Janis Notes Flashcards

Question

Histological zones of distraction osteogenesis (5).

Answer 1

1. **Central zone:** cellular proliferation. 2. **Transitional zone of vasculogenesis** 3. **Paracentral zone:** Parallel orientation of collagen fibers with osteoid production. 4. **Transitional mineralization front:** Primary mineralization found with bone spicule formation. 5. **Mature bone zone:** Progressive calcification of primary mineralization front with formation of cortical and cancellous elements.

Answer 2

* Present at birth on scalp or face. * Well-circumscribed, hairless, yellowish plagque that becomes verrucous and nodular at puberty. * 10-15% malignant degeneration to BCC.

Answer 3

* **Keratinocyte:** Major cell type. Protective barrier. * **Melanocyte:** Neural crest origin. Pigmentation. UV protection. * **Merkel cells:** Neural crest origin. Constant pressure and touch. Static two-point discrimination. * **Langerhands cells:** Mesenchymal origin (from precursor cells of bone marrow). Antigen presenting cells.

Answer 4

* Mature skin = 4:1 * Hypertrophic = 2:1 * Keloid = 3:1

Answer 5

1. Subciliary ('lower bleph') 2. Subtarsal ('mid lid') 3. Infraorbital ('inferior orbital rim') 4. Tranconjunctival

Answer 6

* Posterior fontanelle: 3-6 months. * Anterior fontanelle: 9-12 months.

Answer 7

1. Thoracoacromial. 2. Lateral thoracic. 3. Axillary. 4. Retrograde flow in IM vein. 5. Cephalic turned down. 6. External jugular turned down.

Answer 8

**Tessier Cleft Number 8** **One liner:** Largely isolated to the orbit with the cleft affecting the frontozygomatic suture with a hypoplastic or absent zygoma with coloboma of the lateral commisure. **Soft tissue:** * Largely isolated to the orbit. * Coloboma of the lateral commissure with abscence of the lateral canthus. **Skeletal involvement:** * Involves frontozygomatic suture. * Zygoma hypoplastic or absent with lateral orbital wall missing. * Continuit of orbital and temporal fossa. **Other:** * Almost always concurrent with another rare cleft * Associated with Goldenhar's syndrome

Answer 9

3 minutes at 3000 rpm.

Answer 10

* Large facial port-wine stain with V1 and commonly V2 trigeminal nerve distribution. * Associated with leptomeningeal venous malformations and frequent mental retardation.

Answer 11

Pseudopapilledema, microcephaly, vascular malformations.

Answer 12

1. _Size_ of hemangioma or _sex_ of patient has _no influence_ on the speed or completeness of resolution. 2. _Site_ of hemangioma has _minimal effect_ on final result. 3. _Multiple hemangiomas_ may resolve at _different rates_. 4. Presence of _subcutaneous tumor elements_ has _no effect_ on final outcome. 5. Early _dramatic growth_ is _not a prognostic sign_ of resolution. 6. _Time of involution_ is _indicative of outcome_. 7. Prescence of _ulceration_ has _no prognostic significance_ except for scar consequences.

Answer 13

Advantages: 1. Lower initial costs compared with autologous reconstruction. 2. Technical ease. 3. No donor site morbidity. 4. Shorter operative time and recovery time compared with autologous. Disadvantages: 1. Early cost advantage disappears over time as revisions surgeries are required. 2. Potential capsular contracture. 3. Potential implant rupture / failure. 4. Potential infection requiring removal. 5. Increased probability for future surgery. 6. Difficult to acheive symmetry with unilateral reconstruction.

Answer 14

1. Correction of upper-third protrusion. 2. Visibility of the helix beyond the anithelix when viewed from the front. 3. Smooth and regular helix. 4. No marked distortion or decrease in the depth of the postauricular sulcus. 5. Correct placement of the ear; helix-to-mastoid distance falls in the normal range of 10-12mm at the top, 16-18mm in the middle, and 20-22 in the lower third. 6. Bilateral symmetry to **within 3mm at any given point**. 7. Smooth, rounded, and well-define antihelical fold. 8. Concoscaphal angle of 90 degree. 9. Conchal reduction or reduction of the conchomastoidal angle. 10. Helical rim that projects laterally farther than the lobule.

Answer 15

1. Poorly defined antihelical fold. 2. Conchoscaphal angle \>90 degrees. 3. Conchal excess.

Answer 16

**Tessier Cleft Number 4** **One liner:** Cleft begins between lateral incisor and canine teeth extending superiorly lateral to the piriform and medial to the infraorbital foramen into the lower eyelid. **Soft tissue:** * Begins lateral to Cupid's bow between commisure of mouth and philtral crest -\> passes onto cheek lateral to nasal alar -\> curves into lower eyelid to terminate medial to the punctum * Lower canniculus disrupted along with most of the inferior supporting structures of the eye. * Colobomas. * Medial canthal ligament and lacrimal aparatus usually *intact*. **Skeletal involvement:** * Begins between lateral incisor and canine teeth * Extends onto anterior surface of maxilla, lateral to piriform aperature, medial to infraorbital foramen * Medial and inferior portions of orbital disrupted * Nose displaced superiorly (especially in bilateral cases)

Answer 17

**Contents of superior orbital fissure:** The order of the nerves passing through the superior orbital fissure from superior to inferior (*Lazy French Tarts Sit Nakedly In Anticipation*): * L: lacrimal nerve (branch of CN V1) * F: frontal nerve (branch of CN V1) * T: trochlear nerve (CN IV) * S: superior division of the oculomotor nerve (CN III) * N: nasociliary nerve (branch of CN V1) * I: inferior division of the oculomotor nerve (CN III) * A: abducens nerve (CN VI) **Presentation of superior orbital fissue syndrome (SOFS):** * *Ophthalmoplegia:* due to compression or damage to oculomotor, trochlear and abducens nerves * *Ptosis:* due to loss of oculomotor motor supply to the levator palpebrae superioris and loss of sympathetic input (third order postganglionic) to Muller’s muscle * *Proptosis:* due to decreased tension in the extraocular muscles with loss of innervation * *Fixed dilated pupil:* due to loss of parasympathetic supply to the pupil by the oculomotor nerve * *Lacrimal hyposecretion and eyelid or forehead anaesthesia:* due to damage to branches of the ophthalmic division of the trigeminal nerve * *Loss of corneal reflex:* due to loss of afferent input from the ophthalmic division of the trigeminal nerve. **Orbital apex syndrome** presents the same but also has loss of vision because of involvement of the optic nerve at the orbital apex.

Answer 18

1. Age 2. % TBSA 3. Inhalational injury

Answer 19

* **Sutural growth:** perpendicular to sutures. * **Appositional growth:** Bone resoprtion on the inner surgace and deposition on the outer surface of the skull.

Answer 20

**Temporary** * Allograft * Xenograft * Biobrane (nylon fabric coated with porcine dermal collagen with silicone membrane) * TransCyte (biobrane and cultured human neonate fibroblasts) **Permanent** * FTSG / STSG * Integra (bovine collagen, shark chondroitin-6-sulfate, silicone layer) * AlloDerm * Cultured epithelial autograft

Answer 21

1-2cm incision made laterally in the buccal sulcus. Subperiosteal elevation allows the eleator to be placed behind the arch.

Answer 22

* Posterior fossa malformations * Hemangiomas (large facial hemangiomas) * Arterial anomalies * Coarctation of the aorta and other cardiac anomalies * Eye abnormalities

Answer 23

**Low-energy injuries:** * ZM exposed with with upper buccal sulcus incision * ZF and ZS exposed with upper bleph incision * ZS articulation best to assess reduction * Stabilize ZF and then ZM; if needed ZS fixation can be performed as well * Lower lid incision not required unless floor exploration or reconstruction desired **High-energy injuries:** * Require wide exposure with coronal approach to visualize temporal articulation * Will likely require exploration and fixation of the floor

Answer 24

1. Intracranial injury / hemmorrhage (18%). 2. Abdominal organ injury (16%). 3. Pneumothorax (13%). 4. Pulmonary contusion (13%). 5. Cervical spine fracture (13%).

Answer 25

Collectively referred to as *_trigonocephaly_* ('keel shaped, triangular'). 1. Keel-shaped forehead 2. Bitemporal narrowing 3. Hypotelorism 4. Bilateral supraorbital retrusion

Answer 26

**Tessier Cleft Number 1.** **One liner:** Cleft begins between the lateral and central incisor moving superiorly through the margin of cupid bow and up between the nasal bones and the frontal process of the maxilla. *\*Can continue as cleft number 13\** **Soft tissue:** * Pattern similar to cleft lip and palate. * Cleft through lateral margin of Cupid's bow progresses into nose, causing notching of the dome and soft triangle but may travel medially to a malpositioned medial canthus. **Skeletal involvement:** * Cleft between central and lateral incisor. * Cleft separates nasal floor from piriform and the nasal bone from the frontal process of the maxilla.

Answer 27

1. Familial Atypical Multiple-Mole Melanoma (FAMMM Syndrome) * \>100 melanocytic nevi measuring 6-15mm * one or more measuring \> 8mm * 10% risk of melanoma 2. Dysplastic nevus (6-10% risk of melanoma). 3. Congenital nevus (6% lifetime risk of melanoma). 4. Typical moles (risk if \>50) 5. Melanoma in situ 6. Xeroderma pigmentosum 7. Lentigo maligna (Hutchinson freckle)

Answer 28

* Face develops from five prominences: * Frontonasal prominence (1) which is composed of bilateral medial and lateral nasal prominences. * Paired maxillary prominences (2) * Paired mandibular promincens (2) * **Frontonasal prominence:** * Pulled ventrally and caudally to form the forehead, nasal dorsum, and medial and lateral nasal prominences. * Outpouchings of the lateral nasal walls form the sinsuses (maxillary at 3 months gestations, ethmoid at 5 months gestation, sphenoid 5 months postnatally, and frontal 2-6 years postnatally). * *Medial nasal prominence* forms the primary palate, midmaxilla, midlip, philtrum, central nose, and septum. * *Lateral nasal prominence* forms the nasal alae. * **Maxillary prominences:** * Migrate medially to form the secondary palate, lateral maxilla, and lateral lip. * Junction with the lateral nasal prominences forms the nasolacrimal groove and nasolacrimal duct system. * **Mandibular prominences:** * Form the mandible, lower lip, and lower face.

Answer 29

Collectively referred to as *_scaphocephaly_* or dolichocephaly ("boat shaped") 1. Elongated anteroposterior head. 2. Frontal and occipital prominence. 3. Biparietal narrowness

Answer 30

**Nevus of Ito:** Usually appears at birth. Typically found in Asians and blacks. Large, blue-brown macula located on the *_posterior shoulder_*, areas innervated by the posterior supraclavicular and lateral cutaneous brachial nerves.

Answer 31

**Tessier Cleft Number 12** **One-liner:** Cleft lies medial to the medial canthus extending upward and coming out lateral to the cribriform plate, yielding hypertelorism. **Soft tissue:** * Cleft lies medial the medial canthus, which is displaced laterally. * Colobomas extend to the root of the eyebrow. * Paramedian frontal hairline projects downward. **Skeletal involvement:** * Orbital hypertelorism and telecanthus from increased dimension of ethmoid air cells. * Frontal and sphenoid sinuses pneumatized. * Lies lateral to cribriform plate, which remains normal. * Anterior and middle cranial fossa enlarged.

Answer 32

Surgery typically delayed until school age when child may beging to have psychological consequences. Indications for urgent surgery in proliferative phase: 1. Visual obstruction * During first year of life, visual obstruction for 1 week can result in deprivation amblyopia or anisometropia. 2. Nasolaryngeal obstruction * Hemangiomas in "beard distribution' proliferating in subglottic airway = potentially life threatening. Requires aggressive treatment with beta-blockers, surgery, and potentially LASER. 3. Auditory canal obstruction * Can result in conductive hearing loss.

Answer 33

**Neurocranium** is the portion of the skull encasing and protecting the brain. It develops from both intramembranous ossification and endochondral ossification. * ***Membranous neurocranium*** * Forms via *intramemranous* ossification of neural crest origin. * Includes the paired frontal, squamosal, and parietal bones, and upper occipital bones. * ***Cartilaginous neurocranium (ie basicranium)*** * Forms via *endochondral* ossification of mesodermal origin. * Includes sphenoid and ethmoid bones, mastoid and petrous temporal bone, and the base of the occipital bone. **Viscerocranium** is the bones of the facial skeleton and forms primarily via intramembranous ossification of pharyngeal arch I, except for Meckel's cartilage (which forms the malleus and the mandibular condyles)

Answer 34

**Tessier Cleft Number 2** **One liner:** Cleft originates at lateral incisor and margin of cupid bow and extends superiorly through the alar rim. *\*Can extend as cleft number 12\** **Soft tissue:** * Originates at the lateral margin of cupids bow and extends into the lateral alar rim lateral to dome. * Ala typically hypoplastic. * Medial canthus displace but lacrimal duct not involved **Skeletal involvement:** * Cleft through lateral incisor extends into piriform aperature.

Answer 35

Pathy port-win stain on an extremity overlying a deeper venous and lymphatic malformation with associated skeletal hypertrophy.

Answer 36

1. Multiple basal cells 2. Odontogenic keratocysts 3. Palmar and plantar pits 4. Calcification of falx cerebri 5. Bifid ribs 6. Hypertelorism 7. Broad nasal root

Answer 37

* **Intracranial:** hydrocephalus, ICP elevation, Chiari malformation. * **Cranial:** bicoronal most common; usually brachycephalic, but scaphocephally, trigonocephaly, cloverleaf deformity, and normocephalic described. * **Orbit:** Exorbitism. * **Midface:** hypoplasia with anterior open bite, class III occlusion, narrow and high arched palate.

Answer 38

1. Mandibular lengthening. * Hemifacial microsomia, micrognathia 2. Le Fort I adavanacement * For large anterior _movements \> 1cm_ * Particularly helpful for significant class III occlusion in clefts secondary to maxllary hypoplasia. 3. Le Fort III / monobloc * Syndromic craniosynostosis with severe midface hypoplasia and exorbitism. 4. Posterior cranial vault reconstruction. * Can be used in some craniosynostosis.

Answer 39

1. FGFR2 2. FGFR3 3. TWIST1 4. EFNB1

Answer 40

**Tessier Cleft Number 10.** **One liner:** Cleft lateral to the supraorbital foramen, yielding encephaloceles and hypertelorism from inferolateral orbital rotation. **Soft tissue:** * Begins at middle third of upper eyelid and eyebrow. * Coloboma in mid-upper lid and irregular retraced brow. **Skeletal involvement:** * Cleft at middle orbital rim just lateral to supraorbital foramen. * Encephalocele common * Hypertelorism from inferolateral rotation of orbit * Anterior cranial base distortion

Answer 41

* **Silver sulfadiazine (silvadene)** * Gram positive and gram negative coverage. * Transient leucopenia. * Penetrates eschar poorly. * **Mafenide acetate (sulfamylon)** * Gram positive. * Potent carbonic anyhydrase inhibitor. * Hyperchloremic metabolic acidosis. * Compensatory hyperventilation. * Penetrates deeply. * **Silver nitrate (0.5% solution)** * Staphylococcus species and gram negative (pseudomonas). * Hyponatremia and hypokalemia. * **Sodium hypochlorite** * Broad spectrum. * at 0.025% is bactericidal without inhibiting fibroblasts or keratinocytes.

Answer 42

* Medical * Topical 5-FU for premalignant lesions * Chemotherapy for adjuvant therapy * Radiation (adjuvant or primary treatment; 90% cure) * Destructive * Curettage and electrodessication * Photodynamic therapy * Surgery * WLE (95% cure; 4-6 mm margins) * Mohs (95% cure)

Answer 43

Bilateral Tessier cleft 6, 7, and 8. * Coloboma and retraction of the lower lid * Upper lid redundancy in lateral half gives impression of ptosis * Lateral canthus displaced inferiorly * Absence of zygomatic arch * Hypoplasia of temporalis * Ear malformations * Hairline abnormalities * Abscence of lateral inferior orital rim * Hypoplasia of malar ones and mandible

Answer 44

**1. Pretendinous cord:** in the palm. **2. Spiral cord:** composed of pretendinous, spiral band, lateral digital sheet, and Graysons (can displace NVB centrally and superficially). **3. Central cord:** continuation of pretendinous. **4. Lateral cord:** runs from the natatory to the lateral digital sheet. **5. Natatory cord:** natatory band. **6. Retrovascular cord.**

Answer 45

1. Male gender. 2. Earlier disease onset. 3. Family history. 4. Bilateral involvement. 5. Ectopic involvement (Peyronies, Ledderhose, Garrods).

Answer 46

Incision made 2cm anterior and superior to the helix. Dissection carried down to and through the deep temporal fascia (overlying temporalis muscle). Elevator placed beneath the deep temporal fascia but superficial to temporalis allowing access to the medial aspect of the zygoma while protecting the facial nerve.

Answer 47

**Tessier Cleft Number 7** **One liner:** Cleft begins at the oral commissure and extends outward affect the ramus/condyle/coronoid of the mandible and include the ear. **Soft tissue:** * Begins at oral commissure and varies from mild broadening to complete fissure. * Extends toward the ear, ceasing at the anterior border of the masseter. * Ear involvement varies from a skin tag to microtic ear. * Paralysis of CN V and CN VII common. **Skeletal:** * Cleft passes through pterygomaxillary junction. * Posterior maxilla and ramus (condyle and coronoid) are hypoplastic. * Zygomatic body is also severely hypoplastic and displaced. * Cranial base asymmetrical. * Open bite or cross bite seen. **Other:** * Often accompanies crnaiofacial microsomia.

Answer 48

Depends on degree of displacement and involvement of nasofrontal duct.

Answer 49

* By the third year of life the ear has reached 85% of adult size. * Ear WIDTH reaches mature size by 6-7 years of age (girls-boys) * Ear LENGTH reaches mature size by 12-13 years of age (girls-boys).

Answer 50

* Trunk: 2-5% * Face / extremity: 10-20%

Answer 51

1. Café au lait spot 2. Nevus spilus 3. Epidermal nevus 4. Acquired nevus 5. Dysplastic nevus 6. Blue nevus 7. Becker's nevus 8. Halo nevus 9. Mongolian spot 10. Nevus of Ota 11. Nevus of Ito 12. Spitz nevus 13. Nevus sebaceus

Answer 52

* **Intracranial:** mental status usually normal. * **Cranial:** bi or uni-coronal synostosis. * **Orbits:** Ptosis. * **Ears:** Prominent crus helicis extending through the conchal bowl. * **Midface:** deviated nasal septum, narrow palate. * **Extremities:** Patrial syndactyly with short stature.

