PL Plastic Surgery Ryan Austin, Imran Jivraj and Anthony So, chapter editors Alaina Garbens and Modupe Oyewumi, associate editors Adam Gladwish, EBM editor Division of Plastic: and Reconrrtructive Surgery, Univenity of Toronto, staff editors

Basic Anatomy Review ................... 2 Skin Hand Brachial Plexus Face

Differential Diagnoses of Common Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . 5 DDx of Skin Lesions/Masses

Basic Surgical Techniques ................ 5 Sutures and Suturing Excision

Wounds ............................... 6 Causal Conditions Principles of Wound Healing Contaminated and Infected Wounds Dressings Reconstruction

Soft Tissue Infections ................... 12 Erysipelas Cellulitis Necrotizing Fasciitis

Ulcen ... 13 Lower Limb Ulcers Pressure Ulcers

Management of Skin Lesions ............ 14

Burns ................................ 15 Burn Injuries Pathophysiology of Burn Wounds Diagnosis and Prognosis Indications for Transfer to Burn Centre Acute Care of Burn Patients Special Considerations

Toronto Notes 2011

Hand ................................. 20 Traumatic Hand General Management Hand Infections Amputations Tendons Fractures and Dislocations Dupuytren's Disease Carpal Tunnel Syndrome (CTS) Rheumatoid Hand

Brachial Plexus ........................ 26 Common Palsies Differential Diagnosis Investigations Management

Craniofacial Injuries . . . . . . . . . . . . . . . . . . . . 26 Approach to Facial Injuries Mandibular Fractures Maxillary Fractures Nasal Fractures Nasa-orbital Ethmoid (NOE) Fractures Zygomatic Fractures Orbital Floor Fractures

Breast Surgery .. 31 Breast Reconstruction Breast Tissue Expanders

Aesthetic Surgery ...................... 32 Aesthetic Procedures

Pediatric Plastic Surgery . . . . . . . . . . . . . . . . 33 Craniofacial Anomalies Congenital Hand Anomalies

References . . . 35

Plastic Surgery PLI

PL2 Pladic Surgery

't' C."llla11 MIMIDIIIC (in order. pi'IIDnallhan d-.lrow; nadial ID ul111r aidal Some-Scaphoid Lovera- Lunate Try-Triqlllllrum Positions-Pisiform ThBI-Trlplllilrn Thay-Trapamid Cannot-Cepillbl Hard! - HanultB

1'oroDio 2011

Basic Anatomy Review Skin

F"11r 1. Split and Full (whala} Thiclmus SWn Grafts

Hand BONES AND NERVES

F"111ra Z. Carpal Ban.

1. RadiUI 2. Scllllhoid 3. TnpaziiJII 4. T1111J8ZDid 5. Capiblbl I. Ulna 7. Llllltll 8. Pilliorm 10. Hamalll 11. Mrtllearpll

boon

Rgun1 3. Se1101J Disbiblltia1 in tile Hand

Toronto Notes 2011

TENDONS

Flexor digitorum profundus

]- Proximal interphalangeal joint

Camper's chiasm Flexor digitorum superficialis

}-- Metacarpal phalangeal joint

Figure 4. Flexor Tendon Insertion at PIP and DIP

Basic Anatomy Review

Extensor hood

Lumbrical

Interosseous muscles

Extensor digitorum communis

Figure 5. Extensor Mechanism of Digits

Palmar Flexor retinaculum----'"\c

Median nerve----...

Dorsal Figure B. Carpal Tunnel

Figure 9. Extensor Compartments of the Wrist (dorsal view and cross-sectional view)

Plastic Snrgery PL3

..... , , ,._ _________ __

DIP

PIP

Flexor Tendons All require OR repair. Extensor Tendons ER repair unless proximaVmultiple tendons.

Figure 6. Testing Profundus (FDP)

Figure 7. Testing Superficialis (FDS)

1. Extensor retinaculum Compartment 1 2. Abductor pollicis longus 3. Extensor pollicis brevis Compartment 2 4. Extensor carpi radialis brevis 5. Extensor carpi radialis longus Compartment 3 6. Extensor pollicis longus

(EPL tendon passes around Lister's tubercle) Compartment 4 7. Extensor digitorum 8. Extensor indicis Compartment 5 9. Extensor digiti minimi Compartment 6 1 0. Extensor carpi ulnaris

j 0:: "

.!!J @

PIA Pladic Surgery

llnchmi'IDIIIIIIH .. IIIB Rob-Roots Thomas-Trurb llrink8- Divillicm Cold-Cords Ba1n-

Brachial Plexus

Medial MIMI$ of arm 111d fol'llllm BIWICHES

Flg1re 10. Brachllll Plexus AnlhiiiY

Face

11. Skul and fllcilll BCIIIas

CORDS

I. IJicriiTllll bans 2. Zygomatic bona 3. MllCII1 4. Maidlle S.Nalllbo"'

DMSIONS

8

&. Sphanaid bana 1. TempDI'III bana B. Pllrielll bone 8. , o. Flunlal bo"'

1'oroDio 2011

lRUNIKS

10

'IbroDlo Nota 2011 Di&reDiial Diapo&el of Common Prele:DlalioD&/k Surgical Techniques

Differential Diagnoses of Common Presentations DDx of Skin Lesions/Masses

For background information, see DermatDlo&f. D3

Basic Surgical Techniques Sutures and Suturing

ANESTHESIA inject anesthetic before final debridement and irrigation lidocaine (Xylocame) epinephrine (vasoconstrictor, limits bleeding)

toxk limit and duration of action ( 1 cc of 1 CJ6 solution contains 10 mg lidocaine): without epinephrine: 5 mglkg.lasts 46-60 min with epinephrine: 7 mg/kg, lasts 2-6 hours

slgn8 of umctty: CNS excitation followed by CNS, respiratory, and cardiovascular depression bupivicalne (Marcaine) epinephrine used fur longer analgesic effect toxic limit and duration of action:

without epinephrine: 2 mglkg, lasts 2-4 hours with epinephrine: 3 mglkg, lasts 3-7 hours

tmicity of mixtures (i.e. lidocaine + bupivicaine) is no greater than ita individual components

IRRIGATION AND DEBRIDEMENT irrlgate copiously with a phy&iologic solution such as Ringer's lactate or normal saline to remove

surface clots, fureign material, and bacteria debride all obviously devitaliud tissue. irregular or ragged wounds must be excised to produce

sharp wound edges that will assist healing when approximated

SUTURES use of a particular suture IIlllterial is highly dependent on surgeon preference suture IIlllterial divided by two categories:

absorbable vs. non-absorbable: absorbable materials commonly used fur deep sutures under short-term tension

- also used fur akin closure in children or uncooperative adults - lose at least 5096 of their strength in 4 weeks and are eventually absorbed - aamples include Plain gut", Vlcryl, Polysorb

non-absorbable materials commonly used fur skin clorure or in sites of long term tension - lower li.kelibood of wound dehiscence - examples include nylon, polypropylene, stainlell5 steel

monofilament VII. mult:ifil.ament (a.k.a twisted or bmided) monofilament sutures slide through tissue with less friction but have more memory/

stiffness - used in contaminated and infected wounds -lower likelihood of bacterial trapping in suture material - examples include Monosof", Monocryi, Biosyn"

multifilament sutures have less memory/rtift'ness making them easier to work with - increased lilcelihood of bacterial trapping, should be avoided in contaminated wounds - includes Vicryi and Silk

BASIC SUTURING TECHNIQUES

Basic SUb.lre Methods (F.Igure 12) simple interrupted- can be used in almost all situations intra-cutl.cula.r - good cosmetl.c result but weak. used in combination with deep IJUture8 vert1cal mattress- for areas diffi.cul.t to evert (e.g. dorsum of the hand) horizontal matt.rell5 - everting, time saving continuous over and over (a.k.a "running", "bueball stitch") - time slrving. good fur hemostasis

Plaalk Surgery PLS

PL6 Pladic Surgery

Grey regio1111 indicale areu of llkin to be ercieed

Figure 1 3. lnclllo of l.8donl Aloll Relaxed Sldn Te ... on Unea '. , ..

IIIIU811 &ldn TIMIDn Llnll NaturallkWwrinkle lin11 with mininal linwta1111iD11. incili-plllllalto IISTI.s minimizes widanllgl l!wlllrlru!lhY, and helps to I*!IDulllllll IC81'1.

'. , Myofibrobluts are the cals rasp-1118 far wound conlnlction. Thev dD this Ita 1111e Df 11111 than o. 75 IMV'dev.

