Plastics

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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.   The arm was exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg.   The laceration was extended with two oblique incisions in order to gain more proximal access to the ulnar nerve and more distal access to the flexor tendons as they were entering the carpal tunnel. The wound was explored and the flexor tendons to the index finger was intact as well as the median nerve. The more ulnar sided structures had obvious injuries. Flexor carpi radialis has a 5% partial laceration. Flexor digitorum superficialis (FDS) of the long finger was lacerated, but the flexor digitorum profundus (FDP) was intact. The ring and small fingers had both FDS and FDP lacerated. The ulnar nerve was lacerated distal to takeoff of the dorsal sensory branch. Flexor carpi ulnaris was lacerated. The wrist and fingers were flexed in order to provide a tensionless repair of the tendons, nerves and artery.   The injuries were repaired from the radial to ulnar. The proximal muscle belly and tendon of FDS of the long finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDP of the ring finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDS of the ring finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDP of the small finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDS of the small finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair.   The microscope was brought into the room and the distal and proximal ulnar neurovascular bundles were identified and the artery and nerve ends were bluntly dissected. The distal and proximal ends of the ulnar artery were clamed and the repaired with 9-0 nylon sutures in a 0-180 fashion repair. At this point, 2 hours had past and the tourniquet was released. The clamps were removed and there was pulsatile flow through the artery. Next, we turned our attention to the ulnar nerve. The nerve was lacerated distal to the branching of the dorsal sensory branch. Both the ulnar nerve and dorsal sensory branch were identified and bluntly dissected under the microscope. The ulnar nerve was repaired with 9-0 nylon epineural sutures taking care to line up the fascicles followed by a 0.5cm diameter nerve wrap. Next, the dorsal sensory branch was repaired with 9-0 nylon epineural sutures taking care to line up the fascicles followed by a 0.5cm diameter nerve wrap.   Finally, the microscope was removed and flexor carpi ulnaris proximal and distal tendons were identified and the ends bluntly dissected free. Flexor carpi ulnaris was repaired with a 3-0 supramid using a modified kessler 4 strand repair followed by a figure of 8 repair with a 4-0 fiberwire. The incision was closed with 4-0 nylon simple interrupted sutures. Xeroform, 8×8 were applied followed by a dorsal extension blocking splint with the wrist and the fingers in flexion.

Note about wrist flexors. Since the cross the elbow, the elbow should be immobilized as well in 90 degrees when you make the splint.
FDS flexors go through the carpal tunnel like spiderman.

Trapeziectomy with ligament reconstruction and tendon interposition Partial trapezoid excision

Consent: possible injury to the 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 to the patient's satisfaction prior to completing the consent.

Operative Procedure: 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.

The arm was exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg. A Wagner longitudinal incision at the junction of the glabrous skin was made over the carpometacarpal joint, curving at the proximal wrist and stopping at the crossing of the flexor carpi radialis tendon. The incision was completed down to the subcutaneous tissue. The dorsal radial sensory nerve and its branches were identified and protected. The extensor pollicis brevis tendon and abductor pollicis longus tendon were identified and retracted radially. The joint space between the first metacarpal and the trapezium was identified using the c-arm and a subperiosteal longitudinal capsulotomy was made over the joint. Full-thickness flaps were raised using mixture of blunt and sharp dissection with scissors. The capsular incision extended for visualization of the base of the first metacarpal and full trapezium and part of the scapho-trapezial-trapezoid joint. Position was confirmed using a mini C-arm. Care was taken to preserve the capsule to facilitate later reattachment. The trapezium was then dissected circumferentially. A K-wire pin was then driven into the trapezium to use as a joystick handle to further help with retraction and movement to further facilitate fully dissecting free the trapezium. The FCR tendon at the base of the CMC joint was identified and care was taken to avoid injury to the tendon. The trapezium was removed piecemeal using the rongeur with careful attention not to injure the FCR tendon lying in the volar groove of the bone. * The trapezoid was evaluated and appeared denuded of cartilage. An osteotomy was made to remove the articulating surface with scaphoid. The flexor carpi radialis position was marked about 10 cm from the proximal wrist crease. A 2 cm transverse incision was made and using the scissors with blunt dissection through the subcutaneous tissues, the FCR tendon was visualized. Using a freer, dissection was carried over the FCR tendon superficially and deep to it, freeing it up as much as possible from the forearm incision as well as from the Wagner incision moving proximally along the FCR. The musculotendinous junction was identified, and the tendon was lifted into the incision using a right-angle clamp. The FCR was then transected. Then at the base of the FCR tendon, the FCR was pulled distally into the trapezial bed. The proximal forearm incision was closed with a 4-0 nylon suture. Using a burr drill bit, the volar aspect of the base of the thumb metacarpal was burred down to cortical bone. Then a position onto the more dorsal aspect of the thumb base, the position for the Mitek anchor suture was chosen and predrilled. Then * two #2-0 mini-Mitek anchor were placed into the thumb metacarpal base. The FCR tendon was then pulled into its new anatomic position, and the suture of the Mitek anchor was then passed through the FCR tendon and tied. The remaining FCR tendon was then rolled up into an anchovy using 3-0 vicryl sutures.

