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--- resident:stephanie_malliaris [2020/08/08 21:11] – [Hand] jonathan
+++ resident:stephanie_malliaris [2021/08/19 13:13] (current) – taylor
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 ===== Introduction =====
-placeholder
+Medical School at Tulane - 2003-2007\\
+Integrated Plastic Surgery at Weill Cornell - 2007-2014\\
+Fellowship in Hand at Hospital for Special Surgery (HSS) - 2015\\
+Denver Health - 2015 - Forever \\
+[[https://drive.google.com/drive/folders/13OAdYirQWQssfwj0gS8XHlykjXFoTq-a?usp=sharing|Dr. Malliaris Publications]]
 ===== Operative Reports =====
+General Tips:\\
+\\
 ===== Hand =====
-==== Cubital Tunnel ====
+==== Flexor Tendon Repair (Zones 1 and 2) ====
+<WRAP group>
+<WRAP half column>
+POSTOPERATIVE DIAGNOSES:
+.  Crush injury to hand.
+.  Complete transection of the flexor digitorum profundus, zone 2, right long
+finger.
+.  One slip, complete transection of flexor digitorum superficialis, zone 2 to
+right long finger.
+.  A 90% transection FDP to index finger, zone 1.
+.  Laceration to ring finger and small finger volar aspect.
+PROCEDURES:
+.  Washout and excisional debridement of crush wound to right hand index finger,
+long, ring, and small fingers.
+.  Repair of FDP tendon, right long finger, zone 2.
+.  Repair of FDP tendon in zone 1, right index finger.
+.  Closure of simple laceration, right ring finger and small finger.
+DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room.  He
+remained on the stretcher.  The right upper extremity was put on a hand table.  Bony
+prominences were padded.  SCD boots were placed.  Preoperative antibiotics were
+given.  General anesthesia was administered.  The right upper extremity was prepped
+and draped in the usual sterile fashion with a tourniquet on the upper arm.
+Surgical pause was performed in accordance with hospital regulations.  The right
+upper extremity was elevated and exsanguinated using Esmarch bandage and the
+tourniquet was inflated to 250 mmHg.  We used a Tupper retractor and removed all the
+prior placed sutures and investigated the wounds.  We started with the long finger.
+A Bruner incision was used to extend the wound proximally and distally, and it was
+noted that the neurovascular bundles were grossly intact, but there was complete
+disruption of the FDP tendon in zone 2, as well as one of the slips of the FDS
+tendons.  The A3 pulley and part of the A4 were also injured and not in continuity.
+The tendon injury was actually more distal, and as such, we opened Bruner wires
+distally to the distal phalanx and located the distal end of the tendon through the
+A4-A5 area.  The remainder of the A4 pulley needed to be opened.  The proximal end
+of the tendon was brought through the A2 and A3 area pulleys.  We irrigated this
+with copious saline and used a 3-0 Supramid to do a modified Kessler repair of the
+FDP tendon.  This then had an epitendinous 6-0 Prolene placed circumferentially
+around the tendon.  The finger was ranged and it did achieve what appeared to be
+full flexion.  The other slip of the FDS tendon was trimmed and the radial slip
+remained intact and had not been injured in the accident.  The area was irrigated
+and the Bruner flaps were placed over the tendon.
+We turned our attention to the index finger.  The laceration was irrigated and
+excisional debridement was performed of skin and subcutaneous tissue.  This was done
+with scissors, and the area was 3 x 2 cm.  We explored the wound and found a 90%
+lacerated FDP tendon in zone 1.  As there was not much tendon distally, we elected
+to repair this with a suture anchor.  The area was cleaned off and a mini Mitek with
+-0 suture was drilled and placed into the volar aspect of the distal phalanx.  We
+then used the 2-0 suture to repair the tendon to the distal phalanx, and 6-0 Prolene
+was then used for further strength repair at the tendon laceration site.  This was
+then irrigated.
+We then did the excisional debridement of the skin and subcutaneous tissue of the
+long finger.  The nonviable edges were trimmed.  This was approximately 3 x 0.5 cm
+area.  The debridement was skin and subcutaneous tissue and it was done with an
+Adson.
+We then turned our attention to the ring and small fingers.  The 2 other lacerations
+were explored, tendons were intact in the ring finger and in the small finger.  It
+did not extend into the flexor sheath either.  Excisional debridements were
+performed, 1 cm x 0.5 cm for of these lacerations.
+The Irrisept wound irrigation system was used, 500 mL to irrigate all four of the
+lacerations.  We then released the tourniquet and normal perfusion returned to the
+hand and fingers.  Hemostasis was ensured and then the incisions were closed with
+interrupted 4-0 nylon sutures.
+A dorsal blocking splint was placed after bacitracin, Adaptic, and sterile Webril.
+</WRAP>
+<WRAP half column>
+Irrigation with Irrisept 500mL
+Tourniquet: Sterile; arm
+Drain: None
+Sutures:
+- Skin: 4-0 nylon
+- FDP zone 2: modified Kessler with 3-0 Supramid, epitendinous with 6-0 Prolene
+- FDP zone 1: mini Mitek with 2-0 suture was drilled and placed into volar aspect of distal phalanx, 2-0 suture to repair tendon to distal phalanx, 6-0 prolene to reinforce
+Dressing: Bacitracin, Adaptic, Webril, dorsal blocking splint\\
+Anatomy: FDP/FDS insertions, zones of injury, Camper's chiasm, neurovascular bundles\\
+Post-operative care: Elevate LUE, splint care, f/u 1-2 weeks, OT referral for flexor rehab protocol\\
+Attending Pearls (Learning points/Pimp Questions): N/A\\
+</WRAP>
+</WRAP>
+==== Metacarpal Nail ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Right 5th metacarpal closed reduction and intra-medullary nail internal fixation placement\\
+\\
+The 5th metacarpal fracture was reduced with manual pressure and reduction was confirmed under the c-arm. The appropriate k-wire for the exomed intramedullary nail was placed through the metacarpal head and down the shaft of the fracture. A small incision was made at the metacarpal head to allow placement of the ream and drill. A 40 mm intramedullary nail was chosen. The shaft was reamed and a 40 mm intramedullary nail placed into the shaft. The c-arm was used to confirm that the nail was not in the joint and the joint was also directly inspected. The incision was closed with a 4-0 nylon suture. The patient was dressed with xeroform, 4x8s and webril and placed in an ulnar gutter splint.
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: finger / forearm / arm\\
+Drain: Type of drain and placement\\
+Sutures: List all layers\\
+Dressing: What's preferred?\\
+Anatomy: Pertinent anatomy should be listed\\
+Post-operative care: Include restrictions, splints, etc...\\
+Attending Pearls (Learning points/Pimp Questions):\\
+</WRAP>
+</WRAP>
+==== Dequervain's Release ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Right First Dorsal Compartment Release
+A sterile forearm tourniquet was placed and the arm was exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg. We began with the right first dorsal compartment release. A 2 cm transverse incision was made just proximal to the radial styloid over the first compartment. Bipolar electrocautery was used for hemostasis and using blunt dissection with scissors the subcutaneous tissue was dissected longitudinally with care to avoid any injury to neurovascular structures. Extension was then further carried down to the extensor sheaths.  Using a scalpel, an incision was made over the tendon sheath over the distal part of the radial styloid.  Then the tendon sheath was further bluntly dissected to release any underlying structures or tendons underneath the tendon sheath.  The tendon sheath was then opened up proximally and distally, fully releasing the first dorsal compartment. There were no sub-sheaths located within the first compartment.
+The wound was then irrigated and hemostasis was excellent. The wounds were closed using a 4-0 nylon locking horizontal mattresses were placed in interrupted fashion and a sterile dressing including a plaster volar splint was placed using a Xeroform, 4 x 8 gauze, Webril, bias wrap.
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: Sterile forearm tourniquet\\
+Drain: None\\
+Sutures: 4-0 nylon locking horizontal mattress\\
+Dressing: Plaster volar splint was placed using a Xeroform, 4 x 8 gauze, Webril, bias wrap\\
+Anatomy: Makes a transverse incision over the 1st dorsal compartment\\
+Post-operative care:\\
+Volar plaster splint used to rest thumb\\
+Attending Pearls (Learning points/Pimp Questions):\\
+Makes a transverse incision over the 1st dorsal compartment\\
+When releasing the tendon sheath should you cut on the volar or dorsal side? Dorsal to prevent volar subluxation that can result in tendon clicking.\\
+There can be multiple sub-sheaths and it is essential to release them all.\\
+</WRAP>
+</WRAP>
+==== Wedge Osteotomy of Metacarpal with ORIF ====
+<WRAP group>
+<WRAP half column>
+Procedure:\\
+. Wedge Osteotomy of Metacarpal with Open Reduction and Internal Fixation
+\\
+OPERATIVE APPROACH: The patient was identified in the preoperative care area where written consent was reviewed with the patients. The surgical site was marked with a marker. All of her questions were answered and concerns were addressed. The patient was brought back to the operating room by the anesthesia staff. All pressure points were well padded. A surgical time-out was performed per protocol, and 2 grams of Ancef were administered prior to the start of the procedure. General anesthesia was then obtained. A nonsterile tourniquet was placed to the appropriate extremity, which was then prepped and draped in a standard sterile fashion.
+We began by making a curvilinear incision on the radial aspect of the second metacarpal bony prominence, extending the incision proximally and distally to the base and head of the metacarpal, respectively. A tenotomy was used to dissected down through the subcutaneous tissue to the periosteum. Bipolar electrocautery was used to achieve hemostasis. Significant scar tissue was encountered around the malunion segment of the metacarpal.  Once there was adequate clearance of the overlying scar tissue, a 15 blade was used to sharply incise the periosteum. A freer was used to elevate periosteal flaps from the metacarpal shaft in the radial and ulnar directions, taking care to leave it attached at the most volar aspect of the bone.
+Fluoroscopic imaging was used to visualize the second metacarpal and design the wedge osteotomy.  It was determined that an open wedge osteotomy would be most adequate to correct the dorsal osseous hump and align the metacarpal in a more anatomic position. Using an oscillating saw, two cuts were made to remove a wedge of bone. A rongeur was used to smooth the edges of the proximal and distal aspects of the cut metacarpal. Next a 1.5 mm plate was chosen, the metacarpal was reduced and fluoroscopic imaging was obtained to determine plate length and placement. A plate cuter was used to remove 4 drill holes from the plate and once we were satisfied with plate placement, we used a 0.45" K-Wire to place the proximal aspect of the plate.
+Next we drilled a bicortical screw hole most proximal to the fracture site, placed a non-locking screw and confirmed plate placement with fluoroscopic imaging. These steps were repeated to place non-locking, bicortical screws at the most proximal screw hole distal to the osteotomy site and then again on the proximal aspect of the plate until 3 screws were placed at both the proximal and distal aspects of the osteotomy site for a total of 6 screws. The K-wire was removed and the final reduction was confirmed with fluoroscopic imaging. The wound was irrigated and hemostasis was achieved. 4-0 vicryl was used to approximate the subcutaneous tissue over the hardware in simple and interrupted figure of eight fashion. Finally, the skin was closed with simple interrupted stitches of 4-0 Nylon. 10 cc of 0.25% plain marcaine was injected into the operative site. The wound was dressed with xeroform,  4x4s and Webril. The right hand was placed into a well-padded volar splint with the hand in intrinsic plus. The patient was awakened from anesthesia and taken to PACU in stable condition.
+</WRAP>
+<WRAP half column>
+Operative Photos\\
+{{ :resident:img_7965.jpg?200 |}}
+{{ :resident:img_7966.jpg?200 |}}
+{{ :resident:img_7967.jpg?200 |}}
+{{ :resident:img_7968.jpg?200 |}}
+\\
+\\
+Images include dissection down to the malunion, wedge design, more appropriate alignment after wedge resection and lastly plate fixation.\\
+\\
+Tourniquet: forearm
+Drain: none
+Sutures: 4-0 vicryl suture for periosteum/subq tissue. Skin with 4-0 nylon.
