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resident:michael_gordon [2020/08/10 19:45] – jonathanresident:michael_gordon [2022/12/23 13:52] (current) – [Panniculectomy] haley.d
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 [[https://drive.google.com/open?id=1Bvf-utw-nCot5vsijWAfoeTpqHAKpCdv|Dr. Gordon Publications]] [[https://drive.google.com/open?id=1Bvf-utw-nCot5vsijWAfoeTpqHAKpCdv|Dr. Gordon Publications]]
  
-===== Pimp Questions =====+=====Operative Reports=====
  
 +General Tips:\\
 +Loupe magnification for ALL cases. Yes, even breast reductions.\\
 +Always likes patient on the OR bed. HATES the stretcher.\\
 +Always prep out both sides. You never know when you'll need to check contralateral and it's always nice to have.\\
 +Always collect culture data if there is pus expressed. (It will likely come back negative if antibiotics have already been given)\\
 +\\
 Why isn't the bovie working? Because we infiltrated with local and it's too wet.\\ Why isn't the bovie working? Because we infiltrated with local and it's too wet.\\
 After a surgical block, why does the patient feel like their arm is floating? Because they no longer have the sensation that it is resting on a surface, so the brain is tricked into thinking it is elevated. (It's not because the arm was elevated in the "last position" -- that's ridiculous.\\ After a surgical block, why does the patient feel like their arm is floating? Because they no longer have the sensation that it is resting on a surface, so the brain is tricked into thinking it is elevated. (It's not because the arm was elevated in the "last position" -- that's ridiculous.\\
 When releasing PIP contracture what is the order of structure release? Collateral ligaments before checkrein.\\ When releasing PIP contracture what is the order of structure release? Collateral ligaments before checkrein.\\
- +What is the relationship with renal failure and carpal tunnel syndrome? Amyloid disease\\
- +
-=====Operative Reports===== +
- +
-Loupe magnification for ALL cases. Yes, even breast reductions.\\ +
-Always collect culture data if there is pus expressed. (It will likely come back negative if antibiotics have already been given)\\+
  
 ===== Hand ===== ===== Hand =====
Line 48: Line 49:
 3. blue towel wrapped around arm help by penetrating towel clamp\\ 3. blue towel wrapped around arm help by penetrating towel clamp\\
 4.  long sheet over patient - held in place by 4 non penetrating towel clamps\\ 4.  long sheet over patient - held in place by 4 non penetrating towel clamps\\
 +====Trigger Finger====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
 +Operative Report:\\
 +
 +Indication: This is a 69 year old male who previously presented to clinic with trigger fingers of the right long and ring fingers that was severe and caused the patient significant discomfort. Excision of A1 pulleys of the ring and long fingers was recommended. The risks of the procedure including pain, bleeding, infection, wound healing complications, injury to nearby structures, persistent pain, stiffness, need for hand therapy, and need for other procedures we explained to the patient. The patient was in agreement with the plan and provided informed consent. \\
 +Report:
 +The patient was marked in the pre-operative area, and then brought to OR #4. A timeout was performed, and the patient was placed under sedation anesthesia. Lidocaine was locally infiltrated into the surgical site, and the patient was prepped and draped in sterile fashion.
 +A second timeout was performed confirming correct patient and surgical site, and the patient’s extremity was exsanguinated and tourniquet inflated to 250mmHg. First attention was turned to the ring finger. A longitudinal incision was made over the palmar aspect of the metacarpal head, directly over the A1 pulley. Litler scissors were used to carefully dissect down to the flexor tendon. The proximal end of the A1 pulley was identified and incised ulnarly and radially using Litlers to fully excise the A1 pulley and the proximal portion of A2. This was passed off the table. The finger was ranged and demonstrated no further triggering. 
 +Next, attention was turned to the long finger. A longitudinal incision was made over the palmar aspect of the metacarpal head, directly over the A1 pulley. Litler scissors were used to carefully dissect down to the flexor tendon. The proximal end of the A1 pulley was identified and incised ulnarly and radially using Litlers to fully excise the A1 pulley and the proximal portion of A2. The pulley was examined and appeared thickened. The underlying tendon demonstrated moderate fraying. The pulley was passed off the table, and the finger was ranged. The long finger did not stick, but demonstrated stiffer joint motion. Finally, both incisions were closed with 5-0 Nylon and dressed with Xeroform, wet gauze, dry gauze, Kerlix bandage, and an Ace wrap. All final instrument and sponge counts were correct.
 +
 +Tourniquet Time: 36 minutes
 +
 +Dr. Gordon was scrubbed in for the entirety of this procedure. \\
 +
 +</WRAP>
 +</WRAP>
 +
 ====Carpal Tunnel Release==== ====Carpal Tunnel Release====
  
Line 73: Line 94:
 Technical Steps:\\ Technical Steps:\\
 -He will mark the incision.\\ -He will mark the incision.\\
--Uses Knife to cut until fat is seen, 2 ski hooks\\+-Uses Knife to cut until fat is seen, 2 skin hooks\\
 -Bovie and smooth pickup to buzz vessels\\ -Bovie and smooth pickup to buzz vessels\\
 -then he uses ragnels and sens and you use litler scissors to dissect down to transverse carpal ligament.\\ -then he uses ragnels and sens and you use litler scissors to dissect down to transverse carpal ligament.\\
Line 110: Line 131:
  
 ==== Trapeziectomy with Ligament Reconstruction Tendon Interposition ==== ==== Trapeziectomy with Ligament Reconstruction Tendon Interposition ====
 +
 +<WRAP group>
 +<WRAP half column>
 +
 +Operative Report:\\
 +1. Right trapeziectomy with ligamentous reconstruction.\\
 +
 +After instillation of a supraclavicular block in the pre-operative area, the patient was brought to OR #4. A timeout was performed, and the patient was placed under general anesthesia. Pre-operative clindamycin was administered within 30 minutes of incision, and the patient was prepped and draped in sterile fashion.
 + Preoperative skin markings were designed as a 3 cm oblique incision along the dorsal radial aspect of the base of the 1st metacarpal. The hand and arm were then exsanguinated with the Ace wrap and finger tourniquet, and the tourniquet on the upper arm was inflated to 250 mmHg. The thumb was placed on 10 pounds of traction using a finger trap. Next, a scalpel was used to incise through the skin into subcutaneous tissues. After achieving hemostasis in the subcutaneous plane with use of electrocautery, incision was deepened using Litler scissors until EPB and APL tendon sheaths were identified, and the capsule over the dorsal aspect of the trapezium was incised with a scalpel from the trapeziometacarpal joint to the scaphotrapezial joint. Using the small Freer elevator and the small Joseph elevator, the trapezium was freed from its attachments taking care not to injure the neighboring carpal cartilage. The trapezium was rocked carefully back and forth until free, and was passed off the table en bloc. There was severe disease at the trapeziometacarpal joint with lesser disease of the scaphoid and the trapezoid joints.
 +Next, the FCR tendon could be seen in the base of the wound, and the FCR tendon was sharply divided proximally, leaving a tail of about 2 to 3 cm still attached to the base of the 2nd metacarpal. A G2 Mitek drill bit was then used to drill into the central base of the 1st metacarpal, and then a G2 Mitek anchor with 2 additional sutures of 2-0 FiberWire was then placed into the base of the 1st metacarpal. The distal FCR tendon still attached to the 2nd metacarpal was then tied into position with horizontal mattress sutures of the 3 sutures in the G2 Mitek anchor. The wound was then checked for hemostasis, and the closure was accomplished with interrupted 5-0 nylon sutures in the skin. Dressings consisting of Xeroform, wet gauze, dry gauze, Kerlix bandage, followed by application of a 4-inch plaster thumb spica wraparound splint to the patient's hand. All final instrument and sponge counts were correct. 
 +
 +</WRAP>
 +
 +<WRAP half column>
 +
 +Photos\\
 +
 +**DOES NOT USE C-ARM**
 +
 +Pre-operative block: Supraclavicular\\
 +Tourniquet: upper arm, sterile\\
 +Sutures: List all layers\\
 +Dressing: What's preferred?\\
 +
 +Anatomy: Dorsal sensory branch of radial nerve, EPB/APL (1st extensor compartment), FCR, trapezium and its articular surfaces\\
 +
 +Post-operative care: Include restrictions, splints, etc...\\
 +
 +Learning points/Pimp Questions:\\ 
 +  * Will ask you to identify the articulations. The big saddle joint articulates with the metacarpal. Note the articulation with the second metacarpal as well. The others are of course the articulations with the trapezoid and the scaphoid.\\
 +
 Special equipment: Bone anchor\\ Special equipment: Bone anchor\\
 Sutures: 2-0 fiber wire for tendon reconstruction, 5-0 nylon for skin closure\\ Sutures: 2-0 fiber wire for tendon reconstruction, 5-0 nylon for skin closure\\
 Notes: Removes trapezium whole. (ie. does not use rongeur unless a piece breaks)\\ Notes: Removes trapezium whole. (ie. does not use rongeur unless a piece breaks)\\
 +Sends trapezium for gross only pathology.\\
 +{{url>https://www.youtube.com/embed/glldA0RXIDg}}
 +
 +
 +</WRAP>
 +</WRAP>
 +
 +====Distal Radius Fracture Volar Plate ORIF====
 +
 +<WRAP group>
 +<WRAP half column>
 +
 +Operative Report:\\
 +After induction of general anesthesia, the patient had his right hand and arm prepped and draped.  Preoperative skin markings were designed as a 6 cm longitudinal incision over the FCR tendon, beginning 1 cm proximal to the volar wrist crease and extending proximally from that point.  The hand and arm were then exsanguinated with an Ace wrap.  The tourniquet on the upper arm was inflated to 250 mmHg. \\ 
 + \\
 +Finger traps were placed on the index and long finger.  Approximately 25 pounds of longitudinal traction was applied to the patient's arm throughout the course of most of the surgical procedure.  A scalpel was then used to incise along the marked lines, going down through the skin, into the subcutaneous tissues, whereafter the rest of the dissection was performed with loupe magnification using Littler scissors.  Hemostasis was achieved in the subcutaneous plane with use of electrocautery.  Then, the incision was carefully deepened down to identification of the FCR tendon.  \\
 + \\
 +The anterior portion of the FCR tendon sheath was opened.  Then the FCR tendon was retracted toward the ulnar side of the forearm.  Posterior aspect of the FCR tendon sheath was then opened.  Dissection continued down along the radial border, down to the radial border of the distal radius.  Once the radial border was identified, this was freed up.  A scalpel was used to incise along the radial border from the area of the ulnar radial styloid, down proximal to the pronator on the distal forearm.  A transverse incision through the periosteum was also made, going to the watershed area on the distal border of the distal radius.  The Freer and Joseph elevators were then used to elevate the pronator quadratus muscle and its corresponding periosteum towards the ulnar aspect of the forearm, thereby exposing the distal radius fracture.  The distal radius fracture was noted to be partially callused.  Using a Freer elevator and a Joseph elevator, gradual separation of the volar impaction was performed, followed by loosening of the fragments going dorsally.  Once this was accomplished, it was possible to reduce the distal radius fracture in what appeared to be a near-anatomical reduction.  \\
 + \\
 +Holding the fracture in reduction, a plate from the Stryker VariAx distal radius set was chosen and placed onto the volar aspect of the distal radius.  The first screw was placed through the slotted screw hole and temporally fixed.  The OrthoScan was then used to align the plate in its proper positioning on the distal radius.  The fracture was then re-reduced.  The most distal ulnar screw hole was filled, stabilizing the distal fragment of bone.  This was checked under the OrthoScan.  Good alignment appeared to be achieved.  A second stabilizing screw was then placed in the radial styloid screw.  Then the proximal screw holes were filled on the volar aspect of the distal radius proximal to the fracture segment.  Once these were placed, the final screws were placed in the distal plate, for a total of 4 screws of stabilization distally and 4 screws proximally.\\  
 + \\
 +Final evaluation of the position of the bone plate and screws was done under the OrthoScan.  The wrist was tested for any DRUJ instability (none was identified).  Closure of the wound began with a running 4-0 Vicryl suture to close the periosteum of the pronator muscle along the distal segment, as well as along the radial segment.  Following this, the skin closure was accomplished with multiple deep dermal sutures of 5-0 Vicryl, followed by a running subcuticular 5-0 Monocryl suture in the skin.  \\
 + \\
 +Approximately 5 mL of 0.5% Marcaine without epinephrine was instilled beneath the wound edge with use of a plastic angiocatheter for postoperative analgesia.  Then dressings, consisting of benzoin, Steri-Strips, Tegaderm dressing, followed by a Kerlix bandage, and finally a 4-inch plaster splint, were applied to the patient's arm.  The tourniquet was then released, after a total of 113 minutes of inflation time.
 +
 +</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...\\
 +
 +Learning points/Pimp Questions:\\
 +OR Tips: Block w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ 5-0 Vicryl, 5-0 Nylon (Monocryl if younger or female), kerlix, short arm splint, 4” ace. \\
 +\\
 +Where do you divide the PQ muscle? Transversely at the WATERSHED area (where it thins), and then with a small cuff longitudinally along the radial border. Remember he wants you to suture this back together over the plate.\\
 +
 +</WRAP>
 +</WRAP>
  
