Hypermetabolism

Immunosuppression 4

Progressive Pulmonary Insufficiency

r n

Renal Failure (2°to X Renat Blood Row) 4- L J

Increased Gut Mucosal Permeability

(Gl Bleed Risk)

Figure 21. Systemic effects of severe burns

+

• nutrition

hypermetabolism: TBSA >40% have BMR 2-2.5x predicted

consider nutritional supplementation (e.g. calories, vitamin C, vitamin A, Ca 2+, Zn 2+ I-

'

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PL23 Plastic Surgery Toronto Notes 2023

• immunosuppression and sepsis

must keep bacterial count <105 bacteria/g of tissue (blood culture may not be positive)

signs ofsepsis:sudden onset of hyper/hypothermia, unexpected CHF or pulmonary

edema, development of ARDS,ileus >48 h post-burn,mentalstatus changes, azotemia,

thrombocytopenia, hypofibrinogenemia, hyper/hypoglycemia (especially if burn >40% TBSA)

•GI bleed may occur with burns >40% TBSA (usually subclinical)

treatment:tube feeding or NPO if there is a Gl bleed, antacids, H2 blockers (preventative)

• renal failure secondary to under resuscitation,drugs, myoglobin, etc.

• progressive pulmonary'insufficiency

• can occur after:smoke inhalation, pneumonia, cardiac decompensation,sepsis

• wound contracture and hypertrophic scarring

outcomes optimized with timely wound closure,splinting, pressure garments, and physiotherapy

Special Considerations

CHEMICAL

• major categories:acid bums,alkaline burns, phosphorus burns,chemical injection injuries

• common agents:cement, hydrofluoric acid, phenol, tar

• mechanism of injury:chemicalsolutions 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 of tissue penetration

• bums are deeper than they 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 (contraindicated in elemental metal burns,such as

sodium, potassium, magnesium, and lithium; in these cases,soak in mineral oil instead)

• inspect eyes;if affected, wash with saline and refer to ophthalmology

• inspect nails, hair, and webspaces

•correct metabolic abnormalities and provide tetanus prophylaxisif necessary

• contact poison control line if necessary

•local wound care 12 h after initial dilution (debridement)

• wound closure same asfor thermal burn

• beware of underestimated fluid resuscitation,renal, liver, and pulmonary damage

Table 20. Special Bums and Treatments

Burns Treatment

AridBurn

Hydrofluoric Acid

Waterirrigation,followed by dilute solution of sodium bicarbonate

Waterirrigation:clip fingernails to avoid acid trapping:topical calcium gel t subcutaneous injection of calcium

gluconate

- 10 c calcium gluconate IVdepending on amount of exposure and pain

Treat with soap1

lime prior to irrigationas direct water exposure produces extremeheat

Remove with repeatedapplication of petroleum based antibiotic ointments (e.g.Polysporin'

)

Sulfuric Acid

Tar

ELECTRICAL BURNS

• injury occurs due to flow of current through body, arc flash,or clothing catching on fire

• depth of burn depends on voltage and resistance of the tissue (injury more severe in tissues with high

resistance)

• often presents assmall punctate burns on skin, with extensivedeep tissue damage which requires

debridement

• electrical burns require ongoing monitoring (ECG and neurovascularstatus),aslatent injuries can

occur

• watch for system-specific damages and abnormalities

• abdominal:intraperitoneal damage

bone:fractures and dislocations especially of the spine and shoulder

cardiopulmonary: anoxia,ventricular fibrillation,arrhythmias

muscle: myoglobinuria indicatessignificant muscle damage -> compartmentsy ndrome

neurological:seizures and spinal cord damage

ophthalmology:cataract formation (late complication)

* renal:acute tubular necrosis resulting from toxic levels of myoglobin and hemoglobin

vascular:vessel thrombosis -> tissue necrosis (increased Cr,K+, and acidity),decrease in RBC

count (beware of hemorrhages/delayed vessel rupture)

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PL24 Plastic Surgery Toronto Notes 2023