+Dressing: Xeroform, 4x4 gauze, Volar splint in intrinsic plus
+\\
+Anatomy: Pertinent anatomy should be listed
+\\
+Metacarpals are triangular in cross-section. The medial and lateral surfaces meet at the volar ridge, providing attachment to the interossei. These attachments together with the intermetacarpal ligaments proximally and distally help splint fractured bones, making functionally significant malunions of the ring and small metacarpals less common.\\
+\\
+Significant extra-articular malunions can cause crossing or scissoring of fingers, pain due to distortion of joints, disturbance of muscle/tendon balance, and reduction of grip strength.\\
+\\
+Extra-articular malunions associated with shortening can lead to an extension lag proportional to the degree of shortening.\\
+\\
+Intra-articular malunion with a significant step (0.5 mm) or gap (1 mm) may cause joint surface incongruity, synovitis, capsular loosening or stiffness, and, ultimately, painful posttraumatic arthrosis.\\
+Post-operative care:\\
+Volar splint in intrinsic plus positioning.\\
+If adequate stability is obtained at the time of surgery, remove the postoperative splint 3 to 5 days after surgery and initiate protected motion.\\
+Initiate an early active and active-assisted ROM program.\\
+\\
+Learning points/Pimp Questions:
+\\
+Know the difference between an open vs closed wedge osteotomy. More commonly done in ortho in relation to the tibia, but concepts can be applied to other long bones as well.\\
+\\
+The wedge should be designed to help better align the long bone along its anatomical central axis.\\
+\\
+In the case of an intra-articular malunion, consider a salvage procedure rather than a repositioning osteotomy in the face of arthrosis.\\
+\\
+Accurate plate and screw placement is essential. A screw offset of 1 mm can cause as much as 10 degrees of rotation.
+\\
+At least three screw holes are need proximal and distal to the osteotomy.\\
+</WRAP>
+</WRAP>
+==== Palmar Fasciectomy ====
+<WRAP group>
+<WRAP half column>
+INDICATION: This is a man who had previously been evaluated for Dupuytren's contracture of his left hand.  He had a pit that has gotten deeper with a proximal nodule turning into more of a Dupuytren's cord with some decreased extension of the RF MCP joint.  The patient complained of things getting caught in this on a regular basis and desired excision. We discussed the options for treatment of Dupuytrens and the risks and benefits of each
+with the patient.  Patient elected for fasciectomy. These risks include pain, bleeding, scarring, infection, recurrence, possible need for wound care if unable to close the overlying skin, need for additional procedures.  The patient understood and wished to proceed.
+OPERATIVE APPROACH:
+The patient was identified in the preoperative holding area. Consent was confirmed, the appropriate side was marked as well as the boundaries of the cords. The primary cord was pre-tendinous proximal to the ring finger.  The patient was then taken to the operating suite and was left on the stretcher supine with all bony prominences padded. SCDs were placed. Appropriate perioperative antibiotics were given. A tourniquet was placed on his left arm.  Total tourniquet time was 75 minutes. An appropriate preoperative timeout was performed in which all parties were in agreement.The patient was then turned over to the anesthesia team for induction of anesthesia. The patient was then prepped and draped in the standard sterile fashion.
+We began our procedure, marking a Brunner's incision that incorporated the pit for excision. We dissected down bluntly and easily identified the palmar cord just proximal to the ring finger. We dissected this out both ulnarly and radially until we had normal tissue and could isolate the cord. We then proceeded proximal and distal until we again encountered more normal fascia. We then dissected out the cord circumferentially, identifying both the radial and the ulnar neurovascular bundles. We also identified the flexor tendon to the ring finger underlying the cord. These structures were all carefully preserved.  We then excised the cord sharply. The RF was able to be extended to past 0 once the cord was cut. This was sent as a specimen for pathology.
+We then established hemostasis using a bipolar electrocautery. We then, using iris scissors fully excised the pit, which did communicate with the cord. We then irrigated the wound and closed using interrupted 4-0 nylon sutures. We dressed the incision with Xeroform gauze, Webril, and then placed the patient in a resting volar splint.  The patient was turned over to the anesthesia team for awakening and taken to the PACU in good condition with plan for discharge home the same day.  All counts were correct at the end of the case.  The patient tolerated the procedure well.
+</WRAP>
+<WRAP half column>
+Photos\\
+{{:resident:img_7907.jpg?400|}}
+{{:resident:img_7906.jpg?400|}}
+FINAL PATHOLOGY: Fibrovascular connect tissue and adipose tissue with focal increased myofibroblasts, consistent with palmar fibromatosis.
+</WRAP>
+</WRAP>
+***
+==== A1 Trigger Finger Release ====
+<WRAP group>
+<WRAP half column>
+The patient was taken to the operating suite and was placed supine on the operating table.  Then the surgical site identification was performed and the left index, middle and ring fingers were correctly identified as the correct sites. Everybody in the operating room including nurses, anesthesiologist, as well as surgeon and surgical assistant agreed with both patient identification and site identification.
+After adequate anesthetic was given by the anesthesiology team, 4 cc of 1:1 mixture of 1% lidocaine and 0.25% bupivacaine was injected subcutaneously above the A1 pulley of the three identified digits. The left upper extremity was then prepped and draped in the standard sterile manner. A sterile tourniquet was applied on the forearm. Esmarch was used to exsanguinate the arm and the tourniquet was inflated to 250 mmHg.
+A 2cm incision was placed in-line with the distal palmar flexion crease over the A1 pulley of the left index finger and a combination of sharp and blunt dissection was performed down to the A1 pulley. The radial and ulnar neurovascular bundles were protected during the duration of the procedure. Then the A1 pulley of the left index finger was divided sharply with a Beaver blade. Full release was achieved in this manner. The flexor tendons were inspected and visualized to be gliding smoothly without bunching or clicking.
+This approach was repeated to release the A1 pulleys of the middle and ring finger as well, again with careful dissection down to the A1 pulley, protection of the nerves on either side, and division of the complete A1 pulley. Then the three surgical incisions were copiously irrigated with normal saline and the tourrniquet was released. Then the surgical incisions was closed with interrupted horizontal stitches of 4/0 nylons. Finally, a soft sterile dressing was applied. All counts verified at the end of the case.
+</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>
+==== Cubital Tunnel Release ====
 <WRAP group>
@@ Line 25: / Line 323: @@
 The patient was awaken from anesthesia and transferred to PACU in good condition.
-POSTOPERATIVE PLAN:
 </WRAP>
@@ Line 94: / Line 389: @@
 ==== Spaghetti Wrist ====
-The patient was taken to the the operating room and secured with all bony prominences padded and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed.
+<WRAP group>
+<WRAP half column>
-The arm was exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg.
+Operative Report:\\
-The laceration was extended with two oblique incisions in order to gain more proximal access to the ulnar nerve and more distal access to the flexor tendons as they were entering the carpal tunnel. The wound was explored and the flexor tendons to the index finger was intact as well as the median nerve. The more ulnar sided structures had obvious injuries. Flexor carpi radialis has a 5% partial laceration. Flexor digitorum superficialis (FDS) of the long finger was lacerated, but the flexor digitorum profundus (FDP) was intact. The ring and small fingers had both FDS and FDP lacerated. The ulnar nerve was lacerated distal to takeoff of the dorsal sensory branch. Flexor carpi ulnaris was lacerated. The wrist and fingers were flexed in order to provide a tensionless repair of the tendons, nerves and artery.
+The patient was taken to the the operating room and secured with all bony prominences padded and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed.\\
+ \\
-The injuries were repaired from the radial to ulnar. The proximal muscle belly and tendon of FDS of the long finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDP of the ring finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDS of the ring finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDP of the small finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDS of the small finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair.
+The arm was exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg.\\
+ \\
-The microscope was brought into the room and the distal and proximal ulnar neurovascular bundles were identified and the artery and nerve ends were bluntly dissected. The distal and proximal ends of the ulnar artery were clamed and the repaired with 9-0 nylon sutures in a 0-180 fashion repair. At this point, 2 hours had past and the tourniquet was released. The clamps were removed and there was pulsatile flow through the artery. Next, we turned our attention to the ulnar nerve. The nerve was lacerated distal to the branching of the dorsal sensory branch. Both the ulnar nerve and dorsal sensory branch were identified and bluntly dissected under the microscope. The ulnar nerve was repaired with 9-0 nylon epineural sutures taking care to line up the fascicles followed by a 0.5cm diameter nerve wrap. Next, the dorsal sensory branch was repaired with 9-0 nylon epineural sutures taking care to line up the fascicles followed by a 0.5cm diameter nerve wrap.
+The laceration was extended with two oblique incisions in order to gain more proximal access to the ulnar nerve and more distal access to the flexor tendons as they were entering the carpal tunnel. The wound was explored and the flexor tendons to the index finger was intact as well as the median nerve. The more ulnar sided structures had obvious injuries. Flexor carpi radialis has a 5% partial laceration. Flexor digitorum superficialis (FDS) of the long finger was lacerated, but the flexor digitorum profundus (FDP) was intact. The ring and small fingers had both FDS and FDP lacerated. The ulnar nerve was lacerated distal to takeoff of the dorsal sensory branch. Flexor carpi ulnaris was lacerated. The wrist and fingers were flexed in order to provide a tensionless repair of the tendons, nerves and artery.\\
+ \\
+The injuries were repaired from the radial to ulnar. The proximal muscle belly and tendon of FDS of the long finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDP of the ring finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDS of the ring finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDP of the small finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDS of the small finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair.\\
+ \\
+The microscope was brought into the room and the distal and proximal ulnar neurovascular bundles were identified and the artery and nerve ends were bluntly dissected. The distal and proximal ends of the ulnar artery were clamed and the repaired with 9-0 nylon sutures in a 0-180 fashion repair. At this point, 2 hours had past and the tourniquet was released. The clamps were removed and there was pulsatile flow through the artery. Next, we turned our attention to the ulnar nerve. The nerve was lacerated distal to the branching of the dorsal sensory branch. Both the ulnar nerve and dorsal sensory branch were identified and bluntly dissected under the microscope. The ulnar nerve was repaired with 9-0 nylon epineural sutures taking care to line up the fascicles followed by a 0.5cm diameter nerve wrap. Next, the dorsal sensory branch was repaired with 9-0 nylon epineural sutures taking care to line up the fascicles followed by a 0.5cm diameter nerve wrap.\\
+ \\
 Finally, the microscope was removed and flexor carpi ulnaris proximal and distal tendons were identified and the ends bluntly dissected free. Flexor carpi ulnaris was repaired with a 3-0 supramid using a modified kessler 4 strand repair followed by a figure of 8 repair with a 4-0 fiberwire. The incision was closed with 4-0 nylon simple interrupted sutures. Xeroform, 8x8 were applied followed by a dorsal extension blocking splint with the wrist and the fingers in flexion.
+</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:\\
 Note about wrist flexors. Since the cross the elbow, the elbow should be immobilized as well in 90 degrees when you make the splint.\\
 FDS flexors go through the carpal tunnel like spiderman.\\
-==== LRTI ====
+</WRAP>
+</WRAP>
-Trapeziectomy with ligament reconstruction and tendon interposition
-Partial trapezoid excision
-Consent: possible injury to the nerve, vessel, tendon, the need for secondary or revision procedures and occupational therapy. The patient had adequate time for discussion and all questions were answered to the patient's satisfaction prior to completing the consent.
-Operative Procedure: The patient was taken to the the operating room and secured with all bony prominences padded and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed.
