PRSPPE

What is the origin of TE?

1. 1956 Dr Neumann used subcut baloon filled with air to fill periauricular area, but was forgotten about 2. Dr Radovan popularised it in PRS using silicone envelope w injection port for saline

Describe the preop evaluation of CMF pt

1. Analysis of morphologic abnormality 2. Evaluation of functional risks 3. Detection of assoc malformations eg cerebral, cardiac 4. Classification of any syndrome 5. Prep for surgery

Name three syndromes associated with hand anomalies.

1. Aperts: AD. CS, exorbitism, midface hypoplasia, symmetrical syndactyly of hands & feet (key difference from Crouzons) 2. Pfeiffers: AD. CS, exorbitism, midface hypoplasia, & enlarged thumbs & great toes 3. Carpenters: AR. CS, polysyndactyly of feet, short hands w variable soft tissue syndactyly

What is major sequalae of unrepaired CP?

1. Breathing probs esp if PRS 2. Feeding probs: no negative pressure, regurgitation 3. Hearing probs: poor ET fxn, recurrent OM 4. Speech: hypernasality of vowels, distortion of pressure consonants 5. Dentition abnormal esp if alveolus involved

Where does lengthening come from in a Z-plasty?

-Lengthening is related to the difference between long & short axes of the parallelogram formed by the Z. As the angle increases, the degree of lengthening increases -30° = 25% elongation -45° = 50% -60° = 75% -75° = 100% -90° = 125% -Amount of elongation obtained for each flap angle can be worked out by starting at 30° and 25% and adding 15° and 25% to each of the figures

5 year survival rates for localised, regional, metastatic melanoma?

-Localised 98% -Regionally 63% -Metastatic 34% 80% of melanomas are diagnosed when localised

What are contraindications to tissue expansion?

-Near a malignancy -Under a SSG -Under very tight tissue -Near an open leg wound -In irradiated field -Relative contraindications include under an open wound not on a leg, under an incision, near a haemangioma, in a crazy person

When does collagen production peak in a healing wound?

-Net collagen accumulation peaks at 2-3 wks -Collagen production peaks at 6 weeks but is balanced by collagen degradation. -Collagen synthesis & degradation continue at elevated rates for up to 1 year

Maximal dose lignocaine in tumescent solution?

35 mg/kg

How many pedicles does SCM have?

4- POST from above down: Posterior auricular, Occipital, Superior thyroid, Thyrocervical trunk (suprascapular). Type II with occipital artery dominant

what % of breast ca is hereditary

4-9% 1 in 200-400 are BRCA1 mutation positive Lifetime risk of breast Ca for BRCA is 85%

maximal dose of lignocaine?

4mg/kg plain 7mg/kg w adrenaline

How many structures traverse the carpal tunnel?

4x FDP 4x FPS 1x FPL 1x MN = 10

Describe the metastatic potential of SCCs

5-10% spread •SCCs from Marjolin's ulcer (Ix) or XP more likely •Ears, nostrils, scalp, limbs more likely •SCCs from UV less likely

Rx of frontal sinus #s

-ant table: plates -nasofrontal duct involved: safest is to obliterate the sinus: remove all muscosa & inner cortex from sinus & upper duct w burr, then pack ducts & sinus with anything that encourages scarring & ossification eg bone, muscle, fat -post table: often a/w dural tear so req craniotomy. frontal sinus should then be cranialised: dura repaired, then post table removed, and ant table & floor are reduced & stabilsied. Remaining mucosa & inner cortices of sinus & duct are burred, & duct packed w bone. Brain then resumes position in bigger ant cranial fossa

Can infantile haemangioma be associated with a facial malformation?

PHACES. F>>>M - Posterior fossal malformation - Hemangioma, often regional - Arterial anomalies incl agenesis, dilation, & stenosis of intracranial and extracranial vessels - Cardiac anomalies, most commonly coarctation - Eye anomalies - Sternal cleft and supraumbilical raphe

Causes of a SND

PIPJ extension & DIPJ flexion, mainly from excessive traction by extensor apparatus inserted on base of MP

5 bones of nose

maxilla, frontal, nasal, vomer, ethmoid

commonest malignant bone tunours in hand

mets (#1 is lung Ca) myeloma

what is a rubens flap?

named after peri-iliac fat pad seen in his paintings DCIA & DCIV

which cleft is an incomplete treacher collins?

no 6 cleft from angle mandible, to ZM suture, to lat third eyelid zygoma is hypoplastic

when to explore obstetric BPX

no biceps or deltoid by 3 months age

xray changes RA

periarticular OP periarticular soft tissue swelling marginal erosions jt space narrowing proximal bilateral symmetric dz

What are "box osteotomies" of the orbit?

"Box osteotomies" refer to combined intracranial/extracranial approach with circumferential ("box") orbital osteotomies. Ethmoidal air cells and paramedian sections of anterior cranial vault are resected with preservation of cribriform plate and the associated mucosa. Once mobilized, the orbital segments should medialize with minimal effort.

What are the most common complications following OHT repair?

"PREST IN" Pseudohypertelorism Relapse via inadequate exoneration of interorbital contents Enophthalmos Strabismus Temporal hollowing Infection Nasolacrimal dysfunction

Clostridium tetani

(1) anaerobic GP found in soil spores & animal GIT (2) 2 exotoxins, tetanolysin & tetanospasmin (3) tetanospasmin binds to & inhibits inhibitory presynaptic motor nerves, resulting in increased alpha motor neuron firing (4) Sx incl risus sardonicus (rigid smile), trismus, opisthotonus (rigid, arched back) (5) Rx tetanus incl tetanus Ig, supportive care incl diazepam, maxalon

Name the four insertions of the extrinsic extensor tendon

(1) base of PP (2) base of MP (3) base of DP (via slips to lateral bands) (4) transverse metacarpal ligament & volar plate

Metastatic calcification

(1) deposition of Ca++ salts in previously normal tissue, 2ndary to abnormal Ca++/phosphorus metabolism (2) Hypercalcemia as in primary hyperparathyroidism, CRF (3/4 HD pts), milk-alkali syndrome, hypervitaminosis D, widespread bone destruction from metastases or myeloma (3) cf dystrophic calcification is deposition of Ca++ in previously damaged tissue with normal Ca++ metabolism, eg lung: TB, pneumoconiosis, sarcoid, others

vascular supply of mobilised le fort I maxillary segment

(1) descending palatine artery (divides into greater & lesser palatine vessels), (2) posterior superior alveolar artery, (3) infraorbital artery, (4) ascending palatine branch of the facial artery, (5) palatine branch of ascending pharyngeal artery *mainly 4 and 5

What influences the permanent appearance of suture marks?

(1) length of time that skin suture remains in place (2) tension on the wound edges (3) region of the body (4) presence of infection (5) tendency for hypertrophic or keloid formation.

What is Poland syndrome?

(A) Upper limb related - Shortened digits (absent middle phalanx) - Complete simple syndactyly - Hand hypoplasia - Absent sternocostal head of the ipsilateral pectoralis major - Absent pectoralis minor (B) Other associations - Breast and nipple hypoplasia - Absent anterior axillary fold - Absent latissimus dorsi, deltoid, serratus anterior - Bony abnormalities of chest wall - Dextrocardia

Histological changes w age

* Changes in the collagen composition of the dermis - loss of type III collagen. * Loss of elastin - elastin production ceases > 70 years. * Reduction in glycosaminoglycans (GAGs) component of matrix (ground substance). * Flattening of the dermo-epidermal junction. * Depletion of Langerhans cells and melanocytes (will lead to immunological changes).

dupuytrens pathophysiology theories

* Intrinsic theory (McFarlane) - perivascular fibroblasts within normal fascia are source of disease. * Extrinsic theory (Hueston) - disease starts with proliferation of fibrous tissue de novo (due to say, trauma, DM or smoking) as nodules appear superficial to palmar fascia. * Synthesis theory (Gosset) - combines both theories with nodules arising de novo and cords from pre-existing fascia. * Murrell's hypothesis - age, environmental and genetic factors cause micro-vessel narrowing leading to local tissue ischaemia and oxygen free radical formation which stimulates fibroblasts. Subsequent increase in cell density and contracture exacerbates the ischaemia.

three phases of dupuytrens

* Proliferative - no purposeful arrangement. * Involutional - alignment of myofibroblasts along lines of tension. * Residual - tissue becomes mostly acellular, devoid of myofibroblasts and resembles a tendon.

How are cranial base bones formed?

**Endochondral ossification** •Involves replacement of preexisting cartilage model •Is also mode for axial & appendicular skeleton •Base articulations are different as they are synchondroses - separated by cartilage instead of syndesmoses NB facial bones are intramembranous ossification

Trapezius attachements

**Origin: Med third sup nuchal line, lig nuchae, spinous processes & supraspinous ligs to T12 **Insertion: Upper fibres to lat third of post clavicle; med acromion & lat spine of scapula. Lower fibres to med end of spine of scapula as far as deltoid tubercle **Action: Elevates & retracts scapula. Rotates it during abduction of arm. If scapula is fixed, extends & lat flexes neck **Nerve: SAN (XI) (lat roots, C1-5) (spinal nerves C3 & C4 for proprioception) *Vessel: Type 2. TCA from thyrocervical trunk (80%) or subclavian (20%). Runs between SCM & scalenius, crosses BPx, then enters deep surface of trap at base of neck, before dividing into ascending & descending branches. Design skin paddle over either

earliest clinical evidence of nerve compression

*1st: symptoms without signs *2nd: vibration, muscle weakness, pressure threshold *3rd: 2PD, muscle atrophy

What is giant cell tumour of hand (pigmented villonodular synovitis)

*2nd commonest ST hand tumour *benign tumour found in synovial producing sites eg joints, capsular ligs, tendon sheaths *firm, nodular, nontender. slow growing *typically in radial 3 digits on volar side *histo: multinucleated giant cells & xanthoma cells *Rx is careful complete excision

Lid reconstruction NB 10% all skin tumours found on eyelid Most lid lesions BCC 5-10% all lid lesions are SCC

*<35% wedge eg pentagonal, not triangular *35-50% canthotomy & cantholysis eg Tenzel semicirc flap for upper *50-75% myocut advancement flaps eg cheek advancement flap (Mustarde) *>75% need import tissue from adjacent lid, cheek, forehead -eg Cutler-Beard or Mustardé total lid flap.

Kenacort injection A40 in 1cm keloid - would you use the whole vial (40mg)

*A10 = 10mg/ml *A40 = 40mg/ml *0.1 mL per cm2 of involved skin *usual doses - 40mg/mL for thick keloid scar - 10 mg/mL for moderate thickness hypertrophic scar

Mathes Nahai FC classification

*A: Direct cutaneous perforator (similar to the older term "axial") *B: Septocutaneous perforator (courses directly along an intercompartmental or intermuscular septum) *C: Musculocutaneous perforator (indirect) (least reliable as based on indirect perfs)

Cormack-Lamberty fasciocutaneous classification

*A: Multiple perforators (with no discrete origin; may be a combination of direct or more commonly, indirect perforators); (least reliable as based on indirect perfs) *B: Solitary perforator (single perforator, usually direct) *C: Segmental perforators (multiple, arising periodically from the same underlying source vessel, usually direct)

McCormack & Lamberty Flap Classification

*A: Multiple perforators (without any known discrete origin) *Type B: Solitary perforator (single perforator, usually direct) *Type C: Segmental perforators (multiple, arising periodically from same underlying source vessel, usually direct)

Gorlins syndrome - Calcification of falx cerebrae?

*AD disorder caused by faulty tumour suppressor gene *Multiple basal cell nevi w malignant changes by puberty. *Get other tumours eg melanoma, medulloblastoma, meningioma, breast Ca, NHL *Jaw cysts *Pitting of palms and soles *Pseudohypertelorism *Frontal bossing *Syndactyly *Spina bifida *Calcified falx cerebri (noted on skull X-ray)

Radiocarpal joint

*AKA wrist joint, between distal radius & TFCC (proximally) & scaphoid, lunate, triquetrum (distally) *TFCC holds lower ends of radius/ulna together & separates wrist/radiocarpal joint from DRUJ

AD / AR/ X linked

*AR: if both parents +ve, 25% chance of dz (need 2 copies) & 50% chance of being carrier (need 1 copy) *AD: have 50% chance of dz (need only 1 copy because its dominant) *X linked (usually recessive): if mum has abnormal X XSome, theres 25% healthy boy, 25% healthy girl, 25% carrier girl, 25% diseased boy. If Dad has disease, theres 0% son being carrier/dz, 100% daughter have disease

Boundaries & contents of the temporal fossa

*Above - sup & inferior temporal lines *Below - zygomatic arch *Roof - temporalis fascia *Floor - pterion: frontal, parietal, temporal, sphenoid, occipital *Ant wall: zygoma, zygomatic process of frontal bone & maxilla *Contents: temporalis; deep temporal branches from Vc; Deep temporal arteries from maxillary

Chx of titanium

*Biocompatible, inert, and nonferromagnetic. *Has elemental characteristics equivalent to calcium. *Has a surface oxide layer that forms a thin proteoglycan layer over the implant that helps it osseointegrate with bone. *Safe for CT and MRI, with minimal artifact. *Doesnt degrade with time

What is biobrane

*Biological skin substitute used in PT burns *Bilaminar material with outer silicone layer attached to nylon fabric, & inner collagen layer

Adductor magnus anatomy - what courses through

*Arises: Adductor portion-ischiopubic ramus. Hamstring portion-lower outer quadrant of post surface of ischial tuberosity *lnserts: Adductor portion: lower gluteal line & linea aspera. Hamstring portion: adductor tubercle *Action: Adductor adducts hip, hamstring extends hip *Nerve: Adductor-post div obturator N (L2,3,4). Hamstring-tibial portion of sciatic (L4) *Notes -MCFA passes ABOVE it -Hiatus: FA & FV pass through it becoming popliteal; saphenous nerve & genicular artery enter but dont leave they pass through wall -Along linea aspera attachment theres 4 holes for Profunda vessel perforators and

LD Movements of glenohumeral joint Does it extend?

*Arises: All thoracic spines & supraspinous ligs from T7 downwards & lumbar & sacral spines via lumbar fascia, post third iliac crest, last four ribs (interdigitating with EO) & inf angle of scapula *lnserts: Floor of bicipital groove of humerus after spiraling around teres major *Action: Med rotates, Adducts, Extends a flexed arm. Costal attachment helps with deep inspiration, rest of muscle helps w forced expiration *Test by adducting an abducted arm against resistance *Nerve Thoracodorsal N (C6,7,8) (from post cord)

External oblique

*Arises: Ant angles of lower eight ribs. *lnserts Outer ant half of iliac crest, inguinal lig, pubic tubercle & crest, & aponeurosis of ant rectus sheath, linea alba & xiphisternum *Action: Supports abdo wall, assists forced expiration, aids raising intraabdo pressure &, with muscles of opposite side, abducts & rotates trunk *Nerve: Ant primary rami (T7-12) *Notes: Interdigitates with four slips of serratus anterior & four of latissimus dorsi

Buccinator - attachments/ innervation/ arterial supply (external oblique line of mandible?)

*Arises: Ext alveolar margins of maxilla by molar teeth, to pterygomaxillary ligament, maxillary tubercle & pterygoid hamulus (interdigitates w superior constrictor) & mylohyoid line, then oblique line of mandible then mandible alvolar margin. Pierced by parotid duct opposite third upper molar *lnserts: Decussates at modiolus of mouth & interdigitates with opposite side *Action: Hybrid of facial expession and mastication muscle. Aids mastication by emptying vestibule, tenses cheeks in blowing & whistling, aids closure of mouth *Nerve: Buccal br of facial N (VII). It is a second arch structure. Buccal br of Vc pierces it but supplies afferent sensation only. *Blood supply is by facial artery (ant) & maxillary artery (post)

Triceps

*Arises: Long head-INFRAglenoid tubercle of scapula. Lat head-upper half post humerus (linear origin). Med head-lower half post humerus inferomedial to spiral groove & both intermuscular septa *lnserts: Post part of upper surface of olecranon process of ulna & post capsule *Action: Extends elbow. Long head stabilises shoulder jnt. Med head retracts capsule of elbow jnt on extension *Nerve: Radial N (C6,7,8) (from post cord), four brs

Tensor fascia latae anatomy

*Arises: Outer surface of ant iliac crest between tubercle of the iliac crest & ant sup iliac spine *lnserts: Iliotibial tract (ant surface of lat condyle of tibia) *Action: Maintains knee extended (assists gluteus maximus) & abducts hip *Vessel: type I muscle - ascending branch of LCFA, enters 10cm below ASIS *Nerve: Sup gluteal N (L4,5,S1)

gluteus maximus anatomy

*Arises: Outer surface of ilium behind post gluteal line & post third of iliac crest, lumbar fascia, lat mass of sacrum, sacrotuberous lig& coccyx *lnserts Deepest quarter into gluteal tuberosity of femur, remaining three- quarters into iliotibial tract (ant surface of lat condyle of tibia) *Action: Extends & lat rotates hip. Maintains knee extended via iliotibial tract *Vessel: type III via SGA (D1) & IGA (D2) both from internal iliac artery *Nerve: Inf gluteal N (LS,Sl,2)

gluteus minimus anatomy

*Arises: Outer surface of ilium between ant & inf gluteal lines *lnserts: Ant surface of greater trochanter of femur *Action: Abducts & med rotates hip. Tilts pelvis on walking *Nerve: Sup gluteal N (L4,5,S1) **Action and nerve same as glue medius

gluteus medius anatomy

*Arises: Outer surface of ilium between post & ant gluteal lines *lnserts: Posterolateral surface of greater trochanter of femur *Action: Abducts & rned rotates hip. Tilts pelvis on walking *Nerve Sup gluteal N (L4,5, S1) **Action and nerve same as glue minimus

Teres major anatomy

*Arises: Oval area (lower third) of lat side of inf angle of scapula below teres minor *lnserts Med lip of bicipital groove of humerus *Action Med rotates & adducts arm. Stabilises shoulder jnt. Fxnally part of subscapularis *Nerve: Lower subscapular N (C5,6,7) (from post cord)

EDB muscle

*Arises: Sup surface of ant calcaneus *lnserts: Four tendons into prox phalanx of big toe & long extensor tendons to toes 2, 3 and 4 *Action: Extends toes when foot fully dorsiflexed *Nerve: Deep peroneal N (L5,Sl) *Notes: Med one of four tendons could be regarded as extensor hallucis brevis

Tibialis anterior muscle

*Arises: Upper half of lat shaft of tibia & interosseous membrane *lnserts: Inferomedial aspect of med cuneiform & base of 1st MT *Action: Extends & inverts foot at ankle. Holds up med longitudinal arch of foot *Vessel: type IV via 8-12 arterial muscular branches of ant tibial artery & vein *Nerve: Deep peroneal N (L4,S) *Notes: Inversion is at subtalar & mid tarsal joints

Posterior tibialis -invertor of foot? -relations to medial malleolus -bones of origin

*Arises: Upper half of post shaft of tibia & upper half of fibula between median crest & interosseous border, & interosseous membrane *lnserts: Tuberosity of navicular bone & all tarsal bones (except talus) & bases of metatarsals 2-4 *Action: Plantar flexes & inverts foot. Supports med longitudinal arch of foot *Nerve: Tibial N (L4,S) *Behind med malleolus ant to post TDANH: *T*ib post, F*D*L, PT*A*, PT*N*, F*H*L

What is integra?

*Artificial skin composed of 2 layer composite of artificial dermis & epidermis *Artificial dermis is shark glycosaminoglycans & bovine collagen in 3D pattern. This provides scaffold for fibroblasts to lay down collagen in orderly fashion, so neodermis instead of scar is formed. This neodermis replaces artificial dermis & inherits a vasculature to become permanently incorporated as host *Artificial epidermis is temporary silicone layer, which acts as infection barrier *Used in burns: excise burn early, place thin SSG on neordermis.

Xeroderma pigmentosum

*Autosomal recessive *Acute sensitivity to sunlight from defective DNA repair mechanism *Photophobia and conjunctivitis in 80% *Development of cutaneous malignancy (basal and squamous carcinoma, malignant melanoma) *Often fatal before the age of 10 years, 60% die by 20 years of age

thumb hypoplasia classfication

*Blauth classification, based on XR. *II & IIIA are recon canditates eg osteoplastic, webspace deepening, MCPJ stabilisation, correction of extrinsic tendon probs, opponensplasty (usually Huber tech: ADM-->APB) *IIIB, IV, V are for pollicisation

Erbs palsy

*C5,6 nerve root damage *No supraspinatus, infraspinatus, deltoid, brachialis, biceps *Arm is internally rotated, adducted, elbow extended *C7 involvement causes loss of elbow, wrist, finger extension

Management of nutrition in burns -ideal nitrogen blance (100:1 - 150:1) -when to start -pattern of metabolic changes (hypo, then hyper) -higher in children -changes to immunoglobulin levels

*Calories: Adults: 25 kcal/kg (usual body weight) + 40 kcal/% BSA per day (Curreri). Protein: 1 to 2 g/kg/day. * Children: 1800 kcal/m2 BSA + 2200 kcal/m2 burn area *Check nutritional status twice weekly w serum prealbumin.

Stahl deformity of the ear

*Chx deformities -formation of third crus, by abnormal cartilaginous fold extending from antiheli to helical rim -area of helix where third crus exists presents an unfolded appearance -hypoplasia of superior crus -broad scapha *More common in Japan *Rx involves either cartilage excision or cartilage support

how are flaps classified (5 c's)

*Circulation: random or axial (direct, FC, or MC), venous *Composition: cutaneous, FC, MC, muscle, etc *Contiguity: local (beside), regional (same region), distant (pedicled or free) *Contour: Rotation, Advancement, Transposition *Conditioning: Delay (any preoperative technique that increases flap survival eg cut DIEA/DIEV before superior pedicled TRAM breast recon)

Clavicle intramembranous ossification?

*Clavicle forms by intramembranous ossification *First bone of skeleton at 5W *Has 2 primary ossification centres *Elongation occurs at the sternal end *Fuses during 20s

Holt-Oram

*Commonest heart-hand anomaly *Radial dysplasia & congenital heart problem *Usually have abnormal scaphoid w extra carpal bone *Thumb is abnormal *Cardiac septal defects

What is a chimeric flap

*Composed of more than one flap each on its own pedicle but with both on a common source pedicle. With a single pedicle supplying more than one flap, only one pair of microsurgical inflow and outflow recipient vessels is needed. *EG serratus & LD can be raised together on the common subscapular pedicle *EG ALT & RF muscles *EG ALT split into two skin & fat paddles on two different perforators both connected to LCFA

How much angulation acceptable in MC neck #s

*Controversial, but angulation is unacceptable if it causes pseudoclawing on extension: compensatory MCPJ hyperextension & PIPJ flexion on attempted extension *In RF & LF 40 degrees *In IF & MF 10-20 degrees

histology of dupuytren nodule

*DD has much more type III collagen than normal fascia (40% vs 5%)

Reasons why a repaired tendon won't heal -

*Damage to vinculae *Gapping *Improper post op mobilisation *Type of repair

Inhalational injury -Dx -Effects -Rx

*Dx suggested by enclosed space fire, carbonaceous sputum, COHb >10% *Dx confirmed by fibreoptic bronchoscopy, but may not get oedema until resuscitated; radionuclide imaging can help Dx but not clinically used *CO poisoning shifts O2 curve to LEFT resulting in Loading of O2 in lungs (CADET look R, causes Release of O2 from Hb). *Rx ABCs, mech ventilation, 100% O2 until COHb <10%. CO has 210x greater affinity for Hb than O2. 100% O2 reduces t1/2 from 4.5hrs (RA) to 45mins

what is trenchfoot

*Extremities exposed to damp environment over long time at temperatures 32-50C. Heat lost from being wet, vasoconstriction causes low blood flow *Sx: numb, pain, red oedematous foot->gray/blue->hyperemic->can necrosis. Sx resolve after 3-6/52, but still sensitive to cold *Rx is *slow* rewarming & keep dry

The proliferative stage of wound healing is characterised by ...

*Fibroblasts proliferate to become dominantcell of the proliferative phase. They produce collagen, which provides structure to the wound and replaces the fibronectin-fibrin matrix. Angiogenesis of new capillaries occurs to sustain the fibroblast proliferation. Keratinocytes also epithelialize the wound.

Ponten flap

*Found that undelayed cutaneous flaps in LL if orientated longitudinally w retention of deep fascia could be safely used with ratio up to 3:1. They were proximally based & sensate, with no perforator seen (ie CL type A)

Dorsalis pedis artery

*From ATA halfway between malleoli *Runs to base of 1st MT space, then joins lat plantar artery to complete plantar arch *Lies between EHL (medial) & DPN digital be (lateral), & is crossed by EHB tendon *3 branches -Lateral tarsal artery: runs under EDB -Arcuate artery: also runs under EDB, gives off dorsal metatarsal arteries -First dorsal metatarsal artery: direct continuation of DPA, supplies 1st webspace

Botox -source -moa -effects -use

*From Clostridium botulinum *MOA: binds to presynaptic cholinergic receptors--> presynaptic inhibition of acetylcholine release *Effects: denervates striated muscle; anhidrosis; onset 1 week, peak 1-2 weeks, last several months (new motor end plates) *US licensed for spasmodic torticolis, blepharospasm, hemifacial spasm, glabellar frown lines, hyperhydrosis. *Alcohol prep inactivates toxin; max dose 70kg adult 400U; usual dose 25U

Hypoglossal nerve

*From hypoglossal nucleus in 4th ventricle *Fibres pass out of anterolateral surface of medulla between olive & pyramid as series of 10-15 rootlets. These fuse to form two roots which pass posterior to vertebral artery as they run into the hypoglossal canal where they themselves fuse. The nerve runs out of the canal anteriorly, lateral to the occipital, internal carotid, external carotid and lingual arteries before passing over apex of greater cornu of hyoid bone. It then runs anteriorly, looping lateral to hyoglossus, deep to mylohyoid, to end in terminal branches beneath the submandibular gland. C1 fibres also join the hypoglossal

What are two workhorse flaps of leg

*Gastroc covers knee & upper third leg *Soleus covers middle third *Lower third is 'free flap country'

Rx of segmental nerve loss

*Gold standard is autogenous nerve graft: can restore defects >15cm, however success rate is inversely proportional to length of graft needed *Vein grafts & artificial conduits only bridge 3cm defects

Name several osseous flaps

*Great toe: Based on first dorsal metatarsal artery *Second toe: Based on first dorsal metatarsal artery *Rib: based on intercostal neurovascular pedicle *Fibula: based on peroneal vessels *Radial forearm: Based on radial vessels *Iliac crest: Based on deep circumflex iliac system *Scapula: Based on circumflex scapular vessels *Calvarium: Based on superficial temporal artery *Lateral arm: Based on posterior collateral radial artery *Second metatarsal: Based on first dorsal metatarsal

How do leeches work

*Hirudo medicinalis*, endemic to SEA, is used to promote venous decongestion by 2 mechanisms 1) Minor: Directly *sucking up* to 5-15CC blood through its sucker 2) Major: *injects anticoagulant* *(hirudin) *that lasts several hrs causing loss up to 50cc blood via inhibition of thrombin catalysed conversion of fibrinogen to fibrin, & blocks platelet aggregation in response to thrombin *Use until venous competence develops eg D4-5 for replanted digits, D6-10 for free flaps

Hutchinsons sign

*Hutchinsons sign is pigmentation extending from the nail onto the surrounding periungual skin. It is highly suggestive of a subungual melanoma. It represents the radial growth phase of the subungual melanoma *DDX for nail hyperpigmentation include subungual hematoma from trauma, onychomycosis, benign pigmented nevi, and melanoma. *Clinical observation is paramount, with excisional biopsy being diagnostic

Complications of massive blood transfusion

*Hypothermia *Dilutional coagulopathy *HypoCa, hypoMg *Citrate toxicity *Lactic acidosis *Hyperkalaemia *Air embolism

Nerve supply classification by Taylor -does the major vascular pedicle usually run with the motor nerve? -increased # = increased complexity = decreased suitable for dynamic transfer

*I: Single unbranched nerve enters muscle *II: Single nerve branches just before entering muscle *III: Multiple branches from same nerve trunk *IV: Multiple branches from different nerve trunks

list anti-inflammatory cytokines

*IL-4: inhibits pro-Ix cytokines; high in scleroderma *IL-10: inhibits pro-Ix cytokines; high in chronic venous ulcers

options for multiple rapidly growing melanoma lesions in limb

*ILI - melphalin, hyperthermic, very technical and risky *ILP - simpler, as effective as ILI, 90% response rate

How are cranial bones formed?

