7 years you can perform correction at that time.
• Surgery can be done at a younger age if they demonstrate with maturity enough to cooperated with postoperative restriction and instructions.

Question 317

Desribe the Mustarde technique in otoplasty.

Answer 317

• Access through incision on the posterior auricular skin (with or within skin excision).
• Optimal position of antihelical simulated and marked with methylene blue and a 25-gauge needle.
• Permanent matress sutures placed through cartilage and capturing anterior pericondrium.
  
  • May require floating sutures.

Question 318

Describe the furnas technique in the context of otoplasty.

Answer 318

• Postauricial access +/- skin excision
• Expose the mastoid fascia and posterior auricular cartialge.
• Secured cartilage to mastoid fascia.

Question 319

Describe the Converse-Wood-Smith technqiue in otoplasty.

Answer 319

• Converse-wood-smith technique is a cartilage BREAKING technique, rather than cartilage moulding
• Can be useful in stiffer cartilage of young adults and adults.
• Same as mastarde technique but instead you incise and break the cartilage.

Question 320

List the three typical deformities that make up the prominent ear deformity.

Answer 320

1. Poorly defined antihelical fold.
2. Conchoscaphal angle > 90 degree
3. Conchal excess

Question 321

Describe the blood supply to the ear.

Answer 321

Posterior auricular artery (dominant)

• Supplies anterior and posterior auricle.
• Perforators enter at the medial aspect of the triangular fossa, cymba, cavun, helical root, earlobe.

Superficial temporal artery

• Supplies lateral surface of auricle

Occipital artery

• Supplies posterior skin in 7% of people.

Venous drainage

• Posterior auricular veins drain into venous system
• Superficial temporal vein
• Retromandibular veins

Question 322

Describe sensory innervation of the ear.

Answer 322

Greater auricular nerve (C2-C3)

• Supplies lower lateral and inferior cranial surface

Auriculotemporal nerve (V3)

• Supplies lateral surface and anterior surface of EAM

Lesser occipital (C2-C3)

• Superior cranial surface of ear.

Arnold’s nerve (CN VII, XI, X)

• Auricular branch of vagus nerve (X) that received contributions from facial and glossopharyngeal nerve
• Supplies posterior inferior EAC and inferior conchal bowl

Question 323

Describe the lymphatic drainage of the ear.

Answer 323

• Pattern pertains to embryologic origins.
• Anterior hillocks (1-3; first branchial arch) drain to parotid nodes (tragus, helical root, superior helix)
• Posterior hillocks (4-6; second branchial arch) drain to cervical nodes (antihelix, antitragus, lobule).

Question 324

Identify this pathology.

Answer 324

Chondrodermatitis nodularis chronica helicis.

Question 325

Draw and describe the operative steps of an ANTIA-BUCH PROCEDURE. What is the cut off defect size for an antia-buch procedure?

Answer 325

Antia-Buch Procedure

• Defects up to 2cm can be closed by advancing the helix in both directions
• V-Y advancement is critical at the helical root.
• Incision made through antihelical skin, cartilage, with flap based on infact posterior skin.

Question 326

What rae options for reconstruction of small helical rim defects (< 2cm)?

Answer 326

• Contralateral composite grafts (<1.5cm)
• Antia-buch procedure
• Chondrocutaneous rotation flaps

Question 327

What are options for reconstruction of large helical rim defects (>2cm)?

Answer 327

• Auricular cartilage grafts covered by preauricular flap or staged postauricular pocket flap.
  
  • Converse tunnel technique
  • Dieffenbach flap
• Tubed pedicle flaps.
• Chondrocutaneous flaps

Question 328

Describe the steps for a Converse tunnel technqiue for helical rim reconstruction.

Answer 328

Converse Tunnel Technique

• Stage 1: Contralateral cartilage graft inset under postauricular skin adjacent to helical defect.
• Stage 2: After 3 weeks, anteriorly based skin flap and underlying cartilage inset into helical rim.

Question 329

Draw 4 patterns for Tanzer’s excision for auricular reconstrction.

Answer 329

Question 330

Describe Baudet’s fenestration technique for partial ear replantation.

Answer 330

• Posterior skin of amputated part is removed and fenestrations are made in the avulsed auricular cartilage to increase the recipient vascular area.
• Amputated portion is reattached and exposed cartilage is covered with a posterior auricular flap.
• Flap is divided after 3 months and a skin graft is applied.

Question 331

Describe the blood supply to the nose.

Answer 331

• From ophthalmic artery
  
  • Dorsal artery
  • Supraorbital artery
  • Supratrochlear artery
  • External nasal branch of the anterior ethmoid artery
• From maxillary artery
  
  • Infraorbital artery
• From facial artery
  
  • Angular artery
  • Lateral nasal artery (branch of angular artery)
  • Superior labial artery
  • Columellar artery (branch of superior labial artery)

Question 332

Goals of nasal reconstruction.

Answer 332

1. AIrway patency.
2. Replace like with like.
3. Optimize aesthetics.
4. Miniize morbidity.

Question 333

List the aesthetic subunits of the nose and describe the subunit principle.

Answer 333

• Nasal dorsum (unpaired)
• Nasal tip (unpaired)
• Columella (unpaired)
• Nasal sidewalls (paired)
• Soft triangle (paired)
• Alar lobule (paired)

Subunit principle: If a defect occupies more than 50% of the subunit, resect the entire subunit and reconstruct.

Question 334

List and briefly describe options for nasal lining reconstruction (7).

Answer 334

1. Turn in nasal flap
   
   • Essentially a local flap rotated into the nose for lining and the resulting defect closed by another local flap.
   • Flap hinged on the outer cicatricial edge and flipped over to span defect. The resulting skin defect on the nose then closed with a rotation/transposition flap.
2. Folded extranasal flap
   
   • Essentially creating a long enough local/regional flap to allow for a folded over element.
   • Can be forehead, nasolabial, or superiorly based upper lip flap turned in.
3. Skin graft to forehead flap
   
   • Skin graft to underside of forehead flap
   • Hard palate mucosa can also be used.
4. Septal door flap (de Quervain)
   
   • ​​Essentially uses septal cartilage and contralateral septal mucosa to reconstruct cartilage and mucosa from the nasal side wall.
   • The mucosa is left attached to the nasal dorsum.
5. Septal mucoperichondral flap
   
   • Large rectangle of mucosa (or mucosa + perichondrium) is elevated from septum, based on the septal branch of the superior labial artery.
   • Flap pivots on an anterior-inferior point near nasal spine and folds outward.
6. Mucosal advancement flap
   
   • Bipedicled mucosal advancement flap based medially on remaining septum and laterally at the piriform aperature.
7. Septal pivot flap
   
   • Pedicle flap of septal cartilage and mucosa rotated forward to provide nasal septum and dorsal cartilaginous support.
   • Excess mucosa can be rotated outward to line the vault bilaterally.

Question 335

Draw and describe a septal door flap for lining reconstruction.

Answer 335

Septal door flap

• Flap used to reconstruction mucosa +/- cartilage of the nasal side wall.
• Uses CONTRALATERAL septal mucosa and septal cartilage.
• Pedicle left intact to dorsal nose and swung outwards to fill the defect.

