Abbé flap Abdominal wall Abdominal wall reconstruction

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Abbé flap Abdominal wall Abdominal wall reconstruction Powered By Docstoc
					A     Abbé flap to Axonotmesis


Abbé flap                                             the internal oblique splits and half passes deep
● Useful flap for reconstructing moderate-            to rectus. Below this the posterior sheath is
  sized defects (too big to close directly) of       only composed of transversus abdominus.
  the lip.                                           Neurovascular structures lie between internal
● Pedicled flap, usually taken from the lower         oblique and transversus abdominus.
  lip to reconstruct a defect on the upper lip,      Blood supply:
  although this can be reversed.                     ● Superior epigastric artery: terminal branch
● Blood supply is from the inferior labial artery.
                                                       of the internal mammary artery.
● The flap is positioned so that the width of
                                                     ● Thoracic and lumbar intercostal arteries: run
  the vermilion matches the lip segment being          between internal and external oblique.
  replaced.                                          ● Deep inferior epigastric artery: from the exter-
● The Abbé flap may be quadrilateral, forked or
                                                       nal iliac artery, enters rectus abdominus and
  winged to assist closure of the lower lip defect     supplies it and the overlying skin.
● The lower lip can sacrifice 25–35% of its
                                                     ● Deep circumflex iliac artery: from the exter-
  length.                                              nal iliac artery to the inner ileum and skin.
● While pedicle remains attached the patient
                                                     ● Superficial inferior epigastric artery: from
  requires a soft diet.                                the femoral artery, to the skin of the lower
● Divide the flap in 1–2 weeks.
                                                       abdomen.
● A similar principle can be used for upper
                                                     ● Superficial circumflex iliac artery: from the
  eyelid reconstruction.                               femoral artery to the lower abdomen.
See Lip reconstruction. See Secondary lip and        ● Superficial external pudendal artery: from
nasal deformities.                                     the femoral artery to the skin over the pubis.
Abdominal wall                                       Abdominal wall reconstruction
Function: Abdominal wall muscles important           Indications:
                                                     ● Trauma.
for posture, standing, walking and bending.
                                                     ● Tumour:     Desmoid, Dermatofibrosarcoma
Anatomy:                                               protuberans.
Muscles:                                             ● Radiation.
● External oblique: from lower 8 ribs, inserts
                                                     ● Infection: Gas gangrene, Necrotizing fasciitis.
  into iliac crest and forms inguinal ligament.      ● Iatrogenic: Incisional hernia.
● Internal oblique: deep to external oblique.
                                                     ● Congenital: Omphalocoele, Gastroshisis, Prune
  From lumbodorsal fascia, iliac crest and             belly syndrome.
  inguinal ligament. Lower fibres form con-
  joint tendon. Superior fibres insert into           Management of acute loss: After aggressive
  linea alba and 7–9 cartilage.                      debridement, avoid closure under tension and
● Transversus abdominus: deep to internal            avoid raising flaps acutely. Cover viscera with
  oblique. From lower 6 ribs, lumbodorsal            synthetic mesh.
  fascia and iliac crest into linea alba and con-    Objectives: Cover abdominal contents, pre-
  joint tendon.                                      vent herniation and restore the appearance.
● Rectus abdominus: Longitudinal from sym-
                                                     When direct closure is not possible, closure
  physis to xiphoid and 5–7 ribs.                    may be achieved with fascial releases and com-
● Pyramidalis: small triangular muscle super-
                                                     ponent separation. If a defect remains, then
  ficial to rectus. From pubis to linea half way      closure will require alloplastic material or
  between symphysis and umbilicus.                   musculofascial flaps for strengths, and skin
Linea semicircularis or arcuate line lies mid-       grafts or flaps for cover.
way between umbilicus and pubis. Above this
2   abdominoplasty


Procedures:                                          Abductor pollicis brevis
● Ramirez Component separation.

● Local flaps: based on vessels supplying
                                                     APB: Most superficial muscle of thenar
  abdominal skin. The external oblique can be        eminence.
  used as a turn over flap. Rectus can be used.       Origin: Transverse carpal ligament, palmaris
● Regional flaps: pedicled tensor fascia lata         longus and there may also be another slip from
  (TFL), Rectus femoris, anterolateral thigh         abductor pollicis longus.
  flap. Gracilis is less useful as it only reaches
  to the perineum.                                   Insertion: The tendon is adherent to the radial
● Distant flaps: omentum, latissimus dorsi.
                                                     side of the MCP joint capsule. A few fibres join
● Mesh: apply over omentum to prevent adhe-
                                                     FPB and radial sesamoid. The rest join the
  sions. Suture under tension.                       extensor expansion.
                                                     Nerve supply: Median nerve.
Abdominoplasty
An aesthetic procedure which aims to pro-            Action: Abduction of the thumb at the carpo-
vide a flatter, narrower abdomen by excis-            metacarpal and MCP joint. This is a forward
ing skin and fat excess and addressing rectus        movement in the anteroposterior plane. See
divarication, generally by using a lower trans-      Muscles.
verse abdominal scar.
                                                     Abductor pollicis longus
Classification:
● I: Excess fat, liposuction.
                                                     Origin: Dorsum of radius, ulnar and interos-
● II: Lax skin infra-umbilical, resect lower abdo
                                                     seous membrane. It runs obliquely around the
  skin.                                              radius coursing over the wrist extensors. It
● III: Lax skin and muscle with fat infraum-
                                                     runs in the 1st extensor compartment with
  bilical mini-abdominoplasty with muscle            extensor pollicis brevis and may have several
  plication.                                         slips.
● IV: Lax muscle, complete abdominoplasty            Insertion: Lateral 1st metacarpal. It gives off a
  without umbilical translocation.                   slip to trapezium and another to APB.
● V: Lax skin and fat, complete abdomino-

  plasty with umbilical translocation.               Nerve supply: Posterior interosseous nerve.
● VI: Circumferential laxity, circumferential        Action: Abducts the thumb through slip to
  abdominoplasty.                                    APB. Extends the thumb and radially deviates
Operation: Mark skin incision with a large           the wrist. See Muscles.
ellipse. The lower line passes just above the
pubic hairs and is flattened centrally. For           Absorbable polymers
a full abdominoplasty, the upper line will be        Synthetic:
                                                     ● Used    for sutures and investigated for
around the level of the umbilicus. Dissect out
umbilicus. Elevate flap leaving thin layer of           other devices such as plates and screws
fascia intact. Proceed up to xiphoid if needed.        (LactoSorb).
                                                     ● One class of polymers used is the alpha-
Limit lateral dissection. Tighten aponeurosis.
Flex the back. Skin excision should be gener-          hydroxy acids including L-lactic acid, glycolic
ous laterally – high-tension abdominoplasty            acid, and dioxanone.
                                                     ● As polymers these are
(HTA). Suture flap and find new location for
                                                       ● PLLA: poly-l-lactic acid;
the umbilicus. If there is significant lateral lax-
                                                       ● PGA: polyglycolic acid;
ity add a vertical component to produce a
                                                       ● polydioxanone.
Fleur-de-Lys abdominoplasty.
                                                     ● PLLA and PGA are used together. Breakdown