Balle Suqkal Techniques/WoundJ 1'oroDio 2011

Basie Principles minimize tissue traUDlll! fullow curve of needle, handle wound edges gently (UBe toothed

forceps), use just enough tension to appr works well on small areas without much tension or shearing. Advisable in children. May tattooing

staples - steel-titanium ailoy5 that incite minimal tissue reaction (healing is comparable to wounds closed by suture)

Excision incise along relaxed skin tension lines (RSTLs) to minimize appearance of scar use elliptical Incision to prevent .. dog eat(' (heaped up skin at end of Incision) if needed, undermine skin edges to deaeaae wound tension use layered closure Including dermal sutures when wound Is deeper than superficial (decreases

tension)

Wounds Causal Conditions

laceration - cut or torn tissue abl'll8ian - superficial skin layer is removed. variable depth cootuaion - injury by forceful blow to the skin and soft tissue; entire outer layer of skin

intact yet injured avulsion - tlssue/Umb forcefully separated from surrounding tissue, either partially or fully;

"de-gloving" puncture wounds- opening relatively small as compared with depth (e.g. needle)

includes bite wounds crush injuries - caused by compression thermal and chemiall wounds

Principles of Wound Healing wound: disruption of the normal anatomical relationships of tissue as a result of injury

STAGES OF WOUND HEAUNG see Figure 14 growth factors released by tissues play an important role

FACTORS INFWENCING WOUND HEALING Local (revenlble/controllable): General {often .lrrevenible): mechaniall (local trauma, tension) age blood supply (ischemia/circulation) nutrition (protein. vit C, temperature smoking tedml.que and suture materials cbronic Illness (e.g. diabetes, cancer, CVD) retained furelgn body lmmuno9t1ppresslon (steroids, chemo, radiation) infection collagen vascular disease hematoma/seroma ( 1' infection rate) tissue irradiation venous hypertension peripheral vaacular disease

Toronto Notes 2011 Wounda

__________ _________ P_RO_C_EU ________ 1. lnflllmm.taiJ Phullleactivl} pJ..p 1-6}

Limits damage, prsyants further injury Debris and organisms deared viii inflammlllllry respDnse:

Nautrophils {24--48 hours) H 1. Hemostasis- vasoconstriction + PLT plug I Macro phages: critical to wound heeling by z. ChemDIIXis- migration of mecrophages and PMN

orchestrating growth factors for collagen production {4S-96 hours)

Lymphocytes: role poorly defined {5 7 days)

Z. Pralfllrwtin ""- {hgan1r.tiVII) (Day 4 - W.ak 3) Fibroblasts

PL8 Plastic Surgery

.... ,

Infection is based on: 1. V"rrulence of the infecting

microorganism 2. Amowrt of bac:terill prvli8nt 3. Host resistance

Wounds Toronto Notes 2011

Tertiary {3) Closure/Delayed Primary Closure {Third Intention) definition: intentionally interrupt healing process (e.g. with packing), then wound is usually

closed at 4-10 days post-injury after granulation tissue has formed and there is

Toronto Notes 2011 Wounda

BITES

Dog and Cat Bites pathogens: PasteureUa multocida, S. aureus, S. viridans investigations: same as for human bites; see below treatment: Clavulin (500 mg PO q8h started immediately- amoxicillin + clavulinic acid)

consider rabies prophylaxis if animal has symptoms of rabies or unknown animal rabies Ig {20 IU/kg around wound, or IM) and 1 of the 3 types of rabies vaccines

(1.0 ml 1M in deltoid, repeat on days 3, 7, 14, 28) agressive irrigation with debridement healing by second intention is mainstay of treatment (see Emergency Medicine, ER47) only consider primary closure for bite wounds on the face; otherwise primary closure is

contraindicated contact Public Health if animal status unknown

Human Bites pathogens: Staph> a-hemolytic Strep > Eikenella corrodens >Bacteroides) mechanism: most commonly over dorsum of MCP from a punch in mouth; "fight-bite serious, as mouth has microorganisms/mi., which get trapped in joint space when fist

unclenches and overlying skin forms an air-tight covering ideal for anaerobic growth- can lead to septic arthritis

investigations: radiographs prior to therapy to rule out foreign body (tooth)/fracture culture for aerobic and anaerobic organisms, Gram stain

treatment: urgent surgical exploration of joint, drainage and debridement of infected tissue wound must be copiously irrigated Clavulin 500 mg PO q8h, clindamycin 300 mg PO q6h + ciprofloxacin 500 mg PO q12h

(if allergic to penicillin) + secondary closure (see Emergency Medicine. ER47) splint

Dressings there is no one dressing for any given type of wound. Dressing selection depends on the

wound characteristics as the wound progresses through healing it will require different types of dressings, therefore,

routine inspection is recommended principles of dressings:

wet vs. dry wounds - purpose of dressings should be to keep wound appropriately moist (i.e. moistening

dry wounds or removing excess exudate/blood from wet wounds) - dry wounds -+ options include films and hydrogel dressings; require secondary dressing - light to moderately exudative -+ options include hydrocolloid dressing and hypertonic

saline gauze - highly exudative -+ options include hydrofibre dressings, foam dressing , and

hypertonic saline gauze - bleeding wounds-+ options include alginate dressings, as they have hemostatic properties

clean vs. infected wounds - clean wounds can be dressed with petroleum based gauze, which is non-adhering to

epithelializing tissue; requires secondary dressing - infected wounds can be dressed with iodine gauze or silver-containing dressings

wide-based vs. cavitary/tunneling wounds - cavitary or tunnelling wounds (ie. through a fascial layer) can be packed with saline-

soaked (non-infected), betadine-soaked (infected) ribbon gauze, or other easily retrievable one-piece moisture providing dressing

Reconstruction SKIN GRAFTS

Definition a segment of skin detached from its blood supply at the donor site and dependent on

revascularization from the recipient site

Donor Site Selection must consider size, hair pattern, texture, thickness of skin, and colour (facial grafts best if taken

from "blush zones" above clavicle e.g. pre/post auricular or neck) partial thickness grafts usually taken from inconspicuous areas (e.g. buttocks, lateral thighs, etc.)

Plastic Surgery PL9

... , ,

Elwnplp of Dr ... inp Films (Opsita8 ) (lnlnlsitl8 , Nui!1118 , Ouaderm} Hychfib11s (Aquacal) Hyd-ocolloid {Duoderm8 , Teglderm8 ) Hyper1Dnic saline gauza (Masa!t8} FOIUTI (Mepilex4', Allavyn8 } Alginates (Sorb68n8 , Kalmmrt8) Peboleum basad gauze Silver dressings Iodine (lodolorb8 ]

..... ,

lleeonsln1c:tion l.addtr SICOnduy closu11 Primary cl0111n1 Skin graft Locallllp fliiP Free tissue 1nlnsfer

PLIO Plastic Surgery

..... , .. Gnft Cantraction Primary- immediate reduction in size upon h11Mr1ing Secoodary- reduction in 5ize once graft placed on wound bad

Wounds Toronto Notes 2011

Partial Thickness Skin Graft Survival 3 phases of skin graft "take"

1. plasmatic imbibition - diffusion of nutrition from recipient site (first 48 hours) 2. inosculation- vessels in graft connect with those in recipient bed (day 2-3) 3. neovascular ingrowth - graft revascularized (day 3-5)

requirements for survival bed: well-vascularized (unsuitable: bone, tendon, heavily irradiated, infected wounds, etc.) contact between graft and recipient bed: fully immobile {decreased shearing and hematoma

formation) staples, sutures, splinting, and appropriate dressings (pressure) are used to prevent

movement of graft and hematoma or seroma formation site: low bacterial count (

Toronto Notes 2011 Wounds

FLAPS definition: tissue transferred from one site to another with vascular supply (pedicle) intact (not

dependent on neovascularization, unlike a graft) may consist of: skin, subcutaneous tissue, fascia, muscle, bone, other tissue (e.g. omentum) classification: based on blood supply to skin (random, axial) and anatomic location (local,

regional, distant) indications for flaps

reconstruction - replaces tissue loss due to trauma or surgery provides skin and temporary soft tissue coverage through which surgery can be carried out

later improves blood supply to poorly vascularized bed (e.g. bone)

main complication: flap loss due to vascular thrombosis (in free flaps), flap necrosis caused by extrinsic compression (dressing too tight) or excess tension on wound closure, hematoma, seroma, infection, fat necrosis, poor flap design

Random Pattern Flaps (Figure IS) blood supply by dermal and subdermal plexus to skin and subdermal tissue with random

vascular supply limited length:width ratio to ensure adequate blood supply (typically 2:1) flap choice is often a combination of available tissue and surgeon preference types

rotation: cover wounds of various sizes; common use: sacral pressure sores transposition Z-plasty: used to reorient a scar, lengthen the line of a scar or to break up a scar advancement flaps (single/bipedicle, V-Y, Y-V)

V-Y flaps: wounds with lax surrounding tissue; the pedicle is the deep tissue underlying the flap

... Rotation Flap Z-plasty

Rhomboid Transposition Flap (Umberg) Single Pedicle Advancement Flap

V-Y Advancement Flap Figure 15. Wound Care Flaps - Random Pattern

Axial Pattern Flaps (Arterialized) flap contains a well defined artery and vein allows greater length: width ratio ( S-6: 1) types

peninsular flap- skin and vessel intact in pedicle (see Figure 16) island flap - vessel intact, pedicle is better defined (see Figure 17) free flap - vascular supply anastomosed at recipient site by microsurgical techniques

can be sub-classified according to tissue content of flap: e.g. musculocutaneous/myocutaneous [e.g. Transverse Rectus Abdominal Myocutaneous

(TRAM)] vs. fasciocutaneous

Free Flaps transplanting expendable donor tissue from one part of the body to another by isolating and

dividing a dominant artery and veins to a flap and performing a microscopic anastomosis between these and the vessels in the recipient wound

survival rates >95% types: muscle and skin (common), bone, jejunum, omentum

e.g. radial forearm, scapular, latissimus dorsi

"' "' "'

Plastic Surgery PLll

Figure 16. Peninsular Axial Pattern Flap

/ ; . . ; =

Figure 17. Island Axial Pattern Flap

PL12 Plastic Surgery

.... ,

Clllulilia n. E,.,.._lu Cellulitis: indistinct bordm Ery$ipelal: lhlllp borde!'$

Wounds/Soft TIBSue Infections

Teble 5. Free Rep Cherecteristics c .. ractBrillic Nonnll Arllnialllllllllic:ianc:y Colour Pilk Pale T-..l'llln Wa-rn Cool Arlllrill Pulll (Doppler} + ::!: T11111or SDit, but with tissue turgor Decreased

Soft Tissue Infections Erysipelas

Definition acute skin infection that is more superficial than cellulitis

Etiology typically caused by Group A Streptococcus (GABHS) Clinical Features

Toronto Notes 2011

Purple or blue Wa-rn or cool ::!:

Increased (i.e. tensel

intense erythema, induration, and sharply demarcated borders (differentiates it from other skin infections)

Treatment penicillin or first generation cephalosporin (e.g. cefazolin or cephalexin)

Table 6. Classification of Soft Tissue Infections by Depth Erysipal Superficial subcutaneous tissue ilvolvement Calulitis Full thickness with subcutaneous tissue iwolvement flsciilil Myasitis