Treatment

• ABCs, primary and secondary survey, treat associated injuries

• beware of cardiac arrhythmias (continue cardiac monitoring)

• monitor:hemochromogenuria, compartmentsyndrome, urine output

• wound management:topical agent with good penetrating ability (silver sulfadiazine or mafenide

acetate)

• debride nonviable tissue early and repeat prn (every 48 h ) to prevent sepsis

• amputationsfrequently required

FROSTBITE

• see Emergency Medicine. ER46

Hand s

Traumatic Hand

Compartment

<®

Syndrome

Watch out tor these signs:tense,painlul

extremity (worse on passive stretch),

paresthesia/paralysis,pallor,and distal

pulselessness (often late in process).

Intracompartmental pressures can

be measured,commonly via needle

manometry (generally abnormal

pressures are considered to be >30 40

mmHgl. Ot note,upper and lower

extremity pressures are different and

comorbidities can result in variability in

measured pressures.As such,indication

for an emergent fasciotomy is based on

clinical diagnosis:if untreated,end result

is Ischemic contracture of the extremity

(Volkmann's contracture)

Table 21. Key Features of the History and Physical Exam of the Injured Hand

HISTORY

Key Questions tge Tetanus status

Diabetes

Smoking status

last oral intake

Previous bistory of band injury

Hand dominance

Occupation

Time and place of accident

Mechanism ol Injury

Initial treatment received

PHYSICAL EXAM

Structure Examination

Observation Position of finger Abnormal cascade (fingers normally slightly flexed and point towards

scaphoid),scissoring

Bony protrusions or specific deformities (e.g. mallet,boutonnibre, and swan

neck deformity)

May indicate underlying skeletal injury

Deformity

Approach to Hand Lacerations Bruising or swelling

Sweating pattern (usually felt more May indicate denervation

so than from observation)

Anatomical structures beneath If open laceration,need to explore within wound (under sterile conditions)

Palpate pulses

Allen's test

Assess capillary refill (<2-3 s)

Doppler ultrasound

For each test, need to compare both sides

Volar radial tip of index finger

TIN AX

Tetanus prophylaxis

Irrigate with NS (copious irrigation and

debridement in a timely manner)

NPO (NPO if you are considering

replanting or an urgent OR,otherwise

most operations are done as elective

procedures)

Antibiotic prophylaxis (controversial

- most require no antibiotics,mainly

needed for lacerations associated with

fractures)

X-rays

Vascular Status Radial and ulnar arteries

Digital arteries

Temperature and skin turgor

Sensory Median nerve

(see Figure3.PL3)

Volar ulnartipof little finger

Dorsal web space ol the thumb

2-point discrimination on both the radial and ulnar side of the DIP creases

(static or moving 2-point discrimination)

Flex DIP of index finger (to test the AIN branch)

Touch the tip of the index finger to the thumb trying to break through (“OK

sign")(to test the AIN branch)

Thumb to ceiling with palm up (to testthe recurrent motor branch)

Thumb to tip of 5th digit (to testthe recurrent motor branch)

Extrinsic muscles:flex DIP of little finger

Intrinsic muscles:abduct index finger ("Peace sign") or patient able to hold

piece of paper between adducted thumb and index finger and resist pulling

(“Froment’ssign")

Extrinsic muscles: extend thumb (“thumb's up") and wrist

Assess active and passive range of motion of wrist:extension/flexion/ulnar/

radial deviation; finger abductionfadduction/flexioniextension;thumb flexionl

extension/abduction/adduction/opposition

Stabilize PIP in extension,ask patient to flex fingers (at DIP)

Stabilize non- exam fingers in extension (neutralizes FDP) and ask patient to Ilex

examination finger (atPIP)

