Plastic Surgery Flashcards
Surgical margins for low risk BCC
3 mm
Surgical margin for high-risk BCC
3-5 mm
High risk features for BCC
>20 mm trunk >6 mm face, hand, feet Poorly defined borders Recurrent lesion Poor differentiation Type of lesion: morpheic
Surgical margins for low risk SCC
4 mm
Surgical margins for high-risk SCC
5-10 mm
High risk features for SCC
Depth > 2mm Facial lesions Poorly defined borders Recurrent Perineural invasion Poor differentiation Type of lesion (morpheaform)
Surgical margins for Malignant melanoma
In Situ : 0.5 cm
< 1 mm: 1 cm
1-2 mm: 1-2 cm
2mm or higher: 2 cm
Limit of epinephrin injection for anesthesia
Without epinephrin:
5 mg/kg
Duration: 45-60 min
With epinephrine:
7 mg/kg
Duration of effect: 2-6 h
May add more after 30 min
Limit of bupivacaine
Without epi:
2 mg/kg
2-4 h
With epi:
3 mg/kg
3-7 h
Suitable syringe for wound irrigation
19 gauge
35 cc
25-35 psi
Wound left unapproximated, next step?
If unapproximated for 8 h or longer, need to debride and copiously irrigated to optimize for healing
Also high risk of infection
Indications for wound debridement
Devitalized
Irregular edges
Ragged edges
Unapproximated for 8 h
Suture suitable for skin closure with traumatic mechanism involved
Non-absorbable
Nylone, silk, prolene
Suture optimal for contaminated and infected wounds
Monofilament:
Prolene, monocryl
Suture that should be avoided in contaminated wounds
Multifilament:
Vicryl, silk
Prevention of traumatic tattoo
Debridement and irrigation ASAP
Suture removal time
Face:5-7 d
Elsewhere: 10-14d
Suture method not suitable for trauma
Sub-cuticular
Weak
Indication of vertical mattress siture
Areas difficult to evert (volar hand…)
Benefit of horizontal mattress suture
Everting
Time-saving
Benefit of running (baseball stich) suture
Time saving
Good hemostasis
Indication for tape for wound closure
Superficial, opposable edges, non-bleeding
Indications of skin adhesives
Small wound
Not much tension or shearing
My cause irreversible tattooing
Length/width ratio of ellipse
3
Contraindication to shave Bx
Should not be used for pigmented lesions
Which size of punch Bx does require closure?
Greater than 3 mm. Because may leave scarring
Is punch/shave biopsy in clinic aseptic or sterile?
Is aseptic but not sterile
Sterile gloves are indicated
Maximum chlorhexidine and betadine concentration on face
4% for chlorhexidine
7.5% betadine
Esp around eyes and ears
Local anesthetics with epinephrine indications and contraindications
Can be used anywhere in the body even digits.
Exception: If the digits have been significantly injured and could have vascular compromise for example saw injury
Epinephrine should only be avoided in patients with history of vascular compromise if injecting into an area that is compromised
Phases of wound healing
- Inflammatory phase:
1-6 d (in secondary healing continues until wound closed)
Hemostasis
Chemotaxis
2. Proliferation phase: Day 4- week 3 Collagen synthesis Angiogenesis Epithelialization
3. Remodeling phase: Week 3- year 1 Type I collagen replaces type III (nl: 4-1) Contraction Scarring Rrmodeling
Wound tensile strength begins to increase at:
4-5 d
Peak tensile strength of wound:
Achieved at 60 d
80 % of normal
Contraindication to primary wound healing (first intention)
Animal/human bites (except on face) Crush injuries Infection Long time lapse since injury (>6-8h) Retained foreign body
Indication: recent clean wound
Tertiary healing
Wound healing intentionally interrupted
Then
Closed primarily at 4-10 d post-injury after granulation tissue formed, and <105 bacteria/gram of tissue
Methods: packing, sharp debridement
Prolongation of inflammatory phase decreases bacterial count and lessens chance of infection after closure
Indications for third intention healing
Contaminated wounds (high bacterial count)
Long time-lapse since injury
Severe crush component with significant tissue devitalization
Closure of fasciotomy wounds
Tx of hypertrophic scar
Scar massage Pressure garment Silicone gel sheeting CS injection Surgical excision if other options fail. May recur
Keloid Tx
Multimodal therapy:
Pressure garments
Silicone gel sheeting
CS injection
Surgical excision (high risk of recurrence)
Fractional CO2 ablative lasers, radiation
Spread scar Tx
Excision and closure
has the same order of collagen fibers as normal scar
Chronic wound definition
Fail to heal within 4-6 wk Consider Bx (marjolin’s ulcer)
Risk factors for wound infection
>8h Severely contaminated Human/animal bites Immunocompromised Bites Involvement of deeper structures
Systemic AB for wounds
If acute (<24h) contaminated: AB indicated if obvious infection
If late (>24h) contaminated: systemic AB indicated
Wounds requiring tetanus prophylaxis
All wounds except clean, minor ones.