Complications: Thrombo-embolism, respira-              is by hydrolytic scission of the ester bond.
tory difficulties, skin necrosis, wound dehis-        ● PGA is degraded more rapidly than PLLA.

cence, wound infections, haematoma, seroma.          ● Dexon is pure PGA. Vicryl is 8% PLA, 92%

                                                       PGA.
                                                                                 adductor pollicis 3


Natural:                                              ● Occur mainly on neck, upper chest and axilla.
● Many materials are produced from Collagen.          ● The only symptoms relate to local irritation.
● Haemostatic properties can be reduced by            ● Excise with scalpel or scissors.

  isolating collagen into fibrils.                     See Mesodermal tumours.
● The haemostatic properties can also be

  utilized.                                           Acrosyndactyly
See Alloplasts.                                       ●   One of the Congenital hand anomalies.
                                                      ●   Fusion of digits distally.
Acanthosis                                            ●   Mainly sporadic, non-hereditary occurrence.
Hyperplasia of epithelium. See Skin.                  ●   Associated with Constriction ring syndrome.
                                                      ●   Bilateral in 50%, but asymmetric.
Accutane                                              ●   Also associated with craniofacial syndactyly,
Isotretinoin. The synthetic retinoid deriva-              such as Apert’s syndrome, in which it is
tive 13-cis-retinoic acid (Accutane) used for             symmetrical.
severe Acne vulgaris. The dose is 1 mg/kg body
weight for an initial 4–5-month course of             Actinic keratosis
therapy. It reduces sebum excretion and is            Also called senile keratosis and solar keratosis.
anti-inflammatory.                                     ● The most frequently occurring premalignant

                                                        cutaneous condition.
Acne vulgaris                                         ● Due to the cumulative effect of UV exposure.

●   Acne vulgaris is a common skin disorder           ● Occur on exposed skin and often multiple

    seen in adolescents and young adults.               lesions.
●   Seborrhoea, small comedones, and inflam-           ● Lesions may regress if sun exposure is

    matory papulopustules found.                        limited.
●   Acne conglobata is the severe form with deep      ● They occur in genetically predisposed people.

    cysts and sinuses with extensive scarring of      ● Arsenic keratosis occurs secondary to expo-

    face back and chest.                                sure to inorganic arsenic compounds.
                                                      ● Get well circumscribed, erythematous and
Management:
● Incision of the cystic lesions reduces the
                                                        maculopapular lesions, red to light brown
                                                        and scaly.
  inflammation that produces the scarring.             ● Microscopically
● Dietary control does not appear to be
                                                                           get hyperkeratosis with
                                                        dyskaryosis and acanthosis. In the dermis
  beneficial.
● Topical medications with benzoyl peroxide,
                                                        there is an actinic elastosis with inflamma-
                                                        tory infiltrate.
  topical antibiotics or tretinoin (retinoic acid).   ● Over time many progress to SCC and 20–25%
● Skin hygiene and long-term administration
                                                        become invasive. SCCs arising from actinic
  of antibiotics, such as tetracycline, has been
                                                        keratosis rarely metastasize.
  helpful.                                            ● Treat with excision, curettage, liquid nitro-
● Ultraviolet rays and superficial X-ray ther-
                                                        gen, 5-fluorouracil (efudex), chemical peel,
  apy are effective, but with unacceptable long-
                                                        dermabrasion and photodynamic therapy
  term effects.
● Accutane is effective for severe acne.
                                                        (PDT).
● Dermabrasion, laser resurfacing and colla-
                                                      See Cutaneous horn.
  gen injections may help reduce the scarring.
● A facelift procedure may reduce skin laxity,
                                                      Adductor pollicis
                                                      See Muscles.
  which may improve the appearance of the
  acne scarring.                                      Origin:
                                                      ● Oblique head: transverse carpal ligament,

Acrochordon                                             anterior surface base of 2nd and 3rd
●   Common papillomatous lesion occurring               metacarpal.
    in middle adult life.                             ● Transverse head: from anterior surface of

●   Multiple, fleshy, skin-coloured tags.                shaft of 3rd metacarpal. Two heads join.
4    adipofascial flaps


    The transverse fibres insert mainly into the        is maintained though distorted to varying
    medial sesamoid and the oblique into the           degrees.
    extensor expansion.                            ●   They are classified by the degree and the
                                                       direction of differentiation to sweat and
Insertion: With the 1st palmar interosseous
                                                       sebaceous glands, and hair follicles.
into medial side of base of proximal phalanx.      ●   They are also termed organoid or appenda-
Nerve: Deep branch of ulnar nerve.                     geal tumours or Hamartomas.
                                                   ●   A tumour with fully developed appendageal
Action: Adduction of the thumb at the carpo-
                                                       structures is called a Naevus.
metacarpal and metacarpophalangeal joint.          ●   A tumour with incomplete development of
This is a backward movement in an antero-
                                                       structures is an Adenoma.
posterior plane.                                   ●   A poorly organized tumour is an Epithelioma.
Adipofascial flaps                                  Adrenaline
A flap comprised of fascia and overlying fat.       ●   Extensively used in plastic surgery to pro-
Essentially, the same as a fasciocutaneous flap
                                                       duce vasoconstriction, which reduces blood
with the skin dissected away from the flap.
                                                       loss during surgery, although there is some
Anatomy:                                               concern that this may increase the risk of
● Dermal and fascial plexuses exist in subcu-          post-operative haematoma.
  taneous tissues. Both gain their blood sup-      ●   Adrenaline can cause cardiac arrhythmias
  ply from perforators.                                especially in conjunction with halothane.
● In adipofascial flaps the tissues are divided     ●   The maximum recommended dose is 10 ml
  between plexuses leaving the dermal and              of 1:100 000 (100 µg) over 10 minutes or
  subdermal plexuses to supply the skin and            30 ml (300 µg) over 1 hour.
  the fascial plexuses are taken with the flap to   ●   1 ml 1:1000 in 200 ml = 1:200 000.
  supply it.                                       ●   Topical soaks for haemostasis can be 1:10
● Three perifascial plexuses are described –           000.
  sub-, intra- and prefascial plexuses. All        ●   The total dose of adrenaline should not exceed
  anastomose, but only pre- and subfascial             500 µg and it is essential not to exceed a con-
  plexuses receive branches from perforators.          centration of 1 in 200 000 (5 µg/ml) if more
  The prefascial plexus (superficial to fascia)         than 50 ml of the mixture is to be injected.
  is dominant.                                     ●   Generally avoided in end arteries, such as
                                                       digital vessels, although several trials have
Properties: Adipofascial flaps are easy to raise,
                                                       shown no adverse effects in such situations.
are more malleable and conform better than
fasciocutaneous flaps. They are not so robust
                                                   Adson’s test
and require a skin graft onto the flap.
                                                   Adson’s test arm adducted. A test used in the
Indications:                                       assessment of Thoracic outlet syndrome.
● Lower limb: medial flaps use posterior tib-       ● Patient stands with arm adducted against

  ial perforators. Usually 2–5 of these, fairly      front of trunk. Feel radial pulse.
  constant. There are usually 4–5 anterior tib-    ● Extend neck and turn chin to affected side.