Focal tenderness or abnormal alignment

Instability may indicate ligamentousinjury or dislocation

Ulnar nerve

Radial nerve

Digital nerves

Motor Function Median nerve

Allen’s Test You need to exsanguinate

the hand by having the patient open and

close the hand.Then,while patient's

hand is firmly closed,occlude both radial

and ulnar arteries.Once fist is open,

release one artery and assess collateral

flow.The process should be repeated for

the other artery

Ulnar nerve

Radial nerve

Tendons,bones,joints,nerves

ri

Tissue Resistance to Electrical Current

Nerve< vessel,blood < muscle< skin <

tendon < fat <bone

Range of Motion L J

Tendons FDP

FDS +

Palpation Bones

Joints

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PL25 Plastic Surgery Toronto Notes 2023

General Management of Hand Injuries (Categorized by

Tissue)

Nerves

• test the nerve function BEFORE putting in local anesthesia

• primary repair for a clean injury within 2 wk and without concurrent major injuries:secondary repair

if >2 wk (may require nerve graft)

• epineurial repair of all digital nerves with minimal tension

• postoperative: dress wound, elevate hand, and immobilize

•

‘

find’ssign (cutaneous percussion over the repaired nerve) produces paresthesias and defineslevel of

nerve regeneration

Wallerian degeneration occurs in the first 2 wk, which is why there is no'

findssign until after

thistime period

• a peripheral nerve regenerates at 1 mm/d

paresthesiasfelt at area of percussion because regrowth of myelin (Schwann cells) isslower than

axonal regrowth -» percussion on exposed free-end of axon generates paresthesia

Hand Exam

• Never blindly damp a Weeding

vessel as nerves are often found in

close association witti vessels

• Never explore any volar hand wound

intheER

• Arterial Weeding from a volar digital

laceration is likely associated with a

nerve laceration (nervesin tigitsare

superficial to arteries)

Vessels

• often associated with nerve injury in the digits (anatomical proximity)

• control bleeding with direct pressure and hand elevation

• if digit devascularized, optimal repair within 6 h

• close skin, then dress, immobilize, and splint hand with fingertips visible

• monitor colour, capillary refill,skin turgor,fingertip temperature post-revascularization

Tendons

• most tendon lacerations require repair

• most extensors are repaired in the emergenq- room,flexors are repaired in the operating room within

2 wrk

• see Tendons,PL27

Bones

• see Fractures and Dislocations, PL28

Nailbed

• subungual hematomas >50% of the nailsurface area need to be drained (trephination),done under a

digital block by puncturing nail plate

• if suspecting greater severity of injury'

(e.g.distal phalanx displaced fracture,laceration of nail bed),

remove nail plate to examine underlying nailbed under digital block anesthesia

• irrigate wound and nail thoroughly

• suture repair of nailbed with chromic suture

• replace cleaned nail, which acts as a splint for any underlying distal phalangeal fracture and prevents

adhesion formation between nail fold and nailbed

Hand Infections

Principles

• trauma is most common cause

• 90% caused by Gram-positive organisms

• most common organisms (in order):S.aureus, S.viridans,GAS,£ epidermidis,and Bacteroides

melaninogenicits (MRSA is becoming more common)

TYPES OF INFECTIONS

Deep Space Infections

• abscess formation in deep spaces of the hand, parona’sspace, web spaces,or most commonly thenar

or midpalmarspace

Felon

. definition:abscess in the pulp of a fingertip or thumb that occurs following a puncture wound into

the pad of the digit; may be associated with osteomyelitis

• treatment: elevation, warm soaks, cloxacillin 500 mg PO q6 h (if in early stage); if obvious abscess

or pressure on the overlying skin or failure to resolve with conservative measures, then l&D,take

cultures/Gram stain, and adjust antibiotics to culture results

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PL26 Plastic Surgery Toronto Notes 2023

Flexor Tendon Sheath Infection

• Staphylococcus > Streptococcus > Gram-negative rods

• definition:abscess within the flexor tendon sheath (flexor tenosynovitis), commonly caused by a

penetrating injury and can lead to tendon necrosis and rupture if not treated

• clinical features: Kanavel’

s 4 cardinalsigns

1.point tenderness along flexor tendon sheath from A1 pulley onwards

2.severe pain on passive extension of digit

3.fusiform swelling of entire digit

4.flexed posture (increased comfort)

