Plastics Flashcards
(124 cards)
1
Q
Categories of burns?
A
- Thermal (flame contact, scald)
- Chemical
- Radiation (UV, medical/therapeutic)
- Electrical
2
Q
Peds predominance in ______ injuries whereas adults is ______ injuries.
A
Peds predominance in scald and flame injuries whereas adults is flash and flame injuries.
3
Q
How to calculate burn size?
A
- % of TBSA burned: rule of 9s for 2nd and 3rd degree burns only (blister burns)
- Children <10 yr old use Lund-Browder chart)
- For patchy burns, surface area covered by patient’s palm (fingers closed) represents approximately 1% of TBSA
- Each arm is 9% of body coverage, legs are 18% each (9 for front/back), chest/back is 36%, head is 9%
4
Q
How to determine diagnosis and prognosis of burns?
A
- Burn size
- Depth: history of etiologic agent and time of exposure helpful
- Location
- Inhalation injury: can severely compromise respiratory system, affect fluid requirement estimation (underestimate), mortality secondary to ARDS
- Associated injuries (e.g. fractures)
5
Q
To what level does a 1st degree burn go to?
A
1st degree: epidermis
6
Q
To what level does a 2nd degree burn go to?
A
2nd degree: down to dermis.
7
Q
To what level do 3rd/4th degree (full thickness) degree burn go to?
A
3rd/4th degree (full thickness): beyond dermis into deep fascia/muscle. Cannot re-epithelialize.
8
Q
Signs and symptoms of 1st degree burn?
A
Painful, sensation intact, erythema, blanchable
9
Q
Signs and symptoms of 2nd degree burn?
A
Painful, sensation intact, erythema (deeper rad), blisters with clear fluid, blanchable (less blanching), hair follicles present
10
Q
Signs and symptoms of 3rd/4th degree (full thickness)?
A
- Insensate (nerve endings destroyed), hard leathery eschar that is black, grey, white, or cherry red in colour (Proteins denatured and don’t stretch); hairs do not stay attached, may see thrombosed veins
- High risk for infection, will need surgical excision and grafting.
11
Q
Indications for Transfer to Burn Centre
A
- Partial thickness burns >10% body surface area
- Partial thickness burns >20% TBSA in patients aged 10-50 yr old
- Partial thickness burns >10% TBSA in children aged >10 or adults aged >50yrold
- Full thickness burns >5% TBSA in patients of all ages
- Electrical burns, including lightning (internal injury underestimated by TBSA), and chemical burns
- Inhalation injury - Inhalation burns are responsible for 50% of all burn deaths! It doubles mortality and is present in 5-30% burn admissions and is associated with increased fluid need.
- Burns in sensitive areas (involving face, hands, feet, genitalia, perineum, or major joints).
12
Q
When is extra fluid administration required for burns?
A
- Burn >80% TBSA
- 4 degree burns
- Associated traumatic injury
- Electrical burn
- Inhalation injury
- Delayed start of resuscitation
- Pediatric burns
13
Q
What is the calculation for resuscitation using Parkland formula to restore plasma volume?
A
4 ml/kg x %TBSA (greater than first degree) x wt(kg) (1/2 within first 8 h of sustaining burn, 1/2 in next 16 h)
14
Q
How do you monitor fluid resuscitation for burns?
A
- Urine output is best measure: maintain at >0.5 cc/kg/h (adults) and 1.0 cc/kg/h in children <12 yr
- Maintain a clear sensorium, HR <120/min, MAP >70 mmHg
15
Q
When to preform an escharotomy?
A
- In circumferential extremity burn, including digits
- Do it if there is cyanosis, impaired capillary filling, neuro changes, loss of palpable or Doppler pulses, subeschar pressure >30mmHg.
16
Q
All patients with burns >10% TBSA, or deeper than superficial-partial thickness, need
A
0.5 cc tetanus toxoid
Also give 250 U of tetanus Ig if prior immunization is absent/unclear, or the last booster >10 yr ago
17
Q
Baseline laboratory studies for burns
A
Hb, U/A, BUN, CXR, electrolytes, Cr, glucose, CK, ECG, cross-match if traumatic injury, ABG, carboxyhemoglobin
18
Q
Treatment of first degree burns?