*Intramembranous ossification* •Mesenchymal tissue is directly converted into bone, without a cartilage precursor •Starts at 2nd month gestation, with neural crest derived MSC's turning into osteoblasts & starting osteogenesis centre •This centre expands radially via appositional growth, initially forming cancellous then compact bone •Bones become big enough until they articulate with each other via syndesmosis or suture, then growth proceeds at suture •Until 8yo they are single plates of compact bone. After this they become 2 plates of compact bone separated by marrow & cancellous bone, or diploe

KA

*KA similar to well diff SCC on histopathology *75% in H&N region, 10% equally on upper & lower lip *Begins as small red papule & typically progresses to large ulcerated mass thats "volcano shaped" with a large central crater. *Need total excisional Bx for Rx *Derived from epithelium of hair follicles typically found on hair-bearing regions within the upper extremity. *Muir-Torre syndrome is AD disorder a/w multiple KA's

difference in le fort # & osteotomy

*Le Fort #: # line extends through pterygoid plates. *Le Fort osteotomy: preserve the pterygoid plates by precise separation through the pterygomaxillary junction.

le fort #s

*Le Fort I - horizontal transmaxillary fracture that goes through the maxilla at about the level of the piriform rim. *Le Fort II - involves the nasofrontal junction, nasal processes of maxilla, & medial aspect of inferior orbital rim. Also crosses the anterior maxilla & extends back to & through pterygoid plates. *Le Fort III - craniofacial dysjunction: results in separation at frontozygomatic suture, nasofrontal junction, medial orbital wall, orbital floor, and zygomatic arch. Lower maxilla is intact in a pure Le Fort III fracture

Merkel cell

*MC is a slow-acting neurotactile cells of epidermal origin with neuroendocrine features. Located in dermo-epidermal junction. May play role in signal transduction by functioning as slowly adapting mechanoreceptors to sense touch and hair movement, as MC's are often found alongside nonmyelinated axon terminals of dermal nerve fibers & touch receptors *MCC Px is from Merkel cell or neural crest cell or new is Merkle cell polyomavirus (80% MCC infected). MCC occurs in dermis (MC is in epidermis), occurs in SEA (HN 50%, 20% UL), p/w small nonulcerated painless red blue intradermal nodule. Histo has closely packed small cells with high nuclear cytoplasmic ratio, high mitotic index, cellular apoptosis. CK20 very sensitive for Dx, no TTF-1 (only in SCLC), no S100 (melanoma). Rx is EOL 2cm margin w RTX. F/U 3m for 1 year, then 6m 2yr, then annual as recurrenceusually 8 months

What chemical burns dont you irrigate with water

*Mainly elemental sodium, potassium, lithium: spontaneously ignite with water *Phenol also penetrates more in dilute solution, Rx w H20 & polyethylene glycol (antifreeze)

Popliteal fossa NV relations

*Med to lat is SAVNNB: Semimem, Semitend, PA, TN, CPN, BF *Artery deepest of all structures; at all times PV is between PA & TN *PV has triple relation to artery: medial in lower bit, superficial in middle bit, lateral at upper bit *Tibial N has triple relation to popliteal vessels: upper is lateral, middle is superficial, distal is medial

Types spina bifida

*Meningocele: meninges in cystic herniation, no neuro Sx *Meningomyelocele: cystic herniation of meninges and neural tissue, motor and sensory deficit; most common form *Syringomyelocele: Similar to meningomyelocele, with dilated central cord canal; rare *Myelocele: Exposed neural elements without meningeal/cutaneous coverage, high fatality; rare

Why is hydrofluoric acid burn different?

*More like alkaline than acid burn *Free fluoride ions cause liquefactive necrosis of skin, bone decalcification, severe hypoCa++ & hypoMg++ *Rx w RO all clothes, water irrigation, clip nails, inactivate fluoride ions w topical calcium gluconate > injections of calcium gluconate >> intraarterial calcium infusion

Local anaesthetics -bases or acids -agents duration & dose

*Most LA's are weak bases, with pKa between 8- 9 so mainly ionised at physiological pH. Alkalinsation makes more nonionised & better intracellular entry. *Lignocaine plain: lasts 30-60 min. Dose 5mg/kg *Lignocaine w adrenaline: 120-360min. 7mg/kg *Bupivacaine (Marcaine): 120-240min. Plain 2.5 mg/kg *Ropivacaine: 120-360min. 5mg/kg.

what is a frontal sinus mucocele

*Mucocele is retention cyst composed of enclosed collection of mucus that usually results from inadequate sinus drainage. A mucocele of frontal sinus traditionally develops after an obstruction of nasofrontal drainage system (NDS), which is involved in >1/3 frontal sinus #s. Frontal sinus is lined w respiratory epithelium w ciliated membrane & mucus-secreting glands. Blockage of NDS prevents normal drainage of mucus & predisposes to dvmt of obstructive epithelium-lined cysts called mucoceles. Mucoceles may develop when islands of epithelium become trapped in the fracture lines and continue to grow. Growth of a mucocele results in local bony destruction via production of bone-resorbing factors eg prostaglandin E2, collagenase. Mucoceles infection can cause osteitis, osteomyelitis, intracranial abscess, meningitis, via venous drainage of frontal sinus mucosa through foramina of Breschet to dural veins. Common infecting agents are group B α-hemolytic streptococcus, Haemophilus influenzae, Staphylococcus, and Bacteroides. Mucoceles typically develop an average of 7.5 years after frontal sinus trauma. Traditional techniques of mucocele management consisting of frontal sinus obliteration have been supplanted with endoscopic drainage maneuvers.

Serratus anterior anatomy and test

*Origin: Upper 8 ribs & ant intercostal membranes from midclavicular line. Lower four interdigitating with external oblique *Inserts: Inner med border scapula. 1 & 2: upper angle; 3 & 4: length of costal surface; 5-8: inf angle *Action: whole muscle protracts scapula (eg pushing and punching); lower 4 slips help trapezius rotate scapula laterally; holds scapula against chest wall *Vessel: type 3 muscle - lateral thoracic artery, branches of thoracodorsal artery *Nerve: Long thoracic n from BPx roots (C5,6,7). Segmental supply: C5 into upper 2 digitations, C6 into next 2, C7 into lower 4. *Test: Push against wall and feel. Paralysis results in 'winged scapula', where the vertebral border becomes promi nently raised off the posterior chest wall.

list growth factors

*PDGF: via platelets, +s immune cells & fibroblasts; then secreted by m0's & stimulates collagen synthesis; low in nonhealing wounds; essential for wound healing; rPDGF approved for diabetic ulcers *TGF-B: via plts, m0's, fb's; central for wound healing; +s fb migration & maturation, & ECM prodn; high in fibroproliferative states eg keloid; important in fibrosis; three isoforms, w 1&2 increasing scar, 3 reducing; low in foetus *FGF: +s angiogenesis & epithelisation *KGF: related to FGF; regulates keratinocyte proliferation *EGF: via keratinocytes, directs epithelisation; important in wound remodelling *VEGF: via keratinocytes; levels rise steadily; potent angiogenic factor; high in ischemia *IGF: via liver, also found in wounds; +s fb & keratinocyte production & collagen synthesis

Infections -Can humans have pasturella -Can dogs have klebsiella

*Pasturella is oral commensal of many animals *Rarely found in human nasopharynx of animal handlers *Dogs have klebsiella

Delay Phenomenon - what does it achieve anatomically? Used in pedicled TRAMS/how many choke zones you can use (2:1)

*Portion of vascular supply to flap divided before definite elevation & transfer *Extends the longitudinal reach of vascular pedicle as theres extended random component *Multifactorial mechanism -Sympathectomy: vasodilation from altered SANS tone -Reorientation of BS along length of flap -Dilation of choke vessels allowing capture of adjacent angiosomes -Tolerance to ischemia

methods to prevent hypertrophic scar

*Pressure garment 25-30mmHg 22hrs day until graft flat & not hypermic (for ~1 year). MOA unknown - ?relative hypoxia in burn scar, ?improvement in collagen alignment (seen on histo) *Silicone: Helpful in hypertrophic/keloid scars, but not in normal wounds. MOA unknown too-?retained moisture, silicone oils, increased surface temperature, improved wound O2 *Harlan tape (steroid impregnated) or steroid injections *Surgical release or excision then cover w graft/flap

Keloid Read keloid chapter in PSS+

*Proliferation of scar outside the border of scar *Commoner in dark skinned. AD or AR. A/w blood group A. *Hormonally related as appears in puberty & resolves after pregnancy. *Fibroblast no's not increased. Both keloid & hypertrophic have rich vasculature & thick epidermal layer. Collagen fragmented & shortened. Get collagen nodules. Collagen synthesis increased in both, but more in keloid. Less cross-linkage & more type III. *Sx include pruritis, pain, nothing

What is a pure blow out fracture of the orbit?

*Pure blowout #s involve thin areas of orbital floor, medial wall, and lateral wall. The orbital rim, however, remains intact. *Impure blowout #s are a/w # of adjacent facial bones. Thick orbital rim is also fractured; its backward displacement causes comminution of the orbital floor. Transmission of the traumatic force to the orbital contents produces a superimposed blowout fracture.

what is endophthalmos & how do you measure it

*Retrodisplacement of globe within bony confines of eye socket. Chx include increased depth and hollowing of supratarsal fold, decreased anterior projection of globe, shortening of the horizontal dimension of the palpebral fissure, pseudoptosis of the upper lid, and a decrease in the canthal angles. *Enophthalmos becomes clinically obvious if anterior globe projection is <12 mm or differs from the opposite side by 3 mm or more as measured by a Hertel exophthalmometer. The Hertel exophthalmometer uses the lateral orbital rim as a reference point so if this has been #ed then measurement might be inaccurate

Skin grafts - FTSG vs SSG mitotic activity sensory outcomes

*SSG have increased mitotic activity in epidermis by D3, while FTSGs have reduced. *Graft "scales off" & epithelium doubles thickness by D4. Between D4-8 rapid cell turnover causes 7x increase in epithelium thickness, present until W4 when its normal

classification of nerve injury

*Seddon described neurapraxia (local conduction block), axonotmesis, neurotmesis. Sutherland (longer name so added more) & Mackinnon added more.

What is Kasabach-Merritt phenomenon?

*Serious thrombocytopenia (<5000 platelets/mm3) + coagulopathy + hemangioma *Seen with locally aggressive vascular tumor (KHE) & sometimes w less aggressive tumor (tufted angioma). *Rx with high dose steroids (poorly effective) & vincristine or interferon alfa.

Indications to take out teeth with mandibular fractures?

*Severe loosening of tooth with chronic periodontal disease *Fracture of the root of the tooth *Extensive periodontal injury and broken alveolar walls *Displacement of teeth from their alveolar socket.

Suture sizes, classes, needle types

*Size: more zeroes means smaller strand diameter *Traumatics haveeye for threading suture while atraumatics attached to suture *3 classes: natural/collagen, synthetic absorbable, nonabsorbable *NESH: Absorption Natural via enzymatic degradation, & in Synthetics via Hydrolysis. Less tissue reaction with hydrolysis *Cutting: 2 cutting surfaces; for skin *Conventional cutting: 3 cutting surfaces, 3rd on inner curve *Reverse cutting: 3 cutting surfaces, 3rd on outer curve; for tougher tissue; causes less trauma *Spatula: flat on top & bottom, have side cuts to causes minimal trauma *Taper: sharp tip at point becomes oval; enters by stretching & not cutting; for easily penetrated tissues eg fascia

list pro-inflammatory cytokines

*TNFA: released by m0; starts immune cascade after injury; matures Ix cells; excess in sepsis/MOF, chronic venous ulcers *IL-1: similar to above, promotes Ix cells to secrete pro-Ix cytokines *IL-2: made by T-cells, activates Y cells *IL-6: activates B & T cells, +s fibroblasts, low in fetuses so ?scarless healing; marker for severity of wound *IL-8: via m0's & fibroblasts; +s n0 & monocytes; high in psoriasis & low in foetus *IFNY: important in tissue remodelling, reduces wound contraction

Linburgs sign

*Thumb IPJ flexion causes IF DIPJ flexion in 30% people *Due to adhesions in carpal tunnel between FPL & IF FDP

Frostbite on cells. Cold antibodies?

*Tissue damage may result from direct cellular damage or secondary effects of microvascular thrombosis and subsequent ischemia. *Recognized changes during freezing are (1) extracellular ice formation, (2) intracellular ice formation, (3) cell dehydration and crenation, (4) abnormal electrolyte concentrations due to above, (5) perturbations in lipid-protein complexes. *With rewarming 1) ice crystals melt & injured endothelium promotes edema 2) epidermal blisters form, and free radical formation continues the insult 3) elaboration of inflammatory mediators, prostaglandins, and thromboxanes induces vasoconstriction and platelet aggregation, which worsen ischemia. 4) 72hrs after freezing & thawing, the endothelium may be completely obliterated and replaced by fibrin deposition.

PIA flap *Type *Dominant *Minor *Attachments *Nerve *Territory *Good *Bad *Method *DSM

*Type *Dominant: PIA from common IO in 90%, UA in 10%. Vessel found 2cm proximal to ulnar styloid, beneath EI *Minor *Attachments *Nerve *Territory: from distal & middle 1/3s dorsal forearm. *Uses: dorsal & palmar hand defects incl webspace *Good: *Bad *Method *DSM

TRAPEZIUS FLAP *Type *Dominant *Minor *Attachments *Nerve *Territory *Uses *Good *Bad *Method *DSM

*Type 2 *Dominant: TCA from thyrocervical trunk (80%) or subclavian (20%). Runs between SCM & scalenius, crosses BPx, then enters deep surface of trap at base of neck, before dividing into ascending & descending branches. Design skin paddle over either *Minor: dorsal scapular artery, perforating post intercostal artery, branch of occipital artery *Attachments: EOP, sup nuchal line, lig nuchae, C7-T12 SP-> lat 1/3 clavicle, spine scapula, acromion *Fxn: stabilise scapula w rotation. Denervation -> shoulder droop, winging *Nerve: SAN enters deep surface 5cm above clavicle *Territory: vertical flap based over middle or inf fibres, lateral flap over sup fibres *Uses: pedicled, with rotation point post base of neck. Can reach post skull, Cx & Tx vertebrae, middle & upper face, neck *Bad: unreliable flap, ugly donor scar if transverse flap, can cause shoulder problems *Method: Prone. If vertical skin paddle, draw axis for descending branch: midpoint clavicle, vertically bkwds between scapula & spine. If transverse, push ant border of trapezius to acromion & mark. This is centre of axis, with flap drawn over this

GLUT MAXIMUS *Type *Dominant *Attachments *Fxn *Nerve *Territory *Use *Bad

*Type 3 *Dominant: SGA (above piriformis, supplies sup half) & IGA (below piriformis, inf half) from internal iliac artery. Short pedicle 2-3cm but wide diameter vessels *Attachments: gluteal line ilium, iliac crest, sacrum --> 1/4 on gluteal line inf to greater tuberosity of femur, 3/4 on iliotibial tract *Fxn: extend & laterally rotate hip, extend knee. If ambulant, lose abduction & extension of thigh *Nerve: IGN (L5,S1-2) from sacral plexus *Territory: arc of rotation (based on SGA) is 5cm below PSIS. Can reach sacrum, contralat ischium, perineum, ant thigh *Use: pedicled for sacral & lower trunk coverage; free as SGAP/IGAP for breast *Bad: Risk IGN injury. SGAP difficult perforator

Groin flap *Type *Dominant *Minor *Attachments *Nerve *Territory *Uses *Good *Bad *Method *DSM

*Type B *Dominant: SCIA from femoral artery. Divides st medial sartorius into superficial & deep branches *Territory: axis is centered on line parallel but 3cm below inguinal lig, from FA to as lateral spine, can be 10cm wide *Uses: pedicled to cover hand and forearm defects, lower abdo, perineum *Good: no DSM, hidden scar *Bad: short pedicle, small size artery *Method: mark axis, then raise from lat to medial until sartorius, then include fascia over sartorius to ensure capture pedicle. Can divide deep branch, keep superficial. Dissect until origin from SCIA seen

SCAPULAR FLAP *Type *Dominant *Nerve *Territory *Uses *Good *Bad *Method *DSM

*Type B *Dominant: Transverse branch of CSA, from subscapular artery after enters triangular space, from 3rd part AA. Pedicle 5-14cm depending how far back *Nerve: skin is intercostal nerves *Territory: Axis is horizontal line from triangular space (2cm above posterior axillary crease) & halfway between scapula & midline. Design elipse w sup border top of scapula, inf border scapula tip. 10cm wide so can close *Used as pedicled (axilla, shoulder coverage) >> free (hand, foot cover). Skin >> osseocutaneous *Good: hairless, pliable, large vessels, but short pedicle, hidden scar *Bad: arc rotation limits use *Method: prone or midlateral. Draw axis, & ellipse over triangular space, incise & raise medial to lateral just above deep fascia, find perforator through tri space.

PARASCAPULAR FLAP *Type *Dominant *Nerve *Territory *Uses

*Type B *Dominant: descending branch of CSA, from subscapular artery, after entering tri space *Nerve: skin by intercostals *Territory: Axis is vertical line from triangular space along lat border scapula, to point midway between scapula tip & post iliac spine. *Uses: as for scapular *Good *Bad *Method *DSM

Scapular flaps

*Type B FC flaps *Vessel: CSA from subscapular artery runs in triangular space then divides into horizontal (scap) & longitudinal (parascap) branches *Axis: scap horizontal line from triangular space to vertebrae, medial ends halfway between scapula & vertebrae; parascap centered on vertical line from tri space to post iliac crest, tip lies midway between scapula tip & iliac crest *Uses: cheek & hemifacial recon; doesnt atrophy *Technique: raise medial to lateral just above deep fascia. As lateral scapula border approached, go subfascial. Identify triangular space

RFF *Type *Dominant *Minor *Attachments *Nerve *Territory *Uses *Good *Bad *Method *DSM

*Type C *Dominant is RA, lying in LIMS between BR & FCR *Territory: entire forearm can be raised, but usually ulna border to dorsal brachioradialis. *Uses: hand coverage *Good: thin skin *Bad: sacrifice FA, poor donor *Method: Raise in subfascial plane from ulnar to radial until FCR seen. Then raise from radial to ulnar, going deep to RA, until pedicle seen. *Cx: Do preop Allens test: 15% hands have UA that doesnt perfuse radial digits because of incomplete SPA

Lateral arm flap -Type -Vessels -Good

*Type C fasciocutaneous FC flap *Dominant: PRCA as it travels in LIM between tricpes & brachialis *Territory: posterolateral arm between deltoid insertion & elbow *Good: long pedicle (cm), thin & pliable, use as neurosensory flap *Bad: PCN arm hypothesia, donor site scar

Mathes & Nahai Classification of flaps & examples of each type

*Type I: Single pedicle eg TFL, gastroc *Type II: Dominant pedicle(s), with minor pedicle(s) eg gracilis, biceps femoris, SCM, trapezius, soleus *Type III: Dual dominant pedicles eg GM, pec minor, RAM, serratus, temporalis *Type IV: Segmental pedicles eg FH:, sartorius, tib ant *Type V: Dominant pedicle, with secondary segmental pedicles eg internal oblique, LD, PM

LAT DORSI FLAP *Type *Dominant *Minor *Attachments *Nerve *Territory *Good *Bad *Method *DSM

*Type V *Dominant: TDA from subscapular a via 3rd part axillary. 9cm pedicle, 2.7mm. In 86% TDA bifurcates 2cm medial to muscle border-upper branch 3.5cm from sup border, lateral br 2cm from lat margin *Minor: post intercostal & lumbar artery *Attachments: SLIC *Nerve: TDN via post cord, runs 3cm medial to subscapular artery, then runs w TDA *Territory: NV hiatus is rotation point. Ant arc to ipsilateral hemithorax & sternum, middle & lower 1/3 face, superior abdomen. Post arc to neck, occiput, parietal skull, T1-T12 *Good: workhorse, reliable, long pedicle, big vessels *Bad: long scar; reposition; distal 1/3 unreliable for skin *Method *DSM: seroma; no fxnal deficit (PM, TM)

Cartilage: types, properties - Hyaline, fibro, elastic - Nose alar and septum, intervertebral discs, knee

*Types 1) Hyaline eg joints, nasal septum & alar 2) Elastic eg ear 3) Fibrocartilage eg TMJ, menisci, IV discs *Made of chondrocytes in ECM composed of proteoglycans, collagen, water *Collagen is type II in hyaline, type I in fibrocartilage *Hyaline dissipates loads, fibrocartilage transfers loads

Subclavian artery branches

*Vertebral artery: travels in TP of c6-c1, supplies cerebellum via post inf cerebellar artery

what is wallerian degeneration? dieback?

*WD is process of degeneration of distal segment in nerve injury. Get ground glass appearance of degenerated myelin & aoxnal material. These are phagocytosed by m0's & Schwann cells & space becomes occupied by columns of Schwann cell nuclei. The collapsed columns of SC's have band-like appearance under EM - "bands of Bungner" *dieback occurs in proximal segment to next NoR

list standard tendon transfers for RN palsy (2012)

*Wrist extension -PT to ECRB *Finger extension -FCR to EDC (Starr, Brand); -FCU to EDC (Jones) -FDS RF to EDC (modified Boyes, Chuinard) *Thumb extension/abduction -PL to rerouted EPL -FDS RF to EPL & EI (Boyes, Chuinard)

what types of chemical burns are there?

*acid eg sulfuric *alkali eg cement *phosphorus burns *chemical injection

what is biphasic response to burn?

*all organs have initial hypofunction then later hyperfuction, from catecholamines *hypermetabolic rate reduces once wounds are grafted, but metabolism is increased until remodelling is complete

axial flap random flap island flap pedicle flap

*axial flap: Harvested from an area with a known arteriovenous blood supply while remaining connected by skin and subcutaneous tissue to its donor site *random flap: Perfusion derived exclusively through the subdermal plexus of vessels *island flap: In all respects identical to axial pattern flap, but skin and soft tissue attachments are divided, leaving the flap attached only to its dominant blood vessels. *pedicle flap: Arteriovenous connection; "leash" of blood vessels supplies flap.

frontal sinus dvmt

*begins pneumatic expansion at 7yo *dvmt complete by 18yo *nasofrontal ducts are bilateral structures that drain *frontal sinus from its posteromedial aspect, through ethmoidal air cells and out into nasal cavity, usually at middle meastus

frostbite -cause -pathology -Sx -Rx -Cx

*caused by -2C temperature & tissue freezes *Px: extracellular & intracellular ice crystals form-> rewarming injures vascular endothelium->Ix & fibrin deposition blocks blood vessels. *Sx ~ burns: 1st degree red & sore, 2nd blisters, 3rd FT skin necrosis, 4th is gangrene & necrosis incl muscle/bone *Rx is *rapid* rewarming by immersion in 40-42C water. Then debride clear blisters (leave bloody ones), elevate, aspirin. No role for surgery until demarcarted *Cx arthritis, pain, hyperhydrosis, pigment change, growth plate insult

Fetal wound healing: same cells as adult? is there a lag phase?

*different cells -FWH has less n0s, less platelets, less myofibroblasts -FWH has collagen ratio of type III:I as 3:1; AWH is 1:3 *FWH occurs at accelerated pace -finished at 5-7 days postinjury -acute inflammatory stage of healing is missing

concept of favourable & unfavourable mandible #s

*favorable when direction of # line doesnt allow independent muscular distractions, unfavorable when # line permits fragments to separate. *eg 1 ant/post #: post segment pulled superoanterior by masseter & medial pterygoid. Unfavourable is # thats obliquely backwards, favourable is oblique forwards as it locks in *eg 2 med/lat #: lat pterygoid & mylohyoid pull condyle anteromedial. unfavorable # line runs posterolateral to anteromedial; favourable runs anterolateral to posteromedial

which anatomical points do you assess with zygoma #? which points get plated

*five points to check: ZF suture, infraorbital rim, ZM buttress, zygomatic arch, and lateral orbital wall. *If displaced or unstable at these points they need ORIF w plates at ZF suture, infraorbital rim, ZM buttress, and zygomatic arch. 3 out of 4 of these need to be AFP. *reduction is done by checking reduction of lateral orbital wall - most sensitive indicator of zygomatic complex position & least likely to be comminuted

earliest Sx of ischemia in circumferential burnt limb

*if alert: numbness, tingling *if not alert: doppler flowmeter w reduced/absent digital pulse (need escharotomy STAT)

why is phosphorus burn different

*ignites on contact with air *causes low Ca, hi PO4, hepatotoxicity, renal toxicity, ECG changes *Rx by removal clothing & any particles, cover w H2) soaked dressings, irrigate w copper sulfate (coats phosphorus to allow removal & stop ignition)

commonest benign bone tumour in hand? in general?

*in hand - enchondroma -benign cartilaginous growth from medullary cavity -ASx until pathological # occurs -XR: radiolucent expansive lesion w cortical thinning & calcifications -Rx allow to heal then excise and bone graft. 5% risk of malignant change to chondrosarcoma *general: osteochondroma -cartilage-capped bony growths near epiphysis -growth stops when growth plate closes -painless -1% risk of malignant change to chondrosarcoma

describe gillies approach to zygoma #

*incision 2.5cm above & anterior to helix, avoiding STA *incise through skin, subcut tissue, superficial & deep temporal fascia *develop plane between DTF & temporalis muscle down to #

pathogenesis of MCPJ ulnar deviation in RA

*inflammatory arthritis of MCPJ w rise in jt pressure *capsule & ligament destruction *ulnar dispacement of extensor tendons *ligamentous laxity of 4th & 5th CMCJs

axillary block - where is it, what does it block, what does it miss

*inject beneath PM after palpating axillary artery *blocks cords *need supplement blocks for musculocutaneous N, intercostobrachial N, MCNA

excision margins for melanoma thickness

*insitu dz: 5mm margin *<1mm: 1cm margin *1-2mm: 1-2cm margin *2-4mm: 2cm margin >4mm: 2cm margin

what muscle displaces a subcondylar # of mandible

*lateral pterygoid is only muscle that inserts directly on neck of mandibular condyle, results in anterior & medial displacement of condyle w subcondylar #

Stratum lucidum (Latin for 'clear')

*made of 3-4 layers of dead transparent keratinocytes, found only in palm or sole ie thick skin

refractory period of nerves

*motor 1 year before refractory (therefore do nerve transfer) *sensory recovery described 20yrs after injury

significance of multiple enchondromas

*multiple enchondromas = Ollier's dz *multiple enchondromas + haemangiomas = Maffuci's syndrome *both high risk malignant change to chondrosarcoma

interscalene block - where is it, what does it block, what does it miss

*needle inserted at interscalene groove (C6) between anterior & middle scalene muscles *blocks the roots *UN often poorly blocked as far from C8-T1

indications for neurolysis, nerve grafting, neurotization in BPx?