• treatment

non-suppurative:antibiotics, resting hand splint and elevation until infection resolves, hand

therapy after

• suppurative (produces pus):l&D in OR

Herpetic Whitlow

• HSV-1, HSV-2

• definition:painful vesicle(s) around fingertip or thumb

often found in medical/dental personnel and children

• clinical features: can be associated with fever, malaise,and lymphadenopathy, prodromal phase

patient is infectious until lesion has completely healed

• treatment: diagnosed clinically, if in doubt confirm with viral culture/PCR or Tzanck smear, usually

self-limited, consider oral acyclovir in severe cases;debridement of these lesionsis contraindicated

Paronychia

• acute = Staphylococcus;chronic = Candida

• definition: infection (granulation tissue) ofsoft tissue around fingernail (within the paronychium

and/or 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 oral antibioticsif caught early;if abscess present,

drainage with blade (avoid hitting nail bed) and oral/IV antibiotics;if abscess extendsto below

nail plate, nail plate removal may be required

chronic paronychia:antifungals, eponychial marsupialization; nail plate removal may be required

Amputations

Hand or Finger

• emergency management: injured patient and amputated part requires attention

patient:x-rays (stump and amputated part), NRO, clean wound and irrigate with NS, dressstump

with non-adherent dressing, cover with dry sterile dressing, tetanus and antibiotic prophylaxis

(cephalosporin/erythromycin)

• amputated part: x-rays, gently irrigate with RL,wrap amputated part in a NS/RL soaked sterile

gauze and place inside waterproof plastic bag,place in a container,then place container on ice

• indicationsfor replantation

age: children often better results than adults

level of injury: thumb and multiple digit amputations are higher priority; multiple level

amputation is a contraindication to replant

nature of injury:clean cut injuries have greatersuccess;avulsion and crush injuries are relative

contraindicationsto replant

• if replant contraindicated, manage stump with revision amputation

involves debriding stump of wound,trimming back the bone and nerve endings, and gently

dosing the skin

commonly done in the ER under digital block

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PL27 Plastic Surgery Toronto Notes 2023

Tendons

Common Extensor Tendon Deformities

Table 22. Extensor Tendon Deformities

Injury Definition Zone Etiology/Clinical Features Treatment

Mallet Finger DIP flexed with loss of 1

active extension

There are bony and non-bony mallets Splint DIP in extension for

Bony:fracture of distal phalanx distal 6 wk.followed by 2 wk of

lo tendon insertion

Non -bony:forced flexion of the

extended DIP leading to extensor

tendon rupture at DIP (e.g. sudden

blow to lip of the finger)

Injury or disease affecting the

extensor tendon insertion into the

dorsal base ol the middle phalanx

Associated with RA or trauma

(laceration,volar dislocation,acute

forceful flexion of PIP)

night splinting; if inadequate

improvement after 6 wk, check

splinting routine and recommend

4 more wk of continuous splinting

Boutonniere Deformity PIP flexed. DIP 3

hyperextended

Splint PIP in extension and allow

active DIP motion

DIP

n

111 Swan Neck Deformity PlPhypcrcxIended. DIP 1.3 Trauma (PIP volar plate injury) Corrective procedures

Associated with RA and old. untreated involve tendon rebalancing or

ailhrodcslsfartliioplusty

Zone 1

one 2

Ik.nl

mallet deformity

Splint to pievent PIP hyperextension

or DIP flexion

CO

est

Zone 3

B. Zone 4

Zone 5

;

4one 6

'Zone 7

i

DIP flexion v

=c

I

PIP iiyperextension -i

Zone 8

CS £)EmilyTaylor 2020 after Jackie Sobers

^

Figure 23. Zone of extensor tendon

injury (odd numbered zones faII over

a joint)

