Plastic Surgery Flashcards
Description of burn severity
1) depth
depth usually difficult to determine initially and easier to determine after 24 hours
depth based on layers of skin involved in the burn, from superficial to deep
2) percentage of total body surface area
burns need to be described in terms of % total body surface area (TBSA), which is estimated by rule of 9’s for any patient >9 years
head, chest, abdomen, upper back, lower back, left arm, right arm, anterior left leg, posterior left leg, anterior right leg and posterior right leg each approximately have 9% TBSA
genital area approximately have 1% TBSA
for patchy burns, % TBSA estimated using palm method where palm without fingers = 0.5% TBSA and palm with fingers = 1% TBSA
Lund-Browder chart is more accurate and often used in children <9 years
Superficial burns: Involved tissue Appearance Sensation Healing time Common cause
Involved tissue - epidermis
Appearance - Dry, red, Blanches with pressure
Sensation - Painful
Healing time - 3-6 days
Common cause - UV exposure, very short flash
Superficial partial thickness burns: Involved tissue Appearance Sensation Healing time Common cause
Involved tissue - epidermis and part of dermis
Appearance - Blisters, moist, red, weeping, blanches with pressure
Sensation - Painful to temperature and air
Healing time - 7-20 days
Common cause - Scald (spill or splash), short flash
Deep partial thickness burns: Involved tissue Appearance Sensation Healing time Common cause
Involved tissue - epidermis and part of dermis
Appearance - blisters that are easily unroofed, wet or waxy, dry, variable colour, does not blanch with pressure
Sensation - perceptive of pressure only
Healing time - >21 days, scarring
Common cause - scald (spill), flame, oil, grease
Full thickness burns: Involved tissue Appearance Sensation Healing time Common cause
Involved tissue - epidermis and all of dermis
Appearance - waxy white to leathery gray to charred and black, dry and inelastic, no blanching with pressure
Sensation - deep pressure only
Healing time - never heals if >2% TBSA, which would require skin grafting to replace dermal integrity
Common cause - scald (immersion), flame, steam, oil, grease, chemical, electrical
Fourth degree burns: Involved tissue Appearance Sensation Healing time Common cause
Involved tissue - skin and underlying tissue (fascia/muscle)
Appearance - underlying tissue visible
Sensation - deep pressure only
Healing time - never heals, requiring skin grafting to replace dermal integrity
Common cause - scald (immersion), flame, steam, oil, grease, chemical, electrical
ABA burn severity grading system
American Burn Association grading system classified into minor, moderate or major burn based on depth and % TBSA
minor burn =
<15% TBSA in adults
<10% in children and older adults
<2% TBSA full thickness burn
moderate burn =
15-25% TBSA with <10% full thickness burn
10-20% TBSA partial thickness burn in children under 10 and adults over 40 with <10% full thickness burn
major burn =
25%+ TBSA
20%+ TBSA in children <10 and adults >40 years
10%+ full thickness burn or involving eyes/ear/face / hands / feet / perineum that are likely to result in cosmetic of functional impairment or high voltage electrical burn or major trauma or inhalation injury or poor risk patients with burn injury
Primary management of burns
1) Stabilize
2) Assessment of Burn - depth and % TBSA
3) Airway Management if Inhalation Injury
airway management mainly address A) inhalation injury and B) CO poisoning
A) inhalation injury
inhalation injury cause progressive upper airway edema, eventually closing up airway, which is leading cause of death in burn patients
inhalation injury also cause pulmonary injury, causing pulmonary edema and insufficiency by 2-3 days
B) CO poisoning
bronchodilator (Albuterol) if bronchospasm
steroids not indicated in burn patients
4) Fluid Resuscitation
2 large IV bores for IV crystalloids
fluid resuscitation need to be accurate, because inadequate fluid resuscitation increases risk of mortality while over-resuscitation can cause pulmonary edema / acute respiratory distress, pneumonia, multi-organ failure, compartment syndromes
estimation of initial fluid requirement based on Parkland formula
extra fluid administration for the following cases: burn >80% TBSA, 4th degree burns, associated traumatic injury, electrical burn, inhalation injury, delayed resuscitation, pediatric burn
target hourly urine output should be maintained at 0.5mL/kg per hour for adults and 1mL/kg per hour for children
blood transfusion should be avoided when possible
indication for blood transfusion = hemoglobin <80g/L in patient without acute coronary syndrome (ACS) or <100g/L in patient with ACS
5) Immediate Burn Care & Cooling
any hot or burned clothing, jewelry and debris should be immediately removed
