plastic surgery

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nerve compression Froshe Arcade of Struthers Ligament of Struthers Osborne: Froshe = Radial
Archade of Struthers = Median
Ligament of Struthers = Ulnar
Osborne = Ulnar
Collar button Abcess via ?: lumbrical canal or
palmar fascia
juvenile rheumatoid arthritis deformity: wrist = flexion

carpo/metacarpal = ulnar dev.

loss of flexion IP & MPjoints

radial deviation of MP
Subungual melanoma survival: 66%
Upper extremity embryologic development tissue: Apical Ectrodermal Ridge
SLAC wrist: scapholunate advanced collapse

Rx = four corner arthrodesis
thumb hypoplasia: I small

II small, unstable,thenar cone decrease or absent

III short, web space contracture, absent thenar cone, global instability

IV absent
camptodactyly: small finger

not progressive after puberty

mild = splint
severe = surgery
Syndactyly age for surgery inheritance sex distribution: surgery = 12 - 18 mo.

inherited = 10 - 40%

M>F
Scaphoid fracture healing nondisplased displaced 1 mm best rx: nondisplaced = 90% unite (10-14 wks)
displaced 1 mm = 50%
rx = vascularized bone graft
rx of chronic paranechia: epinechial marsupialization
rheumatoid swan neck deformity etiology: tight intrisics
rx of sagital band rupture: splint 2 weeks
Moberg transfer for thumb pinch: FDP tenodesis
Reiters Syndrome (psoriatic arthritis): HIV
oncomysosis rx: terbinafine
intraconazole
trigger finger release in rheumatoid arthritis: contraindicated
further agrivates ulnar drift
structures causing failure of reduction of mp joint dislocation: lumbrical
flxr tendon
volar plate
"clench fist" treatment: botox
sensory fiber function vibration pain (burn) pain(sharp) moving 2pd static 2pd: vib = pacinian
burn = C fibers
sharp = A fibers
mov 2pd = meisner's
stat 2pd = merkel cell
arthrogryposis: present at birth
nonprogressive
ectrodactyly: partial or complete absence of fingers
glomus tumor %recurrance %multiple: recur = 20%
multiple = 25%
C5-6 tetraplegia - correction of forearm suppination: redirect biceps through interosseous membrane
frostbite bone scan result: normal = observation
abnormal = amputate pip and vascular tissue cover
Rx of rupture ring and small finger extensors in rheumatoid arthritis: Darrach procedure
Moberg flap maximun defect size: 2 x 2 cm
structure preventing reduction of volar pip dislocation: condyles of prox phalynx pass through the ext tendon
genetic transmission of congenital amputation: 0%
Rx camptodactyly: release abnormal lumbrical
delta phalynx: longitudinally bracketed epiphysis
brachioradialis flap coverage artery: antecubital fossa
recurrent radial artery
blood supply for osteocutaneous radial forearm flap: fasciocutaneous perforators from radial artery
bet. brachiorad. and fcr
Rx electrical burn: 0.9% NaCl
Mannitol
NaHCO3
how long post injury can a boutinairre still be treated by splinting: 6 wks
nerve repair first sensory return: pain
nerve growth = 1mm/day
Rx osteogenic sarcoma: radical exc.
radio Rx
chemo Rx
Rx frostbite: anti inflammitory Rx
decreases thrombuxane B2
decreases protoglandi F
margin of excision merkel cell ca: 3 cm
type III dislocation pip: communited fracture

Rx = volar plate arthroplasty`
etiol of mp flxn in dupuytren.s: pretendinous cord
first carpal bone to ossify: capitate
most common cause of pip contracture in dupuytren's: central cord
lobster claw hand - inheritence: autosomal domninent
dorsal dislocation mp joint reduction technique: wrist flexion and pressure on proximal phalynx (not distraction)
structures blocking reduction of mp dislocation: lumbrical, fdp, volar plate
giant cell tumor of bone: vascular
multinucleated giant cells
test for radial tunnel syndrome: selective local anesthetic
most common nerve palsy in brachial touniquet: radial
timing of tendon transfer in radial palsy: no return in 6 months
volkman's (mild) most com. nerve involved most com. muscle: median

