Plastic Surgery & Principle of hand injuries

Question 1

What was the first plastic surgery?

Answer 1

Nasal reconstruction using fore arm flaps and cheek flaps

Question 2

The final appearance of a scar is dependent on many factors, including the following

Answer 2

• (a) Differences between individual patients that we do not yet understand and cannot predict;
•(b) the type of skin and location on the body;
•(c) the tension on the closure;
•(d) the direction of the wound;
•(e) other local and systemic conditions;
•(f) surgical technique

Question 3

What are 2 technical factors of definite importance in increasing the likelihood of a “good” scar?

Answer 3

•First is the placement of sutures that are not excessively tight and are removed promptly so disfiguring “railroad tracks”

•The second important technical factor that may affect the appearance of scars is wound-edge eversion.

Question 4

Types of skin closure/ suture techniques

Answer 4

1. Simple Interrupted
2. Vertical mattress
3. Horizontal mattress
4. Subcuticular continuous
5. Half-buried horizontal mattress
6. Continuous over and over
7. Staples
8. Skin tapes (Skin adhesive performs a similar function)

Question 5

What are the BASIC PRINCIPLES of plastics surgery?

Answer 5

SKIN GRAFTS
SKIN FLAPS
OTHER FLAPS
Z-PLASTY
ATRAUMATIC TECHNIQUES
MICROSURGICAL TECHNIQUES AND TRANSPLANTATION SURGERY
TISSUE EXPANSION
USE OF ALLOPLASTIC MATERIALS

Question 6

What are some skin-related birth defects?

Answer 6

CONGENITAL COMPOUND NEVUS, SPINAL BIFIDA, HEMAGIOMA

Question 7

Congenital limb anomalies

Answer 7

FAILURE OF FORMATION- TRANVERSE OR LONGITUDINAL REG PHOCOMELIA
FAILURE OF DIFFERENTIATION
POLYDACTYLY
OVERGROWTH( HYPERTROPHY)
UNDERGROWTH ( ATROPHY E.G HEMI FACIAL ATROPHY),
AMNIOTIC BAND SYNDROME
GENERALISED SKELTAL SYNDROME

Question 8

Describe the hand (number of bones)

Answer 8

• The part of the fore limb which extends beyond the wrist joint including palm, finger and thumb, is understood to b…
  Hand bones 27 bones
• It contains eight short carpal bones of the wrist are organized into a proximal row

Question 9

Hand injuries present either as

Answer 9

1. an isolated injury
2. or as a component of multiple injuries

Question 10

How should you manage an emergency hand injury?

Answer 10

1. Resuscitation, stabilization and dealing with potentially life threatening injuries take priority over the injured hand.
2. Haemostasis and initial wound irrigation along with a scrub of the injured hand is an acceptable during the initial management of multi trauma patient.
3. Surgical management of the hand can be deferred till the patient is stabilized.
4. However, there can be a significant negative impact on long-term quality of life if the hand injuries are not treated

Question 11

Major functions of hand

Answer 11

1. Reaching
2. Grasping
3. Transporting
4. Release

• Object manipulation is the main outcome

Grasp patterns
* Grasp is the position in which an object is held by the hand

Question 12

Discuss the wrist (no. of carpal bones, extent of motion)

Answer 12

The wrist consists of 8 carpal bones grouped in 2 rows with restricted motion between them and is the most complex joint in the body.

Normal flexion/extension motion is 90°/70°, but an 80° arc provides good function

Reduction in hand pronation is well tolerated if one has a functional shoulder to compensate, whereas loss of supination is not as easily tolerated.

Question 13

ACUTE INJURIES: Emergency room management of patients with hand injuries

Answer 13

Emergency room management of patients with hand injuries includes:

• an assessment of other, life-threatening injuries.
  should always remember the expression “life over limb
• hemorrhage can usually be controlled with elevation and direct pressure
• A blood pressure cuff may be inflated above the systolic blood pressure to control bleeding

Question 14

Injuries that require urgent operative intervention include:

Answer 14

• limb-threatening ischemia, most open fractures, pressure
• injection injuries, or active bleeding in the setting of a coagulopathy.

Question 15

What Are Key Management Tips for HandTrauma?

Answer 15

For amputated digits,
hypothermia (wrapped in moist gauze inside a plastic bag and placed on ice) will reduce the metabolic by-products that damage the tissue and improve the likelihood of a successful replant
Pressure injection injuries may appear innocuous on presentation,
CRUSH INJURY- MACHINE HAND INJURY

Question 16

HISTORY of hand injuries

Answer 16

hand dominance,
the time,
MECHANISM OF INJURY
acute injury versus gradual onset
a patient’s level of functioning and difficulty with activities of daily living.
MINOR VS MAJOR INJURIES

Question 17

Physical Examinations for hand injuries

Answer 17

general inspection for edema, bruising or discoloration, deformities of the digits, or previous scars.
Wounds are inspected for infection, surrounding skin viability, proximity to major neurovascular structures.
Nerve laceration may not always be evident in the initial survey.
Range of motion (ROM) of the digits and wrist helps guide further evaluation.
When assessing motion, a concurrent evaluation of rotational deformities, gross instability, or laxity may be completed.
full assessment of ROM is limited by pain, and local blocks may help further assess injuries
but these should not be performed before a full sensory examination is conducted, including two-point discrimination.
A strength assessment should be comprehensive

Question 18

CIRCULATION

Answer 18

Radial and ulnar pulses at the wrist are typically palpable when systolic blood pressures are above 80 mmHg.
The pulses of individual digital arteries are assessed with a Doppler probe,
The Allen test assesses the competency of the HAND PERFUSION.
CAPPILARY REFILL

Question 19

SENSORY EXAMINATION

Answer 19

Adequate sensation of the digits is necessary for practical
use of the hand.
radial nerve -first dorsal web space
median nerve-volar aspect of index fingertip
ulnar nerve-volar tip of the small fingertip
palm or fingers - two-point discrimination distal to the laceration can be tested with a paperclip bent into a 5 mm gap

A Tinel sign may indicate an injured nerve with regenerating axons.