A
- Treatment aimed at comfort - cooling
- Topical creams (pain control, keep skin moist) ± aloe
- Oral NSAIDs (pain control)
19
Q
Treatment of superficial second degree/partial thickness burns?
A
- Daily dressing changes with topical antimicrobials (such as Polysporin, silver nitrate); leave blisters intact unless circulation impaired or over joint and inhibiting motion
20
Q
Treatment of deep second degree/deep partial thickness and third degree/full thickness burns?
A
- Prevent infection and sepsis (significant complication and cause of death in patients with burns)
- Topical antimicrobials
- Remove dead tissue - Surgically debride necrotic tissue, excise to viable (bleeding) tissue
21
Q
Most common organisms for deep second degree/deep partial thickness and third degree/full thickness burns?
A
Most common organisms: S. aureus, P. aeruginosa, and C. albicans
22
Q
The mainstay of treatment for deep/full thickness burns?
A
Early excision and grafting is the mainstay of treatment for deep/full thickness burns
23
Q
Prevention of wound contractures
A
Pressure dressings, joint splints, early physiotherapy
24
Q
What is skin graft harvesting – electric dermatome?
A
Usually take it from thicker skin with lots of epithelial appendages – they will heal within 7-10 days. Skin is meshed to cover the wound
25
TBSA >40% have BMR ____
2-2.5x predicted so consider nutritional supplementation e.g. calories, vitamin C, vitamin A, Ca2+, Zn2+, Fe2+
26
GI bleed may occur with burns >40% TBSA (usually subclinical), what is the treatment?
Treatment: tube feeding or NPO if there is a GI bleed, antacids, H2 blockers (preventative)
27
What should you ask on history for facial injuries?
- Breathe through both parts of your nose
- Trouble speaking – mandibular fracture
- Diplopia – Orbital fracture
- Facial paresthesias
- Malocclusion - mandibular fracture
- Vertigo – temporal bone fracture
28
Facial fractures that warrant urgent evaluation and admission include
- Nasoethmoid fractures, to monitor for cerebrospinal fluid (CSF) leaks and possible complications (eg, meningitis)
- Zygomatic arch fractures associated with trismus, to monitor for airway complications
- LeFort-type fractures of the midface, for surgical repair
- Facial fractures in patients with multiple significant injuries
29
Investigations for facial injuries?
CT (gold standard)
- Axial and coronal (specifically request 1.5 mm cuts): for fractures of upper and middle face, as well as mandible
- Indicated for significant head trauma, suspected facial fractures, and pre-operative assessment
30
Most common sites for mandibular fractures?
Commonly at sites of weakness (condylar neck, angle of mandible)
31
Clinical features of mandibular fractures?
- Pain, swelling, difficulty opening mouth ("trismus")
- Malocclusion, asymmetry of dental arch
- Damaged, loose, or lost teeth
- Palpable "step" along mandible
- Numbness in V3 distribution
- Intra-oral lacerations or hematoma (sublingual)
- Chin deviating toward side of a fractured condyle
32
Investigations for mandibular fractures?
Panorex radiograph: shows entire upper and lower jaw; best for isolated mandible fracture, but patient must be able to sit; however, if high clinical suspicion and negative panorex, CT should be done
33
Treatment for mandibular fractures?
- Maxillary and mandibular arch bars wired together (intramaxillary fixation) or ORIF ideally managed within 48 h as indicated by best current evidence
- Antibiotics from initial presentation until at least 3 doses post-operatively; if late presentation, may consider treatment with antibiotics for an extended course
34
What is a LeFort I injury?
LeFort I injuries involve a transverse fracture through the maxilla above the roots of the teeth.
35
What is a LeFort II injury?
LeFort II injuries are typically bilateral and involve fractures that extend superiorly in the midface to include the nasal bridge, maxilla, lacrimal bones, orbital floor, and rim. The fracture lines are shaped like a pyramid
36
What is a LeFort III injury?
LeFort III injuries (ie, craniofacial dissociation) involve fractures that result in discontinuity between the skull and the face. The fractures begin at the bridge of the nose and extend posteriorly along the medial wall of the orbit and the floor of the orbit, and then through the lateral orbital wall and the zygomatic arch
37
What is the "Tripod" fracture of the midface?
Involves the zygoma, lateral orbit, and the maxilla
38
Clinical features of nasal fractures?
