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--- resident:stephanie_malliaris [2020/08/09 11:39] – [Introduction] jonathan
+++ resident:stephanie_malliaris [2021/08/19 13:13] (current) – taylor
@@ Line 4: / Line 4: @@
 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 =====
-==== ORIF Scaphoid, Volar Approach ====
+==== 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.
-Operative Report
+PROCEDURES:
-.ORIF left scaphoid nonunion with autograft harvested from volar distal radius cortex and headless cannulated 3.0mm Synthes screw
+.  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.
-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>
-The arm was elevated and exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg.
+<WRAP half column>
+Irrigation with Irrisept 500mL
-A volar approach to the wrist was made over the flexor carpi radialis with extension radially at the proximal wrist crease to avoid the palmar cutaneous nerve. The sheath overlying the flexor carpi radialis (FCR) was incised and the tendon was retracted ulnarly. The deep sheath was then incised and the tendons were retracted ulnarly. The joint capsule over the scaphoid was palpated and the position was confirmed by fluoroscopy. The joint capsule/ligaments were incised to reveal the scaphoid non-union. The fracture was opened with the freer and dental pick. Two 0.062 in k-wires were placed as joysticks in the proximal and distal scaphoid fragments. The nonunion was excised using the dental pick, rongeur and osteotome to fresh bone edges.
+Tourniquet: Sterile; arm
-Attention was turned to the volar distal radius. Pronator quadratus was elevated. A 0.045" K wire was used to outline the graft in the volar cortex of the distal radius metaphysis. An osteotome was then used to excise the bone graft. Curette was then used to obtain more cancellous autograft. The graft was set aside. Cancellous bone chips were packed into the donor defect site and the pronator quadratus was repaired with 4-0 vicryl sutures.
+Drain: None
-Attention was returned to the scaphoid. Copious irrigation was performed to ensure that all edges of the proximal and distal aspect of the scaphoid as well as the cancellous portion of the scaphoid was completely debrided. The scaphoid was reduced using the k-wire joysticks, opening the humpback deformity. A guidewire for the 3.0mm Synthes cannulated headless screw was then placed from distal through the distal portion of the scaphoid, across the defect, into the proximal end. Fluoroscopy was used to confirm placement. A Kocher clamp was used to hold the joysticks in reduction. The guidwire was then withdrawn into the distal portion. The autograft from the distal radius was then packed into portion of the scaphoid nonunion, starting with the cancellous bone and then wedging in the corticocancellous graft. This was packed with a combination of a Freer as well as a tamp and gentle mallet.
+Sutures:
-The guidewire was then advanced to the proximal scaphoid. Position of the guidewire was confirmed with fluoroscopy, and then a second de-rotational guidewire was placed. The guidewire was measured and was overdrilled and a 22mm 3.0mm Synthes headless compression screw was placed over the guidewire. This was carefully advanced and some compression was applied, taking care to not extrude the graft. Fluoroscopy confirmed good placement of the screw down the axis of the scaphoid and the guidewires and joy-stick k-wires removed.
+- Skin: 4-0 nylon
+- FDP zone 2: modified Kessler with 3-0 Supramid, epitendinous with 6-0 Prolene
-The joint capsule was closed with 3-0 vicryl sutures. At this point the tourniquet was let down and hemostasis was obtained. The incision was irrigated. The skin was closed with 4-0 nylon horizontal mattress sutures. The incision was dressed with xeroforom, 4x8 gauze and cast padding followed by a thumb spica splint.
+- 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>
@@ Line 45: / Line 136: @@
 Anatomy: Pertinent anatomy should be listed\\
-Post-operative care: - discharge to home with some pain medication; elevate; NWB L arm.\\
+Post-operative care: Include restrictions, splints, etc...\\
-- F/U hand clinic 10-14 days for suture removal and thumb spica cast placement.\\
-- Cast x 6 weeks and then remove for re-evaluation.\\
-Learning points/Pimp Questions:\\
+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 ====
@@ Line 247: / Line 467: @@
 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>
@@ Line 383: / Line 607: @@
 </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>
 ====Abdominally based random pattern skin flap====
@@ Line 435: / Line 728: @@
 </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 =====
@@ Line 476: / Line 860: @@
 </WRAP>
 </WRAP>
-==== Breast Reduction ====
+==== Breast Reduction (Inferior Pedicle)====
 <WRAP group>
@@ Line 506: / Line 890: @@
 </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 ====
@@ Line 655: / Line 1070: @@
 </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>