Answer 53

1. Inject 0.58mg into a given cord (each vial contains 0.9mg). 2. Up to TWO cords or TWO joints in the same hand can be treated each visit. 3. A cord can be treated up to THREE times at 4 week intervals.

Answer 54

Microcephaly, multiple lipomas, multiple vascular malformations.

Answer 55

* Prominent frontal bossing. * Low hairline. * Mandibular hypoplasia. * Low set ears * Colobomas of the UPPER eyelid * Epibulbar dermoids * Bilateral anterior accessory auricular appendages * Vertebral abnormalities

Answer 56

**1. Nodule formation:** type III collagen, disorganized, high cellular density, myofribroblasts. **2. Cord formation without contracture:** decreasing cellularity, more organization to collagen. **3. Mature cords with finger contracture:** organized collagen, hypocellularity.

Answer 57

1. Verrucous 2. Ulcerative 3. Marjolin 4. Subungual

Answer 58

Advantages: 1. Superior cosmetic result previous of preservation of skin envelope and anatomic landmarks. 2. Psychological benefit from immediate return of body image. 3. Single-stage procedure with lower overall socioeconomic cost. 4. Best for stage I/II breast cancer not expected to receive post-operative radiotherapy. Disadvantages: 1. Difficult to assess mastectomy flap viability. 2. Risk of post-operative radiotherapy could jeopradize reconstruction. 3. Increased risk of post-operative complications. 4. Post-operative complications can delay adjuvant thereapy.

Answer 59

1. Inadequate resection of fascia. 2. Failure to address joint contracture. 3. Failure to address central slip attenuation. 4. Poor hand therapy compliance. 5. Contraction of digital vessels over time.

Answer 60

**Spitz nevus:** Usually appears at birth. Also called juvenile melanoma. REd or pigmented smooth, dome-shaped papule. Telangiectasia is a frequent finding. Average diameter is 8mm. Most commonly found on head and neck. Recommend excision for both therapeutic and diagnostic reasons.

Answer 61

1. Partial thickness burns greater than 10% total body surface area (TBSA). 2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints. 3. Third degree burns in any age group. 4. Electrical burns, including lightning injury. 5. Chemical burns. 6. Inhalation injury. 7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality. 8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. 9. Burned children in hospitals without qualified personnel or equipment for the care of children. 10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention.

Answer 62

1. Degree of differentiation (well differentiated = 7%, moderately differentiated = 23%, poorly differentiated = 28%) 2. Depth of tumour invasion 3. Perineural invasion 4. Desmoplastic SCC

Answer 63

1. Collagenase (Clostridium histolyticum) 2. Needle fasciotomy. 3. Open fasciotomy. 3. Limited fasciectomy. 4. Radial fasciectomy. 5. Dermatofasciectomy.

Answer 64

1. Superficial spreading 2. Nodular 3. Lentigo maligna 4. Acral-lentiginous 5. Desmoplasic 6. Amelanotic 7. Noncutaneous 8. Ocular

Answer 65

Traumatic carotid-cavernous sinus fistula arises when a fracture results in a laceration or tear in the arterial wall allowing blood to shunt fron the internal carotid artery to the cavernous sinus. **Signs:** * Proptosis * Ocular bruit * Injection and chemosis (edema of the conjunctiva) * Ophthalmoplegia of CNs II, IV, VI * Dilated ophthalmic vein on CT of orbit **Management:** Surgical ligation of carotid artery or interventional placement of coild to obliterate fistula.

Answer 66

**Tessier Cleft Number 0** **One liner:** Like cleft number 14, can yield *absent or excess* midline skeletal and soft tissue involvement. Cleft begins between the upper incisors, extending through premaxilla, secondary palate (cleft), and nasal bones (potential absence OR potential bifid nose). *\* Can continue as cleft number 14\** **_Deficient_ midline structures:** * *Soft tissue deficiency:* Midline facial cleft includes upper lip/nose, leading to hypotelorism (holoprosencephaly). * *Skeletal deficiency:* Premaxilla is absent, secondary palate cleft, partial / total absence of nasal bones. **_Excess_ midline structures:** * Soft tissue excess: Duplicated frenulum, bifid nose, middorsal furrow. Hypertelorism. * Skeletal involvement: Diastema of the upper incisors, keel shaped maxillary alveolus, nasal maxillary process, nasal bones, septum broadened.

Answer 67

Deformational plagiocephaly is often mistaken for either unilateral lambdoidal or coronal plagiocephaly. In deformational plagiocephaly, the following changes are expected: 1. Head assumes parallelogram configuration. 2. Ipsilateral occipital flattening and frontal bossing. 3. Ear displaced anteriorly.

Answer 68

**Tessier Cleft Number 6** **One liner:** Cleft extends from the oral commissure along the junction of the maxilla and zygoma into the lower eyelid and inferior orbital fissure. **Soft tissue:** * Cleft is a vertical furrow extending from the oral commissure to the lateral lower eyelid. * Lateral palpebral fissure is pulled downward and lateral canthus follows, causing antimongoloid slant. * Creates appearance of ectropion and colobomas and of the lower eyelid. **Skeletal involvement:** * Essentially a cleft at the zygomaxillary junction. * Choanal atresia is common (blocking of the posterior aspect of the nasal passages). * Cleft connected to the inferior orbital fissure. * Zygoma is hypoplastic. * Anterior cranial fossa narrowed.

Answer 69

1. UV exposure 2. Age 3. Prior melanoma 4. Family history 5. Fitzpatrick skin type (I, II) 6. Sex (male \> female) 7. Race (white \> black)

Answer 70

* **Primary palate:** * Develops at 5-6 weeks. * *_Medial and lateral palatine processes_* of the *_medial nasal prominences_* come together to form the *_primary palate_*. * *_Clefts of primary palate_* result from failure of fusion of he *_medial and lateral_* *_palatine processes_*. * **Secondary palate:** * Develops weeks 9-12 weeks. * *_Lateral palatine shelves_* of the *_maxillary prominences_* form the *_secondary palate_*. * Palatine shelves are initially vertical but migrate horizontally as the tongue drops with mandibular growth. * Right palate drops first, explaining the higher incidence of left sided clefts. * *_Clefts of the secondary palate_* result from the *_failure of fusion_* of the *_lateral palatine process with the nasal septum_*.

Answer 71

EPIDERMIS * Compact laminated stratum corneum. * Flattened dermal-epidermal junction. * Fewer layers of keratinocytes. * Melanocyte density decreases. * Langerhans cells decrease. DERMIS * Dermal atrophy. * Fribroblasts enlarge and decrease mitotic activity. * Pacini's and Meissner's corpuscles decrease in density. * Decreased elastic fibers. * Increased ground substance. * Increased Type III collagen.

Answer 72

1. Acute airway obstruction and failed endotracheal intubation. 2. Expected prolonged mechanical ventilation. 3. Multiple facial fractures associated with basilar skull fractures. 4. Destruction of nasal anatomy associated with facial fractures.

Answer 73

* Treatment directed at reconstituting the intercanthal relationship, nasal projection, and internal orbital structures. * Broad exposure with coronal flap. * Bony fragments reduced and fixated with miniplates. * Cranial bone grafts may be required to reestablish nasal projection. * Canthal tendons reconstructed with transnasal wiring. * Soft tissues of nasoorbital valley redraped with bolsters.

Answer 74

The lacrimal system is made up of the superior and inferior canaliculi that coalesce into the common canaluculus. This empties into the lacrimal sac, which drains into the nose (inferior meatus) through the lacrimal duct.

Answer 75

**Tessier Cleft Number 9** **One liner:** Cleft involves the lateral third of the upper eyelid and brow with a hypoplastic greater wing of the sphenoid; can have encephaloceles. **Soft tissue:** * Hallmarks are lateral third of the upper eyelid and brow abnormalities * Micropthalmia. * CN VII palsy of the forehead and upper eyelid. **Skeletal involvement:** * Hypoplastic greater wing of sphenoid causes lateral displacement of orbital rim. * Anterior cranial fossa reduced. * Can have encephaloceles.

Answer 76

Bifrontal craniotomy, fronto-orbital advanacement, repositioning of the frontal bar, recontouring frontal bone, barrel staves.

Answer 77

Collectively referred to as *posterior plagiocephaly* or *occipital plagiocephaly*. 1. Ipsilateral occipital flattening 2. Ipsilateral mastoid bulge 3. Ipsilateral downward cant of the posterior skull base 4. Ipsilateral ear inferior 5. Contralateral large middle cranial fossa

Answer 78

1. Nodular. 2. Micronodular. 3. Superficial spreading. 4. Infiltrative. 5. Pigmented. 6. Morpheaform (sclerosing or fibrosing).

Answer 79

1. Extended strip craniectomy (open vs. endoscopic) with helmet. 2. Spring assisted cranioplasty. 3. Open vault * Anterior and posterior in 2 stages (total cault in 1 stage rarely done). * Posterior reconstruction only: patients shown to normalize their forehead shape if an isolated posterior-middle vault expansion peformed.

Answer 80

Coagulative necrosis.

Answer 81

1. Mustarde (scaphaconchal sutures) 2. Furnas (conchal mastoid sutures) 3. Converse-Wood-Smith (cartilage breaking)

Answer 82

**_AP_** 1. **Facial symmetry and nasal deviation:** line drawn through the midglabella to the menton should bisect the nasal bridge, nasal tip, and cupids bow. 2. **Nasal length:** Nasal length should be ~ 2/3 of the middle third of the face and/or roughly the distance from the stomion to the menton. 3. **Width of the nose and degree of alar flare:** Alar base should be the same as the intercanthal distance and the width of an eye. Normal alar flaring is 2mm wider than alar base (caucasian females). 4. **Dorsal aesthetic lines:** Lines should extend from the medial supraciliary ridges to the tip-defining points on the dorsum. 5. **Nasal tip evaluation:** Tip-defining points bilaterally, supra-tip break superiorly, and columellar-lobular angle inferiorly should form 2 equilateral triangles. 6. **Columella evaluation:** Columella should hang just inferior to alar rims, giving a gentle gull wing. **_LATERAL VIEW_** 1. **Projection:** Tip projection (from the alar base to the nasal tip) should be the same as the alar base width. Put differentialy, tip projection should be 2/3 of nasal length. Also, 50-60% of this projection should line anterior to a line drawn vertically from the most projecting portion of the upper lip. * If \>60% is anterior to the vertical line, tip is overprojected and should be reduced. * If \<50% is anteriot to the vertical line, tip is underprojected and should be augmented. 2. **Dorsum:** Connect a line from the nasofrontal angle to the tip. In women the dorsum should lie 2mm behind this line with a slight supratip break. In men, the dorsum should lie slightly more anterior. 3. **Tip Rotation:** Nasolabial angle is formed by a line through the most anterior and posterior elements of the nostril and a perpindicular line through the natural horizontal facial plane. In women 95-100 is preferred. In men, 90-95 is preferred. 4. **Tip:** Columellar-lobule angle is the angle between the columella and the infra-tip lobule. It is typically 30-45 degrees. **_BASAL VIEW_** * **Nostrils:** Should be tear drop shape. * **Columella to lobule ratio:** 2:1 ratio of the columella to lobule on basal view.

Answer 83

Both the ASCO-SSO and the National Comprehensive Cancer Network (NCCN) guidelines state that for patients with T1b (\<0.8 mm with ulceration or 0.8-1.0 mm with or without ulceration) melanomas, SLNB may be considered and discussed with the patient.

Answer 84

* Medical * Imiquimod 5% or 5-flurouracil (can be used for low risk superficial BCC and SCC in situ) * Vismodegib (adjuvant therapy when surgical and radiation options exhausted) * Radiation (92% cure) * Destructive * Curettage and electrodessication (96-100% cure for tumours \<2mm) * Cryotherapy * LASER phototherapy (CO2) * Photodynamic therapy * Surgical excision * WLE (4mm for small primary BCC on face, 10mm for high risk larger tumors on trunk / extremities) * Mohs

Answer 85

* Distint inferior mandibular border. * Subhyoid depression. * Visible thyroid cartilage bulge. * Visible anterior border of sternocleidomastoid * Cervicomental angle of 105-120 degrees.

Answer 86

Multiple malformed ecstatic vessels in the sin, mucous mebranes, viscera.

Answer 87

**Tessier Cleft Number 3** **One liner:** Cleft begins between lateral incisor and canine and extends superiroly to create communication between oral, nasal, and orbital cavities with disruption of lacrimal system. *\*Can continue as cleft number 10 or 11\** **Soft tissue:** * Originates from lateral margin of Cupid's bow and extends across ala through the frontal process of maxilla. * Extends through the nasolacrimal duct and into lacrimal groove. * Alar base usually superioly displaced and the nose foreshortened. * Lacrimal system usually blocked with anomalous drainage into cheek. * Colobomas of the lower eyelid. * Globe positioned inferiorly and laterally. **Skeletal involvement:** * Between lateral incisor and canine. * Direct communication between oral, nasal, and orbital cavities.

Answer 88

**1. Surviving area**: adipocytes survived. **2. Regeneration area:** adipocytes died and adipose-derived stromal cells survived to replace dead adipocytes. **3. Necrotic area:** adipocytes and adipose-dervied stromal cells died.

Answer 89

1. Secure airway. 2. Posterior nasal and oropharyngeal packing. 3. Immediate reduction of fractures. 4. Selective embolization for stable patients or ligation of external carotid for hemodynamically unstable patients.

Answer 90

1. Protect central nervous system. 2. House specialized sensory organs (olfaction, gustation, vision, balance, hearing, touch). 3. Initiate digestions. 4. Facilitate respiration. 5. Express emotion.

Answer 91

* **Intracranial:** hydrocephalus, potential chiari malformaiton. Usually normal mental status. * **Cranial:** bicoronal synostoses with turribrachycephaly. * **Orbits:** shallow exorbitism, downslanting palpebral fissures, strabismus. * **Midface:** hypoplasia, parrot beak, class III malocclusion, anterior open bite. * **Extremity:** Broad thumbs and halluces, mild cutaneous syndactyly.

Answer 92

**_NON-TETANUS PRONE WOUND_** 1. In a **non-tetanus prone wound**, a patient requires a tetanus booster (0.5 mL) if: * They have an unknown or incomplete tetanus vaccination series. * They received their **booster \>10 years ago**. 2. In a **non-tetanus prone wound**, a patient does not need tetanus immune globulin regardless of their tetanus vaccination status. **_TETANUS PRONE WOUND_** 1. In a **tetanus prone** **wound**, a patient requires a tetanus booster if: * They have an unknown or incomplete tetanus vaccination series. * They received their **booster** **\>5 years ago**. 2. In a **tetanus prone wound**, a patient requires tetanus immune globulin (250 units) if: * They have an unknown or incomplete tetanus vaccination series. * They received their **booster \>10 years ago.**

Answer 93

1. Fitzpatrick skin type (type I and II) 2. Sun 3. Carcinogen (pesticides, arsenic, hydrocarbons) 4. Viral infection (HPV, herpes simplex) 5. Radiation 6. Immunopsupression 7. Chronic wound 8. Premalignant lesions (actinic keratosis, bowen's, leuoplakia, keratoacanthoma)

Answer 94

1. **Ear development:** ear is nearly fully developed at 6-7, so it is reasonable to proceed with surgery at this time. 2. **Child maturity and preferences:** Decision should ideally be driven by child's desire to fix the ear deformity.

Answer 95

1. Previous radiation 2. Multifocial disease 3. Serious connective tissue disorder 4. Pregnancy 5. Large tumours (\>5cm) 6. Inflammatory breast cancer 7. Large cancer in a small breast

Answer 96

1. Spiral bands. 2. Lateral digital sheets. 3. Natatory ligaments. 4. Pretendinous bands. 5. Grayson's ligaments (_NOT_ Cleland's ligaments)

Answer 97

1. Zone of coagulation (necrosis): Non-viable necrotic tissue in the center of the wound. 2. Zone of stasis (edema): Surrounds zone of coagulation, initially viable. 3. Zone of hyperemia (inflammation): Outermost zone, viable.

Answer 98

* **Stratum corneum:** Composed of non-viable keratinocytes. Responsible for thickness of glaborous skin. * **Stratum lucidum:** Composed of non-viable keratinocytes. * **Stratum granulosum:** Composed of marginally viable keratinocytes. Thickens most with tissue expansion. * **Stratum spinosum:** Composed of viable keratinocytes. * **Stratum basal:** Mitotically active keratinocytes, melanocytes, tactile cells, nonpigmented granular dendrocytes. Origin of various skin cancers.

Answer 99

***Neuromelanosis*** is a melanocytic proliferation (benign or malignant; nodular or diffuse) within the leptomeninges and brain parenchyma. ***Neurocutaneous melanosis*** is neuromelanosis associated with congential nevocytic nevi (CNN).

Answer 100

* Anterior hillock is derived from the first branchial arch (mandibular), which contributes with upper third of the ear: * tragus * root of helix * superior helix * Posterior hillock is derived from the second branchial arch (hyoid), which contributes the lower two thirds of the ear: * antihelix * antitragus * lobule

Answer 101

Stain with 0.5% copper sulfate and surgically remove.

Answer 102

**Tessier Cleft Number 14** **One liner:** Midline cleft often with significant CNS abnormalities (including holoproencephaly), midline encephalocele and cyclopia - consequently, limited life expectancy often. *\*Can be paired with a Tessier Cleft Number 0\** **Soft tissue abundance:** * Hypertelorism * Midline encephalocele * Long midline frontal hairline **Soft tissue agenesis:** * Holoproencephaly (forebrain does not develop into two hemispheres), hypotelorism, microcephaly, severe CNS abnormalities * Cyclopia * Malformation of forebrain to proportional degree of facial deformity **Skeletal involvement:** * Medial frontal defect with encephalocele * Midline structure bifidity: crista galli, perpendicular plate of ethmoid. * Cribriform plate displaced caudally * Harlequin deformity of orbits from upslanting anterior cranial fossa **Other:** * Accompanying central nervous system abnormalities. * Life expectancy limited * Like a cleft 0, can create agenesis or overabundance of tissue

Answer 103

Profound thrombocytopenia with kaposiform hemangioendothelioma.