+==== Trapeziectomy LRTI ====
-The arm was exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg. A Wagner longitudinal incision at the junction of the glabrous skin was made over the carpometacarpal joint, curving at the proximal wrist and stopping at the crossing of the flexor carpi radialis tendon. The incision was completed down to the subcutaneous tissue.  The dorsal radial sensory nerve and its branches were identified and protected.  The extensor pollicis brevis tendon and abductor pollicis longus tendon were identified and retracted radially. The joint space between the first metacarpal and the trapezium was identified using the c-arm and a subperiosteal longitudinal capsulotomy was made over the joint. Full-thickness flaps were raised using mixture of blunt and sharp dissection with scissors.  The capsular incision extended for visualization of the base of the first metacarpal and full trapezium and part of the scapho-trapezial-trapezoid joint.  Position was confirmed using a mini C-arm. Care was taken to preserve the capsule to facilitate later reattachment.  The trapezium was then dissected circumferentially.  A K-wire pin was then driven into the trapezium to use as a joystick handle to further help with retraction and movement to further facilitate fully dissecting free the trapezium.  The FCR tendon at the base of the
+<WRAP group>
-CMC joint was identified and care was taken to avoid injury to the tendon.  The trapezium was removed piecemeal using the rongeur with careful attention not to injure the FCR tendon lying in the volar groove of the bone. *** The trapezoid was evaluated and appeared denuded of cartilage. An osteotomy was made to remove the articulating surface with scaphoid.
+<WRAP half column>
-The flexor carpi radialis position was marked about 10 cm from the proximal wrist crease.  A 2 cm transverse incision was made and using the scissors with blunt dissection through the subcutaneous tissues, the FCR tendon was visualized. Using a freer, dissection was carried over the FCR tendon superficially and deep to it, freeing it up as much as possible from the forearm incision as well as from the Wagner incision moving proximally along the FCR. The musculotendinous junction was identified, and the tendon was lifted into the incision using a right-angle clamp.  The FCR was then transected.    Then at the base of the FCR tendon, the FCR was pulled distally into the trapezial bed.  The proximal forearm incision was closed with a 4-0 nylon suture.
+Operative Report:\\
+. Trapeziectomy with ligament reconstruction and tendon interposition\\
+. Partial trapezoid excision\\
+\\
+Consent: possible injury to the nerve, vessel, tendon, the need for secondary or revision procedures and occupational therapy. The patient had adequate time for discussion and all questions were answered to the patient's satisfaction prior to completing the consent.\\
+\\
+Operative Procedure: The patient was taken to the the operating room and secured with all bony prominences padded and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed.\\
+\\
+The arm was exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg. A Wagner longitudinal incision at the junction of the glabrous skin was made over the carpometacarpal joint, curving at the proximal wrist and stopping at the crossing of the flexor carpi radialis tendon. The incision was completed down to the subcutaneous tissue.  The dorsal radial sensory nerve and its branches were identified and protected.  The extensor pollicis brevis tendon and abductor pollicis longus tendon were identified and retracted radially. The joint space between the first metacarpal and the trapezium was identified using the c-arm and a subperiosteal longitudinal capsulotomy was made over the joint. Full-thickness flaps were raised using mixture of blunt and sharp dissection with scissors.  The capsular incision extended for visualization of the base of the first metacarpal and full trapezium and part of the scapho-trapezial-trapezoid joint.  Position was confirmed using a mini C-arm. Care was taken to preserve the capsule to facilitate later reattachment.  The trapezium was then dissected circumferentially.  A K-wire pin was then driven into the trapezium to use as a joystick handle to further help with retraction and movement to further facilitate fully dissecting free the trapezium.  The FCR tendon at the base of the CMC joint was identified and care was taken to avoid injury to the tendon.  The trapezium was removed piecemeal using the rongeur with careful attention not to injure the FCR tendon lying in the volar groove of the bone. The trapezoid was evaluated and appeared denuded of cartilage. An osteotomy was made to remove the articulating surface with scaphoid.\\
+\\
+The flexor carpi radialis position was marked about 10 cm from the proximal wrist crease.  A 2 cm transverse incision was made and using the scissors with blunt dissection through the subcutaneous tissues, the FCR tendon was visualized. Using a freer, dissection was carried over the FCR tendon superficially and deep to it, freeing it up as much as possible from the forearm incision as well as from the Wagner incision moving proximally along the FCR. The musculotendinous junction was identified, and the tendon was lifted into the incision using a right-angle clamp.  The FCR was then transected.    Then at the base of the FCR tendon, the FCR was pulled distally into the trapezial bed.  The proximal forearm incision was closed with a 4-0 nylon suture. \\
-Using a burr drill bit, the volar aspect of the base of the thumb metacarpal was burred down to cortical bone.  Then a position onto the more dorsal aspect of the thumb base, the position for the Mitek anchor suture was chosen and predrilled.  Then *** two #2-0 mini-Mitek anchor were placed into the thumb metacarpal base.  The FCR tendon was then pulled into its new anatomic position, and the suture of the Mitek anchor was then passed through the FCR tendon and tied. The remaining FCR tendon was then rolled up into an anchovy using 3-0 vicryl sutures.
+Using a burr drill bit, the volar aspect of the base of the thumb metacarpal was burred down to cortical bone.  Then a position onto the more dorsal aspect of the thumb base, the position for the Mitek anchor suture was chosen and predrilled.  Then two #2-0 mini-Mitek anchor were placed into the thumb metacarpal base.  The FCR tendon was then pulled into its new anatomic position, and the suture of the Mitek anchor was then passed through the FCR tendon and tied. The remaining FCR tendon was then rolled up into an anchovy using 3-0 vicryl sutures. \\
+\\
+The capsule edges were re-approximated with 3-0 vicryl sutures. The tourniquet was deflated and hemostasis was obtained and the incision irrigated. The incision was closed with 4-0 nylon simple and horizontal mattress sutures. The incision was dressed with xeroform, 4x8 gauze and a thumb spica splint was applied.\\
+\\
-The capsule edges were re-approximated with 3-0 vicryl sutures. The tourniquet was deflated and hemostasis was obtained and the incision irrigated. The incision was closed with 4-0 nylon simple and horizontal mattress sutures. The incision was dressed with xeroform, 4x8 gauze and a thumb spica splint was applied.
+</WRAP>
-Dr. Malliaris was present for the entirety of the case.  The patient tolerated the procedure well and was subsequently extubated and brought to the PACU in stable condition.
+<WRAP half column>
-Post-Operative Plan: The patient extubated and stable to PACU.  Discharge home with thumb spica.  Follow up in clinic as outpatient.
+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:\\
+There are many ways to perform the suspension of the 1st metacarpal, although there is no clear data to show that it is truly vital. The most important part is the thumb spica for 6 weeks-3 months for it to heal.\\
+\\
+When to perform APL/EPB tenodesis? To prevent hyperextension of the MCP joint.\\
+</WRAP>
+</WRAP>
 ==== Distal Radius ORIF ====
-Operative Procedure: The patient was taken to the the operating room and secured and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed.
+<WRAP group>
+<WRAP half column>
-The arm was elevated and exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg. An 8 cm incision was made over the flexor carpi radialis flexor tendon. The incision was continued down to the FCR sheath and the bipolar was used to achieve hemostasis of small vessels. The FCR sheath was incised and the FCR tendon retracted. The radial artery was identified and retracted radially. The antebrachial fascia was incised. Next, the pronator quadratus fascia was sharply incised in an "L" shape and elevated from radial to ulnar. The fracture line was identified and the periosteum elevated.
-The fracture was freed with the dental pick and the freer elevator. The fracture still had some mobility.  Once all the fragments were free, the mini fluoroscopy was brought in and the fracture reduced with traction and dorsal pressure; we confirmed the reduction with multiple views. The regular *** Acumed volar distal radius plate was chosen as the best size match. The plate was secured with ***proximal (?distal) k-wires and fluoroscopy was used to confirm placement; the *** distal radial screw was placed using a locking screw.
-We then turned our attention to the shaft and placed the oblong screw, keeping this a bit loose, and removed the K wires. The radial styloid fragment was then reduced further, and another K wire was used to hold the ulnar two fragments. We then placed the ulnar distal locking screw followed by the remaining distal row, and then the distal most radial styloid screw.
-We reduced the fragments to achieve more volar tilt and tightened the shaft screw, and then placed two more shaft screws.  Final fluoroscopy images were taken confirming reduction and plate placement.
-The pronator quadratus fascia was closed with 4-0 vicryl, achieving almost complete plate coverage.  The skin was closed with 4-0 nylon locking horizontal mattress sutures. Xeroform was placed over the incision and a volar resting splint was placed with the MCP joints free.
+Operative Report:\\
+The arm was elevated and exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg. An 8 cm incision was made over the flexor carpi radialis flexor tendon. The incision was continued down to the FCR sheath and the bipolar was used to achieve hemostasis of small vessels. The FCR sheath was incised and the FCR tendon retracted. The radial artery was identified and retracted radially. The antebrachial fascia was incised. Next, the pronator quadratus fascia was sharply incised in an "L" shape and elevated from radial to ulnar. The fracture line was identified and the periosteum elevated.\\
+ \\
+The fracture was freed with the dental pick and the freer elevator. The fracture still had some mobility.  Once all the fragments were free, the mini fluoroscopy was brought in and the fracture reduced with traction and dorsal pressure; we confirmed the reduction with multiple views. The regular Acumed volar distal radius plate was chosen as the best size match. The plate was secured with proximal (vs. distal) k-wires and fluoroscopy was used to confirm placement; the distal radial screw was placed using a locking screw. \\
+ \\
+We then turned our attention to the shaft and placed the oblong screw, keeping this a bit loose, and removed the K wires. The radial styloid fragment was then reduced further, and another K wire was used to hold the ulnar two fragments. We then placed the ulnar distal locking screw followed by the remaining distal row, and then the distal most radial styloid screw.\\
+ \\
+We reduced the fragments to achieve more volar tilt and tightened the shaft screw, and then placed two more shaft screws.  Final fluoroscopy images were taken confirming reduction and plate placement.\\
+ \\
+The pronator quadratus fascia was closed with 4-0 vicryl, achieving almost complete plate coverage.  The skin was closed with 4-0 nylon locking horizontal mattress sutures. Xeroform was placed over the incision and a volar resting splint was placed with the MCP joints free.\\
+\\
 The incision was irrigated and then closed with 4-0 nylon locking horizontal mattress sutures. The incision was dressed with xeroform and a soft dressing of 4x4 gauze, webril and a volar resting splint. The tourniquet was released and normal perfusion returned to the hand.
-Dr. Malliaris was present for the entirety of the case. All counts were correct. There were no complications. The patient was brought to the PACU and discharged without incident.
+</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>
 ==== Carpal Tunnel Release ====
-Operative Pearls
+<WRAP group>
-Anatomy
+<WRAP half column>
+Operative Report:\\
+The patient was taken to the the operating room and secured and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed.\\
+ \\
+Local anesthesia of 6 ccs of 50:50 1% lidocaine and 0.25% marcaine was injected into the volar wrist in line with the 3rd webspace. A tourniquet was placed sterilely and the forearm and hand were exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg.\\
+ \\
+A 2 cm incision was made over the volar wrist in line with the 3rd webspace. The fat overlying the superficial palmar fascia was excised with the scapel. Retractors were used to visualize the superficial palmar fascia and we encountered origins of the thenar musculature. The superficial palmar fascia was excised ulnar to the muscle insertions. At the level of the transverse carpal ligament, we also encountered hypothernar musculature origins. Retractors were placed deeper into the incision and the transverse carpal ligament (TCL) was excised with the beaver blade to reveal the median nerve. Ragnell scissors were used to spread above the TCL distally and a freer elevator was used to free the nerve off the TCL. Then the TCL was cut until a small fat pad was visualized and the nerve was released. Next we turned our attention to the proximal aspect of the TCL. We again spread with the ragnell scissors above the TCL and freed the nerve from the TCL with the freer. The TCL was cut with the ragnell scissors and then slid through the antebrachial fascia to release the median nerve.The tourniquet was deflated to reveal the median nerve with constriction and hyperemia.
