This is an old revision of the document!
Table of Contents
Dr. Iorio Introduction
- Bachelor of Arts - Cum Laude - University of Chicago - 1998-2002
- Doctor of Medicine - Magna Cum Laude - Georgetown University School of Medicine - 2003-2007
- Intern - Plastic Surgery - Georgetown University (2007-2008)
- Resident - Plastic Surgery - Georgetown University (2008-2013)
- Fellow - Hand and Micro-vascular Surgery - University of Washington (2013-2014)
General Dressing: adaptic, 4×4, kerlix, 2 inch ace
REMOVE STAPLES FOR HEMATOMA AT BEDSIDE. Save the flap.
Cubital Tunnel
Close: Deep dermal, running subQ. Dressing: adaptic, 4×4, webroll, ace. Off on POD#5.
What are the areas of ulnar nerve compression? Remember wrist What vessel runs with ulnar nerve in elbow? ??Superior ulnar collateral
Dupuytren's
Know the cords. Reviewed z-plasty. Measure out. All lengths should be equal. Measure angle by other side of triangle
Thumb Finger
Remember that FPL tendon is coming around thenar muscles. Hold hand in almost an intrinsic plus position with finger tips pointed to ceiling. The A1 pulley is posterior to thenar area in this position. Incision should NOT be over thenar prominence. If so, you are too far radial/anterior. Know what muscles attach to A1 and oblique pulley. Know innervation of thenar musculature
Completion Amputation
2 ovals, cut out the middle and then sew together
Post - Op Protocol
Post-Surgery Time
Immediate Post Op Orders
Goals:
- OFF work x 2 days
- Elevate wrist above elbow x 2-3 days
- Finger and motion and typing as tolerated
- Remove dressing at POD 5
Work Restrictions
- 2-3 days post op: OFF work
- 0-2 weeks: 5-10 lb. lifting limit, no pushing or pulling
- 2-4 week: <20 lbs., then no restrictions
10-14 Days Post-surgery
- Schedule 1st post op visit with Physician Extender
- Wound Check
- Suture Removal
- Range of motion and edema control
- OT PRN
OT (if ordered beyond PE duties on 1st post op visit)
- 2-4 weeks post op
Finger and wrist ROM, scar massage
- 4+ weeks post op
Scar desensitization/massage
Putty use
Strengthening and ROM as tolerated
6-8 weeks
- Second follow up visit (schedule with MD/PA) ONLY IF NEEDED
Carpal Tunnel Release
Any patient with more than 1 elective procedure (trigger and CTR, multiple triggers, etc.…) needs a first postop visit with hand therapy between 5-7 days. OR tips: Local w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon, xeroform/adaptiq, 4×4, webrill 2” ace.
CMC Arthroplasty
PRE-OP DIAGNOSIS: Right 1st CMC OA Right 1st MP hyperextension deformity
POST OP DIAGNOSIS (required): same
ESTIMATED BLOOD LOSS: 0-50mL
Procedure (preliminary CPT codes for reference): 1. Right 1st CMC arthroplasty 2. Right EPB tenodesis 3. Right MP joint capsulodesis
Indications: 69 y.o. female. presents with a painful right thumb and ongoing arthritis, with an MP extension deformity.
We discussed the nature and pathophysiology of the diagnosis. We discussed treatment options and expectations in regards to potential outcomes, including the needs for secondary procedures or revisions.
Consent was obtained by discussion with the patient in regards to the risks and benefits, including possible injury to nerve, vessel, tendon, the need for secondary or revision procedures and occupational therapy. The patient had adequate time for discussion, and all questions were answered prior to completing the consent.
Operative Procedure: The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.
The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg.
A longitudinal incision was made over the 1st CMC joint. The interval between the EPL and EPB was identified, and the tendons were freed from their associated sheaths. Following this, a capsulotomy into the 1st cmc was made. The trapezium was circumferentially dissected, and removed in piecemeal.
The FCR tendon was visualized at the base of the wound and freed distally. A counter incision over the volar forearm was made, and the FCR tendon was verified and transected. This was then brought into the wound.
A cannulated drill was utilized to make a bone tunnel in the 1st metacarpal base exiting at the volar ulnar corner to recreate the AOL ligament. The FCR tendon was then split, and one-half was brought through the bone tunnel.