Question 336

Describe and draw a septal mucoperichondrial flap. Differential with a septal pivot flap.

Answer 336

Septal mucoperichondrial flap

• Flap of septal mucosa +/- perichondrium is elevated from the septum and pedicled on the septal branch of the superior labial artery.
• Flap pivots from a point antero-inferior near the nasal spine and can fold outward to line the nasal domes.
• Septal pivot flap is similar but is used for dorsal nasal support when structure and lining are missing from the dorsal septum.

Question 337

List options for midline structure support in nasal reconstruction (4).

Answer 337

1. Strut technique (Gillies)
   
   • Longitudinal piece of bone or cartilage seated on nasal radix. Extends to the tip and turns sharply to be secured at the anterior nasal spine.
2. Hinged septal flap
   
   • L-shape cartilage designed from residual cartilage and hinged superiorly. Rotated outwards to reconstitute the dorsal nasal spine, with the small limb of the “L” attaching to the anterior nasal spine.
3. Septal pivot flap
   
   • Pedicled flap at the anterior-inferior septum of mucosa and cartilage rotated forward to construct dorsal nasal spine.
4. Cantilever graft
   
   • Longitudinal piece of bone extending from frontal bone or nasal bones (or both).

Question 338

Options for skin coverage for nasal dorsum and/or sidewall reconstruction.

Answer 338

1. Banner flap
2. Bilobed flap
3. Dorsal nasal flap (random pattern flap)
4. Axial frontonasal flap
   • The same as the dorsal nasal flap, EXCEPT based off axial blood supply from vessels emerging from the medial canthus (branch of angular artery joining with the supraorbital arteries) and thus allows cuts to be made almost cricumferentially except for inflow from medial canthus.
5. Axial nasodorsum flap
   
   • Based on the lateral nasal artery branch of the angular artery.
6. Nasalis flap
   
   • Pedicle myocutaneous flap from the upper alar crease.
7. Cheek advancement flap
8. Nasolabial flap
   
   • Superiorly or inferiorly based. Good for alar reconstruction and lateral nasal wall.
9. Turnoever flap
   
   • Nasolabial flap turned over.
10. Forehead flap
11. Scalping flap (historical)
12. Sickle flap (historical)
13. Frontotemporal flap
14. Temporomastoid flap

Question 339

Describe the axial frontonasal flap.

Answer 339

Question 340

Describe the axial nasodorum flap.

Answer 340

Axial patterned flap based off the transverse nasal branch of the angular artery.

Question 341

Describe the turnover nasolabial flap for alar rim reconstruction.

Answer 341

Question 342

Describe the frontotemporal flap for nasal reconstruction.

Answer 342

Question 343

Describe the temporomastoid flap / Washio flap.

Answer 343

Question 344

Options for columellar reconstruction.

Answer 344

• Nasolabial flaps
• Upper lip forked flaps
• Vestibular flaps
• Forehead flaps
• Chondrocutaneous composite grafts

Question 345

Options for soft triangle reconstruction.

Answer 345

• Composite graft
• Nasolabial flap
• Forehead flap

Question 346

Describe Rhinophyma, its staging and treatment.

Answer 346

• Sebceous hyperplasia of nasal skin with bulbus enlargement of the nose and erythematous skin.
• Represents a severe forms of acne rosacea, but has no true association with EtOH intake.

STAGES

• First stage (prerosacea): frequent facial flushing and increased vascularity.
• Secondar stage (vascular rosacea): Thickened skin, telangiectasias, and persistemt facial erythema or erythrosis.
• Third stage (acne rosacea or inflammatory rosacea): Erythemaous papules and pustules of the forehead, glabell, malar region, nose, and chin.
• Fourth stage: Rhinophyma

NON-SURGICAL TREATMENT (STAGES I-III)

• Avoidance of sun exposure UVA/UVB
• Good skin hygiene
• Tetracyclne
• Topical tretinoin
• Isoretinoin
• Topical metronidazole

SURGICAL

• Tangential excision with cold knife, dermabrasion, or dermaplanning
  
  • CO2 laser for hemostasis
  • Non-stick dressing to promote epithelialization

Question 347

Describe the marking for a bilobed flap.

Answer 347

Question 348

Describe the aesthetic units of the cheek.

Answer 348

• Zone 1: Suborbital
  
  • ​Medial boundary: Nose-cheek junction and nasolabial fold
  • Lateral boundary: Anterior edge of the sideburn
  • Inferior boundary: Gingival sulcus
  • Superior boundary: Lower eyelid
• Zone 2: Preauricular
  
  • ​Superolateral junction of the helix and cheek.
  • Medially across sideburn to malar eminence.
  • Inferiorly to the angle of the mandible.
• Zone 3: Buccomandibular
  
  • Includes the lower cheek area and oral lining (in full thickness defects)
  • Inferior to the suborbital area
  • Anterior to the preauricular area

** Zone 1 an 2 can typically be reconstructed with cervicofacial flaps, whereas zone 3 typically cannot**

*

Question 349

What are options for local and regional flaps to be used for large defects in cheek reconstruction?

Answer 349

• Cervicofacial flap
• Anteriorly based cervicofacial flap
• Cervicopectoral flap
  
  • An anteriorly based cervicofacial flap but extends down onto the chest to cpature thoracic perforators from the internal mammary artery.
• Submental flap
• Deltopectoral flap
• Pectoralis majaor myocutaneous flap

Question 350

Options for mucosal lining of the mouth.

Answer 350

• Hemitongue flap
• Turnover or hinge flap
• Masseter crossover
• Facial artery myomucosal flap (FAMM)
• Submental flap
• Skin graft
• Two skin paddle free flaps

Question 351

List the origin, insertion, innervation and action of all muscles acting on the lips (12).

Answer 351

• Buccinator
  
  • O: Alveolar process of the maxilla and mandible along the pterygomandibular raphe
  • I: Orbicularis oris
  • N: Buccal branch
  • A: Compresses cheeks
• Depressor anguli oris
  
  • O: Lateral aspect of the mental tubercle of the mandible
  • I: Modioulus
  • N: Marginal mandibular branch
  • A: Lowers angle of the mouth
• Depressor labii inferioris
  
  • O: Between mandibular symphysis and mental foramen, along oblique line of mandible.
  • I: Skin of lower lip
  • N: Marginal mandibular
  • Action: Draws lip downward and laterally
• Levator anguli oris
  
  • O: Maxilla, inferior to orbital foramen
  • I: Modiolus
  • N: Buccal branch
  • A: Elevates angle of the mouth
• Levator labii superioris
  
  • O: Maxilla, medial half of infraorbital margin
  • I: Modioulus and orbicularis of upper lip
  • N: Buccal branch
  • A: Elevates upper lip
• Levator labii superioris alaeque nasi
  
  • O: Frontal process of maxilla
  • I: Upper lip orbicularis oris, nasal cartilages
  • N: Buccal branch
  • A: Elevates upper lip, flares nostrils
• Mentalis
  
  • O: Incisive fossa of mandible
  • I: Skin of chin
  • N: Marginal mandibular branch
  • A: Elevates and protrudes lower lip
• Orbicularis oris
  
  • O: Alveolar border of the maxilla and mandible
  • I: Circumferentially around the mouth; interdigitates with other muscles
  • N: Buccal branch
  • A: Sphincter of lips
• Platysma
  
  • O: Skin over deltopectoral region
  • I: Mandible and skin of the lower face, including lip.
  • N: Cervical branches
  • A: Lowers lower lip
• Risorius
  
  • O: Parotid fascia
  • I: Modioulus
  • N: Buccal branch
  • A: Draws angle of mouth laterally
• Zygomaticus major
  
  • O: Zygoma, anterior to temporal-zygomatic suture
  • I: Modiolus
  • N: Buccal branch
  • A: Draws angle of mouth superlaterally
• Zygomaticus minor
  
  • O: Zygoma, posterior to zygomaticomaxillary suture
  • I: Skin of upper lip
  • N: Buccal branch
  • A: Elevates upper lip

Question 352

Describe the blood supply to the lips.