Figure 22. Extensor tendon deformities:(A) Mallet finger deformity (B) Boutonniere deformity (C) Swan neck

deformity

De Quervain’s Tenosynovitis

• definition: tenosynovitis is inflammation of the tendon and/or itssheath. Most common is De

Quervain’stenosynovitis (inflammation of the extensor tendons in the 1st dorsal compartment (APL

and EPB))

• clinical features

positive finkelstein’stest (pain over the radialstyloid induced by making fist, with thumb in

palm, and ulnar deviation of wrist)

• pain localized to the Ist extensor compartment

• tenderness and crepitation over radial styloid may be present

• differentiate from CMC joint arthritis(CMC joint arthritis will have a positive grind test, whereby

crepitus and pain are elicited by axial pressure to the thumb)

• treatment

mild: NSAIDs,splinting, and steroid injection into the tendon sheath

severe:surgery to open 1st dorsal compartment and release stenotic tendon sheaths of APL and EPB

Ganglion Cyst

• definition

• fluid-filled synovial lining that protrudes between carpal bones or from a tendon sheath; most

commonly carpal in origin

• most common soft tissue tumour of hand and wrist (60% of masses)

• clinical features

• most commonly on the dorsal wrist overlying the scapholunate ligament,followed by the volar

surface of the wrist overlying the radioscaphoid or scaphotrapezial joints

• 3 times more common in women than in men

• more common in younger individuals (2nd to 4th decades)

• can be large or small (may drain internally so size may wax and wane)

• often non-tender, although tenderness increased when cyst is smaller (from increased pressure

within smaller cyst sac)

<DAva Schroodl 202) after Shelley Wall 2003

^

Figure 24. Zones of the flexor

tendons

r T

L J

• treatment

conservative treatment: observation and reassurance; advise patient against rupturing cyst

aspiration (recurrence rate 30-60% within one yr, risk of damaging nearby neurovascular

structures)

• steroid injection if painful (done in combination with aspiration, as results alone arc no better

than aspiration )

• consider operative excision of cyst and stalk (recurrence rate 5.9% for dorsal wrist ganglion, 30%

for volar)

+

A 2 and A 4 pulleys arc most Important

for function: prevent bowstrlnglng of

tendons

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PL28 Plastic Surgery Toronto Notes 2023

Common Flexor Tendon Deformities

• flexor tendon zones (important for prognosis of tendon lacerations)

• “no-man'

s land" (zone 2)

between distal palmar crease and mid-middle phalanx

zone where superficial

^

and profunduslie ensheathed together

• recovery of glide very difficult after injury

Nodi ic Stenosing Tenosynovitis (Trigger Finger/Thumb)

• definition: inflammation and thickening of tendon or tendon sheath /pulley (most commonly at A- l

pulley near MCP), preventing smooth gliding of tendon through the sheath/pulley and resulting in

locking of thumb or finger in flexion /extension

• etiology: idiopathic or associated with KA, DM, hypothyroidism, gout, and pregnancy

• clinical features

ring finger is most commonly affected, then long finger and thumb

patient complains of catching,snapping, or locking of affected finger

tenderness to palpation/nodule at palmar aspect of MCP over A-l pulley

• women are 4 times more likely to he affected than men

• non-surgical treatment

• NSAlDs

steroid injection; injections lesslikely to be successful in patients >60 yr, or symptoms greater

than 6 mo

splint

• surgical treatment

indicated if no relief of symptoms or minimal relief with steroids

incise A-l flexor pulley to permit unrestricted, full active finger motion

Synovial sheath

Flexor digitor urn

superficialis

Flexor digltorum

prolundus

(SCostio Hillock WallingM21y

Figure 25. Digital flexor pulley

system

Fractures and Dislocations

•for fracture principles,see Orthopaedic Surgery, OR5

FRACTURES

•about 90% of hand fractures are stable in flexion (splint to prevent extension)

•position ofsafety

wrist extension 0-30“

. MCP flexion 70-90°

IP full extension

this is done if you want to immobilize a fracture but are notsure whether there are other injuries