The metacarpal was then placed on maximum longitudinal traction, and secured with a suture anchor. Both halves of the tendon were then imbricated upon themselves with 3-0 fiberwire. The capsule was closed tightly with 4-0 fiberwire. The skin was closed with deep dermal followed by a running monocryl.
Intraoperative fluoroscopy was utilized to verify position of the trapezium, complete excision of the trapezium, and then following closure to verify the stability of the arthroplasty against subsidence against axial compression. A 0.045 k wire was placed from the base of the 1st to the 2nd metacarpal and clipped deep to skin.
The EPB tendon was then identified and the MP joint was brought into flexion. The tendon was then tenodesed to the capsule and base of the metacarpal with 3-0 fiberwire to limit MP motion and extension.
A counter incision was made over the MP crease with a brunner incision. The ulnar digital nerve was identified and protected. The A1 pulley was released, and the volar plate was recessed. An anchor was placed at the base of the metacarpal head, and the joint was brought to flexion and the anchor tied down to the volar plate. The skin was then closed with 4-0 nylon.
A bulky dressing was applied. The tourniquet was released and the hand demonstrated good distal perfusion. The patient was awoken from anesthesia and transported to recovery in stable condition.
Tourniquet: well padded tourniquet was inflated to 250 mmHg.
Drain: No
Sutures: 4-0 nylon
Dressing: bulky dressing
OR tips: OR tips: Block w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 3-0/4-0 Monocryl, Dermabond, 4×4, Thumb spica plaster splint, webrill, 2” ace.
Post-Surgery Time
Immediate Post Op Orders
Goals:
- Keep splint/dressing intact until follow up
- Elevate until follow-up
- Move fingers as splint allows
- OFF work x 3-5 days post op
- POST OP PROTOCOL ORDERS
Work Restrictions
- 0-3 days: OFF work
- 0-2 weeks: Limited use of operative hand to tolerance
- 4-8 weeks: 3-5pound limit, light use of thumb
- 8-12 weeks, no weight limit
10-14 Days Post-surgery
- 1st follow up visit (Schedule with Physician Extender)
- Wound Check
- Suture Removal PRN (often does dissolvable sutures)
- Forearm based thumb spica cast
4 weeks
- 2nd post op follow up visit (Schedule with Physician Extender)
- Remove cast
- Transition to forearm based thumb spica zipper
- Order therapy to begin at 6 weeks post op
OT (start at 6 weeks)
- Begin OT at 6 weeks
- Gentle circumduction, flexion, extension, abduction, opposition, retroposition of thumb as well as AROM of wrist
- Desensitization
- May remove splint for exercises and showering/light activity
OT Progression (10 weeks)
- Wean from splint – use only for heavy activity
- Start light strengthening with putty
- Ok to have splint off in home/controlled environment, splint on when out in community.
- If no problems, d/c from OT to HEP
Cubital Tunnel Release without Transposition
Operating Report
PROCEDURE:
In situ decompression of ulnar nerve at the elbow
She was identified In the holding area and the operative site was marked. She was brought to the operating theatre in stable condition, placed on a regular table in supine position with right arm on an arm board. Preoperative timeout was taken to ensure the patient's identity, operative procedure, as well as the operative location. General anesthesia was administered. She received perioperative antibiotics. All bony prominences were well-padded. Her right arm was sterilely prepped and draped.
I began the procedure by making a longitudinal incision centered between his medial epicondyle and olecranon. I dissected through subcutaneous tissue and protected branches of the medial antebrachial cutaneous nerve. The ulnar nerve was identified just posterior to the medial intramuscular septum. The nerve was then decompressed through the cubital tunnel, as well as between the 2 heads of the FCU fascia. Complete decompression was ensured, both proximally and distally. Full elbow range of motion showed no subluxation and hemostasis was revised.
The wound was irrigated and skin closed using 4-0 Monocryl deep dermal and running subcuticular stitch.. Soft dressing was applied. She tolerated the procedure well. There were no complications. Marcaine 0.25% with 1% lidocaine and epinephrine was injected for postoperative anesthesia. She left the operating room in stable condition
Tourniquet: No
Drain: No
Sutures: Yes
Dressing: Yes
OR tips: OR tips: LMA. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon (sometimes 3-0/4-0 Monocryl), xeroform/adaptiq, 4×4, webrill 2” ace.