Epistaxis/hemorrhage, deviation/flattening of nose, swelling, periorbital ecchymosis, tenderness over nasal dorsum, crepitus, septal hematoma, respiratory obstruction, subconjunctival hemorrhage
39
Treatment of nasal fractures?
- Treated for airway or cosmetic issues
- Always inspect for and drain septal hematoma as this is a cause of septal necrosis and perforation- completed in the ER with small incision in the septal mucosa followed by packing
- Closed reduction with Aschor Walsham forceps under anesthesia, pack nostrils with petroleum or nonadhesive gauze packing, nasal splint for 7 d
- Best reduction immediately (<6h) or when swelling subsides (5-7d)
- Rhinoplasty may be necessary later for residual deformity (30%)
40
What is orbital entrapment?
- Clinical diagnosis that is a surgical emergency
- Diplopia with straight gaze: unable to look up past neutral (entrapment of inferior rectus), limited EOM
- Severe pain or nausea and vomiting with upward globe movement
- Requires urgent ophthalmology evaluation if there are associated visual acuity changes
41
Investigations for orbital fractures?
- CT (diagnostic): axial and coronal views – with fine cuts through orbit; rounding of inferior rectus is a sign of orbital entrapment
- Diagnostic maneuver for entrapment is forced duction test (pulling on inferior rectus muscle with forceps to ensure full ROM) under local anesthesia in the OR
42
Clinical features of orbital fractures?
- Defects in visual fields, decreased visual acuity, injury to globe
- Periorbital edema and bruising, subconjunctival hemorrhage
- Ptosis, exophthalmos, exorbitism, enophthalmos, orhypoglobus
- Orbital rim step-offs with possible infraorbital nerve anesthesia
- Vertical dystopia (abnormal displacement of the entire orbital cone in the vertical plane) - assessed by comparing the symmetry of the two pupils by a horizontal line running through the pupil of the unaffected eye
- Orbital entrapment
43
Treatment of orbital fractures?
- Surgical repair indicated if: entrapment (urgent), any size defect with enophthalmos (if patient is bothered by it) or persistent diplopia (>10 d)
- Reconstruction of orbital floor with bone graft or alloplastic material
- After repair, assess for diplopia (may require additional surgery for strabismus)
44
Complications of orbital fractures?
- Persistent diplopia
| - Enophthalmos
45
Definition of primary healing (first intention)?
Definition: wound closure by direct approximation of edges within hours of wound creation (i.e. with sutures, staples, skin graft, etc.)
46
Indication of primary healing (first intention)?
Indication: recent (<6h, longer with facial wounds), clean wounds
47
Contraindications of primary healing (First Intention)?
Contraindications: Animal/human bites (except on face), crush injuries, infection, long time lapse since injury (>6-8 h), retained foreign body
48
What is an abrasion?
Abrasion: superficial skin layer is removed, variable depth
49
What is a laceration?
Laceration: sharply cut tissue
50
What is a contusion?
Contusion: injury caused by forceful blow to the skin and soft tissue; entire outer layer of skin intact, yet injured
51
What is an avulsion?
Avulsion: skin and soft tissue forcefully separated from deeper structures, potentially compromising blood supply or resulting in full detachment (amputation)
52
What is a puncture wound?
Puncture wounds: cutaneous opening relatively small as compared with depth (e.g.needle), including bite wounds
53
Definition of secondary healing/spontaneous healing (Second Intention)?
Definition: wound left open to heal spontaneously (epithelialization occurs at 1mm/d from wound margins in concentric pattern, contraction [myofibroblasts], and granulation) - maintained in inflammatory phase until wound closed; requires dressing changes; inferior cosmetic result
54
Indication of secondary healing/spontaneous healing (Second Intention)?
Indication: when primary closure not possible or indicated
55
Definition of tertiary healing/delayed primary healing (Third Intention)?
Definition: intentionally interrupt healing process (e.g. with packing, sharp debridement), then wound can be closed primarily at 4-10 d post-injury after granulation tissue has formed and there is <105 bacteria/gram of tissue
56
Indications for tertiary healing/delayed primary healing (Third Intention)?
Indication: contaminated (high bacterial count), long time lapse since initial injury, severe crush component with significant tissue devitalization, closure of fasciotomy wounds
57
Definition of hypertrophic scar?