  ial perforators. The perforators to the pero-      This stretches and tightens the Scalene mus-
  neal artery are less predictable, but usually      cles causing neural or arterial compression
  number 4–5.                                        by scissoring effect.
● Upper limb: small adipofascial flaps can be       ● Now take a deep breath. This depresses

  raised from the dorsum of the finger to             the first rib. Hold breath while traction is
  cover finger tips or exposed bone.                  applied to arm and feel the pulse. Loss of
                                                     pulse volume or neurological signs gives a
Adnexal tumours                                      positive result.
●   In adnexal tumours, the relationship           ● Reverse Adson’s test: patient in same posi-

    between stromal and epithelial components        tion, but patient flexes neck and rotates chin
                                                                                       alexithymia    5


    to contralateral side to shorten the scalenes.    ●   50s: neck rhytids, jowls.
    Push down with chin against chest to con-         ●   60s+: skin atrophy with increasing wrinkles.
    tract scalenes. This may reproduce symp-
                                                      Retaining ligaments:
    toms when there is scalene hypertrophy.           ● Zygomatic osteocutaneous ligaments.

                                                      ● Mandibular osteocutaneous ligaments (these
Advancement flaps                                        two are the most important).
●   A local random pattern flap where tissue is        ● Platysma-auricular ligaments.
    advanced to fill an adjacent defect. Examples      ● Anterior platysma-cutaneous ligaments.
    include
●   Single pedicle: raised as a square or rectangle
                                                      Air embolus
    with two parallel cuts along the sides of the
                                                      Air entering the circulation, usually through
    defect. Burow’s triangles are excised from
                                                      the veins. Complication seen in Neck dissection
    the base of the flap to help advancement.
                                                      and neurosurgery from air entering the inter-
●   Bipedicled advancement flap: useful for long
                                                      nal jugular vein. Air enters the heart and is
    defects in extremities. An incision is made
                                                      compressed, rather than expelled. Air froths
    parallel to the defect and the flap attached at
                                                      in the chamber and reduces cardiac output.
    either end is advanced. As there is a blood
    supply from either end a longer length to         Treatment:
    width ratio is possible. The donor defect can     ● Fill the wound with fluid to reduce further

    be grafted.                                         embolisms.
●   V–Y advancement flap.                              ● Lie the patient on the side with head down

●   Y–V advancement flap.                                and aspirate the heart directly or aspirate
                                                        through a central line.
Aesthetic unit
Gonzalez-Ulloa in 1956 divided the face into          Albinism
regions or units to aid in the planning of recon-     ●   Characterized by the absence of melanin.
struction. Some principles of reconstruction          ●   Due to mutation of genes, which regulate
by units are:                                             melanin synthesis.
● Patients wish to look normal.                       ●   Equal incidence in sex and race.
● The normal is defined by regional units,             ●   Most are autosomal recessive traits.
  adjacent three-dimensional areas of char-           ●   The skin is very sensitive to the carcinogenic
  acteristic skin quality, surface outline and            action of UVB radiation.
  contour.
● The surgeon must restore regional units not         Albright’s syndrome
  fill defects if the normal is the goal.              ●   Polyostotic Fibrous dysplasia.
● The wound may need to be enlarged and               ●   Pseudohypoparathyroidism.
  normal tissue may be discarded to allow a           ●   Autosomal dominant disorder.
  whole subunit to be reconstructed.                  ●   Deficiency of regulatory protein required
● Scars are best positioned in the borders                to couple membrane receptors to adenyl
  between units where they will be less                   cyclase.
  apparent.                                           ●   Present with:
● Donor material should be chosen for simi-               ● rounded low nasal bridge;

  lar quantity and quality.                               ● short neck;

● Restoring three-dimensional contour not                 ● cataracts;

  just filling a hole is important for good                ● short metacarpals and metatarsals;

  reconstruction.                                         ● hypocalcaemia with raised phosphate;

                                                          ● pigmented skin lesions.

Ageing face
Chronology:                                           Alexithymia
● 30s: redundant eyelid skin, crows feet.             Lack of words for mood or emotion. Seen in
● 40s: prominent nasolabial folds, forehead           patients with Reflex sympathetic dystrophy
  furrows.                                            (RSD).
6    alginates


Alginates                                            ●   Sterile.
● Derived from seaweed.                              ●   Withstands stress.
● They contain calcium, which activates the
                                                     Goal: To achieve the goal of reconstruction,
  clotting cascade when exchanged with               the implant should be well covered and scars
  sodium in the wound.                               should be concealed.
● They are very absorbent and become gelati-

  nous upon absorbing moisture.                      Liquids:
● They are used clinically for both their hae-       ● Injectable collagens.


  mostatic and absorbent properties.                 ● Hyaluronic acid preparations.

● Examples include sorbsan and kaltostat.            ● Silicone.


See Dressings.                                       Solids:
                                                     Metals:
Allen’s test                                         ● Stainless steel.
●   To test the integrity of arterial anastomotis    ● Vitallium.
    between the radial and ulnar side of the hand.   ● Titanium.
●   Occlude radial and ulnar artery and empty        ● Gold.
    hand by making a fist.
●   Release one artery, the hand should fill with     Polymers:
    blood immediately.                               ● Polyethylene.

●   A similar test can be applied to the finger to    ● Polypropylene.


    confirm the presence of two digital arteries.     ● Methylmethacrylate.

                                                     ● Cyanoacrylates.


Alloderm                                             ● Fluorocarbons.


An immunologically inert dermis derived from         Ceramics:
human cadaver.                                       ● Hydroxyapatite.

                                                     ● Others: calcium sulphate and calcium phos-
Allodynia                                              phate. Absorbable polymers, sutures.
Marked pain from a usually non-noxious
stimulation. See RSD.                                Oppenheimer effect.
                                                     Fibrous tissue interface: Around an implant
Alloplasts                                           there is a dead space into which fibroblasts
An alloplast is a relatively inert foreign body      and macrophages migrate. As a result of
implanted into tissue.                               this chronic inflammatory response, fibrous
Advantages: No donor site morbidity, quick,          encapsulation occurs. This is termed implant
unlimited supply, can be prefabricated, selected     bursitis.
resorption.                                          Bonding and Osseointegration: Bonding can
Classification:                                       be mechanical or chemical. Mechanical bond-
● Liquid or solid. The physical form deter-          ing occurs when there is in-growth into a
  mines whether it will be encapsulated or           porous substance. Chemical bonding occurs
  whether fibrous tissue will penetrate the           by molecular adsorption and is poorly under-
  implant.                                           stood. Osseointegration refers to bone on an
● Biological or synthetic.                           implant surface with no intervening fibrous
● Permanent or absorbable.                           tissue.
Properties: Ideal properties of an alloplast         Carcinogenicity: Chromium and nickel are
are:                                                 known carcinogens. There are few reports
● Inert.                                             of tumours around implants. Some studies
● Strong.                                            following hip implants have suggested an
● Ability to shape.                                  increase in lymphatic and haemopoietic can-
● Non-toxic, non-carcinogenic, non-allogenic.        cers, but a decrease in breast and colon cancer.
                                                                        ambiguous genitalia 7