The capsule edges were re-approximated with 3-0 vicryl sutures. The tourniquet was deflated and hemostasis was obtained and the incision irrigated. The incision was closed with 4-0 nylon simple and horizontal mattress sutures. The incision was dressed with xeroform, 4×8 gauze and a thumb spica splint was applied.

Dr. Malliaris was present for the entirety of the case. The patient tolerated the procedure well and was subsequently extubated and brought to the PACU in stable condition.

Post-Operative Plan: The patient extubated and stable to PACU. Discharge home with thumb spica. Follow up in clinic as outpatient.

Operative Procedure: The patient was taken to the the operating room and secured 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.   The arm was elevated and exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg. An 8 cm incision was made over the flexor carpi radialis flexor tendon. The incision was continued down to the FCR sheath and the bipolar was used to achieve hemostasis of small vessels. The FCR sheath was incised and the FCR tendon retracted. The radial artery was identified and retracted radially. The antebrachial fascia was incised. Next, the pronator quadratus fascia was sharply incised in an “L” shape and elevated from radial to ulnar. The fracture line was identified and the periosteum elevated.   The fracture was freed with the dental pick and the freer elevator. The fracture still had some mobility.  Once all the fragments were free, the mini fluoroscopy was brought in and the fracture reduced with traction and dorsal pressure; we confirmed the reduction with multiple views. The regular * Acumed volar distal radius plate was chosen as the best size match. The plate was secured with *proximal (?distal) k-wires and fluoroscopy was used to confirm placement; the *** distal radial screw was placed using a locking screw.   We then turned our attention to the shaft and placed the oblong screw, keeping this a bit loose, and removed the K wires. The radial styloid fragment was then reduced further, and another K wire was used to hold the ulnar two fragments. We then placed the ulnar distal locking screw followed by the remaining distal row, and then the distal most radial styloid screw.   We reduced the fragments to achieve more volar tilt and tightened the shaft screw, and then placed two more shaft screws.  Final fluoroscopy images were taken confirming reduction and plate placement.   The pronator quadratus fascia was closed with 4-0 vicryl, achieving almost complete plate coverage.  The skin was closed with 4-0 nylon locking horizontal mattress sutures. Xeroform was placed over the incision and a volar resting splint was placed with the MCP joints free.

  The incision was irrigated and then closed with 4-0 nylon locking horizontal mattress sutures. The incision was dressed with xeroform and a soft dressing of 4×4 gauze, webril and a volar resting splint. The tourniquet was released and normal perfusion returned to the hand.

Dr. Malliaris was present for the entirety of the case. All counts were correct. There were no complications. The patient was brought to the PACU and discharged without incident.

Operative Pearls Anatomy

Technical Steps Will do Lalonde approach in clinic. Only change is to include epi in the local instead of a tourniquet.
1. Inject local
2. Prep and place tourniquet sterilly on forarm if in OR.
3. Rolled blue towels under wrist.
4. Mark approximately 2 cm incision and incise with 15 blade.
5. Go through subcuatneous tissue with 15 blade.
6. Dissect with Ragnell scissors. She will retract with 2 Ragnells and a sharp Sen.
7. Once TCL exposed, sharply incise with beaver blade or 15 blade.
8. Go distally until you reach the distal fat.
9. Incise proximally with beaver blade or 15 blade and then spread above and below with ragnell scissors (not to wide as you only need a tunnel for your scissors). This is so you can ensure the next step is done under direct vision.
10. Slide ragnell scissors proximally. This is a translation of the scissor. The scissor tips are curved and the tip goes straight proximally while your hand is off to the side and you translate it forward.
11. Ensure complete release with the freer.
12. Close with 4-0 nylon. She prefers locked horizontal mattress sutures.