burned area should be cooled immediately using cool water or saline soaked gauze (12C) for 15-30 minutes
monitor core body temperature continuously, because cooling of burns >10% TBSA can cause hypothermia which can be treated with warmed IV fluids to maintain temperature >35C
6) Pain Management
IV morphine for pain
Clinical presentation, physical exam, investigations, diagnosis and management for significant smoke inhalation injury
1) history
burn in a closed space
2) symptoms
hoarseness, persistent cough, stridor or wheezing
3) inspection
conjunctivitis
nares with inflammation or singed hair
carbonaceous sputum or burnt matter in mouth or nose
blistering or edema of oropharynx
deep facial or circumferential neck burns
4) general physical exam
depressed mental status including evidence of drug or alcohol use
respiratory distress, tachypnea
5) investigations
hypoxia or hypercapnia
elevated carbon monoxide (CO) or cyanide level
investigations for inhalation injury and respiratory distress include
vitals: oxygen saturation
arterial blood gas, serial peak expiratory flow rates (PEFR) if obtainable
chest X-ray
capnography, which can monitor end-tidal CO2 (EtCO2)
blood labs: serum lactate; serum cyanide level, blood carboxyhemoglobin (HbCO) level for moderate or severe burns
ECG to assess cardiac function
6) Diagnosis
inhalation injury can be diagnosed on direct bronchoscopy, and cannot be diagnosed based on chest X-ray or arterial blood gas
7) Management
patients with signs of smoke inhalation injury should be given supplemental oxygen and intubated early and prophylactically even without respiratory distress
Signs of CO poisoning
signs of CO poisoning: headache, confusion, coma, arrhythmias
Diagnosis of CO poisoning
CO poisoning diagnosed based on high HbCO
Management of CO poisoning
reversed with hyperbaric oxygen treatment
Cyanide poisoning diagnosis
cyanide poisoning diagnosed based on high blood cyanide level or high serum lactate plus low / decreasing EtCO2
Cyanide poisoning treatment
reversed with hydroxocobalamin
Parkland formula
Calculation for fluid resuscitation for burns
4mL/kg for each % TBSA burned over course of 24 hours where 1/2 is delivered in first 8 hours and other
1/2 is delivered in the subsequent 16 hours
e.g. 70kg patient with 10% TBSA burn = 4mL/kg x 70kg x 10 (for % TBSA) = 2800mL over 24 hours, so 1400mL over first 8 hours (i.e. 175mL/hr for first 8 hours) and 1400mL over subsequent 16 hours (i.e. 87.5mL/hr for subsequent 16 hours)
Hour 24-30 – 0.35-0.5 cc plasma/kg/%TBSA
Hour >30 – D5W at rate to maintain normal serum sodium
Secondary burn management
1) Further Investigations
2) Prevention of Infection
tetanus prophylaxis with 0.5cc tetanus toxoid for any burn deeper than superficial or >10% TBSA
tetanus immunoglobin if prior immunization is absent, unclear or out dated >10 years ago
topical antibiotics (Silver Sulfadiazine SSD) applied to all non-superficial burns
Bacitracin for skin near eyes & mouth, sulphonamide hypersensitivity, pregnant mothers, newborns and nursing mothers
3) Wound Management (Minor to Severe Burns)
if not already done, remove clothing / jewelry / debris and cool wound with saline-soaked gauze (12C)
a) pain management
minor burn can be treated with acetaminophen and NSAID in combination with opioids if required
superficial burn can be treated with non-perfumed moisturizing cream (Vaseline, Nivea) applied to wound with aloe for pain control and keeping skin moist
b) burn wounds cleaned and irrigated
embedded foreign body removed by irrigation
wound washed with mild soap and tap water
c) debridement
sloughed or necrotic skin including ruptured blisters are debrided
d) wound dressing
all partial and full thickness burns should have dressings
e) escharotomy
f) skin grafting
g) rehabilitation
prevention of wound contracture with pressure dressing, joint splints and early physiotherapy
4) NG Tube
thermal burn shock may cause mesenteric vasoconstriction causing gastric distension, ulceration and aspiration
for patients with moderate or severe burns >20% TBSA, nasogastric (NG) tube
What is an eschar, eschartotomy and indications for escharotomy
eschar = stiff and unyielding dermis with deep dermal and full thickness burns
escharotomy = incision of eschar with coagulation electrocautery or scalpel
eschar may limit respiratory function (such as eschar in neck and chest), which require emergency escharotomy
circumferential eschar may cause compartment syndrome or distal ischemia, thus require decompressive escharotomy
Indication for skin grafting in burn
indication for skin graft = full thickness and 4th degree burns that is bigger than size of quarter
Wound dressing for burn process
before wound dressing, the burn should be cleaned thoroughly, debrided and topical antibiotics should be applied
topical antibiotics to prevent infection and sepsis by common skin organisms (Gram positive day 1-3 including staphylococcus aureus; gram negative day 3-5 including