Including:
Contamination with saliva, feces, soil, dirt
Puncture wound, wound resulting from flying or crushing objects, animal bites, burns, frostbites
Tetanus prophylaxis in HIV pts
Should receive TIG regardless of tetanus immunization Hx
Tetanus prophylaxis in infants < 6 wk
Nothing if clean, minor
TIG without vaccine for other wounds
RFs fo tetanus
> 6h
Depth > 1cm
Crush, burn, gunshot, frostbite, puncture through clothing, farming injury
Devitalized tissue present
Contamination: grass, soil, saliva…
Retained foreign body
Pathogens in dog/cat bites
Pasteurella multocida
Staph aureus
Strep viridans
Investigations for cat/dog bite
Radiograph prior to therapy
Culture, gram stain
Treatment of cat/dog bites
Immediately: Clavulin 500 PO q 8h
Consider rabies prophylaxis
(Ig + vaccine)
Tetanus ?
Aggressive irrigation with debridement
Healing by secondary intension
Can consider primary closure for face
Contact public health if animal status unknown
Human bite pathogen
Staph > B hemolytic strep> eikenella corrodens > bacteroids
The most common germ: staph
Inv for human bite
Radiographs prior to therapy
Culture, Gram stain
Tx of human bite
Urgent surgical exploration of joint Drainage Debridement of infected tissue Copiously irrigate Clavulin 500 q 8h Clinda 300 q 6h+ cipro 500 q 12 h if allergic Secondary closure Splint
Negative pressure (vacuum assissted) wound healing
Placed under deep wounds or to enhance skin graft take.
Three phases of skin graft take
Plasmatic imbibition: first 48h
Inosculation: d2-3
Neovascular ingrowth: 3-5 d
Bacterial count required for graft take
< 100,000/cm3
Amount of contraction in partial vs full thickness grafts
Partial:
1° < 2° contraction
Full
1° > 2° contraction
Tendon donor site
Palmaris longus
Plantaris
Nerve donation sites
Sural
Antebrachial cutaneous
Medial brachial cutaneous
Appropriate Length:width ratio in random pattern flaps
3:1 in head and neck
1-2:1 elsewhere
Flap used to lengthen a scar
Z-plasty
Length:width ratio in axial flaps
5-6:1
Inv for cellulitis
CBC
B/C
Culture/Gram stain if wound
Plain x-ray: soft tissue edema
Indications for IV treatment of cellulitis
DM
Lymphangitis
Severe infection
Oral AB failure
Splint if hand
If on oral: reassess in 48 h
Types of necrotizing fasciitis
Type I:
Polymicrobial
Less aggressive
Type II:
Monobacterial
Usually B-hemolytic strep
Clinic of necrotizing fasciitis
Pain out of proportion to clinical findings Pain beyond erythema Edema Ecchymosis Blister Crepitus Tenderness \+/- flu symptoms Sometimes deceptively well at first but rapidly become toxic
Late findings:
Skin blue-black
Induration, bullae
Gangrene
Tx of necrotizing soft tissue infection
ABC
Mainstay:
Early (urgent) and complete surgical debridement, copious irrigation
Repeat surgery in 24-48h
IV Antimicrobial therapy:
Penicillin 4million q 4 h and/or clinda 900 IV q6h until final culture available
Supportive
Close monitoring
Inv for necrotizing fasciitis
Dx is clinical
CT: if suspect other diagnoses
CK: severely elevated (late sign)
Bed side incision, exploration, Bx if: difficult exam, non-supportive presentation, other possible conditions
Dish water pus, hemostat easily passed along facial plane during biopsy
Onset of venous vs arterial ulsers
Venous: rapid
Arterial: slow
Margins of venous vs arterial ulcers vs diabetic
Venous: irregular
Arterial: even, punched out
Diabetic: irregular or punched out
Common site fo diabetic ulcers
Metatarsal heads
ABI in different chronic ulcers
Venous: > 0.9
Arterial: < 0.9
Diabetic: inaccurately high
Pain in different chronic ulcers
Venous: moderate. Increased with leg dependency, decreased with leg elevation. No rest pain.