Fascia Muscle

Cellulitis Definition non-suppurative infection of skin and subcutaneous tissues

Etiology skin flora most common organisms: S. aureus, Streptococcus immunocompromised: Gram-negative rods and fungi

Clinical Features source of infection

trauma, recent surgery PVD, diabetes - cracked skin in feet/toes foreign bodies (IV; orthopaedic pins)

systemic symptoms (fever, chills, malaise) pain, tenderness, edema, erythema with poorly defined margins, regional lymphadenopathy can lead to ascending lymphangitis (visible red streaking in skin proximal to area of cellulitis)

Investigations CBC, blood cultures culture and Gram stain wound/aspirate from wound if open wound plain radiographs if suspect foreign body or abscess

r/o bone invasion (osteomyelitis)

Treatment antibiotics: first line - cephalexin 500 mg PO q6h or diclioxacillin 500 mg PO q6h x 7 days if

complicated (e.g. lymphangitis, DM) consider IV cefamlin 1-2 g q8h outline area of erythema to monitor success of treatment immobilize and splint (hands)

Toronto Notes 2011 Soft Tissue InfectionsJIDcers

Necrotizing Fasciitis Definition rapidly spreading, very painful infection of the deep fascia with necrosis of tissues some bacteria create gas that can be felt as crepitus and be seen on x-rays infection spreads rapidly along deep fascial plane and is limb aud life threatening Etiology Type 1: P-hemolytic Streptococcus Type II: polymicrobial (less aggressive)

Clinical Features pain out of proportion to clinical findings and beyond border of erythema, edema,

tenderness, crepitus (subcutaneous gas from anaerobes) fever infection spreads very rapidly patients may look deceptively well at first, but may rapidly become very sick/toxic late findings:

skin turns dusky blue and black (secondary to thrombosis and necrosis) induration, formation of bullae cutaneous gangrene, subcutaneous emphysema

Investigations a clinical diagnosis CT scan only if suspect it is not necrotizing fasciitis (looking for abscess, myonecrosis, etc.) severely elevated CK: usually means myonecrosis (late sign) hemostat easily passed along fascial plane; fascial biopsy in equivocal situations

Treatment rigorous resuscitation multiple surgical debridements: remove all necrotic tissue, copious irrigation IV antibiotics: as appropriate for clinical scenario; consider penicillin 4 million IU IV q4h

or clindamycin 900 mg IV q6h urgent consultation with infectious disease specialist is recommended

Ulcers Lower Limb Ulcers

Traumatic Ulcers (Acute) failure oflesions to heal, usually due to compromised blood supply and unstable scar usually over bony prominence, edema, pigmentation changes, pain treatment: debridement of ulcer and compromised tissue, reconstruction with local or distant

flap, vascular status of limb must be assessed either clinically or radiographically

Non-Traumatic Ulcers (Chronic)

Table 7. Venous vs. Arterial vs. Diabetic Ulcers

Cause

Hislllry

Distribution Appiii'IRCI

Wound Margins Depth Sunuunding Skin

Valvular incompmce Venous HlN

Dapandant edema, 1nluma Rapid onset throrrtophlebitis,

Medial malleolus Yellow exudates GranulatiDn tissue Irregular Superficial VenDUs stasis discolouration (llrDMI)

2" to smaii111!Vor large vessel disease Be IIWllre of risk factors

Arteriosclerosis, daudication Usually > 45 ya111 Slow progression Distal locations Pale/white, necrotic base ty eschar cowring Ewn ("punched out") Deep Thin shiny dry skin, cool

Diabetic Peripheral neurapa1hy: decreased sensation Atherosclerosis: decreased regional blood flow Diabetes mellitus Peripheral n8Uillpll1hy

Pressure point distribution Necrotic base

Irregular or"punched out" or deep Superficial/deep Thin dry ski! hyperkeratotic border

Plastic Surgery PL13

.... ' j . .----------------.

Soft tlun lnt.ctic11: Su&pae:t nacrotizi'lg fllsciitis with rapidly sp11111ding erythema and edema. Mpllt dmwcllteltylhematousarw on admission in order to determine amount of spread/rapidity of spread.

.... ' Anlde-brachill index IABl) in diabetics can be falsely nonnll due to incompressible arteries secondary to plaq1181/calcificlllion.

.... '

All ch1'1)11ic; ulce,. requinl VBSCullllr lludia Ifill a VIISCI.IIIIIr consult.

PL14 Plastic Surgery tncers/Manasement of Skin Lesion

Tabla 7. Venous VI. Arterial VI. Diabetic Ulcers (continuedl c .. ractBrillic v-UI (70"4 vuc:ulllr ulcarl) Arllrill

No111111l distal pulses Decreased distal pulses ABI >0.9 ABI 6 hours of pressure

Toronto Notes 2011

Dillllltic Decreased pulses likEly ABI is ligh Usually associated with arterial disease

Painless No claudcation or rest pain Associated paresthesia, anesthesia

Control diabates Careful wound care Foot care Orthotics Ell'1y intervention for infections (1apical ancVor systemic antibiotics) Vascular surgical consultation

4. ulcer- necrotic area breaks down - N.B. skin is like tip of an iceberg

Classification (National Pressure Ulcer Advisory Panel 2007) Stage I: nonblanchable erythema present > 1 hr after pressure relief, skin intact Stage II: partial-thickness skin loss Stage III: full-thickness skin loss into subcutaneous tissue, but not through fascia Stage IV: through fascia into muscle, bone, tendon, or joint

if an eschar is present, must fully debride before staging possible

Prevention good nursing care (clean dry skin, frequent repositioning), special beds or mattress (Kin

Air"), proper nutrition, activity, early identification of individuals at risk (e.g. immobility, incontinence, paraplegia, etc.)

Treatment depends on individual patient and condition treat underlying medical issues including nutrition continue with preventative measures (pressure relief) wound debridement, moisture retentive or antimicrobial dressing, regular reassessment topical antimicrobials at treating physican's discretion, systemic antibiotics for infections assess for possible reconstruction

Complications cellulitis, osteomyelitis, sepsis, gangrene

Management of Skin Lesions Skin Lesions see D6

Toronto Nota 2011

Burns Burn Injuries

Causal Conditions thermal (flame contact. scald) chemical radiation (UY, medical/therapeutic) elecbical

Most Common Etiology c:bildren: scald bums adults: flame bums Table 8. Skin Fual:tion d Bum Injury

Con1nll li fluid IDII Loss li l.ge of Wlll8r and pratan Adecr.J8II llid r811J1tibrtian is inpilllliYe from the Kin and other body tissues

Mechanical bllriii'1D becterilll iiMIIion High rilk of inlectic:rl Antl:liGiic oirtrnns (S'jltemic if signs ol m:l inllllnological org1111 spdc infwction pnsent)

Tlllllnua prophylaxi1 if nec1111ery

Pathophysiology of Burn Wounds amount of tissue destructl.on is based on temperature. time of exposure, and specific heat of the

causative agent (see Figure 18) zone of hyperemia - VIIIIOdilation from inflammation; entirely viable, cells recover within 7

days; contributes to systemic consequences seen with major burna zone of stula (edema) - decreased perfusion; microvascular sludging and thrombosis of vessels

results in progressive tissue necrosis -+ cellular death in 24-43 hours without proper treatment factors favoring cell survival: moist, aseptic environment, rich blood 1111pply zone where appropriate early intervention bas most profound effect in minimi1Jng injury

zone of coagulation (isdwnla) - no blood flow to tissue -+ irreversible cell damage -+ cellular death/necrosis

Diagnosis and Prognosis bum size (see F.lglue 19)

%of total body surface area (TBSA) burned- rule ofSl's for 2 and 3 bums only (children

PL16 Plaatic Suqp!ry

.... ,

Proplil blllt determined bV bum Iilii !lBSAI. age of patiaJL llblanca of ilhllation injury .

... ,

blnllll*! rwtrict mpntory m:ursion Mrllar blaod flaw Ill IIKinlmiti88 and I'ICJ!irl 88chlrDimnV.

.... , . TBSA d not include areu with 1

BurDI 1'oroDio 2011

f"IIIIIFI 11. R1l1 af 1'1 fDr TGtllllady S11rf'llce Anll (liSA)

Anlll AgaD Afe1 Afel Agllll Ap15 Mill A= I'. head- 814 B = Y.llll!lh 1M 314 C='AiltaiiH Z'Ai ZY.

F"11111ra ZO. Llnd-8rowd Diagram Tabla I. B11m IJeptll (1st. 2nd, 3nl dear)

Secanddep!

DIIIP"PIItiiiTblcb Secand dep!

Ful Tllicbell

'"' 414 414 3 3

lniD lllpllficiJI d1m1is

41'. 4'Ai 314

31'. 4% 31'.