fdp and fpl
radial forearm flap - bone: 10 -12 cm
brachial plexus birth injury prognosis based on time to recovery of deltoid and biceps function: 2 months = complete recovery
6 months = no recovery
posterior interosseous flap what muscle taken when incorporating bone: epl
lateral arm flap sensory nerve: posterior brachial cutaneous nerve
lateral arm flap bone length: 10 cm
lateral arm flap artery: posterior radial collateral
spastic cerebral palsy, clenched fist with poor sensability and palm masseration (2pd 10mm): transfer fds to fdp

lengthens the flexors
stab wound injuring ant tib artery, most likely area aneathesia: first webspace

deep peroneal nerve
innervation dorsum of foot: superficial peroneal nerve
innervation lateral foot: sural nerve
innervation medial foot: saphneous nerve
HFl burn: copious irrigation water or saline
topical or injected Calcium Gluconate
mid palmar space: bounded
flx tendons, metacarpals,interosseous fascia, septum from 3rd mc to fdp sheath and hypothenar em.
volar dislocation of middle phalynx what structure is interposed in the joint: extensor tendon
artery for toe to hand transfer: 1st dorsal metatarsal artery from the dorsalis pedis
most common organism in hand infection: staph aureus
lumbrical plus deformity: paradoxal extension of the pip joint on attempted flexion

(occurs with dip amputations and with excessively long tendon grafts)
camptodactytly loss of flexion less that 30 degrees: observation
kanavel's signs: fusiform swelling
flex posture
pain on passive extension
pain over the digital theca
devascularized long finger following repalntation best functional result: ray amputation
Rx for venous congested reverse radial forearm flap: anastomsis of outflow vein
most important factor in success of replantation: mechanism of injury
split nail deformity: full thickness nail grafting from the toe
dorsal dislocation of the mp joint structure preventing reduction: lumbrical

volar plate

flexor digitorum profundus
posterior interosseous flap with vascularized bone which muscle supplies the bone: EPL
incomplete simple syndactyly age of repair: 12 - 18 months
pincer or trumpet nail deformity Rx: lateral elevation of nail and dermal grafting
dupuytren's diathesis: knuckle pads
plantar fascial nodules
peyronie's

more agressive, earlier onset, more often bilateral and more often radial
compartment syndrome (hand intrinsics) Rx: two dorsal incisions over the index and ring m/c

hypothenar and thenar cone decompression from mid axial incicions

no palmar incisions
electrical burn of hand and forearm: requires fasciotomy

(not escarotomy alone)
congenital constricting bands of extremities Rx: excision of the bands and z-plasty
painful nail plate and sensativity to cold: glomus tumor
radial palsy tendon transfer: p.t. - ecrb

fcu - edc

pl - epl
painful ulcerations, calcium deposits in soft tissue, ischemia, flexion contractures, ip joint erosion, entrapment neuroapathy: scleroderma
crest syndrome: calcinosis
reynaud's
esophageal envolvemsnt
sclerodactyly
telangiectasia
pain in hand with activity, paresthesia involving palm " " radial digits: pronator syndrome
dorsal dislocation pip joint Rx: irreducible = fdp or volar
plate

open rx = partial division of
A3 pulley
burn hand pip joint active flexion lag with mp flexion intact: read question carefully

if the question reads
"burn hand" and not fingers then rx = tendon release central slip
traumatic amputation of all fingers order of repair: structure by structure beginning with bone

(not finger by finger)
inablity to flex the dip joint of index finger with normal sensability: anterior interosseous syndrome

(pronator syndrome = sensability changes)
digit migration at which level: metacarpal base

(more cancellous bone for union)
ray amputation of the index finger: 20% loss of key pinch and
power grip
50% loss of suppiantion and
pronation strength
better cosmesis
disi: dorsal intercalated segment instability

rx = operative repair (early)
fracture scaphoid with displacement rx: orif (herbert scew or compression screw)
circumflex scapular artery triangular space: long head triceps

teres major

teres minor
nondisplaced scaphoid fracture thumb spica for ____ weeks: 10 - 14
inability to flex the pip joint following dip amputation: lumbrical plus deformity

rx = release of the lumbrical
rheumatoid arthritis flexor tendon most likely to rupture: fpl
pain and crepitus 4 cm proximal to dorsal wrist crease after strenous activity: intersection syndrome
(between 1st and 2nd cmpt)
intersection syndrome RX: injection cortisone and splint

surgery = release 2nd dor cmpt
+ synovectomy when
conservative rx fails
12 cm tibia defect: contra lateral free fibular flap

