Surgical Principles Flashcards
The three Phases of wound healing and the time periods
Inflammatory phase 2-5 days
Proliferative phase 2-3 weeks
Maturation phase 3 weeks - indefinitely.
What are the major cell types in the wound healing phases?
Inflammatory: Neutrophils
Proliferative: Macrophages and Fibropblasts
Maturation: Fibroblasts
When do wounds reach the tensile strength of suture. How does this strength compare to the original strength of the skin?
The wound will reach tensile strength during the proliferative phase at about 14 days.
This skin strength is only 35% of the original strength.
Scars carry only 80% of the original skin strength.
What is the most important cell involved in wound healing?
Macrophages!
Only inflammatory cell able to participate in the low oxygen levels of the wound edges.
Ingests debris, bacteria, forms capillarys, process antigens.
Which two vitamins effect wound healing?
Vitamin A
Vitamin C (Collagen production)
What’s the difference between primary and secondary bone healing?
Primary is seen with stable fixation and works via cutting cone fusion. (Haversian remodeling)
Secondary is seen with unstable fractures/casting and involves the formation of a bony callous.
What are the phases of secondary bone healing?
Hematoma formation Days 1-3
Fibrocartilagenous callus: Osteoclastic phagocytosis of necrotic bone with osteoblastic differentiation into cartilage. (10d - 6 wks)
Primary bone callous forms 6-10 weeks
Primary bone callus is absorbed and forms the secondary bone callus at 2.5 - 4 months.
Remodeling occurs secondary to wolf’s law (form follows function)
What law describes final bony maturation in secondary bone healing?
Wolf’s law
Form will follow function.
What is the name of the classification for non union
Weber and Check after 8-9 months of no healing.
Breaks it down into hypertrophic and atrophic.
What are the hypertrophic non-unions?
Elephants foot
Horse Hoof
Oligotrophic
What are the atrophic non-unions?
Atrophic
Defect
Torsion wedge
Cominuted
What is a Papineau grafting technqiue?
Described for osteomyelitis
Excise necrotic bone, use cancellous bone grafting with overlying skin coverage.
It is designed for rapid revascularization.
Hyaline vs Fibrocartilage
Hyaline: Has type II cartilage and glycosaminoglyxan matrix to maintain compressive forces.
Fibrocartilage is type I and is mostly responsible for tensile forces.
What cell type can differentiate into hyaline cartilage?
Mesenchymal stem cells!
Typically form into fibrocartilage as hyaline cartilage rarely ever reforms.
Whats the name of the classification that covers the extent of damage done directly to a nerve?
Seddons!
Neuropraxia
Axonotmesis
Neurotmesis
What is the name of the classification that covers the type of nerve deficit a patient might be experiencing?
Sunderlands!
Breaks it into 1st degree to 6th degree.
Which nerve degeneration involves wallerian degeneration?
Axonotmesis!
The axon is damaged but the structural framework is intact allowing for internal reconstruction.
Neurotmesis has wallerian degeneration as well distal to the transection resulting in a stump neuroma.
Autolytic debridement
The bodies own enzym removal and moisture.
It is selective in that only necrotic tissue is removed.
Facilitated with hydrocolloid, hydrogels, and transparent films.
Advantages: Safe, body removes and effective.
Disadvantages: Not as rapid as surgical, may promote anaerobic growth with occlusives.
What is mechanical debridement?
Typical Wet to dry, non selective debridement that poses a risk to healthy tissue.
Name the 5 types of debridement
Autolytic Manual Enzymatic Surgical Biological (Maggots)
“SAME B”
Pros vs cons of thin/split thickness skin grafts.
Pros: Take very quickly, require less nourishment.
Cons: Graft is fragile and shrinks up to 75%
Which has better survivability
FTSG or STSG?
Split thickness skin grafts have better survivability but are burdened by being weaker and shrinkage.
What are the ideal angles for Z-plasty skin grafts?
60 degree angles to gain up to 75% in additional length.
What are the three phases of skin graft healing?
Plasmitic 1-2 days (Fibrin anchor layer, nutrition is through diffusion.
Inosculation 2-4 days Capillary budding and lymphatic drainage begins.
Reorganization >5 days
Capillaries invade and the graft begins to reinervate. Will not be normal for a few years.
How does hyponatremia present and how is it treated?
Presents with confusion, anorexia, lethargy, N/V, coma, an seizures.
Treated with insulin if the patient is just hyperglycemic
If the patient is hypotonic or dehydrated just give isotonic saline or salt tablets.
How does hypokalemia present and how is it treated?
Hypokalemia presents with respiratory arrest, arythmias, renal effects.
Simply treat this by giving either oral potassium or IV potassium (dangerous)
How does hyperkalemia present and how should it be treated?
Presents with EKG changes
- Spiked T waves
- ST depression
- Prolonged PR intervals
- QRS widening
- Prolonged QT intervals
can be caused by renal failure, administration of boood, or salt substitutes.
Treat with…
- Calcium chloride tablets
- Sodium Bicarbonate
- Glucose
- Insulin
Name the five W’s of post operative fevers
Wind Water Walk Wound Wonderdrugs
What ion does tourniquette use elevate?
Elevates calcium levels!
Tourniquette pressures for the ankle vs thigh
Ankle: +100 SBP
Thigh: 275-350 with max of 500 mmHg
Time limit of the tourniquette
Do not exceed two hours.
Release for 15-20 minutes for break
What defects can end up causing clubbed nails?
Congenital heart defects
Respiratory ailments
Liver cirrhosis
What is the Lovibond’s angle?
Used to determine clubbed nails.
Defined as an angle >160.
Can also use diamonds sign for this condition.
What are Mee’s lines?
Horizontal striations due to ARSENIC POISONING OR THALLIUM POISONING
Cause of blue nails
Cancer
Cause of black/brown nails
Addisons
Melanoma
Cause of white nails
Hereditary
Anemia
Fungal
Infection
Pitted white nails
psoriasis
White and pink nails
Anemia of chronic dz
Nephrotic syndrome
what is Onychauxis
Thickened nails that might be deviated laterally commonly seen in the elderly.
If NaOH is used for a nail avulsion what can be used for neutralization?
5% acetic acid.
Frost nail avulsion?
L shaped incision
What is a whitney nail avulsion?
A bilateral Frost
AKA L incisions on both sides of the nail.
What is the winograd nail avulsion?
1/4 of the nail edge is removed along with the matrix.
Steps of a hammer toe release?
Extensor tenotomy Extensor hood release Resection of the proximal phalange head Capsulotomy of MTPJ Release of the plantar plate
Arthrodesis with 0.45 or 0.65 dependent on MPTJ fusion..
What are the three types of hammer toe arthrodesis procedures?
End to end: Selig
Peg in hole fusion
Lambrinudi (fusion of PIPJ and DIPJ for claw toe)
V- arthrodesis
Which metatarsals have indicidual axis of motion?
Metatarsal 1 and 5
What is the normal degree of metatarsal declination?
Approximately 15 degrees
