Hands FRCS > Microsurgery > Flashcards

Microsurgery Flashcards

(44 cards)

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1
Q

What are the goals of tx of fingertip amputations?

What is the prognosis for tx?

A
  • Sensate Tip
  • Durable Tip
  • Bone support for nail growth

Prognosis

  • Improper tx may result in stiffness adn longterm functional loss
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2
Q

Can you draw/describe the anatomy of the finger tip?

A
  • Eponychium- soft tissue on dorsal surface just proximal to nail
  • Paronychium- lateral nail folds
  • Hyponychium- plug of kerabtinous material situated beneath the distal edge of nail where nail bed meets skin
  • Lunula- white portion of proximal nail, demarcates sterile from germinal matrix
  • Nail bed
    • Sterile matrix- nail adheres to nail bed
    • Germinal matrix- proximal to sterile matrix, responsible for 90% nail growth
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3
Q

What is the aetiology of amputation?

A
  • Avulsion
  • Laceration
  • Crush
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4
Q

What do you see on examinatio of an amputated finger tip?

A
  • Characteristics of laceration
  • presence/absence of exposed bone
  • range of motion- felxor/extensor involved
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5
Q

What investigations useful for amputation of finger tip?

A
  • Xray- ap and lateral to assess Bony involvment
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6
Q

Describe the tx of finger tip amputations?

A

Non operative

  • Healing by secondary intention
    • adults/children with no bone/tendon exposed with <2cm skin loss
    • children with exposed bone

Operative

  • Primary closure- revision amputation
    • finger amputation w exposed bone and ability to rongeur bone proximally without compromising bony support to nail bed
  • Full thickness skin graft from hypothenar region
    • Fingertip ampuation with no exposed bone and >2cm tissue loss
  • Flap Reconstruction
    • exposed bone/tendon where reongeuring bone proximally is not an option
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7
Q

Describe the technique for secondary intention?

A
  • initial tx with irrigation and soft dressing
  • After 7-10 days saok in water-peroxide solution daily followed by application of soft dressing adn fingertip protector
  • complete healing takes 3-5 weeks
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8
Q

Describe the technique for full thickness skin grafting from hypothenar region?

A
  • Split skin grafts not used as
    • Contractile
    • Tender
    • Less Durable
  • Donor site is closed primarily
  • Graft is sutured over defect
  • Cotton ball secured graft helps maintain coaptation with underlying tissue
  • Ball removed after 7 days
  • Range of motion encourage after 7 dyas
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9
Q

Describe the technique for revision amputation?

A

Primary closure with removal of exposed bone

  • Must ablate remaining nail matrix
    • prevent formation of irrating nail remnants
  • If flexor/extensor tendon insertions can’t be preserved disarticulate at DIPJ
  • transect digtial nerves and remaining tendoms proximal as possible
  • Plamar skin is brought over bone and sutured to dorsal skin
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10
Q

Can you describe the flap types available for Finger tip- to DIPJ ?

A
  • Straight/Dorsal Oblique lacerations
    • V-Y Advancement
    • Digital Island Artery- best axial pattern flap
  • Volar Oblique laceration
    • Cross finger Flap if >30 yrs- less stiffness
    • Thenar Flap if <30 yrs- improved cosmesis
    • Digital Island artery
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11
Q

Can you describe the types of flap available for volar proximal finger?

A
  • Cross finger flaps if > 30 years
  • Axial flag flap from long finger
  • Leads to less stiffness - X finger flaps
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12
Q

Can you describe the types of flap available for dorsal proximal finger and MCP lesion?

A
  • **Reverse Cross FInger **
  • Axial FLag flap from long finger
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13
Q

Can you describe the types of flap available for volar thumb lesion?

A
  • Moberg Advancement Volar flap if <2cm
  • First Dorsal Metcarpal Artery flap FDMA if >2cm
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14
Q

Can you describe the types of flap available for dorsal thumb lesion?

A
  • First Dorsal Metacarpal Artery Flap
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15
Q

Can you describe the types of flaps available for first web space lesions?

A
  • Z plasty with 60 degree flaps
    • can increase length by 75%
  • Posterior interosseous fasciocutanoeous flap
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16
Q

Can you describe the flaps types available for dorsal hand?

A
  • Groin flaps
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17
Q

What are the complications of flaps?

A
  • Flap failure
    • inadequate blood flow
    • vasospasm -> thrombosis at anastomosis
  • Hook nail deformity
    • Tight tip closure
    • insufficient bone support
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18
Q

What is the epidemiology of upper extremity amputations?

