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Table of Contents
Dr. Gordon Introduction
- Massachusetts Institute of Technology, S.B. Physics (1969-1973)
- University of California, Berkeley M.A Physics (1973-1978)
- Standford University, M.S. Mech. Engineering (1978-1979)
- Unordered List ItemAlbert Einstein College of Medicine, M.D. (1979-1983)
- Internship: General Surgery - Albert Einstein College of Medicine, Montefiore Medical Center (1983-1984)
- Residency: General Surgery - Albert Einstein College of Medicine, Montefiore Medical Center (1984-1987)
- Residency: Plastic Surgery - Albert Einstein College of Medicine, Montefiore Medical Center (1987-1989)
- Fellowship: Hand and Microvascular Surgery, Division of Plastic and Reconstructive Surgery, University of Colorado Health Science Center (1989-1990)
Clinical Interests:
(1) Microsurgical Reconstruction
- Replantation
- Development of Innovative transfers to resolve would coverage
(2) Hand Trauma
- Surgical application
- Rehabilitation following surgery
(3) Dupuytren's contractures
(4) Arthroscopy
(5) Swanson implant antroplastics
(6) Carpal tunnel and replantations
(7) Reconstruction of the residual of burn - hand/upper extremity
(8) Hand and bone disorders common to the dialysis population
(9) Animal bites (monkeys, dogs, cats etc.) on the human hand
(10) Analysis of electromyographic indicators for release of the entrapped median nerve
Pimp Questions
Why isn't the bovie working? Because we infilitrated with local and it's too wet.
Operations
Loupe magnification for ALL cases. Yes, even breast reductions.
General Set up for Hand Cases
OR
Very particular so pay attention
arm out and turned 90
tourniquet upper arm- with lots of web well unless stated otherwise
Draping-he will have an xtra large sheet that he cuts
arm in stockinette
1. mayostand on hand table (paper side down)
2. half of the xtra large drape on hand table
3. blue towel wrapped around arm help by penetrating towel clamp
4. long sheet over patient - held in place by 4 non penetrating towel clamps
“If there is pus always collect culture data Uses loupes for all cases”
Carpal Tunnel
Pilar syndrome for post-CTR pain
CTR
arm out and turned 90
tourniquet on forearm- with lots of web well unless stated otherwise
Draping-he will have an xtra large sheet that he cuts
arm in stockinette
1. mayostand on hand table (paper side down)
2. half of the xtra large drape on hand table
3. blue towel wrapped around arm help by penetrating towel clamp
4. long sheet over patient - held in place by 4 non penetrating towel clamps
-He will mark the incision.
-Uses Knife to cut until fat is seen, 2 ski hooks
-Bovie and smooth pickup to buzz vessels
-then he uses ragnels and sens and you use litler scissors to dissect doen to transverse carpal ligament.
-start proximal, sweep ulnar–> radial with freer
-litler to push cut the proximal transverse carpal ligament
then distal- litler until Kaplan's line
USES VICRYL TO CLOSE DEEP DERMAN
then 5-0 nylon interupted
Trapeziectomy with Ligament Reconstruction Tendon Interposition
Special equipment: Bone anchor
Sutures: 2-0 fiber wire for tendon reconstruction, 5-0 nylon for skin closure
Notes: Removes trapezium whole. (ie. does not use rongeur unless a piece breaks)
Distal Radius - Dorsal Spanning Plate
Things to note are there is a template for the spanning plates so you can use this to first make sure that you'll be in the right spot. You're going to make three incisions, one over the metacarpals. You can choose a second or third Dr. Gordon prefers the third over the just the aspect of the distal radius and then a mid distal mid radius.
Things that you will encounter at the most distal incision - juncturiae tendinae. Takes the extensor tendons ulnarly.
Middle incision - Will encounter EPL… Make sure it is elevated so it's not crushed.
Proximal incision - May encounter APL which has a very big tendon with multiple sheaths.
The most proximal screws are a different size than the distal screws. The incisions were closed with 4-0 vicryl although he usually uses 5-0 vicryl, and a 5-O monocryl sub-cuticular layer.
