Lower Extremity Flashcards
A 17-year-old boy undergoes resection of the right distal femur to treat osteosarcoma. A large allogeneic corticocancellous bone graft is used for skeletal reconstruction of the 10-cm bony defect. An intramedullary vascularized fibular free flap is also placed in the construct. Which of the following is the most likely purpose of this additional procedure?
A) Decrease the immunogenicity of the allograft
B) Decrease the rate of infection
C) Increase creeping substitution in the allograft
D) Increase the immediate strength of the construct
E) Shorten union time
E) Shorten union time
The most likely reason to place an intramedullary fibular free flap in the allogeneic bone graft is to shorten union time. Free fibular flaps contain an intrinsic blood supply and osteogenic cells. These offer an alternative to the allograft and the capability of osteogenesis through osteoinduction. Thus, the biologic advantage of fibular free flaps is a shortened union time compared with the allograft, which solely depends upon creeping substitution for healing. Union times may be as short as 3 to 5 months. The healing of massive allografts is generally slow, superficial, and incomplete. The union times for allograft healing have been reported at 14 to 23 months for intercalary defects.
The fibula may add some strength to the overall construct but this is not the primary reason for its use in the scenario described. It also does not mitigate any potential antigenicity that the graft may have.
Most common reason for placing an intramedullary fibular free flap in an allogenic bone graft?
Because?
The most likely reason to place an intramedullary fibular free flap in the allogeneic bone graft is to shorten union time. Free fibular flaps contain an intrinsic blood supply and osteogenic cells.
Intramedullary fibular free flaps: Type/capability of osteogenesis?
Free fibular flaps contain an intrinsic blood supply and osteogenic cells. Free fibular flaps offer an alternative to the allograft and the capability of osteogenesis through osteoinduction.
The graft heals by creeping substitution and as such is only osteoconductive, unlike vascularized bone.
Biologic advantage of fibular free flaps compared with allograft
Free fibular flaps offer an alternative to the allograft and the capability of osteogenesis through osteoinduction. Thus, the biologic advantage of fibular free flaps is a shortened union time compared with the allograft, which solely depends upon creeping substitution for healing.
Union time of free fibula flap + allograft for lower extremity defect
Union times may be as short as 3 to 5 months. The healing of massive allografts is generally slow, superficial, and incomplete.
The union times for allograft healing have been reported at _______ for intercalary defects
The union times for allograft healing have been reported at 14 to 23 months for intercalary defects.
Nonvascularized massive allografts provide a _________ with ___________:
Nonvascularized massive allografts provide a biologic spacer with strong cortical bone.
Nonvascularized massive allografts: Advantages and disadvantages
These grafts give great strength to the construct.
Despite this they have many disadvantages:
- lack of blood supply
- lack of osteogenic cells
- potential for immunologic reaction.
A 67-year-old man comes to the office because of an open wound of the right groin and exposed distal anastomosis of a vascular graft 3 weeks after aorto-femoral bypass grafting. Reconstruction with a sartorius muscle flap is planned to cover the graft. The blood supply of the sartorius muscle flap originates directly from which of the following arteries? A) Deep circumflex iliac B) Lateral circumflex femoral C) Medial circumflex femoral D) Profunda femoris E) Superficial femoral
E) Superficial femoral
The sartorius muscle has a Type IV vascularization pattern consisting of 8 to 10 pedicles from the superficial femoral vessel, which enter the muscle medially.
The sartorius muscle has a Type ____ vascularization pattern
The sartorius muscle has a Type IV vascularization pattern, consisting of 8 to 10 pedicles
Vessel that supplies the sartorius muscle flap
The sartorius muscle has a Type IV vascularization pattern consisting of 8 to 10 pedicles from the superficial femoral vessel, which enter the muscle medially.
A 70-year-old man undergoes open reduction and internal fixation of an open fracture of the ankle. Debridement of nonviable tissue results in the exposure of the joint and hardware. Coverage with a reverse sural artery flap is planned. A photograph is shown. Which of the following is the most likely adverse outcome associated with the use of this flap? A) Infection B) Insufficient bulk C) Insufficient flap coverage D) Partial flap loss E) Wound dehiscence
D) Partial flap loss
The utility of the flap has been proven in both healthy and compromised wounds; neither peripheral arterial disease nor diabetes has precluded its success. Of the possible complications, partial flap loss has occurred most commonly.
Cutaneous paddles have been harvested with dimensions of up to 12 × 15 cm, allowing coverage of most ankle and heel wounds. Reconstruction of larger donor defects with split-thickness skin grafts makes dehiscence unlikely.