Arterial: extreme. Decreased with dependency, increased with leg elevation and exercise. Rest pain.
Diabetic: painless. Associated paresthesia/anesthesia
Tx of venous ulcer
Rest Leg elevation Compression: 30mmHg Moist wound dressings If infected: topical/systemic AB \+/- skin grafting
Tx of arterial ulcers
Rest No elevation No compression Moist dressing If infected: topical/systemic AB Modify risk factors Vascular surgical consultation (angioplasty, bypass) Treat underlying
Tx of diabetic ulcers
Control DM Wound care Foot care Orthotics, off loading Early intervention for infections: topical/systemic AB Vascular surgical consultation
Stages of pressure ulcer development
- Hyperemia: disappears one hour after removal of pressure
- Ischemia: Follows to 2-6 hours of pressure
- Necrosis: follows >6 hours of pressure
- Ulcer: necrotic area breaks down
Classification of pressure ulcers
- Non-blanchable erythema present for more than one hour after pressure removed
- Partial thickness skin loss
- Full thickness skin loss into subcutaneous tissue
- Full thickness skin lost into muscle, bone, tendon, or joint
If an eschar present over a pressure ulcer
Must remove the eschar for staging
Prevention of pressure ulcer
Good nursing care Clean dry skin Frequent repositioning Special beds or pressure relief surface Proper nutrition Activity Early identification of individuals at risk Manage continence issues
Treatment of pressure ulcers
Treat underlying medical issues Proper nutrition Continue preventive measures Wound debridement Moisture retentive or anti-microbial dressing Regular reassessment Systemic antibiotics for infections Assess for possible reconstruction
Zone of thermal burn where early intervention has most profound effect in minimizing injury
Zone of stasis (edema)
Between zone of heperemia and zone of coagulation (ischemia)
Intervention: moist aseptic environment, rich blood supply
Critical burn areas
Face/neck
Hand/feet
Genital
The burn size threshold crucial for morbidity and mortality in children
60%
Indications for a transfer to Burn Center
Involvement of: hands, feet, genitalia, face, eyes, ears, major joints, perineum
Partial thickness 20% or more TBSA in 10-50 yr
Partial thickness 10% TBSA or more in <10 yr or > 50yr
Full thickness 5% or more TBSA in all ages
Electrical burns, chemical burns, lightening
Inhalation injury
Medical comorbidities
Simultaneous trauma (attend trauma first)
If requiring special emotional, social and rehabilitation intervention
Children in a hospital without pediatric care specialist
The best monitoring measure for burn patient
Urine output
Maintain > 0.5 cc/ kg in adults
> 1 cc/kg in children
Also maintain:
Clear sensorium
HR< 120
MAP > 70
Tetanus prophylaxis in burn pt if:
Deeper than superficial-partial thickness
Or
>10% TBSA
0.5 cc toxoid
250 U TIG
Baseline lab studies in burn pt
Hb U/A BUN, Cr CXR Lytes Glucose, ECG Cross match if trauma ABG CO-Hb
Mx of burn (acute care)
ATLS Resuscitate with Parkland formula Extra fluid if needed Intubatiin/escharotomy for respiratory distress Escharotomy if circumferential limb burn Large bore IV x 2 Foley Identify immediate life-threatening conditions (inhalation injury, CO poisoning) TBSA Tetanus Baseline lab Cleanse, debride, treat wounds, antimicrobial dressing Early excision and grafting
If suspect inhalation injury, next step?