Dressing: Benzoin, steri-strips, tegaderm, soft kerlix, splint.
Lipoma Resection
Suture: 4-0 vicryl deep dermal, 4-0 Monocryl subcuticular
Dressing: Steristrips crossing wound with benzoin, pressure dressing
After induction of general anesthesia, the patient was placed into a prone position with padding and had her back prepped and draped. Preoperative skin markings consisted of a 5 cm transverse skin incision directly over the palpable mass. The scalpel was then used to incise along the marked lines going down through the skin into subcutaneous tissues, whereafter the rest of the dissection was performed with loupe magnification using a combination of electrocautery as well as gentle blunt dissection to dissect the mass from the surrounding tissues. Once in the subcutaneous plane, there appeared to be a multilobulated lesion that was contained in this space that was felt to be likely to be consistent with a lipoma. Gentle blunt dissection was then performed at the periphery of the mass, but the mass was poorly encapsulated from the surrounding tissues and dissection was slow to proceed. The mass was eventually isolated from the surrounding tissues and no further presence of the mass was noted on clinical exam. The mass seemed to extend all the way down to the fascia. After verifying complete excision of the mass, the wound was meticulously checked for hemostasis with electrocautery, and then closure of the cutaneous wound was accomplished with multiple deep dermal sutures of 4-0 Vicryl, followed by a running 4-0 Monocryl subcuticular stitch in the skin. Dressings consisting of benzoin, Steri-Strips, and Tegaderm were applied, followed by a modest compressive bandage with 4 x 4's and Medipore tape.
Clinic
Trigger Finger Injection
Injections pure kenalog into proximal phalanx at 45 degree angle between finger and palm. (ie. the needle is pointing distally in the direction of the distal finger tip.) Go all the way down to bone and inject WITHOUT resistance. Place a bandaid dressing.
Post - Op Protocol
CMC Trapeziectomy
OR Tips: Block w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ 3-0/4-0 Monocryl, Steri strips, kerlix, Wrapped thumb spica splint, 4” ace.
Immediate Post Op Orders
Goals:
- Keep splint/dressing clean/dry/intact until follow up
- Elevate/ice wrist x 7 days
- May move fingers as splint allows – NO thumb motion
- Off work x 2 days post op
- Follow up 7 days post op
- POST OP PROTOCOL ORDERS
Work Restrictions
- At 1 week post op can start typing (no thumb)
- No lifting more than 1-2 lbs prior to 1 week (no thumb assistance)
1 week Post-surgery
- Schedule 1st post op visit with Physician Extender
- X-Ray 3 views of operative thumb
- Wound Check
- Suture Removal
- Remove every other suture to determine integrity of incision – if any gapping or if diabetic, have patient return per therapist discretion for remaining suture removal (on Physician Extender schedule)
- OT Order
- Forearm based thumb spica zipper splint, thumb MP in ~ 20 degrees of flexion, IP free
- Have patient schedule to begin therapy at 6 weeks post op
4 weeks
- Second follow up visit (Schedule with MD)
OT (start at 6 weeks)
- Zipper spica splint x 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
12 Weeks
- Final MD visit
- Full use/fully weaned from splint (however can wear for aggressive sports, etc PRN)
- Continue w/ strengthening
- If no problems, d/c from OT to HEP
Cubital Tunnel Release (Endoscopic)
OR Tips: LMA. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ 3-0/4-0 Monocryl, steristrips, kerlix, 4” ace.
Immediate Post Op Orders
Goals:
- Keep surgical dressings clean/dry/intact
- Elevate x 1 week
- Finger motion as tolerated, otherwise no use of hand x 1 week
- POST OP PROTOCOL ORDERS
Work Restrictions
- No use of hand/arm x 1 week
- Starting at 1 week can typically start to use PRN
1 week Post-surgery
- Schedule 1st post op visit with Physician Extender
- Wound Check
- Suture Removal
- Keep steri-strips/Tegaderm on until it falls off, or at least 2 weeks post op
- OT Order (PRN)
OT (if ordered beyond PE duties on 1st post op visit)
- A/AAROM
4 Weeks
- Second follow up visit (Schedule with MD)
12 Weeks
- Typically final MD visit
DeQuervain’s Release
OR Tips: Local w/ sedation vs. Bier block. Forearm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ Monocryl, kerlix, short arm splint, 4” ace.
