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Question

What is a traumatic tattoo?

Answer 1

Traumatic tattos are permanent discolourations resulting from new skin growth over foreign material or dirt left in the dermis.

Answer 2

**5 mg/kg without** epinephrine (45-60 min) **7 mg/kg** **with** epinephrine (2-6 h)

Answer 3

**2 mg/kg without** epinephrine (2-4 h) **3 mg/kg with** epinephrine (3-7 h)

Answer 4

**Initial signs:** * circumoral numbness * light-headedness * drowsiness **Later signs:** * tremors * seizures **Late signs:** * cardiac * respiratory

Answer 5

Lidocaine w/o epi = 5 mg/kg 5 mg/kg X 70 kg = 350 mg 1% lidocaine = 10 mg/1000 mg = 10 mg/g = 10 mg/cc 350 mg / (10 mg/cc) = 35 cc **Therefore, toxic limit is 350 mg and max bolus is 35 cc.** More lidocaine can be added after 30 mins.

Answer 6

* Make incisions along relaxed skin tension lines (Langer's lines) * Attain close apposition of wound edges * Minimise tension on skin by closing in layers * Every wound edges * Use appropriately size sutures * 5-0, 6-0 on face * 3-0, 4-0 elsewhere * Ensure equal width and depth of tissue on both sides * Remove sutures in a timely manner * 5-7 d from face * 10-14 d from scalp/extremities

Answer 7

Irrigation & debridement

Answer 8

Removes bacteria; removes nidi of infection from foreign material, surface clots, devitalised tissue.

Answer 9

19-gauge needle 35 cc syringe ~ 18 psi

Answer 10

Irregular or ragged wound edges must be excised to produce sharp wound edges that will assist with healing when approximated. Wounds left unapproximated \>8h should be debrided to ensure wound edges are optimised for healing.

Answer 11

* absorbable monofilament sutures * Monocryl * PDS II (polydioxanone) * Plain gut / fast absorbing gut * non-absorbable monofilament sutures * Prolene (polypropylene) * Nylon (Ethilon) * absorbable multifilament sutures * Vicryl * non-absorbable multifilament sutures * Ethibond

Answer 12

**Absorbable** * Deep sutures under short-term tension * Skin closure in children * At least 50% of strength lost in 4 weeks **Non-absorbable** * Skin closure * Sites of long-term tension * Lower likelihood of wound dehiscence * More difficult to tie * Makes track marks **Monofilament** * Optimal for contaminated and infected wounds (lower likelihood of bacterial trapping) * Slides through tissue w/ less friction * More memory/stiffness **Multifilament** * AVOID in contaminated wounds * Less memory/stiffness therefore easier to work with

Answer 13

* **simple interrupted:** can almost always be used * **subcuticular:** good cosmetic result but weak; used w/ deep sutures; not used in trauma * **vertical mattress:** for areas difficult to evert (e.g. volar palm of hand) * **horizontal mattress:** everting; time saving * **running "baseball stitch":** time saving; good for haemostasis

Answer 14

1. **Tapes** * ****may work for superficial wounds with opposable edges * cannot be applied to actively bleeding wound * will prevent surface marks * can be applied primarily or after suture sutures have been removed 2. **Skin adhesives** * ****e.g. Dermabond (2-octylcyanoacrylate) * works well on small areas w/o much tension or shearing * may cause irreversible tattooing 3. **Staples** * ****steel-titanium alloys that incite minimal tissue reaction * healing comparable to wounds closed by sutures

Answer 15

* run incision along relaxed skin tension lines (minimises scar) * use elliptical incision (prevents dog ears) * length of ellipse will be approx. 3x width * undermine wound edges to release tension (if needed) * use layered closure, including dermal sutures, when wound is deeper than superficial (decreases tension)

Answer 16

* Perpendicular to muscle fibres * Parallel to existing wrinkle lines

Answer 17

1. **Shave biopsy** * superficial lesions (non-pigmented) 2. **Needle biopsy** * ****breast masses / LNs 3. **Incisional biopsy** * ****punch or ellipse within lesion * take biopsy along border with normal skin * punch knives range from 2-10 mm diameter * punches \>3mm best to be closed w/ sutures to prevent scarring 4. **Excisional biopsy** * ****complete removal for diagnostic and/or therapeutic purposes * best for small lesions that are easily removed and closed * always requires suture closure

Answer 18

**Risks** * avoid in patients with vascular compromise * can be used anywhere except significantly injured digits (e.g. saw injury) * mantra of "fingers nose penis toes" no longer followed **Benefits** * constrict blood vessels which: * decreases bleeding * prolongs anaesthesia * limits lidocaine toxicity

Answer 19

**Chlorhexidine** * comes in [c] 0.5-4% -- only use lower [c] on the face otherwise risk of burning mucous membranes * flammable -- dry completely before cautery **Betadine** * 7.5% povidone-iodine safer around eyes/ears/mucous membranes Both solutions are bacteriostatis and bactericidal.

