PL

Plastic Surgery
Ryan Austin, Imran Jivraj and Anthony So, chapter editors
Alaina Garbens and Modupe Oyewumi, associate editors
Adam Gladwish, EBM editor
Division of Plastic: and Reconrrtructive Surgery, Univenity of Toronto, staff editors

Basic Anatomy Review ................... 2

Skin
Hand
Brachial Plexus
Face
Differential Diagnoses of Common
Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DDx of Skin Lesions/Masses
Basic Surgical Techniques ................ 5
Sutures and Suturing
Excision
Wounds ............................... 6
Causal Conditions
Principles of Wound Healing
Contaminated and Infected Wounds
Dressings
Reconstruction

Hand ................................. 20
Traumatic Hand
General Management
Hand Infections
Amputations
Tendons
Fractures and Dislocations
Dupuytren's Disease
Carpal Tunnel Syndrome (CTS)
Rheumatoid Hand
Brachial Plexus ........................ 26
Common Palsies
Differential Diagnosis
Investigations
Management

Soft Tissue Infections ................... 12

Erysipelas
Cellulitis
Necrotizing Fasciitis

Craniofacial Injuries . . . . . . . . . . . . . . . . . . . . 26
Approach to Facial Injuries
Mandibular Fractures
Maxillary Fractures
Nasal Fractures
Nasa-orbital Ethmoid (NOE) Fractures
Zygomatic Fractures
Orbital Floor Fractures

Ulcen ... 13
Lower Limb Ulcers
Pressure Ulcers

Breast Surgery .. 31
Breast Reconstruction
Breast Tissue Expanders

Management of Skin Lesions ............ 14

Aesthetic Surgery ...................... 32

Aesthetic Procedures

Burns ................................ 15
Burn Injuries
Pathophysiology of Burn Wounds
Diagnosis and Prognosis
Indications for Transfer to Burn Centre
Acute Care of Burn Patients
Special Considerations

Toronto Notes 2011

Pediatric Plastic Surgery . . . . . . . . . . . . . . . . 33

Craniofacial Anomalies
Congenital Hand Anomalies
References . . . 35

Plastic Surgery PLI

1'oroDio

PL2 Pladic Surgery

2011

Basic Anatomy Review

Skin

F"11r 1. Split and Full (whala} Thiclmus SWn Grafts

Hand
BONES AND NERVES
't'

1.

C."llla11 MIMIDIIIC
(in order. pi'IIDnallhan d-.lrow; nadial
ID ul111r aidal
Some-Scaphoid
Lovera- Lunate

RadiUI

2. Scllllhoid
3. TnpaziiJII
4. T1111J8ZDid
5. Capiblbl

I. Ulna
7. Llllltll

Try- Triqlllllrum

Positions-Pisiform
ThBI-Trlplllilrn
Thay- Trapamid
Cannot- Cepillbl
Hard! - HanultB

8. Pilliorm

10. Hamalll
11. Mrtllearpll
boon

F"111ra Z. Carpal Ban.

Rgun1 3. Se1101J Disbiblltia1 in tile Hand

Toronto Notes 2011

Basic Anatomy Review

Plastic Snrgery PL3

TENDONS

.....

,,._, ___________

Flexor Tendons
All require OR repair.

DIP

Extensor Tendons
ER repair unless proximaVmultiple
tendons.

Flexor digitorum
profundus
] - Proximal
interphalangeal
joint

PIP
Extensor hood

Camper's chiasm

Figure 6. Testing Profundus (FDP)

Flexor digitorum
superficialis
Lumbrical
} - - Metacarpal
phalangeal joint

Interosseous
muscles

j
0::

Extensor
digitorum
communis

Figure 4. Flexor Tendon Insertion at PIP and DIP

Figure 5. Extensor Mechanism of Digits

"

.!!J
@

Figure 7. Testing Superficialis

(FDS)

Palmar
Flexor retinaculum - - - - ' " \ c
Median nerve - - - - . . .

Dorsal
Figure B. Carpal Tunnel

1. Extensor retinaculum
Compartment 1
2. Abductor pollicis longus
3. Extensor pollicis brevis
Compartment 2
4. Extensor carpi radialis brevis
5. Extensor carpi radialis longus
Compartment 3
6. Extensor pollicis longus
(EPL tendon passes around Lister's tubercle)
Compartment 4
7. Extensor digitorum
8. Extensor indicis
Compartment 5
9. Extensor digiti minimi
Compartment 6
10. Extensor carpi ulnaris

Figure 9. Extensor Compartments of the Wrist (dorsal view and cross-sectional view)

1'oroDio

PIA Pladic Surgery

Brachial Plexus

llnchmi'IDIIIIIIH..IIIB

Rob-Roots

Thomas- Trurb
llrink8- Divillicm
Cold-Cords
Ba1n-

Medial

MIMI$ of arm 111d fol'llllm

BIWICHES

CORDS

DMSIONS

lRUNIKS

Flg1re 10. Brachllll Plexus AnlhiiiY

Face

10

11. Skul and

fllcilll BCIIIas

I. IJicriiTllll bans
2. Zygomatic bona

&. Sphanaid bana

1. TempDI'III bana

3. MllCII1
4. Maidlle
S.Nalllbo"'

B. Pllrielll bone
8.
,o. Flunlal bo"'

2011

'IbroDlo Nota 2011

Di&reDiial Diapo&el of Common Prele:DlalioD&/k Surgical Techniques

Differential Diagnoses of Common

Presentations
DDx of Skin Lesions/Masses
For background information, see DermatDlo&f. D3

Basic Surgical Techniques

Sutures and Suturing
ANESTHESIA
inject anesthetic before final debridement and irrigation
lidocaine (Xylocame) epinephrine (vasoconstrictor, limits bleeding)
toxk limit and duration of action ( 1 cc of 1CJ6 solution contains 10 mg lidocaine):
without epinephrine: 5 mglkg.lasts 46-60 min
with epinephrine: 7 mg/kg, lasts 2-6 hours
slgn8 ofumctty: CNS excitation followed by CNS, respiratory, and cardiovascular depression
bupivicalne (Marcaine) epinephrine used fur longer analgesic effect
toxic limit and duration of action:
without epinephrine: 2 mglkg, lasts 2-4 hours
with epinephrine: 3 mglkg, lasts 3-7 hours
tmicity of mixtures (i.e. lidocaine + bupivicaine) is no greater than ita individual components

IRRIGATION AND DEBRIDEMENT

irrlgate copiously with a phy&iologic solution such as Ringer's lactate or normal saline to remove

surface clots, fureign material, and bacteria

debride all obviously devitaliud tissue. irregular or ragged wounds must be excised to produce
sharp wound edges that will assist healing when approximated
SUTURES
use of a particular suture IIlllterial is highly dependent on surgeon preference
suture IIlllterial divided by two categories:
absorbable vs. non-absorbable:
absorbable materials commonly used fur deep sutures under short-term tension
- also used fur akin closure in children or uncooperative adults
- lose at least 5096 of their strength in 4 weeks and are eventually absorbed
- aamples include Plain gut", Vlcryl, Polysorb
non-absorbable materials commonly used fur skin clorure or in sites oflong term tension
- lower li.kelibood of wound dehiscence
- examples include nylon, polypropylene, stainlell5 steel
monofilament VII. mult:ifil.ament (a.k.a twisted or bmided)
monofilament sutures slide through tissue with less friction but have more memory/
stiffness
- used in contaminated and infected wounds
-lower likelihood ofbacterial trapping in suture material
- examples include Monosof", Monocryi, Biosyn"
multifilament sutures have less memory/rtift'ness making them easier to work with
- increased lilcelihood of bacterial trapping, should be avoided in contaminated wounds
- includes Vicryi and Silk
BASIC SUTURING TECHNIQUES
Basic SUb.lre Methods (F.Igure 12)
simple interrupted- can be used in almost all situations
intra-cutl.cula.r - good cosmetl.c result but weak. used in combination with deep IJUture8
vert1cal mattress- for areas diffi.cul.t to evert (e.g. dorsum of the hand)
horizontal matt.rell5 - everting, time saving
continuous over and over (a.k.a "running", "bueball stitch") - time slrving. good fur hemostasis

Plaalk Surgery PLS

Balle Suqkal Techniques/WoundJ

PL6 Pladic Surgery

1'oroDio 2011

Basie Principles
minimize tissue traUDlll! fullow curve of needle, handle wound edges gently (UBe toothed
forceps), use just enough tension to appr<Wmate edges (do not st:rangula.te)
use the finest needle and ruture pOSiii.ble
to ensure good cosmesis

'.

Other Skin Closure Materials

tapes - may be indicated for superficial wounds and those with opposable edges. Thpe cannot be
u&ed on actively bleeding wounds. When placed across the lndsion, will prevent surface marks
and can be used primarily or after surface sutures have been removed.. Tape bums may occur if
there is excessive tension or swelling around the incision

Grey regio1111 indicale areu

of llkin to be ercieed

Figure 13. lnclllo of l.8donl

Aloll Relaxed Sldn Te...on Unea

.. ,

evert skin edges when closing

avoid tensl.on on skin (close in layers)
ensure equal width and depth of tissue on both sides
remove sutures within 7-10 days (5 days for the face)

skin adhealves - e.g. 2-octylcyanoacrylate (e.g. Dermabond-> works well on small areas without
much tension or shearing. Advisable in children. May tattooing
staples - steel-titanium ailoy5 that incite minimal tissue reaction (healing is comparable to
wounds closed by suture)

IIIIU811 &ldn TIMIDn Llnll

NaturallkWwrinkle lin11 with mininal

Excision

linwta1111iD11. inciliplllllalto IISTI.s minimizes widanllgl

l!wlllrlru!lhY, and helps to I*!IDulllllll

IC81'1.

incise along relaxed skin tension lines (RSTLs) to minimize appearance of scar
use elliptical Incision to prevent ..dog eat(' (heaped up skin at end of Incision)
ifneeded, undermine skin edges to deaeaae wound tension
use layered closure Including dermal sutures when wound Is deeper than superficial (decreases

tension)

Wounds
Causal Conditions

'.

,

laceration - cut or torn tissue

abl'll8ian - superficial skin layer is removed. variable depth
cootuaion - injury by forceful blow to the skin and soft tissue; entire outer layer ofskin
intact yet injured
avulsion - tlssue/Umb forcefully separated from surrounding tissue, either partially or fully;
"de-gloving"
puncture wounds- opening relatively small as compared with depth (e.g. needle)
includes bite wounds
crush injuries - caused by compression
thermal and chemiall wounds

Myofibrobluts are the cals rasp-1118

far wound conlnlction. Thev dD this Ita
1111e Df 11111 than o.75 IMV'dev.

Principles of Wound Healing

wound: disruption of the normal anatomical relationships of tissue as a result of injury
STAGES OF WOUND HEAUNG
see Figure 14
growth factors released by tissues play an important role

FACTORS INFWENCING WOUND HEALING

Local (revenlble/controllable):
General {often .lrrevenible):
mechaniall (local trauma, tension)
age
blood supply (ischemia/circulation)
temperature

tedml.que and suture materials

retained furelgn body
infection
hematoma/seroma (1' infection rate)

venous hypertension
peripheral vaacular disease

nutrition (protein. vit C,

smoking
cbronic Illness (e.g. diabetes, cancer, CVD)
lmmuno9t1ppresslon (steroids, chemo, radiation)

collagen vascular disease

tissue irradiation

Toronto Notes 2011

Wounda

__________

_
________P_RO_C_EU
________
1. lnflllmm.taiJ Phullleactivl} pJ..p 1-6}
Limits damage, prsyants further injury
Debris and organisms deared viii inflammlllllry respDnse:
Nautrophils {24--48 hours)
Macro phages: critical to wound heeling by
orchestrating growth factors for collagen production
{4S-96 hours)
Lymphocytes: role poorly defined {5 7 days)

Z. Pralfllrwtin ""- {hgan1r.tiVII) (Day 4 - W.ak 3)

Fibroblasts <tnncted and aclivlted by macrophage
growth lilctors
process: re-epithelialisalion, mlltriK synthesis,
angiogenesis {relieves ischemia)
Tensile strength begins to increase at days 4-5

Hz.

1. Hemostasis- vasoconstriction + PLT plug

ChemDIIXis- migration of mecrophages and PMN

.....

