Oral Boards Flashcards
Repair A2 or A4 pulley acutely
z-plasty
FDS tail after split at Camper’s chiasm or palmaris longus to reconstruct
Duran early active flexor tendon protocol
Splint wrist 20-30 flexion, MCP 70 flexion, IP’s 0 flexion
start passive flexion, active extension 3-5 days
active flexion at 4 weeks
discontinue splint 6 weeks
strengthening 8 weeks
full activity 12 weeks
Tendon graft
Excise FDP just distal to lumbrical origin in palm and leave 1cm distal. Remove FDS.
Second stage 3 months later.
Veau classification
I Defect soft palate only
II Hard and soft palate
III Soft palate to alveolus, involved lip
IV Complete bilateral clefts
Goldenhar syndrome (oculoauriculovertebral dysplasia)
hemifacial microsomia, defects in eyes (epidbulbar dermoids), ears and spine
Fitzpatrick scale
I white, very fair - always burns, never tans
II white, fair - usually burns, rarely tans
III beige - usually tans, occasionally burns
IV mediterranean - rarely burns, tans easily
V dark brown - rarely burns
VI black - never burns, deeply pigmented
Brow peak
Just lateral to or at lateral limbus
Just superior to supraorbital rim in women and at rim in men
Supratarsal fold evaluation of upper lid
Margin to crease distance should be 7-11mm. If more then concern for levator dehicsence.
Pinch test
If can pull lower lid greater that 6mm from globe then too much laxity and will require canthal procedure.
Also, lateral canthus should attached posterior to orbital rim 2mm superior to the medial canthus.
Snap back test
For ectropion. Pull lower lid away from globe and hold several seconds. If not rebound immediately without blinking then ectropion
Schirmer test
Filter paper into fornix for 5 min and should have >1cm moisture
nasolabial angle
90-100 degrees female
90 degrees
Gustillo classification
I <1cm II >1cm IIIA <10cm IIIB >10cm IIIC major vascular injury
gastrocnemius flap
origin medial and lateral condyle of femur, inserts on calcaneous through achilles tendon.
medial and lateral sural arteries from the popliteal artery enter the deep proximal muscle. Medial and lateral head separated by the sural nerve and lesser saphenous vein. Lateral gastroc beware of peroneal nerve around the fibular neck or can get foot drop. note plantaris will be in plane between gastroc and soleus.
soleus flap
origin head and upper shaft of tibia and insertion on achilles tendon.
incision 2cm medial to tibia or midlateral along border of tibia
posterior tibial artery between soleus and FDL
peroneal artery between soleus and FHL
medial soleus posterior tibial artery and lateral soleus peroneal artery
vastus lateralis flap
descending branch of the lateral circumflex femoral artery. Can be distally based but less reliable than proximally based.
relative indications for amputation
injury to posterior tibial nerve (loss of sensation to sole of foot)
crush injury
warm ischemia >6 hours
timing for skin graft after integra
3 weeks
Grolleau classification of tuberous breast deformity
Type I: Deficiency of lower medial quadrant
type II: Deficiency of entire lower pole of breast
Type III: Deficiency of all quadrants
Characteristics of tuberous breast
elevated IMF
enlarged nipple areola complex with herniated breast tissue
decreased breast diameter
Regnault classification of ptosis
Grade I: nipple at inframammary fold
Grade II: nipple below IMF
Grade III: nipple at lowest post of breast
pseudoptosis: lower-pole breast parenchyma ptosis
Indications for mammagram before breast surgery
age 45 annual
age 55+ every two years until within 10 years of expected death
if family history then 10 years prior to onset of cancer in family member
FDA approval silicone implants
22 years and older
MRI recommendations for implant surveillance
3 years post op then Q 3 years
Baker capsular contracture
Grade I: normal
Grade II: slightly firm, normal appearance
Grade III: firm, appears abnormal
Grade IV: painful, hard, appears abnormal
Medications that cause gynecomastia
marijuana, spironolactone, steroids, HIV medications, diazepam, tricyclic antidepressants, digoxin, calcium channel blockers, furosemide, risperidone, antibiotics
Pressure ulcer stage
I: Nonblanching erythema
II: Partial thickness dermal loss, blister or shallow red wound bed
III: Full thickness skin loss
IV: Injury through fascia
Components separation
Incise the external oblique aponeurosis lateral to the semilunar line and release from the underlying internal oblique. May also release the posterior sheath of the rectus to advance up to 20cm at middle.
Sternal wound acuity
acute < 1 week: dehiscence and sternal instability, take to OR and close
subacute 2-4 weeks: purulence and leukocystosis, debride and local wound care followed by delayed closure when clean
chronic >4 weeks: chronic osteomylitis and sinus tracts, take for debridement, local wound care, delayed closure when clean, may require long term anitbiotics
Pectoralis muscle flap
thoacoacromial vessels. May disinsert the humeral attachment. Can also turnover based on internal mammary. Cover the superior sternal wound
Omental flap
right gastroepiploic vessels. tunnel for sternal wound over costal margin or through diaphragm. Hangs from stomach and transverse colon like an apron.
Gracilis flap
Innervation: branch from obturator nerve
Blood: medial femoral circumflex (off the profunda femoral)
Pedicle length 6 cm
Origin on pubic symphysis, inferior pubic ramus and ischium then inserts on medial condyle of knee
2-3 finger breadths posterior to the adductor longus
pedicle found under the adductor longus and enters muscle 10 cm below ischium.