Immediate Post Op Orders
- Keep surgical dressings clean/dry/intact
- Elevate x 1 week
- Finger motion as tolerated, otherwise no use of hand x 1 week
- NO thumb motion
- POST OP PROTOCOL ORDERS
Work Restrictions
- No use of hand/arm x 1 week
1 week Post-surgery
- Schedule 1st post op visit with Physician Extender
- Wound Check
- Suture Removal PRN (often does internal/dissolvable sutures)
- Forearm based thumb spica splint
- OT Order (PRN)
OT (if ordered beyond PE duties on 1st post op visit – start 3 weeks post op)
- ROM
- Scar management/desensitization
4-6 weeks
- Second follow up visit (Schedule with MD
12 Weeks
- Typically final MD visit
Distal Radius Fracture s/p ORIF
OR Tips: Block w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ 5-0 Vicryl, 5-0 Nylon (Monocryl if younger or female), kerlix, short arm splint, 4” ace.
Immediate Post Op Orders
- Keep surgical dressings clean/dry/intact
- Elevate x 1 week
- Finger motion as tolerated, otherwise no use of hand x 1 week
- POST OP PROTOCOL ORDERS
Work Restrictions
- No use of hand/arm x 1 week
1 week Post-surgery
- Schedule 1st post op visit with Physician Extender
- X-rays (3 views of wrist)
- Wound Check
- Suture Removal
- Circumferential orthosis
- OT Order
OT
- AROM (AFTER verification of acceptable bony alignment on xray by MD).
- Edema management
4 weeks
- Second follow up visit (Schedule with MD)
- X-rays (3 views of wrist)
- Progression of OT dependent on clinical exam – MD will enter updated orders
8 weeks
- Third follow up visit (Schedule with MD)
- X-rays (3 views of wrist)
- Progression of OT dependent on clinical exam – MD will enter updated orders
Dorsal/Volar Wrist Ganglion Excision
OR Tips: Local w/ sedation vs. Bier block. Forearm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ 5-0 Vicryl, 5-0 Nylon, kerlix, short arm splint, 4” ace.
Immediate Post Op Orders
- Keep surgical dressings clean/dry/intact
- Elevate x 1 week
- Finger motion as tolerated, otherwise no use of hand/arm x 1 week
- POST OP PROTOCOL ORDERS
Work Restrictions
- No use of hand/arm x 1 week
1 week Post-surgery
- Schedule 1st post op visit with Physician Extender
- Wound Check
- Suture Removal
- Volar wrist orthosis
- Ok to return to activities with splint on after 1 week post op
- Wean from splint at 2 weeks post op and start A/AA/gentle PROM
- OT Order (PRN)
OT (if ordered beyond PE duties on 1st post op visit – begin at 2 weeks post op)
- A/AA/Gentle PROM
- Scar/Edema management
4 weeks
- Second follow up visit (Schedule with MD
12 weeks
- PRN follow up visit with MD
Metacarpal Fractures s/p ORIF
OR Tips: Block w/ sedation. Forearm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/Monocryl, kerlix, Forearm based intrinsic plus splint, 4” ace.
Immediate Post Op Orders
- Keep surgical dressings clean/dry/intact
- Elevate x 1 week
- No use of hand/arm x 1 week
- POST OP PROTOCOL ORDERS
Work Restrictions
- No use of hand/arm x 1 week
1 week Post-surgery
- Schedule 1st post op visit with Physician Extender]
- X-rays (3 views of hand)
- Wound Check
- Suture Removal
- Forearm based orthosis, MPs in mid-flexion, IPs in extension
- OT Order
OT
- AROM (AFTER verification of acceptable bony alignment on xray by MD).