+</WRAP>
+<WRAP half column>
 Technical Steps
@@ Line 171: / Line 543: @@
 . Ensure complete release with the freer.\\
 . Close with 4-0 nylon. She prefers locked horizontal mattress sutures.\\
+Tourniquet: finger / forearm / arm\\
+Drain: Type of drain and placement\\
+Sutures: List all layers\\
+Dressing: What's preferred?\\
+Anatomy: Pertinent anatomy should be listed\\
 Postoperative Care
@@ Line 177: / Line 556: @@
 No Narcotics\\
-Operative Procedure: The patient was taken to the the operating room and secured and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed.
+Learning points/Pimp Questions: Has been known to ask brachial plexus questions to interns and medical students during carpal tunnel release. Make sure you can draw it out and especially explain where the median nerve comes from.\\
-Local anesthesia of 6 ccs of 50:50 1% lidocaine and 0.25% marcaine was injected into the volar wrist in line with the 3rd webspace. A tourniquet was placed sterilely and the forearm and hand were exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg.
+</WRAP>
+</WRAP>
-A 2 cm incision was made over the volar wrist in line with the 3rd webspace. The fat overlying the superficial palmar fascia was excised with the scapel. Retractors were used to visualize the superficial palmar fascia and we encountered origins of the thenar musculature. The superficial palmar fascia was excised ulnar to the muscle insertions. At the level of the transverse carpal ligament, we also encountered hypothernar musculature origins. Retractors were placed deeper into the incision and the transverse carpal ligament (TCL) was excised with the beaver blade to reveal the median nerve. Ragnell scissors were used to spread above the TCL distally and a freer elevator was used to free the nerve off the TCL. Then the TCL was cut until a small fat pad was visualized and the nerve was released. Next we turned our attention to the proximal aspect of the TCL. We again spread with the ragnell scissors above the TCL and freed the nerve from the TCL with the freer. The TCL was cut with the ragnell scissors and then slid through the antebrachial fascia to release the median nerve.The tourniquet was deflated to reveal the median nerve with constriction and hyperemia.
 ====ORIF Metacarpal Fractures====
-Description of Procedure: The patient was identified in the preoperative care area where informed consent was reviewed with the patients. The surgical site was marked, all of their questions were answered and concerns were addressed. The patient was brought back to the operating room by the anesthesia staff. All pressure points were well padded. A surgical time-out was performed per protocol, and appropriate perioperative antibiotics were administered prior to the start of the procedure. General anesthesia was then obtained. A nonsterile tourniquet was placed on the right upper extremity, which was then prepped and draped in a standard sterile fashion.
-An incision was made over the right fifth metacarpal in a longitudinal incision.  Bipolar electrocautery was used to cauterize any of the small subcutaneous vessels. Using a Littler scissors, dissection was carried down to the fascia, taking care to protect and move to the side the extensor tendons and sensory nerves.  An incision was made over the dorsal periosteum of the fifth metacarpal, and the freer was used to elevate the periosteum and expose the fracture.  This was performed proximally and distally on the fifth metacarpal to give us enough room for reduction and plating of the fracture. The bone callus was debrided using a rongeur. The fracture was able to be reduced, and a reduction clamp was placed to hold it.  The reduction was confirmed using the mini fluoroscopy and and a Synthes 1.5 mm T-shaped plate was chosen. The most distal ulnar screw hole was cut off to better conform to the metacarpal head, creating an L-shaped plate. The size and shape was confirmed to be appropriate.
+<WRAP group>
+<WRAP half column>
-An olive threaded K wire was used to secure one end of the plate, and the second hole on the other end was drilled and then the appropriate length was determined for bicortical screw, which was placed with good purchase. A second distal screw was placed, angling appropriately in the head of the metacarpal. Orthogonal views were taken to confirm length and placement. Then two proximal shaft screws were placed, and then the olive wire was removed and a third proximal screw was placed.
+Operative Report:\\
+The patient was identified in the preoperative care area where informed consent was reviewed with the patients. The surgical site was marked, all of their questions were answered and concerns were addressed. The patient was brought back to the operating room by the anesthesia staff. All pressure points were well padded. A surgical time-out was performed per protocol, and appropriate perioperative antibiotics were administered prior to the start of the procedure. General anesthesia was then obtained. A nonsterile tourniquet was placed on the right upper extremity, which was then prepped and draped in a standard sterile fashion.  \\
+\\
+An incision was made over the right fifth metacarpal in a longitudinal incision.  Bipolar electrocautery was used to cauterize any of the small subcutaneous vessels. Using a Littler scissors, dissection was carried down to the fascia, taking care to protect and move to the side the extensor tendons and sensory nerves.  An incision was made over the dorsal periosteum of the fifth metacarpal, and the freer was used to elevate the periosteum and expose the fracture.  This was performed proximally and distally on the fifth metacarpal to give us enough room for reduction and plating of the fracture. The bone callus was debrided using a rongeur. The fracture was able to be reduced, and a reduction clamp was placed to hold it.  The reduction was confirmed using the mini fluoroscopy and and a Synthes 1.5 mm T-shaped plate was chosen. The most distal ulnar screw hole was cut off to better conform to the metacarpal head, creating an L-shaped plate. The size and shape was confirmed to be appropriate.\\
+\\
+An olive threaded K wire was used to secure one end of the plate, and the second hole on the other end was drilled and then the appropriate length was determined for bicortical screw, which was placed with good purchase. A second distal screw was placed, angling appropriately in the head of the metacarpal. Orthogonal views were taken to confirm length and placement. Then two proximal shaft screws were placed, and then the olive wire was removed and a third proximal screw was placed. \\
+\\
+A fourth proximal screw was then placed through the plate, followed by a third distal screw. Because of the shape of the fracture, a 1.5mm single dorsal radial lag screw by technique was then placed to further support the construct, and the two middle holes in the plate were left open. \\
+\\
+The incision was irrigated. Using a 4-0 Vicryl, the periosteum was closed in interrupted fashion.   A 4-0 Monocryl was used for deep dermal sutures in an interrupted fashion and then using a 4-0 Monocryl, the skin was closed with a running subcuticular stitch.  Steristrips were applied.  10 mL of 0.25% Marcaine was instilled into the incision.  A volar resting splint was applied. The tourniquet was released and normal perfusion returned to the hand and fingers.
-A fourth proximal screw was then placed through the plate, followed by a third distal screw. Because of the shape of the fracture, a 1.5mm single dorsal radial lag screw by technique was then placed to further support the construct, and the two middle holes in the plate were left open.
-The incision was irrigated. Using a 4-0 Vicryl, the periosteum was closed in interrupted fashion.   A 4-0 Monocryl was used for deep dermal sutures in an interrupted fashion and then using a 4-0 Monocryl, the skin was closed with a running subcuticular stitch.  Steristrips were applied.  10 mL of 0.25% Marcaine was instilled into the incision.  A volar resting splint was applied. The tourniquet was released and normal perfusion returned to the hand and fingers.
+</WRAP>
-The patient was awakened from anesthesia and taken to PACU in stable condition.
+<WRAP half column>
-Counts: All surgical scrub counts were correct at the end of the case.
+Photos\\
-Complications: None.
+Tourniquet: finger / forearm / arm\\
+Drain: Type of drain and placement\\
+Sutures: List all layers\\
+Dressing: What's preferred?\\
+Anatomy: Pertinent anatomy should be listed\\
+Postoperative Plan:  \\
+- He will be discharged home when he meets PACU criteria.  \\
+- Follow up in Hand Clinic as scheduled \\
+- 24 Hours of Keflex post-op \\
+- NWB RUE  \\
+Learning points/Pimp Questions:\\
+</WRAP>
+</WRAP>
+====Thumb UCL Repair====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Repair of left thumb ulnar collateral ligament
+The patient was taken to the operating room. The patient was sedated.  The left arm was prepped and draped in the standard fashion.   A sterile tounriquet was applied to the forearm.  A presurgical time out was performed.  The side site and procedure confirmed.  Antibiotics had been given and scds were on.  The surgical field was anesthetized with local without epinephrine.\\
+\\
+A 4 cm lazy S type incision was outlined on the ulnar aspect of the left thumb over the MCP joint. The forearm was exsanguinated and the forearm tourniquet was turned on.  The marked incision was made just through the skin.  We then bluntly dissected down to the joint capsule and adductor aponeurosis.   We did identify and preserve a superficial radial sensory nerve, and placed a vessiloop for use during the case.  The adductor aponeurosis as then incised and retracted ulnarly.  A longitudinal incision was then made into the joint capsule where we found the ulnar collateral ligament completely avulsed off the proximal phalanx.  This was furled proximally and over the adductor aponeurosis consistent with a stener lesion.   We unfurled the ligament.  With the joint reduced the ligament reached to its prior site of insertion.  At this point we utilized fluoroscopy to select our sites for our bone anchors.  The selected site on the proximal phalanx was cleared of soft tissue to bleeding bone.  We then placed a 2 mm pushlock anchor distally with labral tape and a 2-0 fiber wire suture.   The clean ligament was then sutured in a mattress fashion to the site of bone anchor insertion while holding the joint in reduction.   We then placed a SwiveLock bone anchor in the distal metacarapal just proximal to the ucl origin.  This bone secured two limbs of the labral tape as an internal brace.   4-0 Fiberwire was used to affix the volar accessory ligament to the volar plate.  At this point the mcp joint was well reduced and had no laxity. We then closed the joint capsule and adductor aponeurosis with 3-0 vicryl.  The wound was irrigated and the skin was closed with 4-0 monocryl with deep dermals and then running subcuticular fashion.   A dressing of exofin glue was applied.  The tourniquet was released and distal perfusion returned to the hand.  A well padded thumb spica splint was placed.  The patient was awakened and taken to the pacu.
+</WRAP>
+<WRAP half column>
+Photos\\
+{{:resident:screen_shot_2021-08-02_at_3.56.00_pm.png?600|}}
+Tourniquet: forearm\\
+Drain: none\\
+Sutures: Joint capsule 3-0 vicryl, skin monocryl or nylon\\
+Dressing: Xeroform, gauze, cast padding and Thumb Spica Splint\\
+Special Equipment: Labral tape as an internal brace, ARTHREX DX SwiveLock SL, with Forked Eyelet, 3.5 x 8.5 mm (Bone Anchor)\\
+Operative Steps Summary:\\
+  - Reverse Lazy s over ulnar side
+  - Gentle cut
+  - *Avoid dorsal radial sensory nerve branches
+  - Expose joint capsule using scissors
+  - Open joint capsule with blade
+  - Separate from the adductor aponeurosis using freer
+  - Open adductor aponeurosis sharply
+  - Expose ucl. Identify ends. Try to separate out.
+  - Using k wire and Fluoro identify distal anchor point
+  - Drill hole
+  - Put in anchor with tape and suture
+  - Suture in to proximal ucl
+  - Identify proximal area and place k wire
+  - Drill over k wire
+  - Screw in tape
+  - Close joint calsule
+  - Close aponeurosis with running 4-0 vicryl
+  - Close skin with locking horizontal mattress with 4-0 nylon
+Anatomy: Proper collateral: from fossa in metacarpal neck, dorsal to axis of rotation to lateral and volar aspect of base of proximal phalanx\\
+accessory collateral: from palmar aspect of metacarpal neck into volar plate and sesamoid\\
+Most tears are at site of insertion\\
+Adductor sheath can entrap: stener lesion \\
+\\
+Postoperative Plan:  \\
+Non weight bearing on this hand x 6 weeks.\\
+Thumb spica splint to kept on and dry at all times. \\
+At clinic follow-up visit will transition to thumb spica cast; no suture removal needed.\\
+Pt will have thumb immobilized for a minimum of six weeks.\\
+\\
+Learning points/Pimp Questions:\\
+Mechanism of injury - radially-directed force causing hyper-abduction moment at the thumb MCP (ie a ski pole if acute)\\
+Acute injury - eponym is Skier's thumb\\
+Chronic injury - eponym is Gamekeeper's thumb. An overuse injury. The liagment will not be able to be repaired.\\
+Stener lesion - avulsed ligament with or without bony attachment is displaced dorsal and superficial to the adductor aponeurosis.