Answer 352

Superior and inferior LABIAL arteries.

Travel deep to the orbicularis at apprxomately the level of the red line.

Question 353

Options for subtotal (< 50%), large (>50%), and total vermillion lip defects

Answer 353

SUBTOTAL (<50%)

• Axial myovermilion advancement
  
  • Orbicularis + mucosa + labial artery pedicled and advanced to close defect.
• Myomucosal V-Y advancement
  
  • Mucosa +/- muscle advaced from vestibule to fill vermilion defect.
• Vermilion lip swtich
  
  • Vermillion from opposite lip to defect elevated and interpolated to fill defect. Divided at ~14 days.

TOTAL OR LARGE (>50%)

• Tongue flap
  
  • Transfers ventral tongue in two stage procedure.
• Buccal mucosa advancement

Question 354

Options for full thickness lip reconstruction (upper and lower lip).

Answer 354

• Primary closure (upper and lower)
  
  • Upper and lower lip defects up to ~1/3
• Perialar crescent excisions (upper lip)
  
  • Can be combined with a number of reconstructions to facilitate closures of increasing sizes (e.g. with primary closure or with Abbe.
• Abbe flap (upper or lower lip)
  
  • ​Commisure not involved.
  • Pedicled off labial artery.
  • Flap designed ~1/2 of the size (not 1:1)
• Estlander (upper or lower lip)
  
  • Commisure involved
  • Otherwise same as abbe flap
• Karapandzic (upper or lower lip)
  
  • Essentially large crescenteric extensions to facilitate advancement and primary closure of upper or lower lip defects.
  • Width of perioral extensions should be height of the defect.
• Bernard Burrows (lower lip only)
  
  • For >2/3 lower lip defects
  • Essentially is advancement of bilateral flaps and advancement of vestibular mucosa for reconstruction of the lower lip.
  • This is combined with burrows triangles superiorly and inferior to facilitate advancement.
• Free radial forearm with palmaris longus (upper or lower lip)
  
  • Used for reconstruciton of complete defects.

Question 355

Options for mandibular reconstruction.

Answer 355

• No bony reconstruction
  
  • Acceptable if posterior defects such as ramus, especially if condyle has been removed.
• Mandibular Reconstruction Plates (MRP) alone
  
  • Will break within 18 months with a mean of 6-8 months.
  • Appropriate for patients who cannot tolerate along procedure and have a short life expectancy.
• Soft tissue coverage alone with free / pedicled flap
  
  • Acceptable if posterior defects such as ramus, especially if condyle has been removed.
  • Pec, ALT, VRAM
• Non-vascularized bone
  
  • Can be used in traumatic or BENIGN tumor defects <6cm that will not require radiation.
  • Contraindications: radiation, anterior mandibular defects, malignancy
• Vascularized bone
  
  • Indications: defect >6cm, radiation, malignancy
  • Options: fibula, scapula, parascapula, iliac crest, RFF with distal radius

Question 356

Decribe the 4 FUNCTIONAL subdivisions of the facial nerve.

Answer 356

1. Branchial motor
   
   • Muscles of facial expression
   • Stylohyoid
   • Stapedius
   • Posterior belly of digastric
2. Visceral motor
   
   • Parasympathetic innervation of lacrimal, submandibular, sublingual, and nasal mucosal
3. General sensory
   
   • Sensation to the auricular conhca, external auditory canal, and tympanic membrane
4. Special sensory
   
   • Taste to the anterior 2/3 of the tongue.

Question 357

Describe the three ANATOMIC segments of the facial nerve as they relate to its course.

Answer 357

1. Intracranial
   
   • Primary somatomotor coretx of the facial nerve located in the precentral gyrus.
   • Facial nucleus is in the dorsolateral pons
     
     • Cell bodies that give rise to the TEMPORAL branch recieve BILATERAL cortical input
     • All other facial nucleus cell bodies receive CONTRALATERAL cortical input.
2. Intratemporal
   
   • Facial nerve enters the internal auditory canal and travels with the acoustic and vestibular nerve for approximately 8-10mm.
   • Facial nerve then enters the fallopian canal where it travels for ~30mm
   • The metal foramen is the narrowest part of the canal
   • The fallopian canal as three segments:
     
     1. Labyrinthine segment
        
        • Here the geniculate ganglion is found that contains the nerve cell bodies for taste and sensation.
        • Geniculate ganglion gives rise to the greater petrosal nerve which supplies parasympathetic nerve for lacrimal gland and sensory taste fibers from the palate.
        • Junction between the labyrinthine segments and tympanic segment forms acute angle that is prone to shearing forces.
     2. Tympanic segment
        
        • Extends from geniculate ganglion to the semicircular canal.
     3. Mastoid segment
        
        • From semicircular canal to stylomastoid foramen.
        • Gives off three branches in this section:
          
          • Nerve to stapedius: Motor function for stapedius muscle, which allows dampening of loud sounds. Cell bodies of this motor nerve are not located in the facial nucleus and are therefore not affected by Mobius syndrome.
          • Sensory branch to external auditory canal
          • Chorda tympani: Joins lingual nerve to provide parasympathetic innervation to the submandibular and sublingual glands; special sensory afferents from anterior two thirds of tongue.
3. Extratemporal
   
   • Starts where the facial nerve exits the stylomastoid foramen
   • Nerve is superficial un children less than 2 years old.
   • Facial nerve 1cm deep and ust inferior and medial to the tragal pointer.

Question 358

Describe the anatomic landmarks for the temporal branch of the facial nerve.

Answer 358

• Pitanguy’s line: From 0.5cm below the tragus to 1.5cm ABOVE the lateral brow.

Question 359

List the muscles in each of the FOUR layers of facial musculature.

Answer 359

1. Layer 1 (ZOD):
   
   • Zygomaticus minor, Orbicularis Oculi, Depressor anguli oris
2. Layer 2 (DRPLZ):
   
   • Depressor labii inferioris, Risorius, Platysma, Levator labii superioris alaeque nasi, Zygomaticus major
3. Layer 3 (OL):
   
   • Orbicularis oris, levator labii superioris
4. Layer 4 (MLB):
   
   • Mentalis, Levator anguli oris, Buccinator
   • Innervated in superficial surface

Question 360

List all facial muscles and their function (17).