Answer 20

**Laceration** * cut or torn tissue **Abrasion** * superficial skin layer removed; variable depth **Contusion** * injury caused by forceful blow; entire outer layer of skin is intact but injured **Avulsion** * tissue/limb forcefully separated from surrounding tissue, either partially or fully; "de-gloving" **Puncture wound** * cutaneous opening relatively small as compared with depth (e.g. needle) * includes _bite wounds_ **Crush injury** * caused by compression Also: **Thermal and chemical wounds**

Answer 21

Disruption of the normal anatomical relationships of tissue as a result of injury.

Answer 22

**Local (reversible/controllable)** * mechanical (local trauma, significant crush, avulsion, tension) * blood supply (ischaemia/circulation) * temperature * technique and suture materials * retained foreign body * infection * venous hypertension * peripheral vascular disease * haematoma/seroma (also increases infection rate) **General (often irreversible)** * age * nutrition (protein, vitamin C, O2) * smoking * chronic illness (e.g. DM, cancer, CVD) * immunosuppression (steroids, chemo) * collagen vascular disease * tissue irradiation

Answer 23

**Lower 5 mm: 4 layers** 1. skin (anterior lamella) 2. orbicularis oculi (anterior lamella) 3. tarsus (posterior lamella) 4. conjunctiva (posterior lamella) **Middle 5 mm: 5 layers** 1. skin 2. orbicularis oculi 3. levator aponeurosis 4. tarsus 5. conjunctiva **Upper 10 mm: 7 layers** 1. skin 2. orbicularis oculi 3. septum 4. preaponeurotic fat 5. levator aponeurosis 6. Müller's muscle (inserts into tarsus) 7. conjunctiva

Answer 24

**Upper 5mm: 4 layers** 1. skin 2. orbicularis oculi 3. tarsus 4. conjunctiva **Lower 5mm: 7 layers** 1. skin 2. orbicularis oculi 3. septum 4. pre-capsulopalpebral fascia fat 5. inferior sympathetic muscle (equivalent to Müller's in upper lid) 6. CPF (equivalent to levator aponeurosis) 7. conjunctiva

Answer 25

**Canthopexy**: lateral canthal tendon of the eye is _not cut_, but is fixated to the orbital rim. **Canthoplasty**: lateral canthal tendon is _cut_ and then secured to lateral orbital rim (at Whitnall's tubercle).

Answer 26

**Entropion**: eyelid inverted. **Ectropion**: eyelid everted.

Answer 27

1 to 2 years

Answer 28

1. **Inflammatory (Days 1-6)** * ****limits damage, prevents further injury 1. _Haemostasis_ * vasoconstriction + platelet plug 2. _Chemotaxis_ * __migration of macrophages and PMN * neutrophils (24-48 h); macrophages (48-96 h); lymphocytes (5-7 d) 2. **Proliferative (Day 4 - Week 3)** * ****fibroblasts attracted and activated by macrophage growth factors 1. _Collagen synthesis (mainly type III)_ * tensile strength begins to increase at 4-5 days__ 2. _Angiogenesis_ * relieves ischaemia 3. _Epithelialization_ 3. **Remodelling (Week 3 - 1 year)** * ****increasing collagen organisation and stronger crosslinks 1. _Contraction_ 2. _Scarring_ 3. _Remodelling of scar_ * __type I replaces type III collagen until normal 4:1 ratio achieved * peak tensile strength at 60 d -- 80% of pre-injury strength

