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resident:kia_washington [2020/08/12 13:24] – [Nail Ablation] jonathanresident:kia_washington [2021/08/04 15:21] (current) – [Table Saw Injury] jonathan
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 ====Metacarpal Fractures s/p ORIF==== ====Metacarpal Fractures s/p ORIF====
  
 +<WRAP group>
 +<WRAP half column>
 +
 +Operative Report:\\
 +1. CRPP Right first metacarpal base fracture:\\
 +\\
 +He was brought to the operating room and placed in a supine position. General anesthesia was induced and a time out performed.   An upper arm tourniquet was placed and the right upper extremity was prepped and draped in a standard sterile surgical fashion.  We first proceeded by exsanguinated and raising the tourniquet to 250 mm Hg.  We used the mini carm.  We reduced the fracture and placed two .045  kwires through the first metacarpal and one .045 k-wire through the first metacarpal to the second metacarpal. We burried the k wires underneath the skin.  We then placed a sterile dressing and a thumb spica splint.  The patient tolerated the procedure and went to the post operative care unit without complication. 
 +
 +</WRAP>
 +
 +<WRAP half column>
 +
 +Photos\\
 +
 +Tourniquet: finger / forearm / arm\\
 +Drain: Type of drain and placement\\
 +Sutures: List all layers\\
 +Dressing: What's preferred?\\
 +
 +Anatomy: Pertinent anatomy should be listed\\
 +
 +Post-operative care: Include restrictions, splints, etc...\\
 +
 +Attending Pearls (Learning points/Pimp Questions):\\
 OR tips: Usually close w/ 4-0 nylon, adaptiq/xeroform, 4x4, ace. Usually places whole hand in forearm based intrinsic plus splint w/ IPs included\\ OR tips: Usually close w/ 4-0 nylon, adaptiq/xeroform, 4x4, ace. Usually places whole hand in forearm based intrinsic plus splint w/ IPs included\\
 +
 +</WRAP>
 +</WRAP>
  
  
Line 415: Line 442:
 3. Left scapho lunate ligament repair\\ 3. Left scapho lunate ligament repair\\
 4. EPL transposition\\ 4. EPL transposition\\
-5. Left carpal tunnel release:\\+5. Left carpal tunnel release\\
 \\ \\
 The patient was identified in the holding area and the operative site was marked.  He was brought to the operating theater in stable condition, placed onto a regular OR table in the supine position with the operative extremity on an arm board. A preoperative time-out was taken to ensure the patient's identity, the operative procedure, as well as the operative location. A left arm tourniquet was placed and the arm was prepped and draped in a standard sterile surgical fashion.\\ The patient was identified in the holding area and the operative site was marked.  He was brought to the operating theater in stable condition, placed onto a regular OR table in the supine position with the operative extremity on an arm board. A preoperative time-out was taken to ensure the patient's identity, the operative procedure, as well as the operative location. A left arm tourniquet was placed and the arm was prepped and draped in a standard sterile surgical fashion.\\
-  \\+\\
 A longitiunal incision was made in line with the 3rd metacarpal on the dorsum of the hand.  We spread with tenotomy scissors down to the level of the extensor retinaculum.  We then made step cute incisions through the retinaculum the posterior interosseus nerve appeared to have been avulsed at the based of the 4th metacarpal.  We then made a dorsal sparing capsulotomy.  We pulled traction on the wrist with extension and then flexion while placing volar pressure on the lunate.  We placed two .054 k wires going from the scaphoid to capitate.  We then placed 2 crossed k wires across the scapho lunate interval and 2 k wires across the Luno triquetral interval.  We then repaired the LT ligament with 4-0 ethibond sutures and the scapho lunate ligament with a mini mitek anchor.  We then closed the capsule with 4-0 vicryl.\\ A longitiunal incision was made in line with the 3rd metacarpal on the dorsum of the hand.  We spread with tenotomy scissors down to the level of the extensor retinaculum.  We then made step cute incisions through the retinaculum the posterior interosseus nerve appeared to have been avulsed at the based of the 4th metacarpal.  We then made a dorsal sparing capsulotomy.  We pulled traction on the wrist with extension and then flexion while placing volar pressure on the lunate.  We placed two .054 k wires going from the scaphoid to capitate.  We then placed 2 crossed k wires across the scapho lunate interval and 2 k wires across the Luno triquetral interval.  We then repaired the LT ligament with 4-0 ethibond sutures and the scapho lunate ligament with a mini mitek anchor.  We then closed the capsule with 4-0 vicryl.\\
  \\  \\
Line 449: Line 476:
  