Answer 360

Question 361

What is the proposed pathophysiology of Bell’s Palsy and treatment.

Answer 361

• Pathophysiology: Viral vscular insult to the facial nerve that causes edema within the fallopian canal > disruption of microcirculation > impairing conudciton of neural impulses or nerve degeneration.

Treatment

• No treatment
  
  • All patients begin to recover funciton within 6 months of paralysis.
  • All patients have improvement of paresis.
  • 71% recover completely.
  • Recovery TYPICALLY begins within 3 weeks in 85% of patients, but not until 3-6 months in 15% of patients.
  • Completeness of recovery decreases with age.
• Medical treatment (steroids)
  
  • Prednisone 60mg/day tapering to 5mg/day on the 10th day.
  • Routine corticosteroids NOT recommended in pediatric Bell’s palsy.
• Surgical decompression

Question 362

What is the landmark where facial nerve arborization protects against persistent deficit after penetrating injury?

Answer 362

With penetrating facial wounds, nerve injury to facial nerve branches medial to a line drawn vertically through the lateral canthus of the eye may retain facial movement because of the degree of arborisation; nevertheless, nerves should be repaired if possible. However, injury to the frontal and marginal mandibular nerves manifesting with weakness should always be repaired as the likelihood of spontaneous recovery is poor.

Question 363

What is Ramsay Hunt Syndrome?

Answer 363

Varicella-zoster syndrome virus infection with facial paralysis, ear pain, and varicelliform rash in EAC. Accounts for ~12% of all cases of facial paralysis.

Treated with prednisone and acyclovir.

Question 364

Two causes of bilateral facial paralysis.

Answer 364

• Lyme disease
  
  • Borrelia burgdorferi
• HIV

Question 365

What is Melkersson-Rosenthal syndrome?

Answer 365

Melkersson-Rosenthal syndrome is characterized by recurrent facial nerve paralysis, noninflammatory facial edema, and congenital tongue fissures (lingua plicata).

Interestingly, facial paralysis can alternate sides but is usually self-limited.

Question 366

What is Möbius Syndrome?

Answer 366

• Unilateral or bilateral loss of eye abduction?
• Unilateral or bilateral, complete or incomplete, facial paralysis?
• Facial paralysis may be accompanied by other cranial nerve palsies or congenital defects (extremity anomalies, defective brachial or thoracic musculature, micrognathia, mild mental retardation)

Question 367

What is CULLP?

Answer 367

Congenital Unilateral Lower Lip Palsy (CULLP)

• ‘Asymmetrical crying facies’
• Intrauterine insult during 5th week of gestation.
• Normal resting function but MARGINAL MANDIBULAR DYSFUNCTION when crying.
• Other congenital anomalies in 75% of affected children (cardiovascular, genitourinary, MSK, respiratory).

Question 368

Describe the nature of the characteristic S-shaped deformity found in unilateral facial paralysis.

Answer 368

• In unilateral facial paralysis you get hypercontraction of the non-paralyzed face secondary to a subconcious effort to corect position of the paralyzed side.
• Yields an S-shaped deformity
  
  • Hyper-contraction of the contralateral, normal musculature of facial expression
  • Results in:
    
    • Forehead wrinkling from frontalis contraction
    • Brow elevation and palpebral opening
    • Nasal alar elevation and prominence of the nasolabial fold
    • Bowing of the dorsal nasal lines to the paralyze side
    • Elevation of the lip with resultant pull of the midline lip (cupid’s bow) toward the normal side
  • A line connecting the following structures makes an S-shape that faces AWAY from the paralyzed size:
    
    • Medial aspect of forehead wrinkling
    • Nsal rhadix
    • Nasal tip
    • Cupids bow
    • Midline of chin

Question 369

Describe the three phases of FRACTURE healing.

Answer 369

1. Inflammation
   
   • Starts immediately and lasts several days
   • Formation of hematoma
   • Infiltration of hematopoietic cells and osteogenic precursors
2. Repair
   
   • Begins <24 hours and peaks at 2-3 weeks.
   • Collagen deposition and cartilaginous callus formation over fracture site.
   • Endochondral ossification.
3. Remodelling
   
   • Lasts months - years depending on fracture type.
   • Lamellar bone formation and repopulation of marrow
   • Resoprtion of callus

Question 370

Describe the timing of appearance of callus on radiographs, clinical bony union, total bony healing.

Answer 370

• External callus not visible on plain radiographs until 3-6 weeks after formation.
• Bony union averages 4-8 weeks.
• Total bony union time is 5-7 months.

Question 371

Operative indications of METACARPAL HEAD fractures.

Answer 371

• >25% of articular surface.
• >1mm articular step-off
• Open fracture
• Irreducible
• Malrotation
• Comminuted

Question 372

What are options for of surgical fixation of a METACARPAL HEAD fracture?

Answer 372

1. Closed reduction and percutaneous pinning
2. Open reduction and internal fixaton (pins, screws)
   
   • Minicondylar plates
   • Screws
   • Headless compression screws
   • Cerclage wire
3. External fixation
4. Prosthetic arthroplasty
5. Arthrodesis (salvage procedure)

Question 374

What is the typical orientation of a metacarpal neck fracture and WHY?

Answer 374

Apex dorsal angulation because the intrinsic muscles lie volar to the axis of rotation of MP joint and maintain flexed head posture.

Question 375

What are indications for treatment of METACARPAL NECK fractures?

Bonus: Why are rotational deformities better tolerated in the ring and small finger.

Answer 375

Indications for treatment of METACARPAL NECK fractures.

• Angulation and deformity
  
  • Index and long finger: 10-15 degrees.
  • Ring finger: 30-40 degrees.
  • Small finger: 50-60 degrees.
• Rotational deformity or scissoring
• Shortening (<3 mm)
• Extensor lag

** Ring and small finger can better compensate for fracture angulation because the CMC of the D4 and D5 have 20-30 degrees of obility in the sagittal plane, whereas index and middle fingers are less mobile at CMC joint. **

Question 376

Indications for surgical fixation of METACARPAL SHAFT fractures?

Answer 376

Indications for surgical fixation of METACARPAL SHAFT fractures:

• Angulation
  
  • Index and long: >10 degrees
  • Ring: > 20 degrees
  • Small: >30 degrees
• Shortening (> 3mm)
  
  • Alters length tension relationship and weakens intrinsics
• Rotational deformity / scossoring
• Open fractures

Question 377

What are specific options for OPEN REDUCTION AND INTERNAL FIXATION of metacarpal shaft fractures?

Answer 377

Options for surgical fixation of metacarpal shaft fractures.

• K-wires
• Tension band wiring (K-wire + steel wire)
• Cerclage wiring
• Iterosseous wiring
• Intramedullary fixation
• Lag screws (interfragmentary compression screws)
• Plate fixation
• External fixation
• Bioabsorbable fixation

Question 378

Discuss the management of segmental loss of metacarpal shaft.