+Usually the distal end is retracted proximally\\
+</WRAP>
+</WRAP>
-Postoperative Plan:
-- He will be discharged home when he meets PACU criteria.
-- Follow up in Hand Clinic as scheduled
-- 24 Hours of Keflex post-op
-- NWB RUE
 ====Abdominally based random pattern skin flap====
-PROCEDURES PERFORMED: Abdominally-based random pattern skin flap, 10 cm by 10 cm, for coverage of right dorsal hand shearing degloving injury.
-DESCRIPTION OF PROCEDURE: Care of the patient was assumed from Dr. Ipaktchi and the Ortho Hand team following revision amputation of the right index finger and fillet of finger flap to resurface the dorsal aspects of the long finger and remaining index finger. The wound now measured 10 cm by 8 cm to the dorsal hand with some exposure of the bases of the proximal phalanges of the index and long fingers.
-We began by templating the defect onto a piece of Esmarch bandage as a random-pattern inferiorly-based "omega" flap. The template was transferred to the abdomen at the right lower quadrant and the proposed flap marked out for an inferiorly-based random pattern flap. The template was oriented so as to facilitate a relaxed position of the hand onto the abdomen. The length of the flap was increased by 2 cm so as to reach the superior margin of the flap to the radial aspect of the hand defect without undue tension. 4 cm lateral limbs were marked at the base to facilitate closure of the donor site.
-The superior, medial, and lateral flap margins were incised with a 10-blade scalpel. Dissection was carried through the subcutaneous tissues using Bovie electrocautery. The flap was raised from superior to inferior. Laterally where the tissue was thinner, dissection was carried above the external oblique fascia. Medially where the tissue was thicker, dissection was carried below the superficial fascial system, leaving some fat down on the abdominal wall. Adequate hemostasis was obtained.
-After first ensuring that the flap was of adequate width and length to resurface the right dorsal hand, we began closure of the donor site. The subcutaneous tissue was undermined for several centimeters in each direction for mobilization. The superior corners of the defect were closed with 3-0 Vicryl for the SFS and simple interrupted 3-0 Nylon sutures for approximately 5 cm each. The inferolateral edges were brought together and closed for approximately 4 cm using 3-0 Nylon suture. This left a triangular-shaped defect centrally at the donor site measuring 4 cm by 4 cm.
-The flap was then inset to the dorsal hand using simple interrupted 3-0 Nylon suture, with the lateral, superior, and medial edges of the flap well approximated to the proximal, radial, and distal aspects of the dorsal hand, respectively.
-The incision sites were dressed with bacitracin ointment. The triangular-shaped defect was dressed with wet-to-dry 4x4 gauze. The raw surface of the flap at the base was dressed with wet-to-dry 4x4 gauze. A split ABD pad was placed over the abdomen and under the hand. The hand was wrapped in Burn gauze and Kerlix.
-The forearm and upper arm abrasions were dressed with bacitracin ointment, Xeroform, and Kerlix.
-The patient was awaken from anesthesia and transferred to the PACU in good condition with no apparent complications.
-SPECIMEN: None.
-IMPLANTS/DRAINS: None.
-ESTIMATED BLOOD LOSS: 30 mL.
-COMPLICATIONS: None.
-DISPOSITION: To PACU.
+<WRAP group>
+<WRAP half column>
-POSTOPERATIVE PLAN:
-- Return to ward. Pediatrics primary.
-- Non-weight bearing RUE.
-- Ancef x 24 hours post-operatively.
-- Abdominal binder at all times to keep hand in place.
-- Okay to gently range at elbow and shoulder, keeping hand in place.
-- NO flap checks necessary.
-- Plan for dressing change in OR with Dr. Ipaktchi on Monday, 7/20/20. Otherwise no dressing changes. Okay to re-inforce with 4x4 gauze or ABD pads, gently tucking at inferior aspect, if needed.
-- Ultimately will follow up with Hand/Plastics as outpatient with plan for flap division at 3-4 weeks.
-- Plastics to continue to follow.
+Operative Report: \\
+. Abdominally-based random pattern skin flap, 10 cm by 10 cm, for coverage of right dorsal hand shearing degloving injury. \\
+\\
+Care of the patient was assumed from Dr. Ipaktchi and the Ortho Hand team following revision amputation of the right index finger and fillet of finger flap to resurface the dorsal aspects of the long finger and remaining index finger. The wound now measured 10 cm by 8 cm to the dorsal hand with some exposure of the bases of the proximal phalanges of the index and long fingers.\\
+ \\
+We began by templating the defect onto a piece of Esmarch bandage as a random-pattern inferiorly-based "omega" flap. The template was transferred to the abdomen at the right lower quadrant and the proposed flap marked out for an inferiorly-based random pattern flap. The template was oriented so as to facilitate a relaxed position of the hand onto the abdomen. The length of the flap was increased by 2 cm so as to reach the superior margin of the flap to the radial aspect of the hand defect without undue tension. 4 cm lateral limbs were marked at the base to facilitate closure of the donor site.\\
+ \\
+The superior, medial, and lateral flap margins were incised with a 10-blade scalpel. Dissection was carried through the subcutaneous tissues using Bovie electrocautery. The flap was raised from superior to inferior. Laterally where the tissue was thinner, dissection was carried above the external oblique fascia. Medially where the tissue was thicker, dissection was carried below the superficial fascial system, leaving some fat down on the abdominal wall. Adequate hemostasis was obtained.\\
+ \\
+After first ensuring that the flap was of adequate width and length to resurface the right dorsal hand, we began closure of the donor site. The subcutaneous tissue was undermined for several centimeters in each direction for mobilization. The superior corners of the defect were closed with 3-0 Vicryl for the SFS and simple interrupted 3-0 Nylon sutures for approximately 5 cm each. The inferolateral edges were brought together and closed for approximately 4 cm using 3-0 Nylon suture. This left a triangular-shaped defect centrally at the donor site measuring 4 cm by 4 cm.\\
+ \\
+The flap was then inset to the dorsal hand using simple interrupted 3-0 Nylon suture, with the lateral, superior, and medial edges of the flap well approximated to the proximal, radial, and distal aspects of the dorsal hand, respectively.\\
+ \\
+The incision sites were dressed with bacitracin ointment. The triangular-shaped defect was dressed with wet-to-dry 4x4 gauze. The raw surface of the flap at the base was dressed with wet-to-dry 4x4 gauze. A split ABD pad was placed over the abdomen and under the hand. The hand was wrapped in Burn gauze and Kerlix.\\
+ \\
+The forearm and upper arm abrasions were dressed with bacitracin ointment, Xeroform, and Kerlix.\\
+</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: \\
+- Return to ward. Pediatrics primary.\\
+- Non-weight bearing RUE.\\
+- Ancef x 24 hours post-operatively.\\
+- Abdominal binder at all times to keep hand in place.\\
+- Okay to gently range at elbow and shoulder, keeping hand in place.\\
+- NO flap checks necessary.\\
+- Plan for dressing change in OR with Dr. Ipaktchi on Monday, 7/20/20. Otherwise no dressing changes. Okay to re-inforce with 4x4 gauze or ABD pads, gently tucking at inferior aspect, if needed.\\
+- Ultimately will follow up with Hand/Plastics as outpatient with plan for flap division at 3-4 weeks.\\
+- Plastics to continue to follow.\\
+Learning points/Pimp Questions:\\
+</WRAP>
+</WRAP>
+==== Upper Extremity GSW Re-Exploration, Repair of (Known) Median Nerve Injury ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+.  Left upper extremity previous gunshot wound exploration\\
+. Neurolysis of left median nerve injury at the level of the elbow, near the level of the brachial artery bifurcation and medial antebrachial cutaneous nerve injury, excision of neuromas at both nerves\\
+. Repair of left median nerve injury at the level of the elbow - 7 cm segment reconstructed with 4-5 mm allograft, 70 mm length using microsurgical technique\\
+. Repair of left medial antebrachial cutaneous nerve injury - 6.5 cm segment reconstructed with 1-2 mm allograft, 65 mm in length using microsurgical technique\\
+. Scar revision, distal, volar scar 4 x 1 cm, with simple closure\\
+\\
+INDICATIONS FOR PROCEDURE: The patient is a _-year old male with a history of gunshot wound to the left upper extremity with previous history of operative exploration, with brachial artery repair/reconstruction with reversed interposition vein graft 4 cm, median nerve exploration and neurolysis. The patient has been following up in hand surgery clinic and doing well. He has since had an EMG, with results that were reviewed with him an his guardian. Given his currently clinical and physical examination, we recommended the above procedures. The details of the procedure including risks and benefits were discussed with the patient. He voiced understanding and agreed with the plan. Written and verbal consent was obtained from his guardian (grandmother).
+DESCRIPTION OF PROCEDURE: The patient was transported to Operating Room #4 and placed supine on the table with pressure points appropriately padded. A pre-anesthesia time-out was performed. The patient was administered anesthesia without complication. Pre-operative antibiotic prophylaxis was administered - Ancef. The surgical field was prepped and draped in the usual sterile fashion. A final time-out was performed. Anti-embolic compression devices were placed on bilateral lower extremities prior to induction. A Foley catheter was placed and removed at the end of the case.
+The patient's left upper extremity was prepped into the field from the shoulder to distal. Preoperative diagnostic testing was reviewed prior to surgery and was immediately available throughout the case. A sterile tourniquet was applied, Esmarch was used to exsanguinate the arm, and the tourniquet was inflated to 250 mmHg.
+We began by marking out an incision over the previous incision line. We also included an ellipse of tissue 4 x 1 cm distally, which was one of the previous gunshot wound sites that had persistent granulation tissue that had not been completely epithelialized. We then carefully made the incision over the remainder of the previous incision site, and encountered a significant amount of scar. We meticulously dissected this down to the level of the pronator teres and biceps brachii. We were able to identify the median nerve proximal to the elbow, and carried this dissection down distally. Near the elbow, we encountered the previous brachial artery repair/reconstruction site. We carefully dissected around this and traced the median nerve distally until the previously placed Proline loop was encountered, designating the area of injury. There were ~ 3 fascicles that were still intact, which were carefully isolated with a vessel loop, without tension. The remainder of the median nerve was dissected distally and we freed the adhesions between FCR, FDP and FDS. Once the entirety of the median nerve was clearly identified throughout the length of the incision, we carefully lysed the remainder of the adhesions, and identified the medial antebrachial cutaneous nerve. The proximal and distal aspects had been previously clipped, and were isolated. Careful neurolysis was performed of both the medial antebrachial cutaneous nerve and the median nerve. The distal aspects were scarred into surrounding tissue and neuromas were carefully dissected. Doppler was used to confirm the course of the vasculature throughout the case. The proximal and distal extents of the median nerve were carefully retracted with vessel loops without tension. After the anatomy had been satisfactorily delineated, the tourniquet was released and hemostasis was secured with Bipolar cautery. We then planned for nerve coaptation.
+The arm was once again exsanguinated with an Esmarch and tourniquet inflated to 250 mmHg. The remainder of the neurolysis was performed with microsurgical technique, and excision of neuromas and preparation of the nerves with a fresh edge was performed with a #10 blade. Once the nerves were adequately prepared, the median nerve was repaired with a 4-5 mm allograft, 70 mm in length. Simple interrupted 8-0 Nylon sutures were placed into the epineurium for a tension free coaptation. Tisseel fibrin glue was then applied to the proximal and distal repair sites circumferentially. Attention was then directed towards medial antebrachial cutaneous nerve repair, which was performed in a similar fashion. Once the nerve was adequately prepared, it was repaired with a 1-2 mm allograft, 65 mm in length. Simple interrupted 8-0 Nylon sutures were placed into the epineurium for a tension free coaptation. Tisseel fibrin glue was then applied to the proximal and distal repair sites circumferentially.