(20 cm available)
sudden loss of flexion 5 weeks after repair Rx: explore and repeat repair
thumb volar pad amputation 2x2 cm: moberg vlap
most sensative of kanavel's signs: passive extension
venous congestion of replant immediate Rx: remove dressings
pan-trapezial arthritis failing medical rx: trapeziectomy and tendon interposition
delayed infection of tibial fracture initial rx: debride bone
congenital trigger thumb Rx age dx resolution: rx = tenovaginotomy A1

age = usually not recognized till 6 mo.

30% resolve by age 3
first dorsal metacarpal flap artery location: 1st dor met art located within fascia of 1st dorsal interosseous
game keeper's thumb structure interposing between ulnar collateral ligament and proximal phalynx: adductor pollicus
effort induced carpal tunnel syndrome etiology: lumbrical
fanconi syndrome: radial club hand

autosomal dom

thumb hypoplasia
VATER syndrome: v = vertebral anom
a = anal anom
t = trach anom
e = esoph anom
r = renal anom
dupuytren's contracture pip joint: natatory ligament = NOT involved
thumb-in-palm deformity: spasticity adductor, fpl
skin contracture
dec mobility mp joint

NOT flaccidity ext mech.
finger tip amp with tendon exposed: flap

thenar vs cross finger
(inj may preclude one)
fixed flxn deformity at ip joint thumb in 4 y.o.: dongenital trigger

release A1
absolute contranindication to replantation: life threatening condition

all others are relative contrindications
complete ring finger avulsion rx: complete amputation
contrast extravasation associated with compartment syndrome: volumes greated than 100 cc

(dx - pain on extension confirm with compartment pressures)
football tackle with immediate loss of dip flsx zone of injury: zone I
surgical release of pip with resultant finger tip necrosis cause: stretching of dig arteries

(answer to the question but not in real life, would not happen with intact dorsal skin)
dupuytren's rx with collagenase: relieves mp contracture

not pip contracture
tibial defects: prox 1/3 = gastrocnemius

mid 1/3 = soleus
herpetic whitlow rx: dry dressings

(said that topical acyclovir is of limited benefit, don't know why they don't mention systemic acyclovir)
dupuytren's spiral cord = spiral band +: grason's ligament
terminal branch of posterior interosseous nerve passes beneath: epl
thumb defect 2x3 cm: kite flap

(moberg limited to 1.5 cm)
type IIIb hypoplastic thumb rx: ablation and index migration
wassel type IV muscle transfer: ablation of radial digit requires transfer of APB
C5 tetraplegia most imp muscle reconstructive function: elbow extension

(ability of patient to transfer)
a-v malformation rx: when excising do so widely

"local" excision = high recurrence
nonsmoker with ulnar digit ischemia: ulnar hammer syndrome

(buerger's(thromoangiitis obliterans) usually in smokers)
ulnar nerve elbow structure causing compression: osborne's ligament
infection index finger drains to which space: thenar space
painful digit ischemia (reynaud's or scleroderma) failed medical rx =: conservative ammputation
most definative test of osteomylitis: bone biopsy and culture
ulnar collat lig instability mp thumb structure interposing between lig and insertion: adductor pol
crush injury arm with pain on passive finger extension: fasciotomy
tibial defect - 9 cm rx: free fibular flap

(6 cm or less usually traditional bone graft)
advantage of wrist disarticulation vs forearm amp.: preserve pronation/suppination
stellate laceration sterile matrix rx: repair matrix and replace nail plate

(test answer - not in my patients)
arthrodesis angles pip joints: index = 40
long = 45
ring = 50
small = 55
arthrodesis angles mp joints: thumb= 15
index = 25
long = 30
ring = 35
small = 40
medial antebrachial cutaneous nerve graft located next to: basilic vein
compartment syndrome hand intrinsics minimum # incisions: 4

thenar, hypothenar, two dorsal
if replanting complete ring avulsion best chance for success: use ulnar dig a. from long finger
ray amp ring finger structure to suture to close the gap: deep intermetacarpal ligament
limited pronation/suppination wrist in rheumatoid arthritis rx: Darrach