1. Collagen synthesis (mainly typa Ill)

Z. Angiogenesis
3. Epithelialillllion

r-

1. Contraction
Z. Scarring
3. Remodeling of scar

Plastic Surgery PL7

I. llemadeling Phala (MIItwatian) (Week 1- 1 ytNir)

Increasing collagen organization and stronger crosslinka
Typal collagen replaces Type Ill until normal4:1
ratio achiiMid
Peak tensile strength at 60 days- 811% of preinjury
strength

Figure 14. Stages of Wound Helling

ABNORMAL HEALING

Hypertrophic Scar
scar remains roughly within boundaries of original injury
red, raised, widened, frequently pruritic
common sites: back, shoulder, sternum
treatment: pressure garments, silicone gel sheeting, corticosteroid injection, surgical excision if
other options fail (however, may still recur), typically improves with time
Keloid Scar
scar extends beyond boundaries of original injury
frequently pruritic, often painful; collagen in whorls rather than bundles
common sites: sternum, deltoid, earlobe; more common in darker skinned people
treatment: pressure garments, silicone gel sheeting, corticosteroid injection, radiation therapy,
surgical excision as a last resort
Chronic Wound
fails to heal primarily within 6 weeks
common chronic wounds include diabetic, pressure and venous stasis ulcers
treatment: may heal with meticulous wound care; many require surgical intervention
Marjolin's ulcer: squamous cell carcinoma arising in a chronic wound secondary to genetic
changes caused by chronic inflammation -+ consider biopsy of chronic wound
WOUND CLOSURE

Primary (1) Closure (First Intention}

definition: wound closure by direct approximation of edges within hours of wound creation (i.e.
with sutures, staples, skin graft, etc.)
indication: recent (<6 hours, longer with facial wounds), clean wounds
contraindications: animal/human bites (except on face), crush injuries, infection, longtime
lapse since injury (>6-8 hours), retained foreign body
Secondary (2} Closure/Spontaneous Healing (Second Intention)
definition: wound left open to heal spontaneously (epithelialization 1 mmlday from wound
margins in concentric pattern), contraction (myofibroblasts) and granulation- maintained in
inflammatory phase until wound closed; requires dressing changes; inferior cosmetic result
indication: when 1 closure not possible or indicated (see Primary Closure, above)

PL8 Plastic Surgery

Wounds

Toronto Notes 2011

Tertiary {3) Closure/Delayed Primary Closure {Third Intention)

definition: intentionally interrupt healing process (e.g. with packing), then wound is usually
closed at 4-10 days post-injury after granulation tissue has formed and there is <105 bacteria/
gram of tissue
indication: contaminated (high bacterial count), long time lapse since initial injury, severe crush
component with significant tissue devitalization
prolongation of inflammatory phase decreases bacterial count and lessens chance of infection
after closure

Contaminated and Infected Wounds

Definitions
contamination - the presence of non-replicating microorganisms within a wound
colonization - the presence of replicating microorganisms within a wound
infection - greater than 105 microorganisms in a wound without intact epithelium, a wound
may also be infected with small amounts of a very virulent organism (e.g. GBS)

....

Infection is based on:

1. V"rrulence of the infecting
microorganism
2. Amowrt of bac:terill prvli8nt
3. Host resistance

Acute Contaminated Wound (<24 hr)

cleanse and irrigate open wound with physiologic solution (NS or RL)
debridement: removal of foreign material, devitalized tissue, old blood
surgical debridement: blade and irrigation if indicated
evaluate for injury to underlying structures (vessels, nerve, tendon and bone)
control active bleeding
systemic antibiotics are commonly indicated for obvious infection, wound older than 8 hours,
severely contaminated, immunocompromised, involvement of deeper structures (e.g. joints,
fractures)
tetanus toxoid (Td) 0.5 ml 1M tetanus immunoglobulin 250 U deep 1M (see Table 1 and
Table2)
postexposure treatment of
hepatitis B, HIV, (hepatitis C iftitres confirmed at 6 months)
re-evaluate in 24-48 hours for signs of deep infection
open infected portion of wound by removing sutures if evidence of infection (ie. erythema,
warmth, pain, discharge)
Table 1. Risks for Tetanus
Tlllnui-Prone

Not TlltlnuH'rone

lime since injury

>6h

<6h

Depth of injury

>1 em

<1 em

Mechanilll1l of Injury

Crush. bum. gun&hDt. frostbite, puncture

Sharp cut (e.g. clean knifa, cleen glm)

Present

Not present

1ilough clathilg, farming injury

Devitalized tissue

Contammon (e.g. soil, drt, taliva,

No

No

grass)
Retained ftreign body

Table Z. Tetanus Immunization Racommendations

Histurv af tetanus illnunizalian

All lither wounds

Clean, 11inar wounds

Td orTdiP
Uncertain or <3 doses of i11111'1JJ1ization

Yes

No

3 doses received in immunization series

No-

No

No

0.511'1 Dfcanminadlltl11111nd diptlwia lllxllids acalllpartullis.

.. Telmls irmmeglai!Uin, 250 Ugi'llllah lili!lll'lllsitelrorn T4'Jdrp

- V.. >10yan linea lntllclom'

Tig
Yes
Nof

f Ya-. inrnUI1DCDII1prinil8d.

5yean Iince lastboastlit

Contaminated Wounds (>24 hours. including ulcers)

irrigation and debridement
traumatic tattooing can occur if foreign materials left in wound
topical antimicrobial- avoid inhibitors of epithelialization (see Table 3)
systemic antibiotics indicated if there is concern of infection (eg. redness, swelling, pain,
clinically unwell)
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 prior to
closure and frequent dressing changes

Toronto Notes 2011

Plastic Surgery PL9

Wounda

BITES
Dog and Cat Bites
pathogens: PasteureUa multocida, S. aureus, S. viridans
investigations: same as for human bites; see below
treatment: Clavulin (500 mg PO q8h started immediately- amoxicillin + clavulinic acid)
consider rabies prophylaxis if animal has symptoms ofrabies or unknown animal
rabies Ig {20 IU/kg around wound, or IM) and 1 of the 3 types of rabies vaccines
(1.0 ml 1M in deltoid, repeat on days 3, 7, 14, 28)
agressive irrigation with debridement
healing by second intention is mainstay of treatment (see Emergency Medicine, ER47)
only consider primary closure for bite wounds on the face; otherwise primary closure is
contraindicated
contact Public Health if animal status unknown
Human Bites
pathogens: Staph> a-hemolytic Strep > Eikenella corrodens >Bacteroides)
mechanism: most commonly over dorsum of MCP from a punch in mouth; "fight-bite
serious, as mouth has microorganisms/mi., which get trapped in joint space when fist
unclenches and overlying skin forms an air-tight covering ideal for anaerobic growth- can lead
to septic arthritis
investigations:
radiographs prior to therapy to rule out foreign body (tooth)/fracture
culture for aerobic and anaerobic organisms, Gram stain
treatment:
urgent surgical exploration ofjoint, drainage and debridement of infected tissue
wound must be copiously irrigated
Clavulin 500 mg PO q8h, clindamycin 300 mg PO q6h + ciprofloxacin 500 mg PO q12h
(if allergic to penicillin) + secondary closure (see Emergency Medicine. ER47)
splint

Dressings
there is no one dressing for any given type of wound. Dressing selection depends on the
wound characteristics
as the wound progresses through healing it will require different types of dressings, therefore,
routine inspection is recommended
principles of dressings:
wet vs. dry wounds
- purpose of dressings should be to keep wound appropriately moist (i.e. moistening
dry wounds or removing excess exudate/blood from wet wounds)
- dry wounds -+ options include films and hydrogel dressings; require secondary dressing
- light to moderately exudative -+ options include hydrocolloid dressing and hypertonic
saline gauze
- highly exudative -+ options include hydrofibre dressings, foam dressing , and
hypertonic saline gauze
- bleeding wounds-+ options include alginate dressings, as they have hemostatic properties
clean vs. infected wounds
- clean wounds can be dressed with petroleum based gauze, which is non-adhering to
epithelializing tissue; requires secondary dressing
- infected wounds can be dressed with iodine gauze or silver-containing dressings
wide-based vs. cavitary/tunneling wounds
- cavitary or tunnelling wounds (ie. through a fascial layer) can be packed with salinesoaked (non-infected), betadine-soaked (infected) ribbon gauze, or other easily
retrievable one-piece moisture providing dressing

Reconstruction
SKIN GRAFTS
Definition
a segment of skin detached from its blood supply at the donor site and dependent on
revascularization from the recipient site
Donor Site Selection
must consider size, hair pattern, texture, thickness of skin, and colour (facial grafts best iftaken
from "blush zones" above clavicle e.g. pre/post auricular or neck)
partial thickness grafts usually taken from inconspicuous areas (e.g. buttocks, lateral thighs, etc.)

... , ,

Elwnplp of Dr...inp
Films (Opsita8 )

(lnlnlsitl8 ,

Nui!1118 ,

Ouaderm}
Hychfib11s (Aquacal)
Hyd-ocolloid {Duoderm 8 , Teglderm 8 )
Hyper1Dnic saline gauza (Masa!t8}
FOIUTI (Mepilex4', Allavyn 8 }
Alginates (Sorb68n8 , Kalmmrt8)
Peboleum basad gauze
Silver dressings

Iodine (lodolorb8 ]

..... ,

lleeonsln1c:tion l.addtr
SICOnduy closu11
Primary cl0111n1
Skin graft

Locallllp

fliiP
Free tissue 1nlnsfer

PLIO Plastic Surgery

Wounds

Toronto Notes 2011

Partial Thickness Skin Graft Survival

3 phases of skin graft "take"
1. plasmatic imbibition - diffusion of nutrition from recipient site (first 48 hours)
2. inosculation- vessels in graft connect with those in recipient bed (day 2-3)
3. neovascular ingrowth - graft revascularized (day 3-5)
requirements for survival
bed: well-vascularized (unsuitable: bone, tendon, heavily irradiated, infected wounds, etc.)
contact between graft and recipient bed: fully immobile {decreased shearing and hematoma
formation)
staples, sutures, splinting, and appropriate dressings (pressure) are used to prevent
movement of graft and hematoma or seroma formation
site: low bacterial count (<105, to prevent infection)
Classification of Skin Grafts
1. by species
autograft: from same individual
allograft (homograft): from same species, different individual
xenograft (heterograft): from different species (e.g. porcine)
2. by thickness: (Table 3)
T1ble 3. Skin Grafts
Dillinilion

Split Thickness Skin Grift [mG]

Ful Thickness Skillhft [FTSG]

Epidermis and part of dennis

Epidennis and all of deanis

Limited donor sites (full thickness skin loss, ITIJst be

closed 1" or with STSG)

via dermal appendages in

graft and wound edges

Primary closure or thickness skin graft

..... ,

Hlilg af DilliN" Sill

Ro-hlnatig

-10 days (faster tr1 scalp)

NIA

Gnft Cantraction

Grift Tale

Easier; shorter nutrient diffusion dista1ce

Lower rate of suiVival(thiclcer, sloww vascularization)

upon h11Mr1ing
Secoodary- reduction in 5ize once graft
placed on wound bad

Contraction

Less 1 contraction, greater 7!' contraction

(less with thicbr IJ8ft)

Greater 1 contraction. less 2 contraction

Aesthetic

Poor

Good

Comments

Can be meshed for greater area (see below]

Allow& for extrava&ation of bloD<VslliUIIl

May use on face and fingers

Takes well illess favourable con<itions, can

cover alargar araa

Resists contraction, texture/pigment more nonnal

..

Primary- immediate reduction in size

Contracts sipcantly, abnonnal pigmantation. Requires well vascularized bad

high &uscsptibility to trawna
Must remow fat from IJlit bafore application
Large areas of skin. granulating tissue beds

Uses

Face (colour match), where thick skin or decreased

contracture is dasirad (a.g.fingar)

mesh graft
advantages
prevents accumulation of fluids (e.g. hematoma, seroma)
covers a larger area
best for contaminated recipient site
disadvantages
poor cosmesis {"alligator hide" appearance)
has significant contracture&
common reasons for graft loss: hematoma/seroma, infection, mechanical force (e.g. shearing,
pressure)

OTHER GRAFTS
T1bla 4. Various Tissua Grlfts

Grift Type

u.