Most common complication of reverse sural artery flap
Of the possible complications, partial flap loss has occurred most commonly.
Proposed modification to reduce partial flap loss of the sural artery flap
Maintaining a narrow (2 cm wide) pedicle, including a cutaneous ‘tail’ along the length of the pedicle and maintaining a mesentery between the sural nerve and the deep fascia.
Infection rates of the reverse sural artery flap
Infection rates have been low, ranging from 0 to 2.5%.
Reverse sural artery flap: Type to conform to defects, versus coverage of a deeper defect
The fasciocutaneous variety of the reverse sural flap is often malleable enough to conform to most defects. When a deeper defect exists, a fasciomusculocutaneous variation of the flap has been designed.
Reverse sural artery flap: The fasciomusculocutaneous variation carries a portion of what muscle?
A fasciomusculocutaneous variation of the reverse sural artery flap has been designed to carry a portion of the gastrocnemius muscle via one of the larger proximal perforators typically found deep to the cutaneous paddle in the proximal leg.
Reverse sural artery flap: Cutaneous paddles of dimensions up to ________
Cutaneous paddles have been harvested with dimensions of up to 12 × 15 cm, allowing coverage of most ankle and heel wounds.
Reverse sural artery flap: Cutaneous paddles allow coverage of most wounds in what location?
Most ankle and heel wounds
Reverse sural artery flap: Reconstruction of donor site when a large cutaneous paddle is taken
Larger donor defects are reconstructed with with split-thickness skin grafts
A 33-year-old woman is brought to the emergency department after sustaining a 6 × 8-cm soft-tissue defect over the tibial tuberosity after being hit by a motor vehicle while riding her bicycle. Physical examination shows exposed bone at the proximal third of the leg. Which of the following muscle flaps is most appropriate for this patient? A) Lateral gastrocnemius B) Lateral soleus C) Medial gastrocnemius D) Medial soleus E) Sartorius
C) Medial gastrocnemius
Gastrocnemius muscle: Which compartment ?
The gastrocnemius is a powerful muscle in the superficial posterior compartment of the leg
Gastrocnemius muscle: Actions
In which activities is it involved?
Acts to plantar flex the foot at the ankle joint and flex the leg at the knee joint. It is involved in standing, walking, running, and jumping.
Gastrocnemius muscle: Anatomy
The lateral head originates from the lateral condyle of the femur, while the medial head originates from the medial condyle of the femur. Its other end forms a common tendon with the soleus muscle; this tendon is known as the calcaneal tendon or “Achilles tendon” and inserts onto the posterior surface of the calcaneus.
Gastrocnemius muscle: Anatomical difference between its two heads
The medial head is longer, and its muscular fibers extend more inferiorly.
The gastrocnemius can be harvested as a muscular or musculocutaneous flap if the _____ is intact: Which actions will be preserved?
The gastrocnemius can be harvested as a muscular or musculocutaneous flap if the soleus is intact and plantar flexion of the foot will be preserved.
Gastrocnemius muscle: When is footdrop a possible morbidity?
Footdrop is possible with the use of the lateral muscle belly.
What are the two powerful muscles in the superficial posterior compartment of the leg?
The gastrocnemius and soleus muscles
Actions of the soleus muscle
With the gastrocnemius, the soleus acts to plantar flex the foot at the ankle joint. Specifically, the soleus plays an important role in standing; if not for its constant pull, the body would fall forward.
Which muscle of the leg is important in keeping the body from falling forward?
The constant pull of the soleus
Anatomy of the soleus muscle
The muscle originates from the posterior surfaces of the head of the fibula and its upper quarter, as well as the middle third of the medial border of the tibia. Its other end forms a common calcaneal tendon with the gastrocnemius muscle.
Potential use of the soleus when freed from the Achilles tendon:
The soleus muscle, when freed from its insertion on the Achilles tendon and based proximally, covers defects in the middle third of the tibia.
Potential use of the hemi-soleus:
A hemisoleus may be used to cover distal third tibia.
What tissue types may the sartorius flap contain?
The sartorius flap may be raised as a muscle or myocutaneous flap
The sartorius flap is based on which vessels?
The sartorius is based on segmental branches of the superficial femoral artery and vein.
What type of flap is the sartorius?
Type IV segmental blood supply
Why would the sartorius flap arc of rotation be limited?
Because it has a Type IV segmental blood supply, the arc of rotation both superiorly and inferiorly is limited.
Best indication for the sartorius flap:
Its best indication is for coverage of the femoral vessels.