Biomaterial failure: Due to wear, e.g. by abra-    ●   Small tumours may be treated with external
sion and fatigue, or corrosion, where the              beam irradiation. Osteoradionecrosis may
implant is lost by chemical reaction.                  occur if larger tumours are irradiated.
                                                   ●   Large tumours or node positive tumours
Alopecia                                               are irradiated after resection.
● Primary excision with rotation flaps such as
                                                   Results: Overall 5-year survival rate is 65%.
  the Ortichochea flap are useful to correct        ● Stage I: 78%.
  defects covering 15–20% of the hair-bearing      ● Stage II: 65%.
  scalp.                                           ● Stage III: 35%.
● Also Juri flaps.
                                                   ● Stage IV: 15%.
● Tissue expansion.

See Hair restoration with flaps. See Burns
                                                   Ambiguous genitalia
reconstruction.
                                                   See Embryology. In cases of ambiguous geni-
                                                   talia, assign patients sex before the age of 2.
Alveolar carcinoma                                 Assess by a geneticist and paediatrician. The
See Head and neck cancer.
● Third most common site.
                                                   most common cause is congenital adrenal
● Usually over 50 years.
                                                   hyperplasia.
● Lower jaw is more common than upper jaw,         Female pseudohermaphroditism:
  particularly behind the bicuspid teeth.          ● 46XX    usually with congenital adrenal
● Less directly related to tobacco and ethanol.      hyperplasia.
● Sometimes linked to poor dental hygiene          ● Increased androgen production due to a

  and dentures.                                      deficiency of the enzyme 21-hydroxylase.
● Commonly present with ulcers without pain.       ● The appearance of the external genitalia

● Spread is initially lateral. Dental caries can     varies from a mildly enlarged clitoris to a
  be a site of invasion. If bone is invaded the      normal penis with terminal meatus.
  neurovascular bundle (NVB) is at risk. Direct    ● These children should be raised as female

  mandibular invasion is common.                     and can be fertile.
● Regional node metastasis is more common          ● Surgical  correction may be necessary.
  with carcinoma of the lower alveolus than          Perform at 3–6 months, clitoral recession
  of the upper alveolus mainly to levels I–III.      and vaginoplasty.
Treatment:                                         Male pseudohermaphroditism:
● For T1N0 lesions, a localized excision with      ● 46XY.

  marginal mandibular resection can be             ● Have defects in androgen synthesis and

  accomplished through the mouth.                    other causes of incomplete virilization.
● More extensive lesions with more signifi-         ● It may be advisable to raise as a female as

  cant mandibular involvement require a lip          there will always be an inadequate phallus.
  split, cheek flap, and mandibular resection.        Orchidectomy and vaginal reconstruction
● In the upper jaw, a partial maxillectomy           will be required. May be due to:
  is performed through a modified Weber-              ● enzyme     5-α reductase resulting in
  Fergusson incision. With more invasive                decreased testosterone production;
  lesions that have broken into the maxillary        ● testicular feminization syndrome, with

  antrum, total maxillectomy is indicated.              absence of androgen receptors.
  More extensive involvement (e.g. ethmoid
                                                   True hermaphrodite:
  sinus) will require an anterior cranial fossa    ● 46XX or 46XY or mosaic karyotype with
  approach.
● If access to the neck is required for recon-
                                                     both testicular and ovarian tissue.
                                                   ● Very rare.
  struction, perform a selective neck dissec-      ● Patients have an ovary one side and a testis
  tion for an N0 neck. Palpable nodes make
                                                     on the other or bilateral ovotestes.
  this procedure mandatory.
8    ameloblastoma


●   Raise as female as they will have an inade-     more distal than mid-proximal phalanx will
    quate phallus. Remove the testes.               get equivalent function by terminalizing.
Mixed gonadal dysgenesis:                           Index ray amputation: A racquet incision is
● Most have 46XY/46XO karyotype with testes         made. Divide extensors. Expose metacarpal.
  on one side and streak gonad on the other.        Preserve insertions of FCR and ECRL. Cut
● The normal testes has a high risk of devel-       flexors. Divide NVBs and bury nerves. Similar
  oping gonadoblastoma.                             technique for little finger.
● These patients should be raised as female.
                                                    3rd and 4th ray amputation: Either excise
  Perform gonadectomy, clitoral recession
                                                    metacarpal and narrow the space or transpose
  and vaginoplasty.
                                                    ulnar metacarpals to close the cleft. Perform a
Pure gonadal dysgenesis:                            dorsal longitudinal and volar Bruner incision.
● 45X0, 46XX or 46XY karyotype.                     Remove the metacarpal and two interossei.
● Usually present with delayed adolescence.         Section the border MC and translocate to a
● Bilateral streak gonads. High malignant           central position. Repair deep intermetacarpal
  potential and gonadectomy is recommended.         ligament.
                                                    Wrist disarticulation: Preserves normal pro-
Ameloblastoma                                       nation and supination 50% of which is trans-
An aggressive odontogenic tumour thought
                                                    ferred to the prosthesis. Progressively more
to form from ameloblasts that do not differ-
                                                    supination and pronation is lost with more
entiate to the stage of enamel formation.
                                                    proximal amputations. A more distal prosthe-
                                                    sis has less padding and is more of a challenge
Amplitude: of tendon excursion                      for prosthetics.
See Tendon transfers. Donor muscles should
have similar excursion to that which is replaced.   Shoulder disarticulation: Amputation thro-
● Excursion of wrist flexors and extensors is        ugh the glenohumeral joint, clavicle acromion
  3 cm, finger extensors is 5 cm, finger flexors       and scapula are preserved.
  is 7 cm.
● Increase amplitude of donors by tenodesis
                                                    Forequarter amputation: Removal of entire
                                                    shoulder girdle with clavicle and scapula.
  effect and by freeing fascial attachments.
                                                    Amyotrophic lateral sclerosis (ALS)
Amputation – upper limb                             ●   A type of motor neuron disease with atro-
Digital amputation: Most commonly for                   phy of skeletal muscles of the body.
complex traumatic injuries. Also vascular dis-      ●   Causes degeneration of motor neurons.
orders, tumours and congenital anomalies.           ●   Patients with ALS have weakness, atrophy
A single finger amputation should usually be             and fasciculations.
terminalized, rather than replanted. The aim        ●   Often asymmetric.
is stump coverage with sensate skin and length      ●   No loss of sensation.
preservation. Perform bone shortening and           ●   One-third of patients present with upper
trim back tendons. Extensor tendons should              limb symptoms.
not be sutured to flexor tendons to avoid the
Quadrigia effect. Nerves are cut back and soft      Anaesthesia
tissue opposed without tension. The retracted       See ASA classification, Local anaesthetics, Tume-
FDP can pull on the lumbrical giving an             scent anaesthesia.
intrinsic plus position. This can lead to PIP
joint extension with grasp. Treat by partial or     Andre-Thomas sign
complete excision of the lumbrical.                 ●   In Ulnar nerve palsy.
                                                    ●   The deformity of clawing is made worse by
Thumb: Loss of proximal to mid-proximal
                                                        an unconscious effort to extend the fingers
phalanx results in loss of pinch. Thumb ampu-
                                                        by tenodesing the extensor tendons with
tations should be replanted if possible though
                                                        palmar flexion of the wrist.
                                                                                     angiosome      9


