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Med > Plastic Surgery > Flashcards

Plastic Surgery Flashcards

1
Q

Surgical margins for low risk BCC

A

3 mm

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2
Q

Surgical margin for high-risk BCC

A

3-5 mm

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3
Q

High risk features for BCC

A 
>20 mm trunk
>6 mm face, hand, feet
Poorly defined borders
Recurrent lesion
Poor differentiation
Type of lesion: morpheic
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4
Q

Surgical margins for low risk SCC

A

4 mm

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5
Q

Surgical margins for high-risk SCC

A

5-10 mm

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6
Q

High risk features for SCC

A 
Depth > 2mm
Facial lesions
Poorly defined borders
Recurrent
Perineural invasion
Poor differentiation
Type of lesion (morpheaform)
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7
Q

Surgical margins for Malignant melanoma

A

In Situ : 0.5 cm
< 1 mm: 1 cm
1-2 mm: 1-2 cm
2mm or higher: 2 cm

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8
Q

Limit of epinephrin injection for anesthesia

A

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

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9
Q

Limit of bupivacaine

A

Without epi:
2 mg/kg
2-4 h

With epi:
3 mg/kg
3-7 h

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10
Q

Suitable syringe for wound irrigation

A

19 gauge
35 cc

25-35 psi

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11
Q

Wound left unapproximated, next step?

A

If unapproximated for 8 h or longer, need to debride and copiously irrigated to optimize for healing

Also high risk of infection

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12
Q

Indications for wound debridement

A

Devitalized
Irregular edges
Ragged edges
Unapproximated for 8 h

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13
Q

Suture suitable for skin closure with traumatic mechanism involved

A

Non-absorbable

Nylone, silk, prolene

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14
Q

Suture optimal for contaminated and infected wounds

A

Monofilament:

Prolene, monocryl

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15
Q

Suture that should be avoided in contaminated wounds

A

Multifilament:

Vicryl, silk

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16
Q

Prevention of traumatic tattoo

A

Debridement and irrigation ASAP

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17
Q

Suture removal time

A

Face:5-7 d
Elsewhere: 10-14d

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18
Q

Suture method not suitable for trauma

A

Sub-cuticular

Weak

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19
Q

Indication of vertical mattress siture

A

Areas difficult to evert (volar hand…)

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20
Q

Benefit of horizontal mattress suture

A

Everting

Time-saving

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21
Q

Benefit of running (baseball stich) suture

A

Time saving

Good hemostasis

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22
Q

Indication for tape for wound closure

A

Superficial, opposable edges, non-bleeding

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23
Q

Indications of skin adhesives

A

Small wound
Not much tension or shearing

My cause irreversible tattooing

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24
Q

Length/width ratio of ellipse

A

3

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25
Q

Contraindication to shave Bx

A

Should not be used for pigmented lesions

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26
Q

Which size of punch Bx does require closure?

A

Greater than 3 mm. Because may leave scarring

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27
Q

Is punch/shave biopsy in clinic aseptic or sterile?

A

Is aseptic but not sterile

Sterile gloves are indicated

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28
Q

Maximum chlorhexidine and betadine concentration on face

A

4% for chlorhexidine
7.5% betadine

Esp around eyes and ears

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29
Q

Local anesthetics with epinephrine indications and contraindications

A

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

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30
Q

Phases of wound healing

A
  1. 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
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31
Q

Wound tensile strength begins to increase at:

A

4-5 d

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32
Q

Peak tensile strength of wound:

A

Achieved at 60 d

80 % of normal

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33
Q

Contraindication to primary wound healing (first intention)

A 
Animal/human bites (except on face)
Crush injuries
Infection
Long time lapse since injury (>6-8h)
Retained foreign body

Indication: recent clean wound

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34
Q

Tertiary healing

A

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

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35
Q

Indications for third intention healing

A

Contaminated wounds (high bacterial count)
Long time-lapse since injury
Severe crush component with significant tissue devitalization
Closure of fasciotomy wounds