  
 ==== Distal Radius - Dorsal Spanning Plate ==== ==== Distal Radius - Dorsal Spanning Plate ====
  
 +<WRAP group>
 +<WRAP half column>
 +
 +Operative Report:\\
 +After induction of general anesthesia, the patient had his right hand and arm prepped and draped.  Preoperative skin markings were designed over the 3rd metacarpal as a longitudinal 4 cm incision over the dorsal aspect of the distal radius and carpus (a 3 cm incision and then a 4 cm incision proximally over the midpoint of the dorsal aspect of the distal radius).  The hand was then exsanguinated.  The Ace wrap and tourniquet on the upper arm was inflated to 250 mmHg.  Finger traps were placed on the index and long finger, and approximately 25 pounds of longitudinal traction was applied to the patient's hand throughout most of the surgical procedure.  Towards the end, the weight was dropped down to 15 pounds.  \\
 + \\
 +The scalpel was then used to incise along the marked lines at each of the incisions going down through the skin into subcutaneous tissues.  After achieving hemostasis in the subcutaneous plane with use of electrocautery, incision was carefully deepened down to the 3rd metacarpal.  The extensor tendons were pulled ulnarly, and the scalpel was used to incise through the periosteum on the 3rd metacarpal.  Periosteal elevators were then used to expose the segment of the 3rd metacarpal.  Once this was accomplished, dissection then continued to the dorsal aspect of the wrist where the EPL tendon was identified, and the EPL tendon sheath was opened from distal to proximal.  Elevating the EPL towards the radial side, a scalpel was used to incise down through the periosteum on the distal radius through the 3rd dorsal extensor compartment, and then the Freer and Joseph elevators were used to peel away the periosteum to expose the underlying bone.  There was longitudinal and fragmentation of the bone through this area, and careful dissection was performed to try to prevent additional distraction of the bones.  \\
 + \\
 +Finally, dissection continued at the most proximal incision site and after dissecting down to the bone, the proximal portion of the distal radius was exposed.  There appeared to be good stabilization for the plate at this point.  Noting that this last incision was very close to the palpable bone that was on the radial border of the forearm underneath the skin, a gentle dissection was performed with retrieval of the bony fragment, which was then sent to pathology.  The spanning plate was then brought onto the field after measuring to make sure it was the right dimensions (the short spanning plate was used), and the spanning plate was passed through the incision at the 3rd metacarpal to the wrist and then finally all the way up into the forearm.  After using the x-ray to align the plate appropriately, the plate was fixed with 1 screw hole through the slotted hole on the 3rd metacarpal, and then a second screw through the slotted screw hole on the proximal portion of the radius.  This appeared to give the alignment that was desired, and further stabilization was done with locking screws distally first and then proximally.  Remaining screws were then placed on the 3rd metacarpal as well as the proximal radius, and then finally 3 additional screws were placed in the distal radius area for additional stabilization.  Final x-rays were taken showing good position of screws and plate.  Closure of the cutaneous wound was then accomplished with multiple deep dermal sutures of 5-0 Vicryl, followed by running subcuticular 5-0 Monocryl sutures in the skin.  Dressings consisting of benzoin, Steri-Strips, Tegaderm, followed by Kerlix, and a 4-inch plaster splint were then applied.  Tourniquet was released after 125 minutes of inflation time during the closure of the wound.
 + 
 +
 +</WRAP>
 +
 +<WRAP half column>
 +
 +Photos\\
 +
 +Tourniquet: finger / forearm / arm\\
 +Drain: Type of drain and placement\\
 +Sutures: List all layers\\
 +Dressing: Benzoin, steri-strips, tegaderm, soft kerlix, splint.\\
 +
 +Anatomy: Pertinent anatomy should be listed\\
 +
 +Post-operative care: Include restrictions, splints, etc...\\
 +
 +Learning points/Pimp Questions:\\
 Things to note are there is a template for the spanning plates so you can use this to first make sure that you'll be in the right spot. You're going to make three incisions, one over the metacarpals. You can choose a second or third Dr. Gordon prefers the third over the just the aspect of the distal radius and then a mid distal mid radius.  Things to note are there is a template for the spanning plates so you can use this to first make sure that you'll be in the right spot. You're going to make three incisions, one over the metacarpals. You can choose a second or third Dr. Gordon prefers the third over the just the aspect of the distal radius and then a mid distal mid radius. 
  
Line 124: Line 250:
  
 The most proximal screws are a different size than the distal screws. The incisions were closed with 4-0 vicryl although he usually uses 5-0 vicryl, and a 5-O monocryl sub-cuticular layer. \\ The most proximal screws are a different size than the distal screws. The incisions were closed with 4-0 vicryl although he usually uses 5-0 vicryl, and a 5-O monocryl sub-cuticular layer. \\
 +</WRAP>
 +</WRAP>
 +
  
-Dressing: Benzoin, steri-strips, tegaderm, soft kerlix, splint. 
  
-====CMC Trapeziectomy==== 
-OR Tips: Block w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ 3-0/4-0 Monocryl, Steri strips, kerlix, Wrapped thumb spica splint, 4” ace. \\ 
  
  
 ====Cubital Tunnel Release (Endoscopic)==== ====Cubital Tunnel Release (Endoscopic)====
  
-OR Tips: LMA. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ 3-0/4-0 Monocryl, steristrips, kerlix, 4” ace. \\+<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Cubital tunnel and Carpal Tunnel Release 
 +After induction of general anesthesia by laryngeal mask, the patient had her left hand and arm prepped and draped.  Preoperative skin marking was designed as a 6 cm incision at the elbow Based posterior to the medial epicondyle and following the course of the ulnar nerve.  In addition, a 2 cm longitudinal incision along the hypothenar crease at the level of the wrist was also designed.  The hand and arm were then exsanguinated with the Ace wrap, and the tourniquet on the upper arm was inflated to 250 mmHg.  Scalpel was then used to incise at the level of the elbow along the marked lines going down through the skin into subcutaneous tissues.  After achieving hemostasis in the subcutaneous plane with use of electrocautery, incision was carefully deepened down to identification of the ulnar nerve just proximal to the medial epicondyle.  Once identified, the tissue over the ongoing ulnar nerve was opened up to give visual access to the ulnar nerve and then the fascia overlying the ulnar nerve was divided to a point approximately 8 cm proximal to the medial epicondyle.  This included the thickened band of the fascia that appeared to be consistent with the arcade of Struthers.  Dissecting distally, a relatively loose thickening of the fascia just posterior to the medial epicondyle was encountered and divided (Osborne ligament), and then notably thickened fascia over the 2 heads of the FCU was also encountered and divided.  After freeing up the nerve over the entire course thus marked, a vessel loop was placed underneath the nerve and vessel proximal to the medial epicondyle.  The nerve was elevated out of its bed carefully, making sure to maintain strict hemostasis at all points in time.  After the nerve was elevated out of its bed this distance, the nerve was then elevated out of the bed going from this point distally between the 2 heads of the FCU.  The skin and subcutaneous tissue were then elevated off the fascia of the medial epicondyle, creating a broad pocket for transposition of the ulnar nerve in this area.  The ulnar nerve was then transposed freely into this location without any compression on the nerve, and then the skin flap was sutured back to the medial epicondyle with 3 horizontal mattress sutures of 4-0 Vicryl.  After verification of hemostasis and checking the nerve to make sure that there was no kinking or any other problems with the nerve, attention was then turned to the wrist.  The scalpel was used to incise at the level of the wrist along the marked lines going down through the skin into subcutaneous tissues.  Again, hemostasis was achieved in the subcutaneous plane with use of electrocautery, and the incision was carefully deepened down to identification of the palmar fascia.  Once the palmar fascia was divided along an axis between the palmaris longus tendon and the 4th metacarpal, dissection then continued deep down to the level of the transverse carpal ligament.  Transverse carpal ligament was incised in the central portion until a small entry was made into the carpal canal.  Then, first using the small uterine sound followed by a small Freer elevator, soft tissues from the underneath surface of the transverse carpal ligament going up into the forearm were swept from the ulnar side to the radial side to clear any attachments from the underneath surface of the transverse carpal ligament.  Then with the Aufricht retractor placed up above the transverse carpal ligament, and traction being applied upward, the transverse carpal ligament was divided with Littler scissors going up into the forearm.  After confirmation of complete release of the transverse carpal ligament going proximally, the distal edge of the transverse carpal ligament was visualized and then divided going up into the central palm.  Closure of the wrist incision was accomplished with several deep dermal sutures of 5-0 Vicryl, followed by interrupted 5-0 nylon sutures in the skin.  Closure of the elbow incision was accomplished with multiple deep dermal sutures of 5-0 Vicryl, followed by running subcuticular 5-0 Monocryl suture in the skin.  Approximately 10 mL of 0.5% Marcaine without epinephrine was instilled beneath the wound edge at the level of the elbow with a plastic angiocatheter for postoperative analgesia.  Then, dressings consisting of benzoin, Steri-Strips, Tegaderm dressing, followed by Kerlix and an Ace wrap were applied.  At the wrist, approximately 5 mL of 0.5% Marcaine was instilled beneath the wound edge with the use of a plastic angiocatheter for postoperative analgesia.  Then, dressings consisting of Xeroform, wet gauze, dry gauze, Kerlix bandage, followed by application of a plaster splint was then applied.  Tourniquet was then released after a total of 111 minutes of inflation time. 
 + 
 +</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...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 +OR Tips: LMA. Upper arm tourniquet w/ webril, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ 3-0/4-0 Monocryl, steristrips, kerlix, 4” ace. \\ 
 +Make sure you know all the compression points of the cubital tunnel.\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 + 
  
