II Lecture Chapter 19 Short Answer: Hand Procedures pp 418

Regarding a Bier block or tourniquet, identify at least three precautions. What are the usual settings? What is the Esmarch bandage used for?

- prior to performing the Bier block, be sure that the tourniquet is working properly; - if the tourniquet malfunctions and deflates during the case, the patient will likely have a seizure due to lidocaine toxicity; - in obese patients, consider use of a wide single tourniquet in order to ensure that there will not be leakage of the lidocaine into the systemic circulation The proximal cuff of the tourniquet is inflated to a level approximately 100 mm Hg above the systolic blood pressure. The limb is exsanguinated with the use of an Esmarch bandage.

Replantation of a digit or hand is very extensive. Describe the major steps in the process. Be sure to indicate the usual order of reattachment.

1. bone-to-bone attachment (bone approximation) 2. tendons are reconnected (tenorrhaphy) 3. reanastomosis of the blood vessels (restoration of vascular) 4. nerves are repaired (neurorrhaphy)

If there are duplicated digits, what is the name for that condition? What types of duplicated digits may occur? What is the name of the classification system for a bifid thumb?

Duplication of the digits is referred to as polydactyly. This can be a partial or complete additional digit or digits; it may affect the hands and/or feet and it may be unilateral (more common) or bilateral. The Wassel classification of bifid thumb is the most commonly used classification.

What condition is caused by contraction of the palmar fascia? What three presentations may be seen?

Dupuytren's contracture. 1. a nonpainful nodule in the palm of the hand near the fourth or fifth digit 2. a dimpling or pit in locations just described 3. a longitudinal fibrous band or cord extending from the palm towards the fingers

How many carpal bones are located in the wrist? Name them.

Eight carpal bones comprise each wrist, or carpus. lateral to medial 1. scaphoid 2. lunate 3. triquetral 4. pisiform bones distal row 5. trapezium 6. trapezoid 7. capitate 8. hamate

When a postoperative dressing is applied, why are the fingers left exposed?

If possible, the fingertips should be left exposed so that they may be checked for circulation and feeling.

What is the medical name for "club hand"? At what age would corrective procedures be performed? What is used to stabilize the repair?

Radial dysplasia or hypoplasia is a congenital defect commonly referred to as "club hand". Procedure is performed when the patient is approximately 1 year of age. Soft tissue stabilization is performed by distal advancement of the extensor carpi ulnaris insertion and transfer of the flexor carpi ulnaris to the dorsum.

What is the medical name for webbed fingers or toes? What is the difference between a simple or complicated condition?

Syndactyly, or webbed digits, occurs when the digits of the hands or feet fail to separate. It may be a simple connection to the skin, or it may be more complex, involving conjoined bone and fingernails.

Why must care be taken when dissecting the palmar fascia to release the contracture? If the contracture is extensive, what type of incision may be made to ensure skin will cover the incision postoperatively?

Take care to avoid injury to digital nerves. For extensive contractures, a Z-plasty incision may be used so that the existing tissue can be used to cover the palm.

During a repair of a bifid thumb, what must be done to ensure centralization and stability of the thumb? What is used to stabilize the thumb after repair?

The positions of the extensor and flexor tendons are confirmed to ensure they are in a central position along the thumb. A K-wire is placed across the joint to hold the alignment in place. At four weeks the K-wire is removed and a splint is worn for 3-4 weeks.

What type of stitch is used for an anastomosis of tendons?

The surgeon uses a figure-of-eight suture technique to anastomose the tendons.

What key structures are dissected free with the toe?

The toe is placed in an angulated medial position and, using the #15 knife blade, the joint capsule is incised and disarticulated though the metatarsal joint.

When is a toe-to-hand transfer considered? During this process, communication is essential. What information is shared and why?

Toe-to-hand transfer is performed due to trauma to the hand in which the patient's thumb was traumatically amputated or injured beyond use. The length of surgery is 12-16 hours; therefore, tourniquet time must be carefully monitored and communicated to both teams. Both teams must be in constant communication in regard to the key structures that are identified, mobilized, and isolated. This includes communicating and recording the length of each nerve, vessel, and tendon of the donor toe and hand. The team dissecting the hand should measure, record, and communicate the required length of each structure before any structures are divided in the foot to ensure adequate length is achieved.

What incision will be used to separate the webbed digits? If a skin graft is needed, what type will be necessary?

Using a #15 knife blade, the surgeon makes a Z-plasty incision in the interdigital space on the volar and dorsal side of the hand. Be prepared for a full-thickness skin graft (FTSG)