Preserve saphenous vein
If plan for functional muscle mark 3-4 cm intervals prior to dividing insertion for tension
Drain and ACE wrap. Ambulation ok. Elevate. Ankle splinted in neutral.
Pudendal thigh (Sinapore) flap
Posteriorly based flaps centered on the groin crease
Reconstruct anterior and lateral vaginal defects
posterior labial vessels
sensation from pudendal nerve
Burn estimation
include 2nd and 3rd degree head 9 arm 9 each leg 18 each torso 18 front and 18 back children more head and less leg area singed facial hair or soot in airway - concern inhalation injury
Burn resusciation
1ml/kg hour urine output
Parkland 4mL/kg per % burn over 24 hours (half first 8 and second half next 16)
hand compartments
dorsal interossei (4 compartments) palmar interossei (3 compartments) adductor pollicus thenar hypothenar
lateral arm flap
Innervation: posterior cutaneous nerve
Blood: posterior radial collateral artery off the brachial artery
Flap based over humerus between triceps (posterior) and biceps bracialis, brachioradialis (anterior)
radial nerve is deep. On axis from deltoid insertion to lateral epicondyle.
Start dissection posterior deep to fascia over the triceps to the intermuscular septum. Then dissect anteriorly. The vessels will be in the septum. The radial nerve will come into view proximally.
soft dressing and drain.
latissumus flap
- thoracodorsal nerve
- thoracodorsal artery via subscapular artery via axillary artery (circumflex scapular artery and branch to serratus also come off subscapular artery) enters in posterior axilla 10cm inferior to insertion on humerus
- up to 20x40cm size
- origin iliac crest and thoracolumbar fasica and insert humerus (humeral adductor and internal rotator)
be sure to leave down serratus superiorly, easier to identify plane from starting inferior to scapula and dissecting superior to inferior. - May ligate the serraturs branch and circumflex scapular branch if need more length. May divide nerve to prevent animation deformity.
- Leave 2 JP drains.
- If seroma then aspirate.
plantaris graft
origin lateral supracondylar ridge of femur and insertion posterior calcaneous via calcaneal tendon
missing in 20% people. runs between soleus and gastroc. medial to achilles tendon.
Relative indications intervension Dupuytrens
MCP conrcture 30 degrees
PIP contracture
Adduction thumb interferes with activities
Relative indications intervention Dupuytrens
MCP contracture 30 degrees
PIP contracture
Adduction thumb interferes with activities
Timing syndactyly release
12-18 months
6 months if border digit due to differential growth
matacarpal and phalangeal fracture surgery indications
metacarpal neck angulation: 15 degrees index and middle, 30-40 degrees ring, 40-50 degrees small
intraarticular step off > 2mm and/or >30% articular surface
bony shortening > 3mm
open fracture
rotation
tendon transfer thumb opposition (low median)
extensor indicis proprius to abductor pollicis brevis
tendon transfer thumb flexion (high median)
brachioradialis to FPL
tendon transfer thumb extension
EIP to EPL
if radial nerve palsy then can use PL (if don’t have then FDS of middle)
Tendon transfer finger flexion
ECRL to FDP
tendon transfer finger extension (low radial)
FCU or FCR to EDC
tendon transfer wrist extension (low radial)
PT to ECRB
tendon transfer for claw (low ulnar)
FDS of the middle to the radial lateral bands of the middle, ring and small or ECRL with grafts to the radial lateral bands.
tendon transfer elbow extension
posterior deltoid
tendon transfer elbow flexion
pectoralis major, triceps, latissimus, forearm flexor mass (steindler)
margins for skin cancer
low risk has 95% BCC and 92% SCC disease free 5 years
BCC 4mm
SCC 4-6mm
high risk BCC/SCC
> 2cm in trunk, extremities
1cm scalp, forehead, cheeks, neck, pretibia, genitals, hands, feet
mask area ( periorbital, nose, lips, chin, mandible, ears, temple)
actinic keratosis
5-fluorouracil and imiquimod promote apoptosis of malignant skin cells by inhibition of DNA synthesis and activation of cell-mediated immune response or cryotherapy
apex of orbit
44-50mm posterior to orbital rim
Superior orbital fissure syndrome
Near orbital apex. Compression or fracture causes:
Oculomotor - upper eyelid ptosis, fixed dilation, weakness of superior, inferior and medial rectus and inferior oblique
Trochlear - superior oblique weakness
Abducens - lateral rectus weakness
Ophthalmic division of V1 - numbness forehead and upper eyelid
Superior and inferior ophthalmic veins - proptosis
orbital apex syndrome
superior fissure syndrome with involvement of the optic canal that includes the optic nerve and ophthalmic artery through the greater wing of the sphenoid. This adds blindness.
enophthalmos
posterior displacement of globe in AP axis
detectable at 2mm
measure with Hertel exophthalmometer
increase in globe by 5% will cause enophthalmos
hypoglobus
inferior displacement of globe
evaluate by light reflex
indications for orbital floor surgery
enophthalmos > 2mm
defect > 1-2cm2 or 50% floor
entrapment
reverse sural flap
artery: sural branches from the peroneal (medial superficial sural artery)
veins: branches lesser saphenous
nerve: sural cutaneous
covers the heel and ankle
pivot point 5 cm above the lateral malleolus
instep flap, medial plantar
artery: medial plantar artery from posterior tibial.
vein: vena commintantes or greater saphenous vein
nerve: medial plantar nerve
medial plantar artery runs between abductor halluces and flexor digitorum brevis