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36
Q

Tx of hypertrophic scar

A 
Scar massage
Pressure garment
Silicone gel sheeting
CS injection
Surgical excision if other options fail. May recur
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37
Q

Keloid Tx

A

Multimodal therapy:
Pressure garments
Silicone gel sheeting
CS injection
Surgical excision (high risk of recurrence)
Fractional CO2 ablative lasers, radiation

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38
Q

Spread scar Tx

A

Excision and closure

has the same order of collagen fibers as normal scar

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39
Q

Chronic wound definition

A 
Fail to heal within 4-6 wk
Consider Bx (marjolin’s ulcer)
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40
Q

Risk factors for wound infection

A 
>8h
Severely contaminated
Human/animal bites
Immunocompromised
Bites
Involvement of deeper structures
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41
Q

Systemic AB for wounds

A

If acute (<24h) contaminated: AB indicated if obvious infection

If late (>24h) contaminated: systemic AB indicated

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42
Q

Wounds requiring tetanus prophylaxis

A

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

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43
Q

Tetanus prophylaxis in HIV pts

A

Should receive TIG regardless of tetanus immunization Hx

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44
Q

Tetanus prophylaxis in infants < 6 wk

A

Nothing if clean, minor

TIG without vaccine for other wounds

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45
Q

RFs fo tetanus

A

> 6h

Depth > 1cm

Crush, burn, gunshot, frostbite, puncture through clothing, farming injury

Devitalized tissue present

Contamination: grass, soil, saliva…

Retained foreign body

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46
Q

Pathogens in dog/cat bites

A

Pasteurella multocida
Staph aureus
Strep viridans

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47
Q

Investigations for cat/dog bite

A

Radiograph prior to therapy

Culture, gram stain

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48
Q

Treatment of cat/dog bites

A

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

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49
Q

Human bite pathogen

A

Staph > B hemolytic strep> eikenella corrodens > bacteroids

The most common germ: staph

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50
Q

Inv for human bite

A

Radiographs prior to therapy

Culture, Gram stain

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51
Q

Tx of human bite

A 
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
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52
Q

Negative pressure (vacuum assissted) wound healing

A

Placed under deep wounds or to enhance skin graft take.