Intubation
Dx of inhalation injury
With direct bronchoscope
3 major respiratory problems after burn
- encircling burn scar
- CO poisoning
- Smoke inhalation leading to pulmonary injury
CO poisoning treatment
100% O2 with face mask until carboxyHb < 10%
Burn wound healing
Deep partial: grafting recommended
Third degree: graft/flap necessary
Fourth degree: needs flap
Tx of first degree wound
Oral NSAIDs for pain control
Topical creams for pain control and moisture
Aloe
Tx of superficial partial burn wound
Daily dressing change
Topical antimicrobial (polysporin)
Leave blisters intact ( unless impaired circulation/motion)
Tx of deep partial and third degree burn wound
Topical antimicrobials
Remove dead tissue (surgically debride to viable bleeding tissue)
Early excision and grafting : mainstay
Dressing (decreases bacterial proliferation)
Prevention of contracture:
Pressure dressing, joint splints, early physioterapy
Most common organisms in burn wound infection
Day 1-3: gram positive
Day 3–5: gram negative
Organisms: S. Aureus, P. Aeruginosa, C. Albicans
Silver sulfadiazine
Pain: minimal
Penetration: medium
Eschar: penetrates poorly
Healing: slows down.
Mild inhibition of epithelialization
Leukopenia
Sulfamylon (mafenide)
Pain: moderate
Penetration: well
Eschar: penetrates
Mild inhibition of epithelialization
Metabolic acidosis in wide area
Silver nitrate
Methemoglobinemia
Stains black
Leaches sodium from wound
Nanocrystalline silver-coated dressing
Pain: none or transient
Penetration: mediates
Eschar: no penetration
May stain, producing pseudoscar or facial discoloration (argyria-like symptoms)
Raised liver enzymes
RFs of burn wound infection
> 30% TBSA
Deep partial/ full thickness
Very young/ very old
Comorbidities
Wound dryness
Wound temperature
Secondary impairment of blood flow to wound
Acidosis
> 100,000 organisms/gr tissue
Motility of organism
Virulence/metabolic products
Antimicrobial resistance
Nutrition in burn pts
Consider supplementation with calories, vit C, vit A, Ca, Zn, Fe
Immunosuppression in burn pts
Must keep bacteria count < 105/gr tissue
Signs of sepsis in burn pts
Sudden onset of hypo/ hyperthermia
Unexpected CHF
Unexpected pulmonary edema
ARDS
Ileus > 48h post-burn
Mental status changes
Azotemia
Thrombocytopenia
Hypofibrinogenemia
Hyper/hypoglycemia
GIB in burn pts
If TBSA > 40 %
Usually subclinical
Tx: NPO, antacid, H2 blocker
Mechanism of injury by acids and bases
Acids: coagulation necrosis
Base: saponification, liquefactive necrosis
Tx of chemical burns
ABC
Remove contaminated clothing
Brush off any dry powders
Irrigation with water for 1-2 h
(Water contraindicated in heavy metal burns: Na, K, Mg, Li : soak in mineral oil
Eyes: if affected, wash with NS, refer
Inspect: hair, nail, webspaces
Correct metabolic abn
Tetanus
In necessary: contact poison control line
Local wound care, 12 h after initial dilution (debridement)
Wound closure same as for thermal burns
Beware of fluid, liver, renal, pulmonary damage
Special Tx for acid burns
Water irrigation
Then
Dilute sodium bicarbonate
HF acid special Tx
Water irrigation
Clip fingernails
Topical Ca gel
+/- SQ calcium gluconate
+/- 10% calcium gluconate IV
Sulfuric acid special Tx
Soap/lime prior to irrigation (direct water exposure produces extreme heat)
Special considerations in Tar treatment
Remove with repeated application of petroleum-based AB oint (polysporin…)
Electrical burn clinic
Often: small puncture burns on skin, extensive deep tissue damage requiring debridement
Late ophthalmologic complication of electrical burn
Cataract
Tissue resistance against electrical current
Bone> fat> tendon> skin> muscle> vessel/blood> nerve