  
 ====DeQuervain’s Release==== ====DeQuervain’s Release====
 +
 +
 +<WRAP group>
 +<WRAP half column>
 +
 +Operative Report:\\
 +1. Release and reconstruction of right 1st dorsal extensor compartment.\\
 +\\
 +After installation of a Bier block under tourniquet control at 280 mmHg, the patient had her right hand and arm prepped and draped.  Preoperative skin markings were designed as a 2 cm longitudinal incision directly over the 1st dorsal extensor compartment.  The scalpel was then used to incise along the marked lines going down through the skin into subcutaneous tissues, whereafter the rest of the dissection was performed with loupe magnification using Littler scissors.  Hemostasis was achieved in the subcutaneous plane with use of electrocautery, and then incision was carefully deepened down to identification of the 1st dorsal extensor compartment.  The superficial branch of the radial nerve was visualized and gently retracted to the volar aspect of the incision throughout the course of surgical procedure.  The 1st dorsal extensor compartment was visualized well from the proximal portion of this, and then a stair-step incision was made in the first dorsal extensor compartment.  The tendons of the 1st dorsal extensor compartment were examined, and there was some mucoid degeneration that was noted on several of the tendons and this was gently debrided away.  In addition to this, the tendon seemed to be somewhat adherent in the bed of the 1st dorsal extensor compartment and they were released so they could slice smoothly.  The 1st dorsal extensor compartment was then reapproximated very loosely by stair stepping it back together again and suturing it with 2 horizontal mattress sutures of 4-0 FiberWire.  There was at least 3 times a cross-sectional area of a space after reconstructing the 1st dorsal extensor compartment compared to the what the patient had preoperatively.  The closure of the cutaneous wound was then accomplished with several deep dermal sutures of 5-0 Vicryl, followed by a running subcuticular 5-0 Monocryl suture in the skin.  Approximately 3 mL of 0.5% Marcaine without epinephrine was instilled under the wound edge with use of a plastic Angiocath for postoperative analgesia, and then dressings consisting of benzoin, Steri-Strips, Tegaderm, followed by Kerlix and a 3-inch plaster thumb spica wraparound splint was applied to patient's hand.  Tourniquet was then released after a total of 54 minutes of inflation time.
 +
 +</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...\\
 +
 +Learning points/Pimp Questions:\\
 OR Tips: Local w/ sedation vs. Bier block. Forearm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ Monocryl, kerlix, short arm splint, 4” ace.\\ OR Tips: Local w/ sedation vs. Bier block. Forearm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ Monocryl, kerlix, short arm splint, 4” ace.\\
 +</WRAP>
 +</WRAP>
 +
  
  
-====Distal Radius Fracture s/p ORIF==== 
-OR Tips: Block w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ 5-0 Vicryl, 5-0 Nylon (Monocryl if younger or female), kerlix, short arm splint, 4” ace. \\ 
  
  
 ====Dorsal/Volar Wrist Ganglion Excision==== ====Dorsal/Volar Wrist Ganglion Excision====
 +
 +<WRAP group>
 +<WRAP half column>
 +
 +Operative Report:\\
 +1. Excision of ganglion of left dorsal extensor tendon sheath with tenodesis of EDC of small to EDC of the long.\\
 +\\
 +After instillation of a Bier block under tourniquet control of 280 mmHg, the patient had her left hand and arm prepped and draped.  Preoperative skin markings were designed as a 2 cm transverse skin incision directly over the mass.  The scalpel was then used to incise down through the skin into subcutaneous tissues, whereafter the rest of the dissection was performed with loupe magnification using Littler scissors.  The mass was easily encountered on the extensor tendon, which appeared to be involving more than just the EDC to the small and ring finger, but seemed to be encroaching on the entire EDC complex.  Although the mass initially looked relatively isolated from the tendon, as the mass was dissected down to the tendon, it was found to be significantly adherent and infiltrated into the tendon.  Nevertheless, it seemed like the mass could be removed without having to sacrifice a significant portion of the tendon.  The mass was carefully dissected away from the extensor tendons that appeared to be essentially just the EDC tendons. \\ 
 + \\
 +The mass was peeled away, but the most ulnar resection of the mass was more infiltrative and specifically was involved in attachments to the EDC that was going to the small finger.  Because of the significant amount of infiltration of the mass at this point, it was felt that portion of the tendon needed to be removed, and a small slip of the EDC to the small finger was, therefore, excised with this.  The mass was followed proximally, distally, radially, and ulnar to achieve as complete excision as possible.  In the end, it appeared that the remaining portion of the tendons was free of any obvious disease.  The slip to the EDC tendon was still partially attached to the EDC of the ring finger, but this was further attached through a tenodesis using horizontal buried mattress sutures of 4-0 FiberWire.  Closure of the cutaneous wound was then accomplished with several deep dermal sutures of 5-0 Vicryl, followed by running subcuticular 5-0 Monocryl suture in the skin.  Approximately 3 mL of 0.5% Marcaine without epinephrine was instilled beneath the wound edge with use of a plastic angiocatheter for postoperative analgesia, and then dressings consisting of benzoin, Steri-Strips, Tegaderm, followed by Kerlix and a 4-inch plaster splint holding the fingers in full extension was applied to the patient's hand.  Tourniquet was then released after a total of 68 minutes of inflation time.
 +</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...\\
 +
 +Learning points/Pimp Questions:\\
 OR Tips: Local w/ sedation vs. Bier block. Forearm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ 5-0 Vicryl, 5-0 Nylon, kerlix, short arm splint, 4” ace.\\ OR Tips: Local w/ sedation vs. Bier block. Forearm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ 5-0 Vicryl, 5-0 Nylon, kerlix, short arm splint, 4” ace.\\
 +
 +</WRAP>
 +</WRAP>
 +
  
  
 ====Metacarpal Fractures s/p ORIF==== ====Metacarpal Fractures s/p ORIF====
  
-OR Tips: Block w/ sedation. Forearm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/Monocryl, kerlix, Forearm based intrinsic plus splint, 4” ace.+<WRAP group> 
 +<WRAP half column>
  
 +Operative Report:\\
 +1. ORIF of right 4th metacarpal shaft fracture.\\
 +\\
 +After induction of general anesthesia, the patient had his right hand and arm prepped and draped.  Preoperative skin markings were designed as a 4 cm longitudinal incision over the dorsal aspect of the right 4th metacarpal, centered over the prominent dorsal apex angulation of the 4th metacarpal.  The hand and arm were then exsanguinated with the Ace wrap and the tourniquet on the upper arm was inflated to 250 mmHg.  Scalpel was then used to incise along the marked lines going down through the skin through subcutaneous tissues, whereafter the rest of the dissection was performed with loupe magnification using Littler scissors.  After achieving hemostasis in the subcutaneous plane with use of electrocautery, incision was carefully deepened down to identification of the 4th metacarpal.  The 4th metacarpal was identified and then a scalpel was used to incise on the 4th metacarpal through the periosteum.  A finger trap, which had been placed on the ring finger, had been attached to a rope and approximately 10 pounds of longitudinal traction was applied to the hand throughout the course of surgical procedure.  \\
 + \\
 +The Freer elevator was then used to elevate the periosteum off the 4th metacarpal, revealing the underlying fracture.  With manipulation, it was possible to get the fracture in what appeared to be excellent anatomical reduction.  Soft tissues in between the fracture segments were removed and then a plate from the Osteomed hand plating system was chosen for fracture fixation.  A straight plate was chosen and placed onto the dorsal aspect of the 4th metacarpal and then secured proximally.  The distal fragment was then secured through a compression screw.  The remaining screw holes were then filled with 3 screws proximally and 3 screws distally on the fracture segments.  Final radiographic evaluation of the bone showed good alignment of the fracture and good positioning of the screws.  Closure of the periosteal layer was then accomplished with a running 4-0 Vicryl suture, and then closure of the cutaneous wound was accomplished with several deep dermal sutures of 5-0 Vicryl, followed by a running subcuticular 5-0 Monocryl suture in the skin.  Approximately 3 to 4 mL of 0.5% Marcaine without epinephrine was instilled beneath the wound edge with the use of a plastic Angiocath for postoperative analgesia, and then dressings consisting of benzoin, Steri-Strips, Tegaderm, followed by Kerlix and a 4-inch plaster splint was applied to patient's hand.  Tourniquet was then released after a total of 100 minutes of inflation time.
 +</WRAP>
  
 +<WRAP half column>
  
-===== Plastics =====+Photos\\
  
 +Tourniquet: finger / forearm / arm\\
 +Drain: Type of drain and placement\\
 +Sutures: List all layers\\
 +Dressing: What's preferred?\\
  