+The arm was then cleansed, tourniquet was released. Meticulous hemostasis was secured with Bipolar cautery. The artery was visualized and found to be intact throughout its course. The hand was warm and well perfused with capillary refill 2-3 seconds on all digits. The nerve repairs were visualized and appeared to be tension free with adequate coaptation. Therefore, the wound was irrigated until this ran clear, and the skin was closed with 4-0 Nylon horizontal mattress sutures.
+The skin was then cleansed and the wound was dressed with Xeroform gauze, then 4x4 gauze, then Webril, and posterior arm plaster splint, with the wrist in neutral, and Bias.
+</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>
+==== Enchondroma Curettage ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Left index finger middle phalanx mass (findings consistent with enchondroma) curettage and bone grafting \\
+\\
+The patient was transported to Operating Room #4 and placed supine on the table with pressure points appropriately padded. A pre-anesthesia time-out was performed. Left upper arm tourniquet was placed. The patient was administered anesthesia without complication. Pre-operative antibiotic prophylaxis was administered. The surgical field was prepped and draped in the usual sterile fashion. A final time-out was performed. Anti-embolic compression devices were placed on bilateral lower extremities prior to induction. No Foley catheter was placed.
+A radial midlateral incision was planned over the middle phalanx. The left upper extremity was then exsanguinated with tourniquet at 250 mmHg. Incision was then made and meticulous dissection occurred until we reached the radial aspect of the periosteum overlying the middle phalanx. This was then probed with a freer until a soft spot was reached. Once this was identified, a longitudinal incision was then made with a beaver blade into the radial aspect of the middle phalanx. Once the cortex was penetrated, there was, what appeared to be cartilaginous material encountered. This was carefully curetted and a specimen was sent to pathology. While awaiting preliminary pathology, the remainder of the material was removed, within the confines of the middle phalanx cortex. This was performed in conjunction with review of the MRI as well as with intraoperative fluoroscopy, using a 25-gauge needle to mark the extent of the cavity within the cortex. Once all of the material was removed, this was sent to pathology, and copious irrigation was used to clean the cavity. Additional curettage was performed until the cortex was reached circumferentially. Pathology returned as what appeared to be cartilaginous material. Therefore, the cavity was packed with cancellous bone chips tightly and the area was again cleansed, and the skin was closed with 5-0 Nylon, simple interrupted sutures with good opposition and eversion. Local anesthetic was injected into the surgical site for a digital block. The skin was cleansed, and the wound was dressed with a strip of Xeroform gauze, then 4x4 gauze, and a well-padded radial gutter plaster splint with bias, with the wrist in neutral.
+The tourniquet was released at the end of the case and all digits had good capillary refill afterwards, brisk, 2-3 seconds, and were warm and pink.
+The patient was awoken from anesthesia and transferred to the PACU in good condition with no apparent complications.
+</WRAP>
+<WRAP half column>
+Photos\\
+{{:resident:screen_shot_2021-08-02_at_4.23.58_pm.png?600|}}
+Tourniquet: Forearm tourniquet\\
+Drain: none\\
+Sutures: 5-0 Nylon\\
+Dressing: xeroform, 4x4 gauze, well padded radial gutter plaster splint\\
+Anatomy:
+Enchondroma most commonly arises in the proximal phalanx or metacarpal when seen in the hand. It can be seen in metaphyseal and epiphyseal regions and is typically confined to the bone. The enchondroma may distend the bone and pathologic fracture may be seen.\\
+Post-operative care: Bulky protective dressings are applied and range of motion is initiated at the first dressing change, usually 8 to 10 days postoperatively.\\
+\\
+Periodic surveillance continues for 3 to 5 years.\\
+\\
+Learning points/Pimp Questions:\\
+\\
+Make the bone window to the lesion two-thirds the greatest dimension of the lesion to allow adequate visualization of the cavity.\\
+\\
+Phalanx enchondromas can just have a bulky dressing, but metacarpal fractures usually require splinting for 6 weeks.\\
+\\
+These lesions are similar to giant cell tumors. Remember that these can recur late and metastasize.\\
+{{:resident:screen_shot_2021-02-02_at_10.54.28_pm.png|}}
+</WRAP>
+</WRAP>
 ===== Plastics =====
+==== Tissue Expander (Total Submuscular) ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Total Submuscular Tissue Expander Placement
+In the preoperative area, consent was acquired, and the patient's midline and bilateral inframammary folds were marked in the upright position. The patient was then brought to the operating room and placed in supine position. A time out was performed confirming correct patient, procedure, and site, and the patient received 2g of Ancef prior to induction of general anesthesia. The patient was then prepped and draped in the usual sterile fashion. A bilateral skin-sparing mastectomy and left sentinel lymph node biopsy was completed by Dr. Jaiswal; please see her separate operative note for details on the portion of the procedure. \\
+ \\
+Following completion of the mastectomy, the reconstruction portion of the case commenced. A left subpectoral pocket was created. The pectoralis major muscle was released and the inferior and lateral portion of the pocket was raised beneath the serratus anterior muscle creating a inferolateral muscle flap and rectus abdominus fascia elevated inferiorly.\\
+ \\
+This was repeated on the right side, with the same pectoralis and serratus anterior and rectus fascia flaps were elevated.\\
+ \\
+The pockets were copiously irrigated with normal saline and hemostasis was ensured. The base diameter was measured intra-operatively and confirmed to accommodate a 12 cm base width tissue expander bilaterally. A 15 french round blake drain was placed at this time and secured, exiting inferolaterally in each side.\\
+ \\
+The pockets were again irrigated with normal saline, and hemostasis again confirmed. They were then copiously irrigated with antibiotic containing normal saline. The skin and subpectoral pocket were cleansed with diluted betadine and gloves were changed. Using a minimal-touch technique, the above tissue expanders were placed into the subpectoral submuscular pockets. They were secured in place with 2-0 PDS suture through 4 of the 6 tabs. The pectoralis and serratus flaps were subsequently approximated using interrupted 3-0 vicryl sutures. \\
+ \\
+The skin at the incisions of the NSM were closed with 3-0 monocryl interrupted deep dermal sutures and a subcuticular running suture of 4-0 monocryl. The skin incisions were then covered in surgical skin glue. The patient tolerated the procedure well and without complication. She was transferred to the postoperative care unit if stable condition. All needle and sponge counts were correct at the end of the case.
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: finger / forearm / arm\\
+Drain: 15 french round blake drain x2\\
+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>
+==== Breast Reduction (Inferior Pedicle)====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+The patient was marked in the preoperative holding area. The new position of the nipple areolar complex was marked and correlated to the level of the inframammary fold along the breast meridians and a Wise pattern was delineated.  The patient was then transported to the operating room and placed in supine position.  All bony prominences were padded.  SCD boots were placed. Perioperative antibiotics were given.  General endotracheal anesthesia was administered.  A proper timeout was taken, in which all present parties were in agreement.  The patient was prepped and draped in the usual sterile fashion.\\
+ \\
+The markings were then re-delineated. The nipple-areolar complex was inscribed with a 42 mm cookie cutter and a scalpel was used to incise around the epidermis of the nipple-areolar complex.  The inferior pedicle was also delineated and incised, and the inferior pedicle was de epithelialized.  The remaining incisions were then created, on the medial and lateral breast a dermoglandular wedge excisions were created, taking care not to narrow the base of the inferior pedicle. The nipple-areolar complex was maintained on a dermoglandular inferior pedicle of its tissue.  The chest wall attachments were maintained to the pedicle, in order to include the intercostal and chest wall perforating vessels.  The perfusion of the nipple-areolar complex was assessed, based on arterial and venous bleeding from the cut edges.  The upper breast skin flaps were undermined to the pectoral surface.  These upper skin flaps were contoured by excision of additional fat and parenchyma to better contour the breast.  These skin flaps were about 2 cm thick and well perfused.  This was repeated for the contralateral breast. Preliminary weight of the breast tissue excised and sent to pathology for final weights, The left breast was 300 gm and the right breast weighed 522 gm.  The surgical field was then irrigated with an antibiotic solution.  Hemostasis was achieved using electrocautery Bovie.  The skin was temporarily closed with staples and the patient was then placed in sitting position to assess breast symmetry. The breast symmetry was good.  The incisions were reopened. The field was inspected for hemostasis and irrigated with a sterile saline.  The inferior pedicle and nipple-areolar complex were inspected for bleeding and tissue viability and appeared to be viable.  The pedicle was oriented and had tacking sutures placed with 3-0 PDS to better align the nipple areolar complex to the proposed markings of the new areola on either side. The skin was realigned with staples. A half buried mattress was placed at the T-Junction of each breast using a 2-0 Nylon. Deep dermal sutures were placed using a 3-0 monocryl in simple interrupted fashion.The inferior incision was closed with a running 3-0 V-Loc. 3-0 Monocryl was used on the vertical limb. The patient was sat up again to assess nipple-areolar complex placement. A cookie cutter was used to delineate the site of the new nipple-areolar complex. Nipple position was in correct anatomical position and was anatomically pleasing, with approximately 6cm from nipple to IMF and 4cm from bottom of areola to IMF. 42mm cookie cutter was used. The patient was placed supine again. A scalpel was used to de-epithelialize the area of the new NAC and the dermis was incised in a cruciate fashion.  The nipple-areolar complex was exteriorized on each side and sutured in place with interrupted 3-0 Monocryl sutures, followed by a running 4-0 subcuticular Monocryl suture. The vertical incision was closed with 3-0 deep dermal sutures, followed by 4-0 running subcuticular Monocryl suture. This was also performed for the contralateral breast.  Exofin was placed over the IMF incisions, followed by steris and telfa tegaderm on the NAC, and we placed a surgical bra with fluff. The patient tolerated the procedure well. \\
+</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>
+==== Breast Reduction (Superiomedial Pedicle) ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Bilateral superior medial pedicle wise pattern skin reduction mammoplasty:\\
+\\
+The patient was consented and marked with a wise skin pattern superomedial pedicle breast reduction pattern in the pre op area.  The patient was taken to the operating room.  A pre time out was performed.   The patient was intubated.  The chest was prepped and draped in the usual sterile fashion.  A time out was performed. The side site and procedure were confirmed. scds were on and functioning.  Antibiotics had been given.  We began by using a 38 mm cookie cutter to outline a new NAC on both breasts.  A superior medical pedicle was then outlined.  The skin inside the pedicle marking but outside the new NAC was de-epithelialized, after a lap pad tourniquet was placed on both breasts. The wise pattern skin incision was then made over the entire pattern except for the medial portion of the pedicle.   The pedicle was then divided from the rest of the breast parenchyma. The inferior portion of the breast was freed from the chest wall.  The specimens were passed off.  The wise pattern skin envelope was stapled closed and we sat the patient up to assess for volume and symmetry.  There seemed to still be a bit of excess lateral fullness so we removed the staples and removed some additional skin ellipses laterally as well as some breast tissue from the lateral portion of the breast and deep portion of the pedicle. The additional specimens were then handed off.  The right breast specimen total weighed 822 grams and the left breast specimen total weighed 745 grams.    We irrigated the wounds and ensured hemostasis.  We again tailor tacked the skin closed with staples.  We sat the patient up again and were satisfied with volume, shape and symmetry of the breasts.   We selected symmetrical locations near the top of the vertical limb of the incision to place the nipples in appropriate positions and outlined this with a 42 mm cookie cutter.  We then began to close the incisions.  The horizontal limb was closed with 2-0 pds in the sfs system, 3-0 monocryl in the deep dermis, and a 3-0  V lok in the dermis.  The vertical limb was closed with 3-0 monocryl deep dermis, and 4-0 monocryl subcuticular sutures.  The nipple was closed with 3-0 monocryl deep dermal sutures and 4-0 monocryl running subcuticular.   The wounds were dressed with steri strips and exo fin glue.  The patient was moved to a gurney and a padded compressive bra was applied.   The patient was extubated and taken to the pacu in a 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...\\
+Attending Pearls (Learning points/Pimp Questions):\\
+</WRAP>
+</WRAP>
+==== MTF Breast Augmentation ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+The patient was seen in the preoperative holding area. The procedure and risks, as listed above, and benefits were again discussed in detail. Preoperative markings were made with the patient in erect position. The planned incision, implant type, location and approximate size were again confirmed with the patient, who understood and agreed with the operative plan. The patient was then taken to the operative suite and placed in supine position. All bony prominences were padded. SCD boots were placed. Arms were placed in 90 degrees of abduction. Perioperative antibiotics were given. A proper timeout was taken, which all present parties were in agreement. General endotracheal anesthesia was administered. The patient was prepped and draped in the usual sterile fashion.