Painlui,IIIISBtian inlll:t. arythama. bhn:llllllle Painful. SIIISIItion inlll:t. erythema. blisle!s with clall'lluid, blenc:lllllle, hlir folliclas pre&ant

lniD deep (relicdar) dennis Insensate, dilfiwlt ID distincrJjsh fl1lm ful thiclinasl. does not billdl. acme t.ir folliciBIIII allachad. IIOfta" then ful 11icknass bum

Tlnugh apidannis and damis lnsamall (IIIIVIIR!ings dastroyadl.lwd Injury ta tissue le&thery eschar lhllt is Iiiii, grey, while. 8ll\lciJns (e.g. mUlde, bn) ar cllany lid in colour, hlin do nat ll8y

IUiclled, may a111D!R10&8d wins

Toronto Notes 2011 Burns

Indications for Transfer to Burn Centre American Burn Aaociation Criteria total2 and 3 burns> 10% TBSA in patients 50 years of age total2 and 3 burns >20% TBSA in patients any age 3 bums/full thickness >5% TBSA in patients any age 2, 3 or chemical bums posing a serious threat of functional or cosmetic impainnent (i.e.

circumferential bums, bums to face, hands, feet. genitalia, perineum, major joints) inhalation injury (may lead to respiratory distress) electrical bums, including lightning (internal injury underestimated by TBSA) bums associated with major trauma/serious illness

Acute Care of Burn Patients adhere to ATIS protocol resuscitation using Parkland formula to restore plasma volume and cardiac output

4 cc Ringer's/kg/% TBSA over first 24 hours ( 1/2 within first 8 hours of sustaining bum, 1/2 in next 16 hours)

extra fluid administration required if bum >80% TBSA 4bums associated traumatic injury electrical bum inhalation injury delayed start of resuscitation pediatric burns

monitor resuscitation urine output is best measure -maintain at >0.5 cc/kglhr (adults) and 1.0 cclkg/hour

(children 10% TBSA, or deeper than superficial partial thickness, need 0.5 ml tetanus toxoid

also give 250 U of tetanus Ig if prior immunization is absent/unclear, or the last booster >lOyrs ago

baseline laboratory studies (Hb, U/A, BUN, CXR, electrolytes, ECG, cross-match, ABG, carboxyhemoglobin)

cleanse, debride, and treat the bum injury (antimicrobial dressings) early excision and grafting important for outcome

Respiratory Problems 3 major causes

bum eschar encircling chest distress may be apparent immediately perform escharotomy to relieve constriction

carbon monoxide (CO) poisoning may present immediately or later treat with 100% 0 2 by facemask (decreases half-life of carboxyhemoglobin from 210 to

59 minutes) until carboxyHb < 10% smoke inhalation leading to pulmonary injury

chemical injury to alveolar basement membrane and pulmonary edema (insidious onset) risk of pulmonary insufficiency (up to 48 h) and pulmonary edema ( 48-72 h) watch for secondary bronchopneumonia (3-25 days) leading to progressive pulmonary

insufficiency intubate patient with any signs of inhalation injuries

Plastic Surgery PL17

.... , _._ ______________ Headache Conluaion Coma "Arrhyllwnias

.... .. lnhmtion lnjpr-101 l.lndicaiDrs of lnhlllstion Injury

Injury in 1 closed space Facial bum Singed nasal hair/eyebrows Soot around n.rarloral cavity HOirMIIHII Conjunctivitis Tachypnu Carbon particles in sputum El.vmd blood CO IMs (i.l.

brighter red I 2. Suspected ilhalation injury requires

immediate due ID impending airway adema. FaiiUIIIID dilgnou inhalation can rnult in aifway swelling and obstruction, which, can lead ID death.

3. Nllilher CXR or ABG can be uud ID rull out inhallltion injury.

4. Oirvct broncho&copy now used for diagnosis

PLIB Plastic Surgery

Table 1 D. Burn Shock Ruscitlltion (Parkland Fonnulal Hour W4 4 cc TBSA

with 112 of total 0-8 h llld 1/2 of tcrtal 11-24 h

Hour 24-30 0.3&-0.5 cc

>Hour 30 D5W at rate to maintain normal serum sodium

* da nDtforgBIID add TlllliriBIIIIDfUd ID IISIISCi1mJn

MIINnllflil IIEII!r Wililnfllllrll 8lmr ZOO&; l'lllfiii:TDIIIIblilhilllltyiiiiCilianMdgllfting il IUJ)IIiJr !Dr equillllntj to CGIIIIrvaMJIIItmR llld dlllyad gllfting Dlllll tile lull 81Chlr -IIJ)Irllad. M....,..._AillrQ!re!Mw- prDip8C1M ntndDnillld cuabulud lllll:ililn I

Toronto Notes 2011 Burns

nutrition hypermetabolism: TBSA >40% have BMR 2-2.5x predicted calories, vitamin C, vitamin A, Ca, Zn, Fe

immunosuppression and sepsis must keep bacterial count 48 hours post-bum, mental status changes, azotemia, thrombocytopenia, hypofibrinogenemia, hyper/hypoglycemia (especially ifbum >40% TBSA}

gastrointestinal (GI) bleed may occur with bums >40% TBSA (usually subclinical) treatment: tube feeding or NPO, antacids, H2 blockers (preventative)

renal fallure secondary to under resuscitation, drugs, myoglobin, etc. progressive pulmonary insufficiency

can occur after: smoke inhalation, pneumonia, cardiac decompensation, sepsis wound contracture and hypertrophic scarring

largely preventable with timely wound closure, splinting, pressure garments and physiotherapy

Special Considerations CHEMICAL BURNS major categories: acid burns, alkaline burns, phosphorous bums, chemical injection injuries common agents: cement, hydrofluoric acid, phenol, tar mechanism of injury: chemical solutions coagulate tissue protein leading to necrosis

acids -+ coagulation necrosis alkalines -+ saponification followed by liquefactive necrosis

severity related to: type of chemical (alkali worse than acid), temperature, volume, concentration, contact time, site affected, mechanism of chemical action, degree of tissue penetration

burns are deeper than initially appear and may progress with time

Treatment {general) ABCs, monitoring remove contaminated clothing and brush off any dry powders before irrigation irrigation with water for 1-2 h under low pressure inspect eyes, if affected: wash with saline and refer to ophthalmology inspect nails, hair and webspaces correct metabolic abnormalities and tetanus prophylaxis if necessary local wound care after 12 hours initial dilution (debridement) wound closure same as for thermal bum beware of underestimated fluid resuscitation, renal, liver, and pulmonary damage

ELECTRICAL BURNS depth of bum depends on voltage and resistance of the tissue (injury more severe in tissues with

high resistance} often presents as small punctate burns on skin with extensive deep tissue damage which requires

debridement electrical burns require ongoing monitoring as latent injuries can occur watch for system specific damages and abnonnalities:

abdominal: intraperitoneal damage bone: fractures and dislocations especially of the spine and shoulder cardiopulmonary: anoxia, ventricular fibrillation, arrhythmias muscle: myoglobinuria indicates significant muscle damage -+ compartment syndrome neurological: seizures and spinal cord damage ophthalmology: cataract formation (late complication) renal: acute tubular necrosis (A TN) resulting from toxic levels of myoglobin and hemoglobin vascular: vessel thrombosis -+ tissue necrosis (increased Cr, K and acidity}, decrease in RBC

(beware of hemorrhages/delayed vessel rupture}

Treatment ABC's, primary and secondary survey, treat associated injuries monitor: hemochromogenuria. compartment syndrome, urine output wound management: topical agent with good penetrating ability (silver sulfadiazine or mafenide

acetate) debride non-viable tissue early and repeat pm (every 48 h) to prevent sepsis amputations frequently required

FROSTBITE see Emer.genc.y Medicine, ER45

Plastic Surgery PLHI

..... , . .-----------------, Speed is essential in the m-aement of chemical blms 1111 chemicals cen conti1111e to cause damage untlthey are IVIIIOVlld or neLmllizlld.

..... , .. Tu: remove with repeated applicidiiJil of petroiiUIII-based antibiotic ointments (e.g. Polysporin ).

..... , .. .-----------------. TI'MIIIIIIIC(speclic] Acid br: dilute sokrtion of sodium bicarbonate folowing wmr iniiJIItion llydrvl-": acid: water irriglltion; fingtmails to avoid acid 1npping; topical calcium gel injection of calcium gklconate 1 0"' calcium gluconab!IV depending on 1rn0unt of axposura and pain Wfuric Kid: treat with prior to irrigation, u di111ct wmr axposure produces extreme heat

.... , . T- a.sistMCII te EIIICiriclll Cunallt: nerva < VIISS&liblood < muscle < lkin < tendon < fat < bone

PL20 Plastic Surgery

.... . High pressure injection inj-.y is dacllplivlly b111ign-looking (1111aU pinpoint hole on finger pad] often with few clinical signs. Intense pain and tenderness, along the cour1a tha fllraign mamriallrlvalad, is pmant a faw hours an. th1 iljury. Definitive 1rHiment is EDCpQsure and ramoval of foraign mamrial.

,, I . Allen' Tnt: while patienfs hand is finnly l:lolad, m:luda both radial and ulnar arteries. Once fist is open, release aithar artary and llSSBSS con.teral flow.

It' Appnw:h ID Hand Llcllionl TIN AX Tanus prophylaxis Irrigate with NS NPD Antibiotic prophylaxis X-rays

I ,.}-----------------, Nevw blindly clamp a bleading viSSII as nerves are often found in close IISSIIcillion with vnuls.

,, I

Arterial bleaclinu from a volar digilal laceration may indicate nerve lacellllion (fiiiMII in digits ara suparficial to arteries].