Study These Flashcards
A
  • Trauma
  • 90% occur after trauma
  • 4:1 male cf female ration
  • most occur at level of digits
  • mechanism of traumatic amputation
    • Sharp dissection
    • Blunt dissection
    • Avulsion
    • Crush
19
Q

What is the imortant history and signs of amputation?

Study These Flashcards
A

Hx

Timing of injury

  • type & location of amputation
  • preservation of amputated tissue
  • PMhx

O/E

  • Stump examination
  • zone of injury/ tissue viability/supporting tissue structures/contamination
  • Amputated portion inspected
    • level, segemental injury/ bone/soft tissue damage/ contamination
20
Q

What are the indications for replantation post trauma?

Study These Flashcards
A

Primary

  • Thumb
  • Multiple digits
  • wrist level or proximal wrist
  • Almost all parts in children

Relative

  • Individual digits distal to the insertion of Felxor digitorium superficialis- zone 1
21
Q

What are the contra- indications for replantation post trauma?

Study These Flashcards
A

Primary

  • Single digit proximal to FDS - zone 2
  • mangled limb/crush injury
  • Semgental amputation
  • prolonged ischaemic time

relative

  • Medically unstable patient
  • disabling psychiatric illness
  • tissue contamination
22
Q

Describe the transport of amputated tissue?

Study These Flashcards
A
  • Keep with patient
  • Wrapped in gauze in lactate ringers solution
  • Placed in sealed plastic bag and placed in ice water- avoid direct contact with ice/dry ice
  • Wrap, cover and compress stump wiht moisten gauze
23
Q

Describe the time to reimplantation?

Study These Flashcards
A
  • proximal to carpus
    • warm ischaemic time <6 hours
    • cold ischaemic time <12 hrs
  • Distal to carpus ( digit)
    • warm ischaemic time <12 hours
    • Cold ischaemic time <24 hrs
24
Q

Can you describe the operative sequence of replantation?

Study These Flashcards
A
  1. Bone
  2. extensor tendon
  3. Flexor tendons
  4. Arteries
  5. Veins
  6. Nerve
  7. Skin