4 weeks
- Second follow up visit (Schedule with MD)
- X-rays (3 views of hand)
8 weeks
- Third follow up visit (Schedule with MD)
- X-rays (3 views of hand)
Trigger Finger Release
OR Tips: local w/ sedation. Forearm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ 5-0 Vicryl, 5-0 Nylon, kerlix, short arm splint, 4” ace.
Immediate Post Op Orders
- May remove dressing 4-5 days post op
- Finger motion and typing as tolerated
- Apply Band Aid
- Keep dry, no ointments
- POST OP PROTOCOL ORDERS
Work Restrictions
- Depends on job requirements
14 Days Post-surgery
- Schedule 1st post op visit with Physician Extender
- Wound Check
- Suture Removal
- Instruct in scar massage to begin 2-3 days after suture removal
- Instruct in gentle AROM
- Edema management PRN
- OT Order (PRN)
OT (if ordered beyond PE duties on 1st post op visit)
- As above
4 weeks
- Second follow up visit (Schedule with MD)
12 weeks
- Typically final follow up visit with MD
Operating Reports
Panniculectomy
42-year-old black female, who has been evaluated in the plastic surgery clinic with morbid obesity, prior to undergoing gastric bypass surgery. After this, the patient lost 100 pounds and has maintained it for an extended period of time. The patient has been having difficulties with rashes at the lower portion of the abdomen, but also near the umbilicus, where the patient has a second pannus that was causing overlap of skin near the umbilicus. The patient was thought to be a candidate for panniculectomy, which would require also release of the pannus near the umbilicus and, hence, umbilical repositioning. The patient was accepting of the risks and benefits associated with this and is brought to the operating room today for this purpose.
DESCRIPTION OF PROCEDURE: Prior to induction of general anesthesia, the patient was placed in a standing position in the preoperative area, where the infra pannus crease was marked out in the standing position, as was vertical limbs beginning at the midaxillary line and dividing each abdominal section into 4 parts, and finally at the midline. The patient was then placed in repose with the bed flexed to about 30 degrees. An estimation of total skin that could be removed, was then marked out in this manner. The patient was then brought to the operating room, where the patient was prepped and draped. After reinforcing the skin markings, an incision was made along the inferior fold underneath the pannus along the lower abdomen, extending all the way out, including lateral to the ASIS on both sides for at least 10 to 15 cm. Hemostasis was achieved in the subcutaneous plane with use of electrocautery, and the incisions were deepened all the way down to the abdominal wall. This was extended all the way out to the full length of the incision and then the abdominal skin was elevated off the abdominal wall using the electrocautery, going up to the marked lines. The umbilicus was then incised circumferentially, preserving what was thought to be an acceptable amount of umbilicus for final positioning. The dissection then continued down to the abdominal wall to preserving vascularity to the umbilicus. This was then connected with the abdominal skin flap, which was elevated for additional distance in the midline area to allow repositioning for the umbilicus. An estimation was made for the skin tension that would be necessary to close the abdomen with the markings had been made preoperatively and these were found to be excellent markings for the patient. As a result, a midline incision was made from the inferior portion of the abdominal flap to the location of the umbilicus, and then extended all the way up to the markings that had been made preoperatively. The patient was then placed into a flexed position at the hips and it was felt that there was a good elevation of the mons and still not too tight a closure. The skin flaps were then measured, going from midline towards the outside edge of the incision, checking at each point in time to make sure that the next several centimeters would not under too excessive tension. The total amount of skin was then removed, and weighed at just under 9 pounds. Meticulous hemostasis was then achieved and the superficial fascial layer at the lower border of the incision was then closed with interrupted 2-0 Vicryl sutures.
Then, 15-French Blake drains were placed along the lower edge of each incision and exited through a stab incision on the medial aspect of both thighs. The drains were sutured into position. The markings for the umbilical positioning were made on the skin and this skin was cut out in a shield pattern, and then the umbilicus was brought through the skin incision at this level. The umbilicus was sutured into position with interrupted deep buried 5-0 Vicryl sutures. The incision along the lower portion of the abdomen was then closed with multiple deep dermal sutures of 2-0 Vicryl, separated no more by then 1 cm apart. Final skin closure along the lower incision was then accomplished with running 4-0 Monocryl sutures. Benzoin, Steri-Strips, and Tegaderm dressings were applied to the incision site with the umbilicus being dressed with Xeroform, 2 x 2 gauze, and a small Tegaderm. Biopatch and Tegaderm dressings were placed on the drains.