(ulnar head resection)
neonate complete absence thumb: assoc with hematopoetic disorders
+spinal,cardiovasc,renal,gi,trisomy18,apert, carpenter
basilar thumb joint arthritis: not assoc. with rupture epl
extremity amputation and nerve repairs: when possibel shorten the extremity to perform primary nerve repair
flexor tendon repair strength related to: number of strands crossing the repair
six strand flx t. repair post op management: best = early active motion

(test answer)
ulnar nerve at wrist motor fasicle located: ulnar and dorsal
3 y.o. with finger tip amp. best rx: replant the amp segment as composite graft
(when available)
mallet finger with >30% joint surface rx: closed reduction with k wire

orif also acceptable
limited flexion of adjacent digits post advancement repair of profundus tendon: quadragia effect
TAM (total active motion) of digits =: total flexion - extension lag
glomus tumor rx: simple excsion
congenital band amputation of all fingers rx: toe transfer
moberg flap contains: both digital arteries

both digital nerves
following amputation of distal phalynx paradoxical extension of pip joint on attemnpted flexion: lumbrical plus deformity
exposed dialysis gortex in antecubital fossa best flap artery: radial recurrent

(brachioradialis flap)
arm amputaion at humerus level 1st rx: arterial shunting
(answer for major limb amputations, otherwise bone fixation is first)
dupuytren's nodule rx: observation
delta phalynx also called: longitudinally bracketed epiphysis
severe pain, swelling, and discoloration 1 month post minor injury to hand =: reflex sympathetic dystrophy
most effective method of clearing bone adherent bacteria in open wound: surgical soap
pain over mobile wad and pain with resisted long finger extension and suppination =: radial tunnel syndrome
pacinian corpuscles: vibration
syndactyly associated with what other anomalies: usually none

(usually an isolated finding)
acute closed boutonnier deformity how long delay and still splint: 10-21 days
pronator syndrome sensability change: fingers + palm
delta phalynx deformity?: clinodactyly
Volkman's contracture most common finding: fibrosis of flexor muscles
moberg flap: 1-1.5 cm
healing wound foot pressures and O2 levels: ankle and great toe pressure
>40mmHg

transcutaneous O2 > 30 torr
trans-scaphoid perilunate dislocation Rx: carpal tunnel release

relocate lunate

repair volar raciocarpal lig.
sensation return post graft or flap: ftsg > stsg
rice bodies in tenosynovitis: acid fast organism
finger tip amputation with volar to dorsal angulation Rx: atasoy klinert flap

(test answer)
dupuytren's contracture indication for surgery: mp =/>30 degrees

pip any contracture (15 deg.)
volar wrist ganglion Rx: excision = lowest recurrence rate
touniquet time > 2 hours: release for 20 minutes then re-inflate (5min / 30 min of
inflation)
dorsal finger injury with loss of epitenon Rx: flap coverage - reverse radial forearm

(test answer)
exposed nerve Rx: flap cover
normal scapholunate angle: 30-60 degrees
ulnar hammer syndrome Rx: resection and vein graft
holt-oram syndrome: cardiac plus upper extremity syndrome anomalies
chronic schapholunate dissoc. with pain and radioschaphoid arthritis Rx: prox. row carpectomy
trapeziectomy implant vs tendon interposition: no diff in pain relief

do diff in post op strength
valium and pregency: risk to the fetus exists
compartment syndrome in the hand: pain on passive adduction and abduction of fingers
absent epl function Rx: ext ind proprius transfer
1:1000 of 1% providone-iodine: non toxic and effective antimicrobial
amputation and warm ischemia: with muscle < 8 hrs.

without muscle 10 - 12 hrs.
comminuted frx pip joint acute Rx: dynamic traction
traumatic nail plate deformity Rx: sterile matrix graft

(test answer)
electrical burn upper extremity Rx: fasciotomy
rsd (crps - complex regional pain syndrome) Dx test: three phase bone scan

(diffuse periarticular activity)
palmar numbness and carpal tunnel syndrome: no correlation