Answer 104

Three important factors: 1. Degree of displacement of the posterior table. 2. Presence or absences of CSF leake. 3. Infolvement of the nasofrontal duct. Management options: 1. **ORIF anterior table alone:** * Reserved for isolated anterior table fractures without nasofrontal duct involvement and without CSF leakage. 2. **Sinus obliteration:** * Indicated for fractures of anterior table involving nasofrontal ducts. * Used when posterior table displacement minimal and no CSF leakage. 3. Cranialization: * Indicated for fractures of anterior table with involvement of CSF leakage, significant displacement or comminution of posterior table. * Posterior table removed, remaining mucosa removed, nasofrontal ducts obliterated, nasal cavity isolated from cranial cavity with pericranial flap along floor of anterior cranial fossa. Anterior table recontructed.

Answer 105

* **Auricular temporal nerve** (branch of trigeminal) provides sensation to tragus and crus helicis. * **Great auricular nerve** (branch of cervical plexus) divides into anterior and posterior devisions and supplies the rest of the ear. * **Lesser occipital nerve** has some contribution.

Answer 106

Strong risk factors (RR\>4.0) 1. Female. 2. Age (\>65) 3. Biopsy confirmed atypical hyperplasia 4. Personal history of breast cancer 5. BRCA1/BRCA2 6. Mammographically dense breasts Moderate (RR 2.1-4) 1. Two first-degree relatives with breast cancer 2. High dose radiation to chest 3. High endogenous estrogen or testoterone levels 4. High bone density (postmenopausal) Low (RR 1.1-2.0) 1. EtOH 2. Ashkenazi Jewish heritage 3. Early menarche (\<12) 4. Late menopause (\>55) 5. Never breast fed child 6. Nulliparity 7. Late age at first full term pregnancy (\>30) 8. Hormone replacement therapy 9. Personal history of endometrial, ovarian, or colon cancer 10. Obesity 11. Height (tall) 12. High socieconomic status 13. Jewish heri

Answer 107

1. Internal mammary. 2. Thoracodorsal. 3. Lateral thoracic. 4. Axillary. 5. Retrograde IM artery. 6. Thoracoacromial.

Answer 108

1. Conservative management. 2. Beta-blockers (propranolol oral, timolol topical). 3. Steroids (oral or intralesional). 4. LASER (pulsed dye and Nd:YAG). 5. Surgery.

Answer 109

* Pneumatization begins at age 2. * Reaches adult size by age 12. * Not identifiable radiographically until age 8.

Answer 110

* Arch I form three anterior hillocks, which form essentially the superior half of the ear: * Tragus * Root of helix * Superior helix * Arch II form three posterior hillocks, which form essentially the inferior half of the ear: * Antitragus * Antihelix * Lobule

Answer 111

* **Intramembranous ossification:** Cartilaginous precursor resorb; mesenchymal cells directly differentiate into osteoblasts without a cartilaginous intermediate. * **Endochondral ossification:** A cartilaginous template is directly and gradually replaced with a bony matrix.

Answer 112

* **Hair follicle:** hair growth. * **Sebaceous gland:** sebum. * **Eccrine sweat gland:** thermoregulation. * **Apocrine sweat gland:** sweat. * **Naked nerve fiber:** pain, temperature, chemoreceptor. * **Meissner's corpuscle:** light touch, dynamic two-point discrimination. * **Pacinian corpuscle:** vibration, deep pressure. * **Bulb of Krause:** temperature (cold). * **Ruffini ending:** sustained pressure, temperature (hot)

Answer 113

Collectively referred to as *brachycephaly*. 1. Bilateral retruded forehead and supraorbital rims. 2. Increased biparietal diameter. 3. Elevation of height of skull but short in AP direction.

Answer 114

**Tessier Cleft Number 11.** **One-liner:** Cleft extending upward from the medial third of the eyelid accompanied by hypertelorism and encephaloceles. **Soft tissue:** * Medial third of upper eyelid with coloboma. * Disruption extends to the hairline. Skeletal: * Extensive pneumatization of ethmoid cells produces hypertelorism / enecephalocele. * Cranial base is normal.

Answer 115

1. Beta-transferrin test. 2. Ring test.

Answer 116

1. Posterior auricular artery 2. Superficial temporary artery

Answer 117

1. Do not use sharp cannulas or needles; instead use larger, blunt cannulas. 2. Use epinephrine; a vasocontricted vessel is much harder to cannulate than a dilated one. 3. Inject small volumes around danger areas. 4. Use small syringes; controlled injected volume is much easier with a 1cc Luer-lock syringe han a 10-20cc syringe. 5. Do not use mechanical devices for injecting that can generated high pressures.

Answer 118

1. Deep inferior epigastric artery perforator (DIEP) 2. Periumbilical perforator (PUP) 3. Superior gluteal artery perforator (SGAP) 4. Inferior gluteal artery perforator (IGAP) 5. Posterior thigh 6. Anterolateral thigh 7. Thoracodorsal artery perforator (TDAP) 8. Transverse upper gracilis myocutaneous (TUG) 9. Superficial inferior epigastric artery (SIEA) 10. Rubens (based on cutaneous perforators of the deep circumflex iliac artery and vein)

Answer 119

**Tessier Cleft Number 13** **One liner:** Paramedian cleft with disruption of cribriform plate, hypertelorism, and frontal encephalocele. **Soft tissue:** * Paramedian frontal encephalocele locaed between nasal bone and frontl process of maxilla * V-shaped frontal hairline projection **Skeletal:** * Hypertelorism from widening of cribriform plate and ethmoid cells * Cribriform plate displaced inferiorly by frontal encephalocele * Orbital dystopia

Answer 120

In neonates range is form 0-72 hours. Typically initiated after 5-7 days in most patients.

Answer 121

Advantages: 1. No delay in adjuvant thereapy as a result of reconstructive complications. 2. Allows careful monitoring for advanced malignancy prior to reconstruction. 3. Decreased risk of complications. 4. Skin damage to mastectomy flap can be addressed at time of reconstruction. 5. Improved body image and increase vitality. Disadvantages: 1. Loss of breast skin envelope and natural landmarks. 2. Recipient vessel dissection more tedious because of scarred / irradiated axilla or chest wall. 3. Flap size requirement usually greater than with immediate reconstruction. 4. Psychological morbidity of living with mastectomy defect.

Answer 122

* In situ: 0.5cm * \<1mm: 1cm margin * \>1mm: 2cm margin

Answer 123

* Fitzpatrick skin type * Sun exposure * Age * Immunosuppression * Carcinogenic exposure (UV, ionizing radiation, arsenic, hydrocarbons) * Genetic mutuations / syndrome (Albinism, Nevoid basal cell syndrome / Gorlin's syndrome, Xeroderma pigmentosum)

Answer 124

1. Proliferative phase (0-12 months) * 80% of maximum size at 3-5 months. 2. Involuting phase (12 months to 7-10 years) * Tumor shrinks, color fades, lesion flattens. 3. Involuted phase (complete at \> 10 years) * 50% of cases will have residual bulk, color, or skin redundancy.

Answer 125

Collectively referred to as *anterior plagiocephaly*. 1. Ipsilateral frontal flattening, retruded forehead and supraorbital rim. 2. Ipsilateral raised eyebrow. 3. Ipsilateral widened palpebral fissure (increased diameter of orbital alters origin of levetor muscle and leads to widened palpebral fissure). 4. Ipsilateral deviated nasal root. 5. Ipsilateral ear anterior and superior. 6. Contralateral frontoparietal bossing. 7. Anteriorly displaced glenoid fossa causes chin to point to the contralateral side.

Answer 126

Failure of medial nasal process to contact maxillary process.

Answer 127

Weeks 4-7.

Answer 128

* **Philtral column:** Bilateral verticle buldge created by dermal inseration of the orbicularis rosi fibers. * **Philtral dimple:** Concavity between the phitral columns created by a relative paucity of muscle fibers. * **White roll:** Prominent ridge just above the cutaneous-vermillion border. * **Vermillion:** Red mucosal portion of the lip divided into dry (keratinized) and wet (nonkeratinized); widest at peaks of cupids bow. * **Red line:** Line separting wet and dry vermilion. * **Cupid's bow:** Curvature of the central white roll; two lateral peaks are the inferior extension of the philral columns * **Tubercle:** Vermillion fullness at central inferior apex of cupid's bow.

Answer 129

1. Cleft lip results in projection and outward rotation of the premaxilla and retropositioning of the lateral maxillary segment. 2. Orbicularis oris muscle in lateral lip element ends at the margin of the cleft and inserts into the alar wing. 3. There is hypoplasia and disorientation of the pars marginalis of the orbicularis oris. 4. Philrum is short. 5. Vermillion width is decreased on the cleft side and increased laterally.

Answer 130

1. Two deep clefts separate prolabium from paired lateral elements. 2. Prolabium has no cupid's bow, no philtrum or philtral columns, and no orbicularis. 3. Lateral lip elements muscle fibers run parallel to cleft edges toward alar bases.

Answer 131

**Simonart's band:** Residual skin bridge spanning upper portion of cleft lip.

Answer 132

1. Deviated nasal tip. 2. Attenuated lower lateral cartilage (obtuse angle between medial/lateral crura as well as bucklng of lateral crura). 3. Flattened alar/facial angle. 4. Widened nostril floor. 5. Nasal tip and nostrils asymmetrical. 6. Hypertrophic inferior turbinate on cleft side. 7. Alar base displaced latereally, posteriorly, and sometimes inferiorly. 8. Deficient vestibular lining on cleft side. 9. Columella shorter on cleft side. 10. Caudal spetum deviate to noncleft side with posterio septum convex on cleft side.

Answer 133

* Family history * Phenytoin. * Exposure to anticonvulsants. * Smoing in first trimester.

Answer 134

1. Small notch in vermillion. 2. Band of fibrous tissue running from edge of red lip to nostril floor 3. Deformity of the ala on the side of the notch.

Answer 135

1. Rose-Thomspon * Straight line repair * May be useful in microform clefts and repair of vermillion notching. 2. Triagnular flap repair * Uses single z-plasty as vermillion-cutaneous junction. 3. Quadrangular flap repair 4. Rotation-advancement * Millard * Rotates medial lip element downward and fills resulting defect with lateral lip. * Places scar along proposed philtral column. * Most common method of unilateral repair.

Answer 136

* Mulliken repair * Millard repair * Modified Manchester repair

Answer 137

**Mulliken Repair for Bilateral Cleft Lip** * **Markings:** * subnasale (sn), subalaris (sbal), labiale superisu (ls), crista philtri superioris (cphs), and crista philtri inferioris (cphi), red line. * Prolabium flap dimenions: * 2mm wide superiorly (cphs-cphs) * 4mm wide inferior (cphi-cphi) * 6-7mm in height (sn-ls) * Flanking flaps 2-3mm width on each flap to be deepithelialized * Noordhoff point marked on lateral labial elements (ensure 3mm of white roll medial to this) * Cutaneous advancement flaps drawn just above white roll up to sbal. * **Operative steps:** * Key landmarks tattooed and markings scored with scalpel * Local anesthetic infiltration. * Deepithelialization of flanking flaps. * Discard remaining prolabial skin and vermillion with preservation of prolabial mucosa. Excise prolabial submucosa. * Lateral labial flap are incised at the superior aspect and maxilla exposed. * Alar base released sharply from piriform rim. * Submuscular (supraperiosteal) dissection continued laterally to the level of the malar eminence using Tessier elevator to mobilize the cheek and decrease tension on labial repair. * Vermillion / mucosal flap is then divided from the cutaneous portion of the lateral advancement flap. * Orbicularis separated from overlying skin and oral mucosa. * Mucosal flap secured to the premaxillary periosteum at the anterior nasal spine and gingivoperiosteoplasty is performed. * Vestibular mucosa approximated and lateral labial mucosa is closed. * Orbicularis muscle is approximated in the midline, secured to anterior nasal spine, and closed. * Identify the cphi on each lateral labial flap and mark 3mm medial to cphi. These two points approximated and will later receive the ls of the philtral flap. * Prolabial c-flaps approximated to the alar base flaps. * Alar cinch stich placed to control alar bases (24-26 mm in infants). * Nasal correction (if any). * Lateral labial cutaneous advancements trimmed and closed.

Answer 138

* Short lip * Long lip * Whistling deformity: Central vermillion deformity that presents as notching or inadequate vermillion with exposure of central incisiors in repose. * Widened scar * Lip landmark abnormalities

Answer 139

* Branchial arch syndromes * Goldenhar's syndrome * Treacher Collins Syndrome * Oculoauriculovertebral syndrome * Hemifacial microsomia

Answer 140

* **Brent technique** * Wait until age 4-6 years to allow for ear maturity and to reach appropriate school age. * **Nagata technique** * Wait until age 10 OR when chest circumference at xyphoid is **_60cm_** to allow for sufficient cartilage for recontruction.

Answer 141

* Complete audiometric testing to determine conductive vs. sensorineural defect. * High resolution CT to assess middle ear ossicles. * MRI to assess course of facial nerve which can be displaced and to assess for presence of cholesteatoma (4-7% of atretic ears)

Answer 142

* **Autogenous costal cartilage.** * Originally described by Tanzer, and revised by Nagata and Brent. * Positives: Best long-term recontruction. * Negatives: Donor site morbidity, chest wall deformity, multiple stages. * **Silastic Framework** * Positive: Excellent aesthetic appearnce, no donor site. * Negatives: extrusion, long-term failure, susceptible to trauma. * **Porous polyethtylene implant** * Positive: good short-term aesthetic results and extrusion rates. * Negatives: Limited long term data. * **Posthestic / Osteointegrated Reconstruction** * Positive: good alternative to more invasive options * Negatives: limited by anaplastologist * **Tissue engineering** * Still in development

Answer 143

Brent Technique for microtia reconstruction. * Timing: Begining at 4-6 years of age. * **Stage I:** * High-profile ear *_framework_* fabricated from contralateral costochondal rib cartilage of synchondrosis of 6th-8th rib. Placed in subcutaneous pocket at posterior/infeior border of ear vestige. * **Stage II:** * *_Lobule_* transposition several months after framework. * **Stage III:** * *_Projection_* established. * Incision along margin of the rim. Posterior capsule elevated. Projection established with wedge of cartilage placed subfascially. * Retroauricular skin advanced. STSG + bolster to cover the posterior defect. * **Stage IV:** * *_Tragus_* construction, conchal excavation, and symmetry adjustment. * Tragus fashioned from composite graft from contralateral conchal cault or anteriorly based conchal flap with cartilage support.

Answer 144

**Nagata technique** for microtia recontruction. * **Timing:** Involves two stages starting at 10 years old. * **Stage I:** * *_Ipsilateral_* rib cartilage from 6th-9th ribs. * Perichondrium left in situ to minimize chest well deformity. * Framework recontructed with *_tragal component_*. * Placed subcutaneously through W-shaped flap. * *_Lobule_* transposed at this stage. * **Stage II:** * *_Framework elevated_* 6 months later. * Additional cartilage elevated from 5th rib to use as wedge. * *_Temporoparietal fascia flap_* elevated and tunneled subcutaneously to cover posterior cartilage grafts. * Advancement of retroauricular skin and coverage of defect with STSG.

Answer 145

**International Society of Lymphology** staging of lymphedema. **Stage 0:** Latent or *subclinical*. No edema evident, but *lymph transport impaired*. Can occur months or years before overt edema. **Stage I:** Early accumulation of proteinaceous fluid with edema that *resolves with limb elevation*. Pitting edema can occur. **Stage II:** Pitting edema may or may not be present. *Tissue fibrosis* develops. Does not resolve with limb elevation. **Stage III:** Lymphostatic elephantiasis with *absent pitting*. Acanthosis, fat deposits, warty growth, and other trophic *skin changes*.

Answer 146

**_Congenital Lymphedema (Milroy's Disease)_** * Occurs within *_first 2 years of life_*. * Commonly presents as bilateral lower extremity lymphedema but can afect upper extremity as well (3:1, LE:UE incidence). * Possible associations: lymphangiectasia (pathologic dilation of lymph vessels) and cholestasis **_Familial Lymphedema Praecox (Meige's Disease)_** * Presents during *puberty*. * Most common form of primary lymphedema. * Commonly presents unilateral affecting the foot and calf. * Possible associations: vertebral, cerebrovascular malformation, hearing loss, double row of eyelashes (distichiasis) **_Lymphedema Tarda_** * Usually occurs *after 35 years old*. * Histologically lymphatics are tortuous, hyperplasics and absent competent valves.

Answer 147

* Filariasis (parasitic disease caused by an infection with roundworms) is caused by *Wuchereria bancrofti*. Whereby, the adult forms obstruct the lymphatic sytem. * Drug of choice for treatment is **ivermectin**. * Ciculating filarial antigens are pathognomonic and used to test efficacy of treatment.

Answer 148

1. Erysipelas. 2. Lymphangitis. 3. Lymphangiosarcoma (Stewart-Treves Syndrome) * Rare malignant tumour associated with chronic lymphedema. * Presents with multiple blue/red subcutaneous nodules in the affected extremity.

Answer 149

**Stemmer's sign:** inability to grasp the skin of the *dorsum of the second digit of the feet*.

Answer 150

Conservative management of lymphedema is first line management in all cases, and is called **Complete Decongestive Therapy (CDT)**. It is composed of a **REDUCTIVE PHASE** followed by a **MAINTENANCE PHASE**. CDT can yield 40-60% reduction in excess volume in those with pitting edema. Reductive Phase (3-8 weeks) * Manual lymphatic drainage * Compression bandaging * Therapeutic exercise * Skin care * Education in self-management * Elastic compression garments **Maintenance Phase (ongoing)** * Lifelong self-lymph drainage * Exercise * Skin care * Compressions garments

Answer 151

1. Maintence of normal weight 2. Avoidance of weith gain 3. Participation in supervised exercise programs

Answer 152

1. **Resection procedures** * *Charles procedure:* circumferential excision of lymphedematous tissue down to the deep fascia with coverage with STSG. * *Modified Charles procedure:* circumferential excision of lymphedematous tissue down to the deep fascia, with _temporary coverage with negative pressure dressing for 5-7_ days prior to definitive coverage with STSG. * *Miller procedure:* longitudinal excision of medial tissue (skin and subcutaneous tissue) with a layered closure and placement of drains. 2. **Suction assisted-lipectomy** * Circumferential liposuction of affected extremity 3. **Microsurgical procedures** * *Autologous lymph node transfer:* Flap including myphnodes, artery, and vein is harvested from donor site and placed into lymphedematous tissue follow scar release. * *Interpositional lymph vessel transplation:* Healthy lymphatic vessels used as interpositional grafts to bypass non-functioning area of lymphatic system. * *Lymphovenous bypass:* Subdermal lymphatics anastomosed to neighboring venules.