-====Panniculectomy====+Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 +OR Tips: Block w/ sedation. Forearm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/Monocryl, kerlix, Forearm based intrinsic plus splint, 4” ace.\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 + 
 +==== Scapholunate Repair ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1.  ORIF of left perilunate dislocation with repair of left scapholunate and lunotriquetral ligaments, bone anchors and K-wires\\ 
 +2.  Left posterior interosseous nerve neurectomy\\ 
 +\\ 
 +After instillation of a supraclavicular block on the left side, the patient had his left hand and arm prepped and draped.  Preoperative skin markings were designed as a 4 cm longitudinal incision centered over the radiocarpal joint and crossing over the area just ulnar to the Lister tubercle.  The hand and arm were then exsanguinated with the Ace wrap, and the tourniquet on the upper arm was inflated to 250 mmHg.  Finger traps were placed on the index and long finger, and approximately 20 pounds of longitudinal traction was applied to the patient's arm throughout the course of the surgical procedure.   
 +  
 +The scalpel was then used to incise along the marked lines going down through the skin into subcutaneous tissues, whereafter the rest of the dissection was performed under loupe magnification using Littler scissors.  Hemostasis was achieved in the subcutaneous plane with use of cautery.  Then, the incision was carefully deepened down to identification of the dorsal extensor compartments.  The third dorsal extensor compartment was identified distally, and divided from distal to proximal.  The EPL tendon was taken out of the 3rd dorsal extensor compartment and reflected to the radial side of the wrist.  Scalpel was then used to incise through the periosteum onto the radius in the area of the 3rd dorsal extensor compartment and then continued longitudinally onto the dorsum of the wrist, extending into the radiocarpal joint space.  The periosteum was elevated off the radius and this allowed dissection in the subcutaneous tissues underneath the 4th dorsal extensor compartment, by giving access to the posterior interosseous nerve.  Given the magnitude of the patient's injury, it was felt that the patient would benefit from neurectomy for long-term pain management.  After identifying the nerve, the nerve was divided at that cauterized under a low current setting on the Bovie current.  The dissection then continued to expose the entire carpus.  Getting into the joint, it was immediately obvious that the scapholunate ligament was completely torn, but appeared to be completely attached to the scaphoid and only torn off the lunate.  There was significant damage to the articular surface, particularly of the capitate.  This included abrasions as well as linear scars, missing cartilage along the base of the capitate.  The lunotriquetral joint was evaluated and similar to the scapholunate joint, the ligament appeared to be completely attached to the triquetrum and ripped off from the lunate.  It was felt that after reduction of the lunate, that the most appropriate repair would be to reattach the scaphoid and triquetral aspects of the associated ligaments and suture them to the lunate, which was planned to be done with suture anchors.  Joysticks of 0.054 K-wires were placed in the scaphoid and the lunate and with derotation of the lunate (rotating it volarly), it was possible to get what appeared to be a correct alignment of the scapholunate joint space.  This was held into position with a clamp and then the evaluation was performed radiographically of the lunotriquetral ligament, which was already pretty well in position with a derotation that we did with getting the scapholunate joint space to line up.  Beginning with the scapholunate joint, a 0.054 K-wire was directed across the scapholunate joint space and then a pilot hole was drilled into the bare portion of bone on the lunate corresponding to where the scapholunate ligament had been ripped off the lunate.  A G2 Mitek anchor loaded with two #2 FiberWire sutures, as well as 2-0 Ethibond, was then placed into this hole.  The sutures were then passed in a horizontal mattress suture through the scaphoid, reattaching the scapholunate ligament to the lunate.   
 +  
 +Attention was then turned to the lunotriquetral ligament, where the bare aspect of the lunate was exposed from where the lunotriquetral ligament had been ripped off the lunate, and then the lunotriquetral joint space and the luno-capitate joint space was reduced by taking the traction off the arm and placing first a K-wire across from the scaphoid into the capitate, and then secondarily from the triquetrum through the hamate and into the capitate as well.  This seemed to hold the lunate in good position on the radial, as well as the ulnar side of it.  A Super Mitek anchor was then loaded with 2 additional sutures of 2-0 FiberWire, and then after drilling a pilot hole in the bare area of the lunate, from where the lunotriquetral ligament had been attached, the Super Mitek was placed into this hole and seated well.  The 3 stitches from this was then placed through a horizontal mattress suture through the radial border of the lunotriquetral ligament and tied down.  At this point in time, approximately 138 minutes had elapsed on the tourniquet, and the tourniquet was released.  X-rays of the wrist were taken, confirming what appeared to be excellent alignment of the carpal bones.  The closure of the wound was then accomplished with first closing the dorsal extensor compartment that had been opened through the 3rd dorsal extensor compartment with figure-of-eight stitch of 4-0 Vicryl.  Closure of the skin wound was then accomplished with several deep dermal sutures of 5-0 Vicryl, followed by interrupted 5-0 nylon sutures in the skin.  Dressings consisting of Xeroform, wet gauze, dry gauze, and Kerlix bandage were applied after trimming the 3 remaining K-wires (scapholunate, scaphocapitate, and triquetral, hamate, and capitate).  All K-wires were cut underneath the skin.  Dressings included a Kerlix bandage, and finally a 4-inch plaster splint for the wrist. 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 +{{:resident:256_2017_2676_fig3_html.png?600|}} 
 + 
 +Tourniquet: arm with finger traps (20 lbs weight)\\ 
 +Drain: none\\ 
 +Sutures: Extensor compartment - 4-0 vicryl; deep dermals: 5-0 vicryl; skin: 5-0 nylon\\ 
 +Dressing: Dressings consisting of Xeroform, wet gauze, dry gauze, and Kerlix bandage were applied after trimming the 3 remaining K-wires; Volar resting splint\\ 
 + 
 +Anatomy: Dorsal wrist (3rd dorsal extensor compartment and proximal carpus)\\ 
 + 
 +Post-operative care: NWB to affected extremity; volar based splint with MCPs free. \\ 
 + 
 +Attending Pearls (Learning points/Pimp Questions):\\ 
 +The posterior interosseous nerve can be found deep to 4th dorsal compartment. When exsanguinated, the vein can sometimes be easily visualized first.\\ 
 +\\ 
 +A chronic SL tear will lead do a DISI deformity where the scaphoid is flex and the lunate is extended.\\ 
 +\\ 
 +The sequence of a SLAC wrist occurs in a predictable pattern:\\ 
 +Stage I: Arthritis between scaphoid and radial styloid\\ 
 +Stage II: Arthritis between scaphoid and entire scaphoid facet of the radius\\ 
 +Stage III: Arthritis between capitate and lunate\\ 
 +\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 + 
 +==== DIP Mallet Fusion ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1.  Excision of mucous cyst of right small finger DIP joint. 
 +2.  Fusion of right small finger PIP joint.:\\ 
 +\\ 
 + 
 +After instillation of approximately 8 mL of 1% lidocaine without epinephrine at the level of the MCP joint as a digital block for the finger, the patient had his right hand prepped and draped.  Preoperative skin markings were designed as a transverse skin incision from the midpoint of the radial border of the DIP joint to the midpoint of the ulnar border of the DIP joint.  The finger itself was then exsanguinated with a 1/4-inch Penrose drain, which was wrapped tightly at the base of the digit to act as a tourniquet throughout the rest of the surgical procedure.  
 +A scalpel was then used to incise along the marked lines, going down through the skin and into subcutaneous tissues, whereafter the rest of the dissection was performed under loupe magnification using Littler scissors.  Hemostasis was achieved in the subcutaneous plane with use of electrocautery, and then a very careful dissection was performed in an effort to try to preserve the mucous cyst as much as possible.  This cyst was separated from the surrounding tissues and then was found to be extending down to the area of where the extensor tendon was at the DIP joint and then to go through this, into the joint itself.  There was a considerable amount of scar tissue, and the tissue planes were not well preserved.  The mass and a small portion of the terminal slip of the extensor tendon were excised and sent to pathology.  The joint was exposed, and the remaining cartilage of the joint was then removed using a small rongeur.  The radial and ulnar collateral ligaments were opened to be able to shotgun the joint to be able to achieve good cortical removal of the cartilage and the distal portion of the head of the middle phalanx as well as the corresponding portion on the distal phalanx.  Once cancellous bone was encountered on both surfaces, the joints seemed to be well lined up together.  A 0.062 K-wire was then chosen to direct through the base of the distal phalanx, exiting through the tip of the digit.  The position of this K-wire was verified under the fluoroscan, and then the K-wire was pulled so that it was extending down through the tip of the digit and through the length of the distal phalanx but not going any more proximally from that point.  The K-wire was then directed into the middle phalanx, holding the joint in about 10 to 15 degrees of flexion at the DIP joint.  This was then again verified under the OrthoScan, and the joint appeared to be well aligned, and the K-wire was in good position.  The length of the K-wire that was buried within the bone was then measured at about 24 mm, and an Acutrak fusion screw of 20 mm length was chosen for the fusion.  The K-wire was then removed through the tip of the digit, and the 20 mm fusion screw was then directed through the tip of the digit and then through the distal phalanx.  As it approached the joint level, the joint was lined up again, and the screw was advanced into the middle phalanx.  The screw was progressively advanced, burying it on the distal end and making sure that it maintained within the shaft of the middle phalanx.  Careful attention was applied to continue to get compression at the fusion site without causing any distraction.  After a good purchase of bone was obtained in this manner, the screwdriver was removed, and closure of the cutaneous wound was then accomplished with interrupted 5-0 nylon sutures in the skin.  Dressings consisting of Xeroform, wet gauze, dry gauze, and a 2-inch Kling bandage incorporating an Alumafoam splint for the DIP joint were placed on the hand, and finally a 2-inch Ace wrap was gently applied to the hand and finger.  The tourniquet was then removed after a total of 72 minutes of inflation time. 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 +{{:resident:screen_shot_2021-08-02_at_5.24.50_pm.png?600|}} 
 + 
 +Tourniquet: finger\\ 
 +Drain: None\\ 
 +Sutures: 5-0 nylon for skin\\ 
 +Dressing: Xeroform, wet gauze, dry gauze, 2inch kling with Alumafoam splint for the DIP joint, Ace everything over that\\ 
 + 
 +Anatomy:  
 +The proximal interphalangeal (PIP) joint and distal interphalangeal (DIP) joint configurations are quite similar.\\ 
 +\\ 
 +The condylar heads are biconvex but slightly asymmetric, being about twice as wide volarly as dorsally.\\ 
 +\\ 
 +The reciprocal bases of the distal segment are biconcave, having a central ridge.\\ 
 +\\ 
 +The volar plate extends from the neck of the phalanx to the volar base of the more distal phalanx, preventing joint hyperextension.\\ 
 +\\ 
 +Radial and ulnar collateral ligaments provide additional joint stability. The “true” collateral ligaments have bony attachments at both ends, whereas the accessory collateral ligaments extend from the condylar head to the volar plate.\\ 
 +\\ 
 +The axis of rotation and radius of curvature for a given interphalangeal joint are fairly constant. Consequently, the true collateral ligaments are effectively isometric, whereas the accessory collateral ligaments resist lateral translation when the joint is extended.\\ 
 +\\ 
 +As a result of the ligamentous and bony architecture, the PIP and DIP joints normally function as highly constrained hinge joints.\\ 
 +\\ 
 +The extensor tendon crosses the DIP joint dorsally as the terminal tendon, inserting slightly distal to the dorsal base of the distal phalanx.\\ 
 +\\ 
 +The germinal matrix of the nail bed is close to the terminal tendon insertion (average of 1.3 mm distal).\\ 
 +\\ 
 +The flexor digitorum profundus (FDP) tendon inserts broadly on the volar aspect of the distal phalanx, extending from the base to the midshaft.\\ 
 +\\ 
 +Over the PIP joint, the extensor apparatus splits into thirds. Contributions from the extensor tendon, the interosseous tendons, and lumbricals form the central slip, which inserts onto the dorsal base of the middle phalanx. The lateral bands travel past the PIP joint along the lateral margins and then combine to form the terminal tendon distally.\\ 
 +\\ 
 +The flexor digitorum superficialis (FDS) tendon splits to insert on the volar lateral margins of the proximal shaft of the middle phalanx.\\ 
 + 
 +Post-operative care: For DIP joint arthrodesis, protection with a simple aluminum splint is sufficient. PIP motion is encouraged. Splinting may be unnecessary if a fusion screw is used. Radiographs are taken at 6 weeks postoperatively. Buried pins may be removed once the fusion is radiographically solid (at least 8 weeks postoperatively).\\ 
 + 
 +Attending Pearls (Learning points/Pimp Questions): \\ 
 + 
 +The fusion position varies with the digit and joint involved. Invariably, the decision is a compromise between appearance and function. The ideal posture should replicate the normal digital cascade.\\ 
 +\\ 
 +In general, the DIP joints and thumb interphalangeal joint should be fused in 0 to 10 degrees of flexion.\\ 
 +\\ 
 +For the PIP joint, some authors recommend a uniform 40-degree flexion position for all digits, whereas others recommend 40 degrees for the index finger, progressing ulnarward in 5-degree increments to 55 degrees in the small finger. Many prefer a slightly more extended position for the index PIP that will still allow functional tip-to-tip pinch.\\ 
 +\\ 
 +The recommended fusion angle of the MCP joints is a cascade from 25 degrees of flexion in the index digit, progressing ulnarward in 5-degree increments to 40 degrees in the small finger.15\\ 
 +\\ 
 +The recommended fusion angle of the MCP joint of the thumb is 10 to 15 degrees of flexion and just resting at the radial border of the index finger mid-distal phalanx.\\ 
 + 
 +{{:resident:screen_shot_2021-08-02_at_5.25.55_pm.png?600|}} 
 + 
 +</WRAP> 
 +</WRAP> 
 + 
 +==== Jersey Finger Repair ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. ORIF of right long finger distal phalangeal fracture and advancement of avulsion of FDP tendon to the base of the distal phalanx of the right long finger.\\ 
 +\\ 
 +After instillation of a supraclavicular block, the patient had her right hand and arm prepped and draped.  Preoperative skin markings were designed as a Bruner type incision, extending from the pad of the right long finger distal to the DIP crease to the level of the PIP crease.  The hand and arm were then exsanguinated with the Ace wrap, and the tourniquet on the upper arm was inflated to 250 mmHg.  Scalpel was then used to incise along the marked lines going down through the skin into subcutaneous tissues, whereafter, the rest of the dissection was performed with loupe magnification using Littler scissors.  Hemostasis was achieved in the subcutaneous plane at all points of time with use of electrocautery.  The incision was carefully deepened down to identification of flexor tendon sheath and then the ulnar digital neurovascular bundle near the PIP joint was identified and protected throughout the course of the surgical procedure.  The flexor tendon sheath was markedly thickened and swollen, and the sheath was entered just distal to the A4 pulley, where no identifiable tendon of the FDP was made.  The sheath was then opened just proximal to the A4 pulley and the tendon was identified at this level and after careful palpation, it was possible to identify that the avulsed fragment of distal phalanx was still attached to the tendon under the A4 pulley.  A Freer elevator was then used to progressively free up the tendon from the A4 pulley and then the tendon was pulled out proximally.  A 3-0 nylon suture was placed in the end of the tendon, and then this was used to pass under the A4 pulley all the way up to the level of the distal phalanx.  After applying flexion to the wrist and traction on the FDP tendon, a 25-gauge needle was placed through the tendon, securing and stabilizing it in position, while reduction of the fracture and stabilization of the FDP tendon to the distal phalanx was to be made.  The volar fragment of the distal phalanx could be visualized and after exposing this through an incision through the periosteum and then elevation of the periosteal layer, it was felt that the fracture could be reasonably well reduced with some compression of the distal volar segment of the bone.  In advance of this, it was also felt that the best manner of securing the reinsertion of the FDP tendon was through a Mitek anchor suture in the distal portion of the distal phalanx.  The volar cortical area had been removed by the avulsion fracture and a mini-Mitek anchor loaded with 2 sutures of 4-0 FiberWire was then directed longitudinally into the axis of the tip of the digit.  This was then placed into there and secured.  The fracture reduction was then accomplished with two 0.028 K-wires.  The FDP tendon, which was then sutured with a horizontal mattress suture from each of the 2-0 FiberWire sutures, and advanced into the base of the distal phalanx volarly.  The skin flaps were then returned to their native position and sutured into position with interrupted 5-0 nylon sutures.  Dressings consisting of Xeroform, wet gauze, dry gauze, followed by Kerlix bandage were then applied and then the retaining 25-gauge needle across the FDP tendon was removed, when the hand was placed into a flexed position at the wrist and MCP joints.  A 4-inch plaster splint was then placed as a dorsal blocking splint, holding the hand in this position.  The tourniquet was then released, after a total of 126 minutes of inflation time. 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: upper arm\\ 
 +Drain: none\\ 
 +Sutures: 5-0 nylon sutures (interrupted for skin)\\ 
 +Dressing:Xeroform, wet gauze, dry gauze, followed by Kerlix bandage; 4-inch plaster splint was then placed as a dorsal blocking splint\\ 
 + 
 +Anatomy: Flexor tendon anatomy and anatomy of the pulleys\\ 
 +The ring finger involved in 75% of cases. During grip ring fingertip is 5 mm more prominent than other digits in ~90% of patients and therefore ring finger exposed to greater average force than other fingers during the pull-away motion. 
 + 
 +Post-operative care: NWB; ROM at 6 weeks\\ 
 + 
 +Attending Pearls (Learning points/Pimp Questions):  
 +{{:resident:ch38_table_text_01.jpeg?600|}} 
 + 
 +Mallet fingers are the extensor equivalent, but it is the central slip instead of the tendon itself that is attaching to the distal phalanx. 
 +\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 + 
 +==== Distal Phalanx Amputation ==== 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Amputation of left index finger through DIP joint:\\ 
 +\\
  