(palmar sensory cutaneous nerve enters the palm before the carpal tunnel)
which flexor tendo zone laceration has the best prognosis: Zone 5
thumb mp joint ulnar collateral ligament fracture Rx: orif
thumb mp joint ulnar collateral ligament fracture what structure interposes between the fragments: adductor apponeurosis
thumb mp joint ulnar collateral ligament fracture indications for repair: 30 degrees of radial deviation instability
rheumatoid arthritis in all upper extremity joints sequence of repair: proximal to distal

elbow-wrist-mp joints
rapid onset of psoriatic arthritis or reiter's syndrome: hiv

nail pitting, pain, stiffness,and swelling joints
subungual melanoma with mri suggesting possible extension along nv pedicle Rx: interphalyngeal amputation

(ignore mri with initial rx)
fixed pip joint contracture rx: they want capsulectomy

(does not work, continue p.t. for a long, long, long time)
diabetic foot amputations ankle-brachial indices for wound healing: 0.70 or greater is acceptable for expected wound healing
congenital band syndrome with normal thumb and absent fingers Rx: toe to hand transfer
widened scapholunate joint space =: scapholunate dissociation pattern or disi (dorsal intercolated segment instability)
irreducible volar pip dislocation Rx: open
repair of lateral band and central slip of the extensor mechanism
absent (weak) extension of fingers and thumb with sensory deficiet =: posterior interosseous syndrome
pip joint contracture without trauma: camptodactyly
ischemic fingers Dx Rx: arteriogram
if occluded radial or ulnar artery = bypass
total absence of radius Rx: centralization of the ulna

(dx = radial club hand)
oblique fracture with comminution proximal phalynx thumb type of fixation: lag screw and plate
the most important prerequisite for success of tendon transfers: full supple passive motion of the joints
nail bed (sterile matrix) injuries Rx: test answer = remove nail plate and repair
(not my answer)
exposed achilles tendon repair (soft tissue loss) Rx: free flap
circumferential burn of extremity with vascular compromise Rx: escarotomies
test for intrinsic tightness (bunnell test): extend mp joint and have patient attempt flexion of pip joint
moberg procedure for tetraplegia: thumb for adduction
tenodesis fpl to radius (plus release of annular ligaments)
tenodesis epl to radius
arthrodesis ip joint
% of people with a palmaris longus: 71 - 85%
brachial-ankle index indicating ischemia: 0.7 or less

(look out for this because would need bypass before ftt)
wassel type VII deformity: radial member of duplicated thumb is triphalyngeal
wassel deformities Rx: for the test almost always will be presented with an ulnar dominent duplicate
the radial member is removed and the radial side of the remaining member is reconstructed (collateral lig., abductor tendon etc.)
distal phalynx mass with nail grooving Dx: mucous cyst

(nail grooving resolves with removal of cyst)
SLAC wrist Rx: Scapho Lunate Advanced Collapse

schaphoidectomy plus "four corner" arthrodesis
tendon transfers if you do not recognize the choices: look at what will be "given up" with each transfer and eliminate the ones that would be inappropriate sacrifices
ring avulsions: incomplete should attempt salvage

complete = amputation (poss. attempt in the very young)
most appropriate nerve graft for digital nerve: test answer = posterior interosseous

(some would use the sural)
pain on resisted suppination Dx: radial tunnel syndrome
chronic paranechia first step =: biopsy

"close association between chronic paranehia and scc)
exposed tendon or joint Rx: flap cover (if large ftt. this is better than thick)
pain relief in severe rheumatoid arthritis wrist: arthrodesis
white phosphorus burns: Rx = water lavage

copper sulfate used to identify areas of residual phosphorus
phenol burns: topical glycerol, propyleneor polyethylene glycol
smooth walled lytic lesion in phylanx: enchondroma
most common cause of pathologic fractures age 10 - 30 yrs: enchondroma
reynaud's - which is more effective cervical sympathectomy or periarterial sympathectomy: periarterial sympathectomy
one of the relative "contraindications" to replantation: single digit proximal to fds insertion
radial aplasia or hypoplasia need to evaluate for: bleeding
is associated with several syndromes TAR (thrombocutopenia-absent radius) and Fanconi anemia
dupuytren's most common complication of surgery: recurrence of cord

(reported as 20-25%)
profundus distal phalynx fracture avulsion Rx: orif
avulsion of sterile matrix Rx: great toe sterile matrix graft

(test answer)

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