Answer 153

Oral aperature to the palatoglossal fold.

Answer 154

**Wharton's ducts:** Salivary ducts for the submandibular and sublingual salivary glands on the floor of the mouth. **Stensen's ducts:** Salivary ducts for the parotid gland located on the buccal mucosa across from and at the level of the *maxillary second permanent molar*.

Answer 155

* Total teeth: 20 * 4 incisors, 2 canines, 4 molars per arch * No premolars * Numbering begins with the right maxillary second molar and counts maxillary teeth (A-J). Then begins with the left mandibular second molar and counts mandibular teeth (K-T).

Answer 156

* Total teeth: 32 * 4 incisors, 2 canines, 4 premolars, 6 molars per arch * Numbering begins with the third maxillary molar on the right and counts all the maxillary teeth (1-16). Then continues with left third mandibular molar adn counts all mandibular teeth (17-32).

Answer 157

* **Occlusal:** functional surface of the tooth. * **Apical:** toward the root tip. * **Incisal:** occlusal surface of anterior teeth. * **Medial:** toward midline. * **Distal:** away from midline. * **Buccal:** toward the cheek. * **Lingual:** toward the tongue (mandibular). * **Palatal:** toward the palate (maxillary). * **Overbite:** amount of vertical overlap of incisal edges. * **Overjet:** amount of horizontal overlap of incisal edges. * **Proclined:** anterior tooth angled toward the lip. * **Retroclined:** anterior tooth angled angulated toward the tongue. * **Buccal version:** posterior tooth angulated toward the cheek. * **Lingual version:** posterior tooth angulated toward the tongue. * **Centric occlusion:** occlusion of teeth in maximal intercuspation. * **Centric relation:** occlusion of teeth with condyle in its most anterosuperior position. * **Crossbite:** horizontal malrelationship of teeth; may be classified as anterior or posterior. * **Open bite:** occlusal surfaces not in contact when in centric occlusion.

Answer 158

Occlusion is defined by the relationship of the first maxillary and mandibular molars. Specifically, the normal relationship is that the mesiobuccal cusp of the first maxillary molar occludes in the buccal grove of the first mandibular molar. Normal occlusion exists when the mesiobuccal cusp of the mandibular first molar occludes in the buccal groove of the first mandibular molar **_AND_** there is no malposed or malrotated teeth. **_Angle classification of malocclusion_** * **Class I:** mesiobuccal cusp of the first maxillary molar occludes in the mesiobuccal groove of the mandibular first molar (normal), BUT teeth or malposed or malrotated. * NOTE: Class I is NOT normal occlusion. * **Class II:** The mandibular molar is *distally* positioned relative to the maxillary molar. Two divisions describe the relationship of the incisor. * **Division I:** Overjet with normal angulation of incisor. * **Division II:** Incisor retroclined to some degree, resulting in less overbite and increased overjet. * **Class III:** The mandibular molar is mesially positioned relative to the maxillary molar.

Answer 159

4-7mm below the inferior orbital rim along a line dropped from the medial edge of the limbus.

Answer 160

Foramen for the greater palatine nerve is located halfway between the teeth and the palatal midline at about the *second molar*. Foramen for the nasopalatine nerve is located at the *midline 5-7mm behind the maxillary incisors*.

Answer 161

* Inferior alveolar nerve* enters the mandibular formamen on the medial ramus 5-10mm above the mandibular occlusal plane and 15-20mm posterior to the anterior border of the ramus. * Mental nerve* exits through its foramen below the *second premolar*.

Answer 162

Anteroposterior excess characteristically has class II malocclusion with protrusion of maxillary incisors and convex facial profile. Vertical excess can also include elongation of the lower third, narrow nasal base, excessive incisal amd gingival show, and lip incompetence. Primary surgical correction involves LeFort I osteomtomy.

Answer 163

Features typically include: deficiency of infraorbital / paranasal regions inadequate upper tooth show, short lower third, deficient upper lip. Primary surgical correction involves LeFort I osteotomy.

Answer 164

Typically demonstrates class III molar and canine relationship and reverse overjet of the incisors. Facial features include a prominent lower third. Primary correction involve maxillary advancement or mandibular setback. Mandibular setback can be accomplished by bilateral saggital split osteotomies (BSSO) or intraoral vertical ramus osteotomies (IVRO). IVRO requires MMF.

Answer 165

Typically class II molar and canine relationship. Facial features include: retruded position of chin, acute labiomental fold, abnormal lip posturing, and short thyromental distance. Primary surgical treatment includes mandibular advancement with BSSO.

Answer 166

Anatomic classification of mandible fractures. * **Dentoalveolar:** A fracture without disruption of the underlying osseous structures of the mandile and only involving the tooth-bearing area. * **Condyle:** Any fracture the affects the condylar process of the mandible, further classified into: * Intracapsular * Extracapsular * Neck * **Coronoid:** Any fracture that affects the coronoid process. * **Ramus:** Superior to the gonial angle to the sigmoid notch. * **Angle:** Region of the *gonial angle* extending to the region of the *third molar*. * **Body:** Any fracture between the *mental foramen* and the *distal aspect of the second molar*. * **Parasymphysis:** Any between the *mental foramen (second premolar)* and the distal aspect of the *lateral incisor*. * **Symphysis:** Fracture in the region of the *incisors* in a vertical or near-vertical orientation.

Answer 167

1. Grossly mobile teeth showing evience of periapical pathology or advanced periodontal disease. 2. Partially erupted third molars with associated dental pathology (cycsts or periocoronitis). 3. Teeth prevent fracture reduction. 4. Fractured roots. 5. Exposed root apices.

Answer 168

* **Rigid (absolute) stability:** No movement across the fracture gap. * **Functional stability:** Movement is possible across the fracture gap but is balanced by external forces and remains within the limits that allows the fracture to progress to union. * **Load-sharing stability:** Functional stability is achieved by the fixation system in conjunction with stablizing forces provided by anatomic abutment of noncomminuted fracture segments. * **Load-bearing stability:** Functional stability, provided solely by the fixation system. Accomplished only by reconstruction plates.

Answer 169

Management of **condyle fractures**. * Condyle fracture *without* malocclusion: * Soft diet and close observation * If malocclusion develops (usually deviation to affected side with contralateral posterior open bite) can usually be treated with arch bars and elastics to control occlusion. * Condyle fracture *with* malocclusion: * Closed reduction: * Arch bars and occlusion controlled with elastics * Usually possible with single, class II elastic on the affected side * ORIF necessary when: * Condylar segment displaced and interfers with translation * Condyel is displaced into the middle cranial fossa * Bilateral mandibular condyle fractures and midface fractures exist -- must reestablish posterior verticle height * A normal, reproducible occlusion cannot be established

Answer 170

Fractures of mandibular angle have the higher complication rate of any single region of the mandible. ORIF techniques have similar complication rates to nonrigid technique (requiring MMF).

Answer 171

Mandibular body fractures can be treated with miniplates or recontruction plates. * Miniplates are easier to adapt and place but are useful only in non-comminuted fractures when accurate abutting of fracture segments provides *load-sharing*. * Reconstruction plates are more difficult to adapt and palce but may be used with comminuted fractures when *load-bearing* fixation is necessary.

Answer 172

Symphysis fractures may be treated with miniplates, reconstruction plates, or lag screws. Because of torsional forces generated at the symphysis, if miniplates are used two points of fixation are required.

Answer 173

* Lack of dentition, small bone stock, and poor bone quality compromise the accuracy of reduction and healing capacity. * In the context of the edentulous patient, transfacial approaches with reconstruction plates aid in bony union. * Use of *mini plates* or *closed reduction* with the patient's dentures are *not recommended*. * In severely atrophic mandibles, bone grafting the fracture site may be necessary in the acute setting.

Answer 174

1. Exposure of all fractures. 2. Reduction of all fractures. 3. Placement of MMF. 4. Fixation of fractures. \*\* MMF must be removed and occlusion reassessed after application of hardware. If the patient is to remain in MMF, it may be reapplied after proper reduction is confirmed.

Answer 175

**_Scalp_** * **S (skin):** Measures 3-8mm thick (3mm at vertex, 8mm at occiput) * **C (subcutnaeous tissue):** Vessels, lymphatics, and nerves found in this layer. * **A (aponeurotic layer):** Strength layer, continuous with frontalis and occipitalis muscles. * **L (loose areolar tissue):** Also known as subgaleal fascia and innominate fascia;provides scalp mobility; contains emissary veins. * **P (pericranium):** Tightly aderhent to calvarium. **_Neurocranium_** * External table * Diploic space * Internal table * Epidural space * Dura mater * Subdural space

Answer 176

* **Anterior territory** * Supraorbital and supratrochlear arteries (terminal branches of internal carotid system). * *Supraorbital artery* arises through the supraorbital notch, which is in line with the *medial limbus* * *Supratrochlear artery* arises more medially, in plane with *medial canthus*. * **Lateral territory (largest territory)** * Superficial temporal artery (terminal branch of external carotid system). * Bifurcates at the superior helix of the ear to frontal and parietal branches. * **Posterior territory** * *Occipital arteries* _cephalad_ to the nuchal line. * *Perforating branches of trapezius and splenius capitis muscles* _caudal_ to the nuchal line. * **Posterolateral territory (smallest territory)** * Posterior auricular artery (branch of external carotid system).

Answer 177

**_SENSORY_** Sensory innervation supplied by branches of the three divisions of the trigeminal nerve, cervical spinal nerves, and branches from the cervical plexus. * **Supraorbital nerve** * *_Superficial division:_* Pieces frontalis and supplies skin of the forehead and anterior hairline. * *_Deep division:_* Runs superficial to the periosteum to the level of the coronal suture where it pierces the galeal aponeurosis appropximately 0.5-1.5cm medial to the superior temporal line to innervate the frontoparietal scalp. * **Supratrochlear nerve** * Terminal branch of V1 supplies sensation to lower forehead, conjunctiva, upper eyelid skin. * **Zygomaticotemoral nerve** * Branch of the maxillary division of trigeminal nerve that supplies sensation to a small region lateral to the brow up the superficial temporal crest. * **Auriculotemporal nerve** * Branch of the mandibular division of the trigeminal nerve that supplies the lateral scalp. * **Greater and lesser occipital nerves** * Branches from dorsal rami of cervical spinal nerves and cervical plexus respectively which innervate the occipital territory. * Greater occiptal nerve emerges from semispinalis muscle approximately 3cm below occipital protuberance and 1.5cm lateral to midline. **_MOTOR_** * **Frontal branch of facial nerve (temporal branch)** * Supplies frontalis * **Poserior auricular branch of facial nerve** * Supplies anterior and posterior auricular muscles and occipitalis muscle.

Answer 178

* **Stress relaxation:** Property of skin decreases the amount of force necessary to maintain a fixed amount of skin stretch over time. * **Creep:** Skin property whereby skin gains surface area when a constant load is applied. * As force is applied to a leading skin edge, tissue thickness decreases from extrusion of fluid and mucopolysaccharides, realignment of dermal collagen bundles, elastic fiber microfragmentarion, and mechanical stretching of the skin.

Answer 179

Scoring in 1cm increments will gain 1.67mm for reach relaxing incision.

Answer 180

Approximately 50% of the scalp can be reconstructed with tissue expansion before alopecia becomes a significant issue.

Answer 181

* **Small defect (\<6cm)** * Skin graft * Advancement flaps * Rotation flaps * Bilobed flaps * Pinwheel * Three adjacent rhomboid flaps * **Medium-sized defects** * Skin graft * Large rotation flap +/- back grafting * Orticochea three flap reconstruction (three flap reconstruction based on named vessels of the scalp; the two smaller flaps should be at least 50% of the width of the defect so that when they are brought together they cover the defect) * Not well suited for vertex scalp defects. * Tissue expansion * **Large-sized defects (8-10cm)** * Subtotal scalp flap (essentially a large rotation flap based of STA and posterior auricular arteries with backgrafting) * Temporparietal fascial flap with skin graft * Pericranial flap with skin graft * Free tissue transfers

Answer 182

**_Autologous tissue_** * Split clavarial bone graft (parietal preferred because of increased thickness and abscence of underlying venous sinuses) * Split rib graft (if periosteum left intact, rib may regenerate) * Advantages of autologous: biocompatible, resistance to infection, increased strength. * Disadvantages of autologous: difficult contouring, resorption, donor site availability, and morbidity. **_Alloplastic materials_** * Methymethacrylate * Titanium mesh * Hydroxyapatite * Acrylic * Polyetheretherketone (PEEK) * Advantages of alloplastic: unlimited supply, lack of donor site morbidity * Disadvantages of alloplastic: no integration with recipient site, increased infections, costly

Answer 183

**Outer lamella:** skin and orbicularis oculi muscle. **Inner lamella:** Tarsal plate, medial / lateral canthal tendons, capsulopalpebral fascia, and conjunctiva.

Answer 184

1. **Pretarsal fibers** * Lie over the tarsal plate * Responsible for involuntary blink, lower lid tone, *lacrimal pumping* mechanism 2. **Preseptal fibers** * Overlie the orbital septum * Assist with blink 3. **Orbital fibers** * Overlie orbital rims * Responsible for eyelid squeezing, forceful closure, and animated eyelid movement.

Answer 185

* Tarsal plates are 1-2mm thick and ~25mm long * Laterally they become the medial and lateral canthal tendons * Upper tarsal plate is 12-15mm in height with the superior margin forming the attachment for Muller's muscle and levator aponeurosis. * Lower tarsal plate is 4-10mm in height with the inferior margin continuous with the capsulopalpebral fascia.

Answer 186

**_UPPER LID_** * **Levator palperae superioris** * Innervated by CN III (superior division) * Originates from the lesser wing of the sphenoid, above optic foramen, and extends forward to insert on the edge of the tarsal plate * Whitnall's ligament serves as a fulcrum to redirect the vector of pull from horizontal to superior direction for lid retraction. * **Müller's muscle** * Innervated by *sympathetic nervous system* * Arises from inferior surface of the levator palpebrae superioris and inserts onto superior edge of the tarsus. * Loss of Müller's muscle results in 2-3mm of ptosis. **_LOWER LID_** * **Capsulopalpebral fascia** * Condensation of fibroelastic tissue anterior to Lockwood's ligament, which joins the inferior tarsal plate * Serves as a lower lid retractor * Smooth muscle fibers found at its condensation.

Answer 187

**Blood Supply** * *Upper lid* is supplied by branches of the *ophthalmic artery* * Medial and lateral *superior palpebral arteries* branch to form both *peripheral* and superior *marginal arcades* * *Lower lid* is supplied by branches of the *facial artery* * Medial and lateral palpebral arteries form inferior *marginal artcade* **Innervation** * Upper lid supplied by V1 * Lower lid supplied by V2

Answer 188

* **Defects \< 30% of lid:** closed primarily * **Defect 30-50% of lid:** closed directly with lateral canthotomy + cantholysis. * **Defects of 50-75% of lid:** Closed with myocutaneous advancement flaps. * **Defects \> 75% of lid:** Generally require tissue from opposite lid or adjacent regions (cheekm temporal, forehead)

Answer 189

* Sliding transconjunctival flap (see illustration) * Buccal or nasal mucosa graft (nasal mucosa [20%]contracts less than buccal [50%])

Answer 190

* Palatal mucosal graft * Cartilage graft * Acellular dermal matrix

Answer 191

1. Direct closure (+/- lateral canthotomy and cantholysis) 2. Sliding tarsoconunctival flap + FTSG for anterior lamella 3. Cutler-Beard flap + cartilage graft 4. Lid-sharing (Mustarde pedicled flap) 5. Tenzel semicircular flap 6. Temporal forehead flap (Fricke flap) + mucosal graft for conjunctiva + secondary stage for tarsal plate reconstruction with cartilage graft 7. Paramedian forehead flap + mucosal graft for conjunctiva + secondary stage for tarsal plate reconstruction with cartilage graft

Answer 192

* Defects of 25-30% can be closed primarily (40% if laxity) * Lateral canthotomy + cantholysis may provide additional laxity for closure. * Precise approximation of tarsal plate is critical for proper lid support.

Answer 193

* Combines lateral canthotomy and cantholysis with laterally based myocutaneous flap. * Allows closure of up to 60% of the upper lid.

Answer 194

* Two-stage procedure * Advancement of a full thickness flap (skin, orbicularis, conjuctiva) from the lower lid (elevated BELOW the tarsal plate, ie. tarsal plate is NOT included in the flap) * The flap is made biplanar with a cartilage graft inset between the conjunctiva and the skin/orbicularis. * Flap division performed at 3-6 weeks.

Answer 195

* Used for defets of the central upper lid * Flap divided at 6 weeks and donor site closed primarily.

Answer 196

* Transposition flap from the upper eyebrow * Requires mucosal graft for conjunctiva recon with secondary procedure for cartilage graft OR palatal mucoperiosteal graft which can provide sufficient support.

Answer 197

1. Direct closure 2. Advancement tarsoconjunctival (modified Hughes) flap 3. Tarsoconjunctival (Hughes) flap 4. Semicircular rotation (Tenzel) flap 5. Vertical myocutaneous cheek lift 6. Tripier flap 7. Rotation cheek (Mustarde) flap 8. Temporal (Fricke) flap

Answer 198

* Myocutaneous flap used for partial thickness coverage of lower lid * Can be bipedicled or single pedicle

Answer 199

* Two-stage procedure * Transfers conjunctival lining and a small portion of the tarsal plate for subtotal or total lower lid reconstruction. * Skin coverage provided in the first stage with FTSG * Flap divided at 4-6 weeks.

Answer 200

* Early operative intervention at 4-6 months warranted for border digits (to prevent angular growht and deviation of the longer digit) or when complex (e.g. Apert syndrome with transverse bony components that risk worsening the deformity). * Mostly vommonly waiting until the hand is larger (6-12 months) more appropriate.

