Plastic Surgery Lecture PDF - University of Toronto - Hand and Facial Trauma

Plastic Surgery for the Clerkship Student Jana Dengler, MD, MASc, MHSc Melinda Musgrave, MD, PhD Plastic Surgery is…. …EVERYWHERE! Hand Trauma A 35 year-old intoxicated man presents to the Emergency Department with a deep laceration to his right forearm after putting his hand through...

Plastic Surgery for the Clerkship Student Jana Dengler, MD, MASc, MHSc Melinda Musgrave, MD, PhD Plastic Surgery is…. …EVERYWHERE! Hand Trauma A 35 year-old intoxicated man presents to the Emergency Department with a deep laceration to his right forearm after putting his hand through a window. On examination, he has 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 is unable to flex the distal joint of his little finger. When he flexes his wrist, his hand deviates radially. The examination was otherwise normal. What structure(s) have been damaged? a) Ulnar nerve b) Flexor carpi ulnaris and flexor digitorum profundus muscles c) Median nerve d) Radial nerve e) Brachioradialis Preliminary Management Immediate: Elective:…. everything else: Amputated / devascularized parts / Tendon injury neurovasc compromise Nerve injury Open fractures Closed fractures Compartment syndrome Ligament injury Surgical infections Suppurative tenosynovitis Septic arthritis Necrotizing infections Deep space infections Approach to patient with hand injury ATLS protocol History Physical Exam Imaging X-ray Other (rarely required) History Handedness Occupation Hobbies Previous hand injuries Physical Examination LOOK (Inspection) *compare to other side Swelling, deformity Lacerations, bruising Vascularity Cascade Alignment FEEL (Palpation) MOVE (ROM) Sensation Physical Examination Vascular status Colour Temperature Cap refill Turgor Sensation Pulses / Allen’s Test Essentials of Hand Surgery 2002 Courtesy of Neil F. Jones, MD/Michael L. Gimbel, MD Cascade Tendon injury - high index of suspicion Physical Findings: Pain Loss of cascade Loss of function (test ALL tendons) Testing for FDS Function Testing for FDP Function Alignment Examination of finger flexion – detects rotational malalignment Courtesy of Mark E. Baratz, MD Radiographs Normal bone? Bone quality Bone lesion Fracture pattern Fracture alignment Fracture Analysis Which bone Location Pattern Intraarticular or extraarticular Simple or comminuted Stable or unstable (Non)displaced Deformity: Angulation Rotation Shortening Fracture Analysis Which bone Location Pattern Intraarticular or extraarticular Simple or comminuted Stable or unstable (Non)displaced Deformity: Angulation Rotation Shortening Fracture Analysis Which bone Location Pattern Intraarticular or extraarticular Simple or comminuted Stable or unstable (Non)displaced Deformity: Angulation Rotation Shortening Examination of Sensation Prior to any local anesthetic You must 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 Assume complete cut → surgery Closed injury: gunshot/crush + change in motor/sensory could be neuropraxia or nerve injury Follow for progression of recovery over 6 weeks Referral to peripheral nerve surgeon if no improvement at 6 weeks (splinting is important) Preliminary Management of Open Injuries Ensure tetanus 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 important! Wrap finger in moist gauze Place in plastic bag THEN place into another insulated container with ice DO NOT PLACE DIRECTLY ON ICE Amputation Check the Part(s) To replant or not to replant? Check the Stump(s) Amputation Check the Part(s) To replant or not to replant? Check the Stump(s) Amputation REVIEW Median nerve injury at the elbow… what will be missing? Median nerve injury at the wrist… what will be missing? What does the radial nerve innervate? A 67yo F presents with a 7 year history of progressive numbness and tingling in the radial 3 ½ digits. It wakes her up at night, and 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. What is the most likely diagnosis? a) Cubital tunnel syndrome b) Carpal tunnel syndrome c) Peroneal neuropathy d) Pronator syndrome e) Radial artery thrombosis Facial Trauma A 32 year old man comes into the emergency department after a sustaining facial blow injuries from a fight. The CT head reveals that he has sustained facial bone fractures. Which of the following is an indication for him to have immediate surgery: a) He has a displaced nasal bone fracture b) His CT head reveals an orbital floor fracture with no soft tissue entrapment c) He has ptosis and proptosis of his left eye and is complaining that he cannot see out of this eye even when the eyelid is held open d) He has an unstable fracture of the zygomatic complex e) He has a bilateral LeFort I fracture Approach to the Patient with Facial Trauma ATLS protocol → remember the C-spine History Physical Exam Imaging CT scan: CT facial bones History LOC Visual symptoms Malocclusion Sensory loss Operative Management of Facial Fractures Indications: 1. Restoration of Form: Correct deformity 2. Restoration of Function: Occlusion Vision Sensation (branches of facial nerve) Smell Breathing Primary Wound Management Tetanus Control bleeding Remove FB 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 Maxillary Sinus Entrapment CT facial bones Orbitozygomatic Complex Fracture Rigid fracture fixation 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 Fractures: Malocclusion Mandible Fractures: Panorex  Mandible Fractures: CT facial bones Axial views R para- Left body symphysis Mandible Fractures Operative Fixation Wiring of the jaw Wiring of the jaw + ORIF 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  Lefort 1: Transverse fracture LeFort Fractures Lefort 2: Pyramidal fracture Lefort 3: Craniofacial dysjunction LeFort I Fracture Low horizontal fracture with disruption of the tooth bearing section of the maxilla LeFort II Fracture Triangular or pyramidal central midface fracture LeFort III Fracture High horizontal fracture alongside junction between the cranial and facial skeleton LeFort Fractures Facial Buttresses: Key to evaluation and treatment of the fractured face Lateral buttress Medial buttress Pterygomaxillary Mandibular Facial Buttresses Vertical Horizontal 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??? Which of the following is not a finding in mandibular fractures? a) Palpable step along mandible b) Loose teeth c) Trismus d) Numbness in V2 distribution e) Malocclusion Hand Infections In which of the following are systemic antibiotics not indicated: a) Animal bite to hand b) Laceration over metacarpalphalangeal joint sustained after punching someone in a fight c) Cellulitis d) Burn wound to 75% of the dorsal aspect of the hand e) 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 General findings Early Later Laceration or skin injury Laceration may have sealed Redness or cellulitis at the surface Pain to palpation Redness or cellulitis Diffuse swelling Fluctulant mass Ascending lymphangiitis Tender proximal adenopathy Regional Review Course 1998 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: Kanavel’s Cardinal Signs Flexed resting position of the digit Fusiform swelling Tenderness to palpation of the flexor tendon sheath Pain on passive digital extension 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 confirmed by aspiration of the joint Staphlococcus 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 = uncommon 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 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 Regional Review Course 1998 Bite Wounds: Human Bites Common mechanism: blow to opponents’ mouth Potential injury to: skin, tendon, bone, joint Innoculum of oral pathogens into joint Bite Wounds: Human Bites Bite Wounds: Human Bites Don’t close human bites! Bite Wounds: Management 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 Intrinsic-plus “Safe” Position (Splinting) Which of the following statements is incorrect with respect to wound healing? a) Epithelialization can occur within 24 hours following primary closure of a wound b) Maximum wound strength is often achieved after 2 years c) Wounds continue to gain strength after collagen synthesis has reached an equilibrium d) Wound contraction is mediated by myofibroblasts e) The incidence of wound infection increases with healing by secondary intention  Thank You! 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