Answer 378

• Thorough debridement and maintenance of length
• Provisional stabilization with:
  
  • External fixation +/- methymethacrylate pins
• Freeland believed that osseous stability should be restored within 10 days of injury with bone graft and fixation
  
  • Most defects can be bridged with autogenous iliac crease corticocancellpis graft

Question 379

Describe the deforming forces on a Bennet fracture and the reduction technique.

Answer 379

• Deforming forces are controversial with essentially all muscles inserting on the thumb listed depending on the source.
• The reduction technique however is less controversial, and required:
  
  • Longitudinal traction
  • Palmar abduction
  • Pronation
  • Pressure on the dorsal radial aspect of the thumb MC base

Question 381

Describe the typical orientation of phalanx shaft fractures.

Answer 381

Proximal phalanx shaft fractures angulate apex volar because of flexion of the proximal fragment by the interossei.

Middle phalanx fractures can be apex dorsal or apex volar depending on the relationship of the fractures to the insertion of FDS.

Question 382

Draw a dynamic traction splint for an intraarticular PIP fracture.

Question 383

What is the treatment for a collateral ligament rupture of the MP joint?

Answer 383

• Immobilize in 30 degrees of flexion for 3 weeks.
• Reassess laxity at 3 wees. Buddy tape to adjacent digit for additional 2-3 weeks if instability persists.
• Surgiacl repair if instability or pain persists after more than 6 weeks of nonoperative treatment.

Question 384

Describe the collateral anatomy of the thumb MP joint?

Answer 384

• PROPER collaterals
  
  • Proper colalteral ligaments arise from the condyles of the metacarpal head and insert on the volar proximal phalanx.
• ACCESSORY collaterals
  
  • Accessory collaterals originate on the volar metacarpal head and insert on the sesamoid bones and the volar plate.

** Additional lateral stability is provided by the thenar muscle secondary insertions via adductor and abductor aponeuroses.

Question 385

Describe the management of acute UCL ruptures.

Answer 385

• Partial UCL
  
  • Immobilization.
• Complete UCL
  
  • Operative exploration and repair
  • Reattach ligament avulsions with bone-anchoring technique
  • Mid substances repaired with non-absorbable sutures.
• • Avulsion fractures
    
    • Can have avulsion from proximal phalanx
    • Small fragments can be managed with immobilization
    • Large fragments more than 2mm displacement require closed reduction with pinning or ORIF.

Question 386

Describe the management of chronic UCL injury.

Answer 386

Reconstruction with free tendon graft.

• Scar and remnant UCL resected.
• Tendon graft options: PL, strip of FCR, strip of APL, plantaris, toe expensor.
• Consider temporary pinning of MP joint.
• Immobilize for 6 weeks.

Question 388

Describe the management for acute PIP dislocations.

Answer 388

Type I/II

• Some advocate immobilization for 1-2 weeks in 20-30 degrees of flexion.
• Others advocate for protected range with buddy taping for 2-3 weeks.

Type III STABLE

• Closed reduction and immobilization with dorsal blocking splint in 20-30 degrees of flexion for 3 weeks. Can reduce degrees of flexion 10 degrees each week.
• Active range exercises after 3 weeks.

Type III UNSTABLE

• Dynamic traction
• ORIF
• CRRP with dorsal blocking pin
• Volar plat arthroplasty
• Hemihamate arthroplasty

Question 389

Describe the mechanism and management of a volar rotary subluxation at the PIP.

Answer 389

Volar rotary subluxation at the PIP occurs in the context where ONE side (radial or ulnar) collaterals remain intact. The middle phalanx dislocated volarly and rotates around the intact collateral. The condyle of the proximal phalanx usually ruptures between the central slip of the extensor tendon and the ipisilateral lateral band as the middle phalanx displaced volarly.

Can typically be reduced and managed non-operatively. Gentle traction with MP and PIP flexed to relax volarly displaced lateral band. Gentle rotary motion disengages the intraarticular portion and allows reduction.

Question 390

What is collaeral ligament fibrosis and its management.

Answer 390

• Collateral ligament fibrosis is the inevitable consequence of PIP joint dislocation. Evolves over 10-12 months.
• Collateral ligament excision for PIP contracture release if PIP range of motion is lessthan 60 degrees after compliant rehabilitation. Both collaterals typically excised with lateral bands preserved.

Question 391

Does FDS or FDP have a common muscle belly.

Answer 391

FDP has a common muscle belly.

Question 392

Describe the vascular supply to the tendon.

Answer 392

• Myotendinous junction: Supplies a short segment near the proximal end of the tendon.
• Bony junction (Sharpey’s fibers): Supplies short distal segment.
• VIncula: Fibrovascular structures that supply the tendon.
  
  • Arise from transverse branches of the digital arteries.
  • TWO vincula to the FDS (vinculum breve superficialis, vinculum longum superficialis)
  • TWO vincula to the FDP tendon (vinculum breve superficialis, vinculum longum superficialis)
• Synovial diffusion

Question 393

Describe the boundaries of the flexor zones for the THUMB.

Answer 393

• Zone I: Distal to the IP
• Zone II: Between IP and A1 pulley.
• Zone III: Over thenar eminence
• Zone IV: Within carpal tunnel.
• Zone V: Proximal to the carpal tunnel.

Question 394

What is Lindburg Syndrome?

Answer 394

Adhesions between FPL and the index FDP within the carpal tunnel. Such that flexion of the thumb causes flexion of the index. 30% of the population.

Question 395

Describe the the quadrigia effect AND the lumbrical plus deformity.

Answer 395

Quadrigia effect occurs from a functional shortening of the FDP tendon. Given that the FDP tendon has a common muscle belly to the small, ring, and long finger, functionally shortening the tendon to one finger shortens the excursion for all fingers. This can happen if the FDP is advanced more than 1cm in a tendon repair.

The lumbrical plus deformity is results from lax FDP creating tension on the lumbricals. This tension on the lumricals causes finger extension at the IP joints when attemping to grasp objects.

Question 396

Describe the stages for tendon grafting.

Answer 396

STAGE ONE

• Native tendon excised
• Pulley reconstructed as required.
• Silicone rod (Hunter rod)
• Rod induces formation of a pseudosheath.

SECOND STAGE

• Tendon graft sutures to the DISTAL end of the SILICONE rod and pulled through the pseudosheath.
• Tendon graft secured to the native FDS or FDP with a pulvertaft weave.
• Distal juncture made with a pull-out suture or suture anchor to the distal phalanx.
• Tension adjusted so that cascade of finger is SLIGHTLY tigher in the grafted digit.
• If the tendon graft is placed too loosely or too long, it can result in lumbrical plus deformity.

Question 398

What is the 3-5-7 rule with respect to tendon excursion?

Answer 398

• Smith 3-5-7 rule:
  
  • 3 cm excursion - wrist flexors, wrist extensors
  • 5 cm excursion - EDC, FPL, EPL
  • 7 cm excursion - FDS, FDP

Question 399

Group the actions of the wrist (flex/extend), fingers (flex/extend), and DRUJ (sup/pro) into synergistics groups.

Answer 399

• Wrist extension / Finger flexion / Pronation
• Wrist flexion / FInger extension / Supination

Question 400

What are TENDON TRANSFER options for thumb opposition (median nerve)?