Answer 201

* **Camptodactyly:** congenital flexion contracture of the proximal interphalangeal joint; classically involving the little finger. * Theories regarding etiology: * Abnormal lumbrical insertions and morphology. * Extra or abnormal slips of FDS. * Abnormal extensor or PIP capsular contractures. * Bony abnormality of the PIP.

Answer 202

**Symphalangism:** Joint stiffness secondary to the failure of the IP to differentiate.

Answer 203

* Arthrogryposis: Arthrogryposis, also called arthrogryposis multiplex congenita (AMC), involves a variety of non-progressive conditions that are characterized by multiple joint contractures (stiffness) and involves muscle weakness found throughout the body at birth.

Answer 204

* Operation typically reserved for those when contracture is \>60-90 degrees. * Technique: * Stepwise evaluation assessing volar skin, FDS, laxity of central slip. * Minimalist, stepwise release of tethering structures until satisfactory correction achieved.

Answer 205

* Clinodactyly: Curvature that results from an abnormal MIDDLE PHALANX. * Arises from a c-shaped physis which can be present with a 'delta phalanx' * Surgical correction indicated with severe shortening and angulation, particularly when pinch impaured. * Physiolysis: Bracket resection of longitudinal hysis with preservation of growth plate and fat graft. Works well when true delta phalanx is resected. * Osteotomy: Closing or opening wedge osteomy. Can be done when trapezoidal wedge present.

Answer 206

Indications to restore skeletal stability and structure in chest reconstruction. 1. If \> 4 consecutive ribs are resected. 2. If the defect is \>5cm. \* May reconstruct smaller defect if underlying pulmonary disease (less tolerance of respiratory mechanical efficiency) \* May not reconstruct larger defect if previous radiotherapy (radiotherapy stiffens chest wall through ischemic fibrosis) \* If defect is located posterior and/or superiorly, then a larger defect is tolerated.

Answer 207

Options for ALLOPLASTIC chest wall reconstruction: * Mesh * Polypropylene (Marlex) * Expanded polytetrafluroethylene (ePTFE)(GORE-TEX) * Methylmethacrylate * Acellular dermal matrix * Titanium plate fixation

Answer 208

Options for AUTOGENOUS chest wall reconstruction. * Pectoralis major (advancement, turnover) * Latissimus dorsi * Rectus abdominis * Serratus anterior * Omentum

Answer 209

Reconstructive options for anterior chest wall and mediastinum. * Pectoralis major. * Latissimus dorsi. * Omentum. * Rectus abdominis.

Answer 210

Reconstructive options for anterolateral chest wall. * Latissimus dorsi * Omentum * Rectus abdominis. * External oblique. * Serratus anterior. * Transverse thoracoabdominal flap.

Answer 211

Reconstructive options for diaphragmatic defects. * Direct suture repair. * Acellular dermal matric or mesh. * Deepithelialized transverse rectus abdomninis myocutaneous (TRAM). * Latissimus dorsi. * Omentum.

Answer 212

**Poland Syndrome** * *_Etiology:_* Hypoplasia of subclavian artery secondary to kinking during wee 6 gestation. * *_Features:_* * Absence of sternal head of pectoralis major muscle * Absence of costal cartilages * Hypoplasia / aplasia of breast and subcutaneous tissue, including the nipple-areolar complex. * Deficiency of subcutaneous fat and axillary hair. * Syndactyly or hypoplasia of ipsilateral extremity. * Potential additional features: * Absence or hypoplasia of pectoralis major muscle. * Shortening / hypoplasia of forearm. * Variable deformities of serratus, infraspinatus, latissimus, and external obliques. * Total absence of anterolateral ribs with herniation of the lung. * Symphalangism with syndactyly and hypplasia or aplasia of middle phalanges. * Occaisionallay associated with Mobius syndrome. * *_Indications for treatment:_* * Patient with absent ribs. * Female patients with breast asymmetry (surgery delayed to allow full development of contralateral breast)

Answer 213

* Formed from the medial and lateral cords of the brachial plexus. * Courses medial to the brachial artery, sitting between brachialis and the medial intermuscular septum. * Passes under the ligamenta of Struthers at the supracondylar rim (ligament associated with humeral head of PT) * Crosses the antecubital fossa under the bicipital aponeurosis (lacertus fibrosis). * Separates from the brachial artery to pass between the two heads of PT. * Anterior interosseous nerve comes off and descends on the interosseous membrane. * Median nerve continues deep to the FDS arch and descends between FDS and FDP. * Palmar cutaneous branch comes off 5cm proximal to wrist crease and median nerve passes under the carpal tunnel into the hand. * Median recurrent motor nerve branches off beyond, under, or through the carpal tunnel.

Answer 214

* **Radial:** Scaphoid, trapezium, fascial septum. * **Ulnar:** Hamate hook, trapezium, pisiform. * **Floor:** Carpal bones. * **Roof:** Transverse carpal ligament from scaphoid tuberosity / trapezium to pisiform an hamate hook.

Answer 215

* Terminal branch of the posterior cord. * Run posterior to the axillary / brachial artery. * Travels posterior to profunda brachii artery between lateral / medial heads of triceps. * Transect the lateral intermuscular septum with the radial collateral artery (10cm proximal to distal humerus). * After passing anterior, travels between BR and brachialis, ultimately passing between BR and ECRL. * Traverses the radial tunnel (bounded by the radiocapitellar joint bursa, BR tendon, ECRL/ECRB, biceps tendon). Sits 1cm lateral to biceps tendon at the elbow. * Nerve branches at the elbow with PIN travelling under the leading edge of supinator (arcade of Froshe) and the superficial sensory branch travelling on the underside of BR. * PIN ultimatelly travels on the floor of the 4th dorsal compartment and the superficial sensory branch becomes subcutaneous 9-10cm proximal to the wrist under BR. *

Answer 216

* Terminal branch of the medial cord. Travels medial and posterior to the brachial artery. * Transect medial intermuscular septum in the middle arm 10cm proximal to the medial epicondyle to enter the posterior arm. * Covered by the arcade of Struthers 8cm proximal to the medial epicondyle. * Passes medial to the medial head of triceps and posterior to the medial epicondyle. * Passes through the cubital tunnel where the nerve is covered by the flexor carpi ulnaris tendon / arcuate ligament of osborne. Cubital tunnel is composed of the capsule / medial collateral ligament. * After passing through two heads of FCU ulnar nerve travels between FDP and FDS. * The nerve travels radial to FCU and ulnar to hook of hamate to enter Guyon's canal. * Guyons canal is bounded by: * Roof: the volar carpal ligament * Ulnar: Pisiform/FCU, pisohamate ligament, abductor digiti minimi * Radial: Hook of hamate * Floor: Transverse carpal ligament and hypothenar muscles.

Answer 217

* Beyond the transverse carpal ligament (50-90%) * Beneath the transverse carpal ligament (30%) * Through the transverse carpal ligament (23%)

Answer 218

* Pronator syndrome is proximal median nerve compression typically presenting with numbness and paresthesias but can also have weakness. * Potential compression points: * Lacertus fibrosis * PT * Ligament of struthers * Leading edge of FD * Anomalies of vascular branches in distal forearm

Answer 219

* Pain during movement at the elbow radiating distally to the dorsal hand, accompanied by tingling of the hand and weakness of grip. * Typically arises from repetitive elbow extension / rotation. * Symptoms most effectively elicited by 'middle finger test': pain over ECRB during forceful extension of the middle finger with the elbow held in full extension. * Lidocaine injection into the radial tunnel can be diagnostic and therapeutic. * PIN syndrome in contrast does not have sensory involvement as the radial sensory nerve has already branched.

Answer 220

* Compression of superficial radial nerve at point of exit from beneath BR. * Progress from conservative to surgical decompression.

Answer 221

1. Arcade of struthers 2. Ligament of osborne 3. Medial intermuscular septum 4. Proximal fascia between two heads of FCU 5. Fascial bands within FCU tunnel

Answer 222

* Major blood supply is via the *_dorsal carpal branch of radial artery._* * Enters scaphoid in a nonarticular ridge on the dorsal surface and supplies proximal 80% of scaphoid via retrograde blood flow. * Minor blood supply from *_superficial palmar branch of radial artery._* * Enters distal tubercle and supplies distal 20% of scaphoid.

Answer 223

* SL ligament is important for coordinating the action of the proximal row. * In the context of a scaphoid fracture, the PRXOMAL aspect of the scaphoid remains attached via the SL to the lunate. As such these to elements remain coordinated and are able to extend together. But, the DISTAL aspect of the scaphoid in turn FLEXES without normal restraint. * This creates DORSAL INTERCALATED SEGMENT INSTABILITY (DISI). * This changes the distribution of force and carpal loading and can yield SCAPHOID NON-UNION ADVANCE COLLAPSE (SNAC).

Answer 224

**ETIOLOGY** * Fracture: * Scaphoid fracture: bony DISI * Distal radius fracture: compensatory DISI * Radius malunion: adaptive DISI * Ligamentous injury: * Scapholunate ligament dissociation **RADIOGRAPHIC FINDINGS** * On a lateral radiograph, with the wrist in neutral, DISI typically shows: * A dorsal tilt of the lunate. * Scapholunate angle \>60 degrees (a sign of scapholunate ligament dissociation) * Capitolunate angle \>30 degrees (the capitate is displaced posteriorly compared to the distal radius).

Answer 225

1. AP 2. Lateral 3. Oblique 4. Clenched fist PA: Extends scaphoid and accentuates waist fracture 5. Scaphoid view: Fisted, semipronated, ulnar deviation

Answer 226

CT * Allows more detailed examination of the scaphoid, reliably demonstrates when a fracture is dispalced. * Preferred over MRI in the nonacute setting to define bony alignment. MRI * Can detect presence or abence of fracture * Preferred over CT in acute setting

Answer 227

**Non-displaced fractures** * Immobilize in a long-arm thumb spica for 6 weeeks, followed by 6 weeks in a short arm thumb spica. * Consider operate management with internal fixation for: * High demand patients who cannot tolerate 12 weeks immobilization. * Proximal pole fractures given high rates of non-union. **Displaced fractures** * All displaced fractures require operative treatment. * Typically done with 1-2 cannulated screws through an open or percutaneous approach. * Dorsal approach proxides best access to proximal pole. * Volar approach provides best access to reduce / bone graft a hump back or flexion deformity.

Answer 228

* Distal pole of scaphoid flexed and proximal pole extended. * Creates an angulated scaphoid on lateral radiographs and foreshortened scaphoid on AP radiographs.

Answer 229

1. 1,2 intercompartmental supraretinacular artery (1,2-ICSRA) 2. 2,3 ICSRA 3. Free medial femoral condyle vascularized graft 4. Pronator quadratus graft

Answer 230

45-degree pronated oblique.

Answer 231

Wrist is supinated and ulnar deviated. Force is then applied to the flexor tendons of the small and ring finger. Causes displacing force on the hook of the hamate. Used in ?hook of hamate fractures.

Answer 232

* Hamulus (hook) fractures * Cast immobilization (high non-union rate). * ORIF * Excision of fragment. * Body * Non-displaced fracture can be treated with immoilization * Most displaced body fractures require ORIF as it is in the context of other associated wrist injuries.

Answer 233

* **Carpal Instabiity Dissociative (CID):** Instability between carpal bones within the same row. * **Carpal Instability Nondissociative (CIND):** Instability of the entire proximal row relative to the radiocarpal or midcarpal joint.

Answer 234

* **Palmar radiocarpal (4 + neurovascular bundle)** * Radioscaphoid * Radioscaphoid-capitate * Long radiolunate * Short radiolunate * Radioscapholunate ligament or ligament of Testut (neurovascular bundle and not a ligament) * **Palmar ulnocarpal (3)** * Ulnar capitate * Ulnar triquetral * Ulnar lunate * **Dorsal radiocarpal (1)** * Radiotriquetral / radiocarpal

Answer 235

* In *_radial deviation_*, the *_scaphoid flexes_*. With intact intercarpal ligaments, the lunate and triquetrum follow suit and passively flex. * In *_ulnar deviation_*, the *_triquetrum is guided into extension_* by its articulation with the hamate. With intact intercarpal ligaments, the entire proximal row move into extension along with the triquetrum.

Answer 236

* The DORSAL and VOLAR aspect of DISI and VISI refer to the kinematics of the LUNATE. * In a DISI deformity, the lunate is tipped dorsally (or extended) as the scaphoid is flexed. * As such the scapholunate angle is \>60 degrees. * This the most common dissociative pattern.

Answer 237

* The DORSAL and VOLAR aspect of DISI and VISI refer to the kinematics of the LUNATE. * In a VISI deformity, the lunate is tipped volarly (or flexed) and the scaphoid is extended, * As such the scapholunate angle is \<30 degrees. * This the second most common dissociative pattern.

Answer 238

* **Greater arc injuries:** injuries that progress through the carpal bones; typically fractures that involve one or multiple of the radial styloid, scaphoid, capitate, triqutrum, and the ulnar styloid. * **Lesser arc injuries:** Pure ligamentous perilunate injuries.

Answer 239

* In hyperextension of the wrist with ulnar deviation, the capitate is driven between the scaphoid and the lunate. * The lunate is pushed ulnarly and volarly and the scaphoid is pushed radially and dorsally.

Answer 240

* On the volar aspect of the hand/wrist, the examiner pushes on the distal pole / scaphoid tubercle and exerts a DORSALLY directed force. * The patient is brought from *_ulnar deviation_* and *_slightly extended_* into *_radial deviation_* and *_slightly flexed_*. * In those with incompetent SL ligaments, as the scaphoid flexes it remains unconstrained and the dorsally direct force subluxates the scaphoid out of the scaphoid fossa relative to the radius. * The 'clunk' is the scaphoid reducing back into its anatomic position in the scaphoid fossa.

Answer 241

* Increased scapholunate gap (3mm) ('Terry Thomas sign') * Cortical ring sign: * Represents a hyperflexed scaphoid wherein the distal pole is seen on end and appears as a cortical ring within 7mm of the proximal pole. * DISI deformity (increased scapholunate angle)

Answer 242

1. **Pimary repair** * May be performed acutely * Usually combined with capsulodesis 2. **Thermal shinkage (radiofrequency)** * Thermal energy causes shrinkage (70-80 degrees celcius) and tightens supporting ligaments. 3. **Percutaneous pinning** * Typically combined as an adjunct to other surgical techniques. 4. **Capsulodesis (Blatt)** * Dorsal capsule used as a tether to prevent scaphoid flexion (suture anchor used to secure). 5. **Tenodesis** * ECRL (Taleisnik and Linscheid) * ECRL left attached distally \> passed through scaphoid and triquetrum \> final attachment to capitate. * FCR (Brunelli and Brunelli) * FCR left attached distally \> passed volar to dorsal through scaphoid. * As originally described is then secured to the DISTAL RADIUS, but modification is to secure to the lunate. 6. **Bone-ligament-bone** * Bone-ligament-bone grafts from various auto or allo sites use to recontruct. * Options: * SL Allograft * Tarsometatarsal autograft * Capitohamate autograft * D2 or D3 CMC 7. **Pseudoarthrosis (RASL)** * Reduction association scapholunate (RASL) * Dorsal approach \> decortication of ulnar side of scaphoid and radial side of lunate \> headless compression screw * Combined with radial styloidectomy. 8. **Intercarpal fusion** * SL fusion * Low fusion rates

Answer 243

* Typically occurs as a progressive perilunate instability with loading in a hyperextended / ulnar deviated position. * Injury CAN occur in isolation with a FOOSH but in EXTENSION, PRONATION, and RADIAL deviation.

Answer 244

1. **Ballottement test:** increased anteroposterior laxity, with pain, in lunotriquetral interval. 2. **Shear test:** Dorsal force directed on triquetrum while stabilizing the lunate demonstrates increased laxity and elicts pain. 3. Lateral compression test: Pressure placed on the medial tubercle of the triquetrum between the FCU and ECU tendons elicits pain. \*\* Need to compare with contralateral side \*\*

Answer 245

1. **Nonsurgical management** * Immobilization, NSAID * Consider arthroscopy if no improvement in 6 weeks 2. **Arthroscopic debridement** 3. **Percutaneous pin fixation** * Only if no VISI deformity * Immobilize 8 weeks 4. **Ligament reconstruction** * Slip of ECU passed through drill holes and looped around the lunate and triquetrum to reconstruct ligament. * Can also use bone-ligament-bone auto/allo grafts as done SL reconstruction 5. **Lunotriquetral arthrodesis** 6. **Salvage procedures** * Long term, static VISI * PRC, 4 corner fusion, total wrist

Answer 246

Between the **radioscaphocapitate** and the **long radiolunate ligament**.

Answer 247

* Full analgesia and relaxation critical. * Apply manual traction on slightly extended wrist. * Stablize the lunate volarly with a thumb. * Slowly flex the wrist without releasing pressure on the lunate.

Answer 248

1. Articular disc 2. Dorsal radioulnar ligament 3. Volar radioulnar ligament 4. Meniscus homolog 5. Ulnar collateral ligamenta 6. ECU sheath

Answer 249

* Initial treatment nonoperative unless there is DRUJ instability. Immobilize in long arm cast for 4-6 weeks. * Costisone injections may provide symptomatic relief but may inhibit healing of peripheral tears. * Arthroscopy is indicated in patients with TFCC tears who have failed 3 months of nonoperative treatment. * Early arthroscopic treatment may be considered for high level athletes. * Surgery also indicated for DRUJ instability. * Surgical treatment of Type I tears: * Class IA (central tears): debridement * Class IB: Repair * Class IC: REpair plus extrinsic ligament plication or open repair. * Class ID: Repair to sigmoid notch if DRUJ unstable; debride if DRUJ is stable. * Traumatic tear with positive ulnar variance may require concominant ulnar shorterning or wafer resection. * Surgical treatment of type II tears (degenerative, ulnocarpal impaction) usually requires arthorscopic TFCC disc excision and wafer resection and ulnar shortening

Answer 250

**Clitoris** * Erectile organ typically 2cm in length and 1cm in diameter * Attached to the pubic symphysisby the suspensory ligament of the clitoris. * Consists of root, body, glans. **Prepuce** * Formed from the folds of the labia minora that pass *_anterior_* to the glans. **Frenulum** * Extends from the *_posterior_* aspect of the glans. Meets with an extension of the hood to form the labia minora. **Clitoral Hood** * Parallel folds that are 2-6cm in length. **Labia Minora** * Also called 'nymphae', 'labium minus' * Two longitudinal, hairless cutaneous folds situated between the labia majora. * Core of spongy connective tissue which is erectile tissue; contribute significantly to engorgement and thickening during sexual stimulation. * Posterior ends join across the midline by a fold of skin called the *_frenulum_*, which is also called: * frenulum labiorum pudendi * fourchette * posterior commissure of the labia minora * Anteriorly each labium divides into anterior and posterior parts. * The anterior part passes above the clitoris to meet the contralateral side to form an overhand called *_prepuce_* (preputium clitoridis). * The lower part / posterior part passes below the clitoris to meet the contrlateral part and form teh *_frenulum_*. **Labia Majora** * Prominent folds of skin surrounding the pudendal cleft that contains loose subcutaneous tissue with smooth muscle. * The termination of the round ligament of the uterus. **Mons Pubis** * Rounded, fatty prominence, anterior to the pubic symphysis. * Surface continuous with anterior abdominal wall. **Vestibule** * Space between the labia minora containing openings for the urethera, vagina, and ducts of teh geater and lesser vestibular glands.