Bone

Repair rigid defects

Cranial, rib, iliac, fibula

Cartilage

Restore contour of ear and nose

Ear, nasal septum, costal carliage

Tendon

Repair damaged tendon

Palmaris longus, plantaris

Sural, antebrachial cutaneous, medial brachial cutaneous

Prmrn=d o-r SitB

Nerve

for

Vessel

Bridge vascular gaps

regeneration across nerve gap

Foreann or foot vessels for small vessels, saphenous vein for

larger vessels

Deanis

Ctrltour restoration I:!: fat for bulk)

Thick skin of buttock or abdomen

Fat

Ctrltour restoration

Abdomen, IIIP{ area with fat available

Toronto Notes 2011

Wounds

Plastic Surgery PLll

FLAPS
definition: tissue transferred from one site to another with vascular supply (pedicle) intact (not
dependent on neovascularization, unlike a graft)
may consist of: skin, subcutaneous tissue, fascia, muscle, bone, other tissue (e.g. omentum)
classification: based on blood supply to skin (random, axial) and anatomic location (local,
regional, distant)
indications for flaps
reconstruction - replaces tissue loss due to trauma or surgery
provides skin and temporary soft tissue coverage through which surgery can be carried out
later
improves blood supply to poorly vascularized bed (e.g. bone)
main complication: flap loss due to vascular thrombosis (in free flaps), flap necrosis caused
by extrinsic compression (dressing too tight) or excess tension on wound closure, hematoma,
seroma, infection, fat necrosis, poor flap design
Random Pattern Flaps (Figure IS)
blood supply by dermal and subdermal plexus to skin and subdermal tissue with random
vascular supply
limited length:width ratio to ensure adequate blood supply (typically 2:1)
flap choice is often a combination of available tissue and surgeon preference
types
rotation: cover wounds of various sizes; common use: sacral pressure sores
transposition
Z-plasty: used to reorient a scar, lengthen the line of a scar or to break up a scar
advancement flaps (single/bipedicle, V-Y, Y-V)
V-Y flaps: wounds with lax surrounding tissue; the pedicle is the deep tissue underlying
the flap

...
Rotation Flap

Z-plasty

Rhomboid Transposition Flap (Umberg)

Single Pedicle Advancement Flap

"'
"'
"'

V-Y Advancement Flap

Figure 15. Wound Care Flaps - Random Pattern

Axial Pattern Flaps (Arterialized)

flap contains a well defined artery and vein
allows greater length: width ratio (S-6: 1)
types
peninsular flap- skin and vessel intact in pedicle (see Figure 16)
island flap - vessel intact, pedicle is better defined (see Figure 17)
free flap - vascular supply anastomosed at recipient site by microsurgical techniques
can be sub-classified according to tissue content of flap:
e.g. musculocutaneous/myocutaneous [e.g. Transverse Rectus Abdominal Myocutaneous
(TRAM)] vs. fasciocutaneous
Free Flaps
transplanting expendable donor tissue from one part of the body to another by isolating and
dividing a dominant artery and veins to a flap and performing a microscopic anastomosis
between these and the vessels in the recipient wound
survival rates >95%
types: muscle and skin (common), bone, jejunum, omentum
e.g. radial forearm, scapular, latissimus dorsi

Figure 16. Peninsular Axial Pattern

Flap
/ ;

. ;

Figure 17. Island Axial Pattern
Flap

Wounds/Soft TIBSue Infections

PL12 Plastic Surgery

Toronto Notes 2011

Teble 5. Free Rep Cherecteristics

c..ractBrillic

Nonnll

Arllnialllllllllic:ianc:y

Colour

Pilk

Pale

Purple or blue

T-..l'llln

Wa-rn

Cool

Wa-rn or cool

Arlllrill Pulll (Doppler}

::!:

::!:

T11111or

SDit, but with tissue turgor

Decreased

Increased (i.e. tensel

Soft Tissue Infections

Erysipelas
Definition
acute skin infection that is more superficial than cellulitis
Etiology
typically caused by Group A Streptococcus (GABHS)

Clinical Features
intense erythema, induration, and sharply demarcated borders (differentiates it from other
skin infections)

Treatment
penicillin or first generation cephalosporin (e.g. cefazolin or cephalexin)

Table 6. Classification of Soft Tissue Infections by Depth

Erysipal

Superficial subcutaneous tissue ilvolvement

Calulitis

Full thickness with subcutaneous tissue iwolvement

flsciilil

Fascia

Myasitis

Muscle

Cellulitis
Definition

....

Clllulilia n. E,.,.._lu
Cellulitis: indistinct bordm
Ery$ipelal: lhlllp borde!'$

non-suppurative infection of skin and subcutaneous tissues

Etiology
skin flora most common organisms: S. aureus,
immunocompromised: Gram-negative rods and fungi

Streptococcus

Clinical Features
source of infection
trauma, recent surgery
PVD, diabetes - cracked skin in feet/toes
foreign bodies (IV; orthopaedic pins)
systemic symptoms (fever, chills, malaise)
pain, tenderness, edema, erythema with poorly defined margins, regional lymphadenopathy
can lead to ascending lymphangitis (visible red streaking in skin proximal to area of cellulitis)

Investigations
CBC, blood cultures
culture and Gram stain wound/aspirate from wound if open wound
plain radiographs if suspect foreign body or abscess
r/o bone invasion (osteomyelitis)

Treatment
antibiotics: first line - cephalexin 500 mg PO q6h or diclioxacillin 500 mg PO q6h x 7 days if
complicated (e.g. lymphangitis, DM) consider IV cefamlin 1-2 g q8h
outline area of erythema to monitor success oftreatment
immobilize and splint (hands)

Plastic Surgery PL13

Soft Tissue InfectionsJIDcers

Toronto Notes 2011

Necrotizing Fasciitis
Definition
rapidly spreading, very painful infection of the deep fascia with necrosis of tissues
some bacteria create gas that can be felt as crepitus and be seen on x-rays
infection spreads rapidly along deep fascial plane and is limb aud life threatening

Etiology
Type 1: P-hemolytic Streptococcus
Type II: polymicrobial (less aggressive)

.... '

j
.----------------.

.

Soft tlun lnt.ctic11: Su&pae:t

nacrotizi'lg fllsciitis with rapidly
sp11111ding erythema and edema. Mpllt
dmwcllteltylhematousarw on
admission in order to determine amount
of spread/rapidity of spread.

Clinical Features
pain out of proportion to clinical findings and beyond border of erythema, edema,
tenderness, crepitus (subcutaneous gas from anaerobes) fever
infection spreads very rapidly
patients may look deceptively well at first, but may rapidly become very sick/toxic
late findings:
skin turns dusky blue and black (secondary to thrombosis and necrosis)
induration, formation of bullae
cutaneous gangrene, subcutaneous emphysema
Investigations
a clinical diagnosis
CT scan only if suspect it is not necrotizing fasciitis (looking for abscess, myonecrosis, etc.)
severely elevated CK: usually means myonecrosis (late sign)
hemostat easily passed along fascial plane; fascial biopsy in equivocal situations

Treatment
rigorous resuscitation
multiple surgical debridements: remove all necrotic tissue, copious irrigation
IV antibiotics: as appropriate for clinical scenario; consider penicillin 4 million IU IV q4h
or clindamycin 900 mg IV q6h
urgent consultation with infectious disease specialist is recommended

Ulcers
Lower Limb Ulcers
Traumatic Ulcers (Acute)
failure oflesions to heal, usually due to compromised blood supply and unstable scar
usually over bony prominence, edema, pigmentation changes, pain
treatment: debridement of ulcer and compromised tissue, reconstruction with local or distant
flap, vascular status of limb must be assessed either clinically or radiographically

Non-Traumatic Ulcers (Chronic)

Table 7. Venous vs. Arterial vs. Diabetic Ulcers
Diabetic
Cause

Hislllry

Valvular incompmce
Venous HlN

2" to smaii111!Vor large vessel

disease
Be IIWllre of risk factors

Dapandant edema, 1nluma

Arteriosclerosis, daudication
Rapid onset throrrtophlebitis, Usually > 45 ya111

Slow progression

Peripheral neurapa1hy: decreased

sensation

Atherosclerosis: decreased regional

blood flow
Diabetes mellitus
Peripheral n8Uillpll1hy

Distribution

Medial malleolus

Distal locations

Pressure point distribution

Appiii'IRCI

Yellow exudates
GranulatiDn tissue

Pale/white, necrotic base ty

eschar cowring

Necrotic base

Wound Margins

Irregular

Ewn ("punched out")

Irregular or"punched out" or deep

Depth

Superficial

Deep

Superficial/deep

Sunuunding Skin

VenDUs stasis discolouration

(llrDMI)

Thin shiny dry skin,

cool

Thin dry ski! hyperkeratotic border

'

....

Anlde-brachill index IABl) in

diabetics can be falsely nonnll due to
incompressible arteries secondary to
plaq1181/calcificlllion.

'

....

All ch1'1)11ic; ulce,. requinl VBSCullllr
lludia Ifill a VIISCI.IIIIIr consult.

PL14 Plastic Surgery

tncers/Manasement of Skin Lesion

Tabla 7. Venous VI. Arterial

c..ractBrillic

VI.

Diabetic Ulcers (continuedl

v-UI (70"4 vuc:ulllr ulcarl)

Arllrill

Dillllltic

No111111l distal pulses

Decreased distal pulses

Decreased pulses likEly

ABI >0.9

ABI <0.9

ABI is ligh
Usually associated with arterial
disease

Doppler; abnonnal VIIIOUI system Pallor on elevation. rubor on

dependency
Delayed venous filling

Pain

TI'IBimlllt

Toronto Notes 2011

Moderately painful
lnCI'I!ISed with leg dependency,
decreased with elevation
No rest pain

Exttemely painful
Decreased with dependency,
increased with lag elevation and
8X8rt:ise (claudication)
Rest pain

Painless
No claudcation or rest pain

Lag eiiMilion, l8lt

CCJ11R5Sion at 30 rrmHg
(stockings or elastic bandages)
Moist wound dressings
topicaL systamic antibiotics
skin grafts

Rsst. no aiiiVlllion, no coqnssion

Moist wound dressing topical
artJ/or systemic antibiotics
Modify risk factors (smoking, dist.
8X8rt:ise, 1111:.)
Vascular surgical consultation
Treat underlying conditions (DM,
proximal arterial occlusion, 1111:.)

Control diabates
Careful wound care
Foot care
Orthotics
Ell'1y intervention for infections
(1apical ancVor systemic antibiotics)
Vascular surgical consultation

Associated paresthesia, anesthesia

Pressure Ulcers
Common Sites
over bony prominences; 95% on lower body
Stages of Development
1. hyperemia - disappears 1 hour after pressure removed
2. ischemia - follows 2-6 hours of pressure
3. necrosis - follows >6 hours of pressure
4. ulcer- necrotic area breaks down - N.B. skin is like tip of an iceberg
Classification (National Pressure Ulcer Advisory Panel 2007)
Stage I: nonblanchable erythema present >1 hr after pressure relief, skin intact
Stage II: partial-thickness skin loss
Stage III: full-thickness skin loss into subcutaneous tissue, but not through fascia
Stage IV: through fascia into muscle, bone, tendon, or joint
if an eschar is present, must fully debride before staging possible
Prevention
good nursing care (clean dry skin, frequent repositioning), special beds or mattress (Kin
Air"), proper nutrition, activity, early identification of individuals at risk (e.g. immobility,
incontinence, paraplegia, etc.)
Treatment
depends on individual patient and condition
treat underlying medical issues including nutrition
continue with preventative measures (pressure relief)
wound debridement, moisture retentive or antimicrobial dressing, regular reassessment
topical antimicrobials at treating physican's discretion, systemic antibiotics for infections
assess for possible reconstruction
Complications

cellulitis, osteomyelitis, sepsis, gangrene

Management of Skin Lesions

Skin Lesions
see D6

Toronto Nota 2011

Plutic SIUJCIY PL15

Burns
Burn Injuries
Causal Conditions
thermal (flame contact. scald)
chemical

radiation (UY, medical/therapeutic)

elecbical

Most Common Etiology

c:bildren: scald bums
adults: flame bums
Table 8. Skin Fual:tion d Bum Injury

Con1nll lifluid IDII

Loss li l.ge of Wlll8r and pratan

from the Kin and other body tissues

Adecr.J8II llid r811J1tibrtian is inpilllliYe

Mechanical bllriii'1D becterilll iiMIIion

High rilk of inlectic:rl

Antl:liGiic oirtrnns (S'jltemic ifsigns ol

spdc infwction pnsent)
Tlllllnua prophylaxi1 if nec1111ery

m:l inllllnological org1111

Pathophysiology of Burn Wounds

amount of tissue destructl.on is based on temperature. time of exposure, and specific heat of the
causative agent (see Figure 18)
zone ofhyperemia - VIIIIOdilation from inflammation; entirely viable, cells recover within 7
days; contributes to systemic consequences seen with major burna
zone ofstula (edema) - decreased perfusion; microvascular sludging and thrombosis of vessels
results in progressive tissue necrosis -+ cellular death in 24-43 hours without proper treatment
factors favoring cell survival: moist, aseptic environment, rich blood 1111pply
zone where appropriate early intervention bas most profound effect in minimi1Jng injury
zone of coagulation (isdwnla) - no blood flow to tissue -+ irreversible cell damage -+ cellular
death/necrosis

mlana of hyparamil

r lane

of msis

U lane of CG9111ion
Blood 118118IIMII naiYII
. ...._.dIn IIIII dlamls

Diagnosis and Prognosis

bum size (see F.lglue 19)

%of total body surface area (TBSA) burned- rule ofSl's for 2 and 3 bums only (children
<10 ymrs old use Lund-Browder chart- see Figure 20)
for patchy burns, surface area covered by patient's palm (fingels closed) represents
appronmately 1CJ6 ofTBSA
age: more complications if <3 or >60 years old
depth: difficult to BBSess initially- history of etiologic agent and time of exposure helpful (see
Table 9)
location: face and neck. hands, feet, perineum are critical areas requirillg special care ofa burn
unit (see further discussion on IndiaJtionsfor Thmsfor to Bum Centre)
inhalation injury: can severely compromise respiratory system
associated injuries (e.g. fractures)
comorbid factors (e.g. concurrent disability, alcoholism. seizure disorders, chronic renal failure)
can exacerbate extent of injury

'i

Figu111 1I.Zaaes uf Themallajary

PL16 Plaatic Suqp!ry

....