Answer 29

**Type** Hypertrophic Keloid **Definition** Scar within original boundaries Scar outside original boundaries **Location** Any location; often on extensor surfaces of joints Commonly on sternal skin, shoulders, upper arms, earlobes, cheeks **Change in size** Regress with time Grow for years **Collagen** Fewer thick collagen fibres Thick collagen **Mucoid matrix** Scanty matrix Mucoid matrix **Elevation** Flatten over time Remain elevated \>4mm **Initiation** Appear within one month Appear at 3 months or later **Skin type** Less association with pigmentation More common in darker skin types (genetic component) **Appearance** Red, raised, widened, pruritic Red, raised, widened beyond scar borders, pruritic (constant collagen deposition and growth) **Treatment** Massage, pressure garment, silicone sheeting, corticosteroid injection (Kenalog – triamcinolone), surgical excision (may recur) Multimodal: pressure garments, silicone sheeting, steroid injection, fractional carbon dioxide ablative laser, radiation (sometimes with excision – high risk of recurrence)

Answer 30

1. Genetic factors (highest rates in African/Asian ethnicity) 2. Endocrine factors 3. Excess tension on wound or delayed closure (e.g. burn wounds)

Answer 31

A spread scar is characterised by having the exactly same order of collagen fibres as normal scars. It is typically **flat**, **wide**, and often **dented**. Treatment is with surgical excision and closure.

Answer 32

A chronic wound fails to achieve primary wound healing within **4 to 6 weeks**. Common chronic wounds include **diabetic**, **pressure**, and **venous** **stasis** **ulcers**. Chronic wounds are treated with meticulous wound care +/- surgery.

Answer 33

**Marjolin's ulcer.** Arises secondary to genetic changes caused by chonic inflammation. Always consider a biopsy of a chronic wound.

Answer 34

**Primary intention** * _Definition:_ wound closure by direct approximation of wound edges within hours of wound creation. * _Indication_: recent (\<6 h); clean wound. * _Contraindications_: bites (except on face); crush injury; infection; \>6-8 h since injury; retained FB **Secondary intention (spontaneous)** * _Definition_: wound left open to heal spontaneously * **epithelialisation 1 mm/d** from wound margins * **contraction** **by myofibroblasts at \<0.75 mm/d** * granulation * maintained in inflammatory phase until wound closed * requires dressing changes * inferior cosmetic result * _Indication_: when primary closure not possible or indicated **Third intention (delayed primary)** * _Definition_: intentionally interrupt healing process, then close wound **4-10 d post-injury** after granulation tissue has formed and **\<10⁵bacteria/gram of tissue** * _Indication_: contaminated; long time since injury; severe crush; significant tissue devitalisation; closure of fasciotomy wounds * prolongation of inflammatory phase decreases bacterial count and lessens chance of infection after closure

Answer 35

**Contamination**: presence of _nonreplicating_ organisms within a wound. **Colonisation**: presence of _replicating_ organisms within a wound. **Infection**: greater than _10⁵ microorganisms_ in a wound without intact epithelium; may also be infected with small amounts of a very virulent organism (e.g. GBS).

Answer 36

Group A Strep

Answer 37

1. Virulence of infecting organism. 2. Amount of bacteria present. 3. Host resistance (host defenses).

Answer 38

1. Cleanse and irrigate with NS or RL w/ pressure. 2. Evaluate for injury to underlying structures. 3. Control active bleeding. 4. Debride FB, devitalised tissue, old blood. Surgical debridement as needed. 5. Rx systemic antibiotics for obvious infection. Particularly: wound \>8 h; severely contaminated; bites; immunocompromised; involvement of deeper structures (e.g. joints, fractures). 6. +/- Tetanus. 7. +/- post-exposure tx of hep B, HIV, hep C (if titres confirmed at 6 mo). 8. Re-evaluate in 24-48 h for signs of superficial or deep infection. * If evidence of infection, remove sutures to open infected portion, swab for c&s, irrigate, allow healing by 2ndary intention.

Answer 39

1. **Irrigate and debride.** * Remove particles that could cause traumatic tattooing. 2. **Systemic abx** if concern for worsening infxn (e.g. redness, welling, pain, clinically unwell). 3. **Topical antimicrobials**: beneficial for minor wounds, but doesn not add to systemic abx; may help with chronic wound healing. 4. **Closure via secondary intention** (most common), tertiary closure, skin graft, or skin flap. * Successful closure depends on **bacterial count \<10⁵/cm³**prior to closure and **frequent dressing changes**.

Answer 40

A biofilm is defined as “an assemblage of microbial cells that is irreversibly associated with a surface and enclosed in a matrix of primarily polysaccharide material".