Hand Toronto Notes 2011

Hand Traumatic Hand

Tabla 13. Kay Faaturaa of tha Hiatury and Physical Exam of tha Injured Hand in the Emergency Department HISTORY

PHYSICAL EXAM On.v.tian

SaniHIIY (IIefer to Figum 3)

Matur Functio1

AQe Hand oomilllllce Occupation lime and place of accident Mechani5m of injury Tetanus status

Position of finger Dafonrity Bruising or sweling Sweating pattern Ana!Dmicel strucbues beneath

Radial and ulnar wries Digital arteriee Temperature and skin turgor

Median nerve Ulnar nerve Radial nerve nerves Median nerve

Ulnar nerve

Radial narva

Flexor Digitorum Profundus (FDP)

Flexor Digitorum Superficialis (FDS)

Bones Joints

General Management Nerves

Abnormal cadence (fingen normally slightly ftaxed), scissoring Bony or apacific (e.g. Mallet. Swan Neck) May indicate underlying skl!lellll i;ury May indicate denlli!Mition If open laceration, need to 8llj)lore within wound (under sterile Allen's Test (see sidebar) Capillary refill (

Toronto Notes 2011 Hand

Vessels often associated with nerve injury (anatomical proximity) control bleeding with direct pressure and hand elevation if digit devascularized. optimal repair within 6 hours dress, immobilize, and splint hand with finger tips visible monitor colour, capillary refill, skin turgor, fingertip temperature post-revascularization

Tendons most tendon lacerations require primary repair many extensors are repaired in the emergency room. flexors in the operating room within

2 weeks avoid excessive immobilization (specific protocols for flexors, 2-3 weeks for extensors) to

minimize stiffness and facilitate rehabilitation

Hand Infections Principles trauma is most common cause 5 cardinal signs: rubor (red), calor (hot), tumour (swollen), dolor (painful) and functio laesa (loss

of function) 90% caused by Gram-positive organisms most common organisms (in order) - S. aureus, S. viridans, Group A Streptococcus,

S. epidermidis, and Bacteroides melaninogenicus (MRSA becoming more common)

TYPES OF INFECTIONS

Deep Palmar Space Infections uncommon, involve thenar or mid-palm. treated in OR

Felon definition: subcutaneous abscess in the fingertip that commonly occurs following severe

paronychia or a puncture wound into the pad of digit; may be associated with osteomyelitis treatment: elevation, warm soaks, cloxacillin 500 mg PO q6h (if in early stage); if obvious

abscess then I&D and PO cloxacillin

Flexor Tendon Sheath Infection Staph> Strep >Gram-Negative Rods definition: acute suppurative tenosynovitis commonly caused by a penetrating injury and can

lead to tendon necrosis and rupture if not treated clinical features: Kanavel's 4 cardinal signs:

1. point tenderness along flexor tendon sheath (earliest and most important) 2. severe pain on passive extension of DIP (second most important) 3. fusiform swelling of entire digit 4. flexed posture (increased comfort)

treatment OR incision and drainage, irrigation, IV antibiotics, and resting hand splint until infection

resolves

Herpetic Whitlow HSV-1, HSV-2 definition: painful vesicle(s) around fingertip often found in medical/dental personnel and children clinical features: can be associated with fever, malaise and lymphadenopathy patient is infectious until lesion has completely healed treatment: routine culture and viral prep protection (cover), consider oral acyclovir Paronychia acute = Staph; chronic = Candida definition: infection (granulation tissue) of soft tissue around fingernail (beneath eponychial fold) etiology

acute paronychia - a "hangnail': artificial nails, and nail biting chronic paronychia - prolonged exposure to moisture

treatment acute paronychia - warm compresses and cephalexin 500 mg PO q6h drainage if abscess

present chronic paronychia- anti-fungals with possible debridement and marsupialization, removal

of nail plate

Plastic Surgery PL21

... ,

Co11putmenl Syndrome Watd1 out for these signs with doled or opan injury: tiiiiSI, peinful fiXtrwnity on paHive lilrulch), dilllll pulsaiiiSIIKISs {oftan lata in process). and contracture {irTIIVaraible ischamia). lnti'IICompartmental pressum can be menurad, but a clinicel diagnosis is an indication for an emergent fasciotomy. If untr8111ed, end 1'88Uit is ischemic af the extremity {Volkmann's

PL22 Plaatic Suqp!ry

Figure 22. Zone of Extensor r .. dDn Injury {Odd n1111bered zones fall over a jai nt)

Z3. Millet Finger Dafomity

Figure 24. BaiiiDnniara Dafunrity

DIP Fltxion

I PIP Hyp--.si111 Figure 25. Swa Naclc: Dafarmity

Hand 1'oroDio 2011

Amputations Hand or Finger emergency management: injured patient and amputated part require attention

patieDt: .x-mys, NPO, clean wound and irrigate with NS, dress stump with nonadherent, cover with dry sterile dressing, tetanus and antibiotic prophylaxis (cephal.oaporin/ erythromycin)

amputated part: J:-rays. gently irrigate with RL. wrap amputated part 1n a NSIRL soaked sterile gauze and place inside waterproof plastic bag, place in a. container, then place container on ice

indkalions 1Dr replamation ap: children often better results than adults level of injury: pronmal. thumb and multiple digit amputations are higher priority nature of injury: guillotine injuries have a better potential; avulsion and auab injuries are

relative contraindications to replant If replant contraindicated manage stump with revision amputation

would only allow a fingertip injury to heal by secondary intention

Tendons Common Extensor Tendon Deformities

Table14. Exl:eiiiOI' Tendon Daformltlea II jury Dllililian llna EtiDIIIIf/tinicll fteluNI Trlllnat MllletFiiiJII" Df llaxad 1Mth loss tA active I Fal:ad flaxian of 1ha axtendad DIP Splint liP in axtansian fa-

IIICialsian (s&a Fi!1118 23) joint to axllln&ar tand111 & was fallawad 11y 2 wea1a1 ruplln at DIP jairt (e.g. sudd111 ol night splinq. If inadeqUIIII blow to tip li1be fin gel) 6 weeks..

check aplinting routine and 18C11111111111d 4 men waab tA Clllllilaus spliting ....... Pf flaxad. DIP hyperaxtendld 3 Injury ardis- Splint PIP in axtansian IIIII !Iaw

Dafadr (see Fue 24) exllmsar tenlan insatian i!G 1he active DIP motian dlllllll bala Dl tha midde phlln Assacialad with dlaumad IWthritis (RA) ar tnune will" di!lacation, BCUte fmzful lleiOOn of PIP)

Swa Macl Pf hyperadaldad, DIP flaK8d 3 val plata Splint ta pravant PF Dafadr (588 Fijr.lre ZS) Assacialad with RA 111d aid, llypalvmnsianar Ill' flaxian

Ull1r8Bt8d ..... dnmity Cansid a11radasiWarthrapllmy

Da Quervaln's Tenosynovltls(zone 7; most common cause of radial wrtst pain) de:finl.tion: inflammatl.on in 1st extensor compartment (APL and EPB) cllnl.aal features:

+ve Finkelstein's teat (pain over the radl.al styloid induced by making fist, with thumb in palm, and ulnar deviation of wrist)

pain l..ocallzed to the 1st extensor compartment tenderness and aepitation over radial styloid may be praent diffe:rentiate from CMC joint arthritis (CMC joint artlutti& will have a positive grind test,

whereby crepitus and pain are elldted by axial pressure to the thumb) treatment:

mllcl: NSAIDs, spllnting and steroid injection into the tendon sheath (succeasful. in over 60% of case.)

&eYere: surgical release of stenotic tendon sheaths (APL and EPB); remember there may be 2 or more sheaths

Ganglion Cyat (zone 7) definition:

fluid-filled synovial lining that pratru.dcs between carpal bones or from a. tendon sheath; most commonly carpal in origin

most common soft tissue tumour of hand and wrist (6096 of masses) cllnl.aal farturea:

most common around scapbolunate ligament junction 3 times more common in women than in men more common in younger individuals can be luge or small -may drain internally so size lllll)' wax and wane often non-tender although tenderness increased when cyst smaller (from increased pressure

within amall.er cyst sac)

'IbroDlo Nota 2011 Hand

trcablleDt: conservative treatment: watch and wait aspiration (recurrence rate 6596) consider operative acision of cyst and stalk (recurrence is po88ible) steroids if pa1nful

Common Flexor Tendon Dvformities (see Figure 26) fiemr tendon zones (Important for prognosis of tendon lacerations) "no-man's land":

between distal palmar crease and mid-middle phalanx zone where superficialis and profundus lie ensheathed together recovery of glide very dlfficult after Injury

Stenosing Tenosynovitis (trigger Dnger/thumb) definition: inflammation of synovium Cllll8e8 size discrepancy between tendon and sheath/

pulley (most commonly at A-1 pulley) = locking of tbumb or finger in timon/extension etiology: idiopathic or associated with RA, diabetes, hypothyroidism and gout clinic:al fnlara:

thumb, ring and long fingers most commonly affected patient complains of catching, snapping or locking of affected finger tenderne88 to palpation/nodule at palmar aspect ofMCP over A1 pulley women are 4 times more l.ikdy than men to be affected

conlenative treatment: NSAIDs steroid injection surgical flexor tendon release injectiomlesslikely to be ruccessfu.l in patienb with DM or symptoms greater than 6 months

aurglcal treatment: incise A-1 fluor tendon pulley to permit unrestricted, full active finger motion

Fractures and Dislocations for fracture prindples, see OrthQ,paedljJb ORS FRACTURES about 90% of hand fractures are stable in fl.exl.on (locklprevent extension) polition of fandloo. (like a band holding a pop can) (see Figure 27):

wrist extension 15 MCP fl.mon 45 IP fial.on (slight) thumb abduction/rotation contraindicatlons: post repair of flexor tendons, medlanlulnar nerve injury

polition of safety (see Figure 28): wrist extension 45 (position most beneficial for hand function if immobilized) MCP flmon 600 (maximal collateral ligament stretch) PIP and DIP in full atension (m.ui.mal volar plate origin stretch) thumb abduction and opposition (functional position)

stiffness secondary to immobilization is the most Important complli:ation; Tx = early motion Distal Phalanx Fractures most commonly fractured bone in the hand usual mechanism Is crush injury and thus accompanJ.ed by soft tissue injury subungual hematoma is common and must be decompressed if pamful or nail removed treatment consists of 3 weeks of dJgital splinting (with IP joint movement preserved) Proximal and Middle Phalanx Fractures check for: rotation, sd88oring (overlap of fingers on making a fist), shortening of digit undispla.ced or minimally displaced- closed reduction (if extra-articular) buddy tape to

neighbouring stable digit, elevate hand, motion in guarded fa&hion 10-14 days post injury displaced, non-reducible or not stable with closed reduction- percutaneous pins (K-wires) or

ORIP, and splint Metacarpal Fractures generally accept varying degrees of deviation before reduction required: up to 10" {D2),

20" (D3), 30 (04), or 40" (D5) Boxer\ fraaure (ema-artl.cul.ar): acute angulation of neck of metacarpal of little finger into

pelm (see Figure 29) mechanism: blow on the distal-dOI88l upect of closed fist loss of prominence of metacarpal head, volar displacement ofhead check for scissoring of fingers on making a :fist

Plutic Surgery PL23

A2and A4 pulley5 n most importlfll lor flrlction; pwwent bowstmgWig of bin do..

