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--- resident:stephanie_malliaris [2021/02/08 20:07] – michael
+++ 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 - \\
+Denver Health - 2015 - Forever \\
 [[https://drive.google.com/drive/folders/13OAdYirQWQssfwj0gS8XHlykjXFoTq-a?usp=sharing|Dr. Malliaris Publications]]
@@ Line 14: / Line 14: @@
 \\
 ===== Hand =====
+==== 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 ====
@@ Line 43: / Line 142: @@
 </WRAP>
 </WRAP>
 ==== Dequervain's Release ====
@@ Line 79: / Line 180: @@
 </WRAP>
-==== Dequervain's Release ====
+==== 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.
-Operative Report:\\
+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.
-. 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.
+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.
-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.
+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>
-Photos\\
+Operative Photos\\
+{{ :resident:img_7965.jpg?200 |}}
-Tourniquet: Sterile forearm tourniquet\\
+{{ :resident:img_7966.jpg?200 |}}
-Drain: None\\
+{{ :resident:img_7967.jpg?200 |}}
-Sutures: 4-0 nylon locking horizontal mattress\\
+{{ :resident:img_7968.jpg?200 |}}
-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\\
+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 plaster splint used to rest thumb\\
+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.\\
-Attending Pearls (Learning points/Pimp Questions):\\
+Initiate an early active and active-assisted ROM program.\\
-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.\\
+\\
+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 ====
+==== Palmar Fasciectomy ====
 <WRAP group>
@@ Line 143: / Line 271: @@
 </WRAP>
 </WRAP>
+***
 ==== A1 Trigger Finger Release ====
@@ Line 496: / Line 625: @@
 Photos\\
+{{:resident:screen_shot_2021-08-02_at_3.56.00_pm.png?600|}}
 Tourniquet: forearm\\
@@ Line 661: / Line 792: @@
 Photos\\
+{{:resident:screen_shot_2021-08-02_at_4.23.58_pm.png?600|}}
 Tourniquet: Forearm tourniquet\\
@@ Line 667: / Line 799: @@
 Dressing: xeroform, 4x4 gauze, well padded radial gutter plaster splint\\
-Anatomy: Pertinent anatomy should be listed\\
+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: Include restrictions, splints, etc...\\
+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|}}
@@ Line 948: / Line 1090: @@
 Photos\\
+{{:resident:screen_shot_2021-08-02_at_4.06.02_pm.png?600|}}
-Tourniquet: finger / forearm / arm\\
+Tourniquet: none\\
 Drain: 15Fr drain\\
-Sutures: 3-0 PDS, 3-0/4-0 monocryl\\
+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: Pertinent anatomy should be listed\\
+Anatomy: \\
+Breast Blood Supply:
-Post-Operative Plan:
+  - 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>
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 </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>