Answer 41

**Wound characteristics** **Tetanus-Prone** **Not Tetanus-Prone** Time since injury \>6 h \<6 h Depth of injury \>1 cm \<1 cm Mechanism of injury Crush, burn, gunshot, frostbite, puncture through clothing, farming injury Sharp cut (e.g. clean knife, clean glass) Devitalised tissue Present Not present Contamination (e.g. soil, dirt, saliva, grass Yes No Retained foreign body Yes No

Answer 42

**Clean, minor wounds** **History of tetanus immunization** **Td or Tdap\*** **Tig\*\*** Uncertain, \<3 doses, or 10 y since booster Yes No 3 doses No No \*0.5 mL combined tetanus and diphtheria toxoids +/- acellular pertussis \*\*Tetanus immune globulin, 250 U given at separate site from Td/Tdap **All other wounds** **History of tetanus immunization** **Td or Tdap** **Tig** Uncertain, \<3 doses, or \>5 y since booster Yes Yes 3 doses No No^ ^ Yes, if immunocompromised

Answer 43

1. Decreased body temp 2. Cost 3. Outpatient inconvenience 4. Contamination 5. Pain 6. Trauma to wound

Answer 44

* **Pasteurella multocida** * Staph aureus * Strep viridans

Answer 45

1. **Radiographs** to r/o FB or fracture. 2. **Wound swab** - culture for aerobic and anaerobic organisms, gram stain.

Answer 46

**Clavulin** (amoxicillin + clavulanic acid) **500 mg PO q8h** started immediately

Answer 47

**Could the animal have rabies?** Consider prophylaxis if unknown animal or animal showing symptoms of rabies. Three types of rabies vaccines: 1.0 mL IM in deltoid, repeated on days 3, 7, 14, 28. +/- Rabies Ig: 20 IU/kg around wound, or IM.

Answer 48

1. **Aggressive irrigation and debridement**, with urgent **surgical exploration of joint** (if involved). 2. **Healing by secondary intention** is mainstay of treatment. * Only consider primary closure for bite wounds on the face. 3. **Amox-clav 500 mg PO q8h** * clinda 300 mg PO q6h + cipro 500 mg PO q12h if penicillin allergy 4. **Splint** in functional position (for hand wounds). 5. For animal bites: consider **rabies** and call Public Health if animal status is unknown.

Answer 49

**Wrist extended 20-30 degrees** **MCP flexed 60-70 degrees** **IPs fully extended** **Thumb mid-abduction/extension** The position of safety helps **prevent contracture of the joints** by: * extending the wrist takes tension off extensors and keeps them from pulling MCPJ into extension * stretching out the MCP collaterals in flexion * stretching out the IP collaterals in extension

Answer 50

**Tenodesis function:** when the wrist is extended the fingers and thumb flex into the palm and when the wrist is flexed the fingers and thumb open.

Answer 51

**Promotes healing** through the following: * removes exudate * reduces bacterial count * reduces edema * promotes granulation * increases perfusion (blood flow)

Answer 52

1. Healing by secondary intention 2. Primary closure 3. Delayed closure 4. STSG 5. FTSG 6. Random pattern flap 7. Pedicle flap 8. Tissue expansion 9. Free flap NPWT can go on different levels of the "elevator".

Answer 53

1. Inflammation 2. Inadequate nutritional intake

Answer 54

**Aeromonas** bacteria (gram neg anaerobe) **Ciprofloxacin** 100% effective in studies

Answer 55

Leeches release a polypeptide called **hirudin** that **inhibits** the thrombin-catalysed **conversion of fibrinogen to fibrin**. Hirudin also **blocks platelet aggregation** in response to thrombin and may inhibit Factor X.

Answer 56

Skin that is harvested from a donor site and transferred to the recipient site and **does not carry its own blood supply**.

Answer 57

SG: **-75 mmHg** Other wounds: **-125 mmHg** Intermittent VAC = ?improved granulation

Answer 58

**Greenish** discolouration. **Acetic acid** or **silver**.

Answer 59

**Wet-to-dry** - keeps wound **moisturised** and allows some **mechanical** **debridement**.

Answer 60

* size * hair pattern * texture * thickness of skin * colour * facial grafts best taken from "blush zones" above clavicle, such as pre/post auricular or neck * STSG usually taken from inconspicuous areas such as the buttocks or lateral thigh

Answer 61

1. **Imbibition (first 48 h)** * ****diffusion of nutrients from recipient site 2. **Inosculation (days 2-3)** * ****vessels in graft connect with those in recipient bed 3. **Revascularisation (days 3-5)******

Answer 62

* **poorly vascularised bed** (bone, tendon, irradiated tissue, infected wounds) * **haematoma/seroma** (staples, sutures, splinting, pressure dressings, bolster dressing all used to prevent movement) * **shearing** * **bacterial count \>10⁵**

Answer 63

* **autograft**: from same individual * **allograft**: from same species, different individual * **xenograft**: from different species

Answer 64

**No purpose**; it is a **vestigial structure** of the **panniculus carnosus** (animals such as horses and dogs can use it still to twitch). Vestigial mucles of panniculus carnosus: platysma, palmaris brevis, dartos muscle (scrotum), some muscles of facial expression.