Post-Surgery Time
Immediate Post Op Orders
Goals:
- Remove dressing at POD 5
- May move fingers, wrist, and elbow as tolerated
- OFF work x 2-3 days post-op
Work Restrictions
- Limited use of operative extremity to tolerance
- 0-2/3 days: OFF work
- 0-3 weeks: May use arm as tolerated; 5lb weight restriction
- 3-4 weeks: 10-15lbs as tolerated
- >5 weeks: no restrictions
10-14 Days Post-surgery
- Schedule 1st post op visit with Physician Extender
- Wound Check
- Suture Removal
- Review HEP for strengthening
- OT Order (PRN)
OT (if ordered beyond PE duties on 1st post op visit)
- Scar massage, desensitization, strengthening
8 Weeks
- F/U PRN: If patient has concerns or ongoing symptoms, 2nd follow up visit scheduled with MD/PA
DeQuervain’s Release
OR tips: Local w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 3-0/4-0 Monocryl, dermabond, 4×4, webrill 2” ace.
Post-Surgery Time
Immediate Post Op Orders
Goals:
- Remove dressing at POD 5
- Elevate wrist x 3 days
- May move fingers as splint allows
- OFF work x 2 days post op
- Follow up 10-14 days post op
- POST OP PROTOCOL ORDERS
Work Restrictions
- 2-3 days post op: OFF work
- 0-2 weeks: OK light use for typing and paperwork
- 0-2 weeks: 5 pound lifting limit, no pushing or pulling
- 2-4 wk.: no restriction
10-14 Days Post-surgery
- Schedule 1st post op visit with Physician Extender
- Wound Check
- Suture Removal
- OT Order (PRN)
OT (if ordered beyond PE duties on 1st post op visit)
- ROM, Scar massage, desensitization
6-8 weeks
- FU PRN: If patient has concerns or ongoing symptoms, 2nd follow up visit scheduled with MD/PA
Distal Radius Fracture s/p ORIF
OR tips: Block w/ sedation; Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon, xeroform/adaptiq, 4×4, webrill, Short arm splint, 2” ace.
Post-Surgery Time
Immediate Post Op Orders
Goals:
- Keep splint/dressing intact until follow up
- Elevate wrist until follow up
- May move fingers as splint allows
- OFF work x 3-5 days post-op
- Follow-up 10-14 days post-op
- POST OP PROTOCOL ORDERS
Work Restrictions
- During casting period: No lifting, pushing or pulling more than 5 pounds in casted extremity.
10-14 Days Post-surgery
- 1st post-op visit
- X-rays (3 views of wrist)
- Wound Check
- Suture Removal
- Short arm cast
4 weeks
- Schedule 2nd post op visit with Physician Extender
- Transition to Delta splint at ~4 weeks
- Begin OT vs next visit TBD by MD
- Begin AROM of wrist once transitioned into splint (4 weeks)
- begin weaning splint while at home (i.e. May remove to for ADLS)
6-8 weeks
- 3rd follow up visit with physician/PA, transition to Delta
- Begin OT if not already.
12 weeks
- Final Physician visit
Dorsal/Volar Wrist Ganglion Excision
OR tips: Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 3-0/4-0 Monocryl, Dermabond, 4×4, webrill 2” ace. Send specimen for permanent. Sometimes will place short, short arm splint and have remove after 5 days.
Post-Surgery Time
Immediate Post Op Orders
Goals:
- Remove dressing at POD 5
- Elevate wrist x 5 days
- May move fingers as splint allows
- OFF work x 2-3 days post-op
- Follow-up 10-14 days post-op
- POST OP PROTOCOL ORDERS
Work Restrictions
- 0-3 days: OFF work
- 5 days-2 weeks: may use as tolerated; 5 lbs. weight restriction
- 3-6 weeks: full use
10-14 Days Post-surgery
- Schedule 1st post op visit with Physician Extender
- Wound Check
- Suture Removal
- Review HEP for ROM, scar management
- OT Order (PRN)
6-8 weeks
- F/U PRN: If patient has concerns or ongoing symptoms, 2nd follow up visit scheduled with MD/PA
Metacarpal Fractures s/p ORIF
OR tips: Block w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon (occasionally uses monocryl), xeroform/adaptiq, 4×4, Intinsic plus splint, webrill, 2” ace.