BEFAVNS

25
Can you describe the finger oder for reimplantation?
* Thumb * Middle * Ring * Small * Index
26
How is reimplantation achieved for mutliple digits?
* **Structure by structure most efficient** * Digit by digit takes the most time
27
Describe the post operative care for reimplantated digits?
* **Environment** * **Warm 80F** * avoid caffine, chocolate, nicotine * **Monitor replant** * **Skin temperature**- most reliable, concern \>2o drop in \< 1 hour or temp below 30oC * **Pulse oximetry \<94%** - vascular compromise * **Anticoagulation** * adequte hydration * medications aspirin, heparin * **Arterial insufficiency** * release constriction bandages * place extremity in dependent position * consider heparinisation * consider stellate ganglion blockade * early surgical exploration * thrombosis secondary to vasospasm is most common cause of early implant failure * **Venous congestion** * elevate extremity * leech application * release Hirudin- powerful anticoagulant * aeromonous hydrophila infections can occur * Heparin soaked pledgets if no leeches
28
Describe the complications of reimplantiation?
* **Reimplantation failure** * within 12 hrs- arterial thrombosis from vasospasm * **Stiffness** * 50% of total motion of normal digits * tenolysis is most common secondary procedure * **Myonecrosis** * \> in major limb reimplantation cf digit * **Myoglobinuria** * muscle necrosis in larger implants * can lead to renal failure-\> fatal * **Reperfusion injury** * **​**ischaemia induced hypoxanthine conversion to xanthine * Allopurinol to decrease xathine production * **Infection** * **Cold intolerance**
29
What is the most important factor in influencing immediate and late outcome of amputations?
* **Type of Injury**
30
Describe the regions of thumb reconstruction?
* Region A * Primary closure * Toe to thumb * local flaps * Region B * Web Deepening * Metacarpal lengthening * Toe to thumb * Region C * Toe to thumb * Osteoplastic thumb reconstruction * Dorsal rotational flap * Region D * Pollicization
31
What does thumb reconstruction require?
* An **intact CMCJ t**hat is **stable** but also **appropriately functional **
32
Describe the different tx of thumb reconstruction?
* **Toe to thumb procedure** * Great toe recieves blood supply from 1st dorsal metatarsal artery & dorsalis pedis * morrison/wrap around allows for maintaince of length if hallux. Size and appearance are best replicated. * 2nd MT is not suitable for transfer * **Web Deepening** * **​Z plasty ( 2/4 flaps)** * ​2 flaps provide \> depth * if complete at 45o - relative length increase by 50%, 60o 75% * **Brand Flaps** * Index finger used to provide a full thickness * can close donor site primarily * **Dorsal rectangular flaps** * taken from dorsum of metacarpals * may require skin grafting * **Arterilalized palmar flap** * **​**may use axial ( local) or island flap ( distal) * **​Osteoplastic reconstruction** * ​iliac crest is used to establish mechanical length to the thumb * an island flap from the radial aspect of the 4th ray is combine dwiht reverse radial forearm flap to aid coverage.
33
What is ring avulsion injuries?
* Sudden pull on a ring finger results in **severe soft tissue** injury ranging from circumferential soft tissue laceration to complete amputation * Skin. nerves , vessels are often damaged
34
Describe the epidemiology of ring avulsion injuries?
* Incidence 150,000 incidents of amputation & degloving in us pa * **5%** of upper limb injuries * Usually involves **one digit - ( ring)** * Risk factors * working with **machinery** * wearing a **ring**
35
What is the aetiology of ring avulsion injuries?
* Patients catch wedding ring or finger on moving machinery or protruding object * **Long segment of MACRO & MICRO Vascular injury from crushing, shearing and avulsion**
36
What is the prognosis of avulsion injuries?
* Outcomes of injury * Extent of injury is **greater than** what it appears * **Poor prognosis** because of long segment vascular injury * Outcomes of tx * Advances in interposition graft techniques have improved results with ring avulsion replantation
37
How long will avulsed digits last for?
* As devoid of muscle avulsed digits will survive \>12 h if cooled * Skin is the strongest part - once torn the remaining tissue quickly degloves
38
Can you describe the name and classification system of ring avulsion injuries?
* **Urbaniak** Classification * **Class 1**= (80N) **Circulation adequate**-\>**standard bone and soft tissue care** * **Class 2**-=**Circulation inadequate-\> vessel repair** * **Class 3=** ( 154N)**Complete degloving or complete amputation-\> amputation**
39
what are the signs and symptoms of ring avulsion injury?
* Hx * work with **machinery,** caught in door * Symptoms * Pain * Bleeding * Lack of sensation at tip * OE * **Inspect**- irrigate wound adn inspect for avulsed vessels, damaged tendons, nerves, skin edges * **Staggered injury pattern** * prox skin avulsion from pipj-\>base of digit * Distal bone fracture or dislocation- distal to pipj
40
What investigations are helpful in dx of ring avulsion injuries?
* Xrays of both parts as amputated part may have bone!
41
Describe the tx of ring avulsion injuries?
* Initally * Place amputated part in bag with saline moistened gauze , follwed by bag of ice * **Antibiotics and tetanus prophylaxis** Operative * **Reimplantation +/- Vein graft, DIPJ fusion** * for disruption of venous drainage * disruption of venous/ arterial flow- revascularisation * **Intact PIPJ & FDS insertion** * **​Complete ampuation ( esp distal to PIPJ/FDS is relative CI to reimplantation** **​** * **Revision Amputation** * **​**complete degloving * bony injury with nerve and vessel injury * bony amputation **proximal to FDS or proximal to PIPJ** * **​**reimplantation likely-\> poor hand function * consider revision amputation/ray amputation
42
What are the outcomes of replantation+/- vein graft , dipj fusion for ring avulsion injuries?
* Survival * _lower survival for avulsed digits_ 60% cf finger _reimplantation in general_ 90% * _Lower survival for complete_ 66% vs incomplete avulsion replantation * _Lower survival for avulsed thumb_ than finger * surgeons attempt technically difficult rhumb where conditons are not favourable cf digits * Sensibility * most achieved Protective Sensibilty 2PD 9mm * _Better sensibility when incomplete avulsion_ replantation than complete * Range of motion * Average total arc of motion (TAM) is 170-200 * better TAM in incomplete avulsion implantation than complete
43
Describe the technique for reimplanatation/revascularisation?
* under microscope * lateral incision on ulnar aspect * arteries * thorough debridment of non viable tissue * thorough arterial debridment * repair using vein graft-significant damage * may need another step- down vein graft because of difficutly of matching sizes * may reroute arterial pedicle from adjacent digit * Veins * repair at **least 2 veins** * important factor in **revascularization failure** * ​Bone * ​If amputation at DIPJ , preform **primary arthrodesis DIPJ** * **​Skin** * **​Preform FTSG or venous flap to prevent tight closire**
44
Describe the complications for replantation?
* **Cold Intolerance** * **Revascularization/replanatation failure** * Sig factors is **repair of \<2 veins** * Vascular damage to digital pulp * smoking and level of bione injury not been found to effect survival * **Flexion Contracture** * **Malunion** * **revision surgery** * revision amputations-\> **Hyperaesthesia**
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