Treatment of electrical burns
ABC
Primary and secondary survey
Monitor:
Hemochromogenuria
Compartment syndrome
Urine output
Wound:
Topical silver sulfadiazine, mafenide
Debridement: early, repeat q 48h
+/- amputation
Test for assessing radial and ulnar arteries
Allen
Pulses
Test for assessment of digital arteries
Capillary refill <2-3 sec
Doppler ultrasound
Ischemic contracture due to compartment syndrom
Volkman’s contracture
Normal compartment pressure
Up to 12
30-40: abn
Median nerve testing
To test AIN:
Flex DIP of index finger
OK sign
To test the recurrent motor branch:
Thumb to ceiling with palm up
Thumb to tip of 5th digit
Ulnar nerve testing
Extrinsic muscles:
Flex DIP of little finger
Intrinsic muscles: Peace sign (index finger abduction) Froment test (hold paper between adducted thumb and index finger and resist pulling)
Radial nerve testing
Extrinsic muscles:
Extend thumb (thumb’s up)
Extend wrist
Testing flexor digitorum profundus
Stabilize PIP in extension, ask pt to flex fingers
Examining flexor digitorum superficialis
Stabilize non-exam fingers in extension to neutralize FDP and ask the pt to flex examination finger at PIP
Nerve repair
<7 d and clean and no concurrent injuries: 7 d
Otherwise: secondary repair
To define level of nerve generation
Tinnel sign
Optimal repair of vessels of hand
Within 6 h
Tendon repair
Extensors: usually repaired in ED
Flexors: repaired in OR within 2 weeks
Indication of treatment of subungual hematomas
If > 50% of nail surface: trephination by puncturing the nail bed, under digital block
If suspect laceration of nail bed: remove nail to examine: irrigate, suture repair with chromic suture, replaces cleaned nail
Volar hand wound exploration
Not in ER
Most common organism in hand infection
S. Aureus
The most common spaces becoming infected in hand
Thenar
Mid-palm
Felon Tx
If early stages:
Elevation
Warm soak
Cloxacillin
If abscess/ pressure on skin/ failure to resolve:
I&D
C/S, Gram
Adjust AB
Flexor tendon sheeth infection (flexor tenosynovitis) clinic and Tx
Clinic: Tenderness along flexor tendon sheath Severe pain on passive extension Fusiform swelling of digit Flexed posture
Tx:
OR, I&D, copious irrigation, debridement, resting hand splint, IV AB, aggressive hand therapy after
Herpetic whithlow contagious time
Until completely heald
Tx of paronychia
Acute: warm compress, oral AB if caught early.
If abscess: I&D, avoid hitting nail bed), oral/IV AB
If abscess extending below nail plate: nail plate removal
Chronic: anti-fungals,
+/-eponychium marsupialization
+/- nail plate removal
Mx of amputation
X-ray of pt’s stump and amputated part
NPO
Clean, irrigate wound
Non-adhering dressing of the stump, cover with dry sterile dressing
Tetanus
AB (cephalo/erythro)
Irrigate amputated part gently with RL
Wrap in a NS/RL soaked sterile gauze
Place inside waterproof plastic bag
Place in a container
Place container on ice
Priorities for replantation of amputee
Children: better results
Thumb
Multiple digits
Contraindications to replantation
Multiple level amputation
Avulsion, crush injuries: relative contra
Mx: revision amputation
Mallet finger mechanism of injury
Sudden blow to tip of finger:
Forced flexion of the extended DIP leading to extensor tendon rupture at DIP
Types of mallet finger
Bony: fracture of distal phalanx distal to tendon insertion
Non-bony: forced flexion of the extended DIP
Tx of mallet finger
Splint DIP in extension for 6 wk, followed by 2 wk of night splinting
If inadequate improvement after 6 wk: 4 more wk of continuous splinting
Boutonniere deformity mechanism of injury
Injury or disease affecting the extensor tendon insertion into the dorsal base of the middle phalanx.