Postoperative Care Soft dressing
APAP/Ibuprofen
No Narcotics

Operative Procedure: The patient was taken to the the operating room and secured 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.   Local anesthesia of 6 ccs of 50:50 1% lidocaine and 0.25% marcaine was injected into the volar wrist in line with the 3rd webspace. A tourniquet was placed sterilely and the forearm and hand were exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg.   A 2 cm incision was made over the volar wrist in line with the 3rd webspace. The fat overlying the superficial palmar fascia was excised with the scapel. Retractors were used to visualize the superficial palmar fascia and we encountered origins of the thenar musculature. The superficial palmar fascia was excised ulnar to the muscle insertions. At the level of the transverse carpal ligament, we also encountered hypothernar musculature origins. Retractors were placed deeper into the incision and the transverse carpal ligament (TCL) was excised with the beaver blade to reveal the median nerve. Ragnell scissors were used to spread above the TCL distally and a freer elevator was used to free the nerve off the TCL. Then the TCL was cut until a small fat pad was visualized and the nerve was released. Next we turned our attention to the proximal aspect of the TCL. We again spread with the ragnell scissors above the TCL and freed the nerve from the TCL with the freer. The TCL was cut with the ragnell scissors and then slid through the antebrachial fascia to release the median nerve.The tourniquet was deflated to reveal the median nerve with constriction and hyperemia.  

The patient was marked in the pre-operative area and the patient was brought back to the operative suite, placed in supine position.  All bony prominences were padded.  SCD boots were placed. Perioperative antibiotics were given.  A proper timeout was taken, which all present parties were in agreement.  The preoperative markings were reinforced and remarked.   The surgery started with removing each nipple/areola complex, a 25 mm diameter cookie cutter was used to mark the new areola. It was then elevated as a full thickness skin graft. Both the right and left NACs were placed in saline moistened gauze in small containers and saved for use later in the case.  Hemostasis was achieved at these sites. An incision was made along the superior markings of the breasts. Using electrocautery a flap was then raised in the subcutaneous plane superficial to the breast parenchyma leaving adequate subcutaneous fat to perfuse the skin flaps. Next, the breasts were undermined to the inframammary folds. A demarcator was used to mark the inferior incision. The inferior incision was made sharply and using electrocautery, the subcutaneous tissues were dissected down to the pectoralis fascia and the breast was removed.   Then each side was copiously irrigated with warm saline and complete hemostasis was achieved using electrocautery Bovie.  A 15 french round Blake drain was placed in each wound bed and exited out in the inferior outer portion of the chest wall, they were secured with a 3-0 nylon. The incision was then temporarily closed with skin staples which demonstrated that there was a tensionless closure. The patient was sat up on the flexed bed to confirm symmetry and to choose the appropriate placement for the nipple graft. Using the 25 mm cookie cutter, the new positions of the nipples were marked along the lateral edge of the pectoralis muscle and at the level of the 4th intercostal space.  The circle were created into horizontal ellipses measuring 2.5cm x 1 cm and were then deepithelialized with a 15 blade on each side.  The nipple areolar complex grafts were defatted with the iris scissor and using an 11 blade they were pie crusted. They were then placed onto the bleeding dermal beds. They were inset using 5-0 chromic sutures circumferentially.   The deep tissue was approximated with 3-0 PDS suture. Deep dermals were placed with 3-0 monocryl stures. Lastly the subcutaneous tissue was closed using a running 3-0 V-Loc.      Bolsters were formed from xeroform, mineral oil soaked cotton, and sutured into place with 3-0 Silk, and placed over each nipple graft.   Exofin glue was placed on the inferior incision. A Biopatch was placed at each drain site. Telfa and tegaderm were used to cover the bolster. A compression garment was placed on the patient's chest.   All counts were correct. Dr. Malliaris was present for the entirety of the case.  The patient had pectoralis nerve block performed by anesthesia. The patient was then subsequently extubated and brought to the PACU in stable condition and was discharged home with outpatient followup.   Post-Operative Plan:  PACU discharge Compression vest Okay to remove outer dressings in 2 days and shower Keep bolster in place

Description of Procedure: The patient was identified in the preoperative care area where informed consent was reviewed with the patients. The surgical site was marked, all of their 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 appropriate perioperative antibiotics were administered prior to the start of the procedure. General anesthesia was then obtained. A nonsterile tourniquet was placed on the right upper extremity, which was then prepped and draped in a standard sterile fashion.

An incision was made over the right fifth metacarpal in a longitudinal incision. Bipolar electrocautery was used to cauterize any of the small subcutaneous vessels. Using a Littler scissors, dissection was carried down to the fascia, taking care to protect and move to the side the extensor tendons and sensory nerves. An incision was made over the dorsal periosteum of the fifth metacarpal, and the freer was used to elevate the periosteum and expose the fracture. This was performed proximally and distally on the fifth metacarpal to give us enough room for reduction and plating of the fracture. The bone callus was debrided using a rongeur. The fracture was able to be reduced, and a reduction clamp was placed to hold it. The reduction was confirmed using the mini fluoroscopy and and a Synthes 1.5 mm T-shaped plate was chosen. The most distal ulnar screw hole was cut off to better conform to the metacarpal head, creating an L-shaped plate. The size and shape was confirmed to be appropriate.