Question 20

RADIOLOGICAL EVALUATION

Answer 20

standard x-ray –
a single digit requires a true A/P view of the finger,
MCP, PIP, and DIP joints.
A lateral film must include the condyles of the distal, proximal, and middle
phalanx, without other fingers obscuring the digit in question.
The thumb has a unique orientation and requires oblique views to obtain adequate views of the inter phalangeal (IP), MCP, and CMC joints.
A hand series is most useful for suspected metacarpal injuries,
whereas a wrist series is required to assess distal radius fractures.
Magnetic resonance (MR) arthrograms, are helpful to better define certain conditions and injuries

CT for suspected carpal fractures, intra-articular distal radius fracture,

MRI for soft-tissue tumors, or MR arthrograms for suspected TFCC injuries
But should not replace X-rays as the first line of imaging

digital photography as a means communication, teaching and recording

Question 21

Immobilization

Answer 21

Intrinsic positioning for the hand reduces stiffness by

fully extending the joint capsules of the wrist in slight extension,

the MCPs in near full flexion,

the IPs in full extension.

A cast or other circumferential immobilization is used with caution in acute injuries because swelling could result in a compartment syndrome
The position of safe immobilization (POSI) for a hand is also known as the intrinsic-plus or Edinburgh position:
Wrist: 0–30° of extension
Metacarpophalangeal (MCP) joints: 70–90° of flexion
Interphalangeal (IP) joints: Full extension
Thumb: Widely abducted

Question 22

anaethesia for hand injuries

Answer 22

For most routine hand cases, a local block
with a small amount of sedation is adequate
Regional anesthesia,
such as interscalene blocks, wrist block, digital block
With or without general
anesthesia, provides complete muscle relaxation and is helpful
to reduce initial pain pathways.
However, in trauma cases
where monitoring for compartment syndrome is required
postoperatively, a long-acting block may mask the symptoms and prove dangerous.

Question 23

Tourniquet

Answer 23

Hand and wrist procedures are facilitated by
a tourniquet.
the tourniquet
prevents arterial flow in the arm, leaving the operative field
nearly bloodless.
An upper arm tourniquet (either sterile or non-sterile) should be used for the elbow, forearm, and wrist work.

exsanguinate the arm before inflation to empty the compliant venous system.
100 mmHg greater than the patient’s systolic pressure
monitor the tourniquet time- for upper limb 90min-120min

Question 24

Equipment

Answer 24

Intraoperative imaging with a mini C-arm
is indispensable for fracture work, especially for fractures that
may be amenable to closed reduction and fixation.

If vascular repair is anticipated- microscope is required.

fracture and injury, plates and screw are numerous and should be considered in advance.

basic hand tray may include
drills, Kirschner wires (K-wires), or bone reduction clamps

Question 25

PRINCIPLE OF OPERATIVE MANAGEMENT

Answer 25

FORM VS FUNCTION
FORM- ANATOMIC RESTORATION
FUNCTION KEEP IN VIEW THE USE IT WILL BE PUT TO
GIRFT
GET IT RIGHT THR FIRST TIME
NO DELAYS IN SURGERY
TREAT ALL INJURIES COMPLETELY AT THE SAME SITTING
MOBILIZATION AND IMMOBILIZATION
START WITH SURGERY CONTINUE WITH HAND THERAPY AND END WITH REHABILITATION

Question 26

Incision

Answer 26

When considering incisions in the hand, care should be taken not to cut across flexion creases to prevent the development of scars which will contract and limit motion.

The dorsal aspect of the hand has thinner, more mobile skin and longitudinal incisions can generally be used.
Zigzag incisions allow access to structures in the volar finger and palm.
The common incision techniques, Bruner incisions are diagonal incisions between flexion creases that serve to create
Closure of hand incisions and wounds is generally accomplished with a single layer of interrupted nylon sutures.
Vertical mattress sutures help evert the skin edges.
If a laceration crosses a skin crease, a Z-plasty is considered to prevent contractures

Question 27

Reconstructive Principles in the upper limb

Answer 27

1. Restore circulation
2. Obtain soft-tissue covergae
3. Align and stabilize bony anatomy
4. Restore nerve function
5. Mobilize joints
6. Restore tendon function

Question 28

Post operative care

Answer 28

Most importantly, any circumferential dressings are placed loosely to prevent a tourniquet effect.
Splint immobilization for most operatively repaired fractures is advised and may be useful for soft-tissue procedures to prevent
tension on the incision with movement, especially if the incision crosses a joint.
ELEVATION
can minimize swelling that leads to pain, wound problems,
finger stiffness, and longer recovery times.
The role of postoperative oral antibiotics in routine elective soft-tissue procedures remains controversial with no clear benefit.
Injuries or surgeries involving open fractures or other bony work warrant 24 hours of perioperative IV antibiotic coverage.