-42-year-old black female, who has been evaluated in the plastic surgery clinic with morbid obesity, prior to undergoing gastric bypass surgery.  After this, the patient lost 100 pounds and has maintained it for an extended period of time.  The patient has been having difficulties with rashes at the lower portion of the abdomen, but also near the umbilicus, where the patient has a second pannus that was causing overlap of skin near the umbilicus.  The patient was thought to be a candidate for panniculectomy, which would require also release of the pannus near the umbilicus and, hence, umbilical repositioning.  The patient was accepting of the risks and benefits associated with this and is brought to the operating room today for this purpose. 
    
 +INDICATIONS:
 +The patient is a 61-year-old, right-hand dominant black female, who has been followed by our service now for a couple of months, with an initial injury of a dislocation of the left index finger at the level of the DIP joint, which the patient did not seek medical attention for immediately. The patient was eventually seen about 10 days later in the emergency room. The patient underwent washout and closed reduction of the joint. The patient initially did well. But then developed an infection, resulting in a flexor tenosynovitis, for which the patient underwent an incision and drainage procedure. 　
 + 
 +The patient finally recovered from this. The patient, however, has had a continued exposed open wound over the volar aspect of the left index finger at the level of the DIP joint. Because of the patient's ongoing chemotherapy for end-stage gynecological cancer, the patient was felt to be at too greater risk for considering additional interventions without considering the possibility of an amputation of this digit at the tip. The patient finally decided that the digit was no longer of that much importance to her, given all the trouble digit has caused her over the past couple of months. The patient felt that she would like to proceed with an amputation. Given the overall morbidity and the concerns for healing in this patient, I felt that it was appropriate for the patient to at least consider proceeding with amputation. The patient has elected to proceed with this. The patient is brought to the operating room today for this purpose.
 +
 DESCRIPTION OF PROCEDURE: DESCRIPTION OF PROCEDURE:
-Prior to induction of general anesthesia, the patient was placed in a standing position in the preoperative area, where the infra pannus crease was marked out in the standing position, as was vertical limbs beginning at the midaxillary line and dividing each abdominal section into 4 parts, and finally at the midline.  The patient was then placed in repose with the bed flexed to about 30 degrees.  An estimation of total skin that could be removed, was then marked out in this manner.  The patient was then brought to the operating room, where the patient was prepped and draped.  After reinforcing the skin markings, an incision was made along the inferior fold underneath the pannus along the lower abdomen, extending all the way out, including lateral to the ASIS on both sides for at least 10 to 15 cm.  Hemostasis was achieved in the subcutaneous plane with use of electrocautery, and the incisions were deepened all the way down to the abdominal wall.  This was extended all the way out to the full length of the incision and then the abdominal skin was elevated off the abdominal wall using the electrocautery, going up to the marked lines.  The umbilicus was then incised circumferentially, preserving what was thought to be an acceptable amount of umbilicus for final positioning.  The dissection then continued down to the abdominal wall to preserving vascularity to the umbilicus.  This was then connected with the abdominal skin flap, which was elevated for additional distance in the midline area to allow repositioning for the umbilicus.  An estimation was made for the skin tension that would be necessary to close the abdomen with the markings had been made preoperatively and these were found to be excellent markings for the patient.  As a result, a midline incision was made from the inferior portion of the abdominal flap to the location of the umbilicus, and then extended all the way up to the markings that had been made preoperatively.  The patient was then placed into a flexed position at the hips and it was felt that there was a good elevation of the mons and still not too tight a   closure.  The skin flaps were then measured, going from midline towards the outside edge of the incision, checking at each point in time to make sure that the next several centimeters would not under too excessive tension.  The total amount of skin was then removed, and weighed at just under 9 pounds.  Meticulous hemostasis was then achieved and the superficial fascial layer at the lower border of the incision was then closed with interrupted 2-0 Vicryl sutures.+After instillation of approximately 9 mL of 1% lidocaine without epinephrine at the base of the left index finger MCP joint as a digital block, the patient had her left hand and arm prepped and draped. After careful evaluation of the open wound at the level of the DIP joint volarly, it was felt that it might be possible to remove the body of the distal phalanx through a dorsal incision, through the nail bed, and then contour of the head of the middle phalanx through the open wound at the volar aspect of the DIP joint. The finger was then exsanguinated with a 1/4-inch Penrose drain, which was then wrapped tightly at the base of the digit to act as a tourniquet throughout the course of the procedure. 　
    
-Then, 15-French Blake drains were placed along the lower edge of each incision and exited through a stab incision on the medial aspect of both thighs.  The drains were sutured into position.  The markings for the umbilical positioning were made on the skin and this skin was cut out in a shield pattern, and then the umbilicus was brought through the skin incision at this level.  The umbilicus was sutured into position with interrupted deep buried 5-0 Vicryl sutures.  The incision along the lower portion of the abdomen was then closed with multiple deep dermal sutures of 2-0 Vicryl, separated no more by then 1 cm apart.  Final skin closure along the lower incision was then accomplished with running 4-0 Monocryl sutures.  Benzoin, Steri-Strips, and Tegaderm dressings were applied to the incision site with the umbilicus being dressed with Xeroform, 2 x 2 gauze, and a small Tegaderm.  Biopatch and Tegaderm dressings were placed on the drains.+The scalpel was then used to incise along the periphery of the nail bed (radial, ulnar, and distal), down all the way to the distal phalanx from each of these directions. The nail was removed from the nail bed with a Freer elevator. A Freer was then used to progressively remove all soft tissues from the distal phalanx in a circumferential manner. The rongeur was then used to remove the distal phalanx piecemeal, with specimens of the distal phalanx being sent for culture ( no clinical signs of infection). This continued until the entire distal phalanx was removed, including evaluating through the volar aspect as well. 　
    
