Plastic Surgery

Question 1

Description of burn severity

Answer 1

1) depth
depth usually difficult to determine initially and easier to determine after 24 hours

depth based on layers of skin involved in the burn, from superficial to deep

2) percentage of total body surface area
burns need to be described in terms of % total body surface area (TBSA), which is estimated by rule of 9’s for any patient >9 years

head, chest, abdomen, upper back, lower back, left arm, right arm, anterior left leg, posterior left leg, anterior right leg and posterior right leg each approximately have 9% TBSA

genital area approximately have 1% TBSA

for patchy burns, % TBSA estimated using palm method where palm without fingers = 0.5% TBSA and palm with fingers = 1% TBSA

Lund-Browder chart is more accurate and often used in children <9 years

Question 2

Superficial burns: 
Involved tissue 
Appearance 
Sensation 
Healing time 
Common cause

Answer 2

Involved tissue - epidermis

Appearance - Dry, red, Blanches with pressure

Sensation - Painful
Healing time - 3-6 days
Common cause - UV exposure, very short flash

Question 3

Superficial partial thickness burns: 
Involved tissue 
Appearance 
Sensation 
Healing time 
Common cause

Answer 3

Involved tissue - epidermis and part of dermis

Appearance - Blisters, moist, red, weeping, blanches with pressure

Sensation - Painful to temperature and air

Healing time - 7-20 days

Common cause - Scald (spill or splash), short flash

Question 4

Deep partial thickness burns: 
Involved tissue 
Appearance 
Sensation 
Healing time 
Common cause

Answer 4

Involved tissue - epidermis and part of dermis

Appearance - blisters that are easily unroofed, wet or waxy, dry, variable colour, does not blanch with pressure

Sensation - perceptive of pressure only
Healing time - >21 days, scarring
Common cause - scald (spill), flame, oil, grease

Question 5

Full thickness burns: 
Involved tissue 
Appearance 
Sensation 
Healing time 
Common cause

Answer 5

Involved tissue - epidermis and all of dermis

Appearance - waxy white to leathery gray to charred and black, dry and inelastic, no blanching with pressure

Sensation - deep pressure only

Healing time - never heals if >2% TBSA, which would require skin grafting to replace dermal integrity

Common cause - scald (immersion), flame, steam, oil, grease, chemical, electrical

Question 6

Fourth degree burns: 
Involved tissue 
Appearance 
Sensation 
Healing time 
Common cause

Answer 6

Involved tissue - skin and underlying tissue (fascia/muscle)

Appearance - underlying tissue visible

Sensation - deep pressure only

Healing time - never heals, requiring skin grafting to replace dermal integrity

Common cause - scald (immersion), flame, steam, oil, grease, chemical, electrical

Question 7

ABA burn severity grading system

Answer 7

American Burn Association grading system classified into minor, moderate or major burn based on depth and % TBSA

minor burn =
<15% TBSA in adults
<10% in children and older adults
<2% TBSA full thickness burn

moderate burn =
15-25% TBSA with <10% full thickness burn
10-20% TBSA partial thickness burn in children under 10 and adults over 40 with <10% full thickness burn

major burn =
25%+ TBSA
20%+ TBSA in children <10 and adults >40 years
10%+ full thickness burn or involving eyes/ear/face / hands / feet / perineum that are likely to result in cosmetic of functional impairment or high voltage electrical burn or major trauma or inhalation injury or poor risk patients with burn injury

Question 8

Primary management of burns

Answer 8

1) Stabilize
2) Assessment of Burn - depth and % TBSA

3) Airway Management if Inhalation Injury
airway management mainly address A) inhalation injury and B) CO poisoning

A) inhalation injury
inhalation injury cause progressive upper airway edema, eventually closing up airway, which is leading cause of death in burn patients
inhalation injury also cause pulmonary injury, causing pulmonary edema and insufficiency by 2-3 days

B) CO poisoning
bronchodilator (Albuterol) if bronchospasm
steroids not indicated in burn patients

4) Fluid Resuscitation
2 large IV bores for IV crystalloids

fluid resuscitation need to be accurate, because inadequate fluid resuscitation increases risk of mortality while over-resuscitation can cause pulmonary edema / acute respiratory distress, pneumonia, multi-organ failure, compartment syndromes

estimation of initial fluid requirement based on Parkland formula

extra fluid administration for the following cases: burn >80% TBSA, 4th degree burns, associated traumatic injury, electrical burn, inhalation injury, delayed resuscitation, pediatric burn

target hourly urine output should be maintained at 0.5mL/kg per hour for adults and 1mL/kg per hour for children

blood transfusion should be avoided when possible
indication for blood transfusion = hemoglobin <80g/L in patient without acute coronary syndrome (ACS) or <100g/L in patient with ACS

5) Immediate Burn Care & Cooling
any hot or burned clothing, jewelry and debris should be immediately removed

burned area should be cooled immediately using cool water or saline soaked gauze (12C) for 15-30 minutes
monitor core body temperature continuously, because cooling of burns >10% TBSA can cause hypothermia which can be treated with warmed IV fluids to maintain temperature >35C

6) Pain Management
IV morphine for pain

Question 9

Clinical presentation, physical exam, investigations, diagnosis and management for significant smoke inhalation injury