•stiffnesssecondary to immobilization is the most important complication

Distal Phalanx Fractures

•most commonly fractured bone in the hand

•usual mechanism is crush injury, and thus accompanied by soft tissue injury

•subungual hematoma is common and must be decompressed, especially if there is involvement of

>50% of the nailsurface area,see General Management of Hand Injuries(Categorized by Tissue), PL25

•treatment:3 wk of digitalsplinting (immobilize the DIP with a STAX"

splint); if intra-articular

fracture displaced >30%, then percutaneous pinning (K-wires) and splint, or OKU-

'

Proximal and Middle Phalanx Fractures

•check for: rotation,scissoring (overlap of fingers on making a fist),shortening of digit

•non-displaced or minimally displaced: closed reduction (if extra-articular), buddy tape to

neighbouring stable digit, elevate hand, careful motion of extremity with splint to prevent reinjury,

splinted for 2-3 wk

•displaced, non-reducible, not stable with closed reduction, or rotational or scissoring deformity:

percutaneous pinning (K-wircs) or OR11'

, and splint

Metacarpal Fractures

•generally accept varying degrees of deviation before reduction required: up to 10“ (D2), 20* (D3), 30“

(D4), or 40“ (D5)

•Boxer’s fracture: acute angulation of the neck of the 5th metacarpal into palm

mechanism: blow on the distal-dorsal aspect of closed fist

loss of prominence of metacarpal head, volar displacement of head

up to 30-40“ angulation may be acceptable

closed reduction should be considered to decrease the angle

if stable, ulnar guttersplint for 4-6 wk

•Bennett’sfracture: two-piece fracture/dislocation of the base of the thumb metacarpal, usually intraarticular

» unstable fracture

AFL pulls MC shaft proximally and radially, causing adduction of thumb

treat with percutaneous pinning or OR1F,followed by thumb spica for 6 wk

•Rolando fracture:T- or Y-shaped fracture of the base of the thumb metacarpal

treated like a Bennett’sfracture

ri

1

_ J

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PL29 Plastic Surgery Toronto Notes 2023

DISLOCATIONS

• treatment: must be reduced as soon as possible

• dislocation vs. subluxation

• dislocation:severe injury where articularsurfaces of a joint are no longer in contact with one

another

• subluxation:articularsurfaces of a joint are partially out of place (i.e.“partial dislocation” - often

unstable and requires reduction)

PIP and DIP Dislocations (PIP more common than DIP)

• usually dorsal dislocation (commonly from hyperextension)

• 3 views of hand needed with x-ray imaging to assess degree of dislocation ( posteroanterior, oblique,

and lateral)

• if closed dislocation:closed reduction and splinting in position of function for 1 wk or buddy taping,

and early mobilization (prolonged immobilization causesstiffness)

• open injuries are treated with wound care, irrigation, and debridement, followed by closed or open

reduction and antibiotics

MCP Dislocations (relatively rare)

• dorsal dislocations much more common than volar dislocations

• dorsal dislocation of proximal phalanx on metacarpal head;most commonly index finger

(hyperextension)

• two types of dorsal dislocation

• simple (reducible with manipulation): treat with closed reduction and splinting for 2-4 wk at 60-

70" MCP flexion

complex (irreducible, most commonly due to volar plate blocking the reduction):treat with open

reduction

UCL Injury of the Hand

• forced abduction of thumb (e.g.ski pole injury)

• skier’s thumb: acute UCL injury; if stable (elbow valgusstress test), treated with splint x 6-8 wk; if

unstable, patient may have Stener lesion

• Gamekeeper’s thumb: chronic UCL injury, often requires open repair and tendon graft for

stabilization

• Stener lesion: the distal portion of the UCL can detach and flip superficial to the adductor aponeurosis

and will not appropriately heal; requires open repair (requires x-ray imaging to diagnose)