*neurolysis to release scar around functioning fasicles & determine which nerves are discontinous & req grafting *nerve grafting for postganglionic lesions with loss of fasicular continuity, usually sural nerve donor *neurotization for nerve root avulsions not reconstructable by nerve grafting: intercostal n, SAN, Cx plexus, or MPN used to provide nerve fibres for distal stump of avulsed nerve

lumbrical plus finger

*normally lumbrical pulls FDP distal & lat band prox to flex MCPJ and extend IPJ *FDP division distal to lumbrical insertion causes paradoxical IPJ extension when trying to flex finger, as prox FDP pulls lumbrical proximally, forcing IPJ into extension via lateral band

intersection syndrome - define it

*old theory - tenosynovitis of 2nd compartment as it crosses over 1st *new theory - 2nd compartment tendons entrapped by own sheath

overjet, overbite

*overjet: horizontal distance from labial incisal edge of lower central incisor to upper central incisor (think jet flying horizontal) *overbite: vertical distance from incisal edge of upper central incisors to lower central incisor

risk factors for bcc recurrence

*site: central face eg nose, nasolabial fold, periorbital, *pattern: micronodular, infiltrative, morpheic *excision margins: incomplete has 30% recurrence *size & depth *PNI *Gorlins syndrome *BCC post RT *immunosuppression

flexor tendon repair... - when weakest? - what reduces gapping? - when strong for weight resistance? - what makes them stronger?

*strength decreases 10-50% between day 5-12 if not stressed *less gapping w epitendinous esp horizontal mattress or running locked, cyclic stress *strengthening exercises at week 8 *stronger with dorsal>palmar core sutures, # suture strands, caliber of suture

Telecanthus vs hypertelorism

*telecanthus: increased distance between the medial canthi, produced by abnormal insertion or length of MCT. Check by rule of 4ths *hypertelorism: ncreased distance between bony orbits taken at region of dacryon (lacrimal crest) & associated increase in interpupillary distance.

main maxilla buttresses

*vertical: nasomaxillary, zygomaticomaxillary, and pterygomaxillary buttresses *horizontal: orbital rims and palate

what structures stop dislocated MCPJ being reduced

*volar plate in joint *lumbrical stretched around radial border of MC head *flexor tendons stretched around ulnar border of MC head

cause & Rx of chronic PIPJ dorsal dislocations

*volar plate laxity: volar plate reattachment *extensor tendon imalance eg SND: correcting the extensor tendon

normal ear proportions

*width 60% of length, length is 6cm *from front sits between brow & columella, with helix-scalp distance 10mm at upper 1/3, 20mm at lower 1/3 *from side, lies one ear length behind lat orbit rim, at incline of 20 degrees

How are VMs Rxed?

- 1st is sclerotherapy, sclerotherapy, and sclerotherapy. - Then resection for correction of contour, size, or scarring. - Rarely surgery is 1st line eg tiny localized lesion eg in glomuvenous malformation, blue rubber bleb nevus syndrome, or spindle cell hemangioendothelioma. - In certain areas in an extremity, operation is preferred over sclerotherapy, eg if lesion is within single muscle group & can be excised completely excised, or if there is risk of ulceration, nerve damage, or compartment compression.

What is OK432?

- Agent made from killed streptococcal protein - Believed to act as immunological stimulant - Effective in shrinking macrocystic >> microcystic LM

Despite proper tourniquet application, the wound begins to bleed during repair of a spaghetti wrist. Why?

- Blood is shunted down to the hand via nutrient vessels in the humerus. This process may take an hour or even longer. The ascending branch of the humeral circumflex artery enters the bone in the bicipital groove, perfuses the bone through the medullary cavity with connections to the periosteal vessels, and may exit inferiorly at the elbow. Control under these circumstances may be obtained by wrapping an Esmarch bandage around the elbow at moderate pressure.

What are the similarities and differences of RICH & NICH?

- Both present as raised spherical to ovoid tumor, dark red to purple in color, with central telangiectasias, and often a pale rim. Both forms exhibit rapid flow. RICH can cause neonatal CHF and sometimes thrombocytopenia. -RICH involutes at or soon after birth, & is usually complete by 16 months. -NICH grows in proportion to the child, and fast-flow persists. It is often mistaken for an AVM.

What physical findings suggest an orbital fracture?

- Bruising and SCH are common - Ant #s have step offs & infraorbital nerve numbness - Middle #s have changes in position of globe, oculomotor dysfunction, diplopia - Post #s have visual & oculomotor Sx

How are central duplications classified?

- Central duplications are unusual and account for less than 10% of all duplications; they have no systematic clinical classification system. - Because central duplications are often associated with webbing, the term synpolydactyly is used.

What is contact inhibition and how does it relate to epithelialization?

- Contact inhibition is concept that physical contact halts cell migration. Epithelial cells exhibit contact inhibition. They continue to migrate across wound until they contact each other, forming a continuous single-layer sheet.

What do sunscreens do?

- Decrease actinic keratoses (premalignanct) & SCC incidence - No evidence they decrease BCC or melanoma incidence - No evidence they block vitamin D production

What is the relative incidence of congenital hand duplications? How are they clinically classified?

- Duplications are commonest hand anomalies - Classified by hand position: preaxial (radial), central, postaxial (ulnar). - US blacks: 1:300 live births, mainly postaxial - Caucasians & Asians: 1:3000 births, mainly preaxial

At what age of development does the limb bud appear? When are digital rays evident?

- Limb development and differentiation are rapid processes that occur between W3-W8 - Limb bud is well defined at day 30. It is a ventral swelling mesoderm covered by a thick layer of ectoderm, called the apical ectodermal ridge (AER). - By day 41 digital rays are present, and by day 48 joint interzones are evident histologically.

What is the role of pulsed-dye laser in the treatment of infantile hemangioma?

- Little if any, place for laser photocoagulation of hemangioma in the proliferating phase. - Pulsed-dye laser (PDL) penetrates no more than 0.75 mm; thus, only the most superficial lesions can be destroyed by heat. PDL does not influence the proliferation of the deep portion of the tumor. - There are reports that PDL helps heal ulceration and relieve pain, but these are not controlled studies. Aggressive PDL application can cause ulceration, depigmentation, and scarring.

what are some anaesthetic considerations for malignant hyperthermia

- MH is syndrome of accelerated metabolism with Sx tachycardia, cyanosis, sweating, rigidity, HTN, only 30% are febrile - if MH suspected, stop all anaesthetic agents, give 100% O2, hyperventilate, insert central & arterial lines, give dantrolene for up to 3 days, rapidly cool if febrile -postop watch for coagulopathy; renal failure, pulm oedema, hyperkaelmia, recurrence - if known avoid sux & all volatile inhalational agents; propofol & nitrous are safe

What should you think if you see a sacral haemangioma?

- Midline lumbosacral hemangioma may signal an underlying occult spinal dysraphism. - Dx can be ruled out by US in the first 4 to 6 months of life; thereafter MRI is necessary

What is the difference between pure and impure blowout fractures?

- Pure blowout fractures involve the thin areas of the orbital floor, medial wall, and lateral wall. The orbital rim, however, remains intact - Impure blowout fractures are associated with fracture of the adjacent facial bones. The thick orbital rim is also fractured; its backward displacement causes comminution of the orbital floor.

What are the long-term functional limitations of a well-performed pollicization procedure?

- Such thumbs are never normal. Grip and pinch maneuvers involving the thumb are always deficient. - Results fall into two basic groups: (1) complete or partial radius deficiency and (2) normal radius and preoperative range of motion. The second group has predictably better outcomes because extrinsic flexor and extensor muscles as well as intrinsic muscles to the index ray are normal. A stiff index finger preoperatively will become a very stiff thumb.

What is a constriction ring or anular (ring) band?

- The constricting ring acts as a TQ around the developing digit, toe, or other body part and results in a soft tissue depression beneath the skin. The ring may be superficial or deep, extending into the periosteum. It may extend completely or partially around the circumference of the part. Most digital rings are deep dorsally and extend only partially around the palmar surface. However, this explanation does not account for the frequent association of cleft lip/palate and club feet with CRS. The clefts often are wide lateral clefts that result in a monstrous clinical appearance. It has been postulated that wide bands or aprons of partially separated sac obstruct the fusion of the lateral lip with the prolabial segment.

Why is sun exposure important?

- UVB radiation in sunlight is responsible for production of Vitamin D in skin, which is converted into calcitriol, & important for bone mineralisation. - Adequate vitamin D is generated with 1/3 of the sunburning dose of UVB, which in summer before 10am or after 2pm takes 6 minutes, or 30-50 minutes in winter.

What is stainless steel?

- iron-chromium-nickel alloys - 1st used 1920s - has worst corrosion, resulting in risk of implant failure after several years

Classification of biological implants?

- liquid: injectable silicone, collagen - solid: metal, polymer, ceramic *physical form of implant (solid or mesh, smooth or rough) determines if implant is encapsulated as whole or whether fibrous tissue will penetrate interstices of implant

Advantages of alloplasts?

- no DSM - reduced OT time cf graft harvest - unlimited supply - no resorption w time

Chx of an ideal implant?

- nontoxic, nonallergic, biologically compatible - no FB reaction - doesnt support microbe growth - radiloucent so doesnt interfere with CT/MRI

What is the most common site of an isolated intraorbital fracture?

- orbital floor just medial to the infraorbital canal and usually is confined to the medial portion of the floor and the lower portion of the medial orbital wall - depressed fractures involving this portion of the orbit may allow the orbital soft tissue to be displaced into the maxillary and ethmoid sinuses, effectively increasing orbital volume

Why is an upper eyelid haemangioma important?

-*Any upper lid tumour* (even small ones) can obstruct the visual axis, causing deprivational amblyopia & failure to develop binocular vision. -Also any upper lid tumour can distort the cornea, causing refractive disturbances, such as astigmatism and anisometropia, which also can result in amblyopia. - A large cheek or *lower lid hemangioma rarely* distorts the cornea, probably because of Bell's phenomenon during sleep.

Is screening for melanoma effective?

-11% Aussies have undergone skin screening in previous year -screening for melanomas has a PPV of 6% to 20% -melanomas Dx by screening are thinner than if found incidentally -no evidence population screening program reduces M&M -because of this lack of evidence popn based screening isnt recommended

What is the nodular melanoma subtype?

-15% overall but majority of thick melanomas -Symmetric, raised, firm, enlarging, can be uniformly coloured or non-pigmented, can bleed -More likely in older people, esp men, in H&N area

By what three methods can wound healing be achieved?

-1ary: approximation -2ary: granulation & reepithelisation -3ary: granulate then close aka DPC

what is titanium?

-1st used 1940s -least corrosive -least artifact on CT/MR -unalloyed titanium is most malleable (can bend to fit) -titanium/vanadium alloy has tensile strength similar to Vitallium

Rx of NOE

-3 incisions: coronal, subciliary or mid-lid, and maxillary gingiovobuccal sulcus -need big exposure to fix this complex # -transnasal canthopexy to oreserve eye width

What is the optimal angle for Z-plasty design?

-30° = 25% lengthening -45° = 50% -60° = 75% = optimal angle -90° = 125% = <60° not enough lengthening, narrow flaps = >60° too much tension in adjacent tissue

What is the incidence of melanoma in Australia?

-33/100 000/year: 4th commonest Ca -Lifetime risk 3% females, 4% males -F:M 2:1 -Increasing male mortality -<5% of skin Ca but >75% of skin Ca deaths

What is the prognosis for melanoma?

-5 yr survival of PM <1mm thick is good (93%), while very poor for stage IV disease (10%, with median survival 4-6 months)4 -Worse: Breslow thickness (most important indicator in localised disease) & ulceration of primary tumour; presence of metastatic nodes (most important indicator in metastatic disease); number of metastatic LNs; whether LNs were occult or clinically apparent. -Better prognosis: thinner tumours; women; negative nodes (2 year survival of pts with +ve RND approaches zero2); <50yo;

Parotid duct position

-5cm long -passes across masseter & pierces buccinator -line between intertragic notch auricle & midpoint philtrum -opens on mucous membrane of 2nd upper molar -has valvular mucous membrane flap intraorally to stop saliva reflow

Parotid - tumours

-80% salivary tumours are parotid -80% parotid tumours benign

What investigations in inhalational burn injuries

-ABG incl COHb -CXR -Bronchoscopy -VQ scan (xenon 133) -Not CTPA

Radiation Daily dose causes symptoms Total dose causes symptoms Get cells in active cycles G2M most susceptible How Fibrosis

-Absorbed radiation is measured in grays, where 1 joule/kg = 1 gray = 100 rads -Cell cycle: G2 and M phase most sensitive; G1 average; S phase resistant -Early Sx are Ix with hyperpigmentation. Late Sx are fibrosis, oedema, etc. -Late Sx generally more sensitive to changes in fraction size, and less sensitive to changes in overall treatment time than early Sx -Fibrosis from TGF beta?

PDS suture - spitting? Tension loss %

-Absorption is essentially complete within 6 months, although little occurs before 90 days. Because of this slow absorption, "spitting" is a significant problem. -PDS sutures maintain their tensile strength considerably longer: 50% at 4 weeks and 25% at 6 weeks. Absorption is essentially complete at 6 months.

What is Alloderm?

-Acellular dermal matrix ("cadaver skin") -Rendered immunologically compatible by chemically removing all immunoreactive components (epidermis, antigenic cell components) while leaving the collagen/elastin structure of skin intact

what are advantages & disadvantages of methylmethacrylate?

-Advantages: minimal FB reaction (subsides as its encapsulated by fibrous tissue); ease of surgical manipulation; density similar to bone; radiolucency; good long-term tissue tolerance. -Disadvantages: while curing it forms exothermic reaction that can damage tissues; main LT risks are infection, extrusion, or mechanical failure due to deterioration of the bone-polymer interface

What do you consider when assessing for future risk of melanoma?

-Age -Sex -Hx melanoma or NMSC -FHX melanoma -number of naevi (common & also atypical [dysplastic]) -skin and hair pigmentation -response to sun exposure (fitzpatrick I) -evidence of actinic skin damage *anyone at high risk should be educated about signs of melanoma & undergo regular 6 monthly skin checks with photos & dermoscopy as required

What is a 5 flap Z-plasty?

-Aka as double opposing Z plasty or jumping man flap -Is essentially two opposing Z-plasties with central V-Y advancement -Used to elongate tissue & is often used clinically to release 1st webspace contractures, epicanthal folds, axillary contractures -ABCDE becomes BACED

What is a W-plasty? What is the main disadvantage?

-Another method for reorienting the direction of a linear scar. -Triangles of equal size are outlined on either side of flap with tip of one sides triangle lining up with midpoint of opposite side triangles base -Triangles at either end are are smaller, with limbs of the W tapered, and all corners sutured with Mcgregor stiches to prevent tip necrosis -Main problem is it increases tension from neccessary excision of adjacent tissue. Therefore only use when there is abundant adjacent tissue

Describe the upper limb in a child with severe arthrogryposis multiplex congenita.

-Arthrogryposis, a syndrome of unknown etiology, is always present at birth and manifests with persistent joint contractures. It is classified into myopathic and neurogenic forms. The bottom line is that the muscles do not function. -The UL is unmistakable: shoulders are thin & held in adduction and internal rotation; elbows are extended, & forearms are usually held in a semiflexed pronated position. Some elbow PROM may be present. In severe cases the wrist is held in flexion & ulnar deviation, and the thumb is tightly adducted into the palm. The digits are flexed and ulnarly deviated at the MP joints. The skin may be atrophied and waxy. Skin dimples dorsally and flexion creases on the palmar surfaces signify mobile joint spaces. The lower extremities are more frequently involved than the upper.

What causes OHT?

-As OHT is a finding & not a syndrome, the cause of each case needs to be examined individually. -Pts w Apert or Crouzon syndrome may have cranial base disturbances. Mass effect from sincipital encephaloceles, dermoid cysts, and tumors may lead to OHT. Facial clefts and early ossification of the lesser wings of the sphenoid also have been suggested.

What are the disadvantages of tissue expansion?

-At least 2 sometimes more operations needed -Multiple injections required -Temporary deformity from expansion -Takes time -Often unable to accurately give completion date

Why does your elderly patients SSG form blisters?

-Basal epidermal cells are attached to the underlying dermis by hemidesmosomes. Cells of aged individuals have been shown to be ineffective at forming new hemidesmosomes. Without an adequate dermal base, coverage of the wound by epidermis is unstable and characterized by chronic and recurrent breakdown. Therefore the skin of elderly patients is less tolerant to shearing forces. When shearing occurs, blisters are likely to form.

What causes hypertrophic/keloid scars? What features distinguish them?

-Believed to be due to an excessive inflammatory response during wound healing. Results in overproduction of all components of the ECM, however absolute numbers of fibroblasts are not increased -Keloids extend beyond original injury, commoner in dark skin, sometimes transmitted as autosomal dominant -Hypertrophic scars stay within boundaries, commoner in Asians and African skin

Where are the best and worst places for TE?

-Best: breast, scalp -Worst: hands, feet, neck are all unrewarding

What type and when can genetic tests can be done for melanoma?

-CDKN2A mutations may cause a high melanoma risk, especially in familial melanoma -Screening is only considered after clinical Ax (pt is at high risk of MM), FHx (strong Hx suggesting family mutation) & genetic counselling is done

What are main Cx of CMF surgery?

-CMF combines neuro & PRS, w main Cx being neuro -Cx are reduced by preop planning & experienced surgeon •Death 1% •Bleeding, coma, blindness, meningits, ICH, hydrocephalus •Rhinnorrhea, osteitis, bone flap resorption

Elbow - carrying angle 140deg -arm in line with forearm in pronation -flexion to 170deg -epicondyles and olecranon in line in extension -epicondyles and olecranon in equilateral triangle in flexion?

-Carrying angle changes w elbow flexion (zero) & extension (10-15 degrees) & is greater in women -With pronation the axis of forearm comes into line with humerus -Triangle sign: Elbow flexed & lat epicondyle/med epi/olecranon form equilateral triangle. Post dislocation disrupts this triangle, but supracondylar # wont -In extension the medial & lat epicondyle & top of olecranon process are in straight line -Elbow ROM 0-150 flexion, 90 pronation, 90 supination

TX outlet syndrome cause, Sx, Rx

-Caused by anything that reduces size of triangle outlet of scal anterior/scal medius/1st rib eg Cx rib, tumour -Sx burning pain to shoulder with radiation to inner arm/hand, C8/T1 tingling, intrinsic muscle weakness -Rx conservative (physio, LOW, avoid exacerbants) then surgical release via axillary or supraclavicular approach

Thoracic inlet syndrome - symptoms, tests

-Caused by anything that reduces size of triangle outlet of scal anterior/scal medius/1st rib eg Cx rib, tumour -Sx burning pain to shoulder with radiation to inner arm/hand, C8/T1 tingling, intrinsic muscle weakness -Tests: Adsons test (adduction & head turned); Wrights hyperabduction test (right answer); Falconers test (falcon drivinf=g: military brace position); Roos test; Morleys compression test (pressur eover plexus). -EMG doesnt help -Rx conservative (physio, LOW, avoid exacerbants) then surgical release via axillary or supraclavicular approach

What is Sturge Weber syndrome?

-Choroidal angiomatosis -Leptomeningieal vascular anomalies -CM of V1, or V1-2, or V1-3

What is nasoschizis?

-Clefts of lateral part of nose, aka no 1 or 2 clefts -Cleft 1 begins at Cupids bow eg CL, then causes wide spectrum of changes -Cleft 2: Cupids bow, intact but deviated septum

What is the difference between clinodactyly and camptodactyly?

-Clinodactyly (Greek: clino = deviated, dactylos = digit) refers to digit or thumb that is deviated in radioulnar or mediolateral direction. An inward (radial) deviation of fifth digit is most commonly seen & is often assoc w various other congenital hand anomalies that it represents "background noise" and gives no specific indication of one condition over another -Camptodactyly (Greek: campto = bent, dactylos = digit) refers to a flexion deformity of a digit or thumb in an anteroposterior plane. This deformity also commonly involves the PIP joint of the fifth finger and is seen in two distinct age groups: infants and adolescent girls

What is a rhombic flap?

-Combination of rotation & transposition flap that borrows adjacent loose skin to close a defect -A rhombus is an equilateral parallelogram with angles of 120 and 60, and long and short diagonals perpendicular to one another. The flap is designed as an extension of one of the short diagonals, extended by a distance equal to its length. From here another line of equal length is drawn at 60 degrees

When should Le Fort III be combined with a frontal advancement?

-Combo permits simultaneous advancement of midface + frontal bone, eg for pts w brachycephaly and midfacial retrusion. -Once the frontal bone flap is removed, the supraorbital osteotomy is extended horizontally to region of temporal fossa & continued in stepwise fashion inferiorly toward the base of skull. The step design of this osteotomy permits bony contact after advancement of the frontal bandeau. The osteotomy is continued in a horizontal fashion through lateral orbital wall and roof posteriorly. The procedure is completed by performing the Le Fort III osteotomy. This combination permits simultaneous advancement of the frontal bone, part of the roof, and lateral wall of the orbits. In essence, this combination of osteotomies constitutes the equivalent of a monobloc advancement.

Condylar fractures

-Common 18% -P/w contralateral openbite & premature ipsilateral contact -lateral pterygoid inserts on condyle neck & causes anterior & medial displacement -Usually Rxed by MMF alone for 2-4 weeks (short as long MMF causes TMJ degeneration) _ORIF if displaced into MCF, FB insitu, cant get into occlusion, severe displacement, condyle outside glenoid fossa

What is the superficial spreading subtype?

-Commonest subtype -Initial flat phase w changes in size, shape, colour -Average age is young - 40yo -RFs include naevi (typical & dysplastic), intermittent UV exposur, sunburns

What are the guidelines for excisional biopsy of a pigmented lesion

-Complete excisional biopsy of lesion with 2mm margin, down to subcut tissue, with any focally suspect area marked. -Partial biopsy gives inaccurate results (as naevi often have differing degrees of atypia in different zones) but is sometimes done eg cosmetically sensitive area

How is syndactyly clinically classified?

-Complete if the level of webbing between digits extends to the fingertip and incomplete with a more proximal termination. -A simple syndactyly refers to soft tissue connections between adjacent digits, whereas complex refers to bone or cartilaginous unions. -Complicated refers to abnormal duplicated skeletal parts within the interdigital space. -The most common pattern is bilateral simple, incomplete syndactyly of the long and ring fingers. Many such patients have a simple syndactyly involving toes 2 and 3 on one or both feet.

Phocomelia

-Congenital hand -Longitudinal failure of formation -Absent missing segment from limbs -Distal part looks like they glued it on -Short arm bones, fused fingers, missing thumbs -Non limb probs --facial haemangioma & hypertelorism --mental retard --encephalocele, hydrocephalus --kidney & heart & GIT probs --coagulopathy (DVT) -A/w thalidomide, genetics (AR)

What are the essential parts of a histo report for melanoma?

-Correct Dx -Breslow: microscopic measurement of tumour thickness to nearest 01.mm -Margins: lateral & deep margins in mm -Clark: level of invasion (prognostic only in thin melanomas) -Ulceration: presence & extent -Mitotic rate per mm2

Major phenotypic difference w fetal wound healing (FWH)?

-Cutaneous adult wound healing (AWH) involves the process of scar formation. However, fetal cutaneous wound healing is SCARLESS, appearing more like tissue regeneration than wound repair

Vagus involved in Meniere's Disease?

-Deafness (fluctuating) + Vertigo + Tinnitus -Idiopathic but ?from endolymphatic hydrops, an excess of fluid in the inner ear -Vagus not involved

What role do macrophages play in wound healing?

-Debride wound w phagocytosis -Main source of proinflammatory cytokines & GFs eg interleukins (IL-1, IL-6, IL-8), PDGF, TGF-β, EGF, FGF, VEGF, IGF --> stimulate more m0s, lymphocytes, fibroblasts --> autocrine amplification

What physiological changes happen with tissue expansion

-Dermis THINS w eventual collagen realignment & deposition -Epidermis THICKENS -Other tissues are affected by pressure eg fat atrophies, outer bone cortex may resorb -Mitotic rate of expanded skin increases -Fibrous capsule develops around expander -Angiogenesis, esp at interface of capsule/expanded skin -Subsequent increased blood flow, similar to delayed flap

How does dermoscopy help clinical Dx of melanoma? What other tools may help in Dx?

-Dermoscopy reduces benign:malignant ratio of excised melanocytic lesions & reduces no. patients sent for Bx in specialist setting -Sequential digital dermoscopy can help Dx lesions that lack dermoscopic features of melanoma, & whole body photos can help early Dx in high risk pts

Thoracic sympathetic plexus - 12 sites t/f

-Descend along vert bodies -Has 11 or 12 SANS ganglion (paravert ganglia) corresponsing to the spinal nerves -First Tx ganglion often fuses w inf Cx ganglion to form cevicothoracic (stellate) ganglion -T1-T5 POSTGANG branches go to cardiac branches then to aortic, pulm, oeseophageal plexuses -T5-9 PREGANG branches travel via GREATER SPLANCHNIC NERVE then to aorticorenal ganglia & coeliac ganglia and suprarenal ganglia -T10-11 PREGANG go to LESSER SPLAN. NERVE to aorticorenal ganglia -T12 also PREGANG go to LEAST SPLAN. NERVE the to renal plexus

Are neutrophils essential for strengthening wounds?

-Don't strengthen wounds & not source of growth factors -Instead they remove necrotic debris and bacteria from the wound during inflammatory phase

What are Langers lines?

-Elastic fibers within the dermis maintain the skin in a state of constant tension, as demonstrated by the gaping of wounds created by incising the dermis or by the immediate contraction of skin grafts as they are harvested. -In 1861, Langer demonstrated that puncturing the skin of cadavers with a rounded sharp object resulted in elliptical holes produced by the tension of the skin. He stated that human skin was less distensible in the direction of the lines of tension than across them. -Shortcomings of Langer's lines are that (1) some tension lines were found to run across natural creases, wrinkles, and flexion lines; (2) they exist in excised skin; and (3) they do not correlate with the direction of dermal collagen fiber orientation. -Nonetheless, Langer's lines serve as a useful guide in the planning and design of skin incisions and excisions.

Describe the various types of encephaloceles

-Encephaloceles are classified by location and include sincipital (also known as frontal or frontoethmoidal ), parietal, basal, and occipital. -Sincipital encephaloceles are located between the bregma & anterior ethmoid bone. Sincipital encephaloceles are further divided by direction of herniated contents (nasofrontal, nasoethmoidal, nasoorbital). -Sincipital encephaloceles occur more commonly in people from Southeast Asia and Nigeria and rarely among people of European descent.

When does expansion end?

-Ends when the expanded flap will fit the defect. Measurement over the dome of the expanded tissue minus the base width of the expander gives a rough estimate of the additional tissue available -In making the advancement, use scalpel to incise skin, then scalpel or round monopolar (not needlepoint) to incise the fibrous collagen capsule that surrounds all expanders. Advance the skin forward to ensure its big enough BEFORE excising the defect.

When can expansion begin? How much to inject each time?

-Expansion usually begins 1 week after surgery if wound is stable. -Can't give specific volume to inject: usually begins rapidly then slows with higher volumes & pressures. -Safest thing is to inject until pt says expansion is beginning to feel tight. Pain should be avoided at all times

What is the mechanism of wound contraction?

-Fibroblasts in contracting wounds have increased actin microfilaments and are designated as myofibroblasts. These myofibroblasts orient themselves along lines of tension and pull collagen fibers together. -Wound contraction is normal healing process to close wounds, while wound contracture is abnormal shortening and thickening of a scar

what class is PTFE & goretex?

-Fluorocarbon polymers: as a group they are resistant to chemical degradation and are minimally reactive when placed in the body.

Cipro

-Fluoroquinolone -For GNR, neisseria, some GPs -Damages cartilage: tendon rupture, teratogen

what is hydroxyapatite (HA)?