  
 +==== Scaphoid Excision and 4-Corner Fusion ====
  
 +<WRAP group>
 +<WRAP half column>
  
 +Operative Report:\\ 
 +1. PIN neurectomy\\
 +2. EPL transposition\\
 +3. Scaphoid excision, 4 corner fusion\\
 +4. Carpal tunnel release\\
 +5. Diganostic wrist arthroscopy\\
  
 +INDICATIONS FOR PROCEDURE: This patient is a _ - year old _ diagnosed with a chronic scapholunate ligament tear. We wanted to proceed with wrist arthroscopy for diagnosis and then definitive surgery as well as carpal tunnel release.
 +
 + \\
 +DESCRIPTION OF PROCEDURE: 
 +The patient was identified in the preoperative holding area and the operative site was marked.  They were brought to the operating theater in stable condition, placed onto a regular OR table in the supine position with the operative extremity on an arm board. An upper arm tourniquet was placed and a preoperative time-out was performed to ensure the patient's identity, the operative procedure, as well as the operative location. The _ arm was sterilely prepped and draped in a standard sterile surgical fashion.\\
 +
 + \\
 +We first proceeded by exsanguinating the extremity and raising the tourniquet to 250 mm Hg.
 +We first proceeded with the carpal tunnel release:
 + We made a longitudinal incision in the left palm in line with the 3rd webspace up to Kaplan's cardinal line. We incised through the skin down to the transverse carpal ligament and released it in its entirety. 　
 +We then proceeded with our wrist arthroscopy. We hung the wrist in the Acumed traction tower. We entered the wrist through a dorsal 3/4 portal. We were able to visualize the space between the scaphoid and lunate and the proximal end of the capitate, indicative of a complete SL tear. 　
 +We then proceed to scaphoid excision and four corner fusion, PIN neurectomy, and EPL transposition.
 +We made a dorsal midline incision overlying the radiocarpal joint in line with the 3rd metacarpal.  We spread with our tenotomy scissors down to the level of the extensor retinaculum. We made a step cut incision in the retinaculum and raised thick retinacular flaps. We then located the posterior interosseous nerve and removed the distal end and cauterized the remainder at the level of the radiocarpal joint. We then made a ligament sparing incision in the dorsal wrist capsule. We raised the capsular flap and located the scaphoid and lunate. There was a complete chronic tear of the SL ligament and the cartilage on the capitate was worn, so we made the decision to do a scaphoid excision, 4 corner fusion.
 +We excised the scaphoid in its entirety. We then used a joystick to bring the lunate out of the DISI deformity. We removed the cartilage from the capitate and lunate and used bone graft from the scaphoid. We placed a 22 mm Acumed screw in the capitolunate interval and a 16 mm screw in the hamate capitate interval.  We then closed the remaining capsule with 4-0 Vicryl suture. We then transposed the EPL tendon and then closed the extensor retinaculum and a vest over pants type fashion with 4-0 Vicryl.  
 +We closed the incisions with 4-0 nylon suture in a horizontal mattress fashion.  
 +We placed a sterile dressing and a well-padded sugar tong splint.
 +The patient tolerated the procedure and awoke from anesthesia without known complications.
 +\\
 +
 +</WRAP>
 +
 +<WRAP half column>
 +
 +Tourniquet: Upper arm – 250 mmHg\\
 +Drain: None\\
 +Sutures: Drain stitches: 4-0 Vicryls/Nylons\\
 +Dressing: Sugar tong splint, well-padded. 10 sheets thick. Bias/tape.\\
 +
 +Anatomy: Arthroscopic port entry sites. Anatomy of the carpus.\\
 +
 +Post-operative care:\\
 +- Maintain splint until clinic follow-up.\\
 +- Okay to use sling while arm is numb from block; remove when sensation returns to avoid stiffness/contralateral shoulder pain.\\
 +
 +Learning points/Pimp Questions:
 +- Know arthroscopic port entry sites, how to obtain appropriate intraoperative views with a C-arm.\\