• evaluation: radially deviate thumb MCP joint in full extension and at 30" flexion and compare with

non-injured hand. UCL rupture is presumed if injured side deviates more than 30" in full extension or

more than 15" in flexion

Dupuytren’s Disease

Definition

• proliferative disorder of the palmar fascia,forming nodules (usually painless),fibrous cords, and

flexion contractures at the MCP and interphalangeal joints

• flexor tendons not involved

• Dupuytren’

s diathesis:male sex, early age of onset,strong family history (autosomal dominant

inheritance), involvement of multiple digits, bilateral involvement, and involvement ofsites other

than palmar aspect of hand, including the plantar fascia (Ledderhose'

s) and the penis (Peyronie’s;see

Urology. Table 24, U33)

Epidemiology

• unusual in Asian patients or patients of African descent, high incidence in northern European

patients,men > women, often presentsin 5th-7th decade oflife; associated with but not caused by

alcohol use,smoking, and DM

Clinical Features

• nodules, cords, and contractures of MCP, PIP, and DIP

• order of digit involvement (most common to least common):ring > little > long > thumb > index

• risk of recurrence

1

i

A -

£

Cord m!

Nodule

'

\

'

Palmar T aponeurosis

Figure 26. Dupuytren’s disease

Treatment

• palmar pit or nodule: no surgery (steroid injections for pain)

• palpable band/cord with no limitation of extension (i.e. no contracture) of either MCP or PIP: no

surgery

• MCP contracture >30"or PIP contracture of any degree: needle aponeurotomy, collagenase

Clostridium histolyticum (Xiaflex*) injection (indicated if cord is palpable), orsurgical fasciectomy

• contractures impeding function and/or hygiene: needle aponeurotomy, collagenase injection,or

surgical fasciectomy

• MCP joints have better outcomes than PIP joints post-treatment (achievement of near full extension,

lower risk of recurrence)

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PL30 Plastic Surgery Toronto Notes 2023

Carpal Tunnel Syndrome

Definition

• median nerve compression at the level of the flexor retinaculum/transverse carpal ligament

Etiology

• median nerve entrapment at wrist

• primary cause isidiopathic

• secondary causes:space occupying lesions (tumours, hypertrophic synovial tissue,fracture callus,

and osteophytes);metabolic and physiological (pregnancy,hypothyroidism, acromegaly, and RA);job/

hobby-related repetitive trauma, especially forced wrist flexion

Epidemiology

• l

:

:M»4:l, most common entrapment neuropathy

Clinical Features

• classically, patient awakened at night with numb/painful hand,relieved by shaking/dangling/rubbing

• on exam,sensory loss in median nerve distribution (see Figure 3,PL3), but thenar eminence sensory

loss isspared (palmar cutaneous branch given off prior to carp;

• decreased light touch and 2-point discrimination at DIP radial

touch often lost first

• advanced cases:thenar wasting/weakness due to involvement of the motor branch of the median

nerve

• ± Tinel'

s sign (paresthesia on percussion of nerve)

• ± Durban'

s sign (paresthesia after pressure over carpal tunnel <30 seconds)

• ± Phalen’ssign (wrist flexion inducessymptoms)

Investigations

• generally a clinical diagnosis

• NCS and EMG studies may be used to objectively confirm the diagnosis if clinical history is atypical

al tunnel)

and ulnar creases;discriminative

Treatment

• avoid repetitive wrist and hand motion, wrist splints at night and when repetitive wrist motion

required

• conservative: night-time splinting to keep wrist in neutral position

• medical:NSAlDs,local corticosteroidsinjection (relief from local corticosteroid injections is also

diagnostic)

• surgical decompression:transverse carpal ligament incision to decompress median nerve

• indicationsforsurgery: persistent signs and symptoms of median nerve compression not relieved by

conservative management, or if motor function is compromised

Brachial Plexus

Etiology

• common causes of brachial plexus injury: complication of childbirth and trauma

• other causes of injury: compression from tumours,supernumerary ribs

Common Palsies

Table 23. Named Neonatal Palsies of the Brachial Plexus

Palsey Location of Injury Mechanism of Injury Features

Duchenne-Erb Palsy Upper brachial plexus (C5-C6) Head/shoulder distraction (e.g. “Waiter's lip deformity'