-COMPLICATIONS: +At this point, the head of the middle phalanx was then contoured with a rongeur to remove the volar lip of the head of the middle phalanx, as well as the condylar flares on either side. The inspection of the soft tissues at the back of the digit allowed complete removal of the sterile matrix, as well as the germinal matrix. The flexor tendon to the distal phalanx that had been divided, was then grasped and placed on traction and divided as far proximal as possible. 　
-None.+
    
-SPECIMENS: +The scalpel was then used to cut full-thickness through the skin along the margins of the volar wound to allow eventual suture with good edges. Additionally, trimming of the skin on the dorsal aspect, including the eponychial fold and the paronychial folds, was performed to give good edges to the open wound on the dorsal aspect of the digit as well. The finger was then pulse lavaged with a liter of saline. 　Closure of the cutaneous volar wound was then accomplished with interrupted 5-0 nylon sutures in the skin, everting the wound edges and bringing the skin into approximation volarly. The dorsal incision (using the tip of the digit to fold over dorsally for final wound closure) was accomplished with interrupted 5-0 nylon sutures in the skin. This gave a closed wound with relatively good contour to the digit. Dressings consisting of Xeroform, wet gauze, dry gauze, 2-inch Kling bandage, followed by Kerlix and a 4-inch Ace wrap, were then applied to the patient's hand. The tourniquet on the digit was removed after a total of 67 minutes of inflation time.
-None.+
    
-DRAINS: +</WRAP> 
-Two 15-French Blake drains, one in the right side of the abdomen, one on the left side of the abdomen.+ 
 +<WRAP half column> 
 + 
 +Photos\\ 
 +{{:resident:f049-011ac-9781455774272.jpeg?600|}} 
 + 
 +Tourniquet: Finger - 1/4 inch Penrose\\ 
 +Drain: None\\ 
 +Sutures: 5-0 Nylon, simple interrupted sutures\\ 
 +Dressing: Xeroform, wet gauze, dry gauze, 2-inch Kling bandage, followed by Kerlix and a 4-inch Ace wrap\\ 
 + 
 +Anatomy:  
 +{{:resident:screen_shot_2021-03-13_at_7.55.05_pm.png?400|}} 
 +{{:resident:screen_shot_2021-03-13_at_7.55.12_pm.png?200|}} 
 +{{:resident:screen_shot_2021-03-13_at_7.55.20_pm.png?200|}} 
 +\\ 
 + 
 +Post-operative care: Dressings kept on until follow-up in 1 week.\\ 
 + 
 +Attending Pearls (Learning points/Pimp Questions): Know anatomy in figures above. Especially the extensor and flexor insertions.\\ 
 +\\ 
 +Drawing the "fishmouth" is the most important part of this operation. If you don't draw the fish with a "wide" enough mouth, then you will get little horns on the side or a hammerhead result.\\ 
 +\\ 
 +There are whole chapters on techniques to avoid completion amputations such as V-Y flaps, reverse cross finger flaps, skin grafting and for the thumb moberg flaps.\\ 
 + 
 + 
 +</WRAP> 
 +</WRAP> 
 + 
 +==== Infectious Tenosynovitis ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Incision and drainage of an infectious tenosynovitis of right ring finger.\\ 
 +\\ 
 +After induction of general anesthesia by laryngeal mask, the patient had his right hand and arm prepped and draped. Preoperative skin markings were designed as a series of 1 cm incisions, 1 transversely at the DIP crease, 1 at the PIP crease, and 1 at the MCP crease of the ring finger, and 1 in the palm at the level of the distal palmar crease over the 4th metacarpal. The hand was then elevated for a period of approximately 2 minutes, and then an Ace wrap was used to exsanguinate from the wrist proximally to the upper arm. The tourniquet on the upper arm was inflated to 250 mmHg. The hand was placed into a lead hand for stabilization, and then, a scalpel was used to incise at the MCP crease, where the patient had the site of penetration. In the subcutaneous tissues, it appeared that an abscess was encountered, and this was cultured and drained. Extending deeper down to the flexor tendon sheath, the flexor tendon sheath was opened. In the process of doing so, the patient was found to have very cloudy purulent fluid at this level. The decision to proceed with an incision and drainage of flexor tenosynovitis was then pursued. Incisions were then made at all of the markings and dissection at each location down to the flexor tendon sheath. Using a 0.038 guidewire, the guidewire was then passed from the PIP joint in the flexor tendon sheath, all the way up to the distal palmar crease. The guidewire was located at this position between the FDS and the FDP tendon and retrieved. The other end of the guidewire at the PIP joint was then passed through the flexor tendon sheath at the PIP joint, going up to the DIP joint, and retrieved at the DIP joint. A 4.8-French ureteral stent was then threaded on top of the guidewire, and then passed from the palm to the DIP crease. The catheter was sutured into position and connected to some IV extension tubing and approximately 300 mL of normal saline was irrigated through the palm and exited through the distal palmar crease. The catheter was sutured into position at 3 locations in the palm and at one location at the DIP crease. The hand was then wrapped with a 4 x 4, and Kerlix and then a 4-inch plaster splint was applied to the patient's hand (plaster wrapped in a plastic bag to prevent it from getting wet) and finally secured with a 4-inch Ace wrap. Tourniquet was then released after a total of 46 minutes of inflation time. 　 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: upper arm tourniquet\\ 
 +Drain: Places pediatric feeding tubes for continuous irrigation\\ 
 +Sutures: Nylon sutures to secure feeding tubes. Does not usually close incisions\\ 
 +Dressing: 4 x 4 gauze, and Kerlix and then a 4-inch plaster splint was applied to the patient's hand (plaster wrapped in a plastic bag to prevent it from getting wet) and finally secured with a 4-inch Ace wrap\\ 
 + 
 +Anatomy: Know the flexor pulley system. Space of Parona.\\ 
 + 
 +Post-operative care: Keeps splint and dressing on for usually 48 hours and lets it get absolutely drenched. When you change the dressing, the hand will be completely macerated.\\ 
 + 
 +Learning points/Pimp Questions: 
 +What are the 4 signs of FTS? Fusiform finger, pain with passive extension, flexed posturing and pain along the tendon sheath.\\ 
 +Which sign is specific for FTS? pain along the tendon sheath. The others can be found with abscess and other abnormalities.\\ 
 +What is a horse-shoe abscess? Goes through space of Parona. 
 + 
 +Post-operative catheter order/protocol:\\ 
 +Every shift: 
 + 
 +The patient has a _ - (finger, wrist, hand) catheter that was placed into their flexor tendon sheath in the OR.  
 + 
 +They will receive 10 mL NS irrigation instilled through this, connected to an IV pump. 
 + 
 +Q4H, please PAUSE the NS irrigation and then instill 3 mL of 0.5% Marcaine through the catheter that was placed in the OR.  
 +- Let this sit for 15 minutes.  
 +- Reconnect the continuous NS irrigation afterwards at 10 mL/hr on the iv PUMP 
 + 
 +The patient has dressings in place that will become saturated 
 +Their splint was placed into a water impermeable bag 
 +Please do NOT remove or change the dressings 
 + 
 +If there is drainage from the splint or the dressings, please place the patient’s extremities over a Chux pad and change this PRN 
 +Please allow their wound/irrigation to drain freely 
 + 
 +Thank you 
 + 
 +</WRAP> 
 +</WRAP> 
 + 
 + 
 + 
 + 
 + 
 +===== Plastics ===== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Bilateral Breast Reduction, Inferior Pedicle, Wise Pattern\\ 
 + 
 +Prior to bringing the patient into the operating room, the patient was placed into a standing position and the midline marking as well as the nipple lines were drawn out on both sides.  The patient had standard Wise pattern drawn on both chests and these markings were tested multiple times to verify that they would be accurate markings to achieve a good breast reduction.  The patient was noted to have a smaller breast on the left side, than on the right side.  The patient was then brought to the operating room, placed on the operating table, and underwent induction of general anesthesia.  The patient then had her chest and upper abdomen prepped and draped.  The patient's preoperative skin markings were reinforced at that time, and then approximately 40 mL of 0.5% lidocaine with 1:200,000 epinephrine was infiltrated along the chest wall on both the right and left chest using spinal needles.  The final breast markings were made on the patient with an inferior pedicle technique using about an 8 cm width to the pedicle.  The nipples were marked out with a 40 mm diameter areola.  A tourniquet was placed on the base of each breast and with stabilization, and deepithelialization of the pedicle was then performed with preservation of the nipple centrally.  After achieving successful deepithelialization on both breasts, attention was then turned to the right breast where definition of the pedicle was then accomplished using electrocautery for continuous hemostasis.  The pedicle on the right breast was defined by going straight down along the markings for the medial side first, and then the lateral side of the pedicle, and then finally joining them together over the cephalad tip of the pedicle.  This dissection continued just down to the muscle fascia.  At this point then, the superior Wise pattern markings were incised, and a thickness of about 1 to 1.5 cm of subcutaneous tissue was preserved against the skin flaps going cephalad medially and laterally down to the chest wall at the end of the breasts.  The skin flaps were kept slightly thicker in the central medial portion directly above the pedicle of the breast.  Lateral excavation was performed on the breast to thin out the tissues and fat in the axillary area.  Final incision was then performed of the specimen, and the specimen was sent to pathology.  An identical procedure was then performed on the left breast with similar findings and creation of the pedicle.  After excision of the initial breast tissue, both specimens were weighed and there was a significantly greater amount of breast tissue that had been removed from the right breast than the left breast.  While this was felt to be reasonable, given our expectation that the left breast was smaller than the right breast, the breast was temporarily tacked with the Wise pattern markings that had been cut, and the patient was placed into a sitting position to try to assess the size of the breasts.  It appeared that the left wrist was now somewhat larger (because of the decreased amount of tissue that had been excised from the left side compared to the right side), and the patient was laid back down flat and additional breast tissue was taken from the left breast.  At the same time, markings were made on both the right and the left breast to identify the lateral extent of the breast that was desired on the chest wall, and then tacking was done using 2-0 PDS sutures of Scarpa fascia of the breast laterally to the pectoralis fascia to define and prevent migration of the breast pedicle laterally.  The patient was then sat up again and much improved symmetry was achieved with the additional excision of left breast tissue, but it was still felt that the left breast was somewhat larger than the right breast.  The patient was laid back down again and final excision of breast tissue on the left side was performed with final excisions of 603 grams on the right side and 486 grams on the left side.  The patient was felt to have good symmetry with acceptable skin closure without too severe tightness.  Final tacking sutures of the lateral chest wall were then placed with 3 such sutures placed on the lateral chest on both sides.  Then, 15-French Blake drains were placed exiting through the lateral chest wall area and sutured into position with 3-0 nylon sutures.  Closure of the wounds on both sides was then accomplished with multiple deep dermal sutures along the inframammary fold as well as the vertical incision using 2-0 Vicryl sutures, spaced no more than 1 centimeter apart.  This was then followed by running subcuticular closure of 4-0 Monocryl along both these incisions.  The nipple that had been tacked to the superior end of the vertical incision was noted to be in good position on both breasts, and a cookie cutter was used to mark out a circular opening for the nipple on both sides.  Serrated scissors were then used to cut along these lines, exposing the underlying tissue.  Some fat from the superior end of the skin flap was then defatted to allow a more natural position for the nipple on both breasts, and then the nipple was sutured into position with approximately 8 deep dermal sutures circumferentially around the areola with 5-0 Vicryl sutures.  This was then followed by a running 5-0 plain gut suture along the periphery of the areola.  Dressings to the nipple on both sides was accomplished with Telfa just covering the nipple, Steri-Strips, and Tegaderm.  Dressings to both the vertical and inframammary incisions consisted of benzoin, Steri-Strips, and Tegaderm dressings. 
 + 
 +</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...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 +Uses plastic template to mark patient.\\ 
 +Also folds a lot of blankets!\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +====Panniculectomy==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Panniculectomy\\ 
 +\\ 
 +Prior to induction of general anesthesia, the patient was placed in a standing position in the preoperative area, where the infra pannus crease was marked out in the standing position, as was vertical limbs beginning at the midaxillary line and dividing each abdominal section into 4 parts, and finally at the midline.  The patient was then placed in repose with the bed flexed to about 30 degrees.  An estimation of total skin that could be removed, was then marked out in this manner.  The patient was then brought to the operating room, where the patient was prepped and draped.  After reinforcing the skin markings, an incision was made along the inferior fold underneath the pannus along the lower abdomen, extending all the way out, including lateral to the ASIS on both sides for at least 10 to 15 cm.  Hemostasis was achieved in the subcutaneous plane with use of electrocautery, and the incisions were deepened all the way down to the abdominal wall.  This was extended all the way out to the full length of the incision and then the abdominal skin was elevated off the abdominal wall using the electrocautery, going up to the marked lines.  The umbilicus was then incised circumferentially, preserving what was thought to be an acceptable amount of umbilicus for final positioning.  The dissection then continued down to the abdominal wall to preserving vascularity to the umbilicus.  This was then connected with the abdominal skin flap, which was elevated for additional distance in the midline area to allow repositioning for the umbilicus.  An estimation was made for the skin tension that would be necessary to close the abdomen with the markings had been made preoperatively and these were found to be excellent markings for the patient.  As a result, a midline incision was made from the inferior portion of the abdominal flap to the location of the umbilicus, and then extended all the way up to the markings that had been made preoperatively.  The patient was then placed into a flexed position at the hips and it was felt that there was a good elevation of the mons and still not too tight a   closure.  The skin flaps were then measured, going from midline towards the outside edge of the incision, checking at each point in time to make sure that the next several centimeters would not under too excessive tension.  The total amount of skin was then removed, and weighed at just under 9 pounds.  Meticulous hemostasis was then achieved and the superficial fascial layer at the lower border of the incision was then closed with interrupted 2-0 Vicryl sutures.\\ 
 + \\ 
 +Then, 15-French Blake drains were placed along the lower edge of each incision and exited through a stab incision on the medial aspect of both thighs.  The drains were sutured into position.  The markings for the umbilical positioning were made on the skin and this skin was cut out in a shield pattern, and then the umbilicus was brought through the skin incision at this level.  The umbilicus was sutured into position with interrupted deep buried 5-0 Vicryl sutures.  The incision along the lower portion of the abdomen was then closed with multiple deep dermal sutures of 2-0 Vicryl, separated no more by then 1 cm apart.  Final skin closure along the lower incision was then accomplished with running 4-0 Monocryl sutures.  Benzoin, Steri-Strips, and Tegaderm dressings were applied to the incision site with the umbilicus being dressed with Xeroform, 2 x 2 gauze, and a small Tegaderm.  Biopatch and Tegaderm dressings were placed on the drains. 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Two 15-French Blake drains, one in the right side of the abdomen, one on the left side of the abdomen.\\ 
 +Sutures: List all layers\\ 
 +Dressing:  Benzoin, Steri-Strips, and Tegaderm dressings were applied to the incision site with the umbilicus being dressed with Xeroform, 2 x 2 gauze, and a small Tegaderm.  Biopatch and Tegaderm dressings were placed on the drains.\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 + 
 +====Breast Reduction==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Reduction Mammaplasty\\ 
 +\\ 
 +The patient was taken to the operating room, and positioned on the surgical table. After a timeout confirming the correct patient and surgical procedure was conducted, general anesthesia was started. The patient was prepped and draped in standard fashion. \\ 
 + 
 +A 38 mm cookie cutter was used to mark out the nipple areola complexes bilaterally. Next an approximately 10cm wide inferior pedicle on both breasts was marked and de-epithelialized using a knife.  The pedicles were then dissected down to the chest wall using electrocautery, taking care not to undermine the pedicle. Once the pedicles were established, the remainder of the wise-pattern incisions were incised using a knife. Electrocautery was used to establish superior breast flaps of about 2cm thickness. The excess medial and lateral breast skin and breast parenchyma were passed off the table. All left and right breast specimens were sent separately to pathology. The breasts were then temporarily closed with 2-0 Vicryl, and the patient was sat up to assess symmetry and cosmesis. The right breast was slightly larger than the left, and the left breast had remaining axillary standing cone deformity. The areas requiring additional resection were marked, and the patient was returned to supine position. Electrocautery was then used to excise additional lateral breast tissue from the left breast and remove additional breast tissue from the right breast. Again, the breasts were temporarily closed with 2-0 Vicryl, and the patient was sat up. At this point, the breasts had good size symmetry and shape. The amount of resected specimens were 311 grams on the left breast and 467 grams on the right breast. The patient was returned to supine, and temporary sutures were removed. The breasts were copiously hemostased using electrocautery. 3-0 PDS was then used to anchor superficial fascia to chest wall to reinforce the lateral breast shape bilaterally. A round Blake 15F drain was placed in each breast pocket and secured with 3-0 Nylon. The breasts were then closed with 2-0 Vicryl and 4-0 Monocryl. \\ 
 + 
 +At this point, the new NAC location was marked 6cm above the inferior incision with the 38mm cookie cutter bilaterally. This area of skin was removed using scissors and hemostased with electrocautery. The NAC was then inset with 5-0 Vicryl and 5-0 Fast-absorbing gut. The incisions were then dressed with Benzoin, steri-strips, and Tegaderms. The nipples were dressed with steri-strips, Telfa, sponge, and Tegaderm. \\ 
 + 
 +All final sponge and instrument counts were correct. The patient was extubated, placed in a surgical bra, and transferred to recovery without issue. \\ 
 + 
 +Dr. Gordon was present for the entirety of this procedure. \\ 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Two 15-French Blake drains\\ 
 +Sutures: 2-0 Vicryl, 4-0 Mono, 3-0 PDS, 5-0 Vicryl, 5-0 fast-gut\\ 
 +Dressing:  Benzoin, Steri-Strips, and Tegaderm dressings were applied to the incision sites. Scrub sponge cut into 38mm NAC with 38mm Telfa between NAC and sponge. Cut hole in center of both for nip.  Biopatch and Tegaderm dressings were placed on the drains.\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP>
  
