Untitled

Plastic Surgery Overview

• Plastic Surgery is applicable everywhere on the human body

Hand Trauma

• A 35-year-old intoxicated man presents to the Emergency Department with a deep laceration to the right forearm after putting his hand through a window.
• Examination reveals no sensation to his little finger and the ulnar aspect of his ring finger.
• Power on abduction and adduction of all fingers is markedly decreased.
• He cannot flex the distal joint of his little finger, and his hand deviates radially when he flexes his wrist.
• The rest of the examination was normal, the damaged structure(s) are the Flexor carpi ulnaris and flexor digitorum profundus muscles.

Preliminary Management

• Immediate management is required for amputated/devascularized parts, neurovascular compromise, open fractures, and compartment syndrome.
• Immediate management is also required for surgical infections.
• Surgical infection includes suppurative tenosynovitis, septic arthritis, necrotizing infections and deep space infections.
• Elective management is needed for tendon injury, nerve injury, closed fractures, and ligament injury.

Approach to Hand Injury

• Use ATLS protocol
• History
• Physical exam
• Imaging
• X-ray
• Other imaging (rarely required)

History in Hand Injuries

• Handedness
• Occupation
• Hobbies
• Previous hand injuries

Physical Exam

• LOOK (Inspection) should be compared to the other side for swelling, deformity, lacerations, bruising and vascularity.
• Assess the cascade and alignment.
• FEEL (Palpation)
• MOVE (ROM)
• Sensation

Vascular Status

• Color
• Temperature
• Capillary refill
• Turgor
• Sensation

Pulses/Allen's Test

Cascade Assessment

• This is important for tendon Injury where a high index of suspicion is paramount
• Physical findings such as pain, loss of cascade, and loss of function may be present.
• Test ALL tendons

FDS/FDP Function

• Specific tests for FDS (Flexor Digitorum Superficialis) and FDP (Flexor Digitorum Profundus) function should be performed.

Alignment

• Examination of finger flexion can detect rotational malalignment.

Radiographs

• Normal bone?
• Bone quality
• Bone lesion
• Fracture pattern
• Fracture alignment

Fracture Analysis

• Which bone is fractured
• Location of fracture
• Pattern of the fracture
• Intraarticular or extraarticular
• Simple or comminuted
• Stable or unstable
• (Non)displaced
• Deformity: angulation, rotation, shortening

Examination of Sensation

• Prior to any local anesthetic is administered.
• Know the sensory and motor patterns of nerves, median, radial and ulnar in the upper extremity.
• For fingers: 2 point discrimination at DIPJ on radial and ulnar aspect of finger
• Gross Motor Screen:
  • Radial: thumbs up
  • Median: ok sign
  • Ulnar: cross fingers

Nerve Injury

• Open injury + change in motor / sensory exam is indicative of a nerve injury where complete a cut suggests needed surgery.
• Closed injury: gunshot/crush + change in motor/sensory is indicative of a nerve injury that could be neuropraxia or nerve injury.
• Follow for progression of recovery over 6 weeks.
• A referral to peripheral nerve surgeon if no improvement at 6 weeks (splinting is important).

Preliminary Management of Open Injuries

• Ensure tetanus is up-to-date.
• Remove foreign bodies.
• Irrigate and debride.
• Repair lacerations.
• Presume every structure is cut down to bone.
• Attend to fractures and dislocations.
• DO NOT EXPLORE A WOUND IN THE ER

Digit Amputation

• Storage is important, wrapping finger in moist gauze and placing it in a plastic bag.
• Place bag into another insulated container with ice
• DO NOT PLACE DIRECTLY ON ICE

Amputation

• Determine to Replant or not to replant?
• Check the Stump(s)
• Check the Part(s)

Review Questions

• What will be missing with a Median nerve injury at the elbow?
• What will be missing with a Median nerve injury at the wrist?
• What does the radial nerve innervate?

Peripheral Nerve Compression Question

• A 67-year-old female presents with a 7-year history of progressive numbness and tingling in the radial 3 ½ digits.
• This wakes her up at night.
• She shakes her hands to get relief, on inspection there is some thenar atrophy and some weakness in thumb abduction.
• Her fingers are well-perfused.
• The most likely diagnosis is carpal tunnel syndrome.

Facial Trauma Protocol

• ATLS protocol → Remember the C-spine!
• History
• Physical Exam CT scan for CT of facial bones

Facial Trauma History

• LOC
• Visual Systems
• Malocclusion
• Sensory loss

Operative Management of Facial Fractures Indications

• Restoration of Form: Correct deformity
• Restoration of Function:
  • Occlusion
  • Vision
  • Sensation (branches of facial nerve)
  • Smell
  • Breathing

Primary Wound Management

• Tetanus
• Control bleeding
• Remove FB (Foreign Body)
• Clean & remove dirt
• Repair lacerations
• Presume every structure is cut down to bone.
• Antibiotics for open fractures (air, mouth sinus) = or perioperatively for closed fractures: Ancef, Flagyl/Clindamycin.

The Orbit: Orbital Floor Fractures

• Signs and symptoms:
  • Ecchymosis
  • Diplopia
  • Restricted upward gaze (entrapment)
  • Enophthalmos & Hypoglobus

Orbital Floor Fractures: Mechanism

• Loss of globe support.
• Loss of orbital volume.

Nasal Fractures and Septal Injuries

• Examination – external & internal
• Recognize deformity
• Septal hematoma will lead to perforation.
  • Treatment – drain septal hematoma and pack, closed [open] reduction.
• Closed reduction & Splint Later: septoplasty and rhinoplasty.