+Breasts were dissected simultaneously. An incision was made in the inframammary fold, approximately 6cm inferior from the nipple about 5 cm in length. A plane above the pectoralis muscle was dissected using electrocautery and blunt dissection. This was carried around medially, superiorly and laterally to the preoperative markings of the breast base. Visual and manual inspection of the pocket was performed to ensure a smooth contour, as well as hemostasis. The pocket was irrigated with saline and a 285 mL breast implant sizer was placed into the newly created pocket. This was deemed too large for her frame and a 225ml sizer was placed. This appeared more appropriate to the size the appearance the patient had indicated she wanted. The incisions were temporarily closed with staples and on visual inspection, the sizer seemed to be in a good position and was anatomically pleasing. Final corrections were performed to correct any asymmetry or under-dissection. The patient's incisions were then opened again and hemostasis ensured. The pocket was irrigated with triple antibiotic and the area around the incision re-prepped with betadine and fresh towels. Every instrument from this point on was dipped in betadine prior to being placed in the cavity.
+The silicone prosthesis was then opened and bathed in antibiotic solution. The implant was confirmed to be the correct one selected and then inserted into the pre-pectoral space in a minimal touch technique using a funnel. The inferior mammary fold was re-established using 3-0 PDS. The wounds were then closed using interrupted fascial 3-0 PDS, deep dermal interrupted 3-0 Monocryl and a running 4-0 Monocryl. The incisions were then dressed with Steri-Strips followed by Telfa and Tegaderm. Large foam tape was used to secure the breast in appropriate position. Final dressing consisted of a surgical compression bra, which was placed on the patient. The patient was turned over to the anesthesia team and was awakened easily. Overall the patient tolerated the procedure well.
+</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>
+==== C-V Nipple Recon ====
+<WRAP group>
+<WRAP half column>
+Operative Report
+The patient was taken to the the operating room and following patient and procedure confirmation, anesthesia was started. A pre-operative time-out was performed for our portion of the procedure, confirming site, laterality, patient and procedure to be performed. The patient was then re-prepped and draped.
+Nipple reconstruction was performed using C-V flaps that were marked pre-operatively with the patient standing. The procedure as below, was performed for each breast. An incision was made using a 15-blade along the C-V flap marking. The flap was elevated using a knife. The V components of the flap were then turned inward to create the projected portion of the nipple. These were secured in place using 5-0 Chromic. The C component of the flap was then turned downward to construct the roof of the new nipple. This was secured using 5-0 Chromic suture.
+The limbs of the nipple incisions were dressed with steri-strips and Exofin. Bacitracin was applied to each nipple projection. Once the Exofin was dry, nipple guards were secured in place using 4x4 gauze and Tegederms.
+</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>
 ==== FTM Mastectomy ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
 The patient was marked in the pre-operative area and the patient was brought back to the operative suite, placed in supine position.  All bony prominences were padded.  SCD boots were placed. Perioperative antibiotics were given.  A proper timeout was taken, which all present parties were in agreement.  The preoperative markings were reinforced and remarked.
@@ Line 266: / Line 1005: @@
 All counts were correct. Dr. Malliaris was present for the entirety of the case.  The patient had pectoralis nerve block performed by anesthesia. The patient was then subsequently extubated and brought to the PACU in stable condition and was discharged home with outpatient followup.
-Post-Operative Plan:
+</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 Plan:
 PACU discharge
 Compression vest
 Okay to remove outer dressings in 2 days and shower
 Keep bolster in place
+Learning points/Pimp Questions:\\
+</WRAP>
+</WRAP>
+==== Acell Placement ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+.  Irrigation of left lower extremity wound\\
+. Excisional debridement of skin and subcutaneous tissue of left lower extremity wound using scissors/adson forceps and bovie electrocautery 15x15cm + 20x4cm total area of debridement.\\
+. Application of Acell micromatrix powder and 3-layer wound matrix covering wound 1225 cm squared.\\
+. Application of negative pressure wound therapy, 1225 cm squared.\\
+INDICATIONS FOR PROCEDURE: The patient is a 24 year old woman with traumatic left lower extremity Morel-Lavallee lesion that has undergone prior washouts and debridements with the trauma surgery team. Plastic Surgery was consulted to assist in closure given the extent of the wound. Based on the size, we recommended application of Acell. The details of the procedure including risks and benefits were discussed with the patient. She voiced understanding and agreed with the plan. Written and verbal consent was obtained.\\
+ \\
+DESCRIPTION OF PROCEDURE: The patient was transported to Operating Room #4 and placed supine on the table with pressure points appropriately padded. A pre-anesthesia time-out was performed. The patient was administered general anesthesia without complication. Pre-operative antibiotic prophylaxis was administered. The left leg was elevated using a candy cane. The wound vac was removed in its entirety. The surgical field was prepped and draped in the usual sterile fashion. A final time-out was performed.\\
+ \\
+The wound was sharply debrided of necrotic subcutaneous tissue including fat at the anterior medial aspect of the distal thigh and skin/subcutaneous tissue at the anterior lateral aspect of the proximal lower leg. The areas of excisional debridement were 15x15cm and 20x4cm, respectively. Adson forceps/scissors as well as bovie electrocautery were used for the excisional debridement. The remainder of the wound was mechanically debrided with a laparotomy pad and with the back end of the forceps. The wound was thoroughly irrigated with 3L and adequate hemostasis was obtained. Three 15 French round fluted Blake drains were placed under the skin flaps-- two at the superior aspect, medially and laterally, and one at the inferior aspect. The drains were sutured in place with 2-0 Nylon and attached to drainage bulbs. There was undermining at the lateral aspect of the wound superiorly and inferiorly. The skin flaps were tacked down to the wound bed with 3-0 Vicryl sutures. The wound in its entirety now measured 1225 sq cm.\\
+ \\
+At this time, Acell micromatrix powder was mixed with normal saline into a paste. The paste was applied to the entire wound bed, ensuring application into the undermined areas as well. The Acell wound matrix sheets were laid over the paste and stapled in place. Adaptic was then laid over the Acell sheets and also stapled in place. Black sponge negative pressure wound therapy was applied to the wound with two "lily pad" suction sites attached with a Y-connector to the vac device. Adequate seal was noted on 125 mmHg suction. The drain sites were dressed with BioPatches and Tegederm.\\
+</WRAP>
+<WRAP half column>
+Photos\\
+{{:resident:img_5551.jpg?400|}}
+{{:resident:img_5552.jpg?400|}}
+{{:resident:img_5553.jpg?400|}}
+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>
+==== Sub-pectoral Tissue Expander ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Bilateral Pectoral Block by Regional Anesthesia Team followed by Mastectomies\\
+. Bilateral subpectoral tissue expander placement with AlloDerm sling for breast reconstruction.\\
+\\
+The patient was brought to the operating room. Surgical pause was performed in accordance with hospital regulations. Anesthesia was administered and bilateral PEC blocks were placed. Bony prominences were padded and the entire chestand upper abdomen were prepped and draped in the usual sterile fashion as well as the arms were secured to the arm board and prepped in the usual fashion as well.\\
+\\
+Breast team commenced with their portion of the operation, please see the separate dictation for this.\\
+\\
+The breast team had completed the mastectomy and the mastectomy flaps weighed. We began with inspecting the pocket and ensuring excellent hemostasis. We then proceeded to elevate the pectoralis major from the pectoralis minor and serratus. This was done in a relatively avascular plane and there was minimal bleeding. We closed a portion of the lateral side of the breast using interrupted 3-0 PDS sutures. We then measured the area under the muscle to determine optimal tissue expander size. Her base width was measured bilterally. We then identified the IMF and placed a pre-cut, pre-pie-crusted appropriately sized piece of alloderm at this position using a running 3-0 PDS suture. A 15fr drain was placed and secured out the lateral IMF. We then irrigated and again ensured excellent hemostasis. The breast pocket was then irrigated using triple antibiotic solution. We used betadine to re-prep the chest wall skin. Using provided needle the air was removed from the tissue expanders and they were filled with 100cc of normal saline colored slightly with methylene blue. All providers then changed gloves. The tissue expanders were soaked in triple antibiotic and then placed into the chest with minimal touching. At least 4 tabs were sutured into place with 3-0 PDS. Then the alloderm was closed to the pectoralis major using a running 3-0 PDS. The incisions were closed using 3-0 and 4-0 monocryl and dressed with steri strips with telfa and tegaderm. A compression vest was placed.
+</WRAP>
+<WRAP half column>
+Photos\\
+{{:resident:screen_shot_2021-08-02_at_4.06.02_pm.png?600|}}
+Tourniquet: none\\
+Drain: 15Fr drain\\
+Sutures: TE Tabs with 3-0 PDS, Skin with 3-0/4-0 monocryl\\
+Dressing: Doesn't like exophin d/t reactions. Steri, telfa, tegaderm\\
+Anatomy: \\
+Breast Blood Supply:
+  - Perforating branches of internal mammary artery  Lateral thoracic artery
+  - Thoracodorsal artery
+  - Intercostal perforators
+  - Thoracoacromial artery
+  - Venous drainage mirrors arterial supply and predominantly to the axilla
+\\
+Know the "Breast footprint" vs anatomical borders for surgical resection.\\
+\\
+The pectoralis major muscle has sternocostal, costal, and abdominal origins and inserts on to the proximal humerus. It is a type V muscle, with a dominant arterial pedicle from the thoracoacromial trunk and multiple secondary arterial sources from parasternal perforators.\\
+\\
+Post-Operative Plan: \\
+Can dc home or stay the night; admit to breast team\\
+Ancef x3 doses while in house, keflex on discharge for 10 days or until drains removed.\\
+Continuous wearing of Compression Bra except while showering\\
+\\
+Learning points/Pimp Questions:\\
+  * The NAC is innervated by the anterolateral branch of the fourth intercostal nerve.
+  * Supernumerary nipples and breasts can occur anywhere along the milk line from the axilla to the groin.
+  * Attenuation of Cooper’s ligaments leads to ptosis and increased breast mobility.
+  * The IMF is an important structure to preserve. Violation can be difficult to correct.
+  * Injury to the intercostobrachial nerve results in paresthesias or anesthesia of the upper medial arm.
+  * Perfect symmetry is rare.
+  * Medial cleavage is difficult to create if it does not exist in the native breast.