-HA is major inorganic constituent of bone -made into surgical ceramic by swapping Ca carbonate for phosphate -available as blocks or granules -can be porous, resulting in rapid invasion by fibrovascular tissue -osteoconductive as provides matrix for deposition of new bone from adjacent living bone; union is within 2-3 months -not osteoinductive as doesn't induce new bone formation when placed in ectopic sites -HA strongly bonds to bone, keeps contour and volume, elicits no FB or inflammatory reaction

What is an encephalocele?

-Herniation of intracranial contents through a cranial defect. If herniated material includes CSF & meninges, then it is a meningocele. Herniation of meninges & brain parenchyma is a meningoencephalocele.

what is medpor?

-High density porous polyethylene -Has replaced silicon as #1 polymer used in facial augmentation - Available as sheets/blocks that can be sculpted during OT, or preformed implants for augmentation eg chin, microtia (beneath TPF), malar -Has pore sizes 100-250 μm which allow stabilization via bony & soft tissue ingrowth -Minimal FB reaction (thin fibrous capsule) -Low infection and extrusion rates -No loss w LT follow-up

Silicon advantages?

-Highly biocompatible -Nontoxic -Nonallergenic -Resistant to biodegradation -Topical silicons used successfully in scar Rx

How is diagnosis of a vascular lesion made?

-Hx and exam will accurately Dx 90% -Imaging is often done to confirm Dx & determine extent -Biopsy is done if there is any uncertainty with Dx

How is the ECM different in FWH?

-Hyaluronic acid is increased: helps fibroblast mvmt, helps cell proliferation; might be signal for causing regeneration -Fibronectin is deposited faster: provides scaffold for epithelial cell migration -Glycosaminoglycans are decreased: increased GAGs are a/w scar formation through cytodifferentation

What is the role of prophylactic sentinel LN biopsy in stage I and II melanoma ?

-Hypothesis is 1st draining LN reflects the basin tumour status, so Bx will detect occult mets. -Candidates: PM 1.2mm-3.5mm thick; or <1mm with adverse path (ulceration, ?Breslow thickness, Clark IV/V, ↑mitotic rate) -Benefits: Prognostic (3YS: -ve 97%, +ve 70%); Staging; Identifies pts who do & don't req therapeutic LND -Argument against: no evidence +ve SLNB & subsequent LND ↑s overall survival -Diagnostic only: +ve SLNB are offered therapeutic completion LND

What is the difference between isolated limb perfusion & isolated limb infusion?

-ILP: Arm put on 'bypass' pump of high dose melphalan under hyperthermic conditions. Impressive results (response rates ~90%, complete response rates 60-70%) but skills required, complications, costs too high for centres to do. -ILI (1992, Sydney Melanoma Unit) is more often used as simpler (infused via axillary A & V catheters with TQ proximal), safe, with similar effectiveness as ILP. Note no improvement in survival has been shown for ILP or ILI.

vagina

-IS NOT formed only from union of mullerian ducts. 4/5 by them, 1/5 by sinovaginal bulbs -upper vag surrounds the lower cervix for bit, at the external os. 4 recesses around the cervix are known as ant, lat, post regions. They correspond to vaginal walls -anterior vag wall has base urinary bladder & urethra; post has pouch Douglas

Which flaps do osteointegration in H&N? Why isnt osteointegration done more?

-Iliac > Fibula > scapula, while FRFF doesnt -Takes many stages over 6-9/12, expensive, pts have poor prognosis, moany had crap/no teeth before, potential issues with OI & adjuvant RTX

What is a "dog ear"? How can it be eliminated?

-In excising a lesion in elliptical fashion, theratio should be 4:1 -Dog ears form at the ends of a closed wound when either the ellipse is made too short or one side of the ellipse is longer than the other. -Dog ears may flatten over time, but primary correction is best. If the elliptical excision is too short, the ellipse can be lengthened to include the excessive tissue or the redundant tissue excised as two small triangles. If one side of the incision is longer than the other, the dog ear can be corrected by making a short right-angle or 45° incision at the end of the ellipse with removal of the redundant tissue.

When should a trigger thumb be released surgically?

-In kids <18 months, spontaneous resolution may be seen within 6 months. After age 2 years, children with persistent locking develop compensatory hyperextension of the MP joint as the palmar plate is stretched. This hyperextension may not correct itself with growth after the trigger is corrected. No additional surgery is indicated unless functional problems are present.

Indications & contraindications for LL replant

-Indications: single level, clean transection without crush or avulsion & warm ischemia <6/24 -Contraindications: Poor health, multilevel injury to joint that results in immobility of ankle or knee, warm ischemic time >6hrs, older age

During remodeling, no net increase in collagen occurs but wound tensile strength increases greatly. Why?

-Initial wound healing makes random oriented collagen -Remodelling phase collagen becomes cross linked & replaced with organised collagen that is stronger, but never reaches strength of uninjured collagen

LL coverage -Knee -Prox leg -Middle leg -Distal leg -Ankle

-Knee: gastroc, distal VL, saphenous, FF -Prox tibia: gastroc, saphenous, local FC, FF -Middle tibia: TA turnover, soleus, local FC, FF -Distal tibia: EBM flap < lat supramalleolar flap < dorsalis pedis FC flap < soleus or sural < FF

What is the lentigo maligna & LM melanoma subtype?

-LM & LMM (invasive form of LM) is 10-15% melanomas. -Initial flat phase that can be prolonged -Atypical pigmented macule thats changing -DDx seborrhoeic keratoses, solar lentigines and pigmented actinic keratoses -RF incl large cumulative doses of UV -Usually in H&N, in outdoor workers, in older people, w solar damage & NMSCs -LM is Rxed as per other melanoma: excise w 5mm margin

What investigations are helpful in stage I & II melanoma disease?

-LNs are commonest metastasis site with risk directly related to Breslow thickness. Unfortunately, no evidence that early Dx of occult mets improves survival. -Routine blood tests or CT/PET not helpful in stage I/II, but any suspected LN disease requires FNA to confirm

Pronator syndrome - 4 sites of compression happen *FAST* - Sx

-MN compression in proximal forearm/elbow -Get CTS + palm paraesthesia, forearm pain, forearm Tinels -4 sites compression 1) FDS arch: Test is resisted MF PIP 2) Aponeurosis bicipital (lacertus fibrosus): Test w resisted supination w elbow flexion 2) Struthers lig (from lat supracondylar process): Test w resisted elbow flexion 3) pronator Teres: test w resisted pronation -Rx nonoperative first incl TPS w elbow 90%. Half respond -OT is lazy S incision, decompress all 4 sites incl detach then reattach PT

Which nerve controls thumb IPJ extension?

-MN supplies radial side of thenar eminence, doing MP joint flexion & IPJ extension from the radial side -UN suplpies adductor pollicis & ulnar head of short flexor, which does same actions from ulnar side -RN supplies EPL, which does central IP joint extension. Thus all three major peripheral nerves contribute to extension of the thumb IP joint.

What conditions should be considered in a child born with gross enlargement of a digit?

-Macrodactyly (Greek: makros = large, dactylos = digit) and gigantism have been used to describe enlarged digits and thumbs. Need to rule out -Neurofibromatosis (NF) -Nerve territory-oriented lipofibromatosis not associated with NF -Multiple hereditary exostosis -Proteus syndrome with hyperostotic lesions & overgrowth of phalanges -Vascular malformations, particularly venous, lymphatic, and mixed venous-lymphatic -Hemihypertrophy of the limb

What are the benefits of occlusive dressings?

-Maintain moist environment that promotes faster reepithelialization than occurs under dry conditions. -Watch for infection though b/c moist environment also makes excellent medium for Bx growth.

What is the desmoplastic subtype?

-May arise within a LM or present de novo -De novo presentation is typically as a firm, evenly skin-coloured or pink nodule that is progressively enlarging. -DDx includes includes dermatofibroma & hypertrophic scar

Can a haemangioma cause skeletal overgrowth?

-Minor bony overgrowth may be seen with large cutaneous haemangiomas, but generally *haemangiomas DONT cause overgrowth* -Slow flow VM's however DO cause bony overgrowth, distortion, deformation (*slow=grow*). Fast flow VM's cause bony erosion & osteolysis

What is the main anatomic problem in camptodactyly?

-More than 20 abnormal origins and particularly insertions of the intrinsic and extrinsic muscle tendon units within the hand have been described. The most common variations involve abnormal distal insertions of lumbrical & interosseous muscles within the digits, particularly on the ulnar side of the hand. -Tight joint capsules, collateral ligaments, joint contractures, abnormal articulating surfaces, and proliferative fibrous bands (fibrous substrata) within the digit are more likely secondary and are not the primary forces causing camptodactyly.

What are the indications for joint release in camptodactyly?

-Most are Rxed successfully with stretching and splinting. Few require surgical release. Contractures of 15°-50° usually have favorable outcomes. Adults and adolescents with longstanding contractures >70° of flexion are best treated with arthrodesis. The results of soft tissue releases are inversely proportional to the severity of the contracture. Often initial tight contractures can be improved with conscientious stretching but may need surgery later in childhood to obtain full correction. Surgery may be difficult and must be followed by a strict stretching and night-splinting regimen.

Main sdvantages of pec minor for facial reanimation

-Multidirectional pull: slips for ZM, elevators, retractors of commissure -Dual innervation allows independnt ROM of different muscle parts: upper 1/3 LPN (eg for eye), lower 2/3 MPN (eg for lip)

Do all fetal wounds heal without scar - ie what are the requirements for SCARLESS FWH?

-Must be in 1st or 2nd trimester; 3rd trimester heals w scar -No inflammation at all: any inflammation induces AWH & scar -Bone, skin, mucoperiosteum only -Wound <9mm: anything longer scars regardless

Mastopexy and breast reduction vs nipple sensation

-NAC by lat cut br of 4th intercostal nerve

Femoral ring

-NAVEL = Femoral ring is base of E -Anteriorly = inguinal ligament. -Posteriorly = pectineal ligament. -Medially = Lacunar ligament. -Laterally= medial side of femoral Vein -Fem canal joins abdo via fem ring -If gut drops into ring -> Femoral hernia -Ring SA is pubic tubercle -FH is below & lat to PT, inguinal above & medial

NOE fractures involve which bones

-NOE complex is confluence of nasal, lacrimal, ethmoid, maxillary, and frontal bones

What are the differences among the various nonabsorbable suture materials?

-Nonabsorbable monofilament (Ethilon/nylon and Prolene) sutures incite minimal inflammatory reaction, slide well, and can be easily removed, thus providing ideal running intradermal stitches. -Prolene appears to maintain its tensile strength longer than nylon, which loses approximately 15% to 20% per year. -Nonabsorbable braided materials (Nurolon, Ethibond, and silk) elicit an acute inflammatory reaction that is followed by gradual encapsulation of the suture by fibrous connective tissue.

How does the wound's collagen composition compare between the early and late stages of wound healing?

-Normal dermis: type I is 80-90% -Wk 1 wound healing: type III is 30% (via fibroblasts) -Wk 2 wound healing: type III replaced by type I & % returns to normal

What is different about the process of FWH?

-Occurs at ACCELERATED rate, with normal tissue 5-7 days after injury -Acute inflammatory stage of healing is absent -Has more type III collagen (type III:I is 3:1, while completed AWH has 1:3)

Aging and wound healing

-Old pts patients have slower wound healing, less scarring, less contraction, decreased tensile strength, decreased epithelialization, delayed cell migration, and decreased collagen synthesis. - Can be good (eg few scars w cosmetic surgery) or bad (dehiscence w tension)

What effect does aging have on wound healing?

-Old pts patients have slower wound healing, less scarring, less contraction, decreased tensile strength, decreased epithelialization, delayed cell migration, and decreased collagen synthesis. - Can be good (eg few scars w cosmetic surgery) or bad (dehiscence w tension)

What are osseointegrated implants?

-Osseointegration is the harmonious coexistence of implant, bone, and soft tissue -1st a titanium implant is placed into bone and buried underneath the periosteum or soft tissues for 3 months to provide osseointegration. Must be completely stable otherwise CT & not bone forms at interface -2ns stage implant is uncovered and a permanent prosthesis is made for fixation to the implant. -Threaded implants with small pores are more likely to establish initial stability -Titanium is used because oxide layer that readily forms on the implant's surface is important to the implant's tissue interaction.

Are there any specific products that help accelerate wound healing?

-PDGF for clean well vascularised diabetic foot ulcers -Apligraft is synthetic dermis for venous ulcers

What roles do platelet-derived growth factor and transforming growth factor beta play in wound healing?

-PDGF is released by platelets in inflammatory phase to attract & activate macrophages. M0's orchestrate wound healing & secrete more PDGF --> more m0's - TGF-β is released by m0's & platelets to attract & activate fibroblasts, stimulating them to form collagen.

What is the role of adjuvant immunotherapy in stage I & II melanoma disease?

-PM >1.5mm are offered place in high dose IFN alpha trial. Prolongs disease free survival, and has small effect (3%) on overall survival, is expensive & toxic. IL-2 not used due to toxicities.

Radial forearm flap harvest Qs 1 RA perforators run lateral to brachioradialis? 2 Need to preserve perforators running superficial and medial to RA to obtain good bone union if raising an osteocutaneous flap? 3 Can you raise 2/3 circumference in an osteocutaneous flap?

-Pedicle run between brachioradialis (lat) & FCR (med) & superficial to FDS -Perfs from the pedicle travel deep through FPL to supply the radius periosteum -When raising, need to keep small cuff of FPL muscle to keep LIMS with pedicle attached to bone. -Can only raise 1/3 radius circumference

Abx

-Penicllin GP, GN -Carbapenems good for GP, GN, anaerobes, & are beta-lactam -Vanc is for GP -Aminoglycosides (Gent) for GN, not for anaerobes (need B-lactam) -Clinda anaerobes -Fluorquinolones (cipro) GN & some GP -Ceph 1st & 2nd GP, 3rd GN, 4th GP & Pseudomonas

What are the principles of tissue expander placement?

-Place under tissue that best matches the lost tissue -Normal landmarks must not be distorted -Put incision for insertion on edge of defect, so it will be removed w advancement of expanded flap -Always ask "where do I want the final scars to lie?"

What is silicon?

-Polydimethylsiloxane (PDMS) or silicon is a repeating chain of -Si-O- units -SIlicon SImulates different soft tissues eg liquid, gel, or rubber by varying length & cross-linking of PDMS chains

What is Goretex?

-Polymer sheet of "expanded" PTFE interconnected by Teflon fibrils, yielding tremendous strength. Pores of up to 30 μm result from the expansion, allowing a small amount of tissue ingrowth -Useful for vascular reconstruction & soft tissue augmentation eg lip, chin, nasal, and forehead augmentation; chest or abdominal wall reconstruction; suspension of the paralyzed face -Problems with extrusion or migration of Gore-Tex implants are reduced when the implants are properly fixed to the tissues. Infection rates with Gore-Tex implants are very low.

What is PTFE?

-Polytetrafluoroethylene (PTFE) consists of non-cross-linked linear polymers of fluorinated carbon units -Highly resistant to degradation -Very biocompatible: inert, nonadhesive, nonfrictional, virtually no inflammatory rxn, nonallergenic, noncarcinogenic

What is trigonocephaly? - Does Metopic cause raised ICP - What single suture most common

-Premature metopic suture fusion -Uncommon 10% all CS -Frontal keel, narrow forehead, hypotelorism -Higher risk of brain abnormalities & dvmtal delay -Rxed w FOA with widening by midline osteotomy -Commonest sagittal

What are advantages of tissue expansion?

-Provides tissue that is most like the lost tissue: matched in color, texture, hair bearing chx -Minimal DSM -Seldom is tissue lost

What clotting problems can a VM cause?

-Pt with multiple or large VM is at risk for localised DIC, defined as the presence of activated clotting & fibrinolytic factors in intralesional blood. - DIC can result from any perturbation (eg trauma, sclerotherapy, or an operation), resulting in low fibrinogen and elevated PTT, APTT, D-dimer - Most effective Rx of LIC or DIC is sclerotherapy to diminish the size of the VM. Heparin is given subcutaneously prior to a procedure (sclerotherapy or resection) is continued for 2 weeks after intervention.

What are relaxed skin tension lines?

-RSTLs aka wrinkle lines, natural skin lines, lines of facial expression, or lines of minimal tension, lie perpendicular to long axis of the underlying facial muscles. -They are accentuated by contraction of the facial muscles, as occurs with smiling, frowning, grimacing, puckering the lips, or closing the eyes tightly. An example is the frontalis muscle, which runs vertically straight up the forehead; RSTLs on the forehead run transversely or perpendicular to the underlying frontalis muscle.

What effect does radiation have on wound healing?

-Radiation damages endothelial cells, capillaries, and arterioles --> progressive loss of blood vessel volume & reduced tissue perfusion -Radiated fibroblasts show decreased proliferation and collagen synthesis, leading to diminished deposition of extracellular matrix -Lymphatics are likewise damaged, causing edema and poor clearance of infection in healing tissues.

What is the acral subtype?

-Rare: only 1-3% of melanomas in Australia -On acral skin of palms & soles with similar Sx to SSM but sometimes more light-coloured or pink -May appear flat on foot but be very deep histologically -At least equally common in dark skinned people & may have no relationship with UV exposure

Osteoporosis

-Reduction of primarily trabecular (spongy) bone mass in spite of normal bone mineralization -blood tests all normal -From inc bone resorption from low oestrogen levels -Rx estrogen and/or calcitonin; bisphosphonates or pulsatile PTH for severe cases. Glucocorticoids are contraindicated.

What are the differences among rotation, transposition, and interpolation flaps?

-Rotation: flap that mainly rotates into a defect, classically designed as semicircle with defect one part of it -Transposition: flap that mainly transposes laterally into a defect. classically designed as rectangle -Interpolation: flap transferred over intact bridge of skin, with pedicle travelling usually below (sometimes above) skin. May need second stage to divide. Eg forehead flap

what is cyanoacrylate??

-Superglue: strong, biodegradable tissue adhesive that polymerizes upon contact with tissues -Used as hemostatic agent or to "glue" tissues together in a surgical wound -Eg dermabond

When should scar revision be performed? What are the goals?

-Scar revision should be performed once the scar has matured—usually 9 months to 2 years after the original procedure. -Goals of scar revision are to reorient the scar, divide it into smaller segments, and make it level with adjacent tissue.

what is methylmethacrylate?

-Self curing acrylic resin -Available in 2 forms: heat cured preformed implant or cold cured implant thats molded in OT -Used in PRS forehead augmentation, chest wall recon, gentamicin impreg methylmethacrylate beads

What follow up is recommended for patients with melanoma?

-Self exam + regular GP/derm/surgeon follow up to detect new lesions/recurrences (80% recurrences occur in initial 3 years). -No evidence skin checks reduces mortality, but average thickness decreases with regular RV -Intervals: Stage I, see 6-monthly for 5 years; Stage II or III, see 3 or 4 monthly for 5 years; then yearly for all for lifetime.

What is Kasabach-Merritt phenomenon?

-Serious thrombocytopenia (typically <5000 platelets/mm3) that occurs in association with a locally aggressive vascular tumor (KHE) and sometimes with a less aggressive tumor (tufted angioma). KHE is treated initially with a trial of corticosteroid (only 12% effective); thereafter the options are vincristine or interferon alfa.

signs of NOE #

-Severe medial orbit wall #s can be a/w NOE # -NOE complex is maxillary, lacrimal, ethmoid, sphenoid (MLES) & nasal & frontal bones -SIgns include --Telecanthus (inc distance between medial canthus, but unlike orbital hypertelorism the orbit is not displaced laterally) --Enophthalmos --Saddle nose --Movement of frontal process of maxilla on direct finger pressure over the MCL --Lacrimal drainage problems may occur with epiphora and/or mucocele --Anosmia from cribiform plate #

Thymus

-Site of T-cell differentiation and maturation. -Encapsulated -From epithelium of 3rd branchial pouches. -Lymphocytes of mesenchymal origin. -Cortex is dense with immature T cells; medulla is pale with mature T cells and epithelial reticular cells and contains Hassall's corpuscles. -Positive (MHC restriction) and negative selection (nonreactive to self) occur at the corticomedullary junction -Absent in DiGeorge syndrome

What are the criteria for clinical stage III?

-Stage III = any T, N1 or N2 or N3, M0 -Differing between stage IIIA, IIIB, IIIC is done by pathological stage grouping

Define -Standard abdominoplasty -Extended abdominoplasty -Fleur-de-Lis -High lateral tension abdominoplasty -Reverse abdominoplasty -Panniculectomy -Belt lipectomy -Lower Body Lift -Upper body lift

-Standard: RO excess skin with undermining & plication of wall. -Extended: RO excess tissue that wraps around waistline or love handle, resulting in longer scars -Fleur-de-Lis: RO vertical strip + lower horizontal strip too -HLTA: Lateral tension at outer margins of scar, -Reverse: Contouring of upper abdo using an incision placed in IMF -Panniculectomy: RO pannus only. No undermining, umbi translocation, or fascia plication -Belt: RO excess tissue from abdomen circumferential to the back. - Lower Body Lift: Belt lipectomy + lower back lift, plus/minus thigh lift. -Upper body lift: mastopexy (mastectomy for men) + RO excess upper back skin plus/minus brachioplasty

After giving birth to her first baby, a patient asks if any treatments are available for stretch marks (striae distensae). What causes stretch marks? Are they amenable to treatment?

-Stretch marks form when dermal collagen fibers are stretched and disrupted but the epidermis remains intact. The dermis forms a scar that is visible through the translucent epidermis. Because stretch marks are scars in the dermis, treatment involves scar excision or tissue destruction.

What investigations are recommended for stage IV disease?

-Suspected metastatic disease requires serum LDH (prognostic value), CT, MRI and/or PET. -If MM is confirmed then no further Ixs are required unless surgery is planned & detecting new mets would change Rx. -PET scan better than CT for detecting mets, except in brain, lung, and lesions <6mm size -Routine use of CT/MRI/PET changes management in 49% of stage IV patients.

What does symphalangism mean? What are the more common clinical presentations?

-Symphalangism (Greek: sym = together, phalanx = bone) refers to phalanges that are fused because of a failure of segmentation or incomplete segmentation with cavitation. -More than 15 conditions are a/w with these stiff, often short and slender digits. Most important sign is lack of flexion crease. -There are three general categories 1. True symphalangism demonstrates digits of normal length, positive inheritance, fusion of one or more digits, PIP involvement (common), and long, slender fingers. 2. Symbrachydactyly demonstrates all variations of short digits with and without varying degrees of webbing. Formerly many affected hands were classified as atypical cleft hands. DIP and PIP joints are commonly fused. 3. Syndromic symphalangism is most commonly seen in the Apert and Poland syndromes. In both the central three rays are most commonly involved. Some degree of digital fusion may be seen in the other acrocephalosyndactyly (ACS) syndromes. In neither of these conditions are the MP joints involved.

What does syndactyly mean? Is it the most common congenital anomaly?

-Syndactyly (Greek: syn = together, dactyly = finger) is commonly used to describe webbed digits and is the second most common congenital anomaly. -Commonest is duplications, esp preaxial (thumb) duplications in Asians & postaxial (ulnar) duplications in Blacks. Overall occurs in 3.8:1000 to 12:1000 live births.

What is PDS's origin, Ix reaction, time until hydrolysed, time of tensile strength?

-Synthetic absorbable monofilament, is minimally reactive. Absorption is essentially complete within 6 months, although little occurs before 90 days. PDS sutures maintain their tensile strength considerably longer: 50% at 4 weeks and 25% at 6 weeks. Absorption is essentially complete at 6 months.

Staging of oral cancer

-T1 <2cm -T2 2-4cm -T3 >4cm -T4a mod locally advanced (invades immed adjacent structures) -T4b very locally advanced (invades masticator space, pterygoid plates, skull base, encases ICA) NONRESECTABLE -N1 Single ipsilateral node <3cm -N2 Nodes ipsi or bilateral 3-6cm -N3 Node >6cm -M1 distant mets

What are the criteria for pathological stage IIIA?

-T1-4a, N1a, M0 ie any nonulcerated tumour & 1 occult LN -T1-4a, N2a, M0 ie any nonulcerated tumour & 2-3 occult LN

What are the criteria for pathological stage IIIB?

-T1-4b N1a M0 ie any ulcerated T & 1 occult LN -T1-4b N2a M0 ie any ulcerated T & 2-3 occult LN -T1-4a N1b M0 ie any NONulcerated T & 1 clinical LN -T1-4a N2b M0 ie any NONulcerated T & 2-3 clinical LN -T1-4a/b N2c M0 ie any T & 2-3 intransit met/satellite without metastatic nodes

What are the criteria for pathological stage IIIC?

-T1-4b N1b M0 ie any ulcerated T & 1 clinical LN -T1-4b N2b M0 ie any ulcerated T & 2-3 clinical LNs -Any T N3 M0 ie any T (N/A ulcers) & 4 or more metastatic nodes, matted nodes, intransit mets, satellite(s) with metastatic nodes

Can the hand bursal compartments communicate with each other with the spread of an infection?

-The LF synovial sheath communicates with the ulnar bursa; the ulnar bursa is closely related to the midpalmar space -The thumb synovial sheath (FPL) communicates with the radial bursa; the radial bursa is closely related to thenar space -Both radial & ulnar bursa can communicate proximally in the hand, so thumb can infect LF & vice versa, creating a panpalmar "horseshoe abscess". They can also infect the forearm via the space of Parona.

What is the mechanism of scarless FWH?

-Theories include growth factor regulation & coordinated expression of DNA binding proteins eg homeobox genes -Whatever the mechanism, it likely involves decreased inflammation & regulation of increased fibroblast & epidermal proliferation

What Rxs are available for stage III disease that presents w regional lymphadenopathy?

-Therapeutic LN dissection: Radical clearance of a lymphatic field of metastatic lymphadenopathy. Curative for 30%. 5-10%get significant lymphoedema. Elective (ie routine) LND not recommended. Refer all LN +ve pts to multidisciplinary centre (↑risk for stage IV disease).

What are the genetics and incidence of the constriction ring syndrome?

-There is no positive inheritance in CRS. -Incidence is <10% of hand anomalies -Caused by in utero deformation in which strands of inner layer of chorionic sac detach & wrap around parts of fetus, usually fingers and toes. There are many examples of monozygotic twins with only one partner affected

What is the difference between a typical and atypical cleft hand?

-Typical cleft hand: bilaterality, positive inheritance, foot involvement, V-shaped cleft, and syndactyly (common). A portion or all of the middle ray is commonly missing. It is often called simply a cleft hand. -Atypical cleft hand: unilateral, nonfamilial, U-shaped cleft, no foot involvement. Small nubbins often represent rudimentary digits. This condition often has been called "lobster claw hand." Recent recommendations are that "atypical cleft hand" be officially classified as symbrachydactyly.

Define -US assisted liposuction -Wet technique -Superwet technique -Tumescent technique -Klein formula

-UAL: US energy destroys fat cells ("cavitation") then sucked up as normal -Wet: 250cc wetting solution per area -Superwet: 1cc infiltrate per 1cc aspirate -Tumescent: Infiltrated til turgor, ~2-3cc per 1cc aspirate -Klein: 1L NS, + 50ml 1% lidocaine, 1ml 1:1000 adrenaline, 2.5ml 8.4% sodium bicarbonate

Is USS or MRI better for Dx?

-USS is very operator dependent -MRI with contrast enhancement (gadolinium) is gold standard. Must also include gradient sequences to visualize fast-flow vessels, and fat-suppression sequences may be useful

What is the anatomic snuffbox?