A 40-year-old woman is referred by her orthopedic surgeon for reconstruction because of an exquisitely tender scar over the site of the anterolateral portal for arthroscopy of the left ankle. Examination shows a 1-cm scar over the lateral malleolus. Tinel sign is present over the scar. Sensation is diminished over the middle part of the dorsum of the foot. Which of the following nerves is most likely to have been injured during the arthroscopy? A) Lateral malleolar B) Medial plantar C) Saphenous D) Superficial peroneal E) Sural
D) Superficial peroneal
In the patient described, the dermatomal distribution of numbness of the middle of the dorsum of the foot suggests injury of the superficial peroneal nerve (SPN). The SPN supplies the sensation to the middle portion of the dorsum of the foot, except for the skin in the great toe web space (which is innervated by the deep peroneal nerve).
Superficial peroneal: Innervation to?
The SPN supplies the sensation to the middle portion of the dorsum of the foot, except for the skin in the great toe web space (which is innervated by the deep peroneal nerve).
The lateral malleolar nerve supplies innervation to?
The lateral malleolar nerve is a terminal branch nerve supplying the skin of the lateral malleolus.
The medial plantar nerve supplies innervation to?
The medial plantar nerve supplies the medial three fourths of the plantar surface of the foot.
Course of the saphenous nerve in the distal lower extremity
The saphenous nerve travels to the dorsum of the foot, medial malleolus, and the area of the head of the first metatarsal.
At the level of the ankle, the saphenous nerve is found where?
At the level of the ankle, the saphenous nerve is found between the medial malleolus and the anterior tibial tendon, just lateral to the saphenous vein.
Sural nerve location in the distal lower extremity?
The sural nerve is located at an average of 7 mm posterior to the lateral malleolus
The sural nerve supplies sensation to:
The sural nerve supplies sensation to the lateral aspect of the foot.
A 62-year-old man is brought to the emergency department by helicopter after sustaining severe injuries to the head, neck, and right femur during a motor vehicle collision. The patient's condition is stabilized, and the femur is temporarily reduced and splint immobilized. Peripheral pulses in the right leg are not palpable and capillary refill is noted; handheld Doppler shows weak pulses. Which of the following is the most appropriate next step to establish lower extremity vascular injury in this patient? A) CT angiography B) Doppler ultrasonography C) Measurement of ankle brachial index D) Serial physical examinations
A) CT angiography
Because of significant collateral blood flow in the upper and lower extremities, capillary refill and handheld Doppler tones can often be found even with complete disruption of major arteries.
Although traditional angiography is known as the “gold standard” for the diagnosis of vascular injuries, it is not without its difficulties. A special suite, technicians, and physicians are needed to perform traditional angiography, and the potential for morbidity has been noted. As a result, CT angiography is fast becoming the new “gold standard” for the diagnosis of vascular injuries.
Traditional versus CT angiography for trauma
Although traditional angiography is known as the “gold standard” for the diagnosis of vascular injuries, it is not without its difficulties. A special suite, technicians, and physicians are needed to perform traditional angiography, and the potential for morbidity has been noted. As a result, CT angiography is fast becoming the new “gold standard” for the diagnosis of vascular injuries.
A 25-year-old man is brought to the emergency department after he was hit by a motor vehicle while walking across the street. Physical examination shows a Gustilo Type IIIB open fracture of the tibia. Reconstruction with an anterolateral thigh flap is planned. An incision between which of the following structures is the most appropriate approach to access the posterior tibial vessels?
A) Lateral malleolus and the Achilles tendon
B) Lateral malleolus and the extensor hallucis longus tendon
C) Medial malleolus and the Achilles tendon
D) Tibialis anterior and the extensor hallucis longus tendons
C) Medial malleolus and the Achilles tendon
The sural nerve is located at the distal leg between the lateral malleolus and the Achilles tendon.
The greater saphenous vein is located between the medial malleolus and the extensor hallucis longus tendon.
The posterior tibial vessels are located between the medial malleolus and the Achilles tendon.
The dorsalis pedis artery is located between the tendons of the tibialis anterior and the extensor hallucis longus.
The sural nerve is located at the distal leg between which structures?
The sural nerve is located at the distal leg between the lateral malleolus and the Achilles tendon.
The greater saphenous vein is located at the distal leg between which structures?
The greater saphenous vein is located between the medial malleolus and the extensor hallucis longus tendon.
The posterior tibial vessels are located at the distal leg between which structures?
The posterior tibial vessels are located between the medial malleolus and the Achilles tendon.