Answer 251

* **Stage I: Partial SL Injury** * PT * Percutaneous K-wire fixation of the SL. * Thermal shrinkage * **Stage II: Complete SL Injury, Repairable** * ORIF with primary repair of dorsal SL * **Stage III: Complete SL Injury, Nonrepairable, Normally Aligned Scaphoid** * Bone-ligament-bone (auto/allograft) * Dorsal capsulodesis (Blatt) * SL reconstruction with dorsal ligaments (DIC or dorsal radiocarpal) * **Stage IV: Complete SL injury, Nonrepairable, Reducible Subluxation** * Tendon reconstruction of SL * ECRB * FCR (Modified Brunelli and Brunelli) * RASL * **Stage V: Complete SL Injury, Irreducible, Normal Cartilage** * Partial fusion * STT arthrodesis * SL arthrodesis * Scaphpcapitate arthrodesis * Scaphoid-Lunate-Capitate Arthrodesis * Radioscaphoid-Lunate Fusion + Dital Scaphectomy * **Stage VI: Complete SL Injury with Irreducible Malalignment and Cartilage Degeneration** * Scaphoidectomy + four corner fusion (capitate-lunate-triquetrum-hamate) * PRC * Total wrist arthrodesis * Total wrist arthroplasty

Answer 252

* Disruption of Gilula's lines on AP. * Lunate (triangular) and scaphoid (foreshortend and cortical ring sign) concurrently sitting flexed. * Wide SL distance may be present with is actually just the SL interface being stressed and relying on the volar fibers as a restraint. * On lateral, in advanced cases, the wrist can also sit in VISI with a volarly tilted lunate/scaphoid (scapholunate angle \<30).

Answer 253

* Acute LT injury, repairable, no static deformity / carpal collapse * Percutaneous pinning and immobilization * If immobilization alone, above elbow cast required to limit forces from pronation/supination * Chronic injury, non-repairable, no static deformity / carpal collapse * Arthorscopic debridement * Thermal shrinkage * Tendon reconstruction (ECU to repair PALMAR LT) * LT intercarpal arthrodesis * Chronic injury, non-repairable, static deformity * Intercarpal arthrodesis, but no good treatment * Acute LT in the context of perilunate injury (LT + SL) * Combined dorsal and volar approach for repair of SL and LT * Chronic LT in the context of perilunate injury * Limited treatment options, likely salvage

Answer 254

* Traditional dorsal approach to the wrist; typically capsule avulsed poximally so it can be extended to make a distally based capsular flap so expose midcarpal and radiocarpal joints. * Volarly, wrist approached with an extended CTR approach. L-shaped rent between the radioscaphoid-capitate and long radiolunate ligaments is identified. * Lunate reduced under direct visualization. * Palmar LT ligament repaired with sutures / anchor. * \*\* Palmar SL CANNOT be repaired because it is covered by the intact long radiolunate ligament. * Direct repair of the dorsal SL ligament and LT ligament. * K-wire immobilization

Answer 255

* First (mandibular) and second (hyoid) branchial arches are responsible for auricular development. * During the 6th week ear begins to develop and arises from the six buds of mesenchyme known as the *six hillocks of His.* * *Mandibular arch (first): Hillocks 1-3* * *Hyoid arch (second): Hillocks 4-6* * Lobule is the last component of the external ear to form. * Insults in the 6-8th week can potentially yield microtia. * Teratogens: accutane, retinoic acid, thalidomide * Ischemia: decreased blood supply in utero * Genetic: syndromic causes

Answer 256

1. Branchial arch syndromes 2. Goldenhar's syndrome 3. Treacher Collins Syndrome 4. Oculoauriculovertebral dysplasia 5. Facial nerve absnormalities 6. Cleft lip/palate 7. Hemifacial microsomia 8. Facial clefts 9. Cardiac defects 10. Anopthalmia / micropthalmia 11. Limb reudction defects 12. Renal malformations 13. Holoprosencephaly

Answer 257

**Primary goal:** * Improvement of acoustic function (sound localization, speech perception): various options of hearing aids, bone-anchored conductive devices, or canalplasty in conjunction with auricular reconstruction **Secondary goals:** * Speech * Social acceptance * Emotional development

Answer 258

* **Age of external ear maturity** * *85%* of ear development is attained by *age 4* * Ear width continues to grow until age 10 * **Availability of adequate donor rib cartilage** * Usually adeqaute by age 5-6 * **School age and psychological factors of peer redicule** * **Need for middle ear surgery** * Auricular reconstruction common performed BEFORE middle ear surgery if possible. * If otologic surgery performd first, otologist must coordinate with plastic surgeon to establish: * Canal position * Vascular axis of flaps * Locations of incisions used in auricular reconstruction * Most hearing deficits (especially b/l microtia) are treated with conductiec hearing aids. * Different techniques are more appropriate for different ages to achieve optimal reconstruction. * **Brent technique:** Wait until age 4-6, allowing for ear maturity and appropirate school age. * **Nagata technique:** Wait until age 10, or when chest circumference at **Xyphoid is 60cm** to allow for additional cartilage for use in integrated tragal reconstruction. *

Answer 259

* High resolution CT to assess for middle ear ossicles * MRI to assess course of the facial nerve which can be displaced, especially in the absence of a pneumatized mastoid.

Answer 260

* **Autogenous costal cartilage graft** * Best long term reconstructive option * Originally by Tanzer and mofified by Brent and Nagata * Disadvantages: * Donor site morbidity and postoperative sequelae * Chest wall deformity * Number of staged procedures * **Silastic framework** * Excellent appearance * No donor site morbidity * Discontinued because of: * Spontaneous extrusion * Susceptibility to minor trauma * Unacceptable long term failure rates * **Porous polyethylene implant (medpor)** * Good aesthetic results and acceptable extrusion rates * **Prosthetic / osteointegrated reconstruction** * Limited by availability and skill of anaplastologist * Excellent alternative for patients with poor local tissue or high operative risk

Answer 261

**_Brent Technique_** * Four-staged reconstruction begining at age 4-6 years old. * **Stage I: Ear framework less lobule and tragus.** * Ear framework fabricated from _contralateral_ costochondral rib cartilage of synchondrosis of the 6th-8th ribs * Placed in a subcutaneous pocket at the posterior/inferior border of the vestige. * No lobule reconstruction in stage I. * **Stage II: Lobule reconsturction.** * Lobule transposition occurs several months after framework. * **Stage III: Projection** * Projection of contruct with wedge of banked costal cartilage or polyethylene blocks. * Skin graft used to backgraft skin defect. * **Stage IV: Tragus construction** * Tragus construction, conchal excavation and symmetry adjustment. * Tragus fashioned from composite graft from the contralateral conchal vault, or in bilateral cases using an anteriorly based conchal flap with cartilage support.

Answer 262

**Nagata technique** * Two stages * Begins at age 10 **STAGE I** * IPSILATERAL rib cartilage * High definition framework created from _6th-9th_ ribs * Perichondrium left intact * Framework includes tragal component * W-flap created with lobule transposed at this stage. * Framework inset. **STAGE II** * Peformed 6 months later * Framework elevation * Wedge harvested from previous incision from the 5th rib. * Temporoparietal fascia flap is elevated and tunneled subcutaneously to coverage posterior cartilage grafts. * Advancement of retroauricular skin and coverage with backgrafting.

Answer 263

* Male ears: * Width matures at age 7 * Length matures at 13 * Female ears: * Width matures at age 6 * Length mature at 12

Answer 264

* Auriculotemporal nerve * Branch of trigeminal nerve * Provides sensation to tragus and crus helicis * Great auricular nerve * Branch of cervical plexus (C2-3) * Supplies rest of the ear * Anterior and posterior divisions * Lesser occipital nerve

Answer 265

1. Correction of all upper-third protrusion. 2. Visibility of the helix beyond the antihelix when viewed from the front. 3. Smooth and regular helix. 4. No distortion or decrease in the depth of the postauricular sulcus. 5. Correct placement of the ear. 6. Helix-to-mastoid distance falls in the normal range of: * 10-12mm at the top * 16-18mm in the middle * 20-22mm in the lower third 7. Bilateral symmetry. 8. Position of the lateral border of the ear matches within 3mm at any point between the ears. 9. Smooth, rounded, and well-defined antihelical fold. 10. Concoscaphal angle of 90 degrees. 11. Conchal reduction or reduction of the conchomastoidal angle. 12. Helical rim that projects laterally father than the lobule.

Answer 266

* Timing depends on a rational approach based on auricular growth and age of school matriculation. * Because the ear is nearly fully developed at 6-7 years you can perform correction at that time. * Surgery can be done at a younger age if they demonstrate with maturity enough to cooperated with postoperative restriction and instructions.

Answer 267

* Access through incision on the posterior auricular skin (with or within skin excision). * Optimal position of antihelical simulated and marked with methylene blue and a 25-gauge needle. * Permanent matress sutures placed through cartilage and capturing anterior pericondrium. * May require floating sutures.

Answer 268

* Postauricial access +/- skin excision * Expose the mastoid fascia and posterior auricular cartialge. * Secured cartilage to mastoid fascia.

Answer 269

* Converse-wood-smith technique is a cartilage BREAKING technique, rather than cartilage moulding * Can be useful in stiffer cartilage of young adults and adults. * Same as mastarde technique but instead you incise and break the cartilage.

Answer 270

1. Poorly defined antihelical fold. 2. Conchoscaphal angle \> 90 degree 3. Conchal excess

Answer 271

**Posterior auricular artery (dominant)** * Supplies anterior and posterior auricle. * Perforators enter at the medial aspect of the triangular fossa, cymba, cavun, helical root, earlobe. **Superficial temporal artery** * Supplies lateral surface of auricle **Occipital artery** * Supplies posterior skin in 7% of people. **Venous drainage** * Posterior auricular veins drain into venous system * Superficial temporal vein * Retromandibular veins

Answer 272

**Greater auricular nerve (C2-C3)** * Supplies lower lateral and inferior cranial surface **Auriculotemporal nerve (V3)** * Supplies lateral surface and anterior surface of EAM **Lesser occipital (C2-C3)** * Superior cranial surface of ear. **Arnold's nerve (CN VII, XI, X)** * Auricular branch of vagus nerve (X) that received contributions from facial and glossopharyngeal nerve * Supplies posterior inferior EAC and inferior conchal bowl

Answer 273

* Pattern pertains to embryologic origins. * Anterior hillocks (1-3; first branchial arch) drain to parotid nodes (tragus, helical root, superior helix) * Posterior hillocks (4-6; second branchial arch) drain to cervical nodes (antihelix, antitragus, lobule).

Answer 274

Chondrodermatitis nodularis chronica helicis.

Answer 275

**Antia-Buch Procedure** * Defects up to 2cm can be closed by advancing the helix in both directions * V-Y advancement is critical at the helical root. * Incision made through antihelical skin, cartilage, with flap based on infact posterior skin.

Answer 276

* Contralateral composite grafts (\<1.5cm) * Antia-buch procedure * Chondrocutaneous rotation flaps

Answer 277

* Auricular cartilage grafts covered by preauricular flap or staged postauricular pocket flap. * Converse tunnel technique * Dieffenbach flap * Tubed pedicle flaps. * Chondrocutaneous flaps

Answer 278

**Converse Tunnel Technique** * Stage 1: Contralateral cartilage graft inset under postauricular skin adjacent to helical defect. * Stage 2: After 3 weeks, anteriorly based skin flap and underlying cartilage inset into helical rim.

Answer 279

* Posterior skin of amputated part is removed and fenestrations are made in the avulsed auricular cartilage to increase the recipient vascular area. * Amputated portion is reattached and exposed cartilage is covered with a posterior auricular flap. * Flap is divided after 3 months and a skin graft is applied.

Answer 280

* **From ophthalmic artery** * Dorsal artery * Supraorbital artery * Supratrochlear artery * External nasal branch of the anterior ethmoid artery * **From maxillary artery** * Infraorbital artery * **From facial artery** * Angular artery * Lateral nasal artery (branch of angular artery) * Superior labial artery * Columellar artery (branch of superior labial artery)

Answer 281

1. AIrway patency. 2. Replace like with like. 3. Optimize aesthetics. 4. Miniize morbidity.

Answer 282

* Nasal dorsum (unpaired) * Nasal tip (unpaired) * Columella (unpaired) * Nasal sidewalls (paired) * Soft triangle (paired) * Alar lobule (paired) **Subunit principle:** If a defect occupies more than 50% of the subunit, resect the entire subunit and reconstruct.

Answer 283

1. **Turn in nasal flap** * Essentially a local flap rotated into the nose for lining and the resulting defect closed by another local flap. * Flap hinged on the outer cicatricial edge and flipped over to span defect. The resulting skin defect on the nose then closed with a rotation/transposition flap. 2. **Folded extranasal flap** * Essentially creating a long enough local/regional flap to allow for a folded over element. * Can be forehead, nasolabial, or superiorly based upper lip flap turned in. 3. **Skin graft to forehead flap** * Skin graft to underside of forehead flap * Hard palate mucosa can also be used. 4. **Septal door flap (de Quervain)** * Essentially uses septal cartilage and contralateral septal mucosa to reconstruct cartilage and mucosa from the nasal side wall. * The mucosa is left attached to the nasal dorsum. 5. **Septal mucoperichondral flap** * Large rectangle of mucosa (or mucosa + perichondrium) is elevated from septum, based on the septal branch of the superior labial artery. * Flap pivots on an anterior-inferior point near nasal spine and folds outward. 6. **Mucosal advancement flap** * Bipedicled mucosal advancement flap based medially on remaining septum and laterally at the piriform aperature. 7. **Septal pivot flap** * Pedicle flap of septal cartilage and mucosa rotated forward to provide nasal septum and dorsal cartilaginous support. * Excess mucosa can be rotated outward to line the vault bilaterally.

Answer 284

**Septal door flap** * Flap used to reconstruction mucosa +/- cartilage of the nasal side wall. * Uses CONTRALATERAL septal mucosa and septal cartilage. * Pedicle left intact to dorsal nose and swung outwards to fill the defect.

Answer 285

**Septal mucoperichondrial flap** * Flap of septal mucosa +/- perichondrium is elevated from the septum and pedicled on the septal branch of the superior labial artery. * Flap pivots from a point antero-inferior near the nasal spine and can fold outward to line the nasal domes. * Septal pivot flap is similar but is used for dorsal nasal support when structure and lining are missing from the dorsal septum.

Answer 286

1. **Strut technique (Gillies)** * Longitudinal piece of bone or cartilage seated on nasal radix. Extends to the tip and turns sharply to be secured at the anterior nasal spine. 2. **Hinged septal flap** * L-shape cartilage designed from residual cartilage and hinged superiorly. Rotated outwards to reconstitute the dorsal nasal spine, with the small limb of the "L" attaching to the anterior nasal spine. 3. **Septal pivot flap** * Pedicled flap at the anterior-inferior septum of mucosa and cartilage rotated forward to construct dorsal nasal spine. 4. **Cantilever graft** * Longitudinal piece of bone extending from frontal bone or nasal bones (or both).

Answer 287

1. Banner flap 2. Bilobed flap 3. Dorsal nasal flap (random pattern flap) 4. Axial frontonasal flap * The same as the dorsal nasal flap, EXCEPT based off axial blood supply from vessels emerging from the medial canthus (branch of angular artery joining with the supraorbital arteries) and thus allows cuts to be made almost cricumferentially except for inflow from medial canthus. 5. Axial nasodorsum flap * Based on the lateral nasal artery branch of the angular artery. 6. Nasalis flap * Pedicle myocutaneous flap from the upper alar crease. 7. Cheek advancement flap 8. Nasolabial flap * Superiorly or inferiorly based. Good for alar reconstruction and lateral nasal wall. 9. Turnoever flap * Nasolabial flap turned over. 10. Forehead flap 11. Scalping flap (historical) 12. Sickle flap (historical) 13. Frontotemporal flap 14. Temporomastoid flap

Answer 288

Axial patterned flap based off the transverse nasal branch of the angular artery.