-Ulnar border: APL & EPB -Radial: EPL -Floor: radial styloid, scaphoid, trapezium, thumb MC -RA courses through snuffbox on way to dorsal first web space

Describe CFNG

-Usually 2 stages -1st stage: nerve graft is from contralateral normal nerve to ipsilateral abn nerve stump or banked in tragus. -2nd stage when regeneration present (Tinels on abnormal side causes tingling in normal sides N): free muscle is inserted with its nerve anastomosed to the CFNG stump.

What is the subungal hematoma subtype?

-Variant of ALM that arises within nailbed matrix & causes longitudinal melanonychia (brown to black stripe throughout the full length of nail). Nailfolds may be involved (Hutchinson's sign). -DDx includes subungal hematoma (easy to Dx on dermoscopy), nailbed naevi, ethnic-type pigmentation (seen with dark skin, often familial and affects multiple digits) and drug-induced pigmentation. -Like ALM appears w similar incidence in dark skin people & may not related to UV exposure

What is the Dufourmental flap?

-Variation of rhombic flap where angles are 30 and 150 are used, but angles up to 90 are possible. This is used for covering defects that are rhomboid shaped. -Although used interchangably, a rhomboid is different from a rhombus in that it has i) acute angles of varying size; ii) only opposite sides are equal in length; iii) diagonals are not perpendicular; iv) diagonals are not equal in length -Planning is more complex, and it is often easier to convert it into a rhombic flap ie 120 & 60 angles

B haemolytic strep pg 65 Achauer

-alpha: strep pneumo, viridans strep -beta: staph, s.pyogenes, s.agalactiae, listeria -gamma: enterococcus, peptococcus

What are some non-essential parts of a histo report for melanoma?

-Vascular invasion: melanoma cells within lumen −Microsatellites/local mets −Tumour-infiltrating lymphocytes (TIL) −Regression: loss of invasive tumour w fibrosis & inc vascularity. If present laterally can be reason for re-EOL −Desmoplasia: if present laterallu can be reasons for re-EOL −Neurotropism: increased local recurrence −Associated benign melanocytic lesion: for epidemiology/research −Solar elastosis: for epidemiology/research −Predominant cell type: spindle cell might be better than epithelioid −Histological growth pattern: not prognostic −Growth phase eg radial, vertical: subjective −Immunohistochemistry: most are S100 +ve, but isnt specific for melanocytes

What is vicryl/dexon's origin, Ix reaction, time until hydrolysed, time of tensile strength?

-Vicryl and Dexon are synthetic braided materials that behave similarly. They produce minimal tissue reactivity and are completely absorbed within 90 days. Tensile strength is 60% to 75% at 2 weeks and lost at 1 month.

Which vitamins and minerals affect wound healing?

-Vit A decreases inflammation & may help steroid-dependent patients -Vit C is req for hydroxylation of lysine & proline in collagen cross-linking. -Essential FAs are required for all new cell synthesis. -Magnesium & zinc are important cofactors for DNA synthesis, protein synthesis, and cellular proliferation. -Copper-based enzymes catalyze the cross-linking of collagen and strengthen the collagen framework. -These vitamins and minerals should be supplemented to prevent deficiency states

What are the guidelines for primary excision of melanoma?

-WLE w margins based on Breslow thickness, ie. MIS=5mm; <1mm=1cm; 1-2mm=1-2cm; 2-4mm=1-2cm; >4mm=2cm -No evidence >2cm margin has any survival benefit -All studies had few 2-4mm thick melanoma pts so consider 2cm margin w these -Acral lentiginous & subungual melanoma: margins above, incl partial digital amputation to joint proximal

What is the rationale for not allowing patients with hernias to do sit-ups for 6 weeks after a herniorrhaphy?

-Wound strength is initially weak -Increases slowly for 2 weeks -Then increases rapidly for 4 weeks in linear fashion - At 6 wks is 50% of ultimate strength - Wounds never achieve >80% of normal strength

Is a wound less likely to spread if it is closed with intradermal polyglactic acid suture (Dexon, Vicryl) versus a nylon suture that is removed in 7 days?

-Wounds can spread if closed under tension or if exposed to stretching forces. -In initial 3 wks wound is weak & ROS now will cause spreading. PGA (vicryl) loses strength at W3 so using it is same as RO nylon at week 1. -Leaving a permanent intradermal suture in place for several months decreases spreading, & possibly a synthetic suture that retains strength for 6-8 weeks may have same effect.

cellular changes after a SSG

-^ed epithelial mitotis & cell swelling -^ed epithelial thickness (by 7x until W4) -biphasic (low->high) enzyme activity -^ed monocytes, PMN, fibroblasts -reduced myofibroblast cells (FTSG>>SSG) -collagen & elastin is degraded & turned over til W6 -lymph channels connect -sensory recovery from W4, finished at 24M -donor site epithelium regenerates, but dermis doesnt (so reusing donor sites leads to thinner dermis)

anatomy of zygoma

-articulates with 4 bones via 4 processes, so "tripod" is misnomer *frontal bone at zygomaticofrontal process *temporal bone at its zygomatic process to form zygomatic arch *maxillary at zygomaticomaxillary buttress *infraorbital process *sphenoid bone at intraorbital articulation at zygomaticosphenoid suture is usually added as 5th articulation point

describe platysma flap for intraoral use

-based on submental artery -can be neurotised (VII & V) -previous XRT is contraindication

defn blepharochalasis, dermatochalasis, blepharoptosis, pseudoblepharoptosis

-blepharochalasis: inherited eyelid oedema--> attentuation of LA--> lid ptosis -dermatochalasis: age related attentuation of eyelid skin -blepharoptosis: drooping upper lid -pseudoblepharoptosis: eyebrow ptosis but lid in normal position

what is heterotopic ossification

-bone formation in the soft tissues after UL burn -usually near triceps insertion at elbow->reduced ROM -NSAIDS, surgery

what is Vitallium?

-cobalt-chromium-molybdenum alloy -1st used 1930s -has highest tensile strength (VITAllium is strong like VITAmin) = highest resistance to fatigue

Mobius syndrome is

-congenital bilateral facial paralysis -VII involved, sometimes also VI, VIII, IX, others? -limb anomalies 25% -pectoral muscles abnormal 15% -Rx aim is bilateral smile (do one side at time) -1st stage import motor N: nerve graft from SAN/CN V -2nd stage import muscle

cytokine -what is it and fxn -types

-cytokine is regulatory polypeptide thats essential for host defence, growth factors, wound healing, scarring 1) pro-inflammatory cytokines *TNFA: *IL-1: *IL-2: *IL-6: *IL-8: *IFNY: 2) anti-inflammatory cytokines *IL-4 *IL-10 3) growth factors *PDGF: *TGF-B: *FGF: *KGF *EGF *VEGF *IGF

what is abnormal latency or amplitude on EMG mean?

-decrease in latency or conduction velocity means myelination is decreased or thin. 1st change with chronic nerve compression -decrease in amplitude means loss of nerve fibres

Sebaceous glands

-dermal component but used to be in epidermis until month 3 -appendages of hair follicles -largest and are most densely located in skin of the forehead, nose, and cheeks -secrete oily sebum, which lubricates the hair, keeps the skin supple, and protects it against friction -holocrine glands that drain into pilosebaceous unit -Not sole cause of seb cysts which are epidermal in origin

excision margins for bcc & scc

BCC -aggressive: 3-4mm SCC -favourable (<2cm, well diff): 4mm margin excises 95% -unfavourable: 10mm margin excises 95%

Melanoma staging - breslow

-distance from granular layer epidermis to deepest part tumour -avoids confounding effect of variable reticular dermis seen in clarks levels -groupings are 1,2,4mm and help decide margins for WLE

rx of mandible defects in hemifacial microsomia

-distraction osteogenesis for type I & II -type III reqs costochondral and/or iliac bone grafts

what are these & is facial aesthetic surgery helpful? - ehlers dahlos - cutis laxa - progeria - werners syndrome (adult progeria) - pseudoxanthoma elasticum

-ehlers dahlos: inadequate lysyl oxidase-->poor collagen cross linking. NO OT -cutis laxa: degenrating elastin from inadequate lysyl oxidase in lung diseases. OT OK -progeria: AR, CFD, big ears, etc. NO OT -werners: AR, scleroderma skin, DM. NO OT -psesdoxanthoma: premature skin laxity. OT OK

lacrimal gland tumour

-epithelial < nonepithelial PLEOMORPHIC ADENOMA commonest benign, slow growing, 10% become adenoCa in 10yrs, have pseudocapsule, Sx are gradual painless proptosis & ophthalmoparesis, CT shows round lesion w bony remodelling, avoid Bx & remove w capsule intact as risk of seeding & recurrence, via ant or lat orbitomy ADENOID CYSTIC commonest malignant (them mucoepidermoid Ca, then pleomorph adenoCa), rapid proptosis & ophthalmoparesis plus pain from PNI, CT shows irregular poorly defined lesion w bony destruction, Rx exenteration & RTX w poor prognosis

aging changes in face soft tissue

-forehead: transverse forehead furrows, vertical glabellar frown lines, brow ptosis -eyes: redundant upper lid skin, crows feet, redundant lower lid skin -nose: nasolabial folds prominent, bulbous drooping tip, dorsal overgrowth, sharp nasolabial angle -lips: vertical rhytids, flat upper lip, thin vermillion, marionette lines -chin/neck: jowls, jaw line less distinct & chin ptosis, neck rhytids, platysmal bands

benefits of SNB in melanoma

-gives prognostic info for disease free and overall survival -pts undergoing SLNB have less distant mets than non-SNB group (although MSLT-1 showed no survival benefit) -pts w +ve SNB & have completion dissection may have survival benefit over those who are just clinically observed

How does the fetal wound differ from the adult wound?

-heals with little to no scar formation -bathed in amniotic fluid -less inflammation -increased levels of type III collagen -lack TGF-β -high content of hyaluronic acid

typical face features of hemifacial microsomia

-hypoplasia of mandibular ramus, zygoma, maxilla, and temporal bone, causing flattening of the lateral part of the face -in unilateral cases, the nose and chin are deviated to the affected side and the occlusal plane is tilted upward on the affected side

compensated brow ptosis

-in people with brow ptosis, continuous subconscious frontalis muscle contraction occurs to keep periorbital tissues out of vision -if blepharoplasty with lid resection is done, frontalis relaxes afterwards resulting in brow at same level or dropping more -Dx by looking at brow position with eyes closed & forehead relaxed (ie uncompensated - finds true resting level of eyebrow). Overhanging 'lid' which is actually brow should reduce heaps or disappear -Rx by doing temporal brow lift before/same time as blepharoplasty

postsurgical lagophthalmos defn & cause & rx & prevention

-inability close eye postop -too much skin resected, local blocking OOM>LPS, upper lid oedema -Rx w artificial tear drops/lubricating eye ointment -prevent by leaving >30mm skin

Fibular flap - pedicle / muscle

-pedicle nutrient artery from peroneal, enters fibular posterior to IOM 17cm below styloid process in middle third fibula -as VBG take cuff os soleus, FHL, tib post to keep periosteal & nutritent supply -can take lateral half soleus as vascularised muscle

Nec fasc

-life threatening (>50% mortality) infx of fascia & subcut tissue -mono (type I) or polymicrobial (type II). In most, bacterial synergism between lytic toxins (GAS/Staph ) & anaerobes -RF surgery, DM, NSAIDs, chronic dz -Local Sx: rapid spread, violaceous skin w dusky hue, haemorrhagic bullae, crepitus, ananesthetic zones from nerve necrosis -Systemic septic Sx out of proportion, incl unable mount pyrexic rxn -Early tissue Bx, CT (gas, thick fascia) or MRI (fascial necrosis get no gadolinium enhancement on T1) can help Dx -Rx w radical debridement, 2nd look at 24hours, abx (clinda/gent), maybe HBO

nerve supply to teeth

-maxillary teeth: post sup alveolar br from PPG, middle & ant alveolar br from infraorbital nerve of Vb -mandibular teeth: inf alveolar branch of Vc

teeth descriptions

-mesial: surfaces of teeth facing central incisors/midline -distal: surfaces of teeth facing away from midline -labial: faces lip -buccal: faces cheek

Define -nasal length -ideal nasolabial angle M/F -tip projection

-nasal length: nasofrontal angle to tip-defining point -ideal NLA: M 90-105; F 95-110 -tip projection: alar crease to tip-defining point

What are the most important factorsthat impair wound healing?

-nutritional deficiencies (albumin <2.5 gm/dL) -vitamin deficiencies (unusual) -aging -wound infections -hypoxia -oedema -steroids -diabetes -radiation

what causes -pinched tip -saddle deformity -stairstep deformity -pollybeak deformity

-pinched tip: alar rim collapse from no LLC. Rx alar batten graft -saddle deformity: dorsum too low. Rx cartilage graft -stairstep deformity: prominent nasal bone after infracturing too high (medial) -pollybeak deformity: supratip fullness

What is holoprosencephaly?

-prosencephalon (forebrain) fails to develop into 2 hemispheres -usually so severe that miscarriage occurs -if not born w variable facial & brain anomalies a) lobar: mildest; facial anomalies but nearly normal brain b) semilobar: moderate; hemispheres partially divided c) alobar: severe; brain not divided; can be cyclops

keratoacanthoma - Sx, Rx

-rapid growth -small papule->red nodule->central keratotic plug in 4-8/52 -very tender, symmetric, craterlike, lip like edges -may resolve: plug falls out, resolves in 6-12 weeks -Rx now favours early excisional Bx to rule out SCC

scc metastasis

-rare -inc risk if ear, lip, scalp, >4mm thick, poorly diff, >2cm -happens quick: 12-24months from Rx of 1ary lesion -spread to lung commonest -poor outcome: 1/3 die from scc

earliest signs of recovery after nerve compression

-relief of numbness/tingling -vibration: low frequency before high -2PD: moving before static -strength recovers variably, related to distance of muscle from compression site & amount of weakness

what is and why is rhinion important in nasal #

-rhinion is junction of bony & cartilaginous framework -#s here may dislocate ULC under paired nasal bones & create saddle deformity

define -selective photothermolysis -thermal relaxation time -wavelength

-selective photothermolysis: selective destruction of specific microscopic cell structures, determined by duration pulse of laser -surrounding cells that dont have laser target shouldnt be damaged. this is possible if thermal relaxation time (time taken for target tissue to cool to 50% of its peak temperature) is longer than duration of laser pulse. -wavelength: distance between peaks of wave, is specific to laser medium; longer the wavelength, deeper the penetration into skin

Chillblain

-skin gets red/purple bumps when exposed to chronic high humidity and low temperature without tissue freezing -core body temperature remains normal -mountain climbers typically are affected. -form of vascultis

what is craniofacial microsomia (aka hemifacial microsoma)

-spectrum of morphogenetic anomalies involving the cranial skeleton, soft tissue, and neuromuscular structures derived from the first and second branchial arches -2nd commonest congenital face anomaly after CLP, 1 in 5000, sporadic

signs that solar keratosis or scaly lesion is SCC

-thickening or tenderness (from dermal invasion) suggests early SCC -also worry if persists after cryotherapy, or is enlarging

list scc prognostic factors

-thickness -nodal spread (if ?LN do FNA not open Bx) -mets -pni (clinical worse than histopathological/occult) -recurrence: incomplete EOL has 50% recurrence -poorly differentiated/infiltrative/spindle cell -cutaneous scc NOT from UV eg marjolin, XRT -immunosuppression

Parts of a skull

-viscerocranium or splanchnocranium is the facial skeleton. -neurocranium houses the brain, consists of vault, which forms its roof and walls, and the cranial base, which forms its floor.

Adverse reactions - suxamethonium

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Angiosome defn, how many can an axial flap capture

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Clavipectoral fascia - pierced by A B C

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Colloids - starch dextran

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Crystalloids Na 154, 3CL Dex saline has 90mmol

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DCIA flap - can take internal oblique with it

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Dermis contents and functions

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Epidermis

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External oblique

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Gas Gangrene - organisms, treatment, MRI findings

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Inflammatory phase of wound healing - cell types present

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Internal oblique

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Laser - photons, intensity

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Melanin

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Melanoma - Stage III

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Melanoma prognosis for a particular patient

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Nerve receptors - pain

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Osteomyelitis

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Parotid space includes - x y z structures

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Parotidectomy involves - ...

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Peripheral nerves - segments supplying F/E of joints of upper limb

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Pharynx - constrictors attachment of superior constrictor to crycopharyngeus

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Predominant wound constituents at 7 days - what cell type

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Rectus abdominus - insertions

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Rhomboids - nerve supply

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SCC staging of lip lesion - T2N

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Silicone - physical properties pores, biofilm

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Stages of healing - 3 yes, 2 false

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Submandibular gland - approach and nerve, which artery must be divided

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Sweating etc passes through which nerve

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Temple and parotid dysfunction - which nerves are involved auriculotemporal

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Tongue sensation anteriorly vs posteriorly

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Trigeminal nerve sensory zones

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What is Ilizarov bone transport

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Z plasty - single or multiple - same lengthening?

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Classification of clefts?

0-7 facial clefts 8-14 bone clefts If crosses both hemipsheres, both add to 14

risk of occult cancer in breast reduction

0.4%

What are the steps in designing a z-plasty to realign a scar

1 Mark the desired direction of the scar. 2 Draw central limb along the original scar. 3 Draw lateral limbs of Z-plasty from ends of central limb to line along the desired direction of the scar. 4 Two patterns will be available, one with a wide angle at apex of flaps, the other with a narrow angle 5 Select pattern with the narrower angle as these flaps transpose better than those with a wider angle (AKA take the long way home)

describe temporal fascia dissection for zygoma w coronal incision

1 TPF over temporalis is elevated with coronal flap 2 dissect down to deep layer of DTF, avoiding facial N which runs in superficial layer of DTF 3 several cms above arch the DTF splits to encircle temporal fat pad; DTF is split obliquely to gain full access 4 dont incise directly over arch as periosteum & overlying fascial areas are very adherent, with frontal branch embedded between these two layers

released all soft tissue but PIPJ still flexed - what now?

1 Transverse incision of the flexor sheath 2 Release of check rein ligaments (fibrous condensations between the volar plate & proximal phalanx). 3 Collateral ligament release 4 Volar capsulotomy.

unilateral lower lip paralysis Rx

1 direct repair 2 ipsilateral N transfer eg TF partial CN XII to distal MMN 3 muscle TF eg digastric, platysma

gynecomastia classification & Rx (simon et al)

1 small BE without skin redundancy 2A moderate BE without skin redundancy 2B moderate BE *with* skin redundancy 3 marked BE *with* marked skin redundancy 1, 2a, 2b: excise via inferior periareolar incision +/- liposuction, then CG to reduce skin XS in 2b 3 req skin excision & nipple transposition on pedicle +/- liposuction

deficits in low UN palsy

1) "Clawing" (MCP hyperextension, IP flexion) of RF & LF due to loss of interossei (results in loss of independent MCP joint flexion, contributes to loss of grip strength). 2) Loss of thumb adduction due to loss of AdP, 1st DIO, FPB (results in loss of power pinch) 3) Loss of IF abduction due to loss of 1st DIO (contributes to loss of power pinch) 4) Abducted (ulnarly deviated) LF (Wartenberg's sign) due to ulnar deviating force of EDM unbalanced by loss of 3rd volar interosseous

What are the six dorsal extensor compartments of the wrist?

1) APL & EPB on radial styloid. Site of de Quervain's disease 2) ECRL & ECRB over snuffbox floor 3) EPL on ulnar side of Listers tubercle. 4) EDC & EIP plus PIN termination 5) EDM 6) ECU on head of ulna

Osteoid osteoma 1) Defn 2) Sx 3) XR 4) Rx

1) Benign bone-forming tumour that typically affects distal radius, carpus (esp scaphoid), phalanges during the first 2 decades of life. 2) Sx: night pain, persistent pain, reduced by NSAIDs. 4) XR: bony sclerosis around central lucency is chx. CT scan is more effective in localisation 4) Rx by curettage or resection & bone graft. Leftover nidus is a/w recurrence.

Which 3 craniofacial syndromes have hand anomalies? CAPS

1) Carpenters: AR. CS, polysyndactyly of feet, short hands with variable soft tissue syndactyly. 2) Aperts: AD. CS, exorbitism, midface hypoplasia, symmetric complex syndactyly of hands & feet, elbow fusions hyperhyrdrosis, (no syndactyly in Crouzon's). 3) Pfeiffers: AD. major multi-sutural CS w high ICPs, obstructive sleep problems, exorbitism, midface hypoplasia, spoonlike thumbs and great toes, 4) Saethre-Chotzen: abn TWIST gene XSome 7; BCS > UCS. Ptosis, hypertelorism, hand and feet syndactyly, low hairline

Silicon disadvantages

1) Causes mild tissue response & encapsulation; cant be made porous so no ingrowth occurs 2) Can evoke inflammatory reaction eg silicone synovitis --> jt space destruction & bone resorption 3) Rubbers fail w heavy stress applications (eg Swanson finger joint implants) 4) Difficult to remove silicone gel from tissues in case of implant failure 5) Bone resorption beneath silicone implants placed subperiosteally for augmentation (e.g., chin), 6) Smoothness makes them prone to extrusion when placed superficially eg silastic placed in nose 7) Silicone rubbers are permeable, allowing proteins or lipids to become adsorbed onto surface of an implant, which can cause failure. Cxs related to Silastic orbital floor implants (extrusion, displacement) account for their high removal rate 8) Silicon implants problems included silicon oil could diffuse through shell (gel bleed), causing shell to swell & lose its strength; hard fibrous capsule around implant caused pain or disfigurement. Moratorium in 1992 because of poor safety data 9) Silicon injectable liquid used for face augmentation & breast enlargement. SE incl loss of augmentation effect (from gravity); migration, infection, chronic inflammation, inapprop use. Now withdrawn

MCPJ anatomy -volar plates something about hyperextend past neutral

1) Collateral ligaments have two main parts -metacarpophalangeal part: between these two bones -metacarpoglenoid part: from MC head to volar plate aka accessory collateral lig 2) Volar plate at MCPJ is continuous with DTML 3) Volar plate has strong attachment to PP but is attached to MC head by only membranous insertion and the two lateral check rein ligaments 4) Accessory collateral ligament thus effectively anchors the volar plate to MC head. 5) At point of insertion of ACL to volar plate two other structures attach -sagittal bands of extensor tendon: keep extensor tendon in central position & stabilize the joint -proximal attachment of flexor sheath: A1 pulley 6) Intrinsic muscles pass volar to axis of MCPJ

What are the basic principles of thumb duplication correction?

1) Create best possible thumb by using best parts of each partner. 2) Preserve an intact UCL at the MCPJ level. 3) Reattach all thenar intrinsic muscles. 4) Release a tight thumb index web space (eg four-flap Z-plasty) 5) Preserve as much mobility as possible and preferably have motion in at least two of the three (CMC, MP, IP) joints

How does dextrose, NS, colloid distribute

1) Dextrose 5% -Pure water, mainly goes intracellularly 2) NS -ECF replacement bc only 1/3 remains intravascularly 3) Plasma protein solutions (eg 5% human albumin) -Replaces intravascular volume -ISF and ICF not replenished

tendon transfers for thumb adduction in UN palsy

1) ECRB + tendon graft to AdP 2) FDS of MF or RF to AdP 3) BR/ECRL + graft between 3rd & 4th MCs to AdP (Boyes)

Common brachial plexus injury

1) Erbs: C5,6 damage *Lost supraspinatus, infraspinatus (suprascapular nerve), deltoid (axillary nerve), brachialis, biceps (musculocutaneous nerve) *Arm is internally rotated and adducted, and the elbow is extended in the "waiter's tip" position. The C7 nerve root also may be damaged, causing loss or weakness of elbow, wrist, and finger extension. 2) Whole plexus: flail hand 3) Klumpke C8,T1 *Loss of hand function with sparing of the elbow and shoulder. Infraclavicular injuries commonly show loss of shoulder abduction and flexion but also may be associated with loss of hand, wrist, and elbow function.

LYMPHEDEMA 1) Defn 2) Normal lymph flow 3) Normal lymph path 4) Types 5) Rx

1) Excess protein rich fluid in interstital spaces resulting in abnormal enlargment of affected part 2) Flows by muscle contraction, valves, pulsations, cavity pressures changes. 3) All body except R UL & HN->Tx duct->L subclav vein. R UL & R HN->R lymphatic duct->R subclav vein 4) Primary: Dx exclusion, can be congenital (Milroy dz), early, late. Secondary from damage LN/LV eg tumour, surgery, infection 5) Conservative 1st (elevate, compress, hygiene) then surgery (radical or conservative excision w SSG works best)

Two theories of facial cleft development?

1) Failure of fusion (Dursy & His): face develops by union of free ends of epithelium of facial processes, then mesoderm penetrates. Disruption --> clefts 2) Mesodermal migration: face is bilamellar ectoderm membrane, penetrated by neuroectoderm w mesoderm. If no penetration, wall breaks down --> cleft

Infraspinatus 1 origins 2 actions 3 nerve

1) From infraspinous fossa --> MF on greater tubercle humerus 2) LR, shoulder extension, scapula rotation, GHJ stability 3) Suprascapular n (does supraspinatus too)

midline nasal lesion: compare glioma, dermoid, encephalocele

1) Glioma *Abnormal closure of fonticulus frontalis --> extracranial glial tissue *Firm, noncompressible, dont increase w crying, dont transilluminate *Intracranial connection rare 2) Dermoid *Commonest, firm, noncompressible, nonpulsatile, dont transilluminate *Derived from ectoderm & mesoderm, lined w squamous epithelium, contain specialized adnexal structures eg hair follicles, pilosebaceous glands, and smooth muscle *Usually end in subcutaneous tract but intracranial connection reported between 4 - 45% so get preop MRI/CT 3) Encephalocele *Failure of the fonticulus frontalis to close properly, which leads to herniation of intracranial contents through a skull defect, with connection to the subarachnoid space *Soft, bluish, compressible, pulsatile , located at nasal root, transilluminate *Furstenberg test: enlargement with IJV compression

Complications of parenteral feeding

1) Hyperglycaemia 2) Liver probs: fatty (Linoleic acid), steatosis, hepatitis, cholestasis, cholecysitis 3) Infection of IV 4) Necrosis of gut (villous atrophy) 5) Electrolytes: low or high K, low or high PO4, low or high mag, low or high Ca

Breast implant rupture risk factors ~1% overall per year

1) Iatrogenic -mammography -closed capsulotomy -Betadine (valve malfunction 2) trauma 3) idiopathic

What medical options are available for stage IV disease?

