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--- resident:matt_iorio [2021/04/22 12:17] – [Cubital Tunnel with Transposition] jonathan
+++ resident:matt_iorio [2024/12/20 11:14] (current) – jerry
@@ Line 23: / Line 23: @@
 It's busy. Between 40-60 patients on Tuesdays for Hand.\\
 You need to be extremely concise. "55 yo RHD woman with CTS. I want to order an EMG."\\
+Ask Kayla or Dan to pull meds for injections. He uses 1 cc dex and 1 cc lidocaine mixture for everything.\\
+You could potentially ask for pyxis access to do it yourself.\\
+\\
+How to roll a Dr. Iorio Bulky Jones:\\
+These are usually for lower extremity free flaps. Make sure you glue to vioptix down with dermabond. He holds it down and then cuts the tips of his gloves off. Roll the 1lb of cotton on. No need to break it in half. Next get the webril and use it to keep the cotton on. Now get the bias. Start at the heal. Once you get a roll around the heal, place a folded ABD under the heal for extra padding. Roll up the bias all the way up. Guess where the doppler stitch is and make a hole. Use the 1 slice of medipore tape to re-enforce the wall of the hole. Prop the heal up on blankets and pillows transversely at the foot of the bed. There should be no pressure under the popliteal fossa (the inflow).:\\
+Stoma Revision Protocol (as of 3/20/23).\\
+- Biopsy culture stoma (bx for colonization data) "label screening culture" (Hayden/Damioli will work with lab to work up and grow to ID and susceptibility).\\
+- Vanc/tobra intra op around stoma (1 vial vanc/1 vial tobra).\\
+- Augmentin 875/125 PO BID x14 days.\\
+- If PCN allergy, the Bactrim DS 800/160 PO BID and Flagyl 500 PO BID x 14 days.\\
+\\
+OI soft tissue stoma superficial infection:.\\
+- Linezolid 600mg PO BID x10 days.\\
+- Cipro PO BIX x 10 days.\\
+Order pain buster orderset:\\
+Use Pain Buster order set. - In hospital use CADD pump set at 0.2 Ropivicaine dose, the day of leaving hospital need order the pain ball(400cc) and talk with pharmacy to set rate at 6cc/hr\\
+Do not ever use Keesler method for tendon repair. Use cruciate method (4-strands, 1 knot)
 ===== Operative Reports =====
@@ Line 35: / Line 56: @@
 \\
 When using the knife, he doesn't want any adjustments. Don't grab anything new or move your hand. It changes the perspective.\\
+\\
+OI Stoma Revisions: Dc on Bactrim vs Doxy for 10 days; shrinkers are found in the equipment storage across from OR 2 (need to know length and circumference) as well as donning tubes to help put on the shrinkers. Helps to check chart to know what size patient was wearing before and may have to adjust from there. If you have questions, ask Maria Kouzmina (Stoneback's APP). Tell charge when you're taking them so they can keep track of inventory (Stoneback's request).
 ==== Medial Femoral Condyle Free Flap ====
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 Close: Women :Deep dermal, running subQ. Old men: Nylons with a few deep dermals with monocryl.\\
 Dressing: adaptic, 4x4, webroll, ace. Off on POD#5.\\
+\\
 Anatomy: Pertinent anatomy should be listed\\
+\\
 Post-operative care: She will go home from the hospital today. Arrangements were made to follow up with me in clinic in 2 weeks for a wound check. she is to keep the hand elevated and remove the dressing in 48 hours and begin gentle range of motion as tolerated. If she has problems before followup, she has been told to contact me and I would be happy to see her sooner.\\
+\\
 Attending Pearls (Learning points/Pimp Questions):\\
 Prefers patient to have general anesthesia as opposed to nerve block. The cubital tunnel doesn't get the best spread with nerve blocks.\\
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 What vessel runs with ulnar nerve in elbow? ??Superior ulnar collateral, Posterior recurrent ulnar collateral. There is controversy if these should be cauterized because they are the primary blood supply to the nerve. Iorio does not believe this is true and is happy to cauterize them to mobilize the nerve.\\
 He prefers transposing as a primary operation because the revision rate is high for in-situ and it make is much harder with all the scar tissue. He does tend to do a lot of revisions.\\
+What are the points of compression of the ulnar nerve? Cubital tunnel (know these 5: Arcade of struthers, intermuscular septum, osborne's ligament, anconeus epitrochlearis, 2 heads of FCU), guyon's canal.\\
 \\
 Operates with the arm in a flexed elbow position. When he approaches osborne's ligament, he will straighten the arm.\\
 Marking: He marks like the hunt book. Just over the posterior border of the medial epicondyle.\\
+\\
+How he tackles each compression point:\\
+Usually starts proximally, however in the rare case that a patient is super thin or odd tissue will start distally,\\
+Finds nerve proximally to osbornes. Will go proximally and free up arcade of struthers bluntly with his finger.\\
+Next, will follow nerve and cut osborne's/anconeus.\\