Answer 400

• Thumb opposition is a combination of thumb abduction, flexion, and pronation.
• All options involve inserting donor tendon into teh APB insertion on the dorsoradial aspect of the thumb metacarpal head.

1. EIP (radial)
   
   • Tunnel subcutaneously around ulnar side of the hand, across palm at the level of the pisiform.
2. FDS ring finger (median)
   
   • UNAVAILABLE in a high median injury
   • Loop around FCU as a pulley
3. Palmaris longus (‘Camitz’) (median)
   
   • PL + palmar fascia passed under APB origin as pulley
   • Downside is weaker strength
4. Abductor digiti minimi (‘Huber’) (ulnar)
   
   • Insertion detached and muscle turned over 180 degrees.
5. OTHER” ECRL, ECU, EDQ (radial)
   
   • Similar routing to EIP (at the level of pisiform)
   • May need tendon graft for length.

Question 401

What are options for TENDON TRANSFERS for FPL (median) and/or DIP joint flexion?

Answer 401

1. BR (radial)
2. ECRL (radial)
3. FDS to ring finger (median)

Question 402

What are options for TENDON TRANSFER for thumb ADDUCTION / key pinch?

Answer 402

• Key pinch (referred to because of the fact that is is used to hold a key, as opposed to TIP pinch) uses a combination of adductor pollicis and FDI.
• Potential donors tendons:
  
  1. BR or ECRB
     
     • Notably, passed between the index and long metacarpal to the volar aspect of the hand. Index MC acts as a pulley.
     • Inserted into the ulnar base of thumb proximal phalanx
  2. FDS long/ring finger
     
     • FDS ring NOT available in high ulnar nerve injury (because ring FDP will be gone).
     • Retrieved in the palm and passed deep to the flexors.
     • Drawback: weak power and poor vector of pull.
       *

Question 403

Options for TENDON TRANSFER ofr ring and small finger DIP flexion in ulnar nerve injury.

Answer 403

• Sew to FDP index and long
• Notably, this will make clawing worse.

Question 404

What are TENDON TRANSFER options for clawing in ulnar nerve injury (ring and small finger MP joint flexors: lumbricals/interossei)?

Answer 404

• Generally speaking, donors are passed along the path of the lubmrical (volar to the transverse metacarpal ligament).
• There are then three options for insertion:
  
  • Lateral band
  • Proximal phalanx
  • Loop around A1 or A2 pulley and secured to itself
• FDS Long Finger (‘Modified Stiles-Bunnell’ procedure)
  
  • FDS divided distally, split into four slips to recontruct each lumbrical.
  • Passed along path of lumbrical. VOLAR to transverse metacarpal ligament, and then attached to lateral band.
    
    • This can be alternatively be attached to the proximal phalanx OR passed through the A1/A2 pulley and sewed to itself.
    • If sewed to itself, it is referred to the ‘Zancolli Lasso’
  • Drawback is that is can weaken grip strength
• FCR/ECRL/ECRB/BR
  
  • Require a tendon graft
  • Passed along path of the lumbrical, VOLAR to the transverse metacarpal ligament, and attached to the lateral band.

Question 405

What are options for TENDON TRANSFERS for radial nerve palsy?

Answer 405

• Recipient: ECRB (wrist extension)
  
  • Donor: Pronator Teres (PT)
    
    • Divide PT at insertion, route subcutaneously, superficial to BR
    • Attach end to side into ECRB (recovery expected) or end to end (recovery not expected)
• Recipient: EDC (MP joint extension)
  
  • Donor: FDS of long finger
    
    • Can route around wrist or through IO membrane
  • Donor: FCU
    
    • Route around ulnar border subcutaneously
  • Donor: FCR
    
    • Route round radial border subcutaneously
• Recipient: EPL
  
  • Donor: PL
    
    • Divide PL distally and EPL proximally
    • Transpose EPL radial to listers
    • Used in conjunction with FCU or FCI to EDC
  • Donor: FDS to ring
    
    • Rute around wrist or through IO
    • USed in conjunction with FDS to EDC
  • Donor: FCR to EPB and APL
    
    • Provides independent radial abduction
    • Used in conjunction with FDS to EDC and FDS to EPL

Question 406

Four mechanisms for increased risk of infection with DMII.

Answer 406

• Lymphocyte dysfunction
• Decreased chemotaxis
• Decreased phagocytosis
• Decreased intracellular bactericidal activity

Question 407

Describe the eponychial marsupialization technique for CHRONIC paronychia.

Answer 407

Question 408

Describe the presentation and management of Herpetic Whitlow.

Answer 408

History

• ** Often have a prodrome of 24-72 hours of burning before skin changes develop **
• HSV 1: young children and medical/dental professionals
• HSV 2: adults

Physical Exam

• Red/swollen/painful digit
• Not as tense as felon
• CLEAR VESICLES

Investigations

• Peform TZANCK smear on fresh vesicles
• Viral cultures

Treatment

• Usually a self-limited course.
• Treatment is NON-SURGICAL
  
  • Unroofing vesicles may improve patient comfort.
  • ** DO NOT INCISE these lesions (unless bacterial infection is strongly suspected) – there is a risk of viral encephalitis or death **
• Acyclovir can be used in severe cases
• 20% recur

Question 409

Describe the volar deep spaces of the hand?

Answer 409

THENAR

• Floor (dorsal boundary): Adductor pollicis fascia.
• Superficial (volar boundary): Tendon sheath of index finger and volar fascia.
• Radial border: Adductor insertion on thumb P1
• Ulnar border: Vertical mid volar septum (D3 MC).

MIDVOLAR

• Generally sits in the mid-palm between the thenar and hypothenar; infection here causes loss of the concavity of the palm.
• Floor (dorsal boundary): Interossei fascia of the second and third.
• Superficial (volar boundary): Tendon sheath of the long, ring, and small finger.
• Radial: Midvolar septum.
• Ulnar: Hypothenar septum

HYPOTHENAR

• Radial: hypothenar septum
• Dorsal: Periosteum of the fifth metacarpal and fascia of the DEEP hypothenars.
• Volar: Fascia of SUPERFICIAL hypothenars
• Ulnar: Hypothenar muscle / fascia

PARONA’S SPACE

• Located in the forearm between PQ and the FDP tendon sheaths
• Communication between the radial and ulnar bursa can yield a horseshoe abscess

Question 410

Risk factors for poor outcomes with respect to range of motion and amputation following flexor tenosynovitis?

Answer 410

• Age >43 years
• DM, PVD, renal disease
• Subcutaneous purulence
• Digital ischmia
• Polymicrobial infection

Question 411

What needs to be sent when I&D septic arthritis?

Answer 411

• Gram stain
• Culture (aerobic, anaerobic, AFB, fungal)
• Crystals
• Cell count

Question 412

Describe the diagnosis and manaegement of onychomycosis.

Answer 412

• Onychomycosis (tinea unguium) is a fungal infection of the nail.
• Trichophyton rubrum most common in the US.
• Candida albicans common diabetics.
• Presents as a thickened, discoloured nail

Treatment

• Removal of nailplate can shorten treatment by 50%.
• Antifungals:
  
  • Trichophyton rubrum: Terbinafine
  • Candida albicans:
    
    • Topical nystatin
    • Oral ketoconazole or itraconazole

Question 413

Describe the presentation and management of sporothrichosis.