RA
Laceration
Volar dislocation
Forceful flexion of PIP
Boutonniere deformity Tx
Splint PIP in extension and allow active DIP motion
Swan neck deformity mechanism of injury
PIP volar plate injury
RA
Old, untreated mallet deformity
Swan neck Tx
Splint to prevent PIP hyperextension or DIP flexion
Corrective procedures
Tendon rebalancing
Arthrodesis/arthroplasty
De Quervain’s tenosynovitis
Inflammation of APL, EPB (extensor tendons in the first dorsal compartment)
Test for Dx of De Quervain tenosynovitis
Pain over the radial styloid induced by making fist with thumb in palm and ulnar deviation of wrist
Clinic of De Quervain tenosynovitis
+ finkelstein
Pain localized to the 1st extensor compartment
Tenderness/crepitation over radial styloid
DDx: CMC arthritis ( positive grind test: crepitus/pain elicited by axial pressure to thumb)
Tx of De Quervain tenosynovitis
Mild: NSAID, splint, steroid injection into tendon sheath
Severe: surgery
Most common site for ganglion cyst
Dorsal wrist, overlying scapholunate ligament
Ganglion cyst Tx
Do nothing
Aspiration. High recurrence
Steroid injection in combination with aspiration (if painful)
Operative excision
Common flexor tendon deformities
Between distal palmar crease and mid-middle phalanx
Superficialis and profondus sheathed together
Recovery of glide very difficult
No-man’s hand
Stenosing tenosynovitis
Trigger finger/thumb
Most common: A1 pulley (annular ligament around tendon) near MCP. Esp ring finger
Etiology: idiopathic, RA, DM, hypothyroidism, gout, pregnancy
Clinic: locking of finger in flexion/ extension
Catching, snapping, locking
Tenderness/nodule over palmar aspect of A1 pulley
W>M
Tx of stenosing tenosynovitis
NSAIDs Steroid injection (less successful if >60yr, or >6mo) Splint
Surgery if:
No/minimal relief with steroids
Position of safety for hand fxs
Wrist extension 0-30°
MCP flexion 70-90°
IP full extension
Early motion to prevent stiffness
Distal phalanx fx
Most common injury in hand
Usuallycrush injury
Subungual hematoma: must be decompressed
Tx: 3 week of digital splinting: STAX splint
If intra-articular fx displaced > 30%: K-wire and splint
Proximal/middle phalanx fx
If non/minimally displaced: close reduction Buddy tape to neighboring digit Splint 2-3 wk Early motion in guarded fashion
If displaced/ non-reducible/ non-stable/rotational or scissoring deformity: K-wire Or ORIF and splint
Metacarpal fx acceptable deviation
D2: Up to 10°
D3: 20°
D4: 30°
D5: 40°
Boxer’s fx
Acute angulation of the neck of the fifth metacarpal into Palm
Loss of prominence of metacarpal head
Up to 30-40° angulation accepted
If greater angulation: closed reduction
If stable, ulnar gutter splint x 4-6 wk
Bennett’s fx
Two-piece fx/dislocation of the base of the thumb metacarpal, usually intraarticular
Unstable fx
Tx: percutaneous pinning or ORIF then thumb spica x 6wk
Rolando fx
T or Y shaped fx of base of thumb metacarpal
Tx: like bennett
PIP or DIP dislocation Tx
PIP > DIP
Dorsal > volar
If closed: close reduction, splinting in position of function for 1 wk, or buddy tapping and early mobilization
If open: wound care, irrigation, debridement, close or open reduction, AB
Ulnar collateral injury (ski pole injury)
Mechanism: forced abduction of thumb
Skier’s injury: acute ulnar collateral injury.
Stable: splint 6-8wk
Unstable: may have stener lesion: the distal portion of UCL flips on adductor aponeurosis and does not heal: requires surgery
Gamekeeper’s injury: chronic UCL injury
Tx: open repair and tendon graft
Exam of UCL injury
Radial deviation of MCP in full extension and at 30° flextion
Rupture: if >30° radial deviation in extension or >15° in flexion
Compare with other hand
Dupuytren’s disease
Proliferative disorder of palmar fascia
Tendons not involved
male, early age, strong FHx (AD), multiple digits, sites other than palm (Ledderhose in plantar fascia), (Peyronie in penis)
Association with alcohol, smoking, DM
Most common digit
Ring >little > long> thumb > index
Tx of DuPuytren
If palmar pit/nodule: steroid for pain, no surgery
If palpable band without limitation of extension: no surgery
If MCP contracture > 30°, PIP contracture of any degree: needle aponeurotomy, collagenase, surgical fasciotomy
If contracture impending function/hygiene: needle aponeurotomy, collagenase, surgical fasciotomy
Better outcom in MCP
The most common entrapment neuropathy
CTS
Thenar eminence sensation in CTS
Spared (nerve: palmar cutaneous branch given off prior to carpal tunnel)
First sense lost in CTS
Discriminative touch
Dx of CTS
Clinical
+/- NCV, EMG
Tx of CTS
Avoid repetitive wrist and hand motion
Nighttime splinting to keep wrist in neutral position
NSAIDs,
Local CS injection ( relief is diagnostic)
Surgery if:
Persistent signs and symptoms of median nerve compression not relieved by conservative management.