1'oroDio 2011

BurDI

Proplil blllt determined bV bum

Iilii !lBSAI. age of patiaJL
llblanca of ilhllation injury.

... ,

blnllll*! rwtrict
mpntory m:ursion Mrllar blaod flaw
Ill IIKinlmiti88 and I'ICJ!irl 88chlrDimnV.

....

,.

TBSA d not include areu with 1

f"IIIIIFI 11. R1l1 af 1'1 fDr TGtllllady S11rf'llce Anll (liSA)

Anlll

AgaD

Afe1

A= I'. head-

B = Y.llll!lh 1M

814

C='AiltaiiH

Z'Ai

Afel

Agllll

Ap15

Mill

41'.

31'.

314

'"'
414

414

4'Ai

4%

ZY.

314

31'.

F"11111ra ZO. Llnd-8rowd Diagram

Tabla I. B11m IJeptll (1st. 2nd, 3nl dear)

Painlui,IIIISBtian inlll:t. arythama.
bhn:llllllle

Secanddep!

lniD lllpllficiJI d1m1is

Painful. SIIISIItion inlll:t. erythema.

blisle!s with clall'lluid, blenc:lllllle, hlir
folliclas pre&ant

DIIIP"PIItiiiTblcb Secand dep!

lniD deep (relicdar) dennis

Ful Tllicbell

Tlnugh apidannis and damis lnsamall (IIIIVIIR!ings dastroyadl.lwd

Injury ta tissue
le&thery eschar lhllt is Iiiii, grey, while.
8ll\lciJns (e.g. mUlde, bn) ar cllany lid in colour, hlin do nat ll8y
IUiclled, may a111D!R10&8d wins

Insensate, dilfiwlt ID distincrJjsh fl1lm

ful thiclinasl. does not billdl. acme
t.ir folliciBIIII allachad. IIOfta" then ful
11icknass bum

Toronto Notes 2011

Burns

Plastic Surgery PL17

Indications for Transfer to Burn Centre

American Burn Aaociation Criteria

total2 and 3 burns> 10% TBSA in patients <10 or >50 years of age
total2 and 3 burns >20% TBSA in patients any age
3 bums/full thickness >5% TBSA in patients any age
2, 3 or chemical bums posing a serious threat of functional or cosmetic impainnent (i.e.
circumferential bums, bums to face, hands, feet. genitalia, perineum, major joints)
inhalation injury (may lead to respiratory distress)
electrical bums, including lightning (internal injury underestimated by TBSA)
bums associated with major trauma/serious illness

Respiratory Problems
3 major causes
bum eschar encircling chest
distress may be apparent immediately
perform escharotomy to relieve constriction
carbon monoxide (CO) poisoning
may present immediately or later
treat with 100% 0 2 by facemask (decreases half-life of carboxyhemoglobin from 210 to
59 minutes) until carboxyHb <10%
smoke inhalation leading to pulmonary injury
chemical injury to alveolar basement membrane and pulmonary edema (insidious onset)
risk of pulmonary insufficiency (up to 48 h) and pulmonary edema (48-72 h)
watch for secondary bronchopneumonia (3-25 days) leading to progressive pulmonary
insufficiency
intubate patient with any signs of inhalation injuries

, ______________

.... _._

adhere to ATIS protocol

resuscitation using Parkland formula to restore plasma volume and cardiac output
4 cc Ringer's/kg/% TBSA over first 24 hours ( 1/2 within first 8 hours of sustaining bum, 1/2
in next 16 hours)
extra fluid administration required if
bum >80% TBSA
4bums
associated traumatic injury
electrical bum
inhalation injury
delayed start of resuscitation
pediatric burns
monitor resuscitation
urine output is best measure -maintain at >0.5 cc/kglhr (adults) and 1.0 cclkg/hour
(children <12 years)
maintain a clear sensorium, HR <120/minute, mean BP > 70 mrnHg
bum specific care
relieve respiratory distress- intubation and/or escharotomy (see sidebar)
prevent and/or treat bum shock- 2large bore IVs
identify and treat immediate life-threatening conditions (e.g. inhalation injury, CO
poisoning)
determine BSA affected 1st, since depth is difficult to determine initially (easier to determine
after 24 hours)
tetanus prophylaxis if needed
all patients with bums> 10% TBSA, or deeper than superficial partial thickness, need 0.5 ml
tetanus toxoid
also give 250 U oftetanus Ig if prior immunization is absent/unclear, or the last booster
>lOyrs ago
baseline laboratory studies (Hb, U/A, BUN, CXR, electrolytes, ECG, cross-match, ABG,
carboxyhemoglobin)
cleanse, debride, and treat the bum injury (antimicrobial dressings)
early excision and grafting important for outcome

Headache
Conluaion

Acute Care of Burn Patients

Coma

"Arrhyllwnias

....

..

lnhmtion lnjpr-101
l.lndicaiDrs of lnhlllstion Injury
Injury in 1 closed space
Facial bum

Singed nasal hair/eyebrows

Soot around n.rarloral cavity
HOirMIIHII

Conjunctivitis

Tachypnu

Carbon particles in sputum

El.vmd blood CO IMs (i.l.
brighter red I
2. Suspected ilhalation injury requires
immediate due ID
impending airway adema. FaiiUIIIID
dilgnou inhalation can rnult
in aifway swelling and obstruction,
which, can lead ID death.
3. Nllilher CXR or ABG can be uud ID
rull out inhallltion injury.
4. Oirvct broncho&copy now used for
diagnosis

PLIB Plastic Surgery

Burns

Toronto Notes 2011

Burn Wound Healing

Table 11. Bum Wound Healing

Table 1D. Burn Shock

Ruscitlltion (Parkland
Fonnulal

Hour W4

4 cc

Dl!plll

TBSA

with 112 of total 0-8 h

llld 1/2 of tcrtal 11-24 h

Hour 24-30 0.3&-0.5 cc

>Hour 30 D5W at rate to maintain

Hilling

Fim degll!e

No scarring. Complete healing

Second degree
(Superficial partial)

Spantaneously in 7 to 14 days from retained epidermal structures

residual skin discolouration
Hypartrojtlic scarring uncommon. Grafting nnly required

Deep second degree

(Deep partial)

R&-epithelialize in 14-35 days from retained epidennal structures

Hypartrojtlic scarring frequent
Grafting recommended to expedite healing

Third Degree (Full thickness)

R&-epithelializa from 1ha wound edge

Grafting necessary to replace dermal integrity, limit hypertrophic scarring

Fourth Degree

R&-epithelialize from 1he wound edge

Grafting necessary to replace dermal integrity
Must ensure viable bed to graft onto

normal serum sodium

* da nDtforgBIID add TlllliriBIIIIDfUd ID

IISIISCi1mJn

MIINnllflil IIEII!r Wililnfllllrll

8lmr ZOO&;

l'lllfiii:TDIIIIblilhilllltyiiiiCilianMdgllfting
il IUJ)IIiJr !Dr equillllntj to CGIIIIrvaMJIIItmR
llld dlllyad gllfting Dlllll tile lull 81Chlr IIJ)Irllad.
M....,..._AillrQ!re!Mw

prDip8C1M ntndDnillld
cuabulud lllll:ililn

I<7 dlysl IIIII irnmiCiats grafting IQiilst

lnil1ment v.itllchaings foi1Dwe1111 Piing

JIDII-81ChltlllpRtiaa. AIIQII md lun -as

were ilcUded.lldcames Wile mDrtllty. biODd
lrlniWu5. WDOOd hudng 1iJw ll1d ilngtll gf
lloepimlslly.

._..:A1ulll of361 plllisiQ fTom 71Mdomiz8d

cuabulud lrilil Wlfl inlildld in 111111"1111-nlylia.
180 pllierG!Qiwd allty

181

l'llllivld coRIIMiive nwnagemant. Tlwl WI!

AD si,ificlnt dlnlce il mDrtaily in Pltilllll
wilb irlllllllillllll injury. Ellty acili110 IIIII grafq
in pMients Mhaut im.tiDIIII ijly IIUIId in

Rlllic:ad mD!IIIily IRR 0.36, p<0.051
llld decreued length of holpblizllillll by 8.89
days IP<D.051- The runter of patiarq ntePring
biDod 111111fusili MIS lignilicmly wilb lilt;'
aciliD111111'11nagvmeul ISMO 1.65, p<0.051. There
WI! no lidtlli clllalaca '-ing tima
betweea the two ifDups.
CIIIIIAIIill1: &tvacilioo of bums I<7 dlysl is
beaeticial in reducing mDrtah in patilllll Mhaut
n.latiooal injury, abagwilh llllb:ing . . . of
time spent in bDIJiiml.

Treatment
3 stages
1. assessment - depth determined
2. management- specific to depth of bum
3. rehabilitation
first degree
treatment aimed at comfort
topical creams (pain control, keep skin moist) aloe
oral NSAIDs (pain control)
superficial second degree
daily dressing changes with topical antibiotics, pol)'5porin, may use a temporary biological or
synthetic covering to close the wound; leave blisters intact unless circulation impaired
deep second degree and third degree
prevent infection and sepsis (significant cause of death in bum patients)
most common organisms: S. aureus, P. aeruginosa and C. albicans
- day 1-3: Gram-positive
- day 3-5: Gram-negative (Proteus, Klebsiella)
topical antimicrobials: prevent bacterial infection (from skin flora, gut flora or caregiver)
and secondary sepsis (Table 12)
remove dead tissue
surgically debride necrotic tissue, excise to viable (bleeding) tissue
Table 12. Topical Antibiotic Tharepy
Antililllic

Pain with Appication

Pllnllrllion

Silver nitrate (0.5%

solution)

None

Milimal

May cause methemoglobinemia, stains (black),

leaches sodium from wounds

Silver sulfadiazine
(cream) (Sutn.nyiooGt)

Minimal

Medium. does not penetrate

eschar

Slowed healing, leukopenia,

mild of epithelialization

Mafanida acstate
(sDiutionlcreem)
(Silvadene4')

Moderate

Wall, panetratas eschar

Mild inhibition of epithelialillllion, may causa

matabDiic acidosis with wide application

important to obtain early wound closure

initial dressing should decrease bacterial proliferation
indication for skin graft: deep 2 or 3 bum > size of a quarter
prevention of wound contractures: pressure dressings, joint splints, early physiotherapy

Other Considerations in Burn Management

r----.Aitand
Vaicullll' Purm811bility and Edema +-----,

lmmunoliUpprenion

SEVERE BURN

Renal Failure (2" to ..V Renal Blood Flowl

Figure 21. Systemic Effects of Severe Bums

r r----

CO, 1' SVRI

Hyp111111u!llboli&m

Progressive Pulmonary Insufficiency

L----+lncraased Gut Mucosal Purmaability

(GI Bleed Risk)

Toronto Notes 2011

Burns

Plastic Surgery PLHI

nutrition
hypermetabolism: TBSA >40% have BMR 2-2.5x predicted
calories, vitamin C, vitamin A, Ca, Zn, Fe
immunosuppression and sepsis
must keep bacterial count <105 bacteria/g of tissue (blood culture may not be positive)
signs of sepsis: sudden onset ofhyperlhypothennia, unexpected CHF or pulmonary
edema, development of ARDS, lleus >48 hours post-bum, mental status changes, azotemia,
thrombocytopenia, hypofibrinogenemia, hyper/hypoglycemia (especially ifbum >40% TBSA}
gastrointestinal (GI) bleed may occur with bums >40% TBSA (usually subclinical)
treatment: tube feeding or NPO, antacids, H 2 blockers (preventative)
renal fallure secondary to under resuscitation, drugs, myoglobin, etc.
progressive pulmonary insufficiency
can occur after: smoke inhalation, pneumonia, cardiac decompensation, sepsis
wound contracture and hypertrophic scarring
largely preventable with timely wound closure, splinting, pressure garments and
physiotherapy

Special Considerations
CHEMICAL BURNS
major categories: acid burns, alkaline burns, phosphorous bums, chemical injection injuries
common agents: cement, hydrofluoric acid, phenol, tar
mechanism of injury: chemical solutions coagulate tissue protein leading to necrosis
acids -+ coagulation necrosis
alkalines -+ saponification followed by liquefactive necrosis
severity related to: type of chemical (alkali worse than acid), temperature, volume,
concentration, contact time, site affected, mechanism of chemical action, degree oftissue
penetration
burns are deeper than initially appear and may progress with time
Treatment {general)
ABCs, monitoring
remove contaminated clothing and brush off any dry powders before irrigation
irrigation with water for 1-2 h under low pressure
inspect eyes, if affected: wash with saline and refer to ophthalmology
inspect nails, hair and webspaces
correct metabolic abnormalities and tetanus prophylaxis if necessary
local wound care after 12 hours initial dilution (debridement)
wound closure same as for thermal bum
beware of underestimated fluid resuscitation, renal, liver, and pulmonary damage
ELECTRICAL BURNS
depth of bum depends on voltage and resistance of the tissue (injury more severe in tissues with
high resistance}
often presents as small punctate burns on skin with extensive deep tissue damage which requires
debridement
electrical burns require ongoing monitoring as latent injuries can occur
watch for system specific damages and abnonnalities:
abdominal: intraperitoneal damage
bone: fractures and dislocations especially of the spine and shoulder
cardiopulmonary: anoxia, ventricular fibrillation, arrhythmias
muscle: myoglobinuria indicates significant muscle damage -+ compartment syndrome
neurological: seizures and spinal cord damage
ophthalmology: cataract formation (late complication)
renal: acute tubular necrosis (ATN) resulting from toxic levels of myoglobin and hemoglobin
vascular: vessel thrombosis -+ tissue necrosis (increased Cr, K and acidity}, decrease in RBC
(beware of hemorrhages/delayed vessel rupture}
Treatment
ABC's, primary and secondary survey, treat associated injuries
monitor: hemochromogenuria. compartment syndrome, urine output
wound management: topical agent with good penetrating ability (silver sulfadiazine or mafenide
acetate)
debride non-viable tissue early and repeat pm (every 48 h) to prevent sepsis
amputations frequently required
FROSTBITE
see Emer.genc.y Medicine, ER45

.,

.....