Answer 413

• Sporothrix schenkii
• Most common on rose thorn, moss, and other plants; puncture wound while handling plants or soil.
• Patients present with a nodule that later ulcerates; this is followed by nodule formation along lymphatic channels, which also ulcerate.
• Definitive diagnosis made by fungal culture of nodule aspirate.

Treatment

• Classic treatment is potassium iodine
• However, supplanted by itraconazole or fluconazole (3-6 months or 4 weeks after resolution of symptoms)

Question 414

Discuss the presentation of atypical mycobacterial infections?

Answer 414

• Most commonly Mycobacterium marinum, Mycobacterium kansasii, and Mycobacterium terrae.
• Mycobacterium marinum is found in BOTH fresh and salt water.
• Suspect mycobacteria when a chronic skin lesion, draining sinus tract, or infection fails to heal as expected.
• BIOPSY will show granulomas with negative fungal staining.
• Culture in Lowenstein-Jensen medium at 31 degrees for 8 weeks.

Treatment

• Surgical debridement
• Long term antibiotics for 2-6 months

Question 415

Describe the criteria for reimplanting prosthetic implants (following removal for infection) in the hand.

Answer 415

• Initially management with
• Culture before antibiotics, removal, irrigations, antibiotics spacer, targetted antibiotics
• Before reimplantation, patient should have normal WBC, ESR, CRP
• At the time of surgery, obtain gram stain, and frozen section with <5 PMNs/high pwer field

Question 417

Describe the blood supply to the TIBIA.

Answer 417

• Recieves blood supply from nutrient artery, metaphyseal vessels, and periosteal vessels.
  
  • NUTRIENT ARTERY:
    
    • Enters groove on posterior tibia and enters the medulla where it divides into a network of vessels supply the corext from the endosteal surface
    • This endosteal blood flow supplies the inner two thirds of the cortex.
  • METAPHYSEAL VESSELS:
  • PERIOSTEAL VESSELS:
    
    • Supplies the outer third of the cortex

When a long bone like the tibia is fractures, the nutrient vessels are disrupted and the distal fragment is rendered avascular and must rely on the metaphyseal blood flow and periosteal blood flow.

Question 418

Options for bone gap reconstruction.

Answer 418

• Nonvascularized bone grafting
  
  • Cancellous bone grafts can be used beath vascularized muscle flaps for defects up to 10cm (some authors)
  • 6cm typically used as the cut off.
• Free osseous or osteocutaneous flap
  
  • ​OPTIONS: Fibula, scapula, iliac crest
  • Weiland et al. concluded that for segmental defects >6cm, vascularized bone is required.
  • ** May take up to 15 months for stable union after vascularied bone grafts **
• Distraction osteogenesis (Ilizarov technique)
  
  • May be used for bone grafts larger than 10cm
  • Involves radical debridement of the bony defect and a REMOTE corticotomy (outside the zone of injury) leaving INTACT the medullary blood supply.
  • Wait 7 days before distraction; distract 1mm/day until defect spanned.
  • Frame usually kept for 1 year.
  • CONTRAINICATIONS: Defects >12cm

Question 419

What are options for soft tissue coverage in the UPPER THIRD, MIDDLE THIRD, and LOWER THIRD of the leg?

Answer 419

UPPER THIRD

• Medial gastrocnemius
• Lateral gastrocnemius
• Proximally based soleus
  
  • Soleus blood supply from multiple PT perforators. Soleus exposed and distal perforators divided to allow rotation of the soleus.
• Bipedicled tibialis anterior
  
  • Tibialized anterior exposed and mobilized off tibia. Attachment superiorly and inferiorly maintained for ‘bipedicled’ blood supply. Transposed to cover the defect.

MIDDLE THIRD

• Medial gastrocnemius
• Lateral gastrocnemius
• Proximally based soleus
• Bipedicled tibialis anterior
• Sural artery perforator flap
• Can also use the long extensors OR flexors to GREAT TOE or TOES (certainly not first line options)
  
  • Extensor digitorum longus (EDL)
  • Extensor hallucis longus (EHL)
    
    • Small defects or to augment
  • Flexor digitorum longus (FDL)
    
    • Neurovascular pedicle enters as junction of proximal and middle third.
  • Flexor hallucis longus (FHL)

DISTAL THIRD

• Distally based (sural artery flap)
  
  • Sural nerve + median superficial sural artery + small saphenous vein
  • Most perforators found in the distal half at the midline raphe
• Lateral supramalleolar flap
  
  • Perforating branch of the peroneal artery, which is located 5cm above the lateral malleolus. It branches into a superficial branch (cutaneous perforator) which lies in between extensor hallucis longus and peroneus brevis (supplies skin 12x18x9cm). The descending branch follows the anterior aspect of the lateral malleolus, connecting with the lateral malleolar branch of the tibialis anterior and continuing to the foot.
• Extensor digitorum brevis
  
  • Blood supply: Lateral tarsal artery and vein with a communication to the peroneal
  • The lateral tarsal artery can be found at the junction of the proximal to middle third of the medial EDB muscle, running on the undersurface of the muscle
• Perforator flap / propellar flap
• Cross leg
  
  • Transferred as fasciocutaneous with 3:1 or 4:1 ratio.

Question 420

REGIONAL options for coverage of the foot.

Answer 420

• Medial plantar artery
• Lateral supramalleolar flap
• Extensor digitorum brevis.

Question 421

List two syndromes associated with COMPLICATED syndactyly.

Answer 421

• Polands Syndrome
  
  • Syndactyly, chest wall abnormalities
  • May be associated with symbrachydactyly (short finger, syndactyly, hand hypoplasia)
• Apert Syndrome
  
  • Craniosynostosis, complex syndactyly
  • Autosomal dominant

Question 422

Describe the definitions of the following in the context of syndactyly?

• Simple
• Complex
• Complicated
• Incomplete
• Complete
• Acrosyndactyly
• Acrocephalosyndactyly

Answer 422

• Simple: No bony fusion
• Complex: Presence of bony fusion
• Complicated: Presence of a syndrome
• Incomplete: Web recessed to some degree
• Complete: Syndactyly to the finger tips
• Acrosyndactyly: Associated with contriction bands
• Acrocephalosyndactyly (apert syndrome): Limb abnormalities with craniosynostosis

Question 423

What is optimal timing for surgical intervention for syndactyly.

Answer 423

• EARLIER (4-6 months) for:
  
  • border digits
  • complex (e.g. apert with transverse bony comonents that will worsen with time)
• Most commonly 6-12 months for all others

Question 424

What is CAMPTODACTYLY? How does it differ from CLINODACTYLY?

Answer 424

• Camptodactyly is a FLEXION contracture of the proximal interphalangeal joint (PIP). Classifically involves the little finger and commonly bilateral.
• Painless. May be reducible or irreducible.