An olive threaded K wire was used to secure one end of the plate, and the second hole on the other end was drilled and then the appropriate length was determined for bicortical screw, which was placed with good purchase. A second distal screw was placed, angling appropriately in the head of the metacarpal. Orthogonal views were taken to confirm length and placement. Then two proximal shaft screws were placed, and then the olive wire was removed and a third proximal screw was placed.

A fourth proximal screw was then placed through the plate, followed by a third distal screw. Because of the shape of the fracture, a 1.5mm single dorsal radial lag screw by technique was then placed to further support the construct, and the two middle holes in the plate were left open.

The incision was irrigated. Using a 4-0 Vicryl, the periosteum was closed in interrupted fashion. A 4-0 Monocryl was used for deep dermal sutures in an interrupted fashion and then using a 4-0 Monocryl, the skin was closed with a running subcuticular stitch. Steristrips were applied. 10 mL of 0.25% Marcaine was instilled into the incision. A volar resting splint was applied. The tourniquet was released and normal perfusion returned to the hand and fingers.

The patient was awakened from anesthesia and taken to PACU in stable condition.

Counts: All surgical scrub counts were correct at the end of the case.

Complications: None.

Postoperative Plan: - He will be discharged home when he meets PACU criteria. - Follow up in Hand Clinic as scheduled - 24 Hours of Keflex post-op - NWB RUE

   PROCEDURES PERFORMED: Abdominally-based random pattern skin flap, 10 cm by 10 cm, for coverage of right dorsal hand shearing degloving injury.     DESCRIPTION OF PROCEDURE: Care of the patient was assumed from Dr. Ipaktchi and the Ortho Hand team following revision amputation of the right index finger and fillet of finger flap to resurface the dorsal aspects of the long finger and remaining index finger. The wound now measured 10 cm by 8 cm to the dorsal hand with some exposure of the bases of the proximal phalanges of the index and long fingers.   We began by templating the defect onto a piece of Esmarch bandage as a random-pattern inferiorly-based “omega” flap. The template was transferred to the abdomen at the right lower quadrant and the proposed flap marked out for an inferiorly-based random pattern flap. The template was oriented so as to facilitate a relaxed position of the hand onto the abdomen. The length of the flap was increased by 2 cm so as to reach the superior margin of the flap to the radial aspect of the hand defect without undue tension. 4 cm lateral limbs were marked at the base to facilitate closure of the donor site.   The superior, medial, and lateral flap margins were incised with a 10-blade scalpel. Dissection was carried through the subcutaneous tissues using Bovie electrocautery. The flap was raised from superior to inferior. Laterally where the tissue was thinner, dissection was carried above the external oblique fascia. Medially where the tissue was thicker, dissection was carried below the superficial fascial system, leaving some fat down on the abdominal wall. Adequate hemostasis was obtained.   After first ensuring that the flap was of adequate width and length to resurface the right dorsal hand, we began closure of the donor site. The subcutaneous tissue was undermined for several centimeters in each direction for mobilization. The superior corners of the defect were closed with 3-0 Vicryl for the SFS and simple interrupted 3-0 Nylon sutures for approximately 5 cm each. The inferolateral edges were brought together and closed for approximately 4 cm using 3-0 Nylon suture. This left a triangular-shaped defect centrally at the donor site measuring 4 cm by 4 cm.   The flap was then inset to the dorsal hand using simple interrupted 3-0 Nylon suture, with the lateral, superior, and medial edges of the flap well approximated to the proximal, radial, and distal aspects of the dorsal hand, respectively.   The incision sites were dressed with bacitracin ointment. The triangular-shaped defect was dressed with wet-to-dry 4×4 gauze. The raw surface of the flap at the base was dressed with wet-to-dry 4×4 gauze. A split ABD pad was placed over the abdomen and under the hand. The hand was wrapped in Burn gauze and Kerlix.   The forearm and upper arm abrasions were dressed with bacitracin ointment, Xeroform, and Kerlix.   The patient was awaken from anesthesia and transferred to the PACU in good condition with no apparent complications.     SPECIMEN: None.   IMPLANTS/DRAINS: None.   ESTIMATED BLOOD LOSS: 30 mL.     COMPLICATIONS: None.    DISPOSITION: To PACU.   POSTOPERATIVE PLAN: - Return to ward. Pediatrics primary. - Non-weight bearing RUE. - Ancef x 24 hours post-operatively. - Abdominal binder at all times to keep hand in place. - Okay to gently range at elbow and shoulder, keeping hand in place. - NO flap checks necessary. - Plan for dressing change in OR with Dr. Ipaktchi on Monday, 7/20/20. Otherwise no dressing changes. Okay to re-inforce with 4×4 gauze or ABD pads, gently tucking at inferior aspect, if needed. - Ultimately will follow up with Hand/Plastics as outpatient with plan for flap division at 3-4 weeks. - Plastics to continue to follow.