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53
Q

Three phases of skin graft take

A

Plasmatic imbibition: first 48h
Inosculation: d2-3
Neovascular ingrowth: 3-5 d

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54
Q

Bacterial count required for graft take

A

< 100,000/cm3

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55
Q

Amount of contraction in partial vs full thickness grafts

A

Partial:
1° < 2° contraction

Full
1° > 2° contraction

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56
Q

Tendon donor site

A

Palmaris longus

Plantaris

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57
Q

Nerve donation sites

A

Sural
Antebrachial cutaneous
Medial brachial cutaneous

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58
Q

Appropriate Length:width ratio in random pattern flaps

A

3:1 in head and neck

1-2:1 elsewhere

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59
Q

Flap used to lengthen a scar

A

Z-plasty

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60
Q

Length:width ratio in axial flaps

A

5-6:1

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61
Q

Inv for cellulitis

A

CBC
B/C
Culture/Gram stain if wound
Plain x-ray: soft tissue edema

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62
Q

Indications for IV treatment of cellulitis

A

DM
Lymphangitis
Severe infection
Oral AB failure

Splint if hand

If on oral: reassess in 48 h

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63
Q

Types of necrotizing fasciitis

A

Type I:
Polymicrobial
Less aggressive

Type II:
Monobacterial
Usually B-hemolytic strep

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64
Q

Clinic of necrotizing fasciitis

A 
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

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65
Q

Tx of necrotizing soft tissue infection

A

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

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66
Q

Inv for necrotizing fasciitis

A

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

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67
Q

Onset of venous vs arterial ulsers

A

Venous: rapid
Arterial: slow

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68
Q

Margins of venous vs arterial ulcers vs diabetic

A

Venous: irregular
Arterial: even, punched out
Diabetic: irregular or punched out

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69
Q

Common site fo diabetic ulcers

A

Metatarsal heads

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70
Q

ABI in different chronic ulcers

A

Venous: > 0.9

Arterial: < 0.9

Diabetic: inaccurately high

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71
Q

Pain in different chronic ulcers

A

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

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72
Q

Tx of venous ulcer

A 
Rest
Leg elevation
Compression: 30mmHg
Moist wound dressings
If infected: topical/systemic AB
\+/- skin grafting
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73
Q

Tx of arterial ulcers

A 
Rest
No elevation
No compression
Moist dressing
If infected: topical/systemic AB
Modify risk factors
Vascular surgical consultation (angioplasty, bypass)
Treat underlying
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74
Q

Tx of diabetic ulcers

A 
Control DM
Wound care
Foot care
Orthotics, off loading
Early intervention for infections: topical/systemic AB
Vascular surgical consultation
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75
Q

Stages of pressure ulcer development

A
  1. Hyperemia: disappears one hour after removal of pressure
  2. Ischemia: Follows to 2-6 hours of pressure
  3. Necrosis: follows >6 hours of pressure
  4. Ulcer: necrotic area breaks down
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76
Q

Classification of pressure ulcers

A
  1. Non-blanchable erythema present for more than one hour after pressure removed
  2. Partial thickness skin loss
  3. Full thickness skin loss into subcutaneous tissue
  4. Full thickness skin lost into muscle, bone, tendon, or joint
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77
Q

If an eschar present over a pressure ulcer

A

Must remove the eschar for staging

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78
Q

Prevention of pressure ulcer

A 
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
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79
Q

Treatment of pressure ulcers

A 
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
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80
Q

Zone of thermal burn where early intervention has most profound effect in minimizing injury

A

Zone of stasis (edema)
Between zone of heperemia and zone of coagulation (ischemia)

Intervention: moist aseptic environment, rich blood supply

81
Q

Critical burn areas

A

Face/neck
Hand/feet
Genital

82
Q

The burn size threshold crucial for morbidity and mortality in children

A

60%

83
Q

Indications for a transfer to Burn Center

A

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

84
Q

The best monitoring measure for burn patient

A

Urine output
Maintain > 0.5 cc/ kg in adults
> 1 cc/kg in children

Also maintain:
Clear sensorium
HR< 120
MAP > 70

85
Q

Tetanus prophylaxis in burn pt if:

A

Deeper than superficial-partial thickness
Or
>10% TBSA

0.5 cc toxoid
250 U TIG

86
Q

Baseline lab studies in burn pt

A 
Hb
U/A
BUN, Cr
CXR
Lytes
Glucose,
ECG
Cross match if trauma
ABG
CO-Hb
87
Q

Mx of burn (acute care)

A 
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
88
Q

If suspect inhalation injury, next step?

A

Intubation

89
Q

Dx of inhalation injury

A

With direct bronchoscope

90
Q

3 major respiratory problems after burn

A
  1. encircling burn scar
  2. CO poisoning
  3. Smoke inhalation leading to pulmonary injury
91
Q

CO poisoning treatment

A

100% O2 with face mask until carboxyHb < 10%

92
Q

Burn wound healing

A

Deep partial: grafting recommended

Third degree: graft/flap necessary

Fourth degree: needs flap

93
Q

Tx of first degree wound

A

Oral NSAIDs for pain control
Topical creams for pain control and moisture
Aloe

94
Q

Tx of superficial partial burn wound

A

Daily dressing change

Topical antimicrobial (polysporin)

Leave blisters intact ( unless impaired circulation/motion)