(shoulder internal

rotation, elbow extension and pronation,wrist

flexion)

"Claw hand"

May include Horner'ssyndrome

motorcycle)

Klumpko’s Palsy Lower brachial plexus(C8-I1) Traction on abducted arm

Differential Diagnosis of Adult-Acquired Brachial Plexus Palsies

• trauma (blunt, penetrating)

• thoracic outletsyndrome

• associated with large cervical rib,anomalousfirst rib,strenuous arm work, and neck muscle

hypertrophy

» neurogenic:compression of brachial plexus, resulting in upperlimb paresthesia, pain,and

weakness

vascular: compression/thrombosis of subclavian artery/vein, resulting in pain; pallor and

Raynaud'

s if arterial;swelling and cyanosis if venous

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PL31 Plastic Surgery Toronto Notes 2023

•tumour

schwannoma:well-defined margins enable total resection

• neurofibromas: associated with neurofibromatosis type 1

other: e.g. Pancoast syndrome (apical lung tumour)

•neuropathy (compressive, post-irradiation, viral, diabetic, idiopathic)

Investigations

•EMG

•MR1:gold standard for identifying soft tissue masses and nerve roots

•CT myelogram

•closed injuries:if avulsion suspected, then CT myelogram or MR1 initially;otherwise, EMG/NCS 12

wk post-injury to assess healing progress

•open injuries:OK for exploration within a few days post-injury (once patientstable)

Management

Table 24. Management of Brachial Plexus Injuries*

Closed Injuries Concussive/compressive

Traction/stretch

Obstetric palsy

Olten sell

-resolving (unless eipanding mass, e.g. hematoma)

II no continued insult,follow lor 3-4 mo (or improvement

Surgery il no significant improvement and/or residual paresis

at age 6 mo

Open Injuries Sharp or vascular injury Explore immediately inOK

‘All injuries listed require splinting as well as OT and PI consultstomaintain ROM and function in the joint

Nerve Transfers

• indicated when nerve injury is close to the effector muscle or when other reconstructive options are

possible (e.g. preganglionic root avulsion, complete loss of motor, and/or sensory function);

also serve as adjunct to nerve grafting

• involves the use of an expendable nerve as a donor,such as one that supplies redundant innervation or

one with less importance to daily functioning

• donor nerve serves to:

reconstruct the injured nerve closer to its effector muscle to better facilitate reinnervation,or

directly innervate effector muscle (neurotization)

• cortical plasticity involved in re-programming new nerve function

• can also serve as adjunct to nerve grafting

• both motor and sensory nerve transfers are possible, allowing motor and/or sensory restoration by

neurotization

• three types of donors:

intraplexal (e.g. ulnar or median nerve fascicles)

extraplexal (e.g. contralateral C7 nerve root, intercostal nerve)

distal (e.g.radial nerve branches)

not can

Craniofacial Injuries

• low velocity vs. high velocity injuries determine degree of damage

• fractures cause bruising,swelling,

• management:most can wait ~5 d forswelling to decrease before OR1F required

and tenderness > loss of function

Approach to Facial Injuries

•AT'LS protocol

•inspect, palpate, clinical assessment for injury to underlying structures (e.g. facial nerve, bony

injuries,septal hematoma, ocular involvement,etc.)

•tetanus prophyl

•radiological evaluation:CTscan with fine cuts of 1.5 mm through the orbit

•wound irrigation with NS/RL and removal of foreign materials

•conservative debridement of detached or nonviable tissue

•repair laceration(s) at the time of presentation with 4-0 nylon sutures when the patient'

s general

condition allows

•consider intracranial trauma; rule out skull fracture

Signs of Basal Skull Fracture

• Battle's sign(bruised mastoid

process)

• Hemotympanum

. Raccoon eyes (periorbital bruising)

• CSF otorrhea/rhinorrhea

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