Post-Surgery Time
Immediate Post Op Orders
Goals:
- Keep splint/dressing intact until follow up
- Elevate wrist until follow-up
- May move fingers as splint allows
- OFF work x 3-5 days post-op
- Follow-up 10-14 days post-op
- POST OP PROTOCOL ORDERS
Work Restrictions
- During casting period: No lifting, pushing or pulling more than 5 pounds in casted extremity.
- For 2 wks. post cast removal: May lift, push, or pull up to 10 pounds with splint ON
- For 2-6 wks. post cast removal: May gradually increase weight-bearing as tolerated, with splint always on when lifting more than 10 pounds.
- May d/c splint at 6 wks. following cast removal
10-14 Days Post-surgery
- Schedule 1st post op visit with Physician Extender
- X-rays (3 view hand)
- Wound Check
- Suture Removal
- OT Order (PRN)
- Discussion with physician/PA to determine type of short arm cast or splint.
OT (if ordered beyond PE duties on 1st post op visit)
- If in splint – begin AROM, edema and scar management
4-6 weeks
- 2nd follow up visit scheduled with MD/PA
6 weeks
- begin OT for ROM
Trigger Finger Release
OR tips: Local w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon, xeroform/adaptiq, 4×4, webrill 2” ace.
Post-Surgery Time
Immediate Post Op Orders
Goals:
- OFF work x 2 days
- Remove dressing 5 days post op
- Apply Band-Aid
- Keep wound dry, no ointments
- Motion as tolerated to digits, wrist
- Follow up 10-14 days post op
- POST OP PROTOCOL ORDERS
Work Restrictions
- 2-3 days post op: OFF work
- 0-2 weeks: OK light use of hand for typing, paperwork, 5 pound lifting limit
- 3-4 weeks: No restrictions
10-14 Days Post-surgery
- Schedule 1st post op visit with Physician Extender
- Wound Check
- Suture Removal
- Review HEP for ROM and strengthening, scar management
- OT Order (PRN/if >1 TFR)
OT (if ordered beyond PE duties on 1st post op visit)
- ROM and strengthening
- Edema control
- Scar massage
6-8 weeks
- F/U PRN: If patient has concerns or ongoing symptoms, 2nd follow up visit scheduled with MD/PA
Operative Report
A1 Pulley Release
He was identified in the Holding Area, and the operative site was marked. He was brought into the operative theater in stable condition, with his arm on an arm board. Preoperative time-out was taken to ensure the patient's identity, operative procedure, as well as operative location.
The extremity was prepped and draped in sterile fashion. Local anesthesia was achieved with a mixture of 1% lidocaine and 0.5% marcaine. The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg.
An incision over the volar A1 pulley was made. Soft tissue was dissected, and the radial and ulnar neurovascular bundles were protected. The A1 pulley was released with a scalpel, and proximal and distal release confirmed, taking care to preserve the A2 pulley.
The wound was irrigated and closed with 4-0 nylon horizontal mattress sutures. Sterile dressing was applied. The tourniquet was released. Craig tolerated procedure well. There were no complications. Final instrument count was correct. He left the operating theatre in stable condition.
Tourniquet: Yes
Drain: No
Sutures: Yes
Dressing: Yes
DIP Arthordesis
61 y.o. Female presents with a failed mallet repair and painful DIP joint. We will take her to the OR today for a DIP arthrodesis.
We discussed the nature and pathophsiology of the diagnosis. We discussed treatment options and expectations in regards to potential outcomes, including the needs for secondary procedures or revisions.
Consent was obtained by discussion with the patient in regards to the risks and benefits, including possible injury to nerve, vessel, tendon, the need for secondary or revision procedures and occupational therapy. The patient had adequate time for discussion, and all questions were answered prior to completing the consent.
Operative Procedure: The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.
The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg.
A dorsal incision was made in the prior incision overlying the 5th DIP. The suture anchor was visualized and removed entirely.
The cartilage from the head of the middle phalanx and base of the distal phalanx was removed including subchondral cortical bone with a rongeur.
A provisional K wire was placed across the site and confirmed with fluoroscopy. The track was then tapped, and an accutwist compression screw was placed. The screw position was confirmed on fluoroscopy with good compression. The site was irrigated and closed with 4-0 nylon.