.-----------------,

Speed is essential in the m-aement

of chemical blms 1111 chemicals cen
conti1111e to cause damage untlthey are
IVIIIOVlld or neLmllizlld.

.....

..

Tu: remove with repeated applicidiiJil

of petroiiUIII-based antibiotic ointments

(e.g. Polysporin ).

.....

...-----------------.

TI'MIIIIIIIC(speclic]

Acid br: dilute sokrtion of sodium

bicarbonate folowing wmr iniiJIItion
llydrvl-": acid: water irriglltion;

fingtmails to avoid acid 1npping; topical

calcium gel injection

of calcium gklconate 10"' calcium
gluconab!IV depending on 1rn0unt of

axposura and pain

Wfuric Kid: treat with

prior

to irrigation, u di111ct wmr axposure

produces extreme heat

.,

....

T - a.sistMCII te EIIICiriclll
Cunallt:
nerva < VIISS&liblood < muscle < lkin

< tendon < fat < bone

PL20 Plastic Surgery

Hand

Toronto Notes 2011

Hand
Traumatic Hand
Tabla 13. Kay Faaturaa of tha Hiatury and Physical Exam of tha Injured Hand
in the Emergency Department

HISTORY

AQe

....

High pressure injection inj-.y is
dacllplivlly b111ign-looking (1111aU
pinpoint hole on finger pad] often with
few clinical signs.
Intense pain and tenderness, along the

Hand oomilllllce
Occupation
lime and place of accident
Mechani5m of injury
Tetanus status
PHYSICAL EXAM

Bruising or sweling
Sweating pattern
Ana!Dmicel strucbues beneath

Radial and ulnar wries

Digital arteriee
Temperature and skin turgor

Allen's Test (see sidebar)

Capillary refill ( <2-3 &ac)
For each test. need to CCJ11118re bolh sides

SaniHIIY (IIefer to Figum 3)

Median nerve
Ulnar nerve
Radial nerve
nerves

Dorsal redial tip of index finger

Dorsal ulnar tip Ill little finger
Dorsal web space Ill the thwnb
2point discriminalion crf each finger

Matur Functio1

Median nerve

Exlrinsic muscles: Rex DIP Ill index finger

("OK sign")
Intrinsic muscles: Thwnb to ceiling with
palm up

Ulnar nerve

Extri115ic musclee: Flax DIP of little finger

Intrinsic muscle&: Abduct index finger
("Peace sign") or patient able to hold piece
of paper between adducted fingers and
resist pulling

Radial narva

Extrill5ic muscles: Exland thumb ("Thumb's

up1 and wrist

Flexor Digitorum Profundus (FDP)

Stllbilize PIP joint in extension, ask patient

to flex fingers (II DIP) (see Figure 6)

Flexor Digitorum Superficialis (FDS)

Stabilize non-exam fingers in extension

(neutralizes FDP) and ask patient to nex
examination finger (see Figure 7)

Bones

Focal tenderness or abnonnal alignment

Joints

Instability may indicate igamentous injury

or dislocation

Dafonrity

cour1a tha fllraign mamriallrlvalad,

is pmant a faw hours an. th1 iljury.
Definitive 1rHiment is EDCpQsure and
ramoval of foraign mamrial.

Position of finger

Abnormal cadence (fingen normally slightly

ftaxed), scissoring
Bony or apacific (e.g. Mallet. Swan Neck)
May indicate underlying skl!lellll i;ury
May indicate denlli!Mition
If open laceration, need to 8llj)lore within
wound (under sterile

On.v.tian

,, I

Allen' Tnt: while patienfs hand is

finnly l:lolad, m:luda both radial and

ulnar arteries. Once fist is open, release

aithar artary and llSSBSS con.teral flow.

It'
Appnw:h ID Hand Llcllionl

TIN AX
Tanus prophylaxis
Irrigate with NS

NPD

Antibiotic prophylaxis
X-rays

I

,.}-----------------,

Nevw blindly clamp a bleading viSSII

as nerves are often found in close
IISSIIcillion with vnuls.
,, I

Arterial bleaclinu from a volar digilal

laceration may indicate nerve lacellllion
(fiiiMII in digits ara suparficial to
arteries].

General Management
Nerves
direct repair fur a clean injury within 14 days and without concurrent major injuries -+
otherwise secondary repair
epineural repair of digital nerves with minimal tension
post-operative: dress wound, elevate hand and immobilize
Tinel's sign (cutaneous percussion over the repaired nerve) produces paresthesias and defines
level ofnerve regeneration
a peripheral nerve regenerates at 1 mm/day after the first 4 weeks as a result ofWallerian
degeneration
paresthesias felt at area ofpercussion because re-growth of myelin (Schwarm cells) is slower
than axonal re-growth --+ percussion on exposed free-end of axon generates paresthesia

Toronto Notes 2011

Plastic Surgery PL21

Hand

Vessels
often associated with nerve injury (anatomical proximity)
control bleeding with direct pressure and hand elevation
if digit devascularized. optimal repair within 6 hours
dress, immobilize, and splint hand with finger tips visible
monitor colour, capillary refill, skin turgor, fingertip temperature post-revascularization

Tendons
most tendon lacerations require primary repair
many extensors are repaired in the emergency room. flexors in the operating room within
2 weeks
avoid excessive immobilization (specific protocols for flexors, 2-3 weeks for extensors) to
minimize stiffness and facilitate rehabilitation

Hand Infections
Principles
trauma is most common cause
5 cardinal signs: rubor (red), calor (hot), tumour (swollen), dolor (painful) and functio laesa (loss
of function)
90% caused by Gram-positive organisms
most common organisms (in order) - S. aureus, S. viridans, Group A Streptococcus,
S. epidermidis, and Bacteroides melaninogenicus (MRSA becoming more common)

TYPES OF INFECTIONS
Deep Palmar Space Infections
uncommon, involve thenar or mid-palm. treated in OR

Felon
definition: subcutaneous abscess in the fingertip that commonly occurs following severe
paronychia or a puncture wound into the pad of digit; may be associated with osteomyelitis
treatment: elevation, warm soaks, cloxacillin 500 mg PO q6h (if in early stage); if obvious
abscess then I&D and PO cloxacillin

Flexor Tendon Sheath Infection

Staph> Strep >Gram-Negative Rods
definition: acute suppurative tenosynovitis commonly caused by a penetrating injury and can
lead to tendon necrosis and rupture if not treated
clinical features: Kanavel's 4 cardinal signs:
1. point tenderness along flexor tendon sheath (earliest and most important)
2. severe pain on passive extension of DIP (second most important)
3. fusiform swelling of entire digit
4. flexed posture (increased comfort)

treatment
OR incision and drainage, irrigation, IV antibiotics, and resting hand splint until infection
resolves

Herpetic Whitlow
HSV-1, HSV-2
definition: painful vesicle(s) around fingertip
often found in medical/dental personnel and children
clinical features: can be associated with fever, malaise and lymphadenopathy
patient is infectious until lesion has completely healed

treatment: routine culture and viral prep protection (cover), consider oral acyclovir

Paronychia
acute = Staph; chronic = Candida
definition: infection (granulation tissue) of soft tissue around fingernail (beneath eponychial fold)
etiology
acute paronychia - a "hangnail': artificial nails, and nail biting
chronic paronychia - prolonged exposure to moisture

treatment
acute paronychia - warm compresses and cephalexin 500 mg PO q6h drainage if abscess
present
chronic paronychia- anti-fungals with possible debridement and marsupialization, removal
of nail plate

... ,

Co11putmenl Syndrome
Watd1 out for these signs with doled
or opan injury: tiiiiSI, peinful fiXtrwnity
on paHive lilrulch), dilllll
pulsaiiiSIIKISs {oftan lata in process).
and contracture
{irTIIVaraible ischamia).
lnti'IICompartmental pressum can be
menurad, but a clinicel diagnosis is an
indication for an emergent fasciotomy.
If untr8111ed, end 1'88Uit is ischemic
af the extremity {Volkmann's

1'oroDio 2011

Hand

PL22 Plaatic Suqp!ry

Amputations
Hand or Finger

emergency management: injured patient and amputated part require attention

patieDt: .x-mys, NPO, clean wound and irrigate with NS, dress stump with nonadherent,
cover with dry sterile dressing, tetanus and antibiotic prophylaxis (cephal.oaporin/
erythromycin)
amputated part: J:-rays. gently irrigate with RL. wrap amputated part 1n a NSIRL soaked
sterile gauze and place inside waterproof plastic bag, place in a. container, then place
container on ice
indkalions 1Dr replamation
ap: children often better results than adults
level of injury: pronmal. thumb and multiple digit amputations are higher priority
nature ofinjury: guillotine injuries have a better potential; avulsion and auab injuries are
relative contraindications to replant
Ifreplant contraindicated manage stump with revision amputation
would only allow a fingertip injury to heal by secondary intention

Tendons
Common Extensor Tendon Deformities
Table14. Exl:eiiiOI' Tendon Daformltlea

Figure 22. Zone of Extensor

r ..dDn Injury {Odd n1111bered zones
fall over a jaint)

Z3. Millet Finger Dafomity

IIjury

Dllililian

llna

EtiDIIIIf/tinicll fteluNI

Trlllnat

MllletFiiiJII"

Df llaxad 1Mth loss tA active

IIICialsian (s&a Fi!1118 23)

Fal:ad flaxian of1ha axtendad DIP

joint to axllln&ar tand111
ruplln at DIP jairt (e.g. sudd111
blow to tip li1be fingel)

Splint liP in axtansian fa&was fallawad 11y 2 wea1a1

ol night splinq. If inadeqUIIII

6 weeks..
check aplinting routine and
18C11111111111d 4 men waab tA
Clllllilaus spliting

.......

Pf flaxad. DIP hyperaxtendld

(see Fue 24)

Dafadr

Splint PIP in axtansian IIIII !Iaw

Injury ardis-
exllmsar tenlan insatian i!G 1he active DIP motian
dlllllll bala Dl tha midde phlln
Assacialad with dlaumad
IWthritis (RA) ar tnune
will" di!lacation, BCUte fmzful
lleiOOn of PIP)

Swa Macl
Dafadr

Pf hyperadaldad, DIP flaK8d

(588 Fijr.lre ZS)

val plata

Assacialad with RA 111d aid,

Ull1r8Bt8d ..... dnmity

Splint ta pravant PF
llypalvmnsianar Ill' flaxian

Cansid a11radasiWarthrapllmy

Da Quervaln's Tenosynovltls(zone 7; most common cause of radial wrtst pain)

de:finl.tion: inflammatl.on in 1st extensor compartment (APL and EPB)
cllnl.aal features:
+ve Finkelstein's teat (pain over the radl.al styloid induced by making fist, with thumb in
palm, and ulnar deviation of wrist)
pain l..ocallzed to the 1st extensor compartment
tenderness and aepitation over radial styloid may be praent
diffe:rentiate from CMC joint arthritis (CMC joint artlutti& will have a positive grind test,
whereby crepitus and pain are elldted by axial pressure to the thumb)
treatment:
mllcl: NSAIDs, spllnting and steroid injection into the tendon sheath (succeasful. in over 60%
ofcase.)
&eYere: surgical release of stenotic tendon sheaths

(APL and EPB); remember there may be

2 or more sheaths

Figure 24. BaiiiDnniara Dafunrity

DIP Fltxion

PIP Hyp--.si111

Figure 25. Swa Naclc: Dafarmity

Ganglion Cyat (zone 7)

definition:
fluid-filled synovial lining that pratru.dcs between carpal bones or from a. tendon sheath;
most commonly carpal in origin
most common soft tissue tumour ofhand and wrist (6096 of masses)

cllnl.aal farturea:
most common around scapbolunate ligament junction
3 times more common in women than in men
more common in younger individuals
can be luge or small -may drain internally so size lllll)' wax and wane
often non-tender although tenderness increased when cyst smaller (from increased pressure
within amall.er cyst sac)

'IbroDlo Nota 2011

Plutic Surgery PL23

Hand

trcablleDt:

conservative treatment: watch and wait

aspiration (recurrence rate 6596)
consider operative acision of cyst and stalk (recurrence is po88ible)
steroids ifpa1nful

A2and A4 pulley5 n most importlfll

lor flrlction; pwwent bowstmgWig of
bindo..