 +- Know how to place a sugar tong splint.\\
 +
 +</WRAP>
 +</WRAP>
 +
 +
 +
 +
 +==== Table Saw Injury ====
 +
 +<WRAP group>
 +<WRAP half column>
 +
 +Operative Report:\\
 +1. Right open carpal tunnel release\\
 +2. Right flexor pollicus longus repair\\
 +3. Complex closure right hand\\
 +\\
 +OPERATIVE INDICATIONS:
 +XXX　is a 65 y.o.　male　who had a table saw injury to the palm of his hand and injured his FPL tendons as well as the digital nerves. We wanted to proceed with operative intervention.
 + 
 +DESCRIPTION OF OPERATION:
 +XXX　was identified in the holding area and the operative site was marked. He　was brought to the operating theater in stable condition, placed onto a regular OR table in the supine position with the operative extremity on an arm board. A preoperative time-out was taken to ensure the patient's identity, the operative procedure, as well as the operative location.　A regional block was performed in preoperative holding.
 +　　
 +We first proceeded with a carpal tunnel release:　
 + 
 +A longitidunal incision was made 1 cm distal to the distal wrist crease in line with the 3rd web space, extending Kaplan's　cardinal line. We dissected through the subcutaneous tissue and palmar fascia, and the palmaris brevis muscle fibers. Care was taken to protect the ulnar neurovascular bundle in Guyon's canal. Next we palpated the hook of the hamate. Next we identified the transverse carpal ligament　which was divided longitudinally from the palmar fat pad and proximally into the antebrachial fascia approximate 1 cm proximal to the distal wrist crease under direct vision. Complete release was ensured and the wound was irrigated with normal saline.
 + 
 +We then proceeded with repair of the FPL tendon:
 + 
 +The proximal and distal ends of the FPL tendon were identified. We repaired the tendon with a 4-core strand repair with a modified Kessler stitch and an epitendinous repair. 　
 + 
 +We then isolated the digital nerves, which appeared to be avulsed. We tagged them with 5-0 Prolene suture and burried them underneath the thenar muscles.
 + 
 +We then proceeded to irrigated the wounds extensively. We undermined the tissue with tenotomy scissors. We then sutured the incision closed with 4-0 Nylon suture in an interrupted horizontal mattress fashion. The length of the incision was 30 centimeters.
 + 
 +A sterile dressing and thumb spica splint were applied. The patient tolerated the procedure and went to the post operative care unit without complication.
 +
 +</WRAP>
 +
 +<WRAP half column>
 +
 +Photos:\\
 +{{:resident:img_4872.png?400|}}
 +{{:resident:img_4871.png?400|}}
 +{{:resident:img_4870.png?200|}}
 +{{:resident:img_4869.png?200|}}
 +\\
 +
 +Tourniquet: Arm\\
 +Drain: None\\
 +Sutures: Modified Kessler = 4-0 Fiberwire, Epitendinous = 6-0 Prolene, Skin = 4-0 Nylon horizontal mattress, 5-0 Prolene to tag the nerves\\
 +Dressing: Xeroform on suture line, then 4x4 gauze, well-padded plaster splint with Webril, 4x15, x12 thick, (thumb spica, in this case) - she generally splits the plaster longitudinally, with an extra piece to mold around the thumb\\
 +
 +Anatomy: Obviously for a mangaled hand all hand and forearm anatomy is critical. Usually attending will explore the injury and then write out what needs to be repaired with check boxes. Usually the order is bony fixation, tendon repair and then nerve. If the hand is dysvascular, then that needs to be addressed to prevent muscle necrosis.\\
 +
 +Post-operative care:\\
 +Immobilization in splint until clinic. Depending on repair may attempt early mobilization.\\
 +
 +Attending Pearls (Learning points/Pimp Questions): Known how to draw a modified Kessler prior to performing the suture repair. Know relevant anatomy of the hand and palm.\\
 +
 +</WRAP>
 +</WRAP>
  
  
resident/kia_washington.1597253087.txt.gz · Last modified: 2020/08/12 13:24 by jonathan
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