Answer 289

* Nasolabial flaps * Upper lip forked flaps * Vestibular flaps * Forehead flaps * Chondrocutaneous composite grafts

Answer 290

* Composite graft * Nasolabial flap * Forehead flap

Answer 291

* Sebceous hyperplasia of nasal skin with bulbus enlargement of the nose and erythematous skin. * Represents a severe forms of acne rosacea, but has **no true association with EtOH intake**. **_STAGES_** * **First stage (prerosacea):** frequent facial flushing and increased vascularity. * **Secondar stage (vascular rosacea):** Thickened skin, telangiectasias, and persistemt facial erythema or erythrosis. * **Third stage (acne rosacea or inflammatory rosacea):** Erythemaous papules and pustules of the forehead, glabell, malar region, nose, and chin. * **Fourth stage:** Rhinophyma **_NON-SURGICAL TREATMENT (STAGES I-III)_** * Avoidance of sun exposure UVA/UVB * Good skin hygiene * Tetracyclne * Topical tretinoin * Isoretinoin * Topical metronidazole **_SURGICAL_** * Tangential excision with cold knife, dermabrasion, or dermaplanning * CO2 laser for hemostasis * Non-stick dressing to promote epithelialization

Answer 292

* **Zone 1: Suborbital** * Medial boundary: Nose-cheek junction and nasolabial fold * Lateral boundary: Anterior edge of the sideburn * Inferior boundary: Gingival sulcus * Superior boundary: Lower eyelid * **Zone 2: Preauricular** * Superolateral junction of the helix and cheek. * Medially across sideburn to malar eminence. * Inferiorly to the angle of the mandible. * **Zone 3: Buccomandibular** * Includes the lower cheek area and oral lining (in full thickness defects) * Inferior to the suborbital area * Anterior to the preauricular area \*\* Zone 1 an 2 can typically be reconstructed with cervicofacial flaps, whereas zone 3 typically cannot\*\* *

Answer 293

* Cervicofacial flap * Anteriorly based cervicofacial flap * Cervicopectoral flap * An anteriorly based cervicofacial flap but extends down onto the chest to cpature thoracic perforators from the internal mammary artery. * Submental flap * Deltopectoral flap * Pectoralis majaor myocutaneous flap

Answer 294

* Hemitongue flap * Turnover or hinge flap * Masseter crossover * Facial artery myomucosal flap (FAMM) * Submental flap * Skin graft * Two skin paddle free flaps

Answer 295

* **Buccinator** * O: Alveolar process of the maxilla and mandible along the pterygomandibular raphe * I: Orbicularis oris * N: Buccal branch * A: Compresses cheeks * **Depressor anguli oris** * O: Lateral aspect of the mental tubercle of the mandible * I: Modioulus * N: Marginal mandibular branch * A: Lowers angle of the mouth * **Depressor labii inferioris** * O: Between mandibular symphysis and mental foramen, along oblique line of mandible. * I: Skin of lower lip * N: Marginal mandibular * Action: Draws lip downward and laterally * **Levator anguli oris** * O: Maxilla, inferior to orbital foramen * I: Modiolus * N: Buccal branch * A: Elevates angle of the mouth * **Levator labii superioris** * O: Maxilla, medial half of infraorbital margin * I: Modioulus and orbicularis of upper lip * N: Buccal branch * A: Elevates upper lip * **Levator labii superioris alaeque nasi** * O: Frontal process of maxilla * I: Upper lip orbicularis oris, nasal cartilages * N: Buccal branch * A: Elevates upper lip, flares nostrils * **Mentalis** * O: Incisive fossa of mandible * I: Skin of chin * N: Marginal mandibular branch * A: Elevates and protrudes lower lip * **Orbicularis oris** * O: Alveolar border of the maxilla and mandible * I: Circumferentially around the mouth; interdigitates with other muscles * N: Buccal branch * A: Sphincter of lips * **Platysma** * O: Skin over deltopectoral region * I: Mandible and skin of the lower face, including lip. * N: Cervical branches * A: Lowers lower lip * **Risorius** * O: Parotid fascia * I: Modioulus * N: Buccal branch * A: Draws angle of mouth laterally * **Zygomaticus major** * O: Zygoma, anterior to temporal-zygomatic suture * I: Modiolus * N: Buccal branch * A: Draws angle of mouth superlaterally * **Zygomaticus minor** * O: Zygoma, posterior to zygomaticomaxillary suture * I: Skin of upper lip * N: Buccal branch * A: Elevates upper lip

Answer 296

Superior and inferior LABIAL arteries. Travel deep to the orbicularis at apprxomately the level of the red line.

Answer 297

**_SUBTOTAL (\<50%)_** * Axial myovermilion advancement * Orbicularis + mucosa + labial artery pedicled and advanced to close defect. * Myomucosal V-Y advancement * Mucosa +/- muscle advaced from vestibule to fill vermilion defect. * Vermilion lip swtich * Vermillion from opposite lip to defect elevated and interpolated to fill defect. Divided at ~14 days. **_TOTAL OR LARGE (\>50%)_** * Tongue flap * Transfers ventral tongue in two stage procedure. * Buccal mucosa advancement

Answer 298

* **Primary closure (upper and lower)** * Upper and lower lip defects up to ~1/3 * **Perialar crescent excisions (upper lip)** * Can be combined with a number of reconstructions to facilitate closures of increasing sizes (e.g. with primary closure or with Abbe. * **Abbe flap (upper or lower lip)** * Commisure not involved. * Pedicled off labial artery. * Flap designed ~1/2 of the size (not 1:1) * **Estlander (upper or lower lip)** * Commisure involved * Otherwise same as abbe flap * **Karapandzic (upper or lower lip)** * Essentially large crescenteric extensions to facilitate advancement and primary closure of upper or lower lip defects. * Width of perioral extensions should be height of the defect. * **Bernard Burrows (lower lip only)** * For \>2/3 lower lip defects * Essentially is advancement of bilateral flaps and advancement of vestibular mucosa for reconstruction of the lower lip. * This is combined with burrows triangles superiorly and inferior to facilitate advancement. * **Free radial forearm with palmaris longus (upper or lower lip)** * Used for reconstruciton of complete defects.

Answer 299

* **No bony reconstruction** * Acceptable if posterior defects such as ramus, especially if condyle has been removed. * **Mandibular Reconstruction Plates (MRP) alone** * Will break within 18 months with a mean of 6-8 months. * Appropriate for patients who cannot tolerate along procedure and have a short life expectancy. * **Soft tissue coverage alone with free / pedicled flap** * Acceptable if posterior defects such as ramus, especially if condyle has been removed. * Pec, ALT, VRAM * **Non-vascularized bone** * Can be used in traumatic or BENIGN tumor defects \<6cm that will not require radiation. * *_Contraindications:_* radiation, anterior mandibular defects, malignancy * **Vascularized bone** * *_Indications:_* defect \>6cm, radiation, malignancy * *_Options:_* fibula, scapula, parascapula, iliac crest, RFF with distal radius

Answer 300

1. **Branchial motor** * Muscles of facial expression * Stylohyoid * Stapedius * Posterior belly of digastric 2. **Visceral motor** * *Parasympathetic* innervation of lacrimal, submandibular, sublingual, and nasal mucosal 3. **General sensory** * Sensation to the auricular conhca, external auditory canal, and tympanic membrane 4. **Special sensory** * Taste to the anterior 2/3 of the tongue.

Answer 301

1. **Intracranial** * Primary somatomotor coretx of the facial nerve located in the *_precentral gyrus_*. * *_Facial nucleus_* is in the *_dorsolateral pons_* * Cell bodies that give rise to the TEMPORAL branch recieve BILATERAL cortical input * All other facial nucleus cell bodies receive CONTRALATERAL cortical input. 2. **Intratemporal** * Facial nerve enters the *_internal auditory canal_* and travels with the acoustic and vestibular nerve for approximately 8-10mm. * Facial nerve then enters the *_fallopian canal_* where it travels for ~30mm * The metal foramen is the narrowest part of the canal * The fallopian canal as three segments: 1. Labyrinthine segment * Here the *_geniculate ganglion_* is found that contains the nerve cell bodies for taste and sensation. * Geniculate ganglion gives rise to the *_greater petrosal nerve_* which supplies parasympathetic nerve for lacrimal gland and sensory taste fibers from the palate. * Junction between the labyrinthine segments and tympanic segment forms acute angle that is prone to shearing forces. 2. Tympanic segment * Extends from *_geniculate ganglion to the semicircular canal_*. 3. Mastoid segment * From *_semicircular canal_* to *_stylomastoid foramen_*. * Gives off three branches in this section: * *_Nerve to stapedius:_* Motor function for stapedius muscle, which allows dampening of loud sounds. Cell bodies of this motor nerve are not located in the facial nucleus and are therefore not affected by Mobius syndrome. * *_Sensory branch to external auditory canal_* * *_Chorda tympani:_* Joins lingual nerve to provide parasympathetic innervation to the submandibular and sublingual glands; special sensory afferents from anterior two thirds of tongue. 3. **Extratemporal** * Starts where the facial nerve exits the *_stylomastoid foramen_* * Nerve is superficial un children less than 2 years old. * Facial nerve 1cm deep and ust inferior and medial to the tragal pointer.

Answer 302

* **Pitanguy's line:** From 0.5cm below the tragus to 1.5cm ABOVE the lateral brow.

Answer 303

1. Layer 1 (ZOD): * Zygomaticus minor, Orbicularis Oculi, Depressor anguli oris 2. Layer 2 (DRPLZ): * Depressor labii inferioris, Risorius, Platysma, Levator labii superioris alaeque nasi, Zygomaticus major 3. Layer 3 (OL): * Orbicularis oris, levator labii superioris 4. Layer 4 (MLB): * Mentalis, Levator anguli oris, Buccinator * Innervated in superficial surface

Answer 304

* **Pathophysiology:** Viral vscular insult to the facial nerve that causes edema within the fallopian canal \> disruption of microcirculation \> impairing conudciton of neural impulses or nerve degeneration. **Treatment** * No treatment * All patients begin to recover funciton within 6 months of paralysis. * All patients have improvement of paresis. * 71% recover completely. * Recovery TYPICALLY begins within 3 weeks in 85% of patients, but not until 3-6 months in 15% of patients. * Completeness of recovery decreases with age. * Medical treatment (steroids) * Prednisone 60mg/day tapering to 5mg/day on the 10th day. * Routine corticosteroids NOT recommended in pediatric Bell's palsy. * Surgical decompression

Answer 305

With penetrating facial wounds, nerve injury to facial nerve branches medial to a line drawn vertically through the *_lateral canthus_* of the eye may retain facial movement because of the degree of arborisation; nevertheless, nerves should be repaired if possible. However, injury to the frontal and marginal mandibular nerves manifesting with weakness should always be repaired as the likelihood of spontaneous recovery is poor.

Answer 306

Varicella-zoster syndrome virus infection with facial paralysis, ear pain, and varicelliform rash in EAC. Accounts for ~12% of all cases of facial paralysis. Treated with prednisone and acyclovir.

Answer 307

* Lyme disease * *Borrelia burgdorferi* * HIV

Answer 308

**Melkersson-Rosenthal syndrome** is characterized by recurrent facial nerve paralysis, noninflammatory facial edema, and congenital tongue fissures (lingua plicata). Interestingly, facial paralysis can alternate sides but is usually self-limited.

Answer 309

* Unilateral or bilateral loss of eye abduction? * Unilateral or bilateral, complete or incomplete, facial paralysis? * Facial paralysis may be accompanied by other cranial nerve palsies or congenital defects (extremity anomalies, defective brachial or thoracic musculature, micrognathia, mild mental retardation)

Answer 310

**Congenital Unilateral Lower Lip Palsy (CULLP)** * 'Asymmetrical crying facies' * Intrauterine insult during 5th week of gestation. * Normal resting function but MARGINAL MANDIBULAR DYSFUNCTION when crying. * Other congenital anomalies in 75% of affected children (cardiovascular, genitourinary, MSK, respiratory).

Answer 311

* In unilateral facial paralysis you get hypercontraction of the non-paralyzed face secondary to a subconcious effort to corect position of the paralyzed side. * Yields an S-shaped deformity * Hyper-contraction of the contralateral, normal musculature of facial expression * Results in: * Forehead wrinkling from frontalis contraction * Brow elevation and palpebral opening * Nasal alar elevation and prominence of the nasolabial fold * Bowing of the dorsal nasal lines to the paralyze side * Elevation of the lip with resultant pull of the midline lip (cupid's bow) toward the normal side * A line connecting the following structures makes an S-shape that faces AWAY from the paralyzed size: * Medial aspect of forehead wrinkling * Nsal rhadix * Nasal tip * Cupids bow * Midline of chin

Answer 312

1. Inflammation * Starts immediately and lasts several days * Formation of hematoma * Infiltration of hematopoietic cells and osteogenic precursors 2. Repair * Begins \<24 hours and peaks at 2-3 weeks. * Collagen deposition and cartilaginous callus formation over fracture site. * Endochondral ossification. 3. Remodelling * Lasts months - years depending on fracture type. * Lamellar bone formation and repopulation of marrow * Resoprtion of callus

Answer 313

* External callus not visible on plain radiographs until **3-6 weeks** after formation. * Bony union averages **4-8 weeks**. * Total bony union time is **5-7 months**.

Answer 314

* \>25% of articular surface. * \>1mm articular step-off * Open fracture * Irreducible * Malrotation * Comminuted

Answer 315

1. Closed reduction and percutaneous pinning 2. Open reduction and internal fixaton (pins, screws) * Minicondylar plates * Screws * Headless compression screws * Cerclage wire 3. External fixation 4. Prosthetic arthroplasty 5. Arthrodesis (salvage procedure)

Answer 316

Apex dorsal angulation because the intrinsic muscles lie volar to the axis of rotation of MP joint and maintain flexed head posture.

Answer 317

Indications for treatment of METACARPAL NECK fractures. * Angulation and deformity * Index and long finger: 10-15 degrees. * Ring finger: 30-40 degrees. * Small finger: 50-60 degrees. * Rotational deformity or scissoring * Shortening (\<3 mm) * Extensor lag \*\* Ring and small finger can better compensate for fracture angulation because the CMC of the D4 and D5 have 20-30 degrees of obility in the sagittal plane, whereas index and middle fingers are less mobile at CMC joint. \*\*

Answer 318

Indications for surgical fixation of METACARPAL SHAFT fractures: * Angulation * Index and long: \>10 degrees * Ring: \> 20 degrees * Small: \>30 degrees * Shortening (\> 3mm) * Alters length tension relationship and weakens intrinsics * Rotational deformity / scossoring * Open fractures

Answer 319

Options for surgical fixation of metacarpal shaft fractures. * K-wires * Tension band wiring (K-wire + steel wire) * Cerclage wiring * Iterosseous wiring * Intramedullary fixation * Lag screws (interfragmentary compression screws) * Plate fixation * External fixation * Bioabsorbable fixation

Answer 320

* Thorough debridement and maintenance of length * Provisional stabilization with: * External fixation +/- methymethacrylate pins * Freeland believed that osseous stability should be restored within 10 days of injury with bone graft and fixation * Most defects can be bridged with autogenous iliac crease corticocancellpis graft

Answer 321

* Deforming forces are controversial with essentially all muscles inserting on the thumb listed depending on the source. * The reduction technique however is less controversial, and required: * Longitudinal traction * Palmar abduction * Pronation * Pressure on the dorsal radial aspect of the thumb MC base

Answer 322

**Proximal phalanx** shaft fractures angulate **apex volar** because of flexion of the proximal fragment by the interossei. Middle phalanx fractures can be apex dorsal or apex volar depending on the relationship of the fractures to the insertion of FDS.

Answer 323

* Immobilize in 30 degrees of flexion for 3 weeks. * Reassess laxity at 3 wees. Buddy tape to adjacent digit for additional 2-3 weeks if instability persists. * Surgiacl repair if instability or pain persists after more than 6 weeks of nonoperative treatment.

Answer 324

* **PROPER collaterals** * Proper colalteral ligaments arise from the condyles of the metacarpal head and insert on the volar proximal phalanx. * **ACCESSORY collaterals** * Accessory collaterals originate on the volar metacarpal head and insert on the sesamoid bones and the volar plate. \*\* Additional lateral stability is provided by the thenar muscle secondary insertions via adductor and abductor aponeuroses.

Answer 325

* Partial UCL * Immobilization. * Complete UCL * Operative exploration and repair * Reattach ligament avulsions with bone-anchoring technique * Mid substances repaired with non-absorbable sutures. * + Avulsion fractures * Can have avulsion from proximal phalanx * Small fragments can be managed with immobilization * Large fragments more than 2mm displacement require closed reduction with pinning or ORIF.

Answer 326

Reconstruction with free tendon graft. * Scar and remnant UCL resected. * Tendon graft options: PL, strip of FCR, strip of APL, plantaris, toe expensor. * Consider temporary pinning of MP joint. * Immobilize for 6 weeks.

Answer 327

Type I/II * Some advocate immobilization for 1-2 weeks in 20-30 degrees of flexion. * Others advocate for protected range with buddy taping for 2-3 weeks. Type III STABLE * Closed reduction and immobilization with dorsal blocking splint in 20-30 degrees of flexion for 3 weeks. Can reduce degrees of flexion 10 degrees each week. * Active range exercises after 3 weeks. Type III UNSTABLE * Dynamic traction * ORIF * CRRP with dorsal blocking pin * Volar plat arthroplasty * Hemihamate arthroplasty

Answer 328

Volar rotary subluxation at the PIP occurs in the context where ONE side (radial or ulnar) collaterals remain intact. The middle phalanx dislocated volarly and rotates around the intact collateral. The condyle of the proximal phalanx usually ruptures between the central slip of the extensor tendon and the ipisilateral lateral band as the middle phalanx displaced volarly. Can typically be reduced and managed non-operatively. Gentle traction with MP and PIP flexed to relax volarly displaced lateral band. Gentle rotary motion disengages the intraarticular portion and allows reduction.

Answer 329

* Collateral ligament fibrosis is the inevitable consequence of PIP joint dislocation. Evolves over 10-12 months. * Collateral ligament excision for PIP contracture release if PIP range of motion is lessthan 60 degrees after compliant rehabilitation. Both collaterals typically excised with lateral bands preserved.

Answer 330

FDP has a common muscle belly.

Answer 331

* Myotendinous junction: Supplies a short segment near the proximal end of the tendon. * Bony junction (Sharpey's fibers): Supplies short distal segment. * VIncula: Fibrovascular structures that supply the tendon. * Arise from transverse branches of the digital arteries. * TWO vincula to the FDS (vinculum breve superficialis, vinculum longum superficialis) * TWO vincula to the FDP tendon (vinculum breve superficialis, vinculum longum superficialis) * Synovial diffusion

Answer 332

* Zone I: Distal to the IP * Zone II: Between IP and A1 pulley. * Zone III: Over thenar eminence * Zone IV: Within carpal tunnel. * Zone V: Proximal to the carpal tunnel.

Answer 333

Adhesions between FPL and the index FDP within the carpal tunnel. Such that flexion of the thumb causes flexion of the index. 30% of the population.

Answer 334

Quadrigia effect occurs from a functional shortening of the FDP tendon. Given that the FDP tendon has a common muscle belly to the small, ring, and long finger, functionally shortening the tendon to one finger shortens the excursion for all fingers. This can happen if the FDP is advanced more than 1cm in a tendon repair. The lumbrical plus deformity is results from lax FDP creating tension on the lumbricals. This tension on the lumricals causes finger extension at the IP joints when attemping to grasp objects.