Figura 26. lanes af tla Flexar T811donS

Figura 27. Positian af F1111ction

Figura 21. Positian af Slfety

PL24 Plaatic Suqp!ry

.. 31. RollllldDs Fnelu18

'' ,

I I :I! 0

.. AccurHJ rlth fir C.rlllllmllllynd.,.IH Hilmi SU1pty 1916; p.223 1. Phalen's:

SenaiiMty: 0.75 Specificity: 0.47 2. lira's:

SenaiiMty: 0.60 Specificity: 0.67 3. IMpel Tumel Compnaion Test:

SenaiiMty: 0.87 Specificity: 0.90

Hand 1'oroDio 2011

up to 30-40'> angulation may be acceptable closed reduction should be considered to decrease the angle if stable ulnar gutter splint x 3 weeks with PIP and DIP joints free

Bennett's fraaare (intra-artkular): fracture/dislocation of the base of the thumb metacarpal (see Figure 30)

unstable fracture abductor pollicis longus pulls MC shaft proximally and radially causing adduction of thumb treat with percutaneoue pinning. thumb spica x 6 weeks

Rolando' fraaare (intra-artic:ular): T- or Y-shaped fracture of the base of the thumb metacarpal (see Figure 31)

treat with open reduction, internal :fixation (ORIF) with K-wire

DISLOCATIONS must be reduced as soon as possible PIP and DIP Dislocations (PIP more common than DIP) usually dorsal dislocatl.on (commonly from hyperexteD!Iion) if closed dlslocation: closed reduction and splinting (30 flal.on for PIP and full extension

for DIP) or buddy taping and early mobilization (prolonged immobilization causes stiffness) open injuries are treated with wound care, closed or open reduction and antibiotics MCP Dislocations (relatively rare) dorsal di&locations much more common than volar dislocations dorsal di&location of prmimal phalanx on metacarpal head; most commonly index finger

(hyperenension) two types of dorsal dislocation:

simple (reducible with manlpulation) - treat with 2 weeks of splinting at 30" MCP tlai.on compla: (volar plate blocks reduction)- treat with open reductionand Al pulley release+

cxb:nsion-blocking splint at 30" tlenon (2 weeks) then 100 ftenon (2 weeks)

Ulnar Collateral Ligament (UCL) InJury forced abduction of thumb (e.g. ski pole injury) Lllier"s thumb: acute UCL injury pmekeepen thumb: chronic UCL injury mdaaticm: radially deviate joint in full extension and at 3Qa flexion and compare with non-

injured hand. UCL rupture is presumed if injured side deviates more than 30" in full extension or more than tsa in flexion

Stcner'sle&ioD: the UCL ha8 bony attachments to the adductor aponeurosis and the piOJdmal ligament can displace while the dirtal attachment remains deep to the aponeurosis, forming a barrier that blocks healing and leads to chronic instability; requires surgery

Dupuytren's Disease Definition contraction oflongitudinal palmar fascia. forming nodules (usually painless), fibrous cords and

eventually flexion contractures at the MCP and interphalangeal joints (see Figure 32) flexo.r tendons not involved Dupuytren's diathesis - early age of onset. strong family history, and involvement of sites other

than palmar aspect of hand Epidemiology genetic disorder (unusual in patients from Afrkan and Asian countries, high inddence in

northern Europeans), men> women, often presents in 5th-7th decade oflife, assodated with but not caused by alcohol use and diabetes

Clinic.l FHtures order of digit involvement (most common to least common): ring :> little :> long :>thumb :> index may also involve feet (Lederhosen's) and penis (Peyronie's - see UroloBY. U29) Treatment stages:

1. palmar pit or nodule - no surgery 2. palpable band/cord with no llinitation of atension of either MCP or PIP- no ru.rgery 3. lack of extension at MCP or PIP - smgical fasciectomy indicated 4. irreversible periarticular joint changesfscarring - smgical tn:al:ment possible but poorer

prognosis compared to stage 3

Toronto Notes 2011 Hand

indications for percutaneous release: functional impairment MCP joint contractures >30 any PIP contracture rapidly progressive disease

may recur, especially in Dupuytren's diathesis

Carpal Tunnel Syndrome (CTS) Definition median nerve compressed by nearby anatomic structures Etiology median nerve entrapment at wrist primary cause is idiopathic secondary causes: space occupying lesions (tumours, hypertrophic synovial tissue, fracture

callus, and osteophytes), metabolic and physiological (pregnancy, hypothyroidism, and rheumatoid arthritis), infections, neuropathies (associated with diabetes mellitus or alcoholism), and familial disorders

job/hobby related repetitive trauma, especially forced wrist flexion

Epidemiology female:male = 4:1, most common entrapment neuropathy Clinical Features sensory loss in median nerve distribution i.e. radial3.5 digits (see Figure 3) discriminative touch often lost first classically, patient awakened at night with numb/painful hand, relieved by shaking/dangling/

rubbing decreased light touch, 2-point discrimination, especially fingertips advanced cases: thenar wasting/weakness Tinel's sign (tingling sensation on percussion of nerve) Phalen's sign (wrist flexion induces symptoms)

Investigations a clinical diagnosis nerve conduction velocities (NCV) and EMG may confirm, but do not exclude, the diagnosis

Treatment avoid repetitive wrist and hand motion, wrist splints when repetitive wrist motion required conservative: night time splinting to keep wrist in neutral position medical: NSAIDs,local corticosteroids injection, oral corticosteroids surgical decompression: transverse carpal ligament incision to decompress median nerve indications for surgery: numbness and tingling sensory loss, weakness muscle atrophy,

unresponsive to conservative measures complications: injury to median motor branch, palmar cutaneous branch or superficial

transverse vascular arch, local pain (pilar pain), scar

Rheumatoid Hand General Principles non-surgical treatments form the foundation in the management of the rheumatoid hand surgery only for patients whose goals (improved cosmesis or function) may be achieved Surgical Treatment of Common Problems synovitis: requires tendon repair if ruptured; can lead to carpal tunnel syndrome and trigger

finger ulnar drift: MCP arthroplasty, resection of distal ulna, soft tissue reconstruction around wrist thumb deformities: can be successfully treated by arthrodeses (surgical fixation of joint to

promote bone fusion

Plutic Surgery PL25

Dllllplli: trilldllar Calfll TAll StW-JilllldSIIg,111J6. YGI31 No.6 p.911 ,.._e: To dMgp CIIPII tunlllll1lihrrl tt.lllllllllld till clniclll dilgnolti: piiCii:lll rl axpartl. 57 cinicllllildings -cillsd l"lidiCTS, eight were mild 1 pnlrl aplll clinicilnL lhing Z!i6 -lilmrill.l pal rl mcperts decided wheller a case did did nat I'Md.-riCTS. ,_d .. ..--. the .,dentmiable Ill! a logistic regralioa model. 111 wflicll tilleigbt cinicallildings wn IIIPhd. 1111 modiiWII dwiwldllld l(lliRII till C01118111US of IIICOIIII J*IGI on 1118 dillgnosis af CTS forU. C8l8 hillllriM. blulll: The--between the problblty rl CTS pl'llliclld by tillllgllllion lllldllllld till pnlrJcliicin-0.71. filii lilt ofUIIIWigiDd cmcal rilgnonc Clitlria tt.l OIJIIribulld slgnificlndv bl111e 1. illiWlilfl IIIIW

dillrillllian 2. rtlct!Jmlll"llrilnasl 3. w.knaa lr4'GIIIIIolil rl tilllillall

4. f111f111ign 5. PIMI(stest &. 1.os1 rl Z.paid dilcrimmon

.... ,

Rldlorlrllhlc Evolution of tile Rh-lltoid Hlllll Eullest sign: 1111sion of lh1 uln11r 5tyloid PrOgr811i .. : chracterized by symmetrical joint space narrowing IUid arolions oftha CllrJIIII bones. MCP and PIP (with DIP r.IIIIMiy sparld) ._... st.ge: Swan neck IUid 8outomiara deformities

PL26 Plastic Surgery Brachial PleiUsiCraniofadallnjurlea Toronto Notes 2011

Brachial Plexus Etiology common causes of brachial plexus injury: complication of childbirth and trauma other causea of injury: compression from tumours, ectopic ribs

Common Palsies Tabla 15. Named NaDnlltlll Palsies Df tha Brachial Pinus

DucllenneEIII Pllly Lacation ullnjwy Machlniun ullnjury Upper brachial pi8XliS (C5-C6) HaacVshouldar distraction

(e.g. motorcycle)

Lower brachial plexus (C7-T1) Traction on abducted arm

Differential Diagnosis trauma (blunt, penetrating) thoracic outlet syndrome

neurogenic - associated with cervical rib; compression of C8/Tl

Faaturea Waiter's tip dlllormity (shoulder internal rotation. elbow extension, wrist flexion) May include Homer's syndrome {"claw hand")

vascular - pain or sensory symptoms without cervical rib; cessation of radial pulse with provocative maneuvers

tumour schwannoma- well-defined margins makes it easier for total resection neurofibromas- associated with neurofibromatosis type I (NF-1) other- e.g. Pancoast's syndrome (apical lung tumour)

neuropathy (compressive, post-irradiation, viral, diabetic, idiopathic)

Investigations EMG MRI - gold standard for identifying soft tissue massea CT myelogram - better than MRI for identification of nerve root avulsion and identification

of pseudomeningocele. hnportant for preoperative identication of patients likely to require neurotisation procedures ( esp. for patients with blunt trauma)

Management Tabla 16. Management Df Brachial Plaxuslnjuries

Non.flnllrlling Tra111111 Type Concussivalcomprassive TractiorVstretch Obstetric palsy

Sharp or vascular injury

Craniofacial Injuries

Trennent Usualy improves (unless expanding mass, e.g. hamlllllma) H no continued insult. follow for 3-4 months for improvement Surgery if no significent and/or residual paresis at 6 months Df age Explore immediately in OR

low velocity vs. high velocity injuries determine degree of damage fractures cause bruising, swelling and tenderness -+ loss of function frequency: nasal > zygomatic > mandibular > maxillary management can wait 5-10 days for swelling to decrease before ORIF required