Aneurysmal bone cyst                               Angiogenesis
●   Blood-filled cysts lined with fleshy membrane.   ● Angiogenesis is the process of forming new
●   50% occur secondary to other tumours.            blood vessels.
●   20s–30s.                                       ● Platelets secrete PDGF, which attracts mac-

●   Tendency to recur, can be aggressive.            rophages and granulocytes and promotes
                                                     angiogenesis.
XR: Metaphyseal expansile lesion with a thin       ● The macrophage plays a key role in angio-
rim of reactive bone.
                                                     genesis by releasing a number of angiogenic
Treatment is bloc bone excision and strut            substances, including tumour necrosis factor-
graft.                                               alpha (TNF- α) and basic fibroblast growth
See Bone tumours.                                    factor (bFGF).
                                                   ● VEGF, released by keratinocytes is also a

Aneurysms – upper limb                               potent stimulator of angiogenesis.
See Vascular injuries.                             See Wound healing. See Cytokines and growth
● Most are due to trauma and infection.            factors.
● Traumatic aneurysms are most commonly

  found in the thenar and hypothenar emi-          Angiosarcoma
  nence, and the superficial arch.                  See Sarcoma.
● True aneurysms contain all layers of the ves-    ● Rare vascular neoplasm.

  sel wall. False aneurysms are pulsating hae-     ● Aggressive, recurs locally, spreads widely and

  matomas and occur after penetrating injury.        has a high rate of vascular and lymphatic
● Most patients complain of a pulsatile mass.        metastasis.
  It may be difficult to distinguish from a         ● 50% occur in the head and neck.

  ganglion.                                        ● Male:female, 8:1, elderly.

● Arteriography may be useful.                     ● Associated with irradiation and some envi-

                                                     ronmental carcinogens.
Treatment: Resect and repair pseudo-               ● Soft violaceous painless compressible mass.
aneurysms. Ligation may be adequate if there       ● Treat with wide excision and radiotherapy.
is no vascular compromise.
                                                   Angiosome
Angel kiss                                         ●   Manchot studied skin territories in 1889.
See Nevus flammeus neonatorum. A macular
                                                       Salmon expanded this in 1930s, and Taylor
vascular birthmark seen on the upper lip,
                                                       and Palmer developed the angiosome con-
which fades spontaneously.
                                                       cept in 1987.
                                                   ●   An angiosome is a three-dimensional com-
Angioblastoma of Nakagawa                              posite block of skin, soft tissues and bone
See Tufted angioma.
                                                       supplied by branches of a single source artery.
                                                   ●   Choke vessels link adjoining angiosomes
Angiofibroma                                            and may regulate flow between them. The
●   Skin lesions usually found on the lower cen-
                                                       veins do not contain valves and are called
    tral face.
                                                       oscillating veins as blood may flow in either
●   Fibrous, erythematous papule 1–3 mm in
                                                       direction.
    size.                                          ●   The anatomic territory is the area of tissue
●   When multiple they are associated with the
                                                       supplied by an artery before anastomosing
    Tuberous sclerosis complex (Bourneville’s
                                                       with adjacent vessels.
    disease), and occur on the cheeks and chin.    ●   The dynamic territory of an artery is that
●   Treatment is by dermabrasion, laser, or
                                                       which stains with fluoroscein.
    excision.                                      ●   The potential territory is that which can be
●   Peri-ungual angiofibromas (Koenen’s peri-
                                                       included if the flap is delayed.
    ungual tumours) also are often present in      ●   Flap principles are that a random flap can
    this syndrome.
                                                       support one angiosome. An axial pattern
10 Angle classification


    flap can support another angiosome per-             flared forward, in II2 the anterior upper and
    fused via a choke vessel in a random cutane-       lower teeth are retruded with overbite.
    ous fashion.                                     ● Class   III malocclusion: the mandibular
                                                       dentition is positioned mesial to maxillary
Anatomic concepts of blood supply
                                                       dentition.
developed by Taylor and Palmer:
● Blood supply detours through muscles.
                                                     (NB Mesial means situated toward the middle
● Arteries link to form continuous unbroken
                                                     of the front of the jaw along the curve of the
                                                     dental arch.)
  network.
● The intramuscular territories of arteries and
                                                     See Orthognathic surgery, Teeth.
  veins match.
● The viability of a muscle flap is depend-
                                                     Anterior interosseous syndrome
                                                     ●   Anterior interosseous nerve is a branch
  ent on the size and number of its vascular
                                                         of the median nerve supplying FPL, FDP
  territories.
● The vessels hitchhike with nerves.
                                                         (index and middle) and pronator quadratus.
● The
                                                     ●   Compression produces pain in the forearm
         vessels follow connective tissue
                                                         and a weak pinch grip (O sign).
  framework.
● Vessels radiate from fixed to mobile areas.
                                                     ●   Test pronator quadratus by strength of
● There is a direct relationship between mus-
                                                         resisted forced supination with elbow flexed
                                                         to eliminate humeral head of pronator teres.
  cle mobility, and the size and density of the      ●   EMG may be helpful.
  supplying vessels.
● Vessels tend to have a constant destination,
                                                     ●   Incomplete syndromes can occur.
                                                     ●   Distinguish from Parsonage–Turner syndrome.
  but a variable origin.
● The territory of the intramuscular arteries
                                                     ●   Plan to explore if there is confirmation on
                                                         nerve conduction studies and if there is no
  obeys the law of equilibrium.
● Vessel size and orientation are the product
                                                         improvement after 2–3 months.
  of tissue differentiation in the area.             Compression points:
● The muscles are the prime movers of venous         ● Fibrous bands of pronator teres muscle

  return.                                              between the superficial and deep heads.
● As arterial territories are linked by choke        ● FDS bands.

  vessels, so the venous territories are linked      ● Gantzer’s muscle, an accessory head of FPL.

  by oscillating veins, which are devoid of          ● Aberrant radial artery.

  valves.                                            ● Thrombosis of the ulnar collateral vessel.

                                                     ● As a complication of forearm fracture.

Angle classification                                  ● Accessory bicipital aponeurosis.