The dorsalis pedis artery is located at the distal leg between which structures?
The dorsalis pedis artery is located between the tendons of the tibialis anterior and the extensor hallucis longus.
An otherwise healthy 35-year-old man is brought to the emergency department after he collided with a parked bus while riding his motorcycle at 20 mph. On admission, he is cleared by the trauma service to undergo orthopedic exploration of an open fracture of the tibia and fibula. The surgeon achieves external fixation and begins washout of a 15-cm anterior wound with exposed denuded bone. A consultation regarding initial evaluation for soft-tissue coverage is requested. Which of the following additional findings is most likely to lead to the decision to recommend eventual below-the-knee amputation rather than reconstruction for this patient?
A) Gap of the tibial nerve of 4 cm
B) Grade 2 liver laceration
C) Ipsilateral full-thickness anterior plantar skin avulsion with associated metatarsal fractures
D) New-onset absence of the pulses in the foot following external fixation
E) Parietal contusion requiring endotracheal intubation and neurosurgical consultation
A) Gap of the tibial nerve of 4 cm
Avulsion of the tibial nerve is one of the two absolute indications for amputation in the context of Gustilo Type IIIB and IIIC open tibial fractures. This is because outcomes of microsurgical reconstruction of the insensate foot in these cases are very poor.
The other absolute contraindication to reconstruction is a warm ischemia time of 6 hours or greater, which the patient described does not have. The patient has just lost pulses after manipulation and fixation. This is a new finding, with very recent ischemia time. This is a potentially fixable situation, and not necessarily a contraindication to reconstruction. Recent loss of pulses could contribute to a need for amputation in the future but would not require that decision now.
Polytrauma, such as a liver laceration or an intracranial injury, can evolve into relative contraindications to reconstruction, but they are not absolute contraindications by themselves.
The loss of plantar skin and metatarsal fractures by themselves are also not an absolute contraindication to reconstruction. This is a potentially reconstructible problem that should not push the plastic surgeon to recommend amputation. The additional foot trauma can potentially be reconstructed either with a skin graft or a flap.
Absolute indication for amputation in the context of Gustilo Type IIIB and IIIC open tibial fractures.
- Avulsion of the tibial nerve: Outcomes of microsurgical reconstruction of the insensate foot in these cases are very poor.
- Warm ischemia time of 6 hours or greater, which the patient described does not have.
A 17-year-old boy is brought to the emergency department after sustaining a traumatic injury to the left lower extremity in a motor vehicle collision. Physical examination shows a large area of crush injury, loss of soft tissue, and open fracture of the tibia with exposed bone. The lower leg is cool to touch and pale. No distal pulses are palpable. Angiography shows transsection of the popliteal artery. Which of the following is the most appropriate Gustilo classification of this patient's fracture? A ) Type I B ) Type II C ) Type IIIA D ) Type IIIB E ) Type IIIC
E ) Type IIIC
Type III fractures are greater than 10 cm and involve extensive soft-tissue damage. These injuries create difficulties in coverage of bone or fixation hardware. Gustilo Type III fractures are further subdivided into A, B, and C subtypes. Type IIIA fractureshave sufficient soft tissue to provide for bony coverage. Type IIIB fractures involve periosteal stripping and extensive tissue damage, and local soft-tissue coverage is not possible. These typically result from high-energy mechanisms, such as high-velocity gunshot wounds or significant crush injuries. Gustilo Type IIIB fractures are the most common injuries for which plastic surgeons are consulted. Gustilo Type IIIC fractures include vascular injuries that require repair. The presence of a vascular injurysignificantly increases the probability of amputation.
Most widely accepted method for characterizing open fractures of the lower extremity
The Gustilo classification is the most widely accepted method for characterizing open fractures of the lower extremity.
Gustilo Type I
Type I open fractures involve soft-tissue lacerations smaller than 1 cm.
Gustilo Type II
Type II fractures include lacerations of 1 to 10 cm, with moderate soft-tissue damage
Gustilo Type III
Type III fractures are greater than 10 cm and involve extensive soft-tissue damage. These injuries create difficulties in coverage of bone or fixation hardware.
Gustilo Type IIIA
Type IIIA fractureshave sufficient soft tissue to provide for bony coverage.
Gustilo Type IIIB
Type IIIB fractures involve periosteal stripping and extensive tissue damage, and local soft-tissue coverage is not possible. These typically result from high-energy mechanisms, such as high-velocity gunshot wounds or significant crush injuries.