Mandible Fracture Treatment

• Operative Fixation
  • Wiring of the jaw
  • Wiring of the jaw + ORIF (Open Reduction Internal Fixation)

René Le Fort

• (1869-1951) Used cadaver skulls.
  • Delivered blunt forces of varying degrees of magnitude, as well as from different directions.
• Determined
  • Predictable fracture patterns are the result of certain types of injuries.
• Three predominant types of mid-face fractures.

Le Fort Fractures

• Lefort 1: Transverse fracture.
• Lefort 2: Pyramidal fracture.
• Lefort 3: Craniofacial dysjunction.

Facial Buttresses

• Key to evaluation and treatment of the fractured face.

Facial Buttresses

• Lateral buttress.
• Medial buttress.
• Pterygomaxillary.
• Mandibular.

LeFort Fractures: Treatment Objectives

• Restore Function
  • Perfect dental occlusion
  • Normal orbital volumes
  • Normal nasal competency
• Restore Facial Appearance.
  • Control facial...projection, width, height.
  • Soft tissue repair.
• Knowledge of the predictable anatomy of skeletal buttresses = roadmap to success
• Work from stable to unstable: Lefort I last???

Mandibular Fracture Question

• Palpable step along mandible
• Loose teeth
• Trismus
• Numbness in V2 distribution
• Malocclusion

Hand Infections

• Systemic antibiotics are not indicated for an animal bite to hand, a laceration over metacarpophalangeal joint sustained after punching someone in a fight.
• Systemic antibiotics are not generally indicated for cellulitis, or a burn wound to 75% of the dorsal aspect of the hand.
• They are also not indicated for acute suppurative tenosynovitis.

History

• Hand Injury? Mechanism and time
• Course of development
• History of fever at home
• History of progressive pain, numbness
• Other medical conditions - Diabetes mellitus
• Immune status of the patient - Immunosuppressive medications - History of organ transplantation - History of HIV or AIDS

Physical Examination - Early

• Laceration or skin injury
• Redness or cellulitis
• Pain to palpation
• Diffuse swelling

Physical Examination- Later

• Laceration may have sealed at the surface
• Redness or cellulitis
• Fluctulant mass
• Ascending lymphangiitis
• Tender proximal adenopathy

Physical Examination - Methods

• Spread between the digits, suggestive of abscess
• Loss of the normal palmar concavity
• Fluctuance
• Crepitus or gas
• Examine the digital flexor sheaths for tenderness
• Palpate for bone tenderness
• Palpate for joint swelling, tenderness
• Decreased range of motion
• Adenopathy
• Record the most proximal level of cellulitis

Septic Flexor Tenosynovitis

• Flexed resting position of the digit.
• Fusiform swelling.
• Tenderness to palpation of the flexor tendon sheath.
• Pain on passive digital extension.Kanavel's Cardinal Signs

Septic Arthritis

• Usually from direct joint inoculation.
• Can occur from systemic bacteremia in immunocompromised patients.
• Physical examination: - Joint line tenderness to palpation - Pain with loading joint - Redness around the joint - Limited active joint motion - Painful passive joint mobilization

Septic Arthritis Diagnosis

• Diagnosis confirmed by aspiration of the joint.
• Staphylococcus aureus most common bacteria.

Septic Arthritis Treatment

• Irrigation and debridement.
• Organism specific antibiotics.
• Initial intravenous antibiotic choice is empiric based on the most likely organisms.
• Focus treatment based on the results of culture.

Osteomyelitis

• Acute: Treatment - Surgical debridement - Intravenous antibiotics Chronic: Treatment - Usually requires more extensive debridement for resection of the involved bone. - May require complex soft tissue reconstruction techniques. - Intravenous antibiotics. - Can cause a need for digital amputation. = uncommon

Necrotizing Fasciitis

• Septic shock
• Renal failure
• Adult Respiratory Distress Syndrome (ARDS)
• Multiple system organ failure
• Mortality rate of 33%

Necrotizing Fasciitis Treatment

• Require emergency resuscitation for treatment of systemic sepsis. Emergency surgery:
  • Extensive debridement of involved tissue.
  • May require emergency amputation.
• Serial debridement
• Broad spectrum antibiotic coverage

Human Bites

• Potential injury to: skin, tendon, bone, joint.
• Innoculum of oral pathogens into joint.Common mechanism: blow to opponents' mouth.

Human Bites - DON'T!

• Don't Close Human Bites

Bite Wounds

• Management Includes Tetanus status up-to-date. - Irrigate and debride - XRay - rule out foreign body, fracture - Splint, elevate extremity - Antibiotic prophylaxis - CLOSE FOLLOW-UP (24-48 Hrs)
  • Swollen, red, painful = Admit

Specific Hand infections

• Human Bite - "Fight Bites" S Aureus, Streptococcus, Eikenella Corrodens
• Animal Bite - Dog and Cat bites: Pasturella Multocida Also query the immunization status and observability of the animal: rabies prophylaxis
• History of work in a Dental office Herpetic whitlow
• Injury while fishing Acute infections can be severe and caused by Vibrio species Chronic infections can be caused by Mycobacterial organisms

Wounds Question-True or False?

• Epithelialization can occur within 24 following primary closure of a wound.
• Maximum wound strength is often achieved after 2 years.
• Wounds continue after collagen synthesis has reached an equilibrium.
• Wound contraction is mediated by myofibroblasts.
• The incidence of wound infection increases with healing by secondary intention