95
Q

Tx of deep partial and third degree burn wound

A

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

96
Q

Most common organisms in burn wound infection

A

Day 1-3: gram positive
Day 3–5: gram negative

Organisms: S. Aureus, P. Aeruginosa, C. Albicans

97
Q

Silver sulfadiazine

A

Pain: minimal

Penetration: medium

Eschar: penetrates poorly

Healing: slows down.
Mild inhibition of epithelialization

Leukopenia

98
Q

Sulfamylon (mafenide)

A

Pain: moderate

Penetration: well

Eschar: penetrates

Mild inhibition of epithelialization

Metabolic acidosis in wide area

99
Q

Silver nitrate

A

Methemoglobinemia

Stains black

Leaches sodium from wound

100
Q

Nanocrystalline silver-coated dressing

A

Pain: none or transient

Penetration: mediates

Eschar: no penetration

May stain, producing pseudoscar or facial discoloration (argyria-like symptoms)

Raised liver enzymes

101
Q

RFs of burn wound infection

A

> 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

102
Q

Nutrition in burn pts

A

Consider supplementation with calories, vit C, vit A, Ca, Zn, Fe

103
Q

Immunosuppression in burn pts

A

Must keep bacteria count < 105/gr tissue

104
Q

Signs of sepsis in burn pts

A

Sudden onset of hypo/ hyperthermia

Unexpected CHF

Unexpected pulmonary edema

ARDS

Ileus > 48h post-burn

Mental status changes

Azotemia

Thrombocytopenia

Hypofibrinogenemia

Hyper/hypoglycemia

105
Q

GIB in burn pts

A

If TBSA > 40 %

Usually subclinical

Tx: NPO, antacid, H2 blocker

106
Q

Mechanism of injury by acids and bases

A

Acids: coagulation necrosis

Base: saponification, liquefactive necrosis

107
Q

Tx of chemical burns

A

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

108
Q

Special Tx for acid burns

A

Water irrigation
Then
Dilute sodium bicarbonate

109
Q

HF acid special Tx

A

Water irrigation

Clip fingernails

Topical Ca gel

+/- SQ calcium gluconate

+/- 10% calcium gluconate IV

110
Q

Sulfuric acid special Tx

A

Soap/lime prior to irrigation (direct water exposure produces extreme heat)

111
Q

Special considerations in Tar treatment

A

Remove with repeated application of petroleum-based AB oint (polysporin…)

112
Q

Electrical burn clinic

A

Often: small puncture burns on skin, extensive deep tissue damage requiring debridement

113
Q

Late ophthalmologic complication of electrical burn

A

Cataract

114
Q

Tissue resistance against electrical current

A

Bone> fat> tendon> skin> muscle> vessel/blood> nerve

115
Q

Treatment of electrical burns

A

ABC

Primary and secondary survey

Monitor:
Hemochromogenuria
Compartment syndrome
Urine output

Wound:
Topical silver sulfadiazine, mafenide
Debridement: early, repeat q 48h

+/- amputation

116
Q

Test for assessing radial and ulnar arteries

A

Allen

Pulses

117
Q

Test for assessment of digital arteries

A

Capillary refill <2-3 sec

Doppler ultrasound

118
Q

Ischemic contracture due to compartment syndrom

A

Volkman’s contracture

119
Q

Normal compartment pressure

A

Up to 12

30-40: abn

120
Q

Median nerve testing

A

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

121
Q

Ulnar nerve testing

A

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)
122
Q

Radial nerve testing

A

Extrinsic muscles:
Extend thumb (thumb’s up)
Extend wrist

123
Q

Testing flexor digitorum profundus

A

Stabilize PIP in extension, ask pt to flex fingers

124
Q

Examining flexor digitorum superficialis

A

Stabilize non-exam fingers in extension to neutralize FDP and ask the pt to flex examination finger at PIP