Most common Gustily type fracture for which plastic surgeons are consulted
Gustilo Type IIIB fractures are the most common injuries for which plastic surgeons are consulted.
Gustilo Type IIIC
Gustilo Type IIIC fractures include vascular injuries that require repair. The presence of a vascular injurysignificantly increases the probability of amputation.
A 15-year-old boy is brought to the emergency department 1 hour after his left foot was severed when his leg was run over by a train. Photographs are shown (long tendon stumps that appear ripped off from their muscle bellies, and ankle disarticulation). Which of the following is the most appropriate management?
A ) Construction of a foot filet free flap
B ) Replantation and ankle fusion
C ) Revision amputation to the level of the skin edge and primary closure
D ) Split-thickness skin grafting
E ) Temporary revascularization with shunts and delayed replantation
C ) Revision amputation to the level of the skin edge and primary closure
The patient described has a limb amputation that includes a significant avulsion component, exemplified inthe long tendon stumps that appear ripped off from their muscle bellies, and ankle disarticulation. Avulsion amputations of the lower extremity are not suitable for replantation because of the extended neurovascular damage that is present on both ends well beyond the level of the injury. The incidence of thrombosis at the anastomosis is high. Use of vein grafts on a free flap could be considered, but, in this case, they may have to be connected as high as knee level to ensure patency. The amputated part likely has massive microscopic endothelial damage extending to terminal vessels and could only be used as a donor site for skin grafts. Therefore, there is no role for immediate or delayed replantation.
While preservation of maximum tibial length is desirable in preparing the amputation stump, prosthetic fitting for ankle disarticulations is fraught with trouble. Some tibial shortening is required to have a comfortable, reliable prosthesis. In the scenario described, tibial shortening of 2 and 4 in would have equivalent results because there is still ample length of proximal tibia available to provide the same functionality and equivalent energy expenditure. Therefore, use of a free flap to protect an additional 2 in of tibia adds no advantage for this patient. When the level of amputation is through the proximal tibia, some benefit could be found in that a minimum of 6 in of proximal tibia is available for prosthetic fitting.
How much tibia is necessary for a prosthetic?
6 inches
A 43-year-old man has footdrop and numbness of the left foot following reconstruction of a soft-tissue defect resulting from a Gustilo Type IIIB fracture of the proximal tibia. Which of the following pedicled flaps was most likely used for reconstruction? A ) Gracilis B ) Lateral gastrocnemius C ) Reversed sural artery D ) Sartorius E ) Soleus
B ) Lateral gastrocnemius
The pedicled gastrocnemius flap has been shown to be a reliable source of vascularized soft tissue for injuries of the distal thigh, knee, and proximal leg. The lateral or medial head may be harvested. Lateral gastrocnemius harvest risks damaging the common peroneal nerve, with an incidence of 7.7%. Medial gastrocnemius harvest, for obvious anatomical reasons, does not carry this risk.
There are few data on the morbidity of donor sites, but those studies that have been done demonstrate no functional debility at a walking gait for less than 200 m. Patients do notice difficulty standing on their toes and have slowing with variable calcaneal gait when walking fast. Forty-two percent of patients could run, 22% had pain in the donor site at rest, and 20% had pain when walking more than 200 m. Seventy percent had pain and weakness in the operated leg when attempting to run. Range-of-motion deficit existed in the operated limb, with average loss of 27% flexion and 14% extension
Nerve damage risk of lateral versus medial gastrocnemius flap harvest
Lateral gastrocnemius harvest risks damaging the common peroneal nerve, with an incidence of 7.7%. Medial gastrocnemius harvest, for obvious anatomical reasons, does not carry this risk.
Which nerve is at risk of damage during a lateral gastrocnemius flap?
___%
Lateral gastrocnemius harvest risks damaging the common peroneal nerve, with an incidence of 7.7%.
Morbidity following a pedicled gastrocnemius flap
- Difficulty standing on their toes
- Slowing with variable calcaneal gait when walking fast.