-Tourniquet: No\\ 
-Drain: 15-French Blake\\ 
-Sutures: 4-0 Monocryl sutures\\ 
-Dressing: Benzoin, Steri-Strips, and Tegaderm dressings were applied to the incision site with the umbilicus being dressed with Xeroform, 2 x 2 gauze, and a small Tegaderm.  Biopatch and Tegaderm dressings were placed on the drains.\\ 
  
 ==== Lipoma Resection ==== ==== Lipoma Resection ====
 +
 +
 +
 +
 +<WRAP group>
 +<WRAP half column>
 +
 +Operative Report:\\
 +1. Lipoma Excision\\
 +\\
 +After induction of general anesthesia, the patient was placed into a prone position with padding and had her back prepped and draped.  Preoperative skin markings consisted of a 5 cm transverse skin incision directly over the palpable mass.  The scalpel was then used to incise along the marked lines going down through the skin into subcutaneous tissues, whereafter the rest of the dissection was performed with loupe magnification using a combination of electrocautery as well as gentle blunt dissection to dissect the mass from the surrounding tissues.  Once in the subcutaneous plane, there appeared to be a multilobulated lesion that was contained in this space that was felt to be likely to be consistent with a lipoma.  Gentle blunt dissection was then performed at the periphery of the mass, but the mass was poorly encapsulated from the surrounding tissues and dissection was slow to proceed.  The mass was eventually isolated from the surrounding tissues and no further presence of the mass was noted on clinical exam.  The mass seemed to extend all the way down to the fascia.  After verifying complete excision of the mass, the wound was meticulously checked for hemostasis with electrocautery, and then closure of the cutaneous wound was accomplished with multiple deep dermal sutures of 4-0 Vicryl, followed by a running 4-0 Monocryl subcuticular stitch in the skin.  Dressings consisting of benzoin, Steri-Strips, and Tegaderm were applied, followed by a modest compressive bandage with 4 x 4's and Medipore tape.
 +</WRAP>
 +
 +<WRAP half column>
 +
 +Photos\\
 +
 +Tourniquet: finger / forearm / arm\\
 +Drain: Type of drain and placement\\
 Suture: 4-0 vicryl deep dermal, 4-0 Monocryl subcuticular\\ Suture: 4-0 vicryl deep dermal, 4-0 Monocryl subcuticular\\
 Dressing: Steristrips crossing wound with benzoin, pressure dressing\\ Dressing: Steristrips crossing wound with benzoin, pressure dressing\\
  
-After induction of general anesthesia, the patient was placed into a prone position with padding and had her back prepped and draped.  Preoperative skin markings consisted of a 5 cm transverse skin incision directly over the palpable mass.  The scalpel was then used to incise along the marked lines going down through the skin into subcutaneous tissues, whereafter the rest of the dissection was performed with loupe magnification using a combination of electrocautery as well as gentle blunt dissection to dissect the mass from the surrounding tissues.  Once in the subcutaneous plane, there appeared to be a multilobulated lesion that was contained in this space that was felt to be likely to be consistent with a lipoma.  Gentle blunt dissection was then performed at the periphery of the mass, but the mass was poorly encapsulated from the surrounding tissues and dissection was slow to proceed.  The mass was eventually isolated from the surrounding tissues and no further presence of the mass was noted on clinical exam.  The mass seemed to extend all the way down to the fascia.  After verifying complete excision of the mass, the wound was meticulously checked for hemostasis with electrocautery, and then closure of the cutaneous wound was accomplished with multiple deep dermal sutures of 4-0 Vicryl, followed by a running 4-0 Monocryl subcuticular stitch in the skin.  Dressings consisting of benzoin, Steri-Strips, and Tegaderm were applied, followed by a modest compressive bandage with 4 x 4's and Medipore tape.+Anatomy: Pertinent anatomy should be listed\\
  