●   System for describing dental occlusion in        ● Enlarged communicating veins.

    the anteroposterior plane developed by
                                                     Treatment:
    Edward Angle.                                    ● Surgical exposure as for Pronator syndrome.
●   The upper first molar is the point of refer-      ● Release the deep head of pronator teres and
    ence in describing the anteroposterior rela-
                                                       suture the deep head to the superficial head.
    tionship of the mandible and maxilla.            ● Interfascicular neurolysis of the anterior
●   This classification only tells of the relation-
                                                       interosseus nerve 2–7.5 cm below the elbow
    ship of mandible to maxilla. It doesn’t say
                                                       is probably warranted if no obvious com-
    which is malpositioned or what the cause is.
                                                       pression identified.
●   Class I occlusion: The mesiobuccal cusp of
    the maxillary first molar articulates within
                                                     Anterolateral thigh flap
    the mesiobuccal groove of the lower first         ●   A fasciocutaneous flap raised from the ante-
    molar.
                                                         rolateral aspect of the thigh.
●   Class II malocclusion: the lower first molar is   ●   Supplied by musculocutaneous perfora-
    distal to the upper first usually ½ to a full
                                                         tors from descending branch of the lateral
    cusp. In II1 the upper anterior teeth are
                                                                                 Apert’s hand     11


    circumflex femoral system through TFL and        Classification: Upton.
    rectus femoris.                                 ● Type I: spade hand. Complex syndactyly of

●   The perforators reach the skin via inter-         digits 2–5 with the thumb and little fingers
    muscular septum between vastus lateralis          free.
    and rectus femoris or traverse through the      ● Type II: spoon or mitten hand. Complex

    muscle.                                           syndactyly of digits 2–5 with simple syndac-
●   The largest perforator reaches the deep fas-      tyly of thumbs or thumbs free.
    cia 2 cm inferolateral to the mid point of      ● Type III: rosebud hand. All 5 digits involved

    a line between the ASIS and the supero-           in complex syndactyly.
    lateral corner of the patella. Occasionally     See Apert’s syndrome.
    the descending branch is in two parts run-
                                                    Type I:
    ning parallel to the intermuscular septum.      ● Least severe and most common.
●   Elevate medial edge of flap and fascia.          ● Thumb radial clinodactyly and shallow web.
    Preserve lateral cutaneous nerve of thigh.      ● Side to side fusion of fingers 2–4 with
    Expose the intermuscular septum and look
                                                      phalangeal fusion at DIPJ, spade hand.
    for descending branch.                          ● Simple syndactyly of 4th and 5th finger.
●   This flap can be raised as a proximally or       ● Mobile MPJs, stiff IPJs.
    distally based pedicled flap or more com-
    monly as a free flap. It can be raised below     Treatment:
    the fascia or suprafascially if a thin flap is   ● 4–12 months separate index and 5th finger,

    required. Thinning of the flap has been            after 6/12 separate 3rd web. Division of trans-
    described.                                        verse metacarpal ligaments will increase
                                                      mobility.
Apert’s hand                                        ● Get   frequent tendon, nerve and vessel
See Apert’s syndrome.                                 anomalies.
● All involved portions of upper limb have          ● Perform osteotomies, which may be through

  skeletal unions, incomplete joint segmenta-         cartilaginous bars of IPJs at time of releases.
  tion and incomplete separation of rays.           ● Age 3–5, correct thumb clinodactyly with

● All hands have skeletal coalitions, distal          opening-wedge osteotomy through middle
  bifurcation of tendons, nerves and vessels,         of proximal phalanx. Use bone from iliac
  distal intrinsic insertions and complex             crest. Release 4–5th metacarpal synostosis
  syndactylies.                                       with interposition of dermal graft.
● Shoulder and elbow synostosis may occur
                                                    Type II:
  especially with type 1 and 2 hands. A dis-        ● Thumb joined to index in complete simple
  crepancy in size in shoulder may cause
                                                      syndactyly, but have separate nails.
  reduced ROM with growth. Most have nor-           ● Central fusion gives concave palm, mitten
  mal elbow motion.
● Hand features are short radially deviated
                                                      or spoon hand. Conjoined nail. Abnormalies
                                                      of index proximal phalanx.
  thumb, osseous syndactyly and symbrachy-          ● Complete syndacyly between 4th and 5th
  dactyly of central 3 rays, simple syndactyly
                                                      fingers.
  of 4th web and variable syndactyly of 1st
  web. Carpal coalitions occur, particularly        Treatment:
  between capitate and hamate, and 4th and          ● Release 2nd and 4th web at the same time as

  5th metacarpal.                                     1st web. Need to excise fascial bands between
● Ideally treatment is performed bilaterally          thumb and index.
  between 4–12 months of age. Earlier treat-        ● If not too tight use 4-flap Z-plasty, other-

  ment leads to relapse.                              wise use Y-V. Perform capsulotomy of CMCJ.
● Ideally perform two bilateral releases before     ● If index finger proximal phalanx is abnor-

  the age of 2, mobilize 5th ray, and lengthen        mal and radially deviated it may be better to
  and realign thumb when 4–6 years.                   ablate early.
12 Apert’s syndrome


●   Later correction of thumb clinodactyly as       thumb is free, it is broad and radially devi-
    for type I                                      ated. The feet are similarly involved.
                                                    Acrosyndactyly of hands graded from I–III
Type III:
● Most severe, least common.
                                                    with increasing severity.
                                                    ● Class 1: the little finger and thumb are
● Tight   osseous and cartilaginous union
                                                      separate;
  between fingers 1–4 with single conjoined          ● Class 2: only the thumb is free;
  nail with index and thumb being indistin-         ● Class 3: the whole hand is involved.
  guishable, hoof or rosebud hand.
● Thumb radial clinodactyly less severe, but
                                                  See Craniosynostosis.
  thumb is smaller.
                                                  Aplasia cutis congenita
Treatment:                                        ●   Rare, sporadic congenital deformity most
● Perform index ray resection at time of 1st          often in first-born females.
  web release. Use dorsal advancement flap,        ●   Get failure of differentiation of skin ranging
  and re-advance with subsequent proce-               from total absence of skin, fat, skull, dura
  dures. Release 4th web at the same time.            and occasionally underlying brain. Scalp is
● At time of 1st web release perform osteot-          involved in 60% of cases and ulcers may be
  omy across DIPJs with a transverse K wire,          multiple.
  which converts this to a type I hand.           ●   Mostly occurs in the midline in the area of
                                                      the posterior fontanelle.
Apert’s syndrome                                  ●   Ulcers are sharply marginated with a red
Acrocephalosyndactyly with bicoronal synos-           base and usually heal rapidly by secondary
tosis, Midface hypoplasia, cleft palate, and          intention.
complex syndactyly. See Apert’s hand.
● Most are sporadic, but also autosomal dom-
                                                  Aetiology: May be chromosomal, placen-
                                                  tal infarcts, amniotic adhesions or pressure
  inant inheritance.
● Mutation in Fibroblast growth factor receptor
                                                  necrosis. Also associated with hydrocephalus,
                                                  facial clefts and spina bifida.
  2 (FGFR2).
● Incidence is 1/160 000 live births.             Management:
● Only the lambdoidal suture is present. The      ● May heal with dressings, which should be

  coronal suture is absent. Possibly primary        kept moist.
  cranial base synostosis delays the approx-      ● For large defects with exposed brain, dura

  imation of bones and suture induction             or skull, provide soft tissue cover and recon-
  doesn’t occur.                                    struct bone later.
● The face has a steep forehead and a groove      ● Use local flaps and possibly tissue expansion.

  above the supra-orbital ridge. Orbits are       See Scalp reconstruction.
  shallow with hypertelorism and down slant-
  ing of palpebral fissures.                       Apocrine cystadenoma
● The mid-third of the face is hypoplastic with   ●   A small, benign, translucent nodule, usually
  a normal mandible.                                  appearing on the face.
● The nose is beaked.                             ●   Often pigmented and may contain brown-
● Decreased patency of posterior nasal choa-          ish fluid.
  nae may result in obstructive apnoea.           ●   It may be confused with melanoma or pig-
● 30% have a cleft palate or uvula.                   mented basal cell naevus.
● Mental retardation is frequent.