Answer 335

**STAGE ONE** * Native tendon excised * Pulley reconstructed as required. * Silicone rod (Hunter rod) * Rod induces formation of a pseudosheath. **SECOND STAGE** * Tendon graft sutures to the DISTAL end of the SILICONE rod and pulled through the pseudosheath. * Tendon graft secured to the native FDS or FDP with a pulvertaft weave. * Distal juncture made with a pull-out suture or suture anchor to the distal phalanx. * Tension adjusted so that cascade of finger is SLIGHTLY tigher in the grafted digit. * If the tendon graft is placed too loosely or too long, it can result in lumbrical plus deformity.

Answer 336

* Smith 3-5-7 rule: * 3 cm excursion - wrist flexors, wrist extensors * 5 cm excursion - EDC, FPL, EPL * 7 cm excursion - FDS, FDP

Answer 337

* Wrist extension / Finger flexion / Pronation * Wrist flexion / FInger extension / Supination

Answer 338

* Thumb opposition is a combination of thumb abduction, flexion, and pronation. * All options involve inserting donor tendon into teh APB insertion on the dorsoradial aspect of the thumb metacarpal head. 1. **EIP (radial)** * Tunnel subcutaneously around ulnar side of the hand, across palm at the level of the pisiform. 2. **FDS ring finger (median)** * UNAVAILABLE in a high median injury * Loop around FCU as a pulley 3. **Palmaris longus ('Camitz') (median)** * PL + palmar fascia passed under APB origin as pulley * Downside is weaker strength 4. **Abductor digiti minimi ('Huber') (ulnar)** * Insertion detached and muscle turned over 180 degrees. 5. **OTHER" ECRL, ECU, EDQ (radial)** * Similar routing to EIP (at the level of pisiform) * May need tendon graft for length.

Answer 339

1. BR (radial) 2. ECRL (radial) 3. FDS to ring finger (median)

Answer 340

* Key pinch (referred to because of the fact that is is used to hold a key, as opposed to TIP pinch) uses a combination of adductor pollicis and FDI. * Potential donors tendons: 1. **_BR_** or **_ECRB_** * Notably, passed between the index and long metacarpal to the volar aspect of the hand. Index MC acts as a pulley. * Inserted into the ulnar base of thumb proximal phalanx 2. **_FDS_** long/ring finger * FDS ring NOT available in high ulnar nerve injury (because ring FDP will be gone). * Retrieved in the palm and passed deep to the flexors. * Drawback: weak power and poor vector of pull. *

Answer 341

* Sew to FDP index and long * Notably, this will make clawing worse.

Answer 342

* Generally speaking, donors are passed along the path of the lubmrical (volar to the transverse metacarpal ligament). * There are then three options for insertion: * Lateral band * Proximal phalanx * Loop around A1 or A2 pulley and secured to itself * **FDS Long Finger ('Modified Stiles-Bunnell' procedure)** * FDS divided distally, split into four slips to recontruct each lumbrical. * Passed along path of lumbrical. VOLAR to transverse metacarpal ligament, and then attached to lateral band. * This can be alternatively be attached to the proximal phalanx OR passed through the A1/A2 pulley and sewed to itself. * If sewed to itself, it is referred to the 'Zancolli Lasso' * Drawback is that is can weaken grip strength * **FCR/ECRL/ECRB/BR** * Require a tendon graft * Passed along path of the lumbrical, VOLAR to the transverse metacarpal ligament, and attached to the lateral band.

Answer 343

* **Recipient: ECRB (wrist extension)** * **Donor: Pronator Teres (PT)** * Divide PT at insertion, route subcutaneously, superficial to BR * Attach end to side into ECRB (recovery expected) or end to end (recovery not expected) * **Recipient: EDC (MP joint extension)** * **Donor: FDS of long finger** * Can route around wrist or through IO membrane * **Donor: FCU** * Route around ulnar border subcutaneously * **Donor: FCR** * Route round radial border subcutaneously * **Recipient: EPL** * **Donor: PL** * Divide PL distally and EPL proximally * Transpose EPL radial to listers * Used in conjunction with FCU or FCI to EDC * **Donor: FDS to ring** * Rute around wrist or through IO * USed in conjunction with FDS to EDC * **Donor: FCR to EPB and APL** * Provides independent radial abduction * Used in conjunction with FDS to EDC and FDS to EPL

Answer 344

* Lymphocyte dysfunction * Decreased chemotaxis * Decreased phagocytosis * Decreased intracellular bactericidal activity

Answer 345

**History** * \*\* Often have a prodrome of 24-72 hours of burning before skin changes develop \*\* * **HSV 1:** young children and medical/dental professionals * **HSV 2:** adults **Physical Exam** * Red/swollen/painful digit * Not as tense as felon * CLEAR VESICLES **Investigations** * Peform **_TZANCK smear_** on fresh vesicles * Viral cultures **Treatment** * Usually a self-limited course. * Treatment is NON-SURGICAL * Unroofing vesicles may improve patient comfort. * *\*\* DO NOT INCISE these lesions (unless bacterial infection is strongly suspected) -- there is a risk of viral encephalitis or death \*\** * Acyclovir can be used in severe cases * 20% recur

Answer 346

**THENAR** * *Floor (dorsal boundary):* Adductor pollicis fascia. * *Superficial (volar boundary):* Tendon sheath of index finger and volar fascia. * *Radial border:* Adductor insertion on thumb P1 * *Ulnar border:* Vertical mid volar septum (D3 MC). **MIDVOLAR** * Generally sits in the mid-palm between the thenar and hypothenar; infection here causes loss of the concavity of the palm. * *Floor (dorsal boundary):* Interossei fascia of the second and third. * *Superficial (volar boundary):* Tendon sheath of the long, ring, and small finger. * *Radial:* Midvolar septum. * *Ulnar:* Hypothenar septum **HYPOTHENAR** * Radial: hypothenar septum * Dorsal: Periosteum of the fifth metacarpal and fascia of the DEEP hypothenars. * Volar: Fascia of SUPERFICIAL hypothenars * Ulnar: Hypothenar muscle / fascia **PARONA'S SPACE** * Located in the forearm between PQ and the FDP tendon sheaths * Communication between the radial and ulnar bursa can yield a horseshoe abscess

Answer 347

* Age \>43 years * DM, PVD, renal disease * Subcutaneous purulence * Digital ischmia * Polymicrobial infection

Answer 348

* Gram stain * Culture (aerobic, anaerobic, AFB, fungal) * Crystals * Cell count

Answer 349

* Onychomycosis (tinea unguium) is a fungal infection of the nail. * *Trichophyton rubrum* most common in the US. * *Candida albicans* common diabetics. * Presents as a thickened, discoloured nail **Treatment** * Removal of nailplate can shorten treatment by 50%. * Antifungals: * Trichophyton rubrum: Terbinafine * Candida albicans: * Topical nystatin * Oral ketoconazole or itraconazole

Answer 350

* *Sporothrix schenkii* * Most common on rose thorn, moss, and other plants; puncture wound while handling plants or soil. * Patients present with a nodule that later ulcerates; this is followed by nodule formation along lymphatic channels, which also ulcerate. * Definitive diagnosis made by fungal culture of nodule aspirate. **Treatment** * Classic treatment is potassium iodine * However, supplanted by itraconazole or fluconazole (3-6 months or 4 weeks after resolution of symptoms)

Answer 351

* Most commonly Mycobacterium marinum, Mycobacterium kansasii, and Mycobacterium terrae. * Mycobacterium marinum is found in BOTH fresh and salt water. * Suspect mycobacteria when a chronic skin lesion, draining sinus tract, or infection fails to heal as expected. * BIOPSY will show granulomas with negative fungal staining. * Culture in Lowenstein-Jensen medium at 31 degrees for 8 weeks. **Treatment** * Surgical debridement * Long term antibiotics for 2-6 months

Answer 352

* Initially management with * Culture before antibiotics, removal, irrigations, antibiotics spacer, targetted antibiotics * Before reimplantation, patient should have normal WBC, ESR, CRP * At the time of surgery, obtain gram stain, and frozen section with \<5 PMNs/high pwer field

Answer 353

* Recieves blood supply from nutrient artery, metaphyseal vessels, and periosteal vessels. * NUTRIENT ARTERY: * Enters groove on posterior tibia and enters the medulla where it divides into a network of vessels supply the corext from the endosteal surface * This endosteal blood flow supplies the inner two thirds of the cortex. * METAPHYSEAL VESSELS: * PERIOSTEAL VESSELS: * Supplies the outer third of the cortex When a long bone like the tibia is fractures, the nutrient vessels are disrupted and the distal fragment is rendered avascular and must rely on the metaphyseal blood flow and periosteal blood flow.

Answer 354

* **Nonvascularized bone grafting** * Cancellous bone grafts can be used beath vascularized muscle flaps for defects up to 10cm (some authors) * 6cm typically used as the cut off. * **Free osseous or osteocutaneous flap** * OPTIONS: Fibula, scapula, iliac crest * Weiland et al. concluded that for segmental defects \>6cm, vascularized bone is required. * \*\* May take up to 15 months for stable union after vascularied bone grafts \*\* * **Distraction osteogenesis (Ilizarov technique)** * May be used for bone grafts larger than 10cm * Involves radical debridement of the bony defect and a REMOTE corticotomy (outside the zone of injury) leaving INTACT the medullary blood supply. * Wait 7 days before distraction; distract 1mm/day until defect spanned. * Frame usually kept for 1 year. * CONTRAINICATIONS: Defects \>12cm

Answer 355

**_UPPER THIRD_** * *Medial gastrocnemius* * *Lateral gastrocnemius* * *Proximally based soleus* * Soleus blood supply from multiple PT perforators. Soleus exposed and distal perforators divided to allow rotation of the soleus. * *Bipedicled tibialis anterior* * Tibialized anterior exposed and mobilized off tibia. Attachment superiorly and inferiorly maintained for 'bipedicled' blood supply. Transposed to cover the defect. **_MIDDLE THIRD_** * *Medial gastrocnemius* * *Lateral gastrocnemius* * *Proximally based soleus* * *Bipedicled tibialis anterior* * *Sural artery perforator flap* * Can also use the long extensors OR flexors to GREAT TOE or TOES (certainly not first line options) * Extensor digitorum longus (EDL) * Extensor hallucis longus (EHL) * Small defects or to augment * Flexor digitorum longus (FDL) * Neurovascular pedicle enters as junction of proximal and middle third. * Flexor hallucis longus (FHL) **_DISTAL THIRD_** * *Distally based (sural artery flap)* * Sural nerve + median superficial sural artery + small saphenous vein * Most perforators found in the distal half at the midline raphe * *Lateral supramalleolar flap* * Perforating branch of the peroneal artery, which is located 5cm above the lateral malleolus. It branches into a superficial branch (cutaneous perforator) which lies in between extensor hallucis longus and peroneus brevis (supplies skin 12x18x9cm). The descending branch follows the anterior aspect of the lateral malleolus, connecting with the lateral malleolar branch of the tibialis anterior and continuing to the foot. * *Extensor digitorum brevis* * Blood supply: Lateral tarsal artery and vein with a communication to the peroneal * The lateral tarsal artery can be found at the junction of the proximal to middle third of the medial EDB muscle, running on the undersurface of the muscle * *Perforator flap / propellar flap* * *Cross leg* * Transferred as fasciocutaneous with 3:1 or 4:1 ratio.

Answer 356

* Medial plantar artery * Lateral supramalleolar flap * Extensor digitorum brevis.

Answer 357

* **Polands Syndrome** * Syndactyly, chest wall abnormalities * May be associated with symbrachydactyly (short finger, syndactyly, hand hypoplasia) * **Apert Syndrome** * Craniosynostosis, complex syndactyly * Autosomal dominant

Answer 358

* **Simple:** No bony fusion * **Complex:** Presence of bony fusion * **Complicated:** Presence of a syndrome * **Incomplete:** Web recessed to some degree * **Complete:** Syndactyly to the finger tips * **Acrosyndactyly:** Associated with contriction bands * **Acrocephalosyndactyly (apert syndrome):** Limb abnormalities with craniosynostosis

Answer 359

* **_EARLIER (4-6 months) for:_** * **border digits** * **complex** (e.g. apert with transverse bony comonents that will worsen with time) * Most commonly 6-12 months for all others

Answer 360

* **Camptodactyly** is a **FLEXION** contracture of the proximal interphalangeal joint (PIP). Classifically involves the **little finger** and commonly bilateral. * Painless. May be reducible or irreducible. **CLASSIFICATION** * **Type 1:** Apparent during infancy; usually isolated to small finger. * **Type 2:** Develops during preadolescence; may progress rapidly during growth. * **Type 3:** Severe. Multiple digits and part of a syndrome. **TREATMENT** * Nonsurgical treatment ***_mainstay._*** * If contracture \<30 degrees and not affecting child may consider splinting, particularly during growth spurts. * Consider surgical for contract \>60 to 90 degrees. * Stepwise approach to assessing and releasing volar skin, FDS, central slip laxity. Consider need for skin graft coverage and K-wire fixation of joint in extension.

Answer 361

* Clinodactyly: curvature of the finger in radial/ulnar direction. * Can arise from a C-shaped physis and associated "Delta phalanx" * Most commonly the middle phalanx of the small finger. **_TREATMENT_** * Splinting not beneficial * Surgery indicated with severe shorterning, angulation, and functional impairment AND has a delta phalanx present. * Options: * *_Physiolysis_* * Bracket resection of the *longitudinal physis* combined with fat grafting to the area. * *_Oteotomy_* * Opening or closing wedge osteomy

Answer 362

* **Timing** * Floating thumb with a narrow stalk can be addressed immediately with simple ligation. * Other than that, typically wait until 6-18 months of age. * **General approach:** * Typically the ulnar thumb is preserved so that the UCL is preserved. **Wassel Type I and Type II** * If each duplicated side is symmetrical and of equal size, a Bilhaut-Cloquet procedure can be performed * Largely fallen out of favour for preserving predominantly one of the duplicate thumbs. **Wassell Type III** * Blihaut-Cloquet or delete the small thumb. **Wassell Type IV** * Design skin flap for coverage * Excise duplicate thumb (typically radial). * Shell out (typically with subperiosteal dissection) to preserve and repurpose ligaments / tendons * Identify and reattach/preserve abductor pollicis brevis. * Centralize digit on phalanx. * Reduce MC condyle if is markedly wide. * Pin longitudinally and into the carpus to maintain reduction. **Wassell Type V and VI** * Same as III and IV, but reconstruct basal joint and MC with osteotomy.

Answer 363

**Macrodactyly:** Overgrowth of the digit. **Etiology** * Proposed to be a nerve-stimulated pathology (typically a median nerve distribution) * Englarged soft tissue with *advanced bone age* * One of the digital arteries if often enlarged **Classification (Upton)** * **Type I:** Macrodactyly with *lipofibromatosis* of nerve * **Type II:** Macrodactyly associated with *neurofibromatosis* (von Recklinghausen's disease) * **Type III:** Macrodactyly with *hyperostosis* (excessive bone growth) * **Type IV:** Macrodactyly with *hemihypertrophy* **Associated Conditions** * Neurofibromatosis * Klippel-Trenaunay-Weber syndrome (limb hypertrophy, hamangiomas, varicose veins) * Limb hypertrophy **Clinical presentation** * Enlarged digits often have angular defortmity (radial digits deviated radial, ulnar digits deviated ulnar) * Osseous growth ends at maturity but soft tissue growth continues. **Imaging** * Radiographs + vascular imaging **Treatment** * Goals: * Control size * Maintain sensivibility * Maintian useful function * Potential procedures: * Nerve decompression if compressed. * Epiphysiodesis (growth plate ablation) * Skin and subcutaneous tissue resection * Wedge osteotomies * Amputation

Answer 364

* **Holt-Oram Syndrome:** Autosomal dominant, septal defects, tetrology of fallot, and lower extremity abnormalities. * **VACTERL:** Vertebral, Anal, Cardiac, TrachEosophageal fistula, Renal, Radial and Lower extremity abnormalities. * **TAR:** Thrombocytopenia Absent Radius syndrome. * **Fanconi Anemia:** Autosomal dominant, poor long-term prognosis. * **Work-up:** * Cardiac auscultation * Echocardiography * Renal ultrasound * CBC with differential

Answer 365

**Pollex abductus:** abnormal insertion of the flexor pollicis longus into the extensor mechanism. Causes thumb abudction with concurrent thumb flexion. May be present in radial longitudinal deficiency or raidal polydactyly.

Answer 366

* Split-hand, split-foot syndrome * EEC (ectodactyly, ectodermal dysplasia, and cleft lip/palate) * Cornelia de Lange Syndrome

Answer 367

* **Typical cleft hand:** Bilateral and familial. Syndactyly common. May be associated with cleft lip or palate. * **Atypical cleft hand:** Unilateral and spontaneous. SYndactyly rare. Associated with Poland's. Remaining digits may be hypoplastic.

Answer 368

* Typically these patients have excellent function. * The classification is based on the degree of involvement of the first webspace as that can have implications for function. * **Indications for surgery:** * Progressive deformity (eg. transverse bones) * Deficient first web space * Aesthetic appearance * Absent thumb * **Timing considerations:** * Early surgery may be indicated with the presence of transverse bones. * Otherwise, typically performed at 1-2 years of age. * **Potential surgeries:** * Syndactyly release * First web space deepening * Closure of the commisure * Thumb realignment

Answer 369

Congenital Band Syndrome = Streeter's Syndrome * **Type I:** SImple constriction ring. * **Type II:** Contriction ring with deformity of the distal part * **Type III:** Constriction ring with variable fusion of the distal parts (acrosyndalyl) * **Type IV:** Complete intrauterine disruption

Answer 370

* **Etiology:** Amniotic band compress / encircle extremity cause local compression that heals and results with cleft. * Acute surgery not indicated unless their is vascular compromise -- that said, impending amputations are rarely salvagable. * Best to wait until 2-3 years of age that more larger/more effective flaps can be created. Generally a release of bands with z-plasty.

Answer 371

* Kirner's deformity is an abnormal volar-radial curvature of the distal phalanx. * Associated syndrome: * Cornelia de Lange syndrome * Silver's syndrome * Turner's syndrome * Down's syndrome * Usually present at birth and not progressive * There is also a sporadic form that develops in adolescence. * Can be corrected for aesthetic reasons; best to delay until an age where they can participate in the decision making process.

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