CLASSIFICATION

• Type 1: Apparent during infancy; usually isolated to small finger.
• Type 2: Develops during preadolescence; may progress rapidly during growth.
• Type 3: Severe. Multiple digits and part of a syndrome.

TREATMENT

• Nonsurgical treatment mainstay.
• If contracture <30 degrees and not affecting child may consider splinting, particularly during growth spurts.
• Consider surgical for contract >60 to 90 degrees.
• Stepwise approach to assessing and releasing volar skin, FDS, central slip laxity. Consider need for skin graft coverage and K-wire fixation of joint in extension.

Question 425

What is CLINODACTYLY?

Answer 425

• Clinodactyly: curvature of the finger in radial/ulnar direction.
• Can arise from a C-shaped physis and associated “Delta phalanx”
• Most commonly the middle phalanx of the small finger.

TREATMENT

• Splinting not beneficial
• Surgery indicated with severe shorterning, angulation, and functional impairment AND has a delta phalanx present.
• Options:
  
  • Physiolysis
    
    • Bracket resection of the longitudinal physis combined with fat grafting to the area.
  • Oteotomy
    
    • Opening or closing wedge osteomy

Question 427

Describe the treatment timing and general approach for polydactyly of the thumb. Base the treatment on the Wasell classification.

Answer 427

• Timing
  
  • Floating thumb with a narrow stalk can be addressed immediately with simple ligation.
  • Other than that, typically wait until 6-18 months of age.
• General approach:
  
  • Typically the ulnar thumb is preserved so that the UCL is preserved.

Wassel Type I and Type II

• If each duplicated side is symmetrical and of equal size, a Bilhaut-Cloquet procedure can be performed
• Largely fallen out of favour for preserving predominantly one of the duplicate thumbs.

Wassell Type III

• Blihaut-Cloquet or delete the small thumb.

Wassell Type IV

• Design skin flap for coverage
• Excise duplicate thumb (typically radial).
• Shell out (typically with subperiosteal dissection) to preserve and repurpose ligaments / tendons
  
  • Identify and reattach/preserve abductor pollicis brevis.
• Centralize digit on phalanx.
• Reduce MC condyle if is markedly wide.
• Pin longitudinally and into the carpus to maintain reduction.

Wassell Type V and VI

• Same as III and IV, but reconstruct basal joint and MC with osteotomy.

Question 428

Describe MACRODACTYLY, its proposed etiology, associated conditions, classification, and treatment.

Answer 428

Macrodactyly: Overgrowth of the digit.

Etiology

• Proposed to be a nerve-stimulated pathology (typically a median nerve distribution)
• Englarged soft tissue with advanced bone age
• One of the digital arteries if often enlarged

Classification (Upton)

• Type I: Macrodactyly with lipofibromatosis of nerve
• Type II: Macrodactyly associated with neurofibromatosis (von Recklinghausen’s disease)
• Type III: Macrodactyly with hyperostosis (excessive bone growth)
• Type IV: Macrodactyly with hemihypertrophy

Associated Conditions

• Neurofibromatosis
• Klippel-Trenaunay-Weber syndrome (limb hypertrophy, hamangiomas, varicose veins)
• Limb hypertrophy

Clinical presentation

• Enlarged digits often have angular defortmity (radial digits deviated radial, ulnar digits deviated ulnar)
• Osseous growth ends at maturity but soft tissue growth continues.

Imaging

• Radiographs + vascular imaging

Treatment

• Goals:
  
  • Control size
  • Maintain sensivibility
  • Maintian useful function
• Potential procedures:
  
  • Nerve decompression if compressed.
  • Epiphysiodesis (growth plate ablation)
  • Skin and subcutaneous tissue resection
  • Wedge osteotomies
  • Amputation

Question 429

List FIVE other syndromes or conditions associated with radial longitudinal deficiency? Given these associations, what should be included in a systemic work-up of a patient with radial longitudinal deficiency.

Answer 429

• Holt-Oram Syndrome: Autosomal dominant, septal defects, tetrology of fallot, and lower extremity abnormalities.
• VACTERL: Vertebral, Anal, Cardiac, TrachEosophageal fistula, Renal, Radial and Lower extremity abnormalities.
• TAR: Thrombocytopenia Absent Radius syndrome.
• Fanconi Anemia: Autosomal dominant, poor long-term prognosis.
• Work-up:
  
  • Cardiac auscultation
  • Echocardiography
  • Renal ultrasound
  • CBC with differential

Question 430

What is pollex abductus?

Answer 430

Pollex abductus: abnormal insertion of the flexor pollicis longus into the extensor mechanism. Causes thumb abudction with concurrent thumb flexion. May be present in radial longitudinal deficiency or raidal polydactyly.

Question 431

What are associated conditions with cleft hand?

Answer 431

• Split-hand, split-foot syndrome
• EEC (ectodactyly, ectodermal dysplasia, and cleft lip/palate)
• Cornelia de Lange Syndrome

Question 432

Differentiate between a TYPICAL and ATYPICAL cleft hand.

Answer 432

• Typical cleft hand: Bilateral and familial. Syndactyly common. May be associated with cleft lip or palate.
• Atypical cleft hand: Unilateral and spontaneous. SYndactyly rare. Associated with Poland’s. Remaining digits may be hypoplastic.

Question 433

Discuss the timing and indications for surgery of central longitudinal deficiency (CLEFT)?

Answer 433

• Typically these patients have excellent function.
• The classification is based on the degree of involvement of the first webspace as that can have implications for function.
• Indications for surgery:
  
  • Progressive deformity (eg. transverse bones)
  • Deficient first web space
  • Aesthetic appearance
  • Absent thumb
• Timing considerations:
  
  • Early surgery may be indicated with the presence of transverse bones.
  • Otherwise, typically performed at 1-2 years of age.
• Potential surgeries:
  
  • ​Syndactyly release
  • First web space deepening
  • Closure of the commisure
  • Thumb realignment

Question 434

What is the eponym and classification of congenital band syndrome?

Answer 434

Congenital Band Syndrome = Streeter’s Syndrome

• Type I: SImple constriction ring.
• Type II: Contriction ring with deformity of the distal part
• Type III: Constriction ring with variable fusion of the distal parts (acrosyndalyl)
• Type IV: Complete intrauterine disruption

Question 435

Describe the etiology and treatment of Streeter’s Syndrome (Congenital Band Syndrome)?

Answer 435

• Etiology: Amniotic band compress / encircle extremity cause local compression that heals and results with cleft.
• Acute surgery not indicated unless their is vascular compromise – that said, impending amputations are rarely salvagable.
• Best to wait until 2-3 years of age that more larger/more effective flaps can be created. Generally a release of bands with z-plasty.

Question 436

What is KIRNER’S DEFORMITY, the associated syndromes and treatment?

Answer 436

• Kirner’s deformity is an abnormal volar-radial curvature of the distal phalanx.
• Associated syndrome:
  
  • Cornelia de Lange syndrome
  • Silver’s syndrome
  • Turner’s syndrome
  • Down’s syndrome
• Usually present at birth and not progressive
• There is also a sporadic form that develops in adolescence.
• Can be corrected for aesthetic reasons; best to delay until an age where they can participate in the decision making process.