A bulky dressing was applied. The tourniquet was released and the hand demonstrated good distal perfusion. The patient was awoken from anesthesia and transported to recovery in stable condition.
Tourniquet: Yes
Drain: No
Sutures: Yes
Dressing: Yes
Axillary Hidradenitis Excision with Z-plasty
24 y.o. Female presents with a left axillary hidradenitis and scar tethering.
We discussed the nature and pathophsiology of the diagnosis. We discussed treatment options and expectations in regards to potential outcomes, including the needs for secondary procedures or revisions.
Consent was obtained by discussion with the patient in regards to the risks and benefits, including possible injury to nerve, vessel, tendon, the need for secondary or revision procedures and occupational therapy. The patient had adequate time for discussion, and all questions were answered prior to completing the consent.
Operative Procedure: The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.
The area of left axillary hidradenitis was marked. It was then incised with a scalpel down to axillary fascia and subcutaneous tissue to ensure removal of the glandular tissue. The specimen was sent to pathology. The wound was irrigated, hemostasis was achieved, and it was provisionally stapled closed.
Given the scar tethering across the axillary dome, we marked out a z-plasty with 4cm limbs. These were then incised and similarly carried down to fascia. The flaps were transposed. The deep tissue was closed with 4-0 PDS and the skin was closed in layers.
A bulky dressing was applied. The patient was awoken from anesthesia and transported to recovery in stable condition.
Tourniquet: No
Drain: No
Sutures: Yes
Dressing: Yes
Distal Radius
identified in the Holding Area and the operative site was marked. She was brought to the operating theater in stable condition and placed onto a regular OR table with her operative arm on an arm board. A preoperative time-out was taken to ensure the patient's identity, operative procedure, as well as the operative location. General anesthesia was administered. Her splint was removed and a tourniquet was placed onto her arm which was then sterilely prepped and draped. An Esmarch bandage was used to exsanguinate the limb before elevation of the tourniquet to 250 mmHg.
We began the procedure by making a 10 cm incision longitudinally over his FCR tendon extending from his wrist crease and proximally. We dissected through subcutaneous tissue and identified the FCR tendon. We incised the tendon sheath, retracted the tendon ulnarly, and incised the subsheath. The distal aspect of the FPL origin was released with cautery and the FPL was retracted ulnarly to expose the pronator quadratus which was incised along its radial and distal borders and elevated subperiosteally. We identified the fracture site and cleaned the fracture of callus. We then used fluoroscopic imaging in order to confirm the ability to reduce the fracture.
We then selected an Acumed Acu-Loc 2 volar radius plate. The plate position was provisionally stabilized using 0.054 K-wires and then secured to the proximal fragment using a 3.5 mm compression screw. We then reduced the fracture onto the plate and stabilized the distal fragment using additional 0.054 K-wires. The position of the plate and the fracture reduction were confirmed using fluoroscopic imaging. We then secured the epiphysis and articular fragments to the plate using 2.8 mm locking screws. We completed stabilization of the plate to the proximal fragment using 3.5 mm locking screws. The final position of the plate and fracture reduction were confirmed using fluoroscopic imaging and we were happy with both. Clinical examination showed no impingement of her wrist range of motion and good stability of the DRUJ.
A longitudinal incision over the volar palm was made. Skin, palmar fascia were sequentially divided. The transverse carpal ligament was divided proximally and distally. The incision was closed with 4-0 nylon.
The forearm incision was washed. The skin was closed in layers. A sterile dressing and volar splint were applied. General anesthesia was reversed. She tolerated the procedure well. There were no complications. Final instrument count was correct. Sonja was taken out of the operating theater and to the PACU in stable condition.
POSTOPERATIVE PLAN:
Sonja will go home from the hospital today with arrangements made to follow up with me in clinic in two weeks. She will be transitioned into a short arm removal splint volar which will be worn continuously for an additional four weeks with protected range of motion of her wrist initiated by Hand Therapy. She has been told to strictly elevate her hand at all times as well as move her fingers to prevent stiffness. If she has any difficulty or concerns between now and followup, she has been told to contact me, and I would be happy to see her sooner.
Tourniquet: Yes
Drain: No
Sutures: Yes
Dressing: Yes