- 70% percent had pain and weakness in the operated leg when attempting to run
- Range-of-motion deficit existed in the operated limb, with average loss of 27% flexion and 14% extension
Morbidity of soleus flap harvest versus gastrocnemius flap harvest
- Functional deficit w limited ankle flexion is more severe w/ Soleus
- Less edema with the soleus, because it has better venous muscle pump function
A 62-year-old man is scheduled to undergo reconstruction of a 7-cm bone defect (shown) resulting from excision of a tumor of the distal radius. He has hypertension and has smoked one pack of cigarettes daily for 30 years. Which of the following is the most appropriate technique for reconstruction of the defect? A ) Allograft bone graft B ) Fibula free flap C ) Locking fixation plate D ) Pedicled ulna bone flap
B ) Fibula free flap
Composite tissue reconstruction after tumor ablation is a significant challenge to the plastic surgeon. Generally, bony defects greater than 6 cm require vascularized bone for reconstruction. For large defects, the optimum choice of bone is the vascularized fibula. The fibula also has a reliable blood supply from the peroneal artery and can be harvested with a cutaneous skin paddle. The fibula free flap is the most appropriate technique. Reconstruction with free flaps can be successfully performed in a patient with a smoking history and, in fact, is often the optimal method of reconstruction in smokers. The use of allograft cadaver bone is not indicated, especially in a patient with a history of smoking. For defects of the size shown in the photograph, the locking fixation plate would not give adequate long-term support. A local bone flap is also not a viable option.
Reconstruction of radial defects should generally be performed when they are ____ or greater
Generally, bony defects greater than 6 cm require vascularized bone for reconstruction.
Reconstruction of choice for large radial defects
For large defects, the optimum choice of bone is the vascularized fibula.
Blood supply of a fibular free flap
The fibula has a reliable blood supply from the peroneal artery and can be harvested with a cutaneous skin paddle.
A 70-year-old man is brought to the emergency department after he was hit by a car while walking across the street. Numerous fractures of the ribs, a nonoperative laceration of the spleen, a fracture of the right humerus, and a Gustilo Type IIIC fracture of the middle third of the left lower leg are noted. Examination shows an 8 x 7-cm soft-tissue defect over the anterior aspect with exposed bone. The patient is unable to plantar flex his left foot, and sensation is absent over the plantar aspect. Surgical exploration shows transection of the posterior tibial artery and tibial nerve. Which of the following is the most appropriate management of the injured leg?
A ) Above-knee amputation
B ) Below-knee amputation
C ) Irrigation, debridement, external fixation, free tissue transfer, and delayed repair of the nerve
D ) Irrigation,debridement, external fixation, immediate repair of the artery and nerve, and free tissue transfer
E ) Irrigation, debridement, internal fixation, immediate repair of the artery and nerve, and skin grafting
B ) Below-knee amputation
The treatment goal in the management of open tibial fractures and lower extremity salvage is to preserve a limb that will be more functional than an amputation. If the extremity cannot be salvaged, the goal is to maintain the maximum functional length.
Given the advanced age of the patient described, his associated injuries, and an insensate injured lower extremity, the most appropriate management of the injured leg would be a below-knee amputation.
Below-knee amputations provide better prosthetic function and require less energy for ambulation than above-knee amputations.
An 18-year-old man is brought to the trauma center after sustaining an injury to the right lower extremity. Examination shows an open fracture of the right tibia. Which of the following mechanisms of the injury is most likely to require the most extensive surgical debridement?
A ) A collision on the rink during which one skater runs over another
B ) A fallfrom a bicycle onto a curb after a collision with a pedestrian
C ) A fall from a 6-ft ladder onto a ceramic floor
D ) A fall from a shopping cart onto a parking lot
E ) A vehicle crash into a highway barrier while speeding
E ) A vehicle crash into a highway barrier while speeding
All of the mechanisms could have caused an open fracture requiring surgical intervention. Only the vehicle crash represents a high-energy injury. The approach to high-energy injuries must take into account a wider zone of injury beyond just the fracture site and skin laceration.
A 40-year-old man undergoes open reduction and internal fixation of an open fracture of the ankle. Debridement of nonviable tissue results in the exposure of the lateral joint and hardware. Coverage of the lateral malleolus with the flap shown is planned (reverse flow sural flap). Which of the following arteries must be intact for this flap to be viable? A ) Anterior tibial B ) Dorsalis pedis C ) Lateral genicular D ) Lateral plantar E ) Peroneal
E ) Peroneal
The reverse-flow sural flap has become one of the more dependable solutions in distal third leg wound and heel reconstruction. Survival of the flap depends on intact flow into the superficialsural arterial network via perforators from the peroneal system. The largest perforator arises roughly 5 cm cephalad to the lateral malleolus and typically marks the lowest pivot point for the flap
Blood supply of the reverse-flow sural flap
Superficial sural arterial network via perforators from the peroneal system.