Definition: scar remains roughly within boundaries of original scar
58
Clinical features of hypertrophic scar?
Red, raised, widened, frequently pruritic
59
Causes of keloid scar?
- Genetic factors (highest rates in African Americans, Asians)
- Endocrine factors
- Excess tension on wound or delayed closure (as in burn wounds)
60
Definition of keloid scar?
Definition: scar grows outside boundaries of original scar
61
Clinical features of hypertrophic scar?
Red, raised, widened, frequently pruritic
62
Treatment of keloid scar?
Multimodal therapy including: pressure garments, silicone gel sheeting, corticosteroid injection, surgical excision with post-surgical management if other options fail (however, there is a high chance of recurrence), fractional carbon dioxide ablative laser, radiation
63
Treatment of hypertrophic scar?
Scar massage, pressure garments, silicone gel sheeting, corticosteroid injection, surgical excision if other options fail (however, may still recur)
64
Clinical feature of spread scar?
Clinically, atypical spread scar is flat, wide, and of tendented
65
Treatment of spread scar?
Treatment: surgical excision and closure
66
What is a Marjolin's ulcer?
Marjolin's ulcer: squamous cell carcinoma arising in a chronic wound secondary to genetic changes caused by chronic inflammation - always consider biopsy of chronic wound
67
Definition of chronic wound?
Wound fails to achieve primary wound healing within 4-6wk
68
Treatment of chronic wound?
Treatment: may heal with meticulous wound care; may also require surgical intervention
69
4 categories of infected wound?
- Contamination
- Colonization
- Critical colonization
- Infection
70
Definition of contamination?
Contamination: the presence of non-replicating microorganisms within a wound
71
Definition of colonization?
Colonization: the presence of replicating microorganisms within a wound
72
Definition of critical colonization?
Critical colonization: increasing bacterial burden; have delayed healing but may not exhibit classic signs of infection
73
Definition of infection?
Infection: the presence of >105 microorganisms in a wound without intact epithelium or small amounts of a very virulent organism (e.g. GBS); have delayed healing and exhibit classic signs of infection
74
Management of acute contaminated wound (<24 h)?
Cleanse and irrigate open wound with physiologic solution (NS or RL) using sufficient pressure
Evaluate for injury to underlying structures (vessels, nerve, tendon, and bone)
Control active bleeding; previously closed wounds may require suture removal in order to drain any pus and allow for thorough irrigation and debridement
Debridement: removal of foreign material, devitalized tissue, old blood
Tetanus prophylaxis± post-exposure treatment of:
• hepatitis B, HIV, hepatitis C (if titres confirmed at 6 mo)
75
Risk factors for infection for acute contaminated wound include
Wound >8 h, severely contaminated, human/animal bites, immunocompromised, involvement of deeper structures (e.g. joints, fractures)
76
When to re-evaluate for an acute contaminated wound (<24 h) and what to do if signs of infection?
Re-evaluate in 24-48 h for signs of superficial or deep infection
* If evidence of infection (i.e. erythema, warmth, pain, discharge), open infected portion of wound by removing sutures, swab sample for culture and sensitivity, irrigate wound and allow healing by secondary intention
* Use systemic antibiotics if wound cultures are positive and there are signs of infection
77
Management of chronic contaminated wound (>24 h, including ulcers)?
- Tetanus prophylaxis
- Irrigation and debridement
- Systemic antibiotics if wound cultures are positive and there are signs of infection
- Closure: final closure via secondary intention (most common), delayed wound closure (3 closure), skin graft, or flap; successful closure depends on bacterial count of <105/cm3 prior to closure and frequent dressing changes
78
Most common pathogens for dog and cat bites?
Pasteurella multocida, S.aureus, S.viridans
79
Investigations for dog and cat bites?
- Radiographs prior to therapy to rule out foreign body (e.g. tooth) or fracture
- Culture for aerobic and anaerobic organisms, Gram stain
80
Healing by ____ intention is mainstay of treatment for dog and cat bites?
Secondary
81
Treatment for dog and cat bites?
- Clavulin* (amoxicillin + clavulanic acid) 500mg PO q8h started immediately
- Consider rabies prophylaxis if animal has symptoms of rabies or unknown animal
- Aggressive irrigation with debridement
- Only consider primary closure for bite wounds on the face; otherwise primary closure is contraindicated
- Contact Public Health if animal status unknown
82
Most common pathogens for human bites?