Answer 9

1) history
burn in a closed space

2) symptoms
hoarseness, persistent cough, stridor or wheezing

3) inspection
conjunctivitis
nares with inflammation or singed hair
carbonaceous sputum or burnt matter in mouth or nose
blistering or edema of oropharynx
deep facial or circumferential neck burns

4) general physical exam
depressed mental status including evidence of drug or alcohol use
respiratory distress, tachypnea

5) investigations
hypoxia or hypercapnia
elevated carbon monoxide (CO) or cyanide level
investigations for inhalation injury and respiratory distress include
vitals: oxygen saturation
arterial blood gas, serial peak expiratory flow rates (PEFR) if obtainable
chest X-ray
capnography, which can monitor end-tidal CO2 (EtCO2)
blood labs: serum lactate; serum cyanide level, blood carboxyhemoglobin (HbCO) level for moderate or severe burns
ECG to assess cardiac function

6) Diagnosis
inhalation injury can be diagnosed on direct bronchoscopy, and cannot be diagnosed based on chest X-ray or arterial blood gas

7) Management

patients with signs of smoke inhalation injury should be given supplemental oxygen and intubated early and prophylactically even without respiratory distress

Question 10

Signs of CO poisoning

Answer 10

signs of CO poisoning: headache, confusion, coma, arrhythmias

Question 11

Diagnosis of CO poisoning

Answer 11

CO poisoning diagnosed based on high HbCO

Question 12

Management of CO poisoning

Answer 12

reversed with hyperbaric oxygen treatment

Question 13

Cyanide poisoning diagnosis

Answer 13

cyanide poisoning diagnosed based on high blood cyanide level or high serum lactate plus low / decreasing EtCO2

Question 14

Cyanide poisoning treatment

Answer 14

reversed with hydroxocobalamin

Question 15

Parkland formula

Answer 15

Calculation for fluid resuscitation for burns

4mL/kg for each % TBSA burned over course of 24 hours where 1/2 is delivered in first 8 hours and other
1/2 is delivered in the subsequent 16 hours

e.g. 70kg patient with 10% TBSA burn = 4mL/kg x 70kg x 10 (for % TBSA) = 2800mL over 24 hours, so 1400mL over first 8 hours (i.e. 175mL/hr for first 8 hours) and 1400mL over subsequent 16 hours (i.e. 87.5mL/hr for subsequent 16 hours)

Hour 24-30 – 0.35-0.5 cc plasma/kg/%TBSA

Hour >30 – D5W at rate to maintain normal serum sodium

Question 16

Secondary burn management

Answer 16

1) Further Investigations

2) Prevention of Infection
tetanus prophylaxis with 0.5cc tetanus toxoid for any burn deeper than superficial or >10% TBSA

tetanus immunoglobin if prior immunization is absent, unclear or out dated >10 years ago

topical antibiotics (Silver Sulfadiazine SSD) applied to all non-superficial burns

Bacitracin for skin near eyes & mouth, sulphonamide hypersensitivity, pregnant mothers, newborns and nursing mothers

3) Wound Management (Minor to Severe Burns)
if not already done, remove clothing / jewelry / debris and cool wound with saline-soaked gauze (12C)

a) pain management
minor burn can be treated with acetaminophen and NSAID in combination with opioids if required

superficial burn can be treated with non-perfumed moisturizing cream (Vaseline, Nivea) applied to wound with aloe for pain control and keeping skin moist

b) burn wounds cleaned and irrigated
embedded foreign body removed by irrigation
wound washed with mild soap and tap water

c) debridement
sloughed or necrotic skin including ruptured blisters are debrided

d) wound dressing
all partial and full thickness burns should have dressings

e) escharotomy
f) skin grafting

g) rehabilitation
prevention of wound contracture with pressure dressing, joint splints and early physiotherapy

4) NG Tube

thermal burn shock may cause mesenteric vasoconstriction causing gastric distension, ulceration and aspiration

for patients with moderate or severe burns >20% TBSA, nasogastric (NG) tube

Question 17

What is an eschar, eschartotomy and indications for escharotomy

Answer 17

eschar = stiff and unyielding dermis with deep dermal and full thickness burns

escharotomy = incision of eschar with coagulation electrocautery or scalpel

eschar may limit respiratory function (such as eschar in neck and chest), which require emergency escharotomy

circumferential eschar may cause compartment syndrome or distal ischemia, thus require decompressive escharotomy

Question 18

Indication for skin grafting in burn

Answer 18

indication for skin graft = full thickness and 4th degree burns that is bigger than size of quarter

Question 19

Wound dressing for burn process

Answer 19

before wound dressing, the burn should be cleaned thoroughly, debrided and topical antibiotics should be applied

topical antibiotics to prevent infection and sepsis by common skin organisms (Gram positive day 1-3 including staphylococcus aureus; gram negative day 3-5 including
pseudomonas, proteus, klebsiella; Candida)

basic dressing = 1st layer of fine non-adherent mesh gauze (Telfa, Adaptic) placed over burn, 2nd layer of fluffed dry gauze and 3rd layer of elastic gauze roll (Kerlix)

dressing in successive strips held in place using tubular net bandage or gauze wraps

individually wrap and separate with fluffed gauze all toes and fingers to prevent adherence and maceration
dressing change can range from twice daily to weekly

once epithelialization occurs, non-perfumed moisturizing cream (Vaseline, Nivea) applied to wound

Question 20

Complications of burn

Answer 20

hypermetabolism: nutrition should meet increased metabolic rate with adequate calories, vitamin C, vitamin A, Ca, Zn, Fe

immune suppression: increased risk of sepsis so must monitor for signs of sepsis and treat aggressively with antibiotic therapy if present

GI bleed: NG tube feeding or NPO with TPN; may add antacid and anti-histamine blocker to prevent GI bleed

renal failure: renal failure usually due to pre-renal or myobloginuria, which can be prevented with adequate fluid resuscitation

pulmonary insufficiency (due to inhalation injury, pneumonia, cardiac decompensation, sepsis): treated with intubation and mechanical ventilation

wound contracture and hypertrophic scaring: prevented with timely wound closure, splinting, pressure garments and physiotherapy

vascular permeability and edema

altered hemodynamics (decreased CO, increased SVR)

Question 21

Burn indication for admission to hospital

Answer 21

moderate to major burns according to ABA grading system

involvement of face, neck, hands, feet, genitalia, perineum, major joints

suspected inhalation injury

circumferential partial or full thickness burn

immune compromised patients or poor expected recovery (diabetics, elderly)

chemical burn

high voltage injury with abnormal ECG

Question 22

Transfer to burn centre indications

Answer 22

major burn based on ABA grading system should be transferred to a burn center

> 10% TBSA partial thickness burn

> 5% TBSA full thickness burn

burn involving face, neck, hands, feet, genitalia, perineum or major joints

pre-existing medical condition that can complicate management, prolong recovery or adversely affect outcome

special requirement (social, emotional or long term rehabilitative needs)

children who require qualified pediatric personnel and equipment

Question 23

Stages of wound healing

Answer 23

“In Every Fresh Cut” = Inflammation, Epithelization, Fibroplasia, Contraction

1) Inflammatory Reactive Phase (day 1-6)
inflammation limits damage and prevent further injury
debris and organisms cleared by inflammatory response, mainly neutrophils in day 1-2 and macrophages in day 2-4

hemostasis achieved by vasoconstriction and platelet plug

2) Proliferative Regenerative Phase (day 4 to week 3)

macrophage secrete growth factors that recruit and activate fibroblasts

fibroblasts initiate reparative process of re-epithelialisation, matrix synthesis (mainly type 3 collagen synthesis) and angiogenesis

reparative process increase tensile strength of wound by day 4-5

3) Remodelling Maturation Phase (week 3 to 1 year)
increasing collagen organization and stronger cross links, resulting in wound contraction, scarring, then remodelling of scarring

type 1 collagen replaces type 3 until 4 to 1 ratio is achieved

peak tensile strength at 60 days, which is 80% of pre-injury strength

Question 24

Primary closure indication, contraindication and mechanism

Answer 24

indication: recent (<6 hours) and clean cut wounds such as surgical wounds or acute traumatic wounds where wound edges can be brought together by external mechanism
contraindication: bite wounds, crush injury, infection, long time lapse since injury (>6 hours), retained foreign body
mechanism: wound edges brought together by stitches, staples or adhesive tape within hours of wound creation

Question 25

Secondary closure indication, mechanism

Answer 25

indication: wound that cannot be cleaned or wound too large that skin cannot be brought together (e.g. ulcer) mechanism: wound healed spontaneously by body without any external mechanism means spontaneous healing at rate of 0.75 mm/day from wound margins in concentric pattern require wound care and have inferior cosmetic result

Question 26

Tertiary closure (aka delayed primary closure) indication, mechanism

Answer 26

indication: chronic or contaminated wounds where wound edges can be brought together by external mechanism; severe crush injury with significant tissue devitalization mechanism: wound left open (often healing interrupted with packing), cleaned and observed, where it may be closed 4-5 days later (when granulation / epithelization occurred) prolonged inflammatory phase to decrease bacterial count and lessen chance of infection after closure require wound care

Question 27

Wound contamination definition

Answer 27

contamination = presence of non-replicating micro-organism within wound

Question 28

Wound colonization definition

Answer 28

presence of replicating microorganism within wound

Question 29

Wound infection definition

Answer 29

>105 micro-organism (or small amount of virulent organism) in wound without intact epithelium

Question 30

Acute management of contaminated wounds <24h

Answer 30

evaluate for injury to underlying structure (blood vessel, nerve, tendon, bone) control active bleeding cleanse and irrigate open wound with physiologic solution (NS or RL) surgical debridement with blade and irrigation to remove foreign material, devitalized tissue, old blood Systemic antibiotics and tetanus toxoid, immunoglobin and immunization where applicable post exposure treatment of hepatitis B / C or HIV if indicated re-evaluate wound at 24-48 hours for signs of deep infection (erythema, swelling, warmth, pain, purulence), where infected wound need to have sutures removed and opened

Question 31

Indication for systemic antibiotics in contaminated wounds

Answer 31

Clinically infected wound (wound redness, swelling, pain, purulence; fever; leukocytosis) wound >8 hours severely contaminated wound immune compromised patient wound involving deeper structure

Question 32

Tetanus prone wound characteristics

Answer 32

>6h since injury >1cm depth of injury Crush, burn, gunshot, frostbite, puncture thorugh clothing, farming injury mechanism of injury Devitalized tissue present Contamination present Retained foreign body present

Question 33

Tetanus immunization recommendations

Answer 33

1) Uncertain or <3 doses of immunization : A) Clean, minor wound Tdap yes, Tig No B) All other wounds Tdap yes, Tig yes 3 doses received in immunization series A) Clean, minor wounds Tdap no, but yes if >10 years since last booster Tig No B) All other wounds Tdap No, but yes if >5 years since last booster Tig no, but yes if immunocompromised

Question 34

Long term management of contaminated wounds >24h

Answer 34

irrigation and debridement topical antimicrobial systemic antibiotics if clinical signs of infection (wound redness, swelling, pain, purulence; fever; leukocytosis) when bacterial count <10^5, closure usually by secondary intention, but may be by tertiary intention, skin graft or flap

Question 35

Indications for wound care

Answer 35

wound care only in 2nd or 3rd intention wound healing in general, wound care indicated for any chronic non-healing wounds including surgical wounds and traumatic wounds diabetic wounds/ diabetic foot ulcer venous leg ulcers pressure ulcer complex soft tissue wounds infected wounds

Question 36

What is wound care

Answer 36

wound care encompasses all management to facilitate healing of wound, which can be any combination of the following medical care: antibiotics, controlling of blood sugar wound debridement: irrigation, surgical topical therapy: antiseptics, antimicrobial agents wound dressings wound packing wound closure

Question 37

Aspects of wound care

Answer 37

A) Medical management systemic antibiotic therapy for clinically infected wound with any of the following local signs: cellulitis, lymphagitic streaking, purulence, malodor, wet gangrene, osteomyelitis systemic signs: fever, chills, leukocytosis, nausea, hypotension, hyperglycemia, confusion, blood glucose control, especially for diabetic patients B) Debridement C) Topical Therapy antimicrobial cadexomer iodine (Iodosorb) D) Wound Dressing wound dressing should eliminate dead space, control exudate, prevent bacterial overgrowth, ensure proper fluid balance primary goal of dressing = maintain moisture in wound environment E) Wound Packing wound packing usually indicated for large soft tissue defects (area of dead space between surface of intact healthy skin and wound base) wound packing with gauze dressing requires frequent dressing changes usually 2-3 times daily such that the gauze does not completely dry out wound dressing stopped when necrotic tissue have been removed and granulation is occurring F) Wound Closure / Coverage wound closure in wound care as tertiary intention (delayed primary closure) chronic wound should never be closed primarily, and only delayed primary closure in some cases wounds are closed by delayed primary closure if it demonstrates progressive healing based on granulation tissue and epithelization negative pressure wound therapy for deep wounds to reduce complexity and depth of defect prior to definitive closure after sufficient wound care wound can be closed by closure with suture, staple or tape coverage with skin grafts

Question 38

Classification of skin graft

Answer 38

1) Species classification autograft = donor and recipient sites on same individual allograft (homograft) = donor site from one human to an recipient site on another human xenograft (heterograft) = donor site from a different species (e.g. pig) to an recipient site on a human 2) Thickness classification split vs full thickness (some vs all of dermis)

Question 39

Split thickness vs full thickness skin graft

Answer 39

split thickness skin graft can be used as mesh graft, which can cover a large area advantage: best for contaminated recipient site, prevent accumulation of fluids (hematoma, serum) disadvantage: poor cosmoses (alligator hide appearance), significant secondary contracture Full thickness advantages: may use on face and fingers disadvantages: lower rate of survival (thicker, slower vascularization)

Question 40

Unsuitable and suitable vascularized beds for skin graft

Answer 40

unsuitable bed due to lack of vascularization: bone, tendon, cartilage suitable vascularized bed: muscle, fat, periosteum

Question 41

Skin graft will take under the following conditions

Answer 41

vascularized bed non-contaminated wound with bacteria count <10^5 minimize shearing motion and fluid (including seroma and hematoma) beneath graft, where immobilization by staples, sutures, splinting and appropriate pressure dressing are used to prevent graft movement, hematoma and seroma formation

Question 42

Causes for skin graft loss

Answer 42

fluid collection: hematoma, seroma infection mechanical force: shearing, pressure

Question 43

Skin flaps definition

Answer 43

tissue transferred from one site to another with its original blood supply, thus not dependent on neovascularization on recipient site skin flaps may consist of skin, subcutaneous tissue, fascia, muscle, bone and other tissue

Question 44

Indication for skin flaps

Answer 44

reconstruction to replace tissue loss due to trauma or surgery provide temporary skin and soft tissue cover through which surgery can be carried out later improves blood supply to poorly vascularized bed such as bone

Question 45

Classification for skin flaps

Answer 45

skin flaps can be classified based on blood supply or anatomic location 1) blood supply: random, axial a) random pattern flaps random pattern flaps have random vascular supply limited length to width (2 to 1) ratio to ensure adequate blood supply b) axial pattern flaps flap contains a well defined artery and vein allows greater length to width (6 to 1) ratio 2) anatomic location: local, regional, distant

Question 46

What can cause skin flap loss

Answer 46

fluid collection: hematoma, seroma infection poor flap design mechanical forces: compression vascular failure or thrombosis fat necrosis

Question 47

Characteristics of basal cell carincoma

Answer 47

nodulo-ulcerative type: papule / plaque / nodule with white translucent shiny scaly ("pearly") borders usually well defined, which may contain telangiectasia (tiny blood vessel) lesion may have erosion or ulceration variant include pigmented variant: flecks of pigment in translucent lesion, which may mimic melanoma superficial variant: flat tan to red brown plaque, with scales, pearly border and fine telangiectasia sclerosing variant: flesh / yellowish coloured shiny papule / plaque with indistinct border

Question 48

Typical location of basal cell carcinoma

Answer 48

Sun exposed area such as face, neck and back of hands

Question 49

Etiology of basal cell carcinoma

Answer 49

cancer arising from basal stem cells of epidermis

Question 50

Incidence of basal cell carcinoma

Answer 50

3/10 will develop BCC in their lifetime 75% of all malignant skin tumor in age >40 years with increased prevalence in elderly most common tumour of all cancers

Question 51

Characteristics of squamous cell carcinoma

Answer 51

indurated erythematous nodule / plaque with surface scale crust, which eventually ulcerates SCC tend to have more scales than BCC ulcerated SCC usually have a volcano morphology with central ulcer surrounded by hard raised edges keratoacanthoma = low grade SCC, usually dome shaped lesion with central keratosis / debris more rapid enlargement than BCC do not have pearly border

Question 52

Typical location of squamous cell carcinoma

Answer 52

face, ears, scalp, forearms, hands

Question 53

Etiology of squamous cell carcinoma

Answer 53

cancer arising from supra-basalar stem cells in epidermis

Question 54

Incidence of squamous cell carcinoma

Answer 54

incidence of ~0.1-0.3% for males; 0.03-0.1% for females

Question 55

Characteristics of cutaneous malignant melanoma

Answer 55

dark pigmented lesion, which can be flat and / or raised or nodular usually asymmetric, irregular (jagged) and ill-defined borders, mixture of colours, diameter >6mm and evolves over time (ABCDE) melanoma can be amelanotic (i.e. unpigmented) color correlate with melanoma pathology black = melanoma only in corneum brown = melanoma invading to junction between epidermis and dermis blue = invasion into dermis pink = blood capillary light coloured = undifferentiated melanoma cells ugly duckling rule: in patients with many nevi, melanoma usually looks different in morphology compared to other nevi (i.e. it stands out amongst other nevi) melanoma can occur on nail as acral melanoma, which appear as longitudinal tan, black or brown streak on nail that may involve palms of hands or soles of feet Subtypes include lentigo melanoma in situ, invading dermis, superficial spreading, nodular and acrolentiginous (palmar, plantar or sublingual)

Question 56

Typical location of cutaneous malignant melanoma

Answer 56

skin, mucous membrane, eyes, CNS most common skin sites: back for males calves for females

Question 57

Etiology of cutaneous malignant melanoma

Answer 57

cancer arising from melanocytes on epidermal basement membrane or from pre-existing nevus

Question 58

Incidence of cutaneous malignant melanoma

Answer 58

incidence 1/75 in canada

Question 59

Describe a method used for the determination of prognosis in cutaneous malignant melanoma.

Answer 59

T = Breslow depth, which is most important prognostic factor, especially for stage 1 and 2 Breslow depth = depth from stratum granulosum of epidermis to deepest point of invasion of melanoma cells larger Breslow depth = worse progonosis, where >1mm deep into dermis is a high risk for metastasis T staging also account for ulceration and mitotic index

Question 60

Management of craniofacial injury

Answer 60

consultation with dentistry, ophthalmology if indicated 1) re-establish normal occlusion, ensure normal eye function 2) restore stability of face and appearance (repair of soft tissue injury within 8 hours, repair of fracture can be within 5-10 days for swelling to decrease)

Question 61

Classification of craniofacial injury

Answer 61

craniofacial fracture based on bone affected: nasal, zygomatic, mandibular, maxillary frequency of fracture: nasal > zygomatic > mandibular > maxillary

Question 62

Nasal fracture treatment

Answer 62

if no complication, then no treatment if septal hematoma, drain to prevent septal necrosis with perforation if displaced fracture, then closed reduction with forceps under anesthesia and pack nostril with Adaptic and nasal splint for 7 days best window for reduction = immediately within 6 hours or when swelling subsides within 5-7 days if residual deformity post recovery, then rhinoplasty

Question 63

Naso-Orbital-Ethmoid Fracture classification

Answer 63

Markowitz-Manson Classification type 1 = single, central fragment, medial cantonal ligament intact type 2 = comminuted central fragment, medial canthal ligament intact type 3 = severely comminution of central fragment and disrupted medial canthal ligament

Question 64

Naso-Orbital-Ethmoid Fracture management

Answer 64

surgical repair to retore intercanthal distance, nasal projection and orbital anatomy

Question 65

Mandibular fracture classification

Answer 65

Classifications by anatomic region Symphysis - midline of the mandible, between the central incisors from the alveolar process through the inferior border of the mandible Body - from the symphysis to the distal alveolar border of the third molar Angle - triangular region between the anterior border of the masseter and the posterosuperior insertion of the masseter distal to the third molar Ramus - part of the mandible that extends posteriosuperiorly into the condylar and coronoid processes Condylar - area of condylar process of mandible Subcondylar - area below the condylar neck (ie sigmoid notch) of the mandible Coronoid process - area of the coronoid process of mandible

Question 66

Mandibular fracture treatment

Answer 66

maxillary and mandibular arch bars wired together or ORIF PO antibiotics to cover against S. aureus and anaerobes

Question 67

Maxillary fracture classification

Answer 67

Le Fort I (Guerin fracture): Horizontal Involves piriform aperture, maxillary sinus, pterygoid plates Anatomical result: maxillar divided into 2 segments Le Fort II (Pyramidal fracture): Pyramidal Involves nasal bones, medial orbital wall, maxillar, pterygoid plates Anatomical result: Maxillary teeth separated from face Le Fort III (Craniofacial dysjunction): Transverse Involves nasofrontal suture, zygomatofrontal suture, zygomatic arch, pterygoid plates Anatomical result: detach entire midfacial skeleton from cranial base

Question 68

Maxillary fracture treatment

Answer 68

ORIF in OR under general anesthesia Le Fort 1 fracture: mandibulo-maxillary fixation (MMF) Le Fort 2 fracture: disimpaction, MMF, sub-labial incision and exposure of maxillary bone and fracture lines for stabilization of maxilla to zygoma Le Fort 3 fracture: stabilize mobile segments of bone to stable mandible below and cranium above, disimpaction of maxilla and MMF

Question 69

Zygomatic fracture is associated with what type of fracture

Answer 69

orbital floor

Question 70

Zygomatic fracture classification

Answer 70

category 1 = fracture restricted to zygomatic arch category 2 = depressed fracture of zygomatic complex category 3 = unstable fracture of zygomatic complex (tetrapod fracture) with separation at axilla, frontal bone, temporal bone and orbital rim

Question 71

Zygomatic fracture treatment

Answer 71

undisplaced, stable and asymptomatic: soft diet, no treatment necessary uncomplicated zygomatic arch fracture: elevated using Fillies approach (leverage on anterior part of zygomatic arch via temporal incision) other fractures (especially displaced or unstable fracture): ORIF

Question 72

Orbital floor fracture is associated with what types of fractures

Answer 72

associated with nasoethmoid fracture, zygomatic fracture

Question 73

Orbital floor fracture treatment

Answer 73

ophthalmology consultation and evaluation indication for surgical repair: entrapment (extra-ocular muscle, orbit), floor defect >1cm, exophthalmos, persistent diploplia surgery = surgical reconstruction of orbital floor with bone graft or alloplastic material

Question 74

Superior orbital fissure syndrome treatment

Answer 74

operative reduction

Question 75

orbital apex syndrome treatment

Answer 75

treated with urgent decompression of fracture in optic canal or steroids

Question 76

Felon pathophysiology

Answer 76

Paronychia or puncture wound into pad of digit -> subcutaneous abscess in fingertip (digital pulp)

Question 77

Felon clinical presentation

Answer 77

inflammation of finger tip, tense swelling of finger tip (abscess)

Question 78

Felon treatment

Answer 78

incision & drainage PO antibiotics (Cloxacillin 500mg PO Q6H) elevation, warm soaks

Question 79

Tenosynovitis pathophysiology

Answer 79

Penetrating injury -> infection of flexor tendon sheath, which can lead to tendon necrosis and rupture if not treated

Question 80

Tenosynovitis clinical presentation

Answer 80

Kanavel’s 4 cardinal signs = 1. point tenderness along flexor tendon sheath 2. severe pain on passive extension of DIP 3. fusiform swelling of entire digit 4. flexed posture

Question 81

Tenosynovitis treatment

Answer 81

surgical emergency -> incision and drainage plus irrigation in OR IV antibiotics resting hand splint until infection resolves

Question 82

Deep Palmar Space infection pathophysiology

Answer 82

Infection of 3 deep closed spaces (thenar, midpalmar or hypothenar) space

Question 83

Deep Palmar Space infection clinical presentation for thenar space abscess

Answer 83

thenar space abscess: widely abducted thumb and fulness on dorm of first web space, with severe pain on adduction or opposition of thumb

Question 84

Deep Palmar Space infection clinical presentation for midpalmar space abscess

Answer 84

midpalmar space abscess: loss of normal palmar concavity, 3rd & 4th finger partially flexed posture, pain on passive extension of 3rd & 4th fingers

Question 85

Deep Palmar Space infection clinical presentation for hypothenar space infection

Answer 85

no involvement of fingers or flexor tendons

Question 86

Deep Palmar Space infection treatment

Answer 86

Surgical emergency I&D as well as debridement of closed space in OR IV antibiotics

Question 87

Deep Palmar Space infection clinical presentation

Answer 87

generalized palmar swelling and tenderness over anatomical involved palmar space, generalized dorsal swelling

Question 88

Herpetic Whitlow epidemiology

Answer 88

Associated with medical and dental personnel, children

Question 89

Herpetic Whitlow pathophysiology

Answer 89

infection of skin by Herpes Simplex Virus (HSV-1 or HSV-2)

Question 90

Herpetic Whitlow clinical presentation

Answer 90

fingertip painful vesicle on erythematous base may be associated with fever, malaise and lymphadenopathy

Question 91

Herpetic Whitlow investigation

Answer 91

culture for HSV

Question 92

Herpetic Whitlow treatment

Answer 92

viral prep protection to avoid infection consider oral anti-viral Acyclovir to facilitate healing

Question 93

Herpetic Whitlow treatment

Answer 93

viral prep protection to avoid infection consider oral anti-viral Acyclovir to facilitate healing

Question 94

Stenosing tenosynovitis pathophysiology

Answer 94

non-infectious inflammation of synovium causing size discrepancy between tendon and sheath / pulley

Question 95

Stenosing tenosynovitis etiology

Answer 95

idiopathic, associated with rheumatoid arthritis, diabetes, hypothyroidism, gout

Question 96

Stenosing tenosynovitis clinical presentation

Answer 96

most commonly affect thumb, 3rd and 4th finger catching, snapping or locking of affected finger tenderness to palpation and / or palpable nodule at palmar aspect of MCP over A1 pulley

Question 97

Stenosing tenosynovitis management

Answer 97

conservative management: NSAID, steroid injection surgical treatment: surgical flexor tendon release, incision of A1 flexor tendon pulley to permit unrestricted full active finger ROM

Question 98

Carpal tunnel syndrome epidemiology

Answer 98

Epidemiology 4 females : 1 male ratio most common entrapment neuropathy

Question 99

Carpal tunnel syndrome etiology

Answer 99

1) primary: idiopathic repetitive wrist flexion 2) secondary: space occupying lesion (tumour, hypertrophic synovial tissue, fracture callus, osteophyte) metabolic (pregnancy, hypothyroidism, acromegaly, rheumatoid arthritis) infection neuropathy (diabetes, alcoholism) familial disorder

Question 100

Carpal tunnel syndrome pathophysiology

Answer 100

compression of median nerve at level of flexor retinaculum

Question 101

Carpal tunnel syndrome clinical presentation

Answer 101

sensory loss in median nerve distribution: loss of discriminative touch, decreased light touch and 2 point discrimination especially at finger tips motor loss in advanced cases: wasting of thenar muscles classically, hand pain / numbness, relieved by shaking, dangling or rubbing Tinel’s sign: tingling sensation on percussion of nerve at wrist Phalen’s sign: wrist flexion induces symptoms

Question 102

Carpal tunnel syndrome diagnosis

Answer 102

clinical diagnosis nerve conduction studies can confirm diagnosis

Question 103

Carpal tunnel syndrome management

Answer 103

conservative management: avoid repetitive wrist & hand motion, wrist splints to keep wrist in neutral position when performing repetitive wrist motion and at night medical management: NSAID, local corticosteroid injection, oral corticosteroids surgical treatment: transverse carpal ligament incision to decompress median nerve

Question 104

Carpal tunnel indications for surgery

Answer 104

Numbness and tingling, sensory loss, weakness / muscle atrophy unresponsive to conservative measures

Question 105

Complications for surgery

Answer 105

injury to median nerve branches (median motor branch, palmar cutaneous branch) or superficial transverse vascular arch local pain scar formation

Question 106

Complications for surgery

Answer 106

injury to median nerve branches (median motor branch, palmar cutaneous branch) or superficial transverse vascular arch local pain scar formation

Question 107

Rheumatoid hand clinical presentation

Answer 107

Clinical Presentation early stage: erosion of ulnar styloid progression: symmetrical joint space narrowing and erosion of carpal bones, MCP and PIP, while sparing DIP on X-ray late stage: Swan neck, Boutonniere finger deformity, radial deviation at wrist, ulnar deviation at MCP

Question 108

Rheumatoid hand management

Answer 108

non-surgical treatment is the foundation of management of rheumatoid arthritis surgery: tendon repair of ruptured tendon in synovitis MCP arthroplasty resection of distal ulna soft tissue reconstruction for ulnar MCP deviation arthrodesis (surgical fixation of joint to promote bone fusion) in thumb deformity

Question 109

Rheumatoid hand indications for surgery

Answer 109

Patient’s goal of improving cosmesis or function (ROM) of hand that may be achievable with surgery

Question 110

Surgery for hand arthritis indications

Answer 110

Intractable pain unresponsive to medical management Gross deformity Very limited ROM that is disabling

Question 111

Surgery for hand arthritis surgical options

Answer 111

surgical options: arthrodesis or arthroplasty arthrodesis = fusion of bones within a joint, creating a stronger more stable and pain-free joint, but little flexibility or movement arthroplasty = removing damaged joint and inserting an artificial implant in its place, which relieve pain, restore shape of hand and restore some function of hand arthroplasty do not fully replicate normal finger motion and have risk of breaking and slipping, where >30% fail within 10 years

Question 112

Distal phalanx fracture epidemiology, mechanism, management

Answer 112

Epidemiology: most common fracture in hand Mechanism of injury: crush injury Management: decompression or subungual hematoma & removal of nail, 3 weeks of digital splinting

Question 113

Proximal and middle phalanx fracture assessment, treatment,

Answer 113

Assessment: assess for mal-alignment of fracture resulting in rotation, which cause scissoring (overlap of finger on making fist) and shortening of digit Treatment for undisplaced fracture: closed reduction, buddy tape to neighbouring stable digit, elevate hand, motion in guarded fashion 10-14 days post injury Treatment for displaced, non-reducible or not stable with closed reduction: percutaneous pins (K-wires) or ORIF, then splint

Question 114

Metacarpal fracture: Boxer's fracture definition, mechanism, clinical presentation, treatment

Answer 114

Boxer’s fracture = extra-articular fracture of 5th metacarpal usually with acute angulation of neck of metacarpal into palm mechanism: blow on distal dorsal aspect of closed fist clinical presentation: loss of prominence of metacarpal head, volar displacement of metacarpal head, may be mal-aligned (scissoring on making fist) treatment for slight angulated fracture (<40 degrees): closed reduction to decrease angle, then ulnar gutter splint for 3 weeks with PIP and DIP joints free treatment for non-reducible and displaced fracture: ORIF

Question 115

Metacarpal fracture: Boxer's fracture definition, mechanism, clinical presentation, treatment

Answer 115

Boxer’s fracture = extra-articular fracture of 5th metacarpal usually with acute angulation of neck of metacarpal into palm mechanism: blow on distal dorsal aspect of closed fist clinical presentation: loss of prominence of metacarpal head, volar displacement of metacarpal head, may be mal-aligned (scissoring on making fist) treatment for slight angulated fracture (<40 degrees): closed reduction to decrease angle, then ulnar gutter splint for 3 weeks with PIP and DIP joints free treatment for non-reducible and displaced fracture: ORIF

Question 116

Bennett's fracture definition, clinical presentation, treatment

Answer 116

Bennett’s fracture = intra-articular fracture of based of thumb metacarpal, inherently unstable clinical presentation: adduction of thumb due to abductor policies longus pulling metacarpal shaft proximally and radially treatment: percutaneous pinning, thumb spica cast for 6 weeks

Question 117

Rolando's fracture definition and treatment

Answer 117

Rolando’s fracture = intra-articular T or Y shaped fracture of base of thumb metacarpal treatment: ORIF with K wires

Question 118

Rolando's fracture definition and treatment

Answer 118

Rolando’s fracture = intra-articular T or Y shaped fracture of base of thumb metacarpal treatment: ORIF with K wire

Question 119

Hand fracture post op management

Answer 119

90% of hand fractures are stable in flexion (i.e. lock hand into function or safety position to prevent extension) to facilitate healing and maintain function post recovery immobilization by cast or splint should be in position of function or safety position of function (for splinting hand) = hand holding a pop can (wrist extension 15 degrees, MCP flexion 45 degrees, IP flexion, thumb abduction & rotation) contra-indication for position of function: post-repair of flexor tendon, median / ulnar nerve injury position of safety = wrist extension 45 degrees, MCP flexion 60 degrees, PIP and DIP in full extension, thumb abduction & opposition MCP flexion to maximize collateral ligament stretch, PIP & DIP extension to maximize volar plate origin stretch

Question 120

Immobilization complications

Answer 120

immobilization have complication of stiff, which should be prevented with early rehabilitation post removal of splint or cast

Question 121

Dislocation management timeline

Answer 121

dislocation of fingers must be reduced as soon as possible

Question 122

DIP and PIP dislocation what's more common, clinical presentation, management for closed dislocation and management for open injury

Answer 122

PIP dislocation more common than DIP dislocation clinical presentation: commonly dorsal dislocation from hyperextension closed dislocation: closed reduction -> splinting (PIP flexion 30 degrees and DIP full extension) or buddy taping with early mobilization to prevent stiffness open injury: wound case, open or closed reduction, PO antibiotics

Question 123

MCP dislocation clinical presentation, simple dislocation management, complex dislocation management

Answer 123

clinical presentation: dorsal dislocation more common from hyperextension, commonly index finger simple dislocation (reducible with manipulation): 2 weeks of splinting with MCP flexion 30 degrees complex dislocation (solar plate blocks reduction): open reduction + A1 pulley release -> extension blocking splint with MCP flexion at 30 degrees for 2 weeks then 10 degrees for 2 weeks

Question 124

Ulnar collateral ligament of thumb injury mechanism skier's thumb definition gamekeeper's thumb definition Stener lesion definition Clinical presentation Incomplete UCL tear management Stener's lesion management

Answer 124

mechanism: forced abduction of thumb skier’s thumb = acute UCL gamekeeper’s thumb = chronic UCL injury Stener lesion = complete UCL tear, where aponeurosis of adductor policies muscle is interposed between bones of MCP joint and torn ligament clinical presentation: instability of thumb MCP joint with pain and weakness of pinch grasp, radial deviation of thumb >30 degrees in full extension incomplete UCL tear: immobilization in thumb spica splint or modified wrist splint Stener’s lesion: open surgical repair of UCL