The largest perforator arises roughly 5 cm cephalad to the lateral malleolus and typically marks the lowest pivot point for the flap
A 48-year-old woman undergoes coverage of a defect with an anterolateral thigh flap. Which of the following branches of the lateral femoral circumflex artery is the most likely dominant vascular supply for the flap perforator? A ) Ascending B ) Descending C ) Oblique D ) Transverse
B ) Descending
In recent studies by Wong, et al, and Rozen, et al, attempts have been made to clarify the vascular perforator anatomy of theanterolateral thigh flap. It has been noted that sizeable vascular perforators may arise from the ascending, transverse, or descending branch of the lateral circumflex femoral artery. The most common supply, however, comes from the descending branch, followed by the transverse and ascending branches.
Specific blood supply of the ALT flap
___% of cases
Descending branch of the lateral circumflex femoral artery, in 85%
A 70-year-old man has a mildly tender, clean, 6-cm wound to the lower leg that occurred spontaneously seven months ago. Physical examination of the ankle shows a brown-red discoloration and edema of the surrounding tissue. Which of the following is the most appropriate initial management of the wound? A ) Hyperbaric oxygen therapy B ) Silver sulfadiazine dressing C ) Surgical debridement D ) Unna boot compression dressing E ) Vacuum-assisted closure therapy
D ) Unna boot compression dressing
The patient described has signs and symptoms of a venous stasis ulcer, a common cause of chronic lower leg wounds. Venous valve incompetence leads to chronic venous hypertension, capillary hydrostatic pressure elevation, and leakage of fluidand proteins to the extracellular space. Oxygen transport to the tissues is impaired, causing localized cellular necrosis and ulceration.
The hallmark of treatment is compression of the edematous limb to reduce the severe interstitial edema. By decreasing the tissue pressure, oxygen delivery is enhanced and wound healing mechanisms may be gradually restored. The open wound is best treated with an absorptive and occlusive dressing such as Unna wrap. Care must be taken to avoid overcompression and arterial compromise. Unna boots can be changed weekly or more frequently as needed. After reepithelialization has occurred, compression stocking or elastic bandage wraps are essential to prevent occurrence. Compression therapy is also a cost-effective treatment. Venous insufficiency affects up to 5% of the population; more than 500,000 patients in the United States suffer from ulceration. The economic costs from treatment and lost productivity are enormous.
How do venous stasis ulcers develop?
Venous valve incompetence leads to chronic venous hypertension, capillary hydrostatic pressure elevation, and leakage of fluidand proteins to the extracellular space. Oxygen transport to the tissues is impaired, causing localized cellular necrosis and ulceration.
Treatment of venous stasis: Hallmark?
The hallmark of treatment is compression of the edematous limb to reduce the severe interstitial edema. By decreasing the tissue pressure, oxygen delivery is enhanced and wound healing mechanisms may be gradually restored.
Management of an open venous stasis ulcer
- Compression of the edematous limb to reduce severe interstitial edema.
- Application of an absorptive and occlusive dressing such as Unna wrap
The sural nerve is best localized at which of the following locations?
A ) 1 cm anterior to the fibular head
B ) 1 cm posterior to the lateral malleolus
C ) 1 cm anterior to the lateral malleolus
D ) 1 cm posterior to the medial malleolus
E ) 1 cm anterior to the medial malleolus
B ) 1 cm posterior to the lateral malleolus
Desirable features of cutaneous nerve grafts
(1) large fascicles with little interfascicular connective tissue,
(2) separate parallel fascicles,
(3) overall large diameter,
(4) large-caliber axons,
(5) easy accessibility, with little anatomic variation,
(6) long unbranched segments, and
(7) minimal sensory deficit.
What type of nerve is the sural nerve
Purely sensory
What contributes to the sural nerve?
Contributions from:
- medial sural cutaneous nerve (branch of the tibial nerve)
- lateral sural cutaneous nerve (branch of the peroneal nerve)
What is the diameter of the sural nerve?
It has a mean diameter of 3.61 mm, which is ideal for group fascicular reconstruction
Deficit after harvest of the sural nerve
It leaves minimal residual sensory deficit (the lateral foot and ankle).
How much length can be obtained from the sural nerve?
Up to 30 cm of nerve graft can be obtained.
Location of the distal sural nerve
The distal portion of the nerve is consistently found between 1 and 1.5 cm posterior to the lateral malleolus.
A 1-year-old boy is scheduled to undergo primary surgical reconstruction of congenital talipes equinovarus. Subsequent skin shortage and wound complications are best prevented by which of the following methods?