pseudomonas, proteus, klebsiella; Candida)
basic dressing = 1st layer of fine non-adherent mesh gauze (Telfa, Adaptic) placed over burn, 2nd layer of fluffed dry gauze and 3rd layer of elastic gauze roll (Kerlix)
dressing in successive strips held in place using tubular net bandage or gauze wraps
individually wrap and separate with fluffed gauze all toes and fingers to prevent adherence and maceration
dressing change can range from twice daily to weekly
once epithelialization occurs, non-perfumed moisturizing cream (Vaseline, Nivea) applied to wound
Complications of burn
hypermetabolism: nutrition should meet increased metabolic rate with adequate calories, vitamin C, vitamin A, Ca, Zn, Fe
immune suppression: increased risk of sepsis so must monitor for signs of sepsis and treat aggressively with antibiotic therapy if present
GI bleed: NG tube feeding or NPO with TPN; may add antacid and anti-histamine blocker to prevent GI bleed
renal failure: renal failure usually due to pre-renal or myobloginuria, which can be prevented with adequate fluid resuscitation
pulmonary insufficiency (due to inhalation injury, pneumonia, cardiac decompensation, sepsis): treated with intubation and mechanical ventilation
wound contracture and hypertrophic scaring: prevented with timely wound closure, splinting, pressure garments and physiotherapy
vascular permeability and edema
altered hemodynamics (decreased CO, increased SVR)
Burn indication for admission to hospital
moderate to major burns according to ABA grading system
involvement of face, neck, hands, feet, genitalia, perineum, major joints
suspected inhalation injury
circumferential partial or full thickness burn
immune compromised patients or poor expected recovery (diabetics, elderly)
chemical burn
high voltage injury with abnormal ECG
Transfer to burn centre indications
major burn based on ABA grading system should be transferred to a burn center
> 10% TBSA partial thickness burn
> 5% TBSA full thickness burn
burn involving face, neck, hands, feet, genitalia, perineum or major joints
pre-existing medical condition that can complicate management, prolong recovery or adversely affect outcome
special requirement (social, emotional or long term rehabilitative needs)
children who require qualified pediatric personnel and equipment
Stages of wound healing
“In Every Fresh Cut” = Inflammation, Epithelization, Fibroplasia, Contraction
1) Inflammatory Reactive Phase (day 1-6)
inflammation limits damage and prevent further injury
debris and organisms cleared by inflammatory response, mainly neutrophils in day 1-2 and macrophages in day 2-4
hemostasis achieved by vasoconstriction and platelet plug
2) Proliferative Regenerative Phase (day 4 to week 3)
macrophage secrete growth factors that recruit and activate fibroblasts
fibroblasts initiate reparative process of re-epithelialisation, matrix synthesis (mainly type 3 collagen synthesis) and angiogenesis
reparative process increase tensile strength of wound by day 4-5
3) Remodelling Maturation Phase (week 3 to 1 year)
increasing collagen organization and stronger cross links, resulting in wound contraction, scarring, then remodelling of scarring
type 1 collagen replaces type 3 until 4 to 1 ratio is achieved
peak tensile strength at 60 days, which is 80% of pre-injury strength
Primary closure indication, contraindication and mechanism
indication: recent (<6 hours) and clean cut wounds such as surgical wounds or acute traumatic wounds where wound edges can be brought together by external mechanism
contraindication: bite wounds, crush injury, infection, long time lapse since injury (>6 hours), retained foreign body
mechanism: wound edges brought together by stitches, staples or adhesive tape within hours of wound creation
Secondary closure indication, mechanism
indication: wound that cannot be cleaned or wound too large that skin cannot be brought together (e.g. ulcer)
mechanism: wound healed spontaneously by body without any external mechanism means
spontaneous healing at rate of 0.75 mm/day from wound margins in concentric pattern
require wound care and have inferior cosmetic result
Tertiary closure (aka delayed primary closure) indication, mechanism
indication: chronic or contaminated wounds where wound edges can be brought together by external mechanism; severe crush injury with significant tissue devitalization
mechanism: wound left open (often healing interrupted with packing), cleaned and observed, where it may be closed 4-5 days later (when granulation / epithelization occurred)
prolonged inflammatory phase to decrease bacterial count and lessen chance of infection after closure
require wound care
Wound contamination definition
contamination = presence of non-replicating micro-organism within wound
Wound colonization definition
presence of replicating microorganism within wound
Wound infection definition
> 105 micro-organism (or small amount of virulent organism) in wound without intact epithelium
Acute management of contaminated wounds <24h
evaluate for injury to underlying structure (blood vessel, nerve, tendon, bone)
control active bleeding
cleanse and irrigate open wound with physiologic solution (NS or RL)
surgical debridement with blade and irrigation to remove foreign material, devitalized tissue, old blood
Systemic antibiotics and tetanus toxoid, immunoglobin and immunization where applicable
post exposure treatment of hepatitis B / C or HIV if indicated
re-evaluate wound at 24-48 hours for signs of deep infection (erythema, swelling, warmth, pain, purulence), where infected wound need to have sutures removed and opened
Indication for systemic antibiotics in contaminated wounds
Clinically infected wound (wound redness, swelling, pain, purulence; fever; leukocytosis)
wound >8 hours
severely contaminated wound
immune compromised patient
wound involving deeper structure
Tetanus prone wound characteristics
> 6h since injury
> 1cm depth of injury
Crush, burn, gunshot, frostbite, puncture thorugh clothing, farming injury mechanism of injury
Devitalized tissue present
Contamination present
Retained foreign body present
Tetanus immunization recommendations
1) Uncertain or <3 doses of immunization :
A) Clean, minor wound
Tdap yes, Tig No
B) All other wounds
Tdap yes, Tig yes
3 doses received in immunization series
A) Clean, minor wounds
Tdap no, but yes if >10 years since last booster
Tig No
B) All other wounds
Tdap No, but yes if >5 years since last booster
Tig no, but yes if immunocompromised
Long term management of contaminated wounds >24h
irrigation and debridement
topical antimicrobial
systemic antibiotics if clinical signs of infection (wound redness, swelling, pain, purulence; fever; leukocytosis)
when bacterial count <10^5, closure usually by secondary intention, but may be by tertiary intention, skin graft or flap
Indications for wound care
wound care only in 2nd or 3rd intention wound healing
in general, wound care indicated for any chronic non-healing wounds including surgical wounds and traumatic wounds
diabetic wounds/ diabetic foot ulcer
venous leg ulcers
pressure ulcer
complex soft tissue wounds
infected wounds
What is wound care
wound care encompasses all management to facilitate healing of wound, which can be any combination of the following
medical care: antibiotics, controlling of blood sugar
wound debridement: irrigation, surgical
topical therapy: antiseptics, antimicrobial agents
wound dressings
wound packing
wound closure
Aspects of wound care
A) Medical management
systemic antibiotic therapy for clinically infected wound with any of the following
local signs: cellulitis, lymphagitic streaking, purulence, malodor, wet gangrene, osteomyelitis
systemic signs: fever, chills, leukocytosis, nausea, hypotension, hyperglycemia, confusion, blood glucose control, especially for diabetic patients
B) Debridement
C) Topical Therapy
antimicrobial cadexomer iodine (Iodosorb)
D) Wound Dressing
wound dressing should eliminate dead space, control exudate, prevent bacterial overgrowth, ensure proper fluid balance
primary goal of dressing = maintain moisture in wound environment
E) Wound Packing
wound packing usually indicated for large soft tissue defects (area of dead space between surface of intact healthy skin and wound base)
wound packing with gauze dressing requires frequent dressing changes usually 2-3 times daily such that the gauze does not completely dry out
wound dressing stopped when necrotic tissue have been removed and granulation is occurring
F) Wound Closure / Coverage
wound closure in wound care as tertiary intention (delayed primary closure)
chronic wound should never be closed primarily, and only delayed primary closure in some cases
wounds are closed by delayed primary closure if it demonstrates progressive healing based on granulation tissue and epithelization
negative pressure wound therapy for deep wounds to reduce complexity and depth of defect prior to definitive closure
after sufficient wound care wound can be closed by
closure with suture, staple or tape coverage with skin grafts
Classification of skin graft
1) Species classification
autograft = donor and recipient sites on same individual
allograft (homograft) = donor site from one human to an recipient site on another human
xenograft (heterograft) = donor site from a different species (e.g. pig) to an recipient site on a human
2) Thickness classification
split vs full thickness (some vs all of dermis)
Split thickness vs full thickness skin graft
split thickness skin graft can be used as mesh graft, which can cover a large area
advantage: best for contaminated recipient site, prevent accumulation of fluids (hematoma, serum)
disadvantage: poor cosmoses (alligator hide appearance), significant secondary contracture
Full thickness
advantages: may use on face and fingers
disadvantages: lower rate of survival (thicker, slower vascularization)
Unsuitable and suitable vascularized beds for skin graft
unsuitable bed due to lack of vascularization: bone, tendon, cartilage
suitable vascularized bed: muscle, fat, periosteum
Skin graft will take under the following conditions
vascularized bed
non-contaminated wound with bacteria count <10^5
minimize shearing motion and fluid (including seroma and hematoma) beneath graft, where immobilization by staples, sutures, splinting and appropriate pressure dressing are used to prevent graft movement, hematoma and seroma formation
Causes for skin graft loss
fluid collection: hematoma, seroma
infection
mechanical force: shearing, pressure
Skin flaps definition
tissue transferred from one site to another with its original blood supply, thus not dependent on neovascularization on recipient site
skin flaps may consist of skin, subcutaneous tissue, fascia, muscle, bone and other tissue
Indication for skin flaps
reconstruction to replace tissue loss due to trauma or surgery
provide temporary skin and soft tissue cover through which surgery can be carried out later
improves blood supply to poorly vascularized bed such as bone
Classification for skin flaps
skin flaps can be classified based on blood supply or anatomic location
1) blood supply: random, axial
a) random pattern flaps
random pattern flaps have random vascular supply
limited length to width (2 to 1) ratio to ensure adequate blood supply
b) axial pattern flaps
flap contains a well defined artery and vein
allows greater length to width (6 to 1) ratio
2) anatomic location: local, regional, distant
What can cause skin flap loss
fluid collection: hematoma, seroma
infection
poor flap design
mechanical forces: compression
vascular failure or thrombosis
fat necrosis
Characteristics of basal cell carincoma
nodulo-ulcerative type: papule / plaque / nodule with white translucent shiny scaly (“pearly”) borders usually well defined, which may contain telangiectasia (tiny blood vessel)
lesion may have erosion or ulceration
variant include
pigmented variant: flecks of pigment in translucent lesion, which may mimic melanoma
superficial variant: flat tan to red brown plaque, with scales, pearly border and fine telangiectasia
sclerosing variant: flesh / yellowish coloured shiny papule / plaque with indistinct border
Typical location of basal cell carcinoma
Sun exposed area such as face, neck and back of hands
Etiology of basal cell carcinoma
cancer arising from basal stem cells of epidermis
Incidence of basal cell carcinoma
3/10 will develop BCC in their lifetime
75% of all malignant skin tumor in age >40 years with increased prevalence in elderly
most common tumour of all cancers
Characteristics of squamous cell carcinoma
indurated erythematous nodule / plaque with surface scale crust, which eventually ulcerates
SCC tend to have more scales than BCC
ulcerated SCC usually have a volcano morphology with central ulcer surrounded by hard raised edges
keratoacanthoma = low grade SCC, usually dome shaped lesion with central keratosis / debris
more rapid enlargement than BCC
do not have pearly border
Typical location of squamous cell carcinoma
face, ears, scalp, forearms, hands
Etiology of squamous cell carcinoma
cancer arising from supra-basalar stem cells in epidermis
Incidence of squamous cell carcinoma
incidence of ~0.1-0.3% for males; 0.03-0.1% for females
Characteristics of cutaneous malignant melanoma
dark pigmented lesion, which can be flat and / or raised or nodular
usually asymmetric, irregular (jagged) and ill-defined borders, mixture of colours, diameter >6mm and evolves over time (ABCDE)
melanoma can be amelanotic (i.e. unpigmented)
color correlate with melanoma pathology
black = melanoma only in corneum
brown = melanoma invading to junction between epidermis and dermis
blue = invasion into dermis
pink = blood capillary
light coloured = undifferentiated melanoma cells
ugly duckling rule: in patients with many nevi, melanoma usually looks different in morphology compared to other nevi (i.e. it stands out amongst other nevi)
melanoma can occur on nail as acral melanoma, which appear as longitudinal tan, black or brown streak on nail that may involve palms of hands or soles of feet
Subtypes include lentigo melanoma in situ, invading dermis, superficial spreading, nodular and acrolentiginous (palmar, plantar or sublingual)
Typical location of cutaneous malignant melanoma
skin, mucous membrane, eyes, CNS
most common skin sites:
back for males
calves for females
Etiology of cutaneous malignant melanoma
cancer arising from melanocytes on epidermal basement membrane or from pre-existing nevus
Incidence of cutaneous malignant melanoma
incidence 1/75 in canada
Describe a method used for the determination of prognosis in cutaneous malignant melanoma.
T = Breslow depth, which is most important prognostic factor, especially for stage 1 and 2
Breslow depth = depth from stratum granulosum of epidermis to deepest point of invasion of melanoma cells
larger Breslow depth = worse progonosis, where >1mm deep into dermis is a high risk for metastasis
T staging also account for ulceration and mitotic index
Management of craniofacial injury
consultation with dentistry, ophthalmology if indicated
1) re-establish normal occlusion, ensure normal eye function
2) restore stability of face and appearance (repair of soft tissue injury within 8 hours, repair of fracture can be within 5-10 days for swelling to decrease)
Classification of craniofacial injury
craniofacial fracture based on bone affected: nasal, zygomatic, mandibular, maxillary
frequency of fracture: nasal > zygomatic > mandibular > maxillary
Nasal fracture treatment
if no complication, then no treatment
if septal hematoma, drain to prevent septal necrosis with perforation
if displaced fracture, then closed reduction with forceps under anesthesia and pack nostril with Adaptic and nasal splint for 7 days
best window for reduction = immediately within 6 hours or when swelling subsides within 5-7 days
if residual deformity post recovery, then rhinoplasty
Naso-Orbital-Ethmoid Fracture classification
Markowitz-Manson Classification
type 1 = single, central fragment, medial cantonal ligament intact
type 2 = comminuted central fragment, medial canthal ligament intact
type 3 = severely comminution of central fragment and disrupted medial canthal ligament
Naso-Orbital-Ethmoid Fracture management
surgical repair to retore intercanthal distance, nasal projection and orbital anatomy
Mandibular fracture classification
Classifications by anatomic region
Symphysis - midline of the mandible, between the central incisors from the alveolar process through the inferior border of the mandible
Body - from the symphysis to the distal alveolar border of the third molar
Angle - triangular region between the anterior border of the masseter and the posterosuperior insertion of the masseter distal to the third molar
Ramus - part of the mandible that extends posteriosuperiorly into the condylar and coronoid processes
Condylar - area of condylar process of mandible
Subcondylar - area below the condylar neck (ie sigmoid notch) of the mandible
Coronoid process - area of the coronoid process of mandible
Mandibular fracture treatment
maxillary and mandibular arch bars wired together or ORIF
PO antibiotics to cover against S. aureus and anaerobes
Maxillary fracture classification
Le Fort I (Guerin fracture):
Horizontal
Involves piriform aperture, maxillary sinus, pterygoid plates
Anatomical result: maxillar divided into 2 segments
Le Fort II (Pyramidal fracture):
Pyramidal
Involves nasal bones, medial orbital wall, maxillar, pterygoid plates
Anatomical result: Maxillary teeth separated from face
Le Fort III (Craniofacial dysjunction):
Transverse
Involves nasofrontal suture, zygomatofrontal suture, zygomatic arch, pterygoid plates
Anatomical result: detach entire midfacial skeleton from cranial base
Maxillary fracture treatment
ORIF in OR under general anesthesia
Le Fort 1 fracture: mandibulo-maxillary fixation (MMF)
Le Fort 2 fracture: disimpaction, MMF, sub-labial incision and exposure of maxillary bone and fracture lines for stabilization of maxilla to zygoma
Le Fort 3 fracture: stabilize mobile segments of bone to stable mandible below and cranium above, disimpaction of maxilla and MMF
Zygomatic fracture is associated with what type of fracture
orbital floor
Zygomatic fracture classification
category 1 = fracture restricted to zygomatic arch
category 2 = depressed fracture of zygomatic complex
category 3 = unstable fracture of zygomatic complex (tetrapod fracture) with separation at axilla, frontal bone, temporal bone and orbital rim
Zygomatic fracture treatment
undisplaced, stable and asymptomatic: soft diet, no treatment necessary
uncomplicated zygomatic arch fracture: elevated using Fillies approach (leverage on anterior part of zygomatic arch via temporal incision)
other fractures (especially displaced or unstable fracture): ORIF
Orbital floor fracture is associated with what types of fractures
associated with nasoethmoid fracture, zygomatic fracture
Orbital floor fracture treatment
ophthalmology consultation and evaluation
indication for surgical repair: entrapment (extra-ocular muscle, orbit), floor defect >1cm, exophthalmos, persistent diploplia
surgery = surgical reconstruction of orbital floor with bone graft or alloplastic material
Superior orbital fissure syndrome treatment
operative reduction
orbital apex syndrome treatment
treated with urgent decompression of fracture in optic canal or steroids
Felon pathophysiology
Paronychia or puncture wound into pad of digit -> subcutaneous abscess in fingertip (digital pulp)
Felon clinical presentation
inflammation of finger tip, tense swelling of finger tip (abscess)
Felon treatment
incision & drainage
PO antibiotics (Cloxacillin 500mg PO Q6H)
elevation, warm soaks
Tenosynovitis pathophysiology
Penetrating injury -> infection of flexor tendon sheath, which can lead to tendon necrosis and rupture if not treated
Tenosynovitis clinical presentation
Kanavel’s 4 cardinal signs =
- point tenderness along flexor tendon sheath
- severe pain on passive extension of DIP
- fusiform swelling of entire digit
- flexed posture
Tenosynovitis treatment
surgical emergency -> incision and drainage plus irrigation in OR
IV antibiotics
resting hand splint until infection resolves
Deep Palmar Space infection pathophysiology
Infection of 3 deep closed spaces (thenar, midpalmar or hypothenar) space
Deep Palmar Space infection clinical presentation for thenar space abscess
thenar space abscess: widely abducted thumb and fulness on dorm of first web space, with severe pain on adduction or opposition of thumb
Deep Palmar Space infection clinical presentation for midpalmar space abscess
midpalmar space abscess: loss of normal palmar concavity, 3rd & 4th finger partially flexed posture, pain on passive extension of 3rd & 4th fingers
Deep Palmar Space infection clinical presentation for hypothenar space infection
no involvement of fingers or flexor tendons
Deep Palmar Space infection treatment
Surgical emergency
I&D as well as debridement of closed space in OR
IV antibiotics
Deep Palmar Space infection clinical presentation
generalized palmar swelling and tenderness over anatomical involved palmar space, generalized dorsal swelling
Herpetic Whitlow epidemiology
Associated with medical and dental personnel, children
Herpetic Whitlow pathophysiology
infection of skin by Herpes Simplex Virus (HSV-1 or HSV-2)
Herpetic Whitlow clinical presentation
fingertip painful vesicle on erythematous base
may be associated with fever, malaise and lymphadenopathy
Herpetic Whitlow investigation
culture for HSV
Herpetic Whitlow treatment
viral prep protection to avoid infection
consider oral anti-viral Acyclovir to facilitate healing
Herpetic Whitlow treatment
viral prep protection to avoid infection
consider oral anti-viral Acyclovir to facilitate healing
Stenosing tenosynovitis pathophysiology
non-infectious inflammation of synovium causing size discrepancy between tendon and sheath / pulley
Stenosing tenosynovitis etiology
idiopathic, associated with rheumatoid arthritis, diabetes, hypothyroidism, gout
Stenosing tenosynovitis clinical presentation
most commonly affect thumb, 3rd and 4th finger
catching, snapping or locking of affected finger
tenderness to palpation and / or palpable nodule at palmar aspect of MCP over A1 pulley
Stenosing tenosynovitis management
conservative management: NSAID, steroid injection
surgical treatment: surgical flexor tendon release, incision of A1 flexor tendon pulley to permit unrestricted full active finger ROM
Carpal tunnel syndrome epidemiology
Epidemiology
4 females : 1 male ratio
most common entrapment neuropathy
Carpal tunnel syndrome etiology
1) primary:
idiopathic
repetitive wrist flexion
2) secondary:
space occupying lesion (tumour, hypertrophic synovial tissue, fracture callus, osteophyte)
metabolic (pregnancy, hypothyroidism, acromegaly, rheumatoid arthritis)
infection
neuropathy (diabetes, alcoholism)
familial disorder
Carpal tunnel syndrome pathophysiology
compression of median nerve at level of flexor retinaculum
Carpal tunnel syndrome clinical presentation
sensory loss in median nerve distribution: loss of discriminative touch, decreased light touch and 2 point discrimination especially at finger tips
motor loss in advanced cases: wasting of thenar muscles
classically, hand pain / numbness, relieved by shaking, dangling or rubbing
Tinel’s sign: tingling sensation on percussion of nerve at wrist
Phalen’s sign: wrist flexion induces symptoms
Carpal tunnel syndrome diagnosis
clinical diagnosis
nerve conduction studies can confirm diagnosis
Carpal tunnel syndrome management
conservative management: avoid repetitive wrist & hand motion, wrist splints to keep wrist in neutral position when performing repetitive wrist motion and at night
medical management: NSAID, local corticosteroid injection, oral corticosteroids
surgical treatment: transverse carpal ligament incision to decompress median nerve
Carpal tunnel indications for surgery
Numbness and tingling, sensory loss, weakness / muscle atrophy
unresponsive to conservative measures
Complications for surgery
injury to median nerve branches (median motor branch, palmar cutaneous branch) or superficial transverse vascular arch
local pain
scar formation
Complications for surgery
injury to median nerve branches (median motor branch, palmar cutaneous branch) or superficial transverse vascular arch
local pain
scar formation
Rheumatoid hand clinical presentation
Clinical Presentation
early stage: erosion of ulnar styloid
progression: symmetrical joint space narrowing and erosion of carpal bones, MCP and PIP, while sparing DIP on X-ray
late stage: Swan neck, Boutonniere finger deformity, radial deviation at wrist, ulnar deviation at MCP
Rheumatoid hand management
non-surgical treatment is the foundation of management of rheumatoid arthritis
surgery:
tendon repair of ruptured tendon in synovitis
MCP arthroplasty
resection of distal ulna
soft tissue reconstruction for ulnar MCP deviation
arthrodesis (surgical fixation of joint to promote bone fusion) in thumb deformity
Rheumatoid hand indications for surgery
Patient’s goal of improving cosmesis or function (ROM) of hand that may be achievable with surgery
Surgery for hand arthritis indications
Intractable pain unresponsive to medical management
Gross deformity
Very limited ROM that is disabling
Surgery for hand arthritis surgical options
surgical options: arthrodesis or arthroplasty
arthrodesis = fusion of bones within a joint, creating a stronger more stable and pain-free joint, but little flexibility or movement
arthroplasty = removing damaged joint and inserting an artificial implant in its place, which relieve pain, restore shape of hand and restore some function of hand
arthroplasty do not fully replicate normal finger motion and have risk of breaking and slipping, where >30% fail within 10 years
Distal phalanx fracture epidemiology, mechanism, management
Epidemiology: most common fracture in hand
Mechanism of injury: crush injury
Management: decompression or subungual hematoma & removal of nail, 3 weeks of digital splinting
Proximal and middle phalanx fracture assessment, treatment,
Assessment: assess for mal-alignment of fracture resulting in rotation, which cause scissoring (overlap of finger on making fist) and shortening of digit
Treatment for undisplaced fracture: closed reduction, buddy tape to neighbouring stable digit, elevate hand, motion in guarded fashion 10-14 days post injury
Treatment for displaced, non-reducible or not stable with closed reduction: percutaneous pins (K-wires) or ORIF, then splint
Metacarpal fracture: Boxer’s fracture definition, mechanism, clinical presentation, treatment
Boxer’s fracture = extra-articular fracture of 5th metacarpal usually with acute angulation of neck of metacarpal into palm
mechanism: blow on distal dorsal aspect of closed fist
clinical presentation: loss of prominence of metacarpal head, volar displacement of metacarpal head, may be mal-aligned (scissoring on making fist)
treatment for slight angulated fracture (<40 degrees): closed reduction to decrease angle, then ulnar gutter splint for 3 weeks with PIP and DIP joints free
treatment for non-reducible and displaced fracture: ORIF
Metacarpal fracture: Boxer’s fracture definition, mechanism, clinical presentation, treatment
Boxer’s fracture = extra-articular fracture of 5th metacarpal usually with acute angulation of neck of metacarpal into palm
mechanism: blow on distal dorsal aspect of closed fist
clinical presentation: loss of prominence of metacarpal head, volar displacement of metacarpal head, may be mal-aligned (scissoring on making fist)
treatment for slight angulated fracture (<40 degrees): closed reduction to decrease angle, then ulnar gutter splint for 3 weeks with PIP and DIP joints free
treatment for non-reducible and displaced fracture: ORIF
Bennett’s fracture definition, clinical presentation, treatment
Bennett’s fracture = intra-articular fracture of based of thumb metacarpal, inherently unstable
clinical presentation: adduction of thumb due to abductor policies longus pulling metacarpal shaft proximally and radially
treatment: percutaneous pinning, thumb spica cast for 6 weeks
Rolando’s fracture definition and treatment
Rolando’s fracture = intra-articular T or Y shaped fracture of base of thumb metacarpal
treatment: ORIF with K wires
Rolando’s fracture definition and treatment
Rolando’s fracture = intra-articular T or Y shaped fracture of base of thumb metacarpal
treatment: ORIF with K wire
Hand fracture post op management
90% of hand fractures are stable in flexion (i.e. lock hand into function or safety position to prevent extension) to facilitate healing and maintain function post recovery
immobilization by cast or splint should be in position of function or safety
position of function (for splinting hand) = hand holding a pop can (wrist extension 15 degrees, MCP flexion 45 degrees, IP flexion, thumb abduction & rotation)
contra-indication for position of function: post-repair of flexor tendon, median / ulnar nerve injury
position of safety = wrist extension 45 degrees, MCP flexion 60 degrees, PIP and DIP in full extension, thumb abduction & opposition
MCP flexion to maximize collateral ligament stretch, PIP & DIP extension to maximize volar plate origin stretch
Immobilization complications
immobilization have complication of stiff, which should be prevented with early rehabilitation post removal of splint or cast
Dislocation management timeline
dislocation of fingers must be reduced as soon as possible
DIP and PIP dislocation
what’s more common, clinical presentation, management for closed dislocation and management for open injury
PIP dislocation more common than DIP dislocation
clinical presentation: commonly dorsal dislocation from hyperextension
closed dislocation: closed reduction -> splinting (PIP flexion 30 degrees and DIP full extension) or buddy taping with early mobilization to prevent stiffness
open injury: wound case, open or closed reduction, PO antibiotics
MCP dislocation clinical presentation, simple dislocation management, complex dislocation management
clinical presentation: dorsal dislocation more common from hyperextension, commonly index finger
simple dislocation (reducible with manipulation): 2 weeks of splinting with MCP flexion 30 degrees
complex dislocation (solar plate blocks reduction): open reduction + A1 pulley release -> extension blocking splint with MCP flexion at 30 degrees for 2 weeks then 10 degrees for 2 weeks
Ulnar collateral ligament of thumb injury
mechanism
skier’s thumb definition
gamekeeper’s thumb definition
Stener lesion definition
Clinical presentation
Incomplete UCL tear management
Stener’s lesion management
mechanism: forced abduction of thumb
skier’s thumb = acute UCL
gamekeeper’s thumb = chronic UCL injury
Stener lesion = complete UCL tear, where aponeurosis of adductor policies muscle is interposed between bones of MCP joint and torn ligament
clinical presentation: instability of thumb MCP joint with pain and weakness of pinch grasp, radial deviation of thumb >30 degrees in full extension
incomplete UCL tear: immobilization in thumb spica splint or modified wrist splint
Stener’s lesion: open surgical repair of UCL