● Mirror image abnormalities of hands and         Apocrine glands
  feet with an inverse relationship between       ●   Sweat glands found in axilla and groin.
  the severity of craniofacial abnormality and    ●   They start to function in puberty and give
  the severity of hand anomalies.                     an odour due to bacterial decomposition.
● Syndactyly of fingers 2, 3 and 4 is present      ●   They have a sympathetic adrenergic nerve
  and the whole hand may be fused. If the             supply.
                                                                             arthrodesis hand     13


Apocrine tumours                                     ●   AVM is present at birth and can either man-
See Apocrine cystadenoma,Syringocystadenoma              ifest in infancy, or appear later.
papilliferum, Chondroid syringoma.                   ●   Intracranial AVM is more common than
                                                         extracranial AVM, followed in frequency by
Arachnodactyly                                           AVM of the limbs, trunk, and viscera.
Unusually long slender fingers.                       ●   Some may be hormonally active. The fast-
                                                         flow nature may not be recognized until
Arcade of Frohse                                         trauma or puberty stimulate expansion.
See Radial tunnel syndrome. A fibrous band on         ●   AVMs develop ischaemic skin changes,
the surface of supinator. One of the structures          ulceration, intractable pain, and intermit-
implicated in compression of the radial nerve            tent bleeding. Low-flow lesions may be asso-
at the elbow.                                            ciated with skeletal hypertrophy, high-flow
                                                         with destruction. May present as emergency
Arcade of Struthers                                      with haemorrhage or cardiac failure.
See Cubital tunnel syndrome. Fascial band            Staging: Clinically by Schobinger;
above elbow.                                         ● Stage   I: blush/stain, warmth and AV
                                                       shunting.
Arnez and Tyler classification                        ● Stage II: stage I with enlargement, tortuous
Classification for Degloving injuries.                  veins, pulsations, thrill and bruit.
● Type 1: non-circumferential degloving.
                                                     ● Stage III: stage II with either dystrophic
● Type 2: abrasion, but no degloving.
                                                       changes, ulceration, bleeding, persistent
● Type 3: circumferential degloving.
                                                       pain or destruction.
● Type 4: circumferential degloving plus avul-
                                                     ● Stage IV: stage II with cardiac failure.
  sion between deep tissue planes. Requires
  serial conservative debridement and delayed        Treatment: See Vascular malformations.
  reconstruction.
                                                     Arthrgryposis
Arteriovenous fistulae                                ● Greek meaning curved joint.
Rare in the upper extremity with the excep-          ● Many causes but all have in common immo-
tion of high flow AV malformations and sur-             bility of the joints in utero.
                                                     ● This may be due to abnormal muscles,
gically made AV fistulae. High output failure
rarely occurs distal to the elbow. Most become         abnormal neurology or crowding due to oli-
manifest in the first 10 years of life. Most trau-      gohydramnios, bicornuate uterus etc. Beal’s
matic fistulae are due to penetrating Vascular          syndrome is a contractural arachnodactyly.
                                                     ● Findings:   contractures, usually bilateral,
injuries. An arteriogram will help guide treat-
ment. Fistulae with bony involvement are               adduction and internal rotation of shoul-
poorly controlled by excision. Diffuse digital         ders, fixed flexion or extension of elbows
masses respond poorly to simple excision.              and knees. Club-like hands and wrists, thin
Amputation may be required.                            waxy skin.
                                                     ● Treatment: dynamic and static splintage,


Arteriovenous malformations                            occasionally surgery.
●   These are the most difficult Vascular malfor-     See Congenital hand anomalies.
    mations to treat.
●   They can be high flow and haemodynami-            Arthrodesis hand
    cally active.                                    Wrist:
                                                     ● For pain, reconstruction following tumour
●   Pure arterial malformations such as aneu-
    rysms are rare but they can occur with AVMs.       resection, instability.
                                                     ● Remove all articular surface, maintain car-
●   The epicentre of an AVM is called the
    nidus and consists of arterial feeders, micro-     pal alignment and height, use internal fixa-
    and macro-arteriovenous fistulas (AVFs),            tion, bone graft and splint until radiological
    and enlarged veins.                                union.
14   arthroplasty


● Optimal position is 15º extension 5º ulnar       DIPJ: Approach through H incision. Section
  deviation. If both wrists are being fused        extensor tension. Flex joint and excise collat-
  place dominant hand in extension and non-        eral ligaments to increase exposure. Fix with
  dominant in flexion for personal hygiene.         either Herbert screw or interosseous wire and
● Use bone graft, bone blocks, intramedullary      oblique K wire. For the IPJ can use 90-90 wires
  rods, interosseus wires, external fixators and    or if bone stock poor use K wire.
  dorsal plates.
                                                   PIPJ: Dorsal longitudinal incision. Split
See Proximal row carpectomy.
                                                   extensor tendon and elevate to either side. Cut
Limited fusions:                                   central tendon and collaterals. Use 90-90 or
● Triscaphe    arthrodesis (STT): for rotary       tension band wiring.
  subluxation of the scaphoid, non-union,
                                                   MPJ: Expose through longitudinal incision
  Kienböcks, triscaphe arthritis, DISI.
● Lunotriquetral arthrodesis: for lunotriquet-
                                                   in skin and on radial side of finger. Excise
                                                   collaterals. Fix with mini plate.
  ral ligament tears and instability.
● Capitolunate arthrodesis: mid-carpal degen-

  erative arthritis.
                                                   Arthroplasty
● Scaphocapitate arthrodesis: for rotary sub-
                                                   ●   Wrist: inflammatory, degenerative and post-
                                                       traumatic arthritis. Arthroplasty most com-
  luxation of the scaphoid, Kienböcks, mid-
                                                       monly performed in RA. Contraindicated if
  carpal instability.
● Capitate-lunate-hamate-triquetral
                                                       there are poor wrist motors.
                                         (four     ●   PIP joint: silicone implant arthroplasty may
  corner): for ulnar mid-carpal instability,
                                                       be performed through a palmar, lateral or
  SLAC, scaphoid non-union.
                                                       dorsal approach. For a dorsal approach the
Fusion across radio-carpal joint gives the
                                                       extensor mechanism is opened. Collateral
greatest loss of movement. A single row fusion
                                                       ligaments and volar plate are released. The
gives the least loss of motion.
                                                       articular surfaces are removed, osteophytes
Small joint arthrodesis:                               are removed, the medullary canal reamed
● Indications: pain, instability, deformity and        and the implant inserted. Repair the col-
  loss of neuromuscular control.                       lateral ligament. Commence active motion
● Position: individualize to particular patient.       immediately. Protect finger from lateral
  ● MCP joints cascade radial to ulnar, 25º for        stress.
    the index and add 5º for each digit;           ●   MCP joint: Swanson’s arthroplasty.
  ● PIPJ cascade from 40º in index to 55º;