125
Q

Nerve repair

A

<7 d and clean and no concurrent injuries: 7 d

Otherwise: secondary repair

126
Q

To define level of nerve generation

A

Tinnel sign

127
Q

Optimal repair of vessels of hand

A

Within 6 h

128
Q

Tendon repair

A

Extensors: usually repaired in ED

Flexors: repaired in OR within 2 weeks

129
Q

Indication of treatment of subungual hematomas

A

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

130
Q

Volar hand wound exploration

A

Not in ER

131
Q

Most common organism in hand infection

A

S. Aureus

132
Q

The most common spaces becoming infected in hand

A

Thenar

Mid-palm

133
Q

Felon Tx

A

If early stages:
Elevation
Warm soak
Cloxacillin

If abscess/ pressure on skin/ failure to resolve:
I&D
C/S, Gram
Adjust AB

134
Q

Flexor tendon sheeth infection (flexor tenosynovitis) clinic and Tx

A 
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

135
Q

Herpetic whithlow contagious time

A

Until completely heald

136
Q

Tx of paronychia

A

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

137
Q

Mx of amputation

A

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

138
Q

Priorities for replantation of amputee

A

Children: better results

Thumb

Multiple digits

139
Q

Contraindications to replantation

A

Multiple level amputation

Avulsion, crush injuries: relative contra

Mx: revision amputation

140
Q

Mallet finger mechanism of injury

A

Sudden blow to tip of finger:

Forced flexion of the extended DIP leading to extensor tendon rupture at DIP

141
Q

Types of mallet finger

A

Bony: fracture of distal phalanx distal to tendon insertion

Non-bony: forced flexion of the extended DIP

142
Q

Tx of mallet finger

A

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

143
Q

Boutonniere deformity mechanism of injury

A

Injury or disease affecting the extensor tendon insertion into the dorsal base of the middle phalanx.

RA
Laceration
Volar dislocation
Forceful flexion of PIP

144
Q

Boutonniere deformity Tx

A

Splint PIP in extension and allow active DIP motion

145
Q

Swan neck deformity mechanism of injury

A

PIP volar plate injury

RA
Old, untreated mallet deformity

146
Q

Swan neck Tx

A

Splint to prevent PIP hyperextension or DIP flexion

Corrective procedures

Tendon rebalancing

Arthrodesis/arthroplasty

147
Q

De Quervain’s tenosynovitis

A

Inflammation of APL, EPB (extensor tendons in the first dorsal compartment)

148
Q

Test for Dx of De Quervain tenosynovitis

A

Pain over the radial styloid induced by making fist with thumb in palm and ulnar deviation of wrist

149
Q

Clinic of De Quervain tenosynovitis

A

+ 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)

150
Q

Tx of De Quervain tenosynovitis

A

Mild: NSAID, splint, steroid injection into tendon sheath

Severe: surgery

151
Q

Most common site for ganglion cyst

A

Dorsal wrist, overlying scapholunate ligament

152
Q

Ganglion cyst Tx

A

Do nothing

Aspiration. High recurrence

Steroid injection in combination with aspiration (if painful)

Operative excision

153
Q

Common flexor tendon deformities

A

Between distal palmar crease and mid-middle phalanx

Superficialis and profondus sheathed together

Recovery of glide very difficult

No-man’s hand

154
Q

Stenosing tenosynovitis

A

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

155
Q

Tx of stenosing tenosynovitis

A 
NSAIDs
Steroid injection (less successful if >60yr, or >6mo)
Splint

Surgery if:
No/minimal relief with steroids

156
Q

Position of safety for hand fxs

A

Wrist extension 0-30°
MCP flexion 70-90°
IP full extension

Early motion to prevent stiffness

157
Q

Distal phalanx fx

A

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

158
Q

Proximal/middle phalanx fx

A 
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
159
Q

Metacarpal fx acceptable deviation

A

D2: Up to 10°

D3: 20°

D4: 30°

D5: 40°

160
Q

Boxer’s fx

A

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

161
Q

Bennett’s fx

A

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

162
Q

Rolando fx

A

T or Y shaped fx of base of thumb metacarpal

Tx: like bennett

163
Q

PIP or DIP dislocation Tx

A

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

164
Q

Ulnar collateral injury (ski pole injury)