Common Flexor Tendon Dvformities (see Figure 26)

fiemr tendon zones (Important for prognosis of tendon lacerations)
"no-man's land":
between distal palmar crease and mid-middle phalanx
zone where superficialis and profundus lie ensheathed together
recovery of glide very dlfficult after Injury

Stenosing Tenosynovitis (trigger Dnger/thumb)

definition: inflammation ofsynovium Cllll8e8 size discrepancy between tendon and sheath/
pulley (most commonly at A-1 pulley) = locking of tbumb or finger in timon/extension
etiology: idiopathic or associated with RA, diabetes, hypothyroidism and gout
clinic:al fnlara:
thumb, ring and long fingers most commonly affected
patient complains of catching, snapping or locking of affected finger
tenderne88 to palpation/nodule at palmar aspect ofMCP over A1 pulley
women are 4 times more l.ikdy than men to be affected
conlenative treatment:

NSAIDs
steroid injection
surgical flexor tendon release

Figura 26. lanes af tla Flexar

T811donS

injectiomlesslikely to be ruccessfu.l in patienb with DM or symptoms greater than 6 months

aurglcal treatment:
incise A-1 fluor tendon pulley to permit unrestricted, full active finger motion

Fractures and Dislocations

for fracture prindples, see OrthQ,paedljJb ORS
FRACTURES

about 90% of hand fractures are stable in fl.exl.on (locklprevent extension)

polition of fandloo. (like a band holding a pop can) (see Figure 27):
wrist extension 15

MCP fl.mon 45
IP fial.on (slight)
thumb abduction/rotation
contraindicatlons: post repair offlexor tendons, medlanlulnar nerve injury
polition ofsafety (see Figure 28):
wrist extension 45 (position most beneficial for hand function ifimmobilized)
MCP flmon 600 (maximal collateral ligament stretch)
PIP and DIP in full atension (m.ui.mal volar plate origin stretch)
thumb abduction and opposition (functional position)
stiffness secondary to immobilization is the most Important complli:ation; Tx = early motion

Figura 27. Positian af F1111ction

Distal Phalanx Fractures

most commonly fractured bone in the hand

usual mechanism Is crush injury and thus accompanJ.ed by soft tissue injury

subungual hematoma is common and must be decompressed ifpamful or nail removed

treatment consists of3 weeks of dJgital splinting (with IP joint movement preserved)
Proximal and Middle Phalanx Fractures
check for: rotation, sd88oring (overlap of fingers on making a fist), shortening of digit
undispla.ced or minimally displaced- closed reduction (ifextra-articular) buddy tape to
neighbouring stable digit, elevate hand, motion in guarded fa&hion 10-14 days post injury
displaced, non-reducible or not stable with closed reduction- percutaneous pins (K-wires) or
ORIP, and splint
Metacarpal Fractures
generally accept varying degrees of deviation before reduction required: up to 10" {D2),
20" (D3), 30 (04), or 40" (D5)
Boxer\ fraaure (ema-artl.cul.ar): acute angulation of neck of metacarpal of little finger into
pelm (see Figure 29)
mechanism: blow on the distal-dOI88l upect of closed fist
loss of prominence of metacarpal head, volar displacement ofhead
check for scissoring offingers on making a :fist

Figura 21. Positian af Slfety

PL24 Plaatic Suqp!ry

Hand

1'oroDio 2011

up to 30-40'> angulation may be acceptable

closed reduction should be considered to decrease the angle
ifstable ulnar gutter splint x 3 weeks with PIP and DIP joints free
Bennett's fraaare (intra-artkular): fracture/dislocation of the base ofthe thumb metacarpal
(see Figure 30)
unstable fracture
abductor pollicis longus pulls MC shaft proximally and radially causing adduction ofthumb
treat with percutaneoue pinning. thumb spica x 6 weeks
Rolando' fraaare (intra-artic:ular): T- or Y-shaped fracture ofthe base of the thumb
metacarpal (see Figure 31)
treat with open reduction, internal :fixation (ORIF) with K-wire
DISLOCATIONS

must be reduced as soon as possible

PIP and DIP Dislocations (PIP more common than DIP)
usually dorsal dislocatl.on (commonly from hyperexteD!Iion)
ifclosed dlslocation: closed reduction and splinting (30 flal.on for PIP and full extension
for DIP) or buddy taping and early mobilization (prolonged immobilization causes stiffness)

open injuries are treated with wound care, closed or open reduction and antibiotics

I
I

MCP Dislocations (relatively rare)

:I!

dorsal di&locations much more common than volar dislocations

dorsal di&location ofprmimal phalanx on metacarpal head; most commonly index finger
(hyperenension)
two types of dorsal dislocation:
simple (reducible with manlpulation) - treat with 2 weeks ofsplinting at 30" MCP tlai.on
compla: (volar plate blocks reduction)- treat with open reductionand Al pulley release+

. . 31. RollllldDs Fnelu18

cxb:nsion-blocking splint at 30" tlenon (2 weeks) then 100 ftenon (2 weeks)

Ulnar Collateral Ligament (UCL) InJury

forced abduction of thumb (e.g. ski pole injury)
Lllier"s thumb: acute UCL injury
pmekeepen thumb: chronic UCL injury
mdaaticm: radially deviate joint in full extension and at 3Qa flexion and compare with noninjured hand. UCL rupture is presumed ifinjured side deviates more than 30" in full extension
or more than tsa in flexion
Stcner'sle&ioD: the UCL ha8 bony attachments to the adductor aponeurosis and the piOJdmal
ligament can displace while the dirtal attachment remains deep to the aponeurosis, forming a

barrier that blocks healing and leads to chronic instability; requires surgery

Dupuytren's Disease
Definition

contraction oflongitudinal palmar fascia. forming nodules (usually painless), fibrous cords and
eventually flexion contractures at the MCP and interphalangeal joints (see Figure 32)
flexo.r tendons not involved
Dupuytren's diathesis - early age of onset. strong family history, and involvement ofsites other
than palmar aspect of hand
Epidemiology

genetic disorder (unusual in patients from Afrkan and Asian countries, high inddence in
northern Europeans), men> women, often presents in 5th-7th decade oflife, assodated with
but not caused by alcohol use and diabetes
Clinic.l FHtures

''..,

order of digit involvement (most common to least common): ring :> little :> long :>thumb :> index
may also involve feet (Lederhosen's) and penis (Peyronie's - see UroloBY. U29)

AccurHJ rlth
fir C.rlllllmllllynd.,.IH
Hilmi SU1pty
1916; p.223
1. Phalen's:
SenaiiMty: 0.75 Specificity: 0.47
2. lira's:

SenaiiMty: 0.60 Specificity: 0.67

3. IMpel Tumel Compnaion Test:
SenaiiMty: 0.87 Specificity: 0.90

Treatment

stages:
1. palmar pit or nodule - no surgery
2. palpable band/cord with no llinitation of atension of either MCP or PIP- no ru.rgery
3. lack of extension at MCP or PIP - smgical fasciectomy indicated
4. irreversible periarticular joint changesfscarring - smgical tn:al:ment possible but poorer
prognosis compared to stage 3

Toronto Notes 2011

Plutic Surgery PL25

Hand

indications for percutaneous release:

functional impairment
MCP joint contractures >30
any PIP contracture
rapidly progressive disease
may recur, especially in Dupuytren's diathesis

Carpal Tunnel Syndrome (CTS)

Definition
median nerve compressed by nearby anatomic structures
Etiology
median nerve entrapment at wrist
primary cause is idiopathic
secondary causes: space occupying lesions (tumours, hypertrophic synovial tissue, fracture
callus, and osteophytes), metabolic and physiological (pregnancy, hypothyroidism, and
rheumatoid arthritis), infections, neuropathies (associated with diabetes mellitus or alcoholism),
and familial disorders
job/hobby related repetitive trauma, especially forced wrist flexion
Epidemiology
female:male = 4:1, most common entrapment neuropathy
Clinical Features
sensory loss in median nerve distribution i.e. radial3.5 digits (see Figure 3)
discriminative touch often lost first
classically, patient awakened at night with numb/painful hand, relieved by shaking/dangling/
rubbing
decreased light touch, 2-point discrimination, especially fingertips
advanced cases: thenar wasting/weakness
Tinel's sign (tingling sensation on percussion of nerve)
Phalen's sign (wrist flexion induces symptoms)

Calfll
TAll
StWDllllplli:
trilldllar
JilllldSIIg,111J6. YGI31 No.6 p.911
To dMgp

,.._e:

CIIPII tunlllll1lihrrl tt.lllllllllld till clniclll

dilgnolti: piiCii:lll rl axpartl.
57 cinicllllildings -cillsd
l"lidiCTS, eight were mild 1 pnlrl
aplll clinicilnL lhing Z!i6 -lilmrill.l pal
rl mcperts decided wheller a case did did nat
I'Md.-riCTS. ,_d. ...--.
the .,dentmiable Ill! alogistic regralioa
model. 111 wflicll tilleigbt cinicallildings wn
IIIPhd. 1111
modiiWII dwiwldllld
l(lliRII till C01118111US of IIICOIIII J*IGI on 1118
dillgnosis af CTS forU. C8l8 hillllriM.
blulll: The-- between the problblty
rl CTS pl'llliclld by tillllgllllion lllldllllld till
pnlrJcliicin-0.71.
filii lilt ofUIIIWigiDd cmcal rilgnonc Clitlria
tt.l OIJIIribulld slgnificlndv bl111e
1. illiWlilfl IIIIW
dillrillllian

2. rtlct!Jmlll"llrilnasl

3. w.knaa lr4'GIIIIIolil rl tilllillall

4. f111f111ign

5. PIMI(stest
&. 1.os1 rl Z.paid dilcrimmon

Investigations
a clinical diagnosis
nerve conduction velocities (NCV) and EMG may confirm, but do not exclude, the diagnosis
Treatment
avoid repetitive wrist and hand motion, wrist splints when repetitive wrist motion required
conservative: night time splinting to keep wrist in neutral position
medical: NSAIDs,local corticosteroids injection, oral corticosteroids
surgical decompression: transverse carpal ligament incision to decompress median nerve
indications for surgery: numbness and tingling sensory loss, weakness muscle atrophy,
unresponsive to conservative measures
complications: injury to median motor branch, palmar cutaneous branch or superficial
transverse vascular arch, local pain (pilar pain), scar

Rheumatoid Hand
General Principles
non-surgical treatments form the foundation in the management of the rheumatoid hand
surgery only for patients whose goals (improved cosmesis or function) may be achieved
Surgical Treatment of Common Problems
synovitis: requires tendon repair if ruptured; can lead to carpal tunnel syndrome and trigger
finger
ulnar drift: MCP arthroplasty, resection of distal ulna, soft tissue reconstruction around wrist
thumb deformities: can be successfully treated by arthrodeses (surgical fixation of joint to
promote bone fusion

....