  ● DIPJ fuse in 0º flexion, possibly 5-10º         Arthroscopy – wrist
    supination for index and middle to
                                                   Indications: Diagnose and treat pain, tears of
    achieve pinch grip;
  ● thumb, keep length. IPJ fuse in slight flex-
                                                   ligaments and TFCC. Remove loose bodies.
    ion (recommended between 0–15º). MPJ           Portals:
    5–15º. CMC fuse with 40º palmar abduc-         ● Named by the extensor compartments, e.g.

    tion and 20º of radial abduction.                3–4 portal is between 3rd and 4th dorsal
● Surface preparation:                               compartment.
  ● avoid shortening;                              ● The 5 used are 1–2, 3–4, 4–5, 6R and 6U –

  ● cup and cone method enables accurate             radial and ulna to FCU.
    positioning;                                   ● 3–4 and 4–5 most commonly used, the

  ● remove all the articular cartilage.              former for visualization and the latter for
● Fixation:                                          instrumentation.
  ● K wires: crossed;                              ● With 1–2 the nerve and artery are at risk.

  ● Interosseous wiring: stronger than K wires;      With 6U dorsal branch of ulnar nerve at
  ● Tension band wiring: use for MCP joints          risk
    and pip joints. Compression is produced        ● Some surgeons pre-inflate the joint. Lunot-

    by the dorsally placed tension band.             riquetral ligament is best seen through 6R.
                                                                                          axilla 15


●   Mid-carpal joint: three mid-carpal portals –   minimizing morbidity and mortality in the
    mid-carpal radial (MCR), ulnar (MCU)           3rd peak (days–weeks) by optimizing initial
    and scaphotrapeziotrapezoid (STT).             trauma care.
                                                   ● Prehospital management.

ASA classification                                  ● Triage

Classification adopted by the American Society      ● Primary survey:

of Anaesthesiologists for assessing preopera-        ● A: airway and cervical spine control;

tive physical status.                                ● B: breathing and ventilation;

● I: healthy.                                        ● C: circulation haemorrhage control;

● II: mild systemic disease.                         ● D: disability; AVPU – Alert, Vocal stimulus,

● III: moderate systemic disease, some func-           Painful stimulus, Unresponsive;
   tional limitation.                                ● E: exposure and environmental control.

● IV: severe systemic disease, constant threat     ● Resuscitation and repeat primary survey

   to life.                                          until stabilized.
● V: moribund patient, unlikely to survive         ● Secondary survey.

   24 hours.                                       ● Post-resuscitation monitoring.

                                                   ● Definitive care.

Aspergillosis
● An opportunistic fungal infection seen in        Atypical fibroxanthoma
  immunocompromised patients, e.g. aplastic        ● A small, firm nodule with crusting. Similar
  anaemia, leukaemia and major burns.                in appearance to a BCC.
● It is not seen in healthy individuals.           ● Occurs in the elderly on the head and neck.

● Invasive aspergillosis usually requires surgi-   ● Histologically see atypical spindle and giant

  cal debridement in addition to anti-fungal         cells with a lot of mitoses.
  agents to eradicate infection.                   ● Treat with simple excision and it rarely

See Fungal hand infections.                          recurs.
                                                   ● If it invades deeply it is called a Malignant

Aspirin                                              fibrous histiocytoma and can resemble basal
● Has an inhibitory effect on platelet               cell epithelioma. Appears on chronically
  aggregation.                                       sun-exposed parts of the head and neck, par-
● Cyclo-oxygenase is acetylated, which blocks        ticularly in the pre-auricular area in older
  thromboxane A2 production.                         persons.
See Microsurgery.                                  See Pseudosarcomatous lesions.

Atasoy volar V–Y flap:                              Axial flaps
●   Used in the treatment of Fingertip injuries.   A flap raised with a known vessel that increases
●   Volar Y–V flap taken from defect down to        the length to width ratio available.
    DIP joint.                                     ● Direct: contain a named artery in the subcu-

●   Raise with NVB and free fibrous septa.            taneous tissues. Examples include the Groin
    Tension free closure.                            flap and Deltopectoral flap. They may include
●   Also known as Tranquilli–Leali flap.              a random element in the distal portion.
                                                   ● Fasciocutaneous flap: based on vessels run-

Ataxia-telangiectasia                                ning within or near the fascia.
See Louis–Bar Syndrome.                            ● Musculocutaneous flaps.

                                                   ● Venous flaps:

ATLS
Advanced Trauma Life Support                       Axilla
A system of trauma care that involves sys-         Boundaries:
tematic prioritized evaluation and treatment       ● Anterior: pectoralis major, subclavius, pec-

aimed specifically at preventing deaths in the        toralis minor.
2nd peak (minutes to hours after trauma) and       ● Posterior: subscapularis, lat dorsi, teres major.
16    axillary dissection


●   Medial: 4–5 ribs, serratus anterior.        ● III: medial to pectoralis minor muscle.
●   Lateral: coracobrachialis and biceps.       Make inverted U incision in axilla. Raise skin
                                                flaps and stitch back. Define borders of axilla
Nerves:
● Intercostobrachial nerve: sensory innerva-
                                                anteriorly and posteriorly. Leave fascia on
                                                muscle. Find and preserve long thoracic nerve
  tion to upper medial arm.
● Long thoracic nerve: to serratus anterior.
                                                and NVB to lat dorsi. Having identified these
                                                structures and axillary vein, start distally and
  From C5,6,7. Division cause winging of the
                                                work proximally from an anterior and pos-
  scapula.
● Thoracodorsal nerve: from posterior cord to
                                                terior front to converge on axillary vein and
                                                continue up behind pectoralis minor.
  lat dorsi.
● Medial pectoral nerve: pectoralis major and
                                                Anatomy of axilla.
  often wraps around the lateral border of
                                                Axillary nerve
  pectoralis minor.
                                                C5, C6 roots from the posterior cord. Supplies
                                                deltoid and teres minor.
Axillary dissection
Three levels of axillary nodes:
● I: lateral to lateral border of pectoralis
                                                Axonotmesis
                                                Axonal damage with Wallerian degeneration.
  minor.
● II: under pectoralis minor.
                                                See Seddon classification.

				
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