+</WRAP>
+</WRAP>
+==== Pre-Pectoral Tissue Expander Placement ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Bilateral Pectoral Block by Regional Anesthesia Team followed by Mastectomies\\
+. Bilateral pre-pectoral tissue expander placement with AlloDerm sling for breast reconstruction.\\
+. Use of the endoscope indocyanine green angiography for assessment of flap perfusion.\\
+\\
+The patient was brought to the operating room. Surgical pause was performed in accordance with hospital regulations. Anesthesia was administered and bilateral PEC blocks were placed. Bony prominences were padded and the entire chestand upper abdomen were prepped and draped in the usual sterile fashion as well as the arms were secured to the arm board and prepped in the usual fashion as well.\\
+\\
+Breast team commenced with their portion of the operation, please see the separate dictation for this.\\
+\\
+Once the sentinel lymph node and bilateral mastectomies were performed, we commenced our portion of the operation. The right breast specimen was approximately 602 grams and the left breast was approximately 498 grams. We irrigated both pockets with copious sterile saline, ensured hemostasis, and assessed the skin flaps. We closed down the right breast lateral portion with 2-0 PDS interrupted sutures sequentially in order to recreate the anterior axillary line. We then repeated this in the left breast pocket, again with a 2-0 PDS. The IMF was still for the most part intact.\\
+\\
+On the skin flaps there was some subcutaneous tissue over most with just a couple areas that were fairly thin. We opened a sizer of 560 mL implant and a 520 mL implant, and used the sizers in the pockets.  We injected 3 mL of the indocyanine green dye and used the Vision sense scope laser in order to assess the perfusion. There were some small darker areas, but for the most part, the flaps superiorly and inferiorly were perfused well. On the left side, there was a portion of the middle of the incision inferiorly and on the right side, there was a portion superiorly centrally over the incision that seems a little dark.\\
+\\
+At this point, we elected not to proceed with a direct implant, but rather to use a tissue expander only filled part of the way, but still placed this prepectorally and used the AlloDerm sling. We chose 2 pieces of AlloDerm for each side. These were opened and sewn together with 3-0 PDS. We then inset the AlloDerm along the IMF of the right breast pocket using 2-0 PDS a leaving a centimeter cuff on the chest wall. We repeated this on the left side as well, using 0 PDS, leaving a 1 cm cuff when insetting this AlloDerm along the IMF.\\
+\\
+The chosen tissue expanders were the 133SX-14-T 600 mL. I evacuated the air and then put in 350 mL of methylene blue injectable saline to each expander. This was done with clean gloves in the minimal touch technique. I started with the left side, irrigated with copious antibiotic saline.\\
+\\
+We placed 2 drains, inferolaterally, 15 round fluted Blake drains. These were both secured with 2-0 nylon.\\
+\\
+We then prepped the skin with Betadine and the operative team changed gloves. We placed the expander underneath the AlloDerm, used the suture tabs to fix the expander to the muscle wall, and then used the 2-0 PDS to affix the AlloDerm around the implant circumferentially. There was a snug fit. A small amount of trimming was performed to achieve this and remove the redundancy. More irrigation with antibiotic saline was performed plus more Betadine, and the skin was closed with interrupted 3-0 Monocryl followed by running 4-0 Monocryl. The drains were placed to bulb suction. We repeated this on the right side: We irrigated with copious antibiotic saline, placed two 15 fluted round JP Blake drains out inferolaterally, and secured using 2-0 nylon. Using the minimal touch technique and change of gloves, we prepped with Betadine, and then placed the tissue expander on the right side. This was again affixed to the muscle and chest wall using 2-0 PDS and then the AlloDerm was trimmed and tailor tacked and affixed with 2-0 PDS as well for appropriate coverage. We used the final antibiotic saline and Betadine, and closed the skin again with 3-0 Monocryl and 4-0 running Monocryl. The drains were placed to bulb suction. All drains were holding excellent suction.\\
+\\
+The area was cleaned and Exofin glue was placed in each incision. We then placed a Telfa over the incisions followed by ABD pads and a surgical bra. The patient was awoken and transferred to the recovery room in stable condition. There were no apparent complications. She will be admitted for pain control. She will receive IV Ancef. The drains will be emptied and monitored. We will continue postoperative antibiotics for 10 days or until the drains come out.
+</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>
+==== Abdominoplasty/Panniculectomy ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Panniculectomy with umbilical transposition\\
+\\
+The patient was marked in the pre-operative bay. The inferior incision was marked as well as midline. The patient was taken to the the operating room and secured with all bony prominences padded and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed. We began by incising around the umbilicus with an 11 blade. The dissection was continued with tenotomy scissors on a generous stalk. We then turned our attention to the inferior incision and made the incision with a ten blade. This was carried down through scarpa's fascia down to the abdominal fascia using electrocautery. The pannus was then elevated in a suprafascial plane to the costal margin/xiphoid. We did take care to leave a layer of fat over the ASIS. A lockwood abdominal demarcator was then used to determine the extent of superior skin that we could excise. This was marked.  We then made this superior skin incision with a ten blade and carried it down through the subcutaneous tissues.  The pannus was now free and handed off as a specimen.  It weighed 1300 grams.  The wound was irrigated and we were meticulous in ensuring hemostasis.  We then placed 2 drains in the subcutaneous space and secured them with 2-0 nylon sutures.  We then closed the SFS system with 2-0 vicryl sutures.  We closed the deep dermis with 3-0 monocryl interrupted sutures.  The skin was the closed with a 3-0 v-lok suture.\\
+\\
+Markings for placement of the umbilicus were made at the level of the ASIS. A 1x2cm incision oval with an inferior chevron was made. The skin was excised with an 11 blade and the subcutaneous tissue defatted. The umbilicus was brought to the surface and sutured in place with 3-0 monocryl deep dermal sutures. Surgical glue was then placed over the incisions. The drains were dressed with biopatches and tega derm.  The incision was dressed with telfa and tegaderm.\\
+\\
+The patient was then awakened and transferred to the gurney.  An abdominal binder with abd pads was applied.
+</WRAP>
+<WRAP half column>
+Photos\\
+Drain: 15 french drains x2 secured with 2-0 nylon\\
+Sutures: SFS 2-0 vicryl, 3-0 monocryl deep dermals and 3-0 v-lok\\
+Dressing: Surgical Glue, ABDs, Compression Binder\\
+Anatomy: Pertinent anatomy should be listed\\Post-operative care: Include restrictions, splints, etc...\\
+Learning points/Pimp Questions: The markings in pre-op while upright are very important. It's hard to redo them once on the table supine.\\
+Post op restrictions:\\
+Keep slightly bent at hips\\
+Walk regularly but no strenuous activity\\
+Wear binder at all times\\
+Monitor and record drain output daily.\\
+</WRAP>
+</WRAP>
+==== Mangled Hand ====
+<WRAP group>
+<WRAP half column>
+PREOPERATIVE DIAGNOSES:\\
+. Right mangled hand, crush injury
+\\
+POSTOPERATIVE DIAGNOSES:\\
+. Right mangled hand, crush injury involving: index finger, long finger, ring finger, small finger, palm, dorsum of hand
+. Zone 2 crush injury, multilevel degloving, avulsion, extensive soft tissue damage, dorsal and volar to index finger, long finger, ring finger, small finger, palm, dorsum of hand (Zone VI), with near complete amputation of index finger, long finger, ring finger, small finger
+\\
+Operative Report:\\
+PROCEDURES PERFORMED:\\
+. Evaluation of right mangled hand, crush injury under anesthesia
+. Revision amputation of the right index finger at the level of the mid-proximal phalanx, with radial-based V-Y closure
+. Revision amputation of the right long finger at the level of the mid-proximal phalanx, with radial-based V-Y closure
+. Revision amputation of the right ring finger at the level of proximal phalanx, with ulnar-based V-Y closure
+. Revision amputation of the small finger just distal to the MCP joint (base of proximal phalanx preserved), with ulnar-based V-Y closure\\
+\\
+The patient was transported to Operating Room #10 and placed supine on the table with pressure points appropriately padded. A pre-anesthesia time-out was performed. The patient was administered anesthesia without complication. Pre-operative antibiotic prophylaxis was administered - Ancef (tetanus status was verified in the ER). The surgical field was prepped and draped in the usual sterile fashion. A final time-out was performed. Anti-embolic compression devices were placed on bilateral lower extremities prior to induction. A Foley catheter was placed and removed at the end of the case.
+A sterile upper extremity tourniquet was placed and the fingers were gently wrapped and the right upper extremity was elevated and exsanguinated with an Esmarch, and the tourniquet was inflated to 250 mmHg.
+We began the procedure by evaluating the full extent of her injuries and the viability of the tissues.
+RIGHT HAND:
+INDEX FINGER: The index finger was found to have a near complete, circumferential degloving of the finger tissue in Zone 2, with a small radial-based soft tissue bridge. The flexor tendons were intact, however, there was injury to the central slip, the extensor tendon, and radial and ulnar neurovascular bundles. There was multi-level crush injury, most severe distally, with displaced, open fracture of P1. Due to the extent of the crush injury, at multiple levels, with poor viability of the soft tissue, and open fracture, it was determined that this would benefit from a revision amputation, with attempt to salvage as much of the surrounding soft tissue, as possible. The neurovascular bundle on the radial side of the digit was therefore carefully preserved, with dissection through Cleland's and Grayson's ligaments and used to create a radial-based soft tissue flap for coverage of the amputation site. The periosteum was cleared to the level of proposed amputation, at the mid-proximal phalanx, taking care to preserve the remainder of the surrounding soft tissue and periosteum. The neurovascular bundles were isolated proximally, the nerves were ligated with crush and Bipolar cautery and allowed to retract, and the vessels were ligated with bipolar cautery. The bone was then transected with a reciprocating saw, filed down with a rasp until smooth, and the wound was closed with the radial-based soft tissue flap with 4-0 simple interrupted Nylon sutures.\\
+(Each finger was evaluated/procedure described, as above)\\
+All amputated digits and debrided tissue was sent to pathology, as specimen. The palm was also found to have vertical lacerations extending into Zone 3, with exposed, but intact A1 pulley over the long and ring fingers. The A2 pulley was avulsed on the long, ring, and small fingers. The dorsum of the hand also had puncture wounds over Zone VI, which was inspected and were irrigated thoroughly. A total of 9L of NS was used to irrigate the wounds prior to closure. There were no foreign bodies noted.\\
+The patient had a postoperative supraclavicular block by the anesthesiology team. Please see separate documentation for additional details.\\
+The patient was awoken from anesthesia and transferred to the PACU in good condition with no apparent complications.\\
+</WRAP>
+<WRAP half column>
+Photos:\\
+{{:resident:4b81ee93-a538-4d73-bcdd-69a7f7676f47.jpeg?400|}}
+{{:resident:6ee38d74-ded0-442b-9d3d-e291b915236c.jpeg?400|}}
+{{:resident:38f5db49-24b7-4ad6-bb5c-a97a2bc796da.jpeg?400|}}
+{{:resident:80cb6adc-ba8a-44a4-a6a9-1714c1b519da.jpeg?400|}}
+{{:resident:93b3cbfc-8cfc-487b-94d1-de3a6be9073f.jpeg?400|}}
+{{:resident:321b5b0e-52a1-455c-87f1-524467fa4591.jpeg?400|}}
+{{:resident:d04fca21-4ab8-4f25-ad14-7c6a999f56d9.jpeg?400|}}
+{{:resident:e580c06a-109d-4d2f-8eb0-69d988c0e945.jpeg?400|}}
+{{:resident:5824e227-8a11-4c27-9a54-c326aa016e0a.jpeg?400|}}
+{{:resident:ab12daaf-2171-4544-9196-6f1552e06f49.jpeg?400|}}
+{{:resident:e7ad6d9e-0024-4fb6-a46f-50628a4ea198.jpeg?400|}}
+{{:resident:ee4de1aa-f0c6-4bbd-87b3-790027a514c9.jpeg?400|}}
+\\
+Tourniquet: Forearm / arm\\
+Drain: None\\
+Sutures: 4-0 Nylon simple interrupted\\
+Dressing: Adaptic with bacitracin ointment over all suture lines, 4x4 gauze, Webril, bulky Jones, bias\\
+Anatomy: Flexor/extensor zones of injury\\
+Post-operative care: Gentle graduated compression with the bulky Jones/bias placement. Maintain dressings until postoperative appointment in clinic. There is an orthopedic psychology team at Denver Health that specifically cares for patients that are at high risk for PTSD after injury/amputees. Consult should be placed while inpatient and the patient should be seen prior to discharge.\\
+Attending Pearls (Learning points/Pimp Questions): Assess viability of tissue and then assess structure-by-structure or spare parts. Bony fixation/amputation first, then tendons, neurovascular structures, then soft tissue closure.\\
+</WRAP>
+</WRAP>