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resident:stephanie_malliaris [2021/02/14 19:49] – krystleresident:stephanie_malliaris [2021/08/19 13:13] (current) – taylor
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 Integrated Plastic Surgery at Weill Cornell - 2007-2014\\ Integrated Plastic Surgery at Weill Cornell - 2007-2014\\
 Fellowship in Hand at Hospital for Special Surgery (HSS) - 2015\\ 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]] [[https://drive.google.com/drive/folders/13OAdYirQWQssfwj0gS8XHlykjXFoTq-a?usp=sharing|Dr. Malliaris Publications]]
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 \\ \\
 ===== Hand ===== ===== Hand =====
 +
 +==== Flexor Tendon Repair (Zones 1 and 2) ====
 +
 +<WRAP group>
 +<WRAP half column>
 +POSTOPERATIVE DIAGNOSES:
 +1.  Crush injury to hand.
 +2.  Complete transection of the flexor digitorum profundus, zone 2, right long 
 +finger.
 +3.  One slip, complete transection of flexor digitorum superficialis, zone 2 to 
 +right long finger.
 +4.  A 90% transection FDP to index finger, zone 1.
 +5.  Laceration to ring finger and small finger volar aspect.
 +
 +PROCEDURES:
 +1.  Washout and excisional debridement of crush wound to right hand index finger, 
 +long, ring, and small fingers.
 +2.  Repair of FDP tendon, right long finger, zone 2.
 +3.  Repair of FDP tendon in zone 1, right index finger.
 +4.  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
 +2-0 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 ==== ==== Metacarpal Nail ====
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 <WRAP group> <WRAP group>
 <WRAP half column> <WRAP half column>
 +Procedure:\\ 
 +1. 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 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.
  
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 Images include dissection down to the malunion, wedge design, more appropriate alignment after wedge resection and lastly plate fixation.\\ Images include dissection down to the malunion, wedge design, more appropriate alignment after wedge resection and lastly plate fixation.\\
 \\ \\
-Hot Tips:\\+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.\\ 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.\\ 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>
 </WRAP> </WRAP>
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 Photos\\ Photos\\
 +{{:resident:screen_shot_2021-08-02_at_3.56.00_pm.png?600|}}
 +
  
 Tourniquet: forearm\\ Tourniquet: forearm\\
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 Photos\\ Photos\\
 +{{:resident:screen_shot_2021-08-02_at_4.23.58_pm.png?600|}}
  
 Tourniquet: Forearm tourniquet\\ Tourniquet: Forearm tourniquet\\
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 Dressing: xeroform, 4x4 gauze, well padded radial gutter plaster splint\\ 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:\\ 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|}} {{:resident:screen_shot_2021-02-02_at_10.54.28_pm.png|}}
  
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 Photos\\ Photos\\
 +{{:resident:screen_shot_2021-08-02_at_4.06.02_pm.png?600|}}
  
-Tourniquet: finger / forearm / arm\\+Tourniquet: none\\
 Drain: 15Fr drain\\ 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\\ 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\\ 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.\\ Ancef x3 doses while in house, keflex on discharge for 10 days or until drains removed.\\
 Continuous wearing of Compression Bra except while showering\\ Continuous wearing of Compression Bra except while showering\\
 +\\
 Learning points/Pimp Questions:\\ 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>
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 <WRAP half column> <WRAP half column>
  
-Photos:+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|}}
 \\ \\
  
resident/stephanie_malliaris.1613350166.txt.gz · Last modified: 2021/02/14 19:49 by krystle
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