Toronto Notes 2011 Craniofacial Injuria

Approach to Facial Injuries ATLS protocol inspect, palpate, clinical assessment for injury to underlying structures (e.g. facial nerve) visual assessment tetanus prophylaxis radiological evaluation wound irrigation with NS/RL and remove foreign materials conservative debridement of detached or nonviable tissue repair when patient's general condition allows (soft tissue injury:

PL28 Plaatic Suqp!ry

Figura 33. Maalihlllar flllcbn

Craniofadal.lnjuries 1'oroDio 2011

Classificlltion

Tabla 18. Mandibular Fnctura ClassilicatiDns by Anata11ic Ragi ... (rmr ta Figun 33)

Midln. d the 1111111dibll; bai.WIIII the clldnll R:isars frrm tha aiVIIOI!w J11DC8SS lllwgh the mrior border of 111! IIIIIRJie Fmn the &yl1lllyliB ta the lislllllveollr bardfl' af the 111ird malar ""an batwaan tha anllriar bardar of tha riiiiS88tar and tha postarasuperia" inurliln of 1ha miiiS8bir lislllm tha third niJiar Pllrt olthe that 8ldands poalariaaupericlly illo the CDII!yllr caranid praca Araa of CIJIIdo,W jnC8IIS ofllllllldibla Area below lila cmdylar nack (i.e. &Vnaid natdl) of the mild!! a Araa of the Cllllnlid pnJC8SS d llllllldibla

Treatment muillary and mandibular arch bars wired together (int:ramaDllary fixation) or ORIF antibiotics to cover against S. aureus and anaerobes Complications malocclusion, mal.unlon tooth loss, and possible sensation loss temporomandibular joint (TMn ankylosis

Maxillary Fractures Tabla 19. La Fort Clatiliclllion

t.I'Gitl Allin.._ Nan frlcbn TyJe of lracbn Horizontal Slrur:llns imhad PiriDrm apa11n

Maxilllry sinus PtErygoid plates

La Fllltll Pyrwlidal frlclllre Pynmdal Nasal banes Medial arbittll wall Mad a Plarygcid plltal

La Flllt Ill l:raliollcill dyljiiiCtian TIIIIISIIa18 Nlsafnmlllllllnl ZygarnatGfnlntalmre Zygomatic 8ICh Ptalygaidplltel

Anltlnal...-t Maxilla dividld inta 2. aapants Madery 18eth l8l)8l1ll8d from DBtach entiremdflcill akllaton face frrm cnnial basa

La fait I Fradlns La Flllt II Fncllnl La Flllt II Flldlnl

i j .II i

Toronto Nota 2011 Cnmiofadal.lajurics

Nasal Fractures Etiology lateral force -+ more COlMlOil, good prognosis anterior force -+ can produce more serious injuries most common facial fracture Clinical Features epistaxislhemorrhage, deviationlflattening of nose, swelling, periorbUal ecchymosis, tenderness

over nasal dorsum. crepitus, septal hematoma, respiratory obrtrw:tion. subconjunctival hemorrhage

depression and splayiDg of nasal bones causing a saddle deformity important to clinically assess for naso-orbital-ethmoid (NOE) fractures Treatment nothing always drain ICpta1 hematomu as this is a cause of septal necrosis with perforation (saddle nose

deformity) closed reduction w.lth Asch or Walsbam forceps under anesthesia, pack nostrils with Adaptic",

nasal splint for 7 days best reduction immediately (

PL30 Plaatic Suqp!ry

F'111 .. 35. Blnv-0 .. Fractu ..

.... 1 . Di!llopia Cll1 IIIII illllllillll blow-out liactinl.

Craniofadal.lnjuries

Orbital Floor Fractures see Qphtha1moloK)Io OP43 Definition fracture of floor of orbit intact infraorbital rim (see Figure 35) may be assodated with naaoetbmoid fracture Etiology

1'oroDio 2011

blunt force to eyeball -+sudden increase in intra-orbital presmre (e.g. baseball or fist) Clinical Features daeck ruual ftel.ds and acuity fur injury to Blobe periorbital edema and bruiaing. subconjunctival hemorrhage ptosis, exophthalmos. exorbitism. or enophthalmos orbital rim step-off's with possible Infraorbital nerve anesthesia vertical dystopia (abnormal displacement of the entire orbital cone in the vertical plane);

diplopia looking up or down (entrapment of inferior rectus), limited EOM orbital entrapment:

clinical diagnosis that is a mrgical emergency diplopia with vertical gaze: limited EOM severe pain or nawea and vomiting with eye movement requires urgent ophthalmology evaluation and mrgical repair

Investigations cr (diagnostic) -axial and coronal views diagnostic manoeu.vre for entrapment is Fon:ed Dudion test (pulling on inferior rectus IIIIlScle

with forceps to ensure full ROM) under anesthesia Trelltment surgical repair indicated if: urgent repair for entrapment, floor defect > l em, any size defect

with enopthalmus or persistent diplopia (>10 days) reconstruction of orbital floor with bone graft or alloplastic material ophthalmologic evaluation suggested Complications persistent diplopia enopthalmos Superior Orbital Fl88ure (SOF) Syndrome fracture of SOP causing ptosis, proptosis, anesthesla In Vl distribution. and painful

ophthalmoplegia (paralysis of CN III. IV; VI) uncommon complication seen in LeFort II and m fractures (1/130) recovery time reported as 4.8-23 weeks fullowing operative reduction of fractures Orbital Apex Syndrome fracture through optic canal with involvement of CN II at apex of orbit symptnms are the same as SOP syndrome plus vision loss treatment is urgent decompression of fracture in optic canal or steroids (emergency)

Toronto Notes 2011 Breut Surgery

Breast Surgery Breast Reconstruction

integral part of breast cancer treatment two basic methods: implants (I stage or 2 stage) or autologous tissue (see Table 20) may also require breast balancing procedure and nipple areola reconstruction Pre-Reconstruction Considerations radiation: treatment before and after mastectomy is a relative contraindication to alloplastic

reconstruction recipient tissue: skin sparing mastectomy allows for the use of implants without tissue expanders

( 1 stage process) donor tissue: limited availability of suitable donor tissue (lack of tissue, scar, previous surgery

that interferes with blood supply) may prevent the use of autologous tissue reconstruction timing (immediate vs. delayed) contralateral breast: may not be possible to reconstruct a breast of the same size or shape as the

contralateral breast. Breast reduction or mastopexy may be considered in opposite breast (see Table 21)

other considerations: patient's age and co-morbidities, prognosis, body weight, characteristics of chest wall and patient's attitude

Table ZD. Options for Breast Reconstruction Procedun Definition Surgical Detail Implant Use of synthetic material

(siicone or saline in1)1ml

Aulologou T111ue Use of patient's awn tissue

Nipple Areola Recollltnlction

Final stage of breast R!Construction

Wi!h 8ICp8lldets (Z Stagesl: Use tissue expanders before replacement with implants to help facilitatu breast ptosis. (see further discussion on 1issue belawl Without expanders (1 Stagal: In skin-spiring mastactomy, anough skin is available far immediate placement of implant Reconstruction with implants requns a 1ubmuscular placement of devices Many flap options: DIEP (deep inferior epigastric parfonrtorl. TRAM (trensvarse rectus abdorninusl,l.atissimus SIEA (superfical ilferior epigastric ateryl, SGAP gluteal al'lllry perforatorl, and IGAP (inferior gluteal artery parlonrtorl Usually tilttooing far areDia reconstruction Local vs. distant flap/graft 1. Local: fish tail Dr skate ftap mDst

common; theseilap5 allow siooltaneous nipple and areola reconstruction

Z. Distant: opposite nipple, abdDminal skin, costal cartilage, labia

Breast Tissue Expanders types: textured w. smooth, both with integrated port placement: sub-pectoral, total submuscular (pecoraUserratus) size: depends on contralateral breast and desired size

generally over-expanded to facilitate ptosis

CorrtJiications: capsular contraction (foreign body to implantsl. rupture or leakage of in1)1ant, increased risk of infection, 35% revision rate ovar 5 years

Offers reduced long-18rm morbidity and natural consistency

Usualy performed 3 months post-reconstruction

timing of expansion: begins when wound fully healed {usually 2 weeks post-op), and implants are expanded weekly or bi-weekly until complete (up to 3 months). Expanders are exchanged for implants after another 3 months for consolidation of expanded skin

Plastic Surgery PL31

...... , _._ ______________ l'lltiflnlll may r1quin 1 balancing proc8Wra Dl1 conlnllltar&lside.