Answer 65

**STSG** **FTSG** **Definition** Epidermis + partial dermis Epidermis + full dermis **Donor site** More sites Sites limited by ability to close primarily **Healing of donor site** Re-epithelialisation via dermal appendages in graft and wound edges Primary closure **Re-harvesting** ~10 d (faster on scalp) N/A **Graft take** More reliable, better survival (shorter nutrient diffusion distance) Lower rate of survival (thicker, slower vascularisation) **Contraction\*** Less primary contraction (less dermis); greater secondary contraction (decreased as graft gets thicker) Greater primary contraction (more dermis); less secondary contracture **Aesthetic** Poor Good **Advantages** Takes well in less favourable conditions. Can cover larger area. Can be meshed for greater area, extravasation of blood/serum, and to prevent covering of contaminated material. Potential for healing in less favourable environment. Large number of donor sites. May use on face and fingers Resists (secondary) contraction. Better colour match. **Disadvantages** Contracts significantly (secondarily). Abnormal pigmentation. High susceptibility to trauma. Requires well-vascularised bed. Must remove fat from graft before application. **Uses** Large areas of skin. Granulating tissue beds. Face (colour match). Site where thick skin or decreased contracture is desired (e.g. finger). \*Primary: immediate upon harvesting (d/t elastin); Secondary: once place on wound bed and healing has occurred (d/t myofibroblasts).

Answer 66

45 degree angle: **50%** 60 degree angle: **75%**

Answer 67

Formula for fluid resuscitation to achieve haemostasis post-burn injury. **4 mL X TBSA (%) X body weight (kg)** 50% given in first 8 hours. 50% given in next 16 hours.

Answer 68

Positive test: **flexion of IP joint of thumb** when grasping paper b/w thumb and index. Indicates: adductor pollicis paralysis d/t ulnar nerve damage. **Jeanne's sign** occurs when there is simultaneous **MCP extension** d/t additional ulnar nerve damage.

Answer 69

Ulnar nerve injury results in **weakened medial lumbricals** at D4 and D5. Loss of function of the lumbricals results in **hyperextension at the MCPJ** and **flexion at the IP joints** ("claw hand").

Answer 70

* medial two lumbricals * hyopthenar muscles * interossei * adductor pollicis * FPB (deep head)

Answer 71

Think "**LOAF**": Lateral (radial) two lumbricals Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis (superficial head)

Answer 72

Ulnar paradox is a **lesion of the ulnar nerve at the elbow**. In addition to the intrinsic hand muscles, **FCU** and the **medial two FDP** are paralysed. Still have **hyperextension at MCPJ** (as with claw hand), but **no flexion at IPJ** as FDP paralysed.

Answer 73

**Cause**: damage to **median nerve**. All hand **flexors** are paralysed, except medial 2 FDP (innervated by ulnar nerve). Radial 2 lumbricals are also paralysed (as are thenar muscles), **Test**: ask patient to **make a fist**. If present, index and (possibly) middle finger will not flex at IPJs. Middle finger may flex still due to quadriga effect.

Answer 74

The **quadriga effect** is characterized by an active **flexion lag** in fingers adjacent to a digit with a previously injured or repaired flexor digitorum profundus tendon. This can happen in rev amps if the FDP is pulled over the stump. Named after the four horse-drawn chariot -- if one horse has a shortened lead, then the other three horses' leads will become slack.

Answer 75

1. **Hyperaemia**: disappears 1 h after pressure removed. 2. **Ischaemia**: follows 2-6 h of pressure. 3. **Necrosis**: follows \>6 h of pressure. 4. **Ulcer**: necrotic area breaks down.

Answer 76

**Stenosing tenosynovitis****.** **Definition:** inflammation of synovium causes size discrepancy between tendon and sheath/pulley (most commonly at **A1 pulley**), resulting in **locking** of the thumb or finger in flexion or extension.

Answer 77

1. Streptococcus pyogenes (GAS) 2. Staph aureus

All Sections Flashcards

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