Plastic Surgery & Principle of hand injuries Flashcards
What was the first plastic surgery?
Nasal reconstruction using fore arm flaps and cheek flaps
The final appearance of a scar is dependent on many factors, including the following
• (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
What are 2 technical factors of definite importance in increasing the likelihood of a “good” scar?
•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.
Types of skin closure/ suture techniques
- Simple Interrupted
- Vertical mattress
- Horizontal mattress
- Subcuticular continuous
- Half-buried horizontal mattress
- Continuous over and over
- Staples
- Skin tapes (Skin adhesive performs a similar function)
What are the BASIC PRINCIPLES of plastics surgery?
SKIN GRAFTS
SKIN FLAPS
OTHER FLAPS
Z-PLASTY
ATRAUMATIC TECHNIQUES
MICROSURGICAL TECHNIQUES AND TRANSPLANTATION SURGERY
TISSUE EXPANSION
USE OF ALLOPLASTIC MATERIALS
What are some skin-related birth defects?
CONGENITAL COMPOUND NEVUS, SPINAL BIFIDA, HEMAGIOMA
Congenital limb anomalies
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
Describe the hand (number of bones)
- 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
Hand injuries present either as
- an isolated injury
- or as a component of multiple injuries
How should you manage an emergency hand injury?
- Resuscitation, stabilization and dealing with potentially life threatening injuries take priority over the injured hand.
- Haemostasis and initial wound irrigation along with a scrub of the injured hand is an acceptable during the initial management of multi trauma patient.
- Surgical management of the hand can be deferred till the patient is stabilized.
- However, there can be a significant negative impact on long-term quality of life if the hand injuries are not treated
Major functions of hand
- Reaching
- Grasping
- Transporting
- Release
- Object manipulation is the main outcome
Grasp patterns
* Grasp is the position in which an object is held by the hand
Discuss the wrist (no. of carpal bones, extent of motion)
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.
ACUTE INJURIES: Emergency room management of patients with hand injuries
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
Injuries that require urgent operative intervention include:
- limb-threatening ischemia, most open fractures, pressure
- injection injuries, or active bleeding in the setting of a coagulopathy.
What Are Key Management Tips for HandTrauma?
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
HISTORY of hand injuries
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
Physical Examinations for hand injuries
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
CIRCULATION
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
SENSORY EXAMINATION
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.
RADIOLOGICAL EVALUATION
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
Immobilization
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
anaethesia for hand injuries
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.
Tourniquet
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
Equipment
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