PL32 Plaatic Suqp!ry

Subpac:lcnl

Figure 3&. Augmantation Mmoplally: lncilia Una 1nd lmpl11f: PIIC811111f:

1'oroDio 2011

Aesthetic Surgery Aesthetic Procedures

T1bl1 21. Alltlurtic Pracadres

HaatWeck Hair lln"'nts Aasthalic impravarrulll of hai" growth pattBms using - of flaps ompasty SIIJiicsl carecliJn of prulndng ears Bmw lit SIIJiicll procad.ua to it low brows

fla Rhytidac:tDmy Sllgicll procad.lra to rallce WliiliQ IIIII sagging af lhl flce111d nact. "'flee lift""

Sllil

Dill

Bla!Droplasty Sllgical procad.lra to shape or mocly lhl of ..,.lids by 1111111VirJ axcess svalid skin fat pads

Rhinopllly lnt11111181 flllgiceii'8CDIIIbuction of lhl111118 Genio!Btv Chin llll!rnantatian vii Dlt8olomy or synthetic contour Procedure Ia CI8IIIJ fUIIips 111d 1D wrirtles around lhl nmll using collagen

injeaions, fat transhmd !ram other body parts, or implantabla matnls Cheni:al peel AAJ!ication of ooe ar 111111! exfoliating agem to 1he skin resulting in des1ruction of portions of

the apidarmillllll/or darmil with aubaa-1inua raganaretian Dermllx'asian Skin ra-1urfcing by Slllding wi1h a 111pilly rota1D;I abRI&iva 1DDI. Often used 1D racb:a scars,

imaglilr skin .races and fila lines Laser AAJ!ication of laser to the ski! wlich ullimalely reslJbl in collagen recrig1.1111ian 101

skin DitiJg 101 Often used ID reduce seers IIIII wmdes l._ectlbla filn An injeclatile Ulbn:a il used 1D daCIIIS8 fnrMIIinee, wrinkiBI end

satn:es incllda colagen. fat. hyat.uonic acid and catium Removal of lllCC8SS skin and rapai" of rectus muscle laidly (rectus diastasis). tuck""

Breaslaug111e1Dtian SIIJiicsl breast erllllncement 1Mth siiCillll! ar die (see Figure 36) c aug111e1Dtian Alvnenlllion of 131 nusde with SIIJiicllraJIOVII of llipal81islualor body cadauring (nate weight 111111 pracad.lra) Sllgicll breast lift to eiiVIta breast maund IIIII lil#elllhl skin envaq,. in ptDtic Ina Ills Bnlllll ndJctian Sllgical breast nadlll:lian for ral&f af physic:all'l'"p1Dms SclarathiiiiPY lnjiiCiion with a sclaramt to 1IIBt !Jiangilr:lllllias llld varicas1 wins

Toronto Notes 2011 Pediatric Plastic Surgery

Pediatric Plastic Surgery Craniofacial Anomalies

Table 22. Pediatric Craniofacial Anomalies Definition Epidemiology Clinical Features Treatment

Cleft Lip Failure of fusion of 1 in 1000 live births (1 in 800 Classified as Cleft lip team; Surgery maxillary Caucasians, increased in incomplete/ (3 months): Milliard or and medial nasal Asians, decreased in Blacks) complete and uni/ Tennison-Randall; corrections processes More common on the left bilateral 2/3 cases: usually required later on (esp. for

(cleft of left lip/palate in boys unilateral, left sided, nasal deformity) M:F = 2:1 has hereditary component) male

Cleft Palate Failure of fusion Isolated Cleft Palate: 0.5 per Classified as Special bottles for feeding of lateral palatine/ 1000 (no racial variation) incomplete/complete Speech pathologist median palatine F > M and uni/bilateral Surgery (69 months): processes and nasal Isolated (common Von Langenbeck or Furlow Z-Piasty septum in females) or in ENT consult - often recurrent OM,

conjunction with cleft requiring myringotomy tubes lip (common in males)

Craniosynostosis Premature fusion of 1 in 2000 live newborns; M:F Syndromic- assoc. Multidisc. team (incl. neurosurg, 1 + cranial sutures = 52:48 with genetic mutation ENT, genetics, dentistry, peds, Primary - abnormal Syndromic includes: Secondary (to SLP) suture, no known Crouzon's, Apert's, Saethre microcephaly, Early surgery prevents secondary cause Chotzen, Carpenter's, hyperthyroid, rickets, deformities 1' ICP is an indication This may limit brain Pfeiffer's Jackson-Weiss and etc.) for emergent surgery perpendicular to the Boston-type syndromes Dx: irregular head ICU bed may be req'd post suture and cause shape, craniofacial surgically compensatory abnormalities, x-ray growth parallel to the fused suture

Incomplete Cleft Palate Complete Cleft Palate Cleft lip and Palate

Defects of Soft Palate Only Defects of Soft and Hard Palate

Figure 37. Types of Cleft Lips and Palates

Defects of Soft Palate to Alveolus, Usually Involving Up

Plastic Surgery PL33

Complete Bilateral Cleft

PL34 Plastic Surgery Pediatric: Plastic Surgery Toronto Notes 2011

Congenital Hand Anomalies Tabla 23. Americen Society for Surgery of the Hand (ASSH) Clauificetion of Congenital Hand Anomalies Clllificati111 Exmpla Fa Ilium Tl'llllmlnt A. Failure d fonnrtion Trensverse Absence Al any level (often below Early prosthesis

(congenital amputation) elbow/Wrist) Longitudinal Absence Absent humerus (phocomelia) ThalidomidHSSOc. Radial Dsficiency {radial club Radial deviation Physic + splirting hand) lllJmb hypoplasia Soft tissue splinting fails

M>F Distraction osteogenesis (llizarov) :t wedge osteotomy Tendon transfar Pollicization

lllJmb Hypoplasia Dagrue ranges from small Depends on dagrue - may involw thumb with all C0f11)01lents to no treatment. webspace deepening. complete absence tendon transfer, or pollicization at index

finger Ulnar Cub Hand Rare, compared to radial dub Splinting and soft-tissue stretching

hand therapies Stable wrist Soft-tissue ruleasa abova fails)

Correction of angulation (llizarov distraction)

Cleft Hand Autosomal dominant First web space syndactyly release Often functionally nonnal OSI8atomy/tendon transfer of 1hlmb {dependiiW,l on degree) (if hypoplastic)

B. Failure !I Syndactyly Fusion of 2+digits Surgical separation before 6 1 2 months diffarentiationl 113000 live birth& at age separation M:F=2:1 Usually good result

Classified as partiaVcomplete Simple (skin only) vs. complex (osseous or cartilaginous tridgBB)

Symbrechydactyfy Short fingers with short nails Digital separation (more difficult) at fingertips Webspace deepening

Carnptodactyly CDIW,lenital flaxion contracture Early aplinting {usually at PP. esp. 5th digit) Volar release

Arthnoplasty (rarely) Clinodactyly Radial or ulnar deviation None (usually). If severe, osteotomy

Often middle phalaRK with grafting C. Duplication Polydactyly Congenital duplication of digits Al11)utation of least functional digit

May be radial {increased i1 Usually > 1 yr of age {when functional Aboriginals ll1d Asians) or status can be assassed) central or ulnar (increased in Blacks)

D. Overgrowth Macrodactyly Rare None (if mild) Soft tissue/oony recllction

E. Undergrowth Brachydactyly Short phalqes Removal of non..functional stumps Ostaotomiatltendon transfers Distraction ostaogenasis PhalaiW,lealltree IDe transfer

Symbrechydactyfy Short webbed fingers As above + syndactyly release {Brachysyndectyly)

F. Constriction band AKA amniDiic (annular) band Variety at presentations Urgent release for acute, progressive syndrome syndrome edema dislal to band in newborn

Other reconstruction is caseoipecific G. Generalized skeletal Achondroplasia, Marian's, Variety at presentations Treatment depends on etiology

abnormality Medelung's

Toronto Notes 2011 References

References Gl'lll Plastio Sul'l'l'f Concepti Bruwn Dl, Bortdlul GH. Mielligln manual of ]ilutic IIIITillllY Plilldlllphia: SIIUIId111, 21104. Dmr BM, Antii NH, Fumu liN. H111dbook of plu1ic 111g1111 far the genmluQean seclrlld editilln. New Delhi: Oldord University Pless. 1995. Gaorvilda GS. Rielblll R, Levin LS. Guorgiade pll$tic. lllllilkllacialllld turvery third edition. llallinole: Willia111$llrld Wilkils. 1m. Hunt TK. Wound Heatv.ln: Doherty G'lll, Wrt LW, eels. Cllnent surgical & lrellmenl twellh edition. Norwalk. CT: McGmv-HI, 2006. Jaril JE. of Pllllic Surv111Y: AUT Sautlrwlslim Medical C111111' HIIIIIW. St lolis, MD: lblty 211Jl. Noble J. Tllldbook. of primery CUll medicine thi'd editi:JA. St. LDui&: 2001. Dng YS, Samuel M and S1111g C. Mellilnaly&i of lll!ly IIXl:ision of bum&. Bum&. 2006; 32: 145-50. Plastic Simi illY Educational Fllmllation. Plntic end riCCnlltruc1iva IIIITil&ry ..ntiall fer studlllll. Arlington Hlig!D, IL: Plastic Surv-ry Educa1icnl Fa.mdatian, 2007. _prolwlionait'pliblication.&ential!.for-&udlllll.c:fm. Rimuds AM.Key rns ill Great BrUin: Blacllwell Science Ltd. 2002. S.. Ill. Practical pllllic surgery lor non-surQIOIIL Philedalplia: Hsnley & Bellus Inc. 2001. Snith llJ. Brown AS, Crull CW at II. Plllltic and recgnltructiw IIIIQIIY. ChiRgo: Plastic &r!liiY Educatinl Fudrlill, 1 987. Stiml C.l'lutic llflllly. IKII. l.Dndon: Graanwiell Medical Medii Lid. 2001 TIMII!Hnd CM. SalisiDn 1lDdlloci rl surgary- the bioiiiQiCII bllis rl mod am llfllical p!ICiica six!aenth aditiarl. Phillldelpllia: W.B. Sudars 2001. Yasoonez HC. RBI, V.sconez 1.0. Plastic & reconslrul:live surgery. In: Doherty GM, Wrt LW, eels. Cllnent surgical dilglais & lrellmenl twellh edition. No!wal CT: McGn.w-llill 2006. W8inzwaig J. Plllltic :ugary SICtllls. I'MIIdalphil: Hanley snd Belfuslnc, 1919.

lt.d Am8rican Society for Surgvry rl tha Hand. The hand: l!XIminlltion and diiiiJIOSis third edition. Philad81phia: 1190. Beredjik111r1 PK. Bozenikll DJ. Rft'iew of band ugery. Philadelphia: Suders. 2004. Graham B, llegehr G. Naglie G. Wright J. Devalopment andvaidation of diagnostic critlril forcarpellunnllsyndrome. J Hand 2006; 31[6): 919.tl-919.e7.

Plastic Surgery PL35

PL36 Plastic Surgery

u\foteg __________ _