A

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

165
Q

Exam of UCL injury

A

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

166
Q

Dupuytren’s disease

A

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

167
Q

Most common digit

A

Ring >little > long> thumb > index

168
Q

Tx of DuPuytren

A

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

169
Q

The most common entrapment neuropathy

A

CTS

170
Q

Thenar eminence sensation in CTS

A

Spared (nerve: palmar cutaneous branch given off prior to carpal tunnel)

171
Q

First sense lost in CTS

A

Discriminative touch

172
Q

Dx of CTS

A

Clinical

+/- NCV, EMG

173
Q

Tx of CTS

A

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.

174
Q

Inv in brachial pkexus injury

A

EMG
MRI
CT myelogram

175
Q

Tx of brachial plexus injury

A

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)

176
Q

Approach to facial injuries

A

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

177
Q

Investigation in facial injuries

A

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

178
Q

If high clinical suspicion of jaw fx and negative panorex

A

CT

179
Q

Tx goals for facial injury

A

Reestablish normal occlusion if occlusion is an issue

Normal eye function (extra-ocular eye movements and vision)

Restore stability of face and appearance

180
Q

Common sites of fractures in mandible

A

Condylar neck

Angle of mandible

181
Q

Mandibular fx in anterior force

A

Bilateral

182
Q

Mandibular fx in lateral force

A

Ipsilateral subcondylar and contralateral angle or body fx

Chin deviates towards side of a fractured condyle

183
Q

Tx of jaw fx

A

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

184
Q

Le Fort I fx

A

Horizontal:
Piriform aperture
Maxillary sinus
Pterygoid plates

Maxilla divided into 2 segments

185
Q

Le Fort II

A

Pyramidal:

Nasal bones
Medial orbital walls
Maxilla
Pterygoid plate

186
Q

Le Fort III

A

Transverse:

Nasofrontal suture
Zygomaticofrontal suture
Zygomatic arch
Pterygoid plates

187
Q

Nasal fx

A

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)

188
Q

Pathognomonic features of zygomatic fx

A

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
189
Q

Tx of zygoma fx

A

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

190
Q

Inv for orbital floor fx

A

CT: axial, cronal with fine cuts through orbit

Diagnostic maneuver: forced duction test (pull on inferior rectus with forceps under local anesthesia in OR

191
Q

Tx of orbital floor fx

A

Surgical repair if:
Entrapment
Any size defect with enophthalmos (if pt bothered)
Persistent diplopia (>10d)

192
Q

Superior orbital fissure syndrome

A 
Fx of SOF:
Ptosis
Proptosis
Anesthesia in V1
Painful ophthalmoplagia

Tx: operative reduction

193
Q

Orbital Apex syndrome

A

Fracture through optic Canal

Involvement of CNII

SOF symptoms plus vision loss

Tx: urgent decompression of fx or steroids

194
Q

Indications for breast reduction

A 
Musculoskeletal pain
Chronic headache
Paresthesia in upper limb
Rashes under breast
Breast discomfort
Physical impairment
195
Q

Complications of breast reduction surgery

A 
NAC necrosis
Sensory alteration of nipple
Scarring
Wound complications (esp if elevated BMI)
Difficulty breastfeeding
asymmetry
Hematoma
196
Q

Types of physiologic gynecomastia

A

Neonatal
Pubertal
Elderly

197
Q

Types of pathologic gynecomastia

A

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

198
Q

Tx of cleft lip

A

Surgery at 3 mo

199
Q

Tx of cleft palate

A

Special bottle for feeding
Speech pathologist
Surgery (6-9 mo)

Often require myringotomy tubes due to recurrent otitis media

Med (25 decks)

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