COMPLICATIONS: None.
SPECIMENS: None.
DRAINS: Two 15-French Blake drains, one in the right side of the abdomen, one on the left side of the abdomen.
Tourniquet: No
Drain: 15-French Blake
Sutures: 4-0 Monocryl sutures
Dressing: Benzoin, Steri-Strips, and Tegaderm dressings were applied to the incision site with the umbilicus being dressed with Xeroform, 2 x 2 gauze, and a small Tegaderm. Biopatch and Tegaderm dressings were placed on the drains.
Carpal Tunnel Release
OPERATIVE INDICATIONS: The patient is a 57-year-old right-hand dominant female who has been followed in the hand clinic with symptoms of bilateral carpal tunnel syndrome. The patient has had persistent symptoms on the right side. This was failed to be managed with conservative splint immobilization, and the patient was felt to be a candidate for consideration of surgical intervention. Risks and benefits of surgery were discussed with the patient and the patient elected to proceed with such. The patient was brought to the operating room for this purpose now today.
DESCRIPTION OF PROCEDURE: After instillation of approximately 10 mL of 1% lidocaine without epinephrine at the level of the wrist as a median nerve block as well as infiltrating in the subcutaneous plane both proximal and distal to the volar wrist creases, the patient had her right hand and arm prepped and draped. Preoperative skin markings were designed as a 2 cm longitudinal incision along hypothenar creases at the level of the wrist. The hand and arm were then exsanguinated with the Ace wrap and the tourniquet on the forearm was inflated to 250 mmHg. Scalpel was then used to incise along the marked lines going down through the skin into subcutaneous tissues, whereafter the rest of the dissection was performed with loupe magnification using Littler scissors. Hemostasis was achieved in the subcutaneous plane with use of electrocautery at all points in time. Dissection then continued down to the level of the palmar fascia, which once identified was fully exposed. The palmar fascia was split then longitudinally along an axis between the palmaris longus tendon and the 4th metacarpal, and then dissection continued down to the level of the transverse carpal ligament. Once visualized, the transverse carpal ligament was incised for a small section in the central portion until a small entry had been made into the carpal canal. Using first a small uterine sound, followed by a small Freer elevator, the soft tissues from the underneath surface of the transverse carpal ligament were swept from the ulnar side to the radial side all the way going up into the forearm. Using the Aufricht retractor then, which was placed on top of the transverse carpal ligament going proximally up into the forearm. Attention were applied to this and then the Littler scissors were placed on the proximal edge of the transverse carpal ligament and used to divide the ligament going up into the forearm. After confirmation of a complete release of the transverse carpal ligament going proximally, the distal edge of transverse carpal ligament was visualized and then divided under direct vision going into the central palm. After verifying hemostasis, closure of the cutaneous wound was accomplished with several deep dermal sutures of 5-0 Vicryl, followed by interrupted 5-0 nylon sutures in the skin. Approximately 5 mL of 0.5% Marcaine without epinephrine was instilled beneath the wound edge with use of a plastic Angiocath for postoperative analgesia, and then dressings consisting of Xeroform, wet gauze, dry gauze, Kerlix bandage, followed by application of 4-inch plaster splint was then applied to patient's arm. Tourniquet was then released after a total of 27 minutes of inflation time.
COMPLICATIONS: None.
SPECIMENS: None.
DRAINS: None.
Tourniquet: forearm- inflated to 250 mmHg
Drain: No
Sutures: 5-0 Vicryl, 5-0 nylon sutures
Dressing: Xeroform, wet gauze, dry gauze, Kerlix bandage
OR Tips: Local w/ sedation vs. Bier block. Forearm tourniquet w/ webrill, tourniquet, 1000 drape. Prop arm on suction canister wrapped w/ blue drape packaging. Close w/ 5-0 Vicryl, 5-0 Nylon, kerlix, short arm splint, 4” ace.