+Continue following that proximally and cut the FCU fascia. Be careful around the muscle as branches may start coming off. Remember the first branch is the articular branch to the elbow, and then FCU branches. Dinging FCU branch not nice, but probably not a huge deal.\\
+Go back to medial intramuscular septum. This is between medial and long heads of triceps and brachialis. It's like strumming a guitar string. Cut that out and go down to just above periosteum. Like 1/2 cm wide and 4 cm logitudinal.\\
+Free up the nerve using a vessel loop. He uses combo of blunt with freer and scissors. Once free transpose. Check if you like it for kinks. Remember you can free up the distal half deeply off the bone using a freer. There are no branches going to the bone.\\
+Once you like how it lays, suture the old tract of the ulnar nerve closed with 3-0 monocryl. Then suture the lateral skin flap to the medial epicondyle with 3-0 monocryl.\\
+Close with 4-0 nylon horizontal mattress or 3-0 and 4-0 monocryl.\\
+\\
 </WRAP>
 </WRAP>
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 Attending Pearls (Learning points/Pimp Questions):\\
-Remember that FPL tendon is coming around thenar muscles. Hold hand in almost an intrinsic plus position with finger tips pointed to ceiling. The A1 pulley is posterior to thenar area in this position. Incision should NOT be over thenar prominence. If so, you are too far radial/anterior. Know what muscles attach to A1 and oblique pulley. Know innervation of thenar musculature\\
+Remember that FPL tendon is coming around thenar muscles. Hold hand in almost an intrinsic plus position with finger tips pointed to ceiling. With the thumb and fingers almost at a 90 degree angle. The A1 pulley is posterior to thenar area in this position. Incision should NOT be over thenar prominence. If so, you are too far radial/anterior. Know what muscles attach to A1 (FPB) and oblique pulley (Adductor pollicis). Know innervation of thenar musculature\\
+DO NOT HOLD THE THUMB EXTENDED. that brings the nerves up. Hold it with IP flexion in a resting position.\\
 \\
 OR tips: Local w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon, xeroform/adaptiq, 4x4, webrill 2” ace. \\
@@ Line 382: / Line 417: @@
 Attending Pearls (Learning points/Pimp Questions):\\
-OR tips: Local w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon, xeroform/adaptiq, 4x4, webrill 2” ace. \\
+OR tips: Local w/ sedation (inject into the tunnel, along the incision, and across volar wrist). Upper arm tourniquet w/ webrill, tourniquet, foam tape. Uses scalpel only for entire CTR operation (no Freer, no scissors). Close w/ 4-0 Nylon, xeroform/adaptiq, 4x4, webrill 2” ace. \\
 </WRAP>
 </WRAP>
@@ Line 766: / Line 801: @@
 <WRAP half column>
-Tourniquet: Yes\\
+Tourniquet: Upper arm pneumatic tourniquet\\
 Drain: No\\
-Sutures: monocryl\\
+Sutures: 3-0 monocryl deep dermals and 4-0 monocryl subcuticular\\
-Dressing: bulky dressing with thumb spica\\
+Dressing: bulky dressing with thumb spica splint\\
+Post-operative Protocol:\\
+Splint for 4-6 weeks followed by progression of AROM to PROM.\\
 \\
 Iorio Tips:
@@ Line 803: / Line 842: @@
 \\
-Indications: Ms.XXX　is a 53 y.o.　F that presents with a left forearm trauma involving an ulnar shaft fracture and radial forearm laceration.
+Indications: The patient presents with a left forearm trauma involving an ulnar shaft fracture and radial forearm laceration.
 We discussed the nature and pathophsiology of the diagnosis. We discussed treatment options and expectations in regards to potential outcomes, including the needs for secondary procedures or revisions.
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 Prefers a longitudinal incision unless it's a very young female patient for cosmetic reasons.\\
 Transposes EPL. Sutures wrist capsule back together with 3-0 monocryl.\\
-What interval dose he use?\\
+What extensor interval dose he use?\\
+After transposing EPL, will go longitudinally between DEC 2 & 4 and then elevate off the compartments. He is ALWYAS abele to close this. No stupid step cuts. Repair this at the end. 3-0 monocryl.\\
+Incise joint capsule and elevate off bones. Repair some of this at end with 3-0 monocryl.\\
+Take bone out with rongeur and freer and knife.\\
+Most important ligament to preserve is RSC (Radioscaphocapitate). All the ligaments that will support the wrist are now volar.\\
+Useful positions are flap and bumped up to flex the wrist using a blue towel bump.\\
 x-ray at the end. Take one image distracted to make sure the bone fragments are gone. Take the next image for stability. AP to show capitate sits in lunate fossa. Lateral flexed and extended to make sure the patient doesn't dislocate.\\
-Splint is very important. WRIST needs to be ulnarly deviated and the wrist in slight extension. MCPs free. Hand elevation pillow.\\
+Splint is very important. Volar dorsal. WRIST needs to be ulnarly deviated and the wrist in slight extension. MCPs free. Hand elevation pillow.\\
 This allows the capitate to stay in the lunate fossa of the radius.\\
+Special Equipment: Make sure to have finger traps and weights. 15lbs is a good start.\\