Rldlorlrllhlc Evolution of tile

Rh-lltoid Hlllll
Eullest sign: 1111sion of lh1 uln11r
5tyloid
PrOgr811i. .: chracterized by

symmetrical joint space narrowing IUid

arolions oftha CllrJIIII bones. MCP and
PIP (with DIP r.IIIIMiy sparld)

._... st.ge: Swan neck IUid 8outomiara

deformities

PL26 Plastic Surgery

Toronto Notes 2011

Brachial PleiUsiCraniofadallnjurlea

Brachial Plexus
Etiology
common causes of brachial plexus injury: complication of childbirth and trauma
other causea of injury: compression from tumours, ectopic ribs

Common Palsies
Tabla 15. Named NaDnlltlll Palsies Df tha Brachial Pinus
DucllenneEIII Pllly

Lacation ullnjwy

Machlniun ullnjury

Faaturea

Upper brachial pi8XliS (C5-C6)

HaacVshouldar distraction
(e.g. motorcycle)

Waiter's tip dlllormity (shoulder

internal rotation. elbow extension,
wrist flexion)

Lower brachial plexus (C7-T1) Traction on abducted arm

May include Homer's syndrome

{"claw hand")

Differential Diagnosis
trauma (blunt, penetrating)
thoracic outlet syndrome
neurogenic - associated with cervical rib; compression of C8/Tl
vascular - pain or sensory symptoms without cervical rib; cessation of radial pulse with
provocative maneuvers
tumour
schwannoma- well-defined margins makes it easier for total resection
neurofibromas- associated with neurofibromatosis type I (NF-1)
other- e.g. Pancoast's syndrome (apical lung tumour)
neuropathy (compressive, post-irradiation, viral, diabetic, idiopathic)

Investigations
EMG
MRI - gold standard for identifying soft tissue massea
CT myelogram - better than MRI for identification of nerve root avulsion and identification
of pseudomeningocele. hnportant for preoperative identication of patients likely to require
neurotisation procedures (esp. for patients with blunt trauma)

Management
Tabla 16. Management Df Brachial Plaxuslnjuries
Type
Non.flnllrlling Tra111111

Trennent

Concussivalcomprassive

Usualy improves (unless expanding mass, e.g. hamlllllma)

TractiorVstretch

Hno continued insult. follow for 3-4 months for improvement

Obstetric palsy

Surgery if no significent and/or residual paresis

at 6months Df age

Sharp or vascular injury

Explore immediately in OR

Craniofacial Injuries

low velocity vs. high velocity injuries determine degree of damage

fractures cause bruising, swelling and tenderness -+ loss of function
frequency: nasal > zygomatic > mandibular > maxillary
management can wait 5-10 days for swelling to decrease before ORIF required

Craniofacial Injuria

Toronto Notes 2011

Approach to Facial Injuries

ATLS protocol
inspect, palpate, clinical assessment for injury to underlying structures (e.g. facial nerve)
visual assessment
tetanus prophylaxis
radiological evaluation
wound irrigation with NS/RL and remove foreign materials
conservative debridement of detached or nonviable tissue
repair when patient's general condition allows (soft tissue injury: <8 h preferable)

Investigations (see Table 17)

CT:
Axial and Coronal (specifically request 1.5 nun cuts) - for fractures of upper and middle face
(not good for mandible)
indicated for high velocity trauma, complex facial fractures, orbital floor, panface fractures,
pre-op assessment
panorex radiograph - shows entire upper and lower jaw; best for isolated mandible fracture as
patient must be able to sit

Tabla 17. Imaging oftha Craniofacial Skalaton

Plastic Surgery PL27

... , ,

l'lllilnts with majorfllcilll iljurin ara

at risk ol developing upper airway
obstruction (displaced blood clots,
1eelh or haclure frllgmenl$; swelling of
pharynx 11111 latyruc; loss of support of
hyomandibular complex-+
of tongue). Also at risk of ocLJar injury.

....

,,

Suspect C-spine iljury with any facial

C-spine evaluation before
radiographs n onlmd_

N11albona

CTKilll
Water's view (accipitomental, A-P "fnm below"l, Town's. AP
No x-ray rvquired- clinical

MaxiIll

CT scan - axial and caranaJ

... ' ,

Cor\lider inlnlcranialtrauma; rule out
skul fncturl.

'llalt inlging rnstf1od

Treatment
consultation when indicated (dentistry, ophthalmology)
re-establish normal occlusion
pursue normal eye function
restore stability of face and appearance
Complieations
diplopia/enophthalmos/blindness
intracranial pathology such as cerebrospinal fluid (CSF) leak, bleeding and SIADH
sinusitis
functional abnormalities (i.e. malocclusion)
infection - extremely rare
poor cosmesis; need for 2 surgery

Mandibular Fractures
always two points ofinjury since it is a ring structure (includes fractures and dislocations)
commonly at sites of weakness (condylar neck, angle of mandible, region of 3rd molar or canine
tooth)

Etiology
anterior force: bilateral fractures
lateral force: ipsilateral subcondylar and contralateral angle or body fracture
note: classified as open if fracture into tooth bearing area (alveolus}

Clinical Features
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-orallacerations or hematoma (sublingual)
chin deviating toward side of a fractured condyle

....

',

Sips af IJual Skull Fractur

1. 8Btlle's sign (bruised masiDid proce55}
2- Hemotympanum
3_ Raccoon eyes [periorbital blllising)
4_ CSF otormaa

... '...-----------------,
,
Facial bona injuries with orbit involved
r.quin ophthalmology consult

Craniofadal.lnjuries

PL28 Plaatic Suqp!ry

1'oroDio

2011

Classificlltion
Tabla 18. Mandibular Fnctura ClassilicatiDns by Anata11ic Ragi... (rmr ta Figun 33)

Midln. d the 1111111dibll; bai.WIIII the clldnll R:isars frrm tha aiVIIOI!w J11DC8SS lllwgh the

mrior border of111! IIIIIRJie

Fmn the &yl1lllyliB ta the lislllllveollr bardfl' af the 111ird malar

""an batwaan tha anllriar bardar of tha riiiiS88tar and tha postarasuperia" inurliln
of1ha miiiS8bir lislllm tha third niJiar

Pllrt olthe

that 8ldands poalariaaupericlly illo the CDII!yllr caranid praca

Araa of CIJIIdo,W jnC8IIS ofllllllldibla

Figura 33. Maalihlllar flllcbn

Area below lila cmdylar nack (i.e. &Vnaid natdl) of the mild!!a

Araa of the Cllllnlid pnJC8SS d llllllldibla

Treatment
muillary and mandibular arch bars wired together (int:ramaDllary fixation) or ORIF
antibiotics to cover against S. aureus and anaerobes
Complications

malocclusion, mal.unlon
tooth loss, and possible sensation loss
temporomandibular joint (TMn ankylosis

Maxillary Fractures
Tabla 19. La Fort Clatiliclllion

Allin.._ Nan
TyJe of lracbn

Slrur:llns imhad

Anltlnal...-t

t.I'Gitl

La Fllltll

frlcbn

Pyrwlidal frlclllre

La Flllt Ill
l:raliollcill dyljiiiCtian

Horizontal
PiriDrm apa11n
Maxilllry sinus
PtErygoid plates

Pynmdal

TIIIIISIIa18

Nasal banes
Medial arbittll wall
Mada
Plarygcid plltal

ZygarnatGfnlntalmre
Zygomatic 8ICh

Madery18eth l8l)8l1ll8d from

face

DBtach entiremdflcill akllaton

frrm cnnial basa

Maxilla dividld inta 2. aapants

Nlsafnmlllllllnl

Ptalygaidplltel

La fait I Fradlns

La Flllt II Fncllnl

La Flllt II Flldlnl

.II

Toronto Nota 2011

Cnmiofadal.lajurics

Plutic SIUJCIY PL29

Nasal Fractures
Etiology
lateral force -+ more COlMlOil, good prognosis
anterior force -+ can produce more serious injuries
most common facial fracture

Clinical Features
epistaxislhemorrhage, deviationlflattening of nose, swelling, periorbUal ecchymosis, tenderness
over nasal dorsum. crepitus, septal hematoma, respiratory obrtrw:tion. subconjunctival
hemorrhage
depression and splayiDg ofnasal bones causing a saddle deformity
important to clinically assess for naso-orbital-ethmoid (NOE) fractures
Treatment
nothing
always drain ICpta1 hematomu as this is a cause ofseptal necrosis with perforation (saddle nose
deformity)

closed reduction w.lth Asch or Walsbam forceps under anesthesia, pack nostrils with Adaptic",
nasal splint for 7 days
best reduction immediately (<6 hours) or when swelling subsides (5-7 days)
rhinoplasty may be necessary later for residual defunnity (30%)

Naso-orbital Ethmoid (NOE) Fractures

Etiology
fractures of the nasal and ethmold bones of the medW. orbit
problematic and may lead to greatest change in facial appearance

Markowitz-Manson classification:
Type 1: Single, central fragment. medial canthal ligament intact
Type 2: Comminuted central fragment. medial canthal ligament intact
lYPe 3: Severe comminution of central fragment and disrupted medial canthalllgament

Clinical Presentation

telecanthus (increased intercanthal distance secondary to medial canthal ligament disruption)

orbital rim step-off

s1mJlar to nasal fractures (see above)

Treatment
surgkal repair to restore intercanthal distance. nasal projection and orbital anatomy

Zygomatic Fractures
3 categories (see Figure 34)
L fracture restricted to zygomatic arch
2. depressed fracture of zygomatic complex (zygoma)
3_ unstable fracture of zygomatic complex (tetrapod fracture) - sepanrtions occur at maxilla,
frontal bone. temporal bone and orbital rim

)r-\'\

Clinical Features
flattening ofmalar prominence (view from above)
pain over fractures on palpation
numbness in V2 distribution (infraorbital and superior dental nerves)
palpable step deformity in bony orbital rim (especially inferiorly)
often usociated with fractures of the orbital floor
ipsllateral epJstuis; trismus (lock Jaw)

Treatment
ifundisplaced, stable and no symptoms, then soft diet; no treatment necessary
ophthalmologic evaluation ifsuspected orbital injury
uncomplicated zygomatic arch fractures can be elevated using Gillies approach: leverage on the
anterior part of the zygmnatic arch via a temporal incision; stabilization often unnecessary
ORIF for displaced ar unstable fractures ofzygomatic complex

0..:

\..

":

, .

'}'ntuzygumatic
Zyprullie an:h

PL30 Plaatic Suqp!ry

Craniofadal.lnjuries

1'oroDio 2011

Orbital Floor Fractures

see Qphtha1moloK)Io OP43

Definition
fracture of floor of orbit intact infraorbital rim (see Figure 35)
may be assodated with naaoetbmoid fracture

Etiology
blunt force to eyeball -+sudden increase in intra-orbital presmre (e.g. baseball or fist)

Clinical Features

daeck ruual ftel.ds and acuity fur injury to Blobe

F'111.. 35. Blnv-0.. Fractu..

.... 1

Di!llopia Cll1
out liactinl.

IIIII illllllillll blow-

periorbital edema and bruiaing. subconjunctival hemorrhage

ptosis, exophthalmos. exorbitism. or enophthalmos
orbital rim step-off's with possible Infraorbital nerve anesthesia
vertical dystopia (abnormal displacement of the entire orbital cone in the vertical plane);
diplopia looking up or down (entrapment of inferior rectus), limited EOM
orbital entrapment:
clinical diagnosis that is a mrgical emergency
diplopia with vertical gaze: limited EOM
severe pain or nawea and vomiting with eye movement
requires urgent ophthalmology evaluation and mrgical repair

Investigations

cr (diagnostic) -axial and coronal views

diagnostic manoeu.vre for entrapment is Fon:ed Dudion test (pulling on inferior rectus IIIIlScle
with forceps to ensure full ROM) under anesthesia

Trelltment
surgical repair indicated if: urgent repair for entrapment, floor defect > l em, any size defect
with enopthalmus or persistent diplopia (>10 days)
reconstruction of orbital floor with bone graft or alloplastic material
ophthalmologic evaluation suggested
Complications
persistent diplopia
enopthalmos
Superior Orbital Fl88ure (SOF) Syndrome
fracture ofSOP causing ptosis, proptosis, anesthesla In Vl distribution. and painful

ophthalmoplegia (paralysis ofCN III. IV; VI)

uncommon complication seen in LeFort II and m fractures (1/130)
recovery time reported as 4.8-23 weeks fullowing operative reduction offractures
Orbital Apex Syndrome
fracture through optic canal with involvement of CN II at apex of orbit
symptnms are the same as SOP syndrome plus vision loss
treatment is urgent decompression offracture in optic canal or steroids (emergency)

Breut Surgery

Toronto Notes 2011

Plastic Surgery PL31

Breast Surgery
Breast Reconstruction

Table ZD. Options for Breast Reconstruction

Procedun

Definition

Surgical Detail

Implant

Use of synthetic material

(siicone or saline in1)1ml

Wi!h 8ICp8lldets (Z Stagesl: Use tissue

expanders before replacement with
implants to help facilitatu breast ptosis.
(see further discussion on 1issue
belawl
Without expanders (1 Stagal: In skinspiring mastactomy, anough skin is
available far immediate placement of
implant
Reconstruction with implants requns a
1ubmuscular placement of devices

CorrtJiications: capsular
contraction (foreign body
to implantsl. rupture or
leakage of in1)1ant, increased risk
of infection, 35% revision rate
ovar 5years

Aulologou T111ue Use of patient's awn tissue

Many flap options: DIEP (deep inferior

Offers reduced long-18rm
epigastric parfonrtorl. TRAM (trensvarse morbidity and natural
consistency
rectus abdorninusl,l.atissimus
SIEA (superfical ilferior epigastric ateryl,
SGAP gluteal al'lllry perforatorl,
and IGAP (inferior gluteal artery parlonrtorl

Nipple Areola

Usually tilttooing far areDia

Usualy performed 3 months
reconstruction
post-reconstruction
Local vs. distant flap/graft
1. Local: fish tail Dr skate ftap mDst
common; theseilap5 allow siooltaneous
nipple and areola reconstruction
Z. Distant: opposite nipple,
abdDminal skin, costal cartilage, labia

Recollltnlction

Final stage of breast

R!Construction

Breast Tissue Expanders

types: textured w. smooth, both with integrated port
placement: sub-pectoral, total submuscular (pecoraUserratus)
size: depends on contralateral breast and desired size
generally over-expanded to facilitate ptosis
timing of expansion: begins when wound fully healed {usually 2 weeks post-op), and implants
are expanded weekly or bi-weekly until complete (up to 3 months). Expanders are exchanged for
implants after another 3 months for consolidation of expanded skin

, ______________

......_._

l'lltiflnlll may r1quin 1 balancing

proc8Wra Dl1 conlnllltar&lside.