Immediate Post Op Orders
Goals:
- Off work x 2 days
- Elevate wrist above elbow x 1 week
- Keep surgical dressings clean/dry/intact
- Finger motion as tolerated, otherwise no use of hand
- Follow up 1 week post op
- POST OP PROTOCOL ORDERS
Work Restrictions
- 0-1 weeks: No use of operative hand
- 1-4 weeks: 5 lb lifting limit, no pushing or pulling
1 week Post-surgery
- Schedule 1st post op visit with Physician Extender
- Wound Check
- Suture Removal
- Remove every other suture to determine integrity of incision – if any gapping or if diabetic, have patient return per therapist discretion for remaining suture removal (on Physician Extender schedule)
- OT Order
- Custom volar wrist splint
- Initiate CTR post op protocol
OT (if ordered beyond PE duties on 1st post op visit)
- 2-4 weeks post op
- Finger and wrist ROM
- 4+ weeks post op
- Scar desensitization/massage
- Putty use
- Strengthening and ROM as tolerated
4 weeks
- Second follow up visit (schedule with MD)
- Typically allows full unrestricted use
12 weeks
- Final Follow up visit (schedule with MD)
- Continue with follow up at 6 week interval if 2 point still expanded
Mucous Cyst Excision
POSTOPERATIVE DIAGNOSIS: Mucous cyst of right index finger.
PROCEDURE: Excision of mucous cyst of right index finger.
ANESTHESIA: Digital block with sedation.
OPERATIVE INDICATIONS: The patient is a 66-year-old right-hand-dominant white female who has been treated in the past for a mucous cyst. The patient recently has been evaluated in the hand clinic, where the patient has had a new mass growing on the dorsal aspect of her right index finger, which was quite large, and is causing associated nail bed deformities. Because of the size of the lesion, it was recommended the patient should consider undergoing surgical treatment for this, and the patient was brought to the operating room for this purpose today.
DESCRIPTION OF PROCEDURE: After instillation of approximately 7 mL of 1% lidocaine without epinephrine at the base of the right index finger of the MCP joint as a digital block, the patient had her right hand and arm prepped and draped. Preoperative skin markings were designed as a 1 cm longitudinal incision directly over the mass extending from the DIP joints all the way down to the eponychial fold. The finger was then exsanguinated with a 1/4-inch Penrose drain, and simultaneously was wrapped at the base of the digit to act as a tourniquet for the procedure. The scalpel was then used to incise along the marked lines going down through the skin incision into the subcutaneous tissues, whereafter the rest of the dissection was performed with loupe magnification using Littler scissors. Gentle blunt dissection was performed, isolating the mucous cyst from the surrounding tissue, beginning proximally and working distally. The cyst itself was excised, and after achieving hemostasis, dissection progressed to the level of the DIP joint where a prominent osteophyte was then visualized and appeared to be in the area where the cyst was coming out. The Freer elevator was used to dissect the osteophyte from this point, and then the osteophyte was removed with a small rongeur. The closure the cutaneous wound was then accomplished with interrupted 5-0 nylon sutures in the skin. Dressings consisting of Xeroform, wet gauze, dry gauze, and a 2-inch Kling bandage incorporating an Alumafoam splint was also placed to the finger. Final Kerlix and Ace wrap were applied to the hand. An additional 4 mL of 0.5% Marcaine without epinephrine was instilled at the base of the digit to act as a prolonged postoperative analgesia. Tourniquet was then released after a total of 35 minutes of inflation time.
COMPLICATIONS: None.
SPECIMENS: Mucous cyst to pathology.
DRAINS: None.
ESTIMATED BLOOD LOSS: None.
Tourniquet: drain wrapped around finger Drain: 1/4 Penrose Sutures: 5-0 nylon Dressing: Xeroform, wet gauze, dry gauze, and a 2-inch Kling bandage