A ) Free fasciocutaneous flap transfer
B ) Healing via second intention
C ) Preoperative tissue expansion
D ) Split-thickness skin grafting
E ) Two-stage local flap delay and transfer
C ) Preoperative tissue expansion
Although the treatment of congenital talipes equinovarus (CTEV) has trended toward conservative routines of manipulation and limited surgical release (eg, Ponseti technique), surgical treatment of CTEV may be necessary in cases of delayed treatment or failure of the conservative regime. Surgical correction may be attempted via a gradual technique (Ilizarov) or as an acute correction with release of the contracted posterior and medial elements.
Many acute surgical CTEV corrections can be accomplished without skin or wound difficulties; when such difficulties are anticipated, preoperative placement of tissue expanders has proven useful in allowing primary closure of the release sites with minimal morbidity.
Congenital talipes equinovarus: Common name?
Club foot
When is surgical treatment of congenital talipes equinovarus indicated?
The treatment of congenital talipes equinovarus has trended toward conservative routines of manipulation and limited surgical release.
Surgical treatment may be necessary in cases of delayed treatment or failure of the conservative regime.
How to ensure primary closure following surgical management of congenital talipes equinovarus?
Many acute surgical CTEV corrections can be accomplished without skin or wound difficulties; when such difficulties are anticipated, preoperative placement of tissue expanders has proven useful in allowing primary closure of the release sites with minimal morbidity.
A 60-year-oldman comes to the office because he has had tingling and numbness on the plantar aspects of the toes of both feet for the past seven months. He says that his symptoms are more noticeable after long periods of walking or standing and are relieved by elevation of the legs. Physical examination shows weakness of flexion of the toes. Tarsal tunnel syndrome is suspected. The most likely cause of these findings is palsy of which of the following nerves?
A ) Deep peroneal nerve to flexor digitorum superficialis muscle
B ) Interosseous nerve to quadratus plantae muscle
C ) Medial plantar nerve to flexor digitorum brevis muscle
D ) Superficial peroneal nerve to interosseus muscles
E ) Tibial nerve to flexor digitorum longus muscle
C ) Medial plantar nerve to flexor digitorum brevis muscle
The tibial nerve bifurcates distally into the medial and lateral plantar nerves, and it is these two nerves that are impinged in the tarsal tunnel.
What nerve(s) can be compressed in the tarsal tunnel?
The tibial nerve bifurcates distally into the medial and lateral plantar nerves, and it is these two nerves that are impinged in the tarsal tunnel.
Actions of the flexor digitorum brevis?
The flexor digitorum brevis flexes both the proximal and the middle phalanges of the toes
Innervation of the flexor digitorum brevis
Medial plantar nerve
Intrinsic toe flexors
- Flexor digitorum brevis
- Flexor hallucis brevis
- Flexor digiti minimi brevis
- Interossei
- Lumbricals
Innervation of the Flexor hallucis brevis
Medial plantar nerve
Innervation of the Flexor digiti minimi brevis
Lateral plantar nerve
Innervation of the Interossei of the foot
Lateral plantar nerve
Innervation of the lumbricals of the foot
Medial and lateral plantar nerves
Most severe presentation of tarsal tunnel syndrome
In the most severe situation, a patient with tarsal tunnel syndrome may have “claw toes.”
Actions of the quadratus plantae
Quadratus plantae is a flexor of the lateral four toes through the flexor digitorum longus
Innervation of the quadratus plantae
Lateral plantar nerve.
Innervation of the flexor digitorum longus
The flexor digitorum longus is a toe flexor and is innervated by the tibial nerve
A 34-year-old man who works as a police officer is brought to the emergency department after sustaining a traumatic avulsion of the right heel. Examination shows a 3 * 3-cm area of exposed calcaneus on the weight-bearing aspect of the heel. Which of the following arteries and nerves supply the flap that will provide the most appropriate sensate coverage?
Artery || Nerve
A )Dorsalis pedis || superficial peroneal
B )Medial plantar || medial plantar
C )Medial sural || saphenous
D )Posterior tibial || posterior tibial
E )Radial || medial antebrachial cutaneous
B )Medial plantar || medial plantar
Sensate flaps are beneficial in resurfacing wounds located on weight-bearing areas as in pressure sores or the heel, as in the scenario described.
The most reliable sensate flap for coverage of the plantar calcaneus comes from the medial plantar flap. This flap receives its sensation from the medial plantar nerve (L4-5) and receives its blood supply from the medal plantar artery. This flap comes from the instep of the foot between the head of the first metacarpal and the midpoint of the heel. The size of the flap can be up to 12 * 6 cm. Due to its proximity to the heel and the minimal donor morbidity with loss of sensation to the instep of the foot, this flap is the most appropriate for coverage of this patient’s defect