Pre-Reconstruction Considerations
radiation: treatment before and after mastectomy is a relative contraindication to alloplastic
reconstruction
recipient tissue: skin sparing mastectomy allows for the use of implants without tissue expanders
( 1 stage process)
donor tissue: limited availability of suitable donor tissue (lack of tissue, scar, previous surgery
that interferes with blood supply) may prevent the use of autologous tissue reconstruction
timing (immediate vs. delayed)
contralateral breast: may not be possible to reconstruct a breast of the same size or shape as the
contralateral breast. Breast reduction or mastopexy may be considered in opposite breast
(see Table 21)
other considerations: patient's age and co-morbidities, prognosis, body weight, characteristics of
chest wall and patient's attitude

integral part of breast cancer treatment

two basic methods: implants (I stage or 2 stage) or autologous tissue (see Table 20)
may also require breast balancing procedure and nipple areola reconstruction

1'oroDio

PL32 Plaatic Suqp!ry

2011

Aesthetic Surgery
Aesthetic Procedures
T1bl1 21. Alltlurtic Pracadres

HaatWeck Hair lln"'nts

ompasty
fla

Sllil

Aasthalic impravarrulll of hai" growth pattBms using SIIJiicsl carecliJn of prulndng ears

Bmw lit

SIIJiicll procad.ua to it low brows

Rhytidac:tDmy

Sllgicll procad.lra to rallce WliiliQ IIIII sagging af lhl flce111d nact. "'flee lift""

Bla!Droplasty
Rhinopllly

Sllgical procad.lra to shape or mocly lhl

fat pads
lnt11111181 flllgiceii'8CDIIIbuction of lhl111118

Genio!Btv

Chin llll!rnantatian vii Dlt8olomy or synthetic

Procedure Ia CI8IIIJ fUIIips 111d 1D

of ..,.lids by 1111111VirJ axcess svalid skin

contour

injeaions, fat transhmd !ram other body parts, or implantabla matnls

Dermllx'asian

Skin ra-1urfcing by Slllding wi1h a111pilly rota1D;I abRI&iva 1DDI. Often used 1D racb:a scars,
imaglilr skin .races and fila lines

Laser

AAJ!ication of laser to the ski! wlich ullimalely reslJbl in collagen recrig1.1111ian 101



skin DitiJg 101 Often used ID reduce seers IIIII wmdes

An injeclatile Ulbn:a il used 1D daCIIIS8 fnrMIIinee, wrinkiBI end

satn:es incllda colagen. fat. hyat.uonic acid and catium

Removal of lllCC8SS skin and rapai" of rectus muscle laidly (rectus diastasis).
Breaslaug111e1Dtian SIIJiicsl breast erllllncement 1Mth siiCillll! ar die

lmpl11f: PIIC811111f:

AAJ!ication of ooe ar 111111! exfoliating agem to 1he skin resulting in des1ruction of portions of
the apidarmillllll/or darmil with aubaa-1inua raganaretian

Dill

Figure 3&. Augmantation

Mmoplally: lncilia Una 1nd

wrirtles around lhl nmll using collagen

Cheni:al peel

l._ectlbla filn

Subpac:lcnl

of flaps

tuck""

(see Figure 36)

c aug111e1Dtian

Alvnenlllion of 131 nusde with

SIIJiicllraJIOVII of llipal81islualor body cadauring (nate weight 111111 pracad.lra)

Bnlllll ndJctian

Sllgicll breast lift to eiiVIta breast maund IIIII lil#elllhl skin envaq,. in ptDtic InaIlls
Sllgical breast nadlll:lian for ral&f af physic:all'l'"p1Dms

SclarathiiiiPY

lnjiiCiion with a sclaramt to 1IIBt !Jiangilr:lllllias llld varicas1 wins

Pediatric Plastic Surgery

Toronto Notes 2011

Plastic Surgery PL33

Pediatric Plastic Surgery

Craniofacial Anomalies
Table 22. Pediatric Craniofacial Anomalies
Definition

Epidemiology

Clinical Features

Treatment

Cleft Lip

Failure of fusion of
maxillary
and medial nasal
processes

1 in 1000 live births (1 in 800

Caucasians, increased in
Asians, decreased in Blacks)
More common on the left
(cleft of left lip/palate in boys
has hereditary component)

Classified as
incomplete/
complete and uni/
bilateral 2/3 cases:
unilateral, left sided,
male

Cleft lip team; Surgery

(3 months): Milliard or
Tennison-Randall; corrections
usually required later on (esp. for
nasal deformity)

Cleft Palate

Failure of fusion
Isolated Cleft Palate: 0.5 per
of lateral palatine/ 1000 (no racial variation)
median palatine
F> M
processes and nasal
septum

Classified as
incomplete/complete
and uni/bilateral
Isolated (common
in females) or in
conjunction with cleft
lip (common in males)

Special bottles for feeding

Speech pathologist
Surgery (69 months):
Von Langenbeck or Furlow Z-Piasty
ENT consult - often recurrent OM,
requiring myringotomy tubes

Syndromic- assoc.
with genetic mutation
Secondary (to
microcephaly,
hyperthyroid, rickets,
etc.)
Dx: irregular head
shape, craniofacial
abnormalities, x-ray

Multidisc. team (incl. neurosurg,

ENT, genetics, dentistry, peds,
SLP)
Early surgery prevents secondary
deformities 1' ICP is an indication
for emergent surgery
ICU bed may be req'd post
surgically

M:F = 2:1

Craniosynostosis Premature fusion of

1+ cranial sutures
Primary - abnormal
suture, no known
cause
This may limit brain
perpendicular to the
suture and cause
compensatory
growth parallel to
the fused suture

1 in 2000 live newborns; M:F

= 52:48
Syndromic includes:
Crouzon's, Apert's, Saethre
Chotzen, Carpenter's,
Pfeiffer's Jackson-Weiss and
Boston-type syndromes

Incomplete Cleft Palate

Complete Cleft Palate

Cleft lip and Palate

Defects of Soft Palate Only

Defects of Soft and Hard Palate

Defects of Soft Palate to

Alveolus, Usually Involving Up

Figure 37. Types of Cleft Lips and Palates

Complete Bilateral Cleft

PL34 Plastic Surgery

Pediatric: Plastic Surgery

Toronto Notes 2011

Congenital Hand Anomalies

Tabla 23. Americen Society for Surgery of the Hand (ASSH) Clauificetion of Congenital Hand
Anomalies
Clllificati111

Exmpla

FaIlium

Tl'llllmlnt

A. Failure d fonnrtion

Trensverse Absence
(congenital amputation)

Al any level (often below

elbow/Wrist)

Early prosthesis

Longitudinal Absence
(phocomelia)

Absent humerus
ThalidomidHSSOc.

Radial Dsficiency {radial club

hand)

Radial deviation
lllJmb hypoplasia
M>F

lllJmb Hypoplasia

Dagrue ranges from small

Depends on dagrue - may involw
thumb with all C0f11)01lents to no treatment. webspace deepening.
complete absence
tendon transfer, or pollicization at index
finger

Ulnar Cub Hand

Rare, compared to radial dub

hand
Stable wrist

Splinting and soft-tissue stretching

therapies
Soft-tissue ruleasa abova fails)
Correction of angulation (llizarov
distraction)

Cleft Hand

Autosomal dominant
Often functionally nonnal
{dependiiW,l on degree)

First web space syndactyly release

OSI8atomy/tendon transfer of 1hlmb
(if hypoplastic)

Syndactyly

Fusion of 2+digits
Surgical separation before 612 months
at age
113000 live birth&
M:F=2:1
Usually good result
Classified as partiaVcomplete
Simple (skin only) vs. complex
(osseous or cartilaginous
tridgBB)

Symbrechydactyfy

Short fingers with short nails

at fingertips

Digital separation (more difficult)

Webspace deepening

Carnptodactyly

CDIW,lenital flaxion contracture

{usually at PP. esp. 5th digit)

Early aplinting
Volar release
Arthnoplasty (rarely)

Clinodactyly

Radial or ulnar deviation

Often middle phalaRK

None (usually). If severe, osteotomy

with grafting

C. Duplication

Polydactyly

Congenital duplication of digits Al11)utation of least functional digit

May be radial {increased i1
Usually > 1yr of age {when functional
Aboriginals ll1d Asians) or
status can be assassed)
central or ulnar (increased in
Blacks)

D. Overgrowth

Macrodactyly

Rare

None (if mild)

Soft tissue/oony recllction

E. Undergrowth

Brachydactyly

Short phalqes

Removal of non..functional stumps

Ostaotomiatltendon transfers
Distraction ostaogenasis
PhalaiW,lealltree IDe transfer

Symbrechydactyfy
{Brachysyndectyly)

Short webbed fingers

As above + syndactyly release

F. Constriction band
syndrome

AKA amniDiic (annular) band

syndrome

Variety at presentations

Urgent release for acute, progressive

edema dislal to band in newborn
Other reconstruction is caseoipecific

G. Generalized skeletal
abnormality

Achondroplasia, Marian's,
Medelung's

Variety at presentations

Treatment depends on etiology

B. Failure !I
diffarentiationl
separation

Physic + splirting
Soft tissue splinting fails
Distraction osteogenesis (llizarov)
:t wedge osteotomy
Tendon transfar
Pollicization

Toronto Notes 2011

References

References
Gl'lll Plastio Sul'l'l'f Concepti
Bruwn Dl, Bortdlul GH. Mielligln manual of ]ilutic IIIITillllY Plilldlllphia: SIIUIId111, 21104.
Dmr BM, Antii NH, Fumu liN. H111dbook of plu1ic 111g1111 far the genmluQean seclrlld editilln. New Delhi: Oldord University Pless. 1995.
Gaorvilda GS. Rielblll R, Levin LS. Guorgiade pll$tic. lllllilkllacialllld turvery third edition. llallinole: Willia111$llrld Wilkils. 1m.
Hunt TK. Wound Heatv.ln: Doherty G'lll, Wrt LW, eels. Cllnent surgical &lrellmenl twellh edition. Norwalk. CT: McGmv-HI, 2006.
Jaril JE.
of Pllllic Surv111Y: AUT Sautlrwlslim Medical C111111' HIIIIIW. St lolis, MD: lblty 211Jl.
Noble J. Tllldbook. of primery CUll medicine thi'd editi:JA. St. LDui&: 2001.
Dng YS, Samuel Mand S1111g C. Mellilnaly&i of lll!ly IIXl:ision of bum&. Bum&. 2006; 32: 145-50.
Plastic Simi illY Educational Fllmllation. Plntic end riCCnlltruc1iva IIIITil&ry ..ntiall fer studlllll. Arlington Hlig!D, IL: Plastic Surv-ry Educa1icnl Fa.mdatian, 2007.
_ prolwlionait'pliblication.&ential!.for-&udlllll.c:fm.
Rimuds AM.Key rns ill Great BrUin: Blacllwell Science Ltd. 2002.
S.. Ill. Practical pllllic surgery lor non-surQIOIIL Philedalplia: Hsnley &Bellus Inc. 2001.
Snith llJ. Brown AS, Crull CW at II. Plllltic and recgnltructiw IIIIQIIY. ChiRgo: Plastic &r!liiY Educatinl Fudrlill, 1987.
Stiml C.l'lutic llflllly. IKII. l.Dndon: Graanwiell Medical Medii Lid. 2001
TIMII!Hnd CM. SalisiDn 1lDdlloci rl surgary- the bioiiiQiCII bllis rl mod am llfllical p!ICiica six!aenth aditiarl. Phillldelpllia: W.B. Sudars
2001.
Yasoonez HC. RBI, V.sconez 1.0. Plastic & reconslrul:live surgery. In: Doherty GM, Wrt LW, eels. Cllnent surgical dilglais &lrellmenl twellh edition.
No!wal CT: McGn.w-llill 2006.
W8inzwaig J. Plllltic :ugary SICtllls. I'MIIdalphil: Hanley snd Belfuslnc, 1919.
lt.d
Am8rican Societyfor Surgvry rl tha Hand. The hand: l!XIminlltion and diiiiJIOSis third edition. Philad81phia: 1190.
Beredjik111r1 PK. Bozenikll DJ. Rft'iew of band ugery. Philadelphia: Suders. 2004.
Graham B, llegehr G. Naglie G. Wright J. Devalopment andvaidation of diagnostic critlril forcarpellunnllsyndrome. J Hand 2006; 31[6): 919.tl-919.e7.

Plastic Surgery PL35

PL36 Plastic Surgery

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