1) Immunotherapy eg ipilmumbab: Binds to activated TCR to enhance immune response. Approved in 2011 for failed unresectable MM who have failed/intolerant to other Rxs. Increases survival by 3.7 months 2) Signal transduction inhibitors eg Vemurafenib: Oral BRAF inhibitor. Approved 2011 for unresectable MM that has failed/intolerant to other Rx. Improves survival by 6 months 3) Chemo: Dacarbazine-1st line in WA, well tolerated, poor efficacy (response rates 10-20%, lasting 5 months). No current chemotherapeutic increases survival 4) Palliative care Rx: Localised Sx can be Rxed w XRT

Risks of using leeches

1) Infection - leech has symbiotic relationship with Aeromonas hydrophilia in its gut. Causes infection <20% within 10 days use. Some give empiric tazocin 2) Bleeding

10 sensate flaps & their innervation

1) Lateral arm flap: posterior brachial cutaneous nerve 2) RFF: medial & lateral antebrachial cutaneous nerves 3) Dorsalis pedis flap: DPN (1st webspace) & SPN (elsewhere) 4) Transverse cervical artery flap: supraclavicular nerves 5) Deltoid flap: cutaneous branch of axillary nerve 6) Gluteal thigh flap: posterior cutaneous nerve of thigh 7) Medial thigh flap: medial femoral cutaneous nerve 8) Lateral thigh flap: lateral femoral cutaneous nerve 9) Saphenous flap: medial femoral cutaneous & saphenous nerves 10) Posterior calf flap: medial or posterior cutaneous nerves of thigh & sural nerve

deficits in high UN palsy

1) Less RF & LF clawing (due to loss of deforming forces of FDP RF LF) 2) Loss of DIPJ flexion of RF & LF 3) Loss of power pinch

Frey syndrome occurs through which nerve

1) Parotidectomy skin incision divides SANS fibres supplying skin sweat glands 2) Parotidectomy divides PANS fibers from otic ganglion, carried by auriculotemporal nerve 3) Anastomosis between these 2 results in gustatory sweating, ie sweating instead of salivating before a meal

Jejunum v ileum

1) Plicae circlaris/mucosal folds: jejenum more, ileum less 2) Wall: jejenum wider, thicker, but less fat 3) Location: jejenum more umbi/LUQ, ileum more RIF/pelvic 4) Mesentery vessels: jejenum less arcades with less & long branches to bowel; ileum 4 arcades with many & short branches to bowel 5) Peyers patches: jejenum none, lower ileum has on antimesentric border

anatomy of (nerve & compression)... 1) tarsal tunnel 2) fibular tunnel 3) anterior tarsal tunnel 4) radial tunnel 5) supinator syndrome 6) morton's neuroma 7) meralgia paraesthetica

1) Post tibial nerve beneath FR 2) CPN beneath peroneus longus: Sx of leg "giving out" as nerves control ankle eversion & extension 3) DPN beneath Inferior ER 4) entire radial nerve 5) PIN branch only 6) common plantar digital N between MT heads 7) LFCN. 1/3 cases go *through* ing ligament

Give 3 composite free flap (bone, skin, sensory nerve, tendon) options for arm

1) RFF with PL tendon, LCN forearm, radius 2) Dorsalis pedis w SPN/DPN, long toe extensor tendons, MT bone 3) Lat arm flap w PCN, triceps, segment of humerus Allow single stage recon But leave bad DSM & complex Often multistage w diff flaps is better option

Radial nerve compression - FDS? -distal border of fibrotic supinator?

1) RN palsy in arm: humerus #; LIMS; lateral head triceps; 2) Radial tunnel: elbow->supinator. Forearm pain without motor Sx. FREAS Fibrous bands at elbow; Radial recurrent vessels (Leash of Henry); ECRB; Arcade of Frohse (proximal but if superficial portion of supinator). Supinator 3) PIN syndrome: same sites as above (FREAS). Weak wrist and finger extension (ECRL okay) 4) Wartenberg syndrome: SRN entrapment as travels beneath BR to above ECRL, both scissoring

Radiation injury mcgregor

1) Radiodermatitis - if only skin Rxed then changes are superficial - if skin was portal to deeper tissue then changes are deeper 2) Radionecrosis - a/w deeper ischemia, ulcers - can ulcerate: biopsy to exclude Ca - recurrent Ca post XRT is atypical in look & metastatic spread

common hand soft tissue malignancies in young people

1) Rhabdomyosarcoma -kids, teens -thenar eminence, between metacarpals -metastasise in 20% -Rx is WLE incl amputation then RTX & chemo 2) Epithelioid sarcoma -young adulthood -ulcerating, firm, slow growing, proximal spread along tendon -Rx is WLE plus lymph node sampling as it spreads

tendon transfers in high UN palsy

1) Side-to-side tenorrhaphy of FDP MF to FDP RF & LF 2) Split FDS MF - half to RF, half to LF 3) Conventional TT for pinch and abducted little finger -ECRB or FDS MF ± graft to AdP -accessory slip of APL + graft to 1st DIO for pinch -FDS ring split volar to MCPJ joint then to radial lateral bands of RF & LF

Which excisional methods can be used for removal of skin lesions?

1) Simple elliptical excision: lenticular in shape with angular edges or have rounded edges. Ideally, the long axis should be four times longer than the short axis 2) Wedge excision: performed primarily for lesions on the free margins of ears, lips, eyelids, or nostrils. Lip lesions can be excised as either triangular or pentagonal wedges. Pentagonal rather than triangular excision often leads to less contracture and shortening along the longitudinal axis of the incision with a more favorable scar. 3) Closure of circular defects by purse string suture, skin graft, or local flap

tendon transfers for IF abduction in UN palsy

1) Slip of APL + palmaris tendon graft to first dorsal interosseous (Neviaser) 2) EI (Bunnell) to 1st DIO 3) EPB (Bruner) to 1st DIO

What are the possible options for reconstruction of type 3B thumbs?

1) Staged osteoplastic reconstruction: this involves provision of skeletal continuity with a standard bone graft or a microvascular second toe transfer; creation of an adequate web space; tendon transfers to provide palmar abduction of the first ray as well as MP and IP flexion and extension. 2) Excision of the thumb and index pollicization: this option is preferred by most.

Lymphatic drainage of the lower limb

1) Superficial system -medial follows LSV & lateral follows SSV -both drain to groin glands 2) Deep system -3 in total, follow anterior tibial, posterior tibial, and peroneal vessels -drain into popliteal lymph glands

Describe the two classifications of OHT.

1) Tessier divided OHT into three types based on IOD -type I (30 to 34 mm) -type II (35 to 39 mm) -type III (≥40 mm). 2) Munro classification, based on anatomy of medial orbital wall. -type A: medial orbital walls are parallel. -type B: medial orbital wall width is greatest anteriorly -type C: "" in the middle -type D: "" posteriorly

Pathophysiology of electrical burn injury

1) Thermal burn: Joule heating - conversion of electric current to heat, & heat fries the tissue 2) Nonthermal/electric: electric forces cause electroporation (large CM pores), CM protein denaturation

What are the principles of syndactyly correction?

1) Use of FT flaps for commissure reconstruction 2) Zigzag incisions on palmar surface 3) Use FTSG 4) Equal division of flaps between each partner digit 5) Meticulous, atraumatic technique 6) Adequate postop immobilization 7) Staged release of radial & ulnar sides of digit 8) Kids: GA, TQ, absorbable sutures

5 key exam findings with orbit #?

1) VA 2) pupillary function prior to any dilation 3) anterior chamber exam for blood or fluid, 4) posterior segment exam with a funduscope 5) ocular motility

types of ganglions

1) dorsal wrist 70% - a/w scapholunate jt. 60% resolve 2) volar wrist 20% - a/w radiocarpal lig between FCR & APL 3) flexor sheath - small mobile, near A1 pulley 4) mucous cysts - a/w DIPJ, dorsal, can be a/w osteophyte

principles of CRPS management

1) early Dx: Sx, XR, bone scan, temp sympatholysis by blocking alpha 1 receptors w IV phentolamine 2) remove any causes of pain eg nerve compression 3) interrupt SANS pathway: medications, TENS, surgery 4) aggressive hand therapy

types of sweat glands

1) eccrine -throughout body except lips (lips & ext genitalia) -fxn all through life -clear watery discharge -important for temperature regulation 2) apocrine -mainly eyelids, axilla, pubis -thick milky discharge that increases after puberty -release pheromones, & Bx cause odour -not for temperature regulation

Ossification centres 1) humerus 2) 1st MC 3) Radius

1) humerus: shaft 2) 1st MC: 1ary shaft, 2ndary base 3) 2nd-5th MC: 1ary shaft, 2ndary head 3) Radius & all long bones: 1ary is shaft/diaphysis

nonsurgical Rx of NMSC

1) imiquinod -induces TLR on immunc cells -> inc pathogen recogn -good in SK,sBCC, sSCC: clears ~75% lesions 2) 5% FU -anti-MT that blocks thymidine synthesi -sSCC: 90% clearance -SK's: 33% clearance 3) photodynamic Rx -photosensitive cream applied: localises in ab tissues-> activated by light->ROS -for SK's, sBCC, sSCC, thin nodular bcc

tendon transfers for UN clawing

1) mcpj flexion alone: zancolli sling-fds divided, looped through slit in A2 then sutured to itself 2) mcpj flexion & ipj extension: fds to radial lateral bands of RF & LF (modified Stiles-Bunnell) or PP (Littler) 3) FCR + BR graft to lateral bands (Riordan) 4) EIP + EDQ to lateral bands through the intermetacarpal spaces (Bunnell-Fowler)

Facial clefts 1) midline clefts 2) paramedian clefts 3) orbital clefts 4) lateral clefts

1) midline clefts: 0, 14 2) paramedian clefts: 1, 2, 12, 13 3) orbital clefts: 3, 4, 5, 9, 10, 11 4) lateral clefts: 6, 7, 8.

provocative tests for 1) pronator syndrome 2) radial sensory Sx 3) cubital tunnel

1) pressure over MN in prox forearm, resisted elbow flexion, resisted pronation, resisted MF & RF FDS 2) hyperpronation of forearm, Finklestein +ve 3) elbow flexion

approach to operation for dupuytrens

1) skin management *longitudinal or transverse incisions depending on dz location *excising skin (dermofasciectomy) if severe/recurrent dz 2) fascia management *regional fasciectomy rather than fasciotomy 3) wound management *suture with flaps, skin graft, or can leave open

NAC blood supply

1) via underlying breast tissue: IMA perforators entering 2cm lateral to sternum 2) via subdermal plexus: mainly from lateral thoracic artery plus IMA too

Define 1) assembly line 2) checkrein ligs

1) volar lateral ridges of proximal phalanx, in which nestle the flexor tendons and which give attachment to the fibroosseous tunnel, the oblique retinacular ligament, and Grayson's and Cleland's ligaments, are the so-called "assembly lines." 2) in PIPJ contracture, the proximal sliding volar plate becomes attached to assembly line structures by fibrous adhesions called checkrein ligs, which prevent the volar plate from sliding back

what is the cause, Sx, Rx of fat embolism syndrome?

1. Cause: fat globules blocking small vessels in lung, brain, kidneys 2. Px: chemical changes in chylomicrons cause them to clump together; or trauma allows small veins to rupture & fat to enter veins. Either way fat trapped in pulmonary capillaries & broken down by pulm lipase --> direct toxic damage of microvascular and alveolocapillary units 3. Clinical Dx: Sx are lung (ARDS Sx), cerebral (AMS, lethargy, delirium, coma), cardiac, skin (petechial rash) 4. Rx is supportive: ABCs incl PEEP, IPAP, digitalis, steroids, low dose heparin (to increase lipase activity)

Name two unique types of infection on the palmar side of the hand that are due to the firm fixation of the skin to underlying structures.

1. Collar-button abscess: starts as infx between palmar skin & palmar fascia, then erodes through palmar fascia into the underlying loose space, forming a dumbbell/collar button-shaped abscess 2. Felon: starts in same way as collar-button abscess, but its inhibited from side to side spread by the tight network of vertical fibers attaching skin to DP. Spread occurs by erosion through the walls formed by the vertical fibers, adding to the abscess compartment by compartment.

What are two goals of surgery for patients w CS?

1. Decompress intracranial space 2. Achieve satisfactory CMF form

Why does edema impair wound healing?

1. Extra ECW increases diffusion distances --> lower tissue pO2 2. Protein deposition in ECM acts as diffusion barrier 3. Nutrients & growth factors are diluted

What clinical types of SCC are there?

1. Fast growing - nodular, ulcerated, locally invasive & spreads quicker 2. Slow growing - verrucous, exophytic, more deeply invasive but less metastatic

What is the best method for surgical release of the first web space?

1. Four flap Z-plasty (ABCD-->CADB) provides the greatest release & maintains best concavity between thumb & IF MCPJs. 2. A single Z-plasty or the five flap Z-plasty aka "jumping man," (ABCDE-->BACED) is a good alternative 3. For severe contractures, you need to import tissue. Distally based RFF have been used. Free tissue transfers in infants or young children often are cumbersome and technically difficult.

What are the risk factors for cutaneous melanoma?

1. Genetic determinants: 5-10% have +ve FHx. Relevant genes include BRAF, CDKN2 (tumour suppresor gene for protein p16), N-ras oncogene mutations 2. Sun exposure: UVB > UVA (remember by UVB=Burns); blistering sunburns, childhood sunburns, intermittent sun exposure 3. Pigment traits. Blue eyes, fair or red hair, pale complexion; also if burn easy & tan poorly; freckles 4. Benign melanocytic naevi: Number of naevi rather than their size, especially presence of dysplastic naevi 5. Immunosupressant state 6. Sunbeds: sunbeds & tanning booths are associated with a small increase in melanoma risk, especially if exposure occurs before age 35

How is a standard cephalogram obtained?

1. Head is 60 inches from XR source. 2. Distance from head to film is 6 inches. 3. Central beam is directed through centre of ear rods to strike XR film at right angles 4. Cephalostat is used to avoid parallax error from shifting. 5. XR is done with image magnified 10%

What is the difference between hemangioma and vascular malformation?

1. Hemangiomas are vascular birthmarks that appear shortly after birth, undergo a period of rapid growth and proliferation, and spontaneously involute by age 7 to 9 years. The endothelial cells actively proliferate and create new vascular channels during the growth phase. The mechanism for involution is unknown. 2. Vascular malformations are biologically quiescent lesions. They result from defective embryogenesis, are present at birth or are recognized shortly after birth, and do not undergo a biphasic growth cycle like hemangiomas. The endothelial cells do not actively proliferate. Malformations are subgrouped according to cell types into capillary, venous, lymphatic, mixed venous-lymphatic, and arterial malformations. Arterial malformations include arteriovenous fistulas with active shunting between the arterial and venous sides of circulation.

What treatment options are available for keloid scars?

1. Intralesional injection of steroids 2. Radiation therapy 3. Combination therapy with surgical resection 4. Interferon has recently been used

What are the most commonly used landmarks?

1. Nasion (N): Anteriormost point on frontonasal suture 2. Basion (Ba): Lowermost point on anterior point of foramen magnum 3. Articulare (Ar): Point of cranial base & posterior border of mandibular ramus 4. Porion (Po): Midpoint of upper contour of EAC 5. Sella (S): Center of sella turcica 6. Pterygomaxillary fissure (PTM): Point on base of the fissure where anterior & posterior walls meet 7. Orbitale (Or): Lowest point on inf margin of bony orbit 8. Anterior nasal spine (ANS): Tip of anterior nasal spine

What are the most powerful predictors of survival for Nodal chx?

1. Number of metastatic nodes 2. Metastatic nodes clinically occult/clinically apparent 3. Primary tumour ulcerated/not ulcerated -Therefore number of LNs rather than their gross dimensions are used, & difference between microscopic (occult) vs macroscopic (apparent) LNs is made

What are bioabsorbable plates & screws

1. Polyglycolic (PGA): resorbed FAST, wks-mths eg dexon, vicryl 2. Poly-L-lactic acid (PLA): resorbed SLOW, months-years 3. PGA-PLA mixture: MIX - good initial strength & resorbs after 1 year eg Lactosorb CMF plates. Good for kids as no growth restriction, no migration, doesnt interfere with postop CT/MR like metal

What treatment options are available for hypertrophic scars?

1. Pressure garments 2. Topical silicone sheeting 3. Insoluble steroids 4. Reexcision - may improve it if cause was poor wound closure, inadequate support from wound tension, prolonged inflammation from infection, foreign bodies (excess suture), or delayed epithelialization. You should pay particular attention to using permanent sutures to splint the dermis, achieve early wound occlusion, and apply silicone gel sheeting.

What is the natural history of an infantile hemangioma?

1. Proliferative stage (1st year): Growth is most rapid during neonatal period (birth - 4 weeks) where its disproportional to body growth 2. Plateau stage: 2-4 years 3. Involution stage (5 years): less vascular, less red, softer, smaller size. Regression is complete in 50% by 5yo, 70% by 7yo, with some improvement in rest until 10-12yo

What three vascular arches provide anastomotic connections between the radial and ulnar blood supplies?

1. SPA courses palmar to flexor tendons, gives off the digital vessels, and is a direct continuation of the UA 2. DPA, courses dorsal to the flexor tendons, gives off the volar metacarpal arteries and is a direct continuation of the RA after the takeoff of the princeps pollicis 3. The dorsal carpal arch travels dorsally over the proximal carpal row, linking the radial & ulnar systems dorsally and giving off the dorsal metacarpal arteries

What are the components of cephalometric analysis?

1. Skeletal analysis 2. Profile analysis 3. Dental analysis

What can be done for speech problems after primary CPR?

1. Speech Rx 2. Surgery •pharyngeal flap •sphincter pharyngoplasty •posterior pharyngeal wall augmentation •palatal lengthening

4 ways to prevent melanoma?

1. Sunburn be avoided and UV protection (physical methods complemented by sunscreens) adopted 2. Sunscreens be used to complement but not to replace physical methods of UV protection 3. Risks associated with exposure to tanning booths and sunbeds be explained 4. As brief sun exposures are needed to maintain vitamin D levels, total lack of sun exposure is not advised without vitamin D supplementation

What are 3 theories of CS Px & what is current one favoured?

1. Suture is primary abnormality, & cranial base is 2ndary deformity 2. Cranial base is primary abnormality, resulting in 2ndary cranial deformities 3. Defect is in mesenchymal blastema of both cranial base & suture •1st is favoured. Cultured CS suture cells have raised ALP, thought to be from increased osteoblastic cells.

What are the most powerful predictors of survival for Tumour chx?

1. Thickness 2. Ulceration -Level of invasion had significant impact only within the subgroup of thin (< 1mm) melanomas -Therefore only thickness & ulceration are used in latest T category (except for T1) -All patients w stage I, II, III disease are upstaged if primary is ulcerated

What contributes to thumb-index contracture?

1. Tight skin is the most obvious etiology 2. Tight investing fascias of 1st dorsal IOM & adductor pollicis is almost always found & must be excised. Often a tight band is even present between the two muscles 3. A tight thumb CMCJ is sometimes may be found, it usually is suspected on physical examination.

List several sensate free flaps

1. Toe pulp neurosensory flap 2. Great toe wrap around flap 3. 1st web flap from foot 4. Lat arm flap 5. RFF 6. Dorsalis pedis flap

What is the differential diagnosis of bilateral flexion deformities of the thumb?

1. Trigger thumbs due to flexor tenosynovitis are #1 cause. 2. Congenital absence of EPL: thumb adducted ("clasped thumb"). 3. Congenital camptodactyly doesnt involve thumb but should be considered with any flexion deformity of a digit 4. More generalized musculoskeletal conditions, such as arthrogryposis and Freeman-Sheldon syndrome, also must be considered.

how can you improve TRAM blood supply

1. delay by dividing DIEA & DIEV 2wks beforehand 2. supercharging

30% TBSA burn becomes hypotensive-why?

1. fluid loss: bleeding, hot theatre 2. anaphylaxis: blood, drugs 3. oversedation with narcotics Rx - stop surgery & any drugs/blood, ABCs, give vasoactives as needed

Describe the changes that occur in IOD with age.

16 mm at birth. 25mm at 12 yo 25mm for adult female 28mm for adult males

Incidence of facial clefts

1.5-5 per 100,000 live births

how fast do nerves regenerate

1mm/day or 1 inch/month So axilla (30 inches from hand) nerve injury will take 2.5 years to reach hand

1st arch structures

1st Arch: a Massive list of M's *Nerve: Mandibular *Artery: Maxillary *Cartilage: Meckel's Cartilage - Mandible + sphenoMandibular ligament - Malleus + Incus *Muscles: MAT x 2 - Muscles of Mastication - Mylohyoid - Anterior belly of digastric - Anterior 2/3 of tongue - Tensor veli palatini - Tensor tympani

teeth numbering

1st digit is quadrant (1-4) starting w upper R maxillary 2nd digit is tooth type (1-8) starting with central incisor EG ipper L central incisor is 21

Martin Gruber

10-20% have connection between MN & UN in high forearm *60% MN fibres go to UN to supply "MN hand muscles" *35% MN fibres go to UN to supply "UN hand muscles" *5% UN fibres go to MN

How much lignocaine can be given in suction assisted lipectomy in tumescent fluid.

10-50mg/kg. Higher because poorly vascularised fat delays the absorption. Try to use as little as possible as long absorption means SE can occur hours later, hepatic metabolism can be affected by many things, & lignocaines main MT is active & causes similar SE.

What is the most important web space in the hand?

1st webspace. Of all techniques described for correction of congenital hand anomalies, release of the first web space is the most significant functionally and aesthetically. In a pure analysis, a "basic hand" has three components: a mobile digit or thumb on the radial side, a first web space, and a post or digit on the opposite side of the hand.

2nd arch structures

2nd arch: SSSSecond *Nerve: Seventh *Artery: Stapedial artery and hyoid artery *Cartilage: - Stapes - Styloid - Stylohyoid ligament - leSSer horn of hyoid *Muscles: - Muscles of facial expression (Smiling) - Stapedius - Stylohyoid - poSSSterior belly of digastric

Blood supply of the hand - digital artery anastamosis, thermoregulation, number of capillaries

3 palmar arteries Proximal transverse digital artery is located between A2 and A3 and supplies VBS and VLP. Interphalangeal transverse digital artery is located between A3 and A4 and supplies VBP. Distal transverse digital artery is located between A4 and A5 and supplies VBP.

venous system of UL

3 systems 1) superficial: cephalic, basilic, intercommunicating 2) deep: VCs run with RA, UA, AIA, PIA 3) perforating: connect 1 & 2

follow up for melanoma

80% recurrences are within 1st 3 years, and latest recurrence time was 46 years... 6 monthly for 5 years for stage I dz 3 monthly for 5 years for stage II & III then yearly for all patients

What are the most commonly used landmarks? continued

9. Posterior nasal spine (PNS) 10. Point A (A): Innermost point on contour of premaxilla between ANS & incisor tooth 11. Point B (B): Innermost point on contour of mandible between incisor & bony chin 12. Pogonion (Pog): Anteriormost point on contour of the bony chin 13. Menton (Me): Most inferior point on mandibular symphysis 14. Gonion (Go): Point on angle of mandible obtained by bisecting angle formed by intersection of tangent drawn to lower & posterior borders of ramus 15. Gnathion (Gn): Constructed point located between pogonion & menton

A "U-shaped" osteotomy is performed with which type of OHT reconstruction?

A "U-shaped" osteotomy is performed with the subcranial approach. It involves an osteotomy through the medial wall, lateral wall, and orbital floor. It is used in less severe forms of OHT when the cribriform plate has not prolapsed inferiorly.

How is palate function assessed & by who?

A competent speech pathologist & cleft surgeon •Clinical Ax: intraoral, nasal, speech •Objective Ax: Video fluoroscopy (TOC), lateral cephalogram, nasopharyngoscopy, MRI

How does the unique anatomy of the fingertip shape the development of a paronychia?

A paronychia is infection of nail fold. It seldom exists without the presence of a nail, which is first a foreign-body irritant and then the roof of the abscess

What is a Z-plasty?

A technique involving the transposition of two triangular-shaped flaps, used to -Increase the length of an area of tissue or a scar -Break up a straight-line scar -Realign a scar.

What are the radiologic signs of congenital camptodactyly?

A true lateral XR gives an indication about the duration of congenital camptodactyly. Digits flexed at PIPJs for longer periods show -Flattening of dorsal condylar surface of proximal phalanx -Widened base of the middle phalanx -Flattening of palmar surface of the condyle -Indentation within the surface of the middle phalanx -Narrowed joint space **The most important determining factor in joint formation is motion. A joint that is not moved early in life will not have a rounded condyle and will demonstrate a flat articular surface.

What is the definition of wound infection?

A wound with bacterial counts greater than 10^5 organisms per GRAM of tissue is considered infected and unlikely to heal without further treatment.

Preferred type of facial reanimation for A) Isolated VII branch? B) Proximal stump only? C) Distal stump only?

A) Ipsilateral nerve grafting to isolated branch B) Nerve graft directly to facial muscle C) CFNG or ipsilateral nerve transfer.

What is Cohen craniosynostosis syndrome?

AKA craniofrontonasal dysplasia. Patients are more commonly female, have coronal synostosis, frizzy or curly hair, and frontonasal dysplasia.

What does dental analysis indicate?

AP positioning of teeth in relation to basal bones. Long axis of maxillary incisor should be angled at 104 degrees to cranial base, mandibular incisor 80 to mandibular base

What percentage of melanomas are detected by patients? What do they notice?

About 50% of melanomas are detected by patients via -New or changing lesion -Sx including sensory changes eg itch (but most are ASx)

What is monocryl's origin, Ix reaction, time until hydrolysed, time of tensile strength?

Absorbable monofilament suture with qualities and advantages similar to those of PDS. However it retains its tensile strength for only 3 or 4 weeks; absorption of Monocryl is essentially complete between 3 and 4 months.

What is Latham device?

Active PSO used to align alveolar segments so you can close alveolar cleft w gingivoperiosteoplasty (GVP). Bone grows into area so dont need secondary ABG. Makes symmetrical platform for CLR

What is the V-Y advancement technique?

Advancement flap that brings tissue from either side of the V as it closes into a Y.

How is CRS treated?

After excision of the scarred constriction ring, it is necessary to advance flaps of fat and fascial tissue across the depression to correct the contour deformity. Straight-line dorsal incisions are preferred to Z-plasties; they are conveniently placed along the less visible sides of the digit.

What Rxs are available for stage III disease that presents w intransit or local mets or satellite lesions?

Aim is local control. Poor prognosis overall, but wide spectrum of Sx & progress before stage IV. Rxs include complete surgical excision, regional chemotherapy, & if neither possible, systemic chemotherapy. Isolated Limb Perfusion/Infusion can obviate/delay palliative amputation for nonresectable mets.

What is Rensu-Osler-Weber disease?

Aka hereditary hemorrhagic telangiectasia (HHT) - autosomal dominant - mucosal, skin, visceral AVMs - caused by defects in genese for endoglin & activin receptor like kinase

What is oronasoocular cleft>

Aka oblique facial cleft

Breast implants - types & capsular contracture likelihood

All implants have capsule, but contracture is issue May be from subclinical Staph epi infection Get a fibroplastic FB rxn Rates *silicon: smooth 58% vs textured 8% *saline 5% *subglandular ~30% vs subpectoral implants ~10% (10 years).

Where else do the interosseous muscles insert?

All of the interosseous muscles have deep bellies/lateral tendons, which travel superficial to the sagittal bands into the aponeurotic expansion as transverse (dorsally across the proximal phalanges) and oblique fibers (parallel to the lateral bands).

list thumb opposition tendon transfers

All of these are inserted via into APB. 1) EIP (Burkhalter): TOC as doesnt weaken grip 2) FDS RF through FCU pulley (Bunnell, Royle-Thompsen): 3) PL extended by strip of palmar fascia (Camitz): provides primarily palmar abduction, no true opposition 4) AbDM (Huber): Preferred in congenital opposition deficit 5) FDS little (described by Peimer).

How is trapezius raised?

Along descending portion of transverse cervical artery with vertical or transverse skin island

What face clefts begin at Cupids bow?

Always 1-3 Sometimes 4&5

What effect does amniotic fluid have on FWH?

Amniotic fluid HELPS scarless FWH by inhibiting fibroblast contraction (but this isn't the only cause - experiments removing fetal cells from contact w amniotic fluid still heal without scar)

Which interosseous muscles are innervated by the median nerve?

An easy way to remember the answer is the mnemonic LOAF: L for the two radial lumbricals, O for opponens pollicis, A for abductor pollicis brevis, and F for the superficial head of the f lexor pollicis brevis (FPB). The rest of the intrinsic muscles are innervated by the ulnar nerve. The radial side of the thenar eminence is innervated by the median nerve and the ulnar side by the ulnar nerve (adductor pollicis and deep or ulnar head of the FPB).

What anatomic features distinguish CRS from other congenital anomalies of the upper limb?

Anatomy proximal to level of deformation or in utero injury is completely normal. For this reason, toe transfers for thumb and digital reconstruction are much more predictable. Unfortunately, many severely affected children have no toes to transfer

What is burn anemia?

