Differences

This shows you the differences between two versions of the page.

--- resident:michael_gordon [2021/02/01 20:23] – krystle
+++ resident:michael_gordon [2022/12/23 13:52] (current) – [Panniculectomy] haley.d
@@ Line 28: / Line 28: @@
 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)\\
 \\
@@ Line 34: / Line 36: @@
 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\\
 ===== Hand =====
@@ Line 46: / Line 49: @@
 . blue towel wrapped around arm help by penetrating towel clamp\\
 .  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====
@@ Line 71: / Line 94: @@
 Technical Steps:\\
 -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\\
 -then he uses ragnels and sens and you use litler scissors to dissect down to transverse carpal ligament.\\
@@ Line 115: / Line 138: @@
 . Right trapeziectomy with ligamentous reconstruction.\\
-After instillation of a supraclavicular block, the patient had his right hand and arm prepped and draped.  Preoperative skin markings were designed as a 3 cm oblique incision along the dorsal radial aspect of the base of the 1st metacarpal as well as a 1 cm transverse skin incision over the volar wrist crease directly over the FCR tendon.  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 at the level of the dorsal aspect of the 1st metacarpal, going down through the skin into subcutaneous tissues.  After achieving hemostasis in the subcutaneous plane with use of electrocautery, incision was deepened until identification of superficial branches of the radial nerve could be visualized, which were then carefully retracted to the side, and dissection was performed around them.  The 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, elevation of the periosteal layer on the trapezium was then performed, going both volarly and dorsally.  The trapezium was rocked carefully back and forth in an effort to free up as many of the attachments as possible and after achieving good mobility of the trapezium, the volar incision was made along the marked lines.  Again, after achieving hemostasis in the subcutaneous plane with use of electrocautery, the incision was carefully deepened down to identification of the FCR tendon.  The FCR tendon was then dissected distally, and the sheath overlying the tendon was divided going up into the palm.  The sheath was divided to the point where the FCR tendon could be removed out of the groove of the trapezium.  Returning then to the incision at the base of the 1st metacarpal dorsally, the trapezium was then further rocked back and forth until all ligamentous attachments had been divided, and the trapezium was removed.  There was severe disease at the trapeziometacarpal joint with lesser disease of the scaphoid and the trapezoid joints.  The bone was then sent to pathology for gross evaluation only.  The FCR tendon could be seen in the base of the wound at the base of the 1st metacarpal, and the FCR tendon was divided, 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 thumb was then placed back on traction with 10 pounds, and the FCR tendon was brought from the distal connection to the base of the 2nd metacarpal over to the base of the 1st metacarpal, and 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 then closure of both incisions 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.  Tourniquet was then released after a total of 108 minutes of inflation time.
+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>
@@ Line 123: / Line 148: @@
 Photos\\
-Tourniquet: finger / forearm / arm\\
+**DOES NOT USE C-ARM**
-Drain: Type of drain and placement\\
+Pre-operative block: Supraclavicular\\
+Tourniquet: upper arm, sterile\\
 Sutures: List all layers\\
 Dressing: What's preferred?\\
-Anatomy: Pertinent anatomy should be listed\\
+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\\
 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)\\
-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.\\
 Sends trapezium for gross only pathology.\\
 {{url>https://www.youtube.com/embed/glldA0RXIDg}}
@@ Line 179: / Line 207: @@
 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>
@@ Line 361: / Line 391: @@
 </WRAP>
 </WRAP>
+==== Scapholunate Repair ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+.  ORIF of left perilunate dislocation with repair of left scapholunate and lunotriquetral ligaments, bone anchors and K-wires\\
+.  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:\\
+.  Excision of mucous cyst of right small finger DIP joint.
+.  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:\\
+. 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:\\
+. Amputation of left index finger through DIP joint:\\
+\\
+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:
+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.
+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.
+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.
+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.
+</WRAP>
+<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:\\
+. 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>
@@ Line 426: / Line 712: @@
 </WRAP>
 </WRAP>
+====Breast Reduction====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. 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>
 ==== Lipoma Resection ====
@@ Line 482: / Line 807: @@
 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: Type of drain and placement\\
+Drain: 15 french round drain\\
 Suture: 2-0 Vicryl, 4-0 Nylon\\
-Dressing: Telfa, tegaderm\\
+Dressing: Benzoin, Telfa, tegaderm\\
 Summary of Operative Steps:\\
@@ Line 547: / Line 875: @@
 </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 =====
@@ Line 561: / 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.
-==== Infectious Tenosynovitis ====
-PROCEDURE:
-Incision and drainage of an infectious tenosynovitis of right ring finger.
-DESCRIPTION OF PROCEDURE:
-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.