Inv in brachial pkexus injury
EMG
MRI
CT myelogram
Tx of brachial plexus injury
If closed injuries:
CT myelogram or MRI if avulsion suspected
EMG/NCV if not
Follow 3-4 mo ( in obstetric cases surgery if no improvement after 6 mo)
If open injury:
Explore in OR (within a few days)
Approach to facial injuries
ATLS
Inspect, palpate, clinical assessment for injury to underlying structures
Tetanus
CT scan with fine cuts through the orbit
Wound irrigation
Remove foreign materials
Conservative debridement
Repair with 4.0 nylon
R/O skull fx, intracranial trauma
Investigation in facial injuries
CT (gold std):
Axial, cronal (1.5 cm cuts): for fxs of upper and middle face, as well as mandible
Indicated for:
Significant head trauma
Suspected facial fractures
Preoperative assessment
Panorex radiograph:
Shows entire upper and lower jaw. Best for isolated mandible fx
If high clinical suspicion of jaw fx and negative panorex
CT
Tx goals for facial injury
Reestablish normal occlusion if occlusion is an issue
Normal eye function (extra-ocular eye movements and vision)
Restore stability of face and appearance
Common sites of fractures in mandible
Condylar neck
Angle of mandible
Mandibular fx in anterior force
Bilateral
Mandibular fx in lateral force
Ipsilateral subcondylar and contralateral angle or body fx
Chin deviates towards side of a fractured condyle
Tx of jaw fx
Intramaxillary fixation with wire
Or
ORIF
Ideally within 48 h
AB from initial presentation until at least 3 doses post operatively. Extended course if late presentation
Le Fort I fx
Horizontal:
Piriform aperture
Maxillary sinus
Pterygoid plates
Maxilla divided into 2 segments
Le Fort II
Pyramidal:
Nasal bones
Medial orbital walls
Maxilla
Pterygoid plate
Le Fort III
Transverse:
Nasofrontal suture
Zygomaticofrontal suture
Zygomatic arch
Pterygoid plates
Nasal fx
Lateral > anterior force
Tx: inspect and drain septal hematoma in ER, then packing
Close reduction with forceps under anesthesia, then packing with petrolatum/non-adhesive gauze, nasal splint for 7 days
Best reduction time:
<6 h or when swelling subsides (5-7d)
Pathognomonic features of zygomatic fx
Subconjunctival hemorrhage
Periorbital ecchymosis
V2 numbness (infraorbital and superior dental nerves)
Others: Flattening of malar prominence Pain on palpation Palpable step defirmity in orbital rim Ipsilateral epistaxis Trismus
Tx of zygoma fx
If undisplaced, stable, no symptoms:
Soft diet
Undisplaced, non-comminuted arch fx:
Elevation
Comminuted arch fx:
ORIF
Stabilization is often unnecessary
If displaced, unstable:
ORIF
Inv for orbital floor fx
CT: axial, cronal with fine cuts through orbit
Diagnostic maneuver: forced duction test (pull on inferior rectus with forceps under local anesthesia in OR
Tx of orbital floor fx
Surgical repair if:
Entrapment
Any size defect with enophthalmos (if pt bothered)
Persistent diplopia (>10d)
Superior orbital fissure syndrome
Fx of SOF: Ptosis Proptosis Anesthesia in V1 Painful ophthalmoplagia
Tx: operative reduction
Orbital Apex syndrome
Fracture through optic Canal
Involvement of CNII
SOF symptoms plus vision loss
Tx: urgent decompression of fx or steroids
Indications for breast reduction
Musculoskeletal pain Chronic headache Paresthesia in upper limb Rashes under breast Breast discomfort Physical impairment
Complications of breast reduction surgery
NAC necrosis Sensory alteration of nipple Scarring Wound complications (esp if elevated BMI) Difficulty breastfeeding asymmetry Hematoma
Types of physiologic gynecomastia
Neonatal
Pubertal
Elderly
Types of pathologic gynecomastia
Endocinopathies:
Excess estrogen, androgen deficiency, deficient production or action of testosterone
Tumors
Chronic diseases: liver cirrhosis, renal
Congenital/genetic:
Kleinfelter/ androgen resistance
Pharmacology: Estrogens Gonadoteopins Exogenous steroids Antiandrogens Marijuana Heroin Amphetamines Antihypertensives
Massive wt gain
Tx of cleft lip
Surgery at 3 mo
Tx of cleft palate
Special bottle for feeding
Speech pathologist
Surgery (6-9 mo)
Often require myringotomy tubes due to recurrent otitis media