Anemia from shortened half life of RBC in significant burns (40 days vs normal 120 days)

What is Klippel-Trenaunay syndrome?

Another slow-flow overgrowth disorder involving abnormal veins and lymphatics, with geographic cutaneous capillary-lymphatic staining

What are the criteria for clinical stage IV?

Any T, Any N, M1 ie distant skin, subcutaneous, or nodal mets

What is 2ndary CS?

Any dz interfering with cranial bone dvmt may cause secondary CS, eg hematologic, metabolic (hyperthyroid, rickets), Hurlers, achondroplasia

What causes facial clefts?

Anything that interrupts the fusion of the 5 facial elements (frontonasal, maxillary x2, mandibular x2)

Describe the hand in patients with Apert syndrome.

Apert syndrome (acrocephalosyndactyly) is common only in craniofacial clinics. It occurs in more than 1:45,000 live births. Both hands have enantiomorphic (mirror image) deformities: -Short radially deviated thumb (radial clinodactyly) -Deficient first web space -Complete, complex syndactyly of central three rays -Simple, complete syndactyly between ring and fifth rays

How often is the palmaris longus tendon absent?

Approximately 15% of patients do not have a palmaris longus tendon.

Jejunum vascular supply

Arcade formed by SMA branches Each branch supplies 24cm of jejunum Use proximal jejunum via LUQ incision Tubular flap Can make into flat flap by incising antimesenteric border

What is Holt-Oram syndrome?

Association between congenital hand anomalies and congenital heart defects. The cardiac anomalies vary greatly, but the hand malformations consist primarily of some form of radial dysplasia.

How do doctors detect melanoma?

Ax of whole skin surface + dermoscopy (increases accuracy) -85% melanomas present with initial flat stage: their chx are Asymmetry, Border irregular, Colour variation, Diameter large, Evolution -15% (nodular melanoma) present w symmetric nodule, with single colour that's often pink or red: Elevated, Firm, Growing quick. Require urgent Rx but as they're often misdiagnosed as NMSC so they make up >50% of thick melanomas

What does profile analysis assess?

Ax's soft tissue that covers the skeletal facial profile. •Easy way is to use Rickett's aesthetic plane which is line from nasal tip to chin. •Upper lip should be 2mm behind, lower lip should be on it. •NL angle is between nose & upper lip. Should be 104 degrees +- 8.

classification of breast capsular contracture

Baker 0 4 grades I soft ie normal II palpable III visible IV painful

Name 4 attachments of extrinsic extensor tendon

Base PP, Base MP, Base DP (via slips of lateral bands), transverse metcarpal lig & volar plate

When the intrinsic muscles are paralyzed, how is the finger affected?

Because the primary flexor of the MP joint is lost, the MP joints tend to develop a posture of hyperextension—the position from which the paralyzed intrinsics are needed to extend the IP joints. Thus the IP joints fall into flexion, especially with intact profundus tendons, producing the claw deformity.

what is dupuytrens disease

Benign fibroproliferative disorder characterized by abnormal thickening & contracture of palmar fascia, affecting predominantly the longitudinal fibres and vertical fibres (of Skoog) resulting in palmar nodules and contractures of the fingers. May be a/w other fibromatoses such as Lederhosen's and Peyronie's, also retroperitoneal fibrosis.

Breast reduction and reduced nipple sensation

Between 10-20% have reduced NAC sensation post reduction mammaplasty. Many patients with macromastia have pre-operative decreased sensitivity that has been theoretically reported to be due to elongated, stretched nerves.

How is maxillary alignment maintained?

Bilateral gingivoperiosteoplasty creates mucoperiosteal tunnel across each side of cleft as clefts & nose are closed. This allows bone to grow across the cleft & avoids later ABF

What syndromes have hypotelorism?

Binders, Down syndrome, trigonocephaly, holoprosencephaly, arhinocephaly. All other syndromes have normal or wide orbits.

How are vascular anomalies classified?

Biological classification by Mulliken 1. TUMOURS - Infantile hemangioma - Hemangioendothelioma - Angiosarcoma 2. MALFORMATIONS a. Slow flow - Capillary - Lymphatic - Venous b. Fast flow - Arterial (AM): Aneurysm, coarctation, ectasia, stenosis - Arteriovenous fistula (AVF) - Arteriovenous (AVM)

Outline the five types of hypoplastic thumbs

Blauth classification: based on xray

bone allograft -Qs: can be frozen; needs HLA typing; better if vascularised; creeping substitution

Bone healing needs 1) osteoconduction: scaffold for bone forming cells 2) osteoinduction - growth factors induce MSC-> osteoblasts 3) osteogenesis - bone formed by osteoblasts *Autograft* -osteoconduction, osteoinductive, osteogenic *Allograft* -Fresh; frozen; freeze dried; irradiated. Need HLA -Osteoconductive & weakly osteoinductive -Not osteogenetic -Can heal by creeping substitution (new osteoblasts replace necrotic bone graft cells)

What differentiates Klippel-Trenaunay-Weber from Parkes-Weber syndrome?

Both are neoplastic, but PW has AV fistulas. Other things include asymmetric facial hypertrophy, hemangiomatta, microcephaly. Also mental retardation, abn vessels, limb hypertrophy (soft tissue can be several times bigger)

Can a felon spread around the distal phalanx and become a paronychia? Can a paronychia spread around the nail plate into the palmar pulp and become a felon?

Both events are highly unlikely because of the fingertip anatomy. The paronychia spreads around the nail plate & may lift the entire nail plate off the bed but ultimately drains dorsally. The felon spreads on the palmar side, ultimately breaking through the skin. It may spread proximally into the soft tissue of the MP, or even into the bone & DIPJ —but not dorsally to the nail fold.

Features of Aperts vs crouzons

Both have CS + froglike facies from exorbitism, telecanthus, midface hypoplasia, all worse w Aperts

Difference between penetrance & expression?

Both relate to genetic trait. Penetrance relates to frequency, expression relates to extent.

Blood supply to rectus femoris?

Branches of LCFA. The vessel courses from medial to lateral. Two to three branches enter the undersurface of the muscle at the proximal third.

How do you evaluate effects of Rx?

By *superimposition*, which has 3 types 1. Overall superimposition 2. Maxillary superimposition 3. Mandibular superimposition

Classification of CS?

By suture & morphology •Metopic: trigonocephaly •Sagittal: scaphocephaly •UCS: plagiocephaly •BCS: brachycephaly •Sag & BCS: oxycephaly

Local anaesthetic toxicity - signs (increase BP, low BP, high HR, low HR

CNS *Initial Sx: Lightheadedness; dizziness; visual & auditory disturbances; disorientation; drowsiness *Higher-dose Sx: Initial CNS excitation thenrapid CNS depression eg muscle twitching, convulsions, low GCS, coma, resp depression & arrest *CVS *Direct cardiac effects: myocardial depression, cardiac dysrhythmias (bupivacaine), cardiotoxicity *Peripheral effects: vasoconstriction low doses, vasodilatation higher doses (hypotension). Also CP, SOB, Palps, Lightheadedness, Diaphoresis, Hypotension, Syncope

what 3 muscles oppose the brow lifting of frontalis?

COP corrugator supercili orb oculi procerus

types of CRPS

CRPS 1) Sympathetically maintained pain syndromes (SMPS) - these respond to sympathetic blockade A) CRPS Type 1 * No predisposing event ('primary' non-nerve related CRPS) - RSD, algodystrophy. Increased uptake on bone scan especially around joints. Can be cited as early & late complication of any hand surgery. B) CRPS Type 2 *Identifiable primary nerve insult ('secondary' CRPS) - causalgia plus vasomotor, sudomotor (sweat gland) and trophic changes. Most common type 2) Sympathetically independent pain syndromes (SIPS) - doesnt respond to sympathetic blockade A) CRPS Type 3 *May or may not have evidence of direct nerve injury

Why are transverse absences associated with CRS ideal for toe-to-thumb transfers?

CRS is the only congenital anomaly in which the anatomy proximal to the level of complete or partial loss is completely normal. In other conditions, intrinsic and extrinsic muscle and neural and vascular anatomy may be anomalous.

What is included under failure of differentiation of parts?

Camptodactyly, clinodactyly, symphalangism, syndactyly, arthrogryposis, synostosis.

What is catguts origin, Ix reaction, time until hydrolysed, time of tensile strength?

Catgut, derived from the submucosal layer of sheep intestine, evokes a moderate acute inflammatory reaction and is hydrolyzed by proteolytic enzymes within 60 days. Tensile strength is rapidly lost within 7 to 10 days. C

How is catheter size measured?

Catheters measured by outer diameter Range is 6 - 18 Fr Each French unit equaling 0.33 mm in diameter

Horners syndrome can be caused by...

Caused by interruption of SANS supply to eye -neck surgery/trauma -brainstem vascular lesion -pancoast's -idiopahtic

What is the Harlequin deformity?

Chx XR finding w frontal plagiocephaly. Describes abnormal shape of orbit from ipsilateral superior displacement of LWS

What is internasal dysplasia?

Cleft 0. CLEFT SEPARATES THE 2 NASAL HAVES.

What is the main PRS application for scarless FWH?

Cleft lip & palate. FWH will reduce the extrinsic impairment on facial growth that results from postop scar formation (it won't reduce it completely though CLP pts have intrinsic impairments too, eg unrepaired CLP pts still have maxillary hypoplasia)

What are the indications for multiple Z-plasties?

Compared to a single large Z, multiple Z's produce the same lengthening but less less transverse shortening. This results in less lateral tension that is more equally distributed over entire length of central limbs. -Uses 1) When insufficient tissue is available for large single Z-plasty. 2) Multiple Z's of facial scars often look better

polands syndrome

Congenital anomaly chx by partial or complete absence of pec major muscle & hypoplastic ipsilateral musculosketal components eg partial agenesis of ribs & sternum, brachysyndactyl, mammary aplasia, absence of LD/SA/PM Usual Rx is transfer LD to anterior chest + implant for girl

Can a haemangioma present as a large tumor at birth?

Congenital hemangioma reaches peak of growth at birth, & postnatal growth is important in deciding if it is a rapidly involuting congenital hemangioma (RICH) or noninvoluting congenital hemangioma (NICH).

What physiological changes occur during "creep"?

Creep is permanent stretching seen in TE 1) Collagen is normally convoluted but with creep there's increasingly parallel alignment of random collagen fibers 2) Microfragmentation of elastic fibers 3) Displacement of H2O from ground substance, leading to dehydration of tissue 2) Adjacent tissue migration in the direction of the vector force

How does the level of cribriform plate compare between people with OHT and those with a normal IOD?

Cribriform plate normally is 10 mm below the orbital roof. In OHT, it may be as low as 20 mm below the orbital roof.

What differentiates Crouzons & Aperts?

Crouzons is cruisin *Both have froglike facies 2ndry to exorbitism, hypertelorism, & midface hypoplasia, but all are more severe in Aperts. *Aperts has hand anomalies, Crouzons doesnt *Aperts is retarded, Crouzons isnt

A child presents with a swollen hand and forearm and an associated neck mass diagnosed as a "cystic hygroma." What is the underlying pathophysiology?

Cystic hygroma describes a lymphatic malformation in the head and neck region. The upper limb as well as mediastinum also may be involved. In the hand and forearm the interconnecting lymphatic channels may be much smaller. The size of the limb may be quite large, grotesque on occasion. Besides the symptoms related to bulk and increased weight, many children develop high fevers related to episodic beta-streptococcal infections, which usually originate in the cutaneous vesicles often found in lymphatic lesions. Skeletal enlargement may be present but is not a hallmark of these macrodactylies, which are difficult to treat. Staged aggressive debulking is the treatment of choice once conservative measures and compression garments have failed.

What is Swanson's classification of congenital anomalies?

DOUG FFC Duplication (polydactyly, mirror hand) Overgrowth (macrodactyly) Undergrowth (Madelung's deformity) Generalised skeletal anomalies Failure of formation (heaps) Failure of differentiation (heaps) Constriction ring syndrome Often regarded as being inadequate for clinical use as it is phenotypic with little relevance to treatment and prognosis; the categories are not mutually exclusive.

Where does PTA & peroneal artery run?

Deep posterior compartment PTA is medial, between FDL & soleus Peroneal artery lateral, between TP & FHL

What is the wound healing defect in Ehlers-Danlos syndromes?

Defects in synthesis, cross-linking, or structure of collagen leading to decreased wound strength and delays in wound healing. Patients are prone to wound dehiscence, which forms broad, thin, shiny scars resembling cigarette paper.

Whats main factor responsible for frontal sinus growth after FOA?

Degree of frontal sinus pneumatisation correlates inversely w amount of supraorbital bar advancement

what is dupuytrens diathesis

Denotes aggressive form of DD * Young age of onset and rapid progression. * Early recurrence as well as a greater risk of recurrence. * Strong family history. * Other areas of involvement: eg Garrod's knuckle pads (PIPJ) occur in ~20% of patients, lying between skin and extensor tendon, attached to paratenon. * Plantar fibromatosis (Lederhosen) but no flexion contracture. * Penile curvature (Peyronie). * Frozen shoulder.

Blood supply to gluteal thigh flap?

Descending branch of IGA. Landmark for flap design is the midpoint between greater trochanter & ischial tuberosity proximally. Distally, the flap can extend to the medial femoral condyle & posterior border of tensor fascia lata.

Blood supply to vastus lateralis?

Descending branch of LCFA, from PFA. The vessel courses from medial to lateral. After emerging from beneath rectus femoris muscle, it enters the anterior proximal belly of the vastus lateralis muscle ~10 cm inferior to the ASIS

What does "copper beaten" finding indicate?

Describes classic XR sign of RICP on skull films. Similar to craterlike surface of golf ball, on inside of skull

Is the primary blood supply of the scaphoid distal or proximal?

Distal pole of scaphoid is supplied independently by dorsal & palmar branches of the RA, leaving the proximal pole deficient & susceptible to devascularization with trauma

Sx of bells palsy

Distal to proximal progression of facial paralysis + GCS + recovery 1) Facial paralysis 2) Greater petrosal: decreased tearing 3) Chorda tympani: decreased taste & saliva 4) Stapedius reflex: hyperacusis 5) Abberant nerve recovery: excess lacrimation

What is a Le Fort III advancement osteotomy?

Done to advance midface forward •Osteotomy is at nasofrontal junction, medial orbital walls, then downward to orbit floor to meet inferior orbital fissure. Then lateral orbital wall is divided at ZF suture, then zygoma, then pterygomaxillary fissure. •Once osteotomies done, midface can be loosened with the Rowe disimpacting forceps. Bone grafts are placed in the defects of nasofrontal junction +/- lateral orbital wall & pterygomaxillary fissure. After intermaxillary fixation, interosseous wires or miniplate fixation is used to stabilize the nasofrontal, zygomaticofrontal, and zygomaticotemporal osteotomies

What is the clinical use of cephalometrics?

Dx; growth prediction; visual Rx objective; surgical Rx objective

Which nerve supplies Sensation over angle of mandible

GAN

What is "pointed head"?

Oxycephaly - chx by retroverted forehead, tilted posterioinf on a plane w nasal dorsum. Forehead is usually reduced in horizontal dimension w elevation near ant fontanelle. Usually BCS w multisuture involvement

tendon transfers for LF abduction in UN palsy (Wartenberg's sign)

EDM to collateral ligament of MCPJ

Elevation and lateral mv of lips - which muscles

ELEVATION Levator labii superioris levator labii superioris alaeque nasi Levator anguli oris Zygomaticus minor Zygomaticus major RETRACT Buccinator Risorius ZM

What is Maffucci syndrome?

Enchondromas of long bones + vascular anomalies (venous malformations). At risk for different vascular tumours.

Is there a role for hyperbaric oxygen in wound healing?

Evidence suggests that O2 acts as a signaling molecule for GF production. HBO is commonly used for wound healing eg diabetic feet, but without large RCTs

ganglions - what are they

Ganglion cysts are mucin-filled cysts continuous with underlying joint capsule. Transilluminate. Thought to represent mucoid degeneration of fibrous connective tissue - histo shows collagen without synovial or epithelial cells.Pathogenesis poorly understood: ball valve effect; metaplasia produces microcysts & fibrous metaplasia forms mucoid cells; embryonic rests (ganglions may arise away from synovial joints).

What surgical options are available for stage IV disease?

Excise if resectable as removal prolongs survival. One deposit has much better prognostic than multiple (12% vs 0% 5YS). Resecting brain mets may ↑survival (eg single met, limited extracranial disease).

Absolute indications for LL free flap?

Exposed bypass grafts, open #s, exposed tendons & nerves

tongue scc is most often at base?

FALSE -75% are in anterior mobile part. 40% have +ve LNs so ELND if >10mm -25% in back are more undifferentiated & 75% have +ve LNs The superior cervical (level II) lymph nodes are the most common site of cervical metastasis from oral tongue cancers.

Which extrinsic tendons insert into carpal bones?

FCU on pisiform

In acrocephalosyndactylyl (Aperts) what factors can lead to better outcome?

FOA before 1yo & good psychosocial environment are a/w better outcomes

Parotid - what is the deepest structure passing through it N A V

FREA

How do growth factors differ in FWH?

FWH has decreased growth factors eg TGF-beta, PDGF, basic fibroblast GF. Experiments that increase growth factors result in scar formation

What is a facial bipartition?

Facial bipartition mobilizes the orbit and midface in one piece. It generally is used in patients with OHT and transverse constriction of the maxillary dental arch. This procedure simultaneously narrows the IOD, expands the transverse width of the maxillary dental arch, and levels the maxillary occlusal plane

What is no-reflow phenomenon?

Failure to reperfuse an ischemic organ after reestablishing blood supply. From endothelial injury, platelet aggregation, leakage of intravascular fluid. Severity correlates w ischemia time.

Why is proper management of the medial canthal tendon important in OHT repair?

Failure to secure the medial canthus with transnasal wires results in canthal drift and pseudohypertelorism. This gives the false impression of OHT relapse.

Andy Gump deformity is from loss of width, height, projection of middle 1/3 face?

False. Lower third. From resection of anterior mandible arch. Anterior & medial deviation of lateral mandible from mylohyoid. Superior displacement by MP, masseter, temporalis. Function issues +++ incl aspiration

What are the boundaries of Guyon's canal?

Flooor: TCL Roof: volar carpal ligament (VCL) Ulnar wall: pisiform

Wassle classification thumb

For polysyndactyly. Types I to VII based on level of duplications *I: bifid distal phalanx (DP) *II: duplicated DP *III: bifid proximal phalanx (PP) *IV: V common, duplication of PP which rest on broad metacarpal *V: bifid metacarpal (MC) *VI: duplicated MC *VII: triphalangism

8. What are the principles of FOA in CS?

Forehead has 2 parts: supraorbital bar (bandeau) & forehead convexity. They're mobilised separately, & joined by sutures/etc in bespoke manner •symmetric advancement in brachycephaly •asymmetric advancment in plagiocephaly •ant rotation & Z plasty in oxycephaly •widening in trigonocephaly

What are some methods of fixing the columella in BCL?

Forked flap from excessive prolabium skin will introduce new skin & help release the depressed nasal tip. Forked flap can be banked & later used as 2ndary procedure to narrow a wide prolabium, to revise BCL scars, & to construct a columella

Brachial artery branches

From inferior border of teres major

How is palmar skin so firmly fixed in place?

From the palmar fascia, which is fixed proximally and distally, from side to side, and to the underlying metacarpals by its vertical fibers. The palmar skin is closely attached to the palmar fascia by a tight network of its own vertical fibers. Hence, edema cannot collect as easily on the palmar side of the hand

Smoking's effect on wound healing

Generally -Delayed wound healing & wound breakdown -Increased infection, seroma, hematoma -Poor scar formation -Increased 2ndary procedures & reoperation rate -DVT and PE increased (small risk) Many specific risks -80% replant failure if smoke -TRAM: mastectomy flap necrosis, abdo skin necrosis Not increased: FF loss, vessel thrombosis, fat necrosis

What is the most persistent request of girls with Poland syndrome?

Girls request breast reconstruction, which is different from a simple augmentation or reconstruction after mastectomy. Expansion and overexpansion must be completed before final implant placement because the integument, including the areola, often is highly deficient. Subpectoral implants are preferred, but this muscle is either deficient or absent. Latissimus transfer with submuscular implants is then performed. It is wise to wait until adulthood before doing a transverse rectus abdominis muscle or free tissue transfer reconstruction.

Whats the superficial artery trap in RFF

Good example of anatomical anomalies that plague FC flaps. UA is normally deep within MIS of forearm, but in 9% it lies superficial to fascia. Therefore taking it with FRFF would devascularise hand

Iliac osteocutaneous good and bad bits?

Good: 14cm corticocancellous bone, natural curve looks like hemimandble, best for osteointegration Bad: Soft tissue too bulky for intraoral unless glossectomy done, poor contour of intraoral/chin/submental, unreliable skin paddle, DSM incl LFCN injury, gait painful, hip contour

Jejunum for intraoral reconstruction good and bad bits

Good: xerostomia, full tongue ROM, reliable pedicle,one stage Bad: gen surg & laparotomy etc.

what's safe dose of lignocaine in SAL in tumescent fluid

Guidelines say 10-50mg/kg but no clear evidence - Higher amounts can be used because poorly vascularised fat delays absorption - However absorption lasts 24hrs, liver metabolism can be altered by blood flow, & main metabolite is active & can also cause SE

How do you test for ORL tightness

Haines-Zancolli test

Cranial endochondral ossification & intramembranous ossification post trauma

Heal by intramembranous

breast ca 5YS for stages I-IV

I 85% II 66% III 41% IV 10%

flexor zones

I distal to FDS insertion II from flexor sheath to FDS insertion III distal CT to A1 (where lumbricals arise from FDP) IV within carpal tunnel V proximal to carpal tunnel Thumb Zones I Distal to IPJ II Overlying PP, ie A1 pulley to IPJ III Thenar eminence IV As above V As above

What is included in clinical stage IA & IB for melanoma?

IA: T1a N0 M0 ie <1mm nonulcerated IB: T1b N0 M0 & T2a N0 M0 ie <1mm ulcerated & 1-2mm nonulcerated

ICF & ECF properties

ICF *2/3 of TBW, 40% of body weight *cations: K+, Mg2+ *anions: protein & organic phosphates eg ATP, ADP, AMP ECF *1/3 of TBW, 20% of body weight in man *consists of ISF (16%) and plasma (4%). *cation is Na+ *anions are Cl- and HCO3- *osmolarity is 290 mmol

In what position should PIP joints be fused?

IF 10° MF 25°-30° RF 40° LF 45°-50°.

Describe Gustilo

II Moderate soft tissue (ST) injury IIIA Adequate ST despite laceration or undermining IIIB Extensive ST injury & periosteal stripping, gross contamination IIIC B with limb ischemia

What are the criteria for clinical stage IIA, IIB, IIC for melanoma?

IIA: T2b & T3a ie 1-2mm ulcerated & 2-4mm nonulcerated IIB: T3b & T4a ie 2-4mm ulcerated & >4mm nonulcerated IIC: T4b ie >4mm ulcerated

How do you measure IOD?

IOD is defined as the distance between the medial walls of the orbit at the dacryon. The dacryon is the union of the lacrimal, frontal, and maxillary bones.

When can facial N be repaired

Ideally ASAP ie when divided Within 3/12 of complete division is OK Partial division can get good results at 2 years

What is the second most useful tendon for grafting in the hand?

If the palmaris longus tendon is absent, if a longer tendon is necessary, or if additional tendons are needed, the plantaris tendons are excellent sources of graft material.

What are the "checkrein ligaments"?

In PIPJ flexion contractures the proximal sliding volar plate becomes attached to the firm assembly line structures by fibrous adhesions called the "checkrein ligaments," preventing the volar plate from sliding back distally

Why is the choice of suture material critical in the early stages of wound healing?

In early stages of wound healing, the suture is primarily responsible for keeping the wound together. -D1-4 strength is from fibrin clot -W1: 5% -W2: 10% -W3: 25% -W6: 40% -W8-10: 80%

Lumbar triangle of petite boundaries

Inf (petite) triangle -LD (post), Iliac crest (inf), EO (ant), floor is IO -Rare site lumbar hernia Sup triangle -QL (med), IO (lat), 12th rib (sup), transversalis fascia (floor) -Deeper, more common Lx hernia site

You are asked to consult on a baby who has multiple cutaneous vascular lesions. What is your advice?

Infant likely has multiple haemangiomas ("hemangiomatosis") & need to rule out visceral lesions (esp liver, brain, GIT) -Look for clinical triad of hepatomegaly, CCF, anaemia -Hepatic USS/MRI -Mortality is 20% with Rx

Risk factors for pressure wounds

Infection Immobility Incontinence Poor nutritional status Altered levels of consciousness Smoking

What events occur during 1st stage of wound healing (inflammation)?

Inflammatory phase runs from 0-48hrs, starts with haemostasis & ends with inflammation - Platelets from initial thrombus release GFs that induce chemotaxis & proliferation of neutrophils & macrophages which remove debris & bacteria from wound - macrophages then become main cell of this phase & release various GFs & cytokines that change the relatively acellular wound into a highly cellular environment.

What is main differences between intramtemporal & extratemporal facial N paralysis?

Infratemporal also has GCS -GPN does lacrimal gland -Chorda tympani does ant 2/3 tongue sensation -Stapedius nerve does stapedius

Cause of double bubble?

Inserting implant without tightening the skin in mastopexy. Native ptotic breast skin then overhangs the less mobile and higher positioned implant, creating a double bubble

Where do interosseous muscles insert

Into bases of prox phalanxes, byt also have deep fibres which travel superficial to sagittal bans into aponeurotic expansion as transverse & oblique fibres

Endochondrial and membranous ossification esp clavicle

Intramembranous ossification *Formation of bone directly within loose fibrous CT *Stem cells become osteoblasts, form ossification centre *Ossification expands radially by appositional growth *Initially cancellous bone forms, later becomes cortical *Examples -skull, facial bones, clavicle, thickness of other bones Endochrondral ossification *Mesenchyme-->cartilage model-->bone *Examples -cranial base & everything that isnt skull, face, clavicle

How does an UMN lesion of facial N present?

Ipsilateral lower facial paralysis as upper face has bicortical representation

differences in deformational and CS plagiocephaly

Ipsilateral supraorbital rim & eyebrow LOW in DP, high in CS Ipsilateral ear post & low in DP, ant & high in CS Chin deviated to ipsilateral side in DP, contralateral in CS

what is CRPS

It is an abnormal pain response to injury with multifactorial causes, particularly dysfunction of SANS. •Criteria for Dx include pain disproportionate to inciting event, regional pain that isnt in single peripheral nerve distribution, autonomic dysregulation (edema, hyper/hypoesthesia, skin discoloration, sweating/dryness, osteoporosis), fxnal impairment (weakness, tremor, muscle spasm, dystonia)

Where in the tendon is the longitudinal intrinsic blood supply?

It is concentrated in the dorsal (deep) aspect of the tendon, where the vincula enter.

What is "cloverleaf skull"?

Kleeblattschadel anomaly is chxed by bitemporal & vertex bulging. Spectrum of suture synostosis is broad, newborns w deformity may show no evidence of CS

Why is sodium bicarbonate sometimes added to local anesthesia?

LA is used in balanced solution between ionised & nonionised forms. Nonionised enters tissue quicker. Sodium barcarb (1mEq/10ml lignocaine) --> alkalinisation --> more nonionised LA exists.

Langerhans cells - front line in skin immune system

LC are dendritic cells Professional antigen-presenting cells (APCs). Express MHC II and Fc receptor (FcR) on surface. Main inducers of 1° antibody response

List 4 functional muscle free flaps

LD, serratus anterior, pec minor, gracilis

Role of LF CMCJ in hand movement

LF CMCJ allows 30 degrees flexion & extension, allowing cupping of the hand in opposition

When should a Le Fort III advancement osteotomy be performed with simultaneous Le Fort I osteotomy?