Pathogens: Staphylococcus > B-hemolytic Streptococcus > Eikenella corrodens > Bacteroides
83
Investigations for human bites?
- Radiographs prior to therapy to rule out foreign body (e.g. tooth) or fracture
- culture for aerobic and anaerobic organisms, Gram stain
84
Treatment for human bites?
- urgent surgical exploration of joint, drainage, and debridement of infected tissue
- wound must be copiously irrigated
- Clavulin* 500 mg PO q8h or (if penicillin allergy) clindamycin 300 mg PO q6h + ciprofloxacin 500 mg PO q12h + secondary closure
- splint
85
What is a Boutonniere deformity?
PIP in flexion, DIP hyperextended
86
What is mallet finger?
DIP held in flexion, inability to actively extend
87
What is a trigger finger?
Loss of smooth motion of PIP joint (catching, snapping, locking)
88
What is a swan neck deformity?
PIP hyperextended, DIP in flexion
89
What should be asked on history for hand/wrist injuries?
- Age, Hand dominance, Occupation
- Time and place of accident
- Mechanism of injury
- Initial treatment received
- Tetanus status
- PMHx: previous trauma to hand/wrist
- PSHx: previous hand/wrist surgery
- Social: DM, smoking status
90
Physical exam for hand/wrist injuries?
1. Inspection: posture/resting cascade of the hand - scissoring, SEADS, bony alignment, lacerations
2. Palpation:
- Vascular status (radial and ulnar arteries) - Palpate pulses, Allen’s test, assess capillary refill (<2-3 s), Doppler ultrasound
- Temperature and skin turgor
- Sensory: Median nerve, Ulnar nerve, Radial nerve, Digital nerves
- Motor: Median nerve, Ulnar nerve, Radial nerve
- Joints – palpate for bony deformities (mallet, boutonnière, and swan neck deformity), effusions, tenderness, assess pain with axial loading
- Ligaments – joint stability
3. ROM: Make fist, straighten out your fingers, any rotation, scissoring, decreased or abnormal flexion/extension, assess for pain against resisted flexion/extension
- Passive ROM if any abnormal movements on active ROM
- Tendons: FDP, FDS
91
How to test median nerve sensory?
Volar radial tip of index finger
92
How to test median nerve motor?
- Flex DIP of index finger (to test the anterior interosseus nerve (AIN) branch)
- Touch the tip of the index finger to the thumb trying to break through (“OK sign”) (to test the AIN branch)
- Thumb to ceiling with palm up (to test the recurrent motor branch)
- Thumb to tip of 5th digit (to test the recurrent motor branch)
93
How to test ulnar nerve sensory?
Volar ulnar tip of little finger
94
How to test ulnar nerve motor?
- Extrinsic muscles: flex DIP of little finger
- Intrinsic muscles: abduct index finger (“Peace sign”) or patient able to hold piece of paper between adducted thumb and index finger and resist pulling (“Froment’s sign”)
95
How to test radial nerve sensory?
Dorsal web space of the thumb
96
How to test radial nerve motor?
Extrinsic muscles: extend thumb (“thumb’s up”) and wrist
97
How to test FDS?
FDS - Stabilize non-exam fingers in extension (neutralizes FDP) and ask patient to flex examination finger (at PIP)
98
How to test FDP?
FDP - Stabilize PIP in extension, ask patient to flex fingers (at DIP)
99
How to test digital nerves sensory?
2 point discrimination on both the radial and ulnar side of the DIP creases (static or moving 2 point discrimination)
100
Management of nailbed injuries?
- Subungual hematomas >50% of the nail surface area need to be drained (trephination), done under a digital block by puncturing nail plate
- If suspecting greater severity of injury (e.g. distal phalanx displaced fracture, laceration of nail bed), remove nail plate to examine underlying nailbed under digital block anesthesia
- Irrigate wound and nail thoroughly
- Suture repair of nailbed with chromic suture
- Replace cleaned nail, which acts as a splint for any underlying distal phalangeal fracture and prevents adhesion formation between nail fold and nailbed
101
Definition of colles’ fracture?
Extra-articular transverse distal radius fracture (~2 cm proximal to the radiocarpal joint) with dorsal displacement ¬ ± ulnar styloid fracture
102
Most common fracture in those >40 yr, especially in women and those with osteoporotic bone
Colles’ fracture
103
MOA of Colles' fracture
FOOSH
104
Clinical features of Colles' fracture
- "dinner fork" deformity
| - swelling, ecchymosis, tenderness
105
Xray findings of Colles' fracture
- AP film: shortening, radial deviation, radial displacement
- Lateral film: dorsal displacement, volar angulation
106
Indications for direct surgical management of Colles’ fracture
- Displaced intra-articular fracture
- Comminuted
- Severe osteoporosis
- Dorsal angulation >5° or volar tilt >20°
- >5 mm radial shortening
107
Definition of Smith's fracture
Volar displacement of the distal radius (i.e. reverse Colles' fracture)
108
Non-operative treatment of Colles' fracture
- closed reduction (think opposite of the deformity)
- hematoma block (sterile prep and drape, local anesthetic injection directly into fracture site) or conscious sedation
- closed reduction: traction with extension (exaggerate injury); traction with ulnar deviation, pronation, flexion (of distal fragment - not at wrist)
- dorsal slab/below elbow cast for 5-6 wk
- obtain post-reduction films immediately; repeat reduction if necessary
- x-ray at 1 wk, 3 wk, and at cessation of immobilization to ensure reduction is maintained
109
Operative treatment of Colles' fracture
Percutaneous pinning, external fixation, or ORIF
110
The goal for Colles' fracture is to restore radial height (__), radial inclination (__), volar tilt (__), as well as DRUJ stability and useful forearm rotation
13mm
22
11
111
Operative indications for Colles' fracture
Failed closed reduction, or loss of reduction
112
MOA of Smith's fracture
Fall on to the back of the flexed hand
113
Treatment of Smith's fracture
- Usually unstable and needs ORIF
- If patient is poor operative candidate, may attempt non-operative treatment
o closed reduction with hematoma block (reduction opposite of Colles')
o long-arm cast in supination x 6 wk
114
MOA for scaphoid fracture?
FOOSH: impaction of scaphoid on distal radius, most commonly resulting in a transverse fracture through the waist (65%), distal (10%), or proximal (25%) scaphoid
115
Clinical features of scaphoid fracture?
- Pain with resisted pronation
- Tenderness in the anatomical "snuffbox", over scaphoid tubercle, and pain with long axis compression into scaphoid
- Usually nondisplaced
116
Investigations for scaphoid fracture?
- X-ray: AP, lateral, and scaphoid views with wrist extension and ulnar deviation
- ± CT or MRI: detect occult fracture and prevent AVN
117
Treatment of non-displaced scaphoid fracture?
Non-displaced (<1 mm displacement/<15 angulation): long-arm thumb spica cast x 4 wk, then short arm cast until radiographic evidence of healing is seen (2-3 mo)
118
Treatment of displaced scaphoid fracture?
Displaced: ORIF with headless/countersink compression screw is the mainstay treatment
119
Complications of scaphoid fracture?
- Most common: nonunion/malunion (use bone graft from iliac crest or distal radius with fixation to heal)
- AVN of the proximal fragment
- delayed union (recommend surgical fixation)
- scaphoid nonunion advanced collapse (SNAC) - chronic nonunion leading to advanced collapse and arthritis of wrist
120
Non-surgical treatment for carpal tunnel syndrome
Wrist splinting, NSAIDs, diuretics, intra carpal steroid injection.
121
Sensory clinical presentation of carpal tunnel syndrome
Burning in radial 3.5 digits palmar side – sparing the area over the thenar eminence. Median nerve gives off sensory branch before it goes under the carpal tunnel to supply the thenar eminence - So if you still have feeling at the thenar eminence - this is very suggestive of a wrist median nerve injury. If median nerve injury at the elbow, thenar eminence feeling will also be lost.
122
Motor clinical presentation of carpal tunnel syndrome
LOAF muscles
123
Special tests for carpal tunnel syndrome
Phalen’s (patient flexes their wrist for 60s and will experience paresthesias if +ve) and Tinel’s test (tap over median nerve in wrist to induce paresthesias in the distribution of the median nerve if +ve).
124
Surgical treatment for carpal tunnel syndrome
Carpal tunnel release – split the flexor retinaculum