 +Post-operative care: Include restrictions, splints, etc...\\
 +
 +Learning points/Pimp Questions:\\
 +
 +</WRAP>
 +</WRAP>
 +
 +==== Ischial tuberosity pressure ulcer ====
 +
 +<WRAP group>
 +<WRAP half column>
 +
 +Operative Report:\\
 +1. Debridement of ischial tuberosity pressure ulcer\\
 +2. Right pedicled gluteal muscle flap\\
 +\\
 +The patient was examined in the pre-operative area and the operative site was marked. Informed consent was verified and the patient was then taken to the operating room. Sequential compression devices were placed. General endotracheal anesthesia was induced. The patient had a supra-pubic tube in place. The patient was transferred onto the operating table and placed in the prone jack-knife position with careful attention to applying adequate pressure point padding. Intravenous antibiotics were held until after cultures were obtained. The surgical sites were prepared and draped in standard surgical fashion. A final time-out was performed to correctly identify the patient, procedure, site, and position, with everyone involved in agreement. 
 +
 +The skin was outlined with sterile marker over the proposed flap sites in the right gluteal region. Next, attention was turned to excision of the ischial ulcer. Methylene blue with hydrogen peroxide was applied to the ulcer to stain the entire wound and associated bursa to facilitate a complete excision. The wound was then completely excised using a combination of sharp excision with a blade scalpel and electrocautery. The wound was sent for culture and pathologic evaluation. There was exposed ischial bone and the periosteum was elevated bluntly and a deep bone biopsy was obtained by osteotomy and sent for culture and pathology. After hemostasis was achieved, the wound bed was copiously irrigated with pulse lavage. 
 +
 +Next, skin incision was made along the previous flap marking and dissection was carried down through the subcutaneous tissue to the fascia overlying the gluteus maximus muscle with electrocautery. The skin paddle was originally islandized to be rotated over into the flap, but upon inspection of the muscle, it was found to be robust and more medially then expected. Since the skin island was too lateral to be included in a split of the muscle, the island was excised. Next, the subcutenaous tissue was elevated off the gluteal muscle and was split followed by undermining of the muscle to free it. The muscle was rotated into the ischial cavity. 
 +
 +Next, a 15 French round Jackson-Pratt drains was placed that exited inferolaterally through a stab incisions. After ensuring hemostasis, we completed the closure of the superficial fascia layer with 2-0 Vicryl, followed by 2-0 vicryl for the deep dermal layer. Skin was closed with 4-0 nylon simple interrupted sutures. The area was cleaned, dried, and dressed with benzoin, telfa and tegaderm.
 +
 +At the completion of the procedure, all instrument and needle counts were correct. The patient was transferred onto an air-fluidized mattress bed and placed in the supine position. Anesthesia was reduced and the patient was extubated without incident and transferred to the Post-Anesthesia Care Unit in stable condition. 
 +
 +</WRAP>
 +
 +<WRAP half column>
 +
 +Photos\\
 +{{:resident:screen_shot_2021-08-02_at_4.36.39_pm.png?600|}}
 +{{:resident:screen_shot_2021-08-02_at_4.37.06_pm.png?600|}}
 +{{:resident:screen_shot_2021-08-02_at_4.37.06_pm.png?600|}}
 +
 +Drain: 15 french round drain\\
 +Suture: 2-0 Vicryl, 4-0 Nylon\\
 +Dressing: Benzoin, Telfa, tegaderm\\
 +
 +Summary of Operative Steps:\\
 +  - Prone jackknifed, make sure flexes at hip
 +  - Prep widely
 +  - Methylene blue with hydrogen peroxide so it bubbles with angiocath
 +  - Mark a circle around the defect. Incise and then use cautery to track the bursa down to the bone. Should be relatively thin, less than 0.5cm
 +  - Incise laterally to gluteus insertion on greater trochanter. Establish upper border of skin island. Dissect down and find muscle layers. Dissect superficial fascia off superiorly. Dissect down and take off trochanter. Dissect superior just underneath Maximus until enough to rotate medially
 +  - Inset with 2-0 Vicryl figure of 8s
 +  - 2-0 vicryl deep dermal
 +  - 4-0 nylon interrupted
 +  - Telfa and tegaderm to stay forever with a drain
 +
 +
 +Anatomy:
 +{{:resident:unnamed.jpeg|}}\\
 +
 +Post-operative care: Plan for the both the dressing and drain to stay for up to 8 weeks. DO NOT REMOVE DR. GORDON'S DRESSINGS. He keeps them on as long as he can.\\
 +Sitting protocol per VA\\
 +
 +Learning points/Pimp Questions: Ensure that you know where the superior gluteal and inferior gluteal arteries are located. The triangle is from the PSIS - Greater Trochanter - Ischial Tuberosity. The SGA is 1/3 the distance along PSIS - GT limb. The IGA is 2/3 the distance along the PSIS - IT limb.\\
 +
 +</WRAP>
 +</WRAP>
 +
 +==== Sacral Pressure Ulcer ====
 +
 +<WRAP group>
 +<WRAP half column>
 +
 +Operative Report:\\
 +1. Sacral pressure ulcer debridement\\
 +2. Right gluteal fasciocutaneous Rotational Advancement Flap 
 +\\
 +The patient was examined in the pre-operative area and the operative site was marked. Informed consent was verified and the patient was then taken to the operating room. Sequential compression devices were placed. General endotracheal anesthesia was induced. The patient had a supra-pubic tube in place. The patient was transferred onto the operating table and placed in the prone jack-knife position with careful attention to applying adequate pressure point padding. Intravenous antibiotics were held until after cultures were obtained. The surgical sites were prepared and draped in standard surgical fashion. A final time-out was performed to correctly identify the patient, procedure, site, and position, with everyone involved in agreement. 
 +
 +The skin was outlined with sterile marker over the proposed flap sites in the right gluteal region. Next, attention was turned to excision of the sacral ulcer. Methylene blue with hydrogen peroxide was applied to the ulcer to stain the entire wound and associated bursa to facilitate a complete excision. The wound was then completely excised using a combination of sharp excision with a blade scalpel and electrocautery. The wound was sent for culture and pathologic evaluation. A deep bone biopsy was obtained and sent for culture and the bone edges were removed with a rasp and freer. After hemostasis was achieved, the wound bed was copiously irrigated with pulse lavage. 
 +
 +Next, skin incision was made along the previous flap marking and dissection was carried down through the subcutaneous tissue to the fascia overlying the gluteus maximus muscle with electrocautery. The medial aspect of the flap was carefully undermined in a limited fashion with care not to disrupt the perforating vessels. The flaps were then advanced medially and the superficial fascial layer was closed 2-0 Vicryl suture. Next, two 15 French round Jackson-Pratt drains were placed under each flap and exited medially and inferolaterally through separate stab incisions. After ensuring hemostasis, we completed the closure of the superficial fascia layer with 2-0 Vicryl, followed by 2-0 vicryl for the deep dermal layer. Skin was closed with 4-0 nylon simple interrupted sutures. The area was cleaned, dried, and dressed with benzoin, telfa and tegaderm.
 +
 +At the completion of the procedure, all instrument and needle counts were correct. The patient was transferred onto an air-fluidized mattress bed and placed in the supine position. Anesthesia was reduced and the patient was extubated without incident and transferred to the Post-Anesthesia Care Unit in stable condition. 
 +
 +
 +</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...\\
 +
 +Learning points/Pimp Questions:\\
 +
 +</WRAP>
 +</WRAP>
 +
 +
 +
 +==== Peri-areolar Gynecomastia Excision ====
 +
 +<WRAP group>
 +<WRAP half column>
 +
 +Operative Report: Bilateral Peri-Areolar Excision of Gynecomastia\\
 +\\
 +The patient was marked in the pre-operative bay and his breast tissue was outlined. The patient was then brought to the operative room. SCDs were applied and all bony prominences were sufficiently padded. General anesthesia was started and pre-operative antibiotics were given. The patient was then prepped and draped in sterile manner.\\
 +We started on the right chest. An incision was made along the inferior areola from 3 o'clock to 9 o'clock. The incision was carried through the dermis and subcutaenous tissue with the electrocautery towards the chest wall. An approximately 1 cm superior dermoglandular pendicle was left underlying the nipple areolar complex in order to prevent a saucer deformity. Once the pedicle was set, the underlying breast tissue was dissected from the chest wall using a combination of blunt dissection and electrocautery. After the breast tissue was removed, hemostasis was obtained. The incision was closed with 5-0 vicryl deep dermal sutures and a 5-0 monocryl subcuticular suture. The incision was dressed with benzoin, steristrips perpindicular to the incision and tegaderm.\\
 +\\
 +Next, we turned our attention to the left chest. An incision was made along the inferior areola from 3 o'clock to 9 o'clock. The incision was carried through the dermis and subcutaenous tissue with the electrocautery towards the chest wall. An approximately 1 cm superior dermoglandular pendicle was left underlying the nipple areolar complex in order to prevent a saucer deformity. Once the pedicle was set, the underlying breast tissue was dissected from the chest wall using a combination of blunt dissection and electrocautery. After the breast tissue was removed, hemostasis was obtained. The incision was closed with 5-0 vicryl deep dermal sutures and a 5-0 monocryl subcuticular suture. The incision was dressed with benzoin, steristrips perpindicular to the incision and tegaderm.\\
 +\\
 +An abdominal binder was applied to the chest. All counts were correct. The patient was awakened from anesthesia without issue. There were no complications.
 +\\
 +</WRAP>
 +
 +<WRAP half column>
 +Plan:\\
 +Keep dressings in place for 2-3 weeks\\
 +Okay to shower after 72 hours\\
 +Keep chest binder in place\\
 +Follow up in 5 days\\
 +</WRAP>
 +</WRAP>
 +
 +==== Blepharoplasty ====
 +
 +Pre-operative diagnosis: Left upper eyelid dermatochlasis
 +History of left upper eyelid blepharoplasty
 +
 +Post-operative diagnosis: Same
 +
 +Indications for surgery:
 +
 +Mr. Leonard Hyland is a 74 year old man with history of b/l dermatochalasis and blepharoptosis, s/p blepharoplasty, lower canthopexy, and levator shortening for left side on 2/1/2019 and previously right side (2017). Patient continues to have excess skin on the (L). Of note, patient is unable to raise the lateral portion of his left eyebrow 2/2 forehead surgery in the past. He does have some levator asymmetry, with his left eyelid being slightly higher than the right. His visual field on the right, however, is not affected by this.  Patient was 
 +previously scheduled for surgery in June, however, pre-operatively test (+) 
 +for Covid and surgery was delayed.  He remains asymptomatic.  In addition, he 
 +has been rescheduled for November, and unfortunately the evening prior to 
 +surgery he presented to the ED with acute abdominal pain and went to the OR 
 +the following day for a laparoscopic appendectomy for acute appendicitis.  He 
 +has recovered well from this procedure 
 +
 +He would like to proceed with left upper eyelid revision, as he notes that 
 +currently his symptoms are only improved with holding up eyelid and he would 
 +like to have this surgically addressed.
 +
 +Complications: none
 +
 +Estimated blood loss: minimal
 +
 +Specimens: none
 +
 +Anesthesia: MAC
 +
 +Findings: Excess left upper eyelid skin
 +
 +Procedure: Left upper eyelid revision blepharoplasty. 1-2 mm of lagophthalmos at end of case.
 +
 +Operative Narrative:
 +
 +The patient was consented in the pre-operative suite and brought to the operating room. He was transferred to the operating room table and secured. All bony prominces were padded. The patient was marked to remove the excess skin from the upper eye and a formal timeout was completed. At this point MAC anesthesia was started and 3 ccs of local with epinephrine were injected superficially into the left upper eyelid. An oxygen evacuator was fashioned with a blue tray and a 1000 drape. The patient was then prepped and draped in sterile fashion.
 +
 +The inferiorly marked line was excised with a scalpel and then the extent of the upper incision was checked. The upper incision was made. Then the skin to be removed was excised a full thickness skin graft.
 +
 +The incision was closed with four 6-0 nylon simple interrupted sutures followed by a running subcuticular 6-0 nylon suture. This was checked by running it back and forth every two bites in order to make sure it was gliding and not locked onto itself. Steri-strips with benzoin were used to secure the ends. Antibiotic cream was applied along the incision.
 +
 +
 +Plan:
 +Apply antibiotic cream to eye twice daily
 +Return to clinic in 5 days for removal of nylon sutures.
  
 ===== Clinic ===== ===== Clinic =====
Line 200: Line 962:
  
 Although open release is largely successful in alleviating symptoms, persistent triggering or unresolved flexion contracture can occur. In these rare situations, further surgical intervention is warranted. In patients with persistent flexion contracture after A1 pulley release or who present with advanced flexion contracture, FDS ulnar slip resection results in near-complete resolution of the deformity. 3334 The ulnar slip can be transected at the edge of the A3 border and excised in the A2-A3 interval. In rheumatoid arthritis patients, FDS slip resection decreases the recurrence of flexor tenosynovitis and should be considered as an adjunct to A1 pulley release in this subpopulation. Although open release is largely successful in alleviating symptoms, persistent triggering or unresolved flexion contracture can occur. In these rare situations, further surgical intervention is warranted. In patients with persistent flexion contracture after A1 pulley release or who present with advanced flexion contracture, FDS ulnar slip resection results in near-complete resolution of the deformity. 3334 The ulnar slip can be transected at the edge of the A3 border and excised in the A2-A3 interval. In rheumatoid arthritis patients, FDS slip resection decreases the recurrence of flexor tenosynovitis and should be considered as an adjunct to A1 pulley release in this subpopulation.
- 
  
  
resident/michael_gordon.1597103107.txt.gz · Last modified: 2020/08/10 19:45 by jonathan
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