LFIII + LFI allows differential advancement of midface & maxillary segments, used in pts with deformity in upper midface (exorbitism and maxillary hypoplasia) and in whom dental occlusal relationships are within acceptable range. Done rarely, as instability of bony segments can easily occur if Le Fort I & III components are separated, in which case you would be left with only a portion of the orbits.

What is the last muscle innervated by the ulnar nerve as it courses through the palm?

Last - 1st dorsal interosseus Second last - adductor pollicis

Last muscle innervated by UN in palm?

Last is 1st dorsal IOM Second last is adductor pollicis

What is the role of the lateral orbital wall in OHT repair?

Lateral orbital wall translocation most closely approximates globe movement. Medial translocation of the dacryon is not as reliable for predicting the effects on medial movement of the globe.

What is a Le Fort I osteotomy?

Le Fort I osteotomy is performed superior to apices of teeth & below infraorbital nerve. It is continued medially and superiorly to terminate at upper margin of piriform aperture. The osteotomy continues laterally to join the pterygomaxillary fissure.

Neurovascular plane in thefoot

Lies between first & second layers, upon the long tendons.

What is the Mirault-Blair-Brown repair?

Lip length on CS is increased by triangular flap from CS. Cupids bow is destroyed.

What is the Oppenheimer effect?

METAL implants put in rats cause cancer - max effect w smooth continuous surface - no strong association shown w human implants

what is immune response to burn

Major burns cause an immune paradox: immunosuppression occurs when you need immune system most *skin barrier is lost *immediate activation PRO-inflammatory cascades *initial increased macrophage activity (so more Ix) *decreased immunoglobulin levels *neutrophil dysfunction *complement depletion *immunsuppressive substances

3 main tip supports 6 minor tip supports

Major: LLC; Fibrous connections between ULC & LLC; Attachment of medial crura to caudal septum Minor: Interdomal lig; Soft tissue skin envelope & its attachment to LLC; Anterior nasal spine; Cartilaginous septal dorsum; Membranous septum

Difference between malformation & deformation?

Malformation is abnormal formation that arose during development, while deformation occurs from extrinsic forces

Describe MESS

Mangled Extremity Severity Score is decision making tool for LL trauma. >7 think about amputation -Mean age: <30 O, 30-50 1, >50 2 -Energy: low 1, med 2, high 3, very high 4 -Shock: SBP >90 0, transient <90 1, persistent 2 -Supply/limb ischemia: Pulseless/Reduced CRT 2, Cool/paralysed 3. Double score if ischemia >6hr

How can IP joints be reconstructed?

Many methods have been tried, but none is satisfactory. Examples include silicone caps and spacers; silicone implants with stems into the medullary canals; perichondrial resurfacing; incision of early cartilage bridges followed by early motion; osteointegrated implants (this technique has promise for the future); microvascular second-toe joint transfer

Why is interpupillary distance not used to measure OHT?

Many patients with OHT have esotropia or exotropia, making interpupillary distance unreliable.

What is the percentage of RICP in single & multi suture CS?

Marchac found RICP in 13% single & 42% multiple suture pts, with reduction w vault remodelling

Critical ischemia time

Max ischemia tissue can survive & be viable. CIT50 is time that causes flap necrosis in 50% cases. -SSG 3W at 3 degrees -Normothermic skin flap 9hours

Blood supply to gracilis?

Medial circumflex femoral artery, from profunda femoris. The pedicle courses from medial to lateral & enters undersurface of muscle 10- 12 cm inferior to pubic tubercle.

After correction of OHT, what is done with the excess interorbital skin?

Medial translocation of the orbits results in excess skin over the nasal dorsum. This excess skin may be excised at the time of OHT correction or allowed to contract over time to avoid a midline nasal scar. Nasal dorsum augmentation with a cantilevered bone graft helps to improve the nasal dorsum profile and fill the nasal soft tissue envelope. Excess nasal skin also creates medial epicanthal folds, which may require surgical repair.

What type of CS is most associated with hypotelorism?

Metopic. Has palpable midline forehead ridge & reduced distance between bone orbits

classic deformity with unRxed lefort I #

Midface retrusion and elongation with an anterior openbite

How are SCCs distributed

More trunk & limbs compared to BCCs •Cheeks 45%, nose 13%, ear 12% •UL 17% •Trunk 2%

What is significant about a antenatal USS showing a dorsal midline cervicocephalic lymphatic anomaly?

Most have Turner syndrome, others may have trisomy 13, 18, 21. Need amniocentesis. High rate of miscarriage.

What is a vomerine flap?

Mucosal flap from nasal vomer, used to close anterior HP. Can be inferior or superior based, uni or bilateral.

What are features of superficial BCC?

Multiple, on trunk, bright pink / red, scaly, slightly pigmented, well defined, patchlike, looks like eczema or psoriasis (therefore Bx if single lesion & unsure)

ideal breast measurements

NN 19-21cm N-IMF 5-6cm Areolar 35-45mm

whats safe dose of marcaine for IV regional anaesthesia (Biers block)?

NONE - contraindicated because of cardiotoxicity. Only LA used for IV anaesthesia is lignocaine 0.5%

How is metopic synostosis corrected?

Need supraorbital & frontal remodelling to correct the prominent frontal keel, narrow forehead, & occasional hypotelorism. •Removal of deformed supraorbital bar & flattening of the nasion angle, using a midline osteotomy, facilitates correction with a frontoorbital advancement. •Hypotelorism can be Rxed by insertion of bone graft in frontonasal junction to increase intercanthal distance, however this distorts nasal growth

What Rxs are available for melanoma stage III disease that presents w local recurrence?

Needs complete EOL with same margins as for primary, ± adjuvant XRT for close/positive re-excision margins

Neutrophils in wound healing - iming of arrival - are they first

Neutrophils remove necrotic debris and bacteria from the wound initially during the inflammatory phase of wound healing but play no role in strengthening the wound. Unlike macrophages, neutrophils are not a source of growth factors in a healing wound.

Naevus ota and ito

Nevi of Ota (face/periorbital) & Ito (arm) are coloured skin markings of slate-brown or blue/grey colouring. -Present at birth in 50% -More common in Asians -Specific mutations have been detected within the dermal melanocytes, most often GNAQ or GNA11 -Rx with laser (Q switch Yag) or IPL. Need many Rxs, recurrence - laser doesnt work on all -Risk of melanoma is very very small; risk of glaucoma if involves eye

Does burn from house powerpoint cause entrance & exit burns?

No - AC reverses its direction of current flow with each half cycle of the frequency of power source (120x second), so there is no entry or exit point per se (unlike DC), but instead there is *contact points*

Does a lymphagioma (microcystic LM) or cystic hygroma (macrocystic LM) regress by adolescence?

No - like other VMs they continue to grow proportionately with the patient. Can expand with intralesional bleeding or infection

An infant is born with a large vascular lesion. Is it more likely a vascular malformation or a vascular tumor?

No correct answer unless given more information. -Capillary malformation (CM) can be extensive on the trunk or a limb. -Lymphatic malformation (LM) and venous malformation (VM) are often large at birth. -AVM usually is not seen at birth, although it may manifest as a blush or telangiectasia and often goes undetected. -Common infantile hemangioma is barely noticeable at birth and grows rapidly in the neonatal period, but the uncommon congenital hemangioma is large. -Kaposiform hemangioendothelioma (KHE) also can be congenital and expansive. -Other congenital masses that mimic a vascular tumor or malformation include teratoma and nonvascular tumors, such as infantile fibrosarcoma and infantile myofibroma.

Are the same cells involved in FWH as AWH?

No, FWH -Has few inflammatory cells (AWH has heaps) -Is controlled by fetal fibroblast & epidermis (AWH is controlled by m0) -Macrophage has unknown role

Are all CS a/w a syndrome?

No, only 10-20% are syndromic. Usually single suture CS is isolated & sporadic, while multi-suture are more likely syndromic

Are all CS present at birth?

No, oxycephaly & Crouzons are delayed, often appearing after 3-4 yrs. So shape is different & fxnal Sx eg RICP, are more insidious, w RICP present in 60%

Should an AVM be Rxed by embolising the feeding arteries?

No. The catheter should pass through the feeding arteries into the epicenter (nidus) of the AVM. Proximal embolization of a feeding vessel is just as injurious as proximal ligation, causing collaterals to form with expansion of the AVM. Experienced radiologists agree that "cure" by embolization is unlikely unless the AVM can be completely resected after preoperative interventional preparation. The term control is preferred to cure by those with experience in managing AVMs.

What do you tell parents after a thumb duplication correction? Will the thumb be normal?

No. What you see initially is what you get later. -New thumbs are usually smaller & less mobile -Thenar muscles, esp AbPB & FPB may be weak -MCPJ instability/stiffness can occur after collateral lig reconstruction -More severe types may have inadequate extrinsic tendon excursion

What is the maximal amount of bupivacaine (Marcaine) that can be safely added to 50 mL of 0.5% Xylocaine in an IV regional anesthetic for the upper extremity to prolong duration of action?

None! Long action of marcaine on skeletal muscle means increased risk of cardiotoxicity if given IV. Only IV agent used is 0.5% lignocaine

What are the most powerful predictors of survival for Metastasis chx?

Nonvisceral mets are associated with better survival than visceral mets

Compartment syndrome pressures

Normal 2-7mmHg ACS >30mmHg Some use differential pressure (DBP-compartment pressure), if <30mmHg then need Rx

How is the chest wall reconstructed in children with Poland syndrome?

Nothing is usually done in children. In adolescents, conspicuous deformities can be reconstructed with correction of the pectus carinatum (pigeon breast) or pectus excavatum (caved-in chest) deformities, followed by a latissimus dorsi muscle transfer to recreate the missing pectoralis major muscle.

what blood tests req in gynecomastia?

Oestrogen (if inc get adrenal ct for femininzing tumour) LH/FSH Testosterone (if low & LH/FSH high get karyotype for klinefelters; they have 60x inc risk breast Ca) HCG (if high get teste USS) TFT LFT UEC CXR

indications for SNBx in melanoma

Offer SNB to patients without clinically apparent LN disease with primary melanoma >1mm thick or clark IV. Can offer to thinner if younger pt, ulcerated melanoma, high mitotic rate. Perform SNB before WLE.

What steps must be taken to preserve olfactory function during surgical correction of OHT?

Olfactory function depends on avoidance of injury to the cribriform plate and preservation of superior turbinate mucosa. The olfactory nerve penetrates the cribriform plate and terminates within this mucosa.

What is orbital hypertelorism?

Orbital hypertelorism (OHT) refers to an increase in interorbital distance (IOD). It is a finding on physical examination, not a syndrome.

What is the thickest skin in the hand? Name 3 clinical implications

Palmar skin has the thickest epidermis due to a thick stratum corneum (the dermis is same thickness on dorsum as palm), resulting in: 1) more significant hand burns being on thin dorsal skin (plus if fist is closed this protects the palmar skin) 2) single layer closure of palm wounds is possible because thick stratum corneum hides the ingrowth of epithelium down the suture into the dermis, so they can be left > 1 week without stitch marks 3) thick stratum corneum exaggerates any skin overlap & makes palmar wound eversion more difficult

How to check for FDS in IF?

Paper pulled away from between thumb & IF pulp. *Normal is slightly flexed at PIPJ from FDS & extended at DIPJ, ie 'pseudoboutonniere' *If no FDS then DIPJ will contract & PIPJ will stay extended, as in a 'pseudomallet'

How do you treat a newborn in the nursery with a type I floppy nubbin attached to the fifth finger?

Pediatricians like to "tie them off" with a suture. Type I duplications with large skin bridges often do not fall off. There is often cartilage insitu. Simple excision & closure is a more appropriate option.

How can persistent primary melanoma be differentiated from metastatic melanoma on histopathology?

Persistent primary melanoma -epidermal part -lymphocyte inflammation -fibrosis & scarring Metastatic melanoma -no epidermal part -no inflammation -vascular invasion -high mitosis -necrosis

What is a cephalometric plane?

Plane connects three or more points. Line connects two or more points. These two terms often used synonymously. The commonly used planes are:

How long until new intima covers the anastomosis site?

Platelets deposit at intimal injury sites Pseudointima forms within 5 days New endothelium covers join at 1-2 weeks

What is commonest cause of TE failure?

Pocket made is too small for tissue expander. Once pocket is closed, TE should lie flat & you shouldn't see TE wrinkles through skin

Is a strip craniectomy sufficient treatment for sagittal synostosis?

Possibly, for very very mild isolated sagittal synostosis. Most require cranial vault remodeling, with removal of the affected suture & frontal, parietal, & occipital "barrel-stave" osteotomies.

Tarsal tunnel syndrome

Posterior tibial nerve compression within fibrosseous canal that has flexor retinaculum for roof Sx burning pain in plantar foot & medial calf, worse with activity, w Tinels +ve over MPN/LPN Rx is flexor retinaculum release

Ischemia-reperfusion injury & mechanisms

Postischemic re-establishment of vascular perfusion may cause extra tissue damage from whats already present from ischemia. Mechanisms are 'death by bombardment' eg n0 respiratory burst & free radial formation, release of proinflammatory mediators from lipids, peptides, endothelial cells

Contraindications to salvage of IIIC tibia

Preexisting severe medical disease, severed limb, tibial loss >8cm, ischemic time >6hrs, divided posterior tibial nerve in adults

How can differentiate preganglionic and postganglionic BPx?

Preganglionic -Horners syndrome -No serratus, rhomboid, supraspinatus innervation -Skin denervation with intact histamine response (vasodilation, wheal, flair) -traumatic meningocele on myelogram -proximal nerve lesion on mri -need surgical exploration to determine level of lesion

Main risk of fetal surgery?

Preterm labour. Risk is reduced with indomethacin infusion & using GA drugs that reduce uterine tone

hand tumour classification

Primary tumours 1A) Soft tissue - benign: ganglion, PVS, glomus tumour, pyogenic granuloma, lipoma, inclusion cyst 1B) Soft tissue - malignant: SCC, BCC, melanoma, sarcoma 2A) Bone - benign: enchondroma, osteochondroma, osteoid osteoma 2B) Bone - malignant: osteogenic sarcoma Metastatic *Breast, kidney, thyroid, lung, or colon

Nerve transfer principles & indications - only option in brachial plexus avulsion?

Principles 1) Donor nerve expendable 2) Donor nerve ideally innervate synergistic muscle 3) Minimal dissection to reduce scar Indications ●BPI w very proximal or no nerve available for grafting. ●High proximal injuries that require long distance for regeneration. ● Avoidance of scarred areas in critical locations with potential for injury to critical structures. ● Major limb trauma with segmental loss of nerve tissue. ● As an alternative to nerve grafting when time from injury to reconstruction is prolonged. ● Partial nerve injuries with a defined functional loss. ● Spinal cord root avulsion injuries. ● Nerve injuries in which the level of injury is uncertain, such as with idiopathic neuritides or radiation trauma and nerve injuries with multiple levels of injury.

What events occur during 2nd stage of wound healing (proliferation)?

Proliferative phase: 48hrs - 2 weeks -Fibroblasts proliferate to become the dominant cell. They produce collagen, which provides structure to the wound and replaces the fibronectin-fibrin matrix. - Angiogenesis of new capillaries occurs to sustain the fibroblast proliferation - Keratinocytes epithelialize the wound

What is the Rx for an upper lid haemangioma?

Prompt Rx is mandatory. - Normal eye patched for few hrs per day to encourage use of the affected eye. - Beta blockers (propranolol) ia now used in place of systemic corticosteroids - Surgery: if tumor is well localized, then partial ("debulking") or total resection is done

What is the significance of pseudohypertelorism?

Pseudohypertelorism is caused by lateral displacement of medial canthal tendons, not by an increase in the IOD. It is easy to mistake pseudohypertelorism for OHT if you are not careful.

Roos test?

Pt sits w arm abducted 90 & elbows flexed 90 Open & close hand for 3 minutes Tx outlet syndrome gets Sx & cant finish

What is holdaway ratio?

Relates prominence of mandibular incisor to NB line, & pogonion to NB line. Used to Ax lip retrusion or prominence. Ideally lower incior & pogonion should be same distance from NB line, ie 1:1 ratio.

What limits the rate of expansion?

Relaxation & growth of tissues overlying the expander Eg previous radiation or scar formation may slow or make expansion impossible

What single operation is most beneficial for patients with a congenital hand anomaly?

Release of the 1st webspace. -Mild: four-flap Z-plasty -Severe: distally based RFF or dorsal interosseous flap.

What events occur during 3rd stage of wound healing (remodelling)?

Remodeling phase runs from 2 wks & can last 2 years - Collagen synthesis and degradation reach equilibrium. - Fibroblasts organize & cross-link the collagen, wound strength gradually increases, wound contraction occurs, and wound loses its pink or purple color as capillary and fibroblast density decrease.

Where is the area of maximal sensory crossover in the hand?

RF dorsal middle phalanx: digital nerves from MN & UN course dorsally, SRN courses distally, along with the UN dorsal sensory branch on the ulnar side.

Radial tunnel syndrome

RN compression at the elbow *Potentially compression sites •Fibrous band tethering nerve to radiohumeral joint •Leash of Henry: radial recurrent vessels which pass across the radial nerve. •Tendinous margin ECRB •Arcade of Frohse: fibrous band on surface of supinator muscle *Pain is main Sx, DDx is tennis elbow *Dx is clinical as EMG not helpful •Most tender in RN tunnel over supinator, while tennis elbow is located higher over lateral epicondyle and radial head. •Resisted extension of MF is positive in radial tunnel syndrome and negative in tennis elbow.

Radiation - DNA, free radicals,

Radiation kills cells by 1) directly causing DNA double strand breaks 2) forming O2 free radicals, which damage DNA Therefore XRT is more effective in cells that are oxygenated & currently in mitotic phase Avascularity said to increase until 6/12 post XRT, then plateaus

What is the Hagedorn-Le Mesurier repair?

Rectangular flap from CS is inset into a releasing incision on the NCS to create an artificial cupids bow

ptosis classification

Regnault describes NAC to IMF 1st: NAC at/above IMF 2nd: NAC below IMF but anterior 3rd: NAC below IMF but dependent Pseudoptosis: NAC above IMF but breast mound below IMF

What is an intravelar veloplasty?

Reorientation of LVP muscles & instead of just suturing them end to end, they are sutured in an overlapping position to make a tighter levator sling

What is the retinacular system of the extensor mechanism?

Retinacular system of extensor mechanism stabilizes the components of the extensor mechanism - sagittal bands stabilize the central tendon over MC head - transverse retinacular ligs stabilize the lateral bands and central slip over the PIPJ - triangular ligament stabilizes lateral bands over the MP

Embyology of brain

Rostral part neural tube

What does ORL do?

Runs beneath PIPJ & over DIPJ to coordinate movement between the 2. In boutonnière deformity it is lax, so it shortens, & helps maintain the abnormal position

What is torticollis?

SCM shortening resulting in tilting of head towards affected side (they show you the bad SCM).

compare SH I-V in hand #s

SH I Slipped from # through thick GP of small kids SH II # Above GP >10yo SH III # Lower than GP in >10yo SH IV # Through epiphysis & metaphysis, any age SH V # Rammed crompression #, any age Good prognosis with I-III, potential GP arrest IV-V

What are the most common problems after syndactyly correction?

SHORT TERM -Infection, graft or flap maceration, and graft loss are almost always related to the child's activity and/or inadequate immobilization. Use above elbow POP. LONG TERM 1. Recurrence of webbing or "web creep," which is related to scar contracture at base of commissure or along the incision lines. Zigzag incisions help reduce this potential contracture. 2. Hyperpigmented skin grafts & if harvested within the hair-bearing areas may become hirsute during adolescence. 3. Inadequate correction of 1st web release may be obtained with tight contractures, which can be widened only with additional soft tissue.

Superficial and deep palmar arches

SPA -lies superficial to everything -comes from UA at level of outstretched thumb -incomplete arch in 2/3 -if complete, meets with superficial palmar br of RA -gives off 3 common palmar digital arteries & palmar digital artery to LF DPA -formed by RA -enters palm between 2 heads of add pollicis -runs 1cm proximal to SPA -usually complete, joining with UA deep branch -gives off 3 palmar MC arteries, joining w CPDA of SPA -gives off branches that perforate the intermetacarpal space & join with dorsal metacarpal arteries

Bone healing -stages -types

STAGES (HIP CR) 1) Haemotoma: fibrin clot w haemopoietic cells-> gf's + fb's, mesenchymal cells 2) Inflammation: local Ix rxn--> m0s, n0s, osteoclasts clean up debris 3) Proliferation: more fb's->granulation tissue forms from bone ends; neovascularisation; cartilage forms 4) Callus formation (48hr-2 weeks): stem cells from # turn into osteoblasts (form osteoid, which replaces cartilage by endochrondral ossficiation into woven bone) & chondrocytes (form cartilage); callus from each end joins in middle 5) Remodelling (<5yrs): lamellar bone replaces woven bone in lines of stress TYPES 1) Indirect: callus forms, ingrowth of vessels from # site, fibroblasts, callus converts to fibrocartilage, & finally to ingrowth of fibroblasts. Takes longer than direct 2) Direct: healing begins immediately with proliferation of osteons growing across # site; possible to heal with no scar; needs AFP reduction & no movement/rigid fixation

What metals are used for implants in PRS?

SVT 1. Stainless steel 2. Vitallium 3. Titanium

What is commonest single suture CS?

Sagittal synostosis - narrow elongated cranial vault & reduced bitemporal diameter.

What is cephalometrics? How is it done?

Science of skull measurement. Initially used for quantitative method for describing dentofacial patterns. Done by standardised lateral view of skull, tracing the film, then measuring between landmarks

Do children need more surgery after syndactyly repair?

Secondary operation rate is ~10%, but is higher in complex and complicated cases, especially central complex polysyndactyly which is the most difficult to treat.

How does flashlamp pulse dyed laser cause blanching of a capillary malformation (port wine stain)?

Selective photothermolysis - PDL has wavelength of 585nm, similar to third absorption peak of oxyHb (577nm) - PDL penetrates skin to 0.75mm & is absorbed by RBCs in the dilated vessels, damaging the RBCs, preivascular wall, perivascular collagen - Histo 1 month later shows decreased abnormal blood vessels, resulting in a more normal skin tone

Which individual structures are maintained in dorsal position by the transverse retinacular ligament of Landsmeer?

Seven tendons are held in place in the region of the PIP joint: the central slip of the extrinsic extensor, the two lateral bands, the two slips from the central slip to the lateral band, and the two slips from the lateral bands to the central slip.

Indications for primary amputation in leg trauma

Severe combined injury to bones, skin, joint, nerves, vessels w long term fxn unlikely. Absent sciatic or tibial nerve function is most crucial (insensate plantar surface).

Where does the expanded skin come from?

Short term 1) Pressure forces interstitial fluid out of tissues & causes microfragmentation of elastic fibers, allowing greater skin expansion 2) Creep: viscoelastic deformation & changes in collagen alignment 3) Recruitment of adjacent mobile soft tissue Long term 1) Actual growth of the skin flap occurs with an increase in the area of skin and the collagen content and ground substance as dimensions increase.

What is Sturge-Weber syndrome?

Slow-flow disorder characterized by facial CM (sometimes on other parts of the body) and capillary-venous anomalies of the leptomeninges.

What is Papineau technique

Staged bone grafting for infected nonunion of tibia fracture I Excise infection, exfix, pack w antibiotic swabs II Autologous cancellous bone grafting III Flaps/grafts for coverage once bony union achieved

Frontal sinus fracture Mx

Status of anterior & posterior tables, & nasofrontal ducts dictate need for surgery 1) Nondisplaced anterior table #s: observe 2) Displaced anterior table#s: OT 3) Minimally/nondisplaced posterior table s#: observe if no CSF leak or suspicion of nasofrontal duct injury 4) Displaced posterior table #s greater than one wall thick: surgical exploration and reduction. Suspicion of nasofrontal duct involvement also dictates the need for exploration.

How are postaxial duplications classified?

Stelling's Classification of Polydactyly -Type I: Extra "digit" with attachment by soft tissue only (no bone) -Type II: Extra digit with all normal components articulating with a phalanx or metacarpal -Type III: Extra digit articulating with an extra metacarpal

Your elective burns pt gets hyperkalemia on induction - why?

Succinylcholine. Burn pts have increased #s of acetylcholine receptors, which are filled by sux. Reaction lasts up to 1.5yrs

What are the types of melanoma?

Superficial spreading Nodule Acral Lentigo maligna

Quadrangular space

Superior: subscapularis, or tm from behind Lateral: humerus Inferior: teres major Medial: long head triceps Contains: axillary N & posterior circumflex humeral artery and vein inferiorly

How do you differentiate between deformational & synostostic plagiocephaly?

Synostotic plagiocephaly is rare. -Can be from UCS, occuring in 1 in 10000 live births, & is 0.2% as common as DP. -Can be from unilateral lambdoidal CS, which is even rarer

staging of NMSC

T1 <2cm T2 2-5cm T3 >5cm T4 invades deep extradermal structures eg muscle, bone N1 regional LN mets M1 distant mets stage O = Tis stage I = T1 stage II = T2, T3 stage III = T4 or any T with N1 stage IV = M1

Wrist joint -connections of synovial cavities

TBA

difference in temporalis muscle & fascial flap

TMF: deep temoral vessels TFF: superficial temporal vessels Both can cover mouth except tongue & central FOM as pedicle too short

Blood supply to TFL flap?

Terminal branch of LCFA from PFA, which supplies blood to the small tensor fascia lata muscle. The entire lateral thigh skin is vascularized by perforating arteries from this vessel.

What flaps does LCFA branches supply

Terminal/ascending branch: TFL Transverse branch: VL Descending branch: rectus femoris/VL

How is BCS with exorbitism Rxed? Is this approach useful in an infant with syndromic synostosis (Crouzon or Apert syndrome)?

Tessier type of frontal bone advancement •Osteotomies are made across nasofrontal junction, across orbital roof, & along lateral orbital walls. Do osteotomy extensions into temporal fossa to provide tongue-in-groove arrangement that obviates need for bone grafts for fixation purposes. •Can advance frontal bandeau (supraorbital bar) >20mm this way. Frontal bone is then fixed to advanced bandeau eg sutures. Can close scalp via large stay sutures or galea scoring.

What is Bunnell test

Test for intrinsic tightness. When MCPJ is in extension, the contracted IOM impede PIPJ flexion because of the traction exerted on the extensors. Flexion of MCPJ relaxes the extensors, and flexion becomes possible at PIPJs

Tetanus - facies sardonicus

Tetanus is chx by CNS hyperexcitability, caused by GP anaerobe called C.tetani. Get tonic rigidibility, either generalised or local. Can present w masseter trismus - facies sardonicus. Rigidity then spreads caudal.

Why do the profundus tendons usually not retract into the palm after transection in the fingers?

Tethered by 1) Lumbricals 2) Common muscle belly of other FDPs 3) Vincula (if not avulsed) & DIP/PIP volar plates

Describe the hand in a child with Freeman-Sheldon syndrome

The "whistling face" syndrome presents with characteristic hand and facial anomalies. -Hands are often narrow with prominent ulnar drift. Incomplete, simple syndactyly and varying degrees of PIP camptodactyly are often present. The first web space usually is tight. The descriptive term "windblown hand" is often applied. -Many other musculoskeletal anomalies, such as scoliosis, hip dysplasia, and radial head dislocation, may be present. These children are not retarded mentally.

After downfracture of the maxilla during a Le Fort I osteotomy, profuse bleeding is seen. What vessel is most likely responsible?

The *descending palatine artery* is a branch of third portion of maxillary artery. It descends vertically through the perpendicular portion of palatine bone. