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.
● 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:
for posture, standing, walking and bending.
● Tumour: Desmoid, Dermatoﬁbrosarcoma
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
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.
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
● 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
● 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
● 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%
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
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
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
● Incision of the cystic lesions reduces the
maculopapular lesions, red to light brown
inﬂammation that produces the scarring. ● Microscopically
● Dietary control does not appear to be
get hyperkeratosis with
dyskaryosis and acanthosis. In the dermis
● Topical medications with benzoyl peroxide,
there is an actinic elastosis with inﬂamma-
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
● Accutane is effective for severe acne.
● Dermabrasion, laser resurfacing and colla-
See Cutaneous horn.
gen injections may help reduce the scarring.
● A facelift procedure may reduce skin laxity,
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
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
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-
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.
● Single pedicle: raised as a square or rectangle
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.
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.
● 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.
● 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
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:
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.
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
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.
● 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
sinus) will require an anterior cranial fossa ● 46XX or 46XY or mosaic karyotype with
● 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.
● 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
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.
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
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-
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.
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
oscillating veins as blood may ﬂow in either
● Fibrous, erythematous papule 1–3 mm in
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
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
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
● The intramuscular territories of arteries and
See Orthognathic surgery, Teeth.
● 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
● The vessels hitchhike with nerves.
(index and middle) and pronator quadratus.
● Compression produces pain in the forearm
vessels follow connective tissue
and a weak pinch grip (O sign).
● 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.
● 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
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.
● 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-
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-
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
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
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
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
● Most severe, least common.
with increasing severity.
● Class 1: the little ﬁnger and thumb are
● Tight osseous and cartilaginous union
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
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
● Mutation in Fibroblast growth factor receptor
necrosis. Also associated with hydrocephalus,
facial clefts and spina biﬁda.
● 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
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.
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.
● 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.
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-
● 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
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.
● 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.
● 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:
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
● 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-
● Thoracodorsal nerve: from posterior cord to
terior front to converge on axillary vein and
continue up behind pectoralis minor.
● Medial pectoral nerve: pectoralis major and
Anatomy of axilla.
often wraps around the lateral border of
C5, C6 roots from the posterior cord. Supplies
deltoid and teres minor.
Three levels of axillary nodes:
● I: lateral to lateral border of pectoralis
Axonal damage with Wallerian degeneration.
● II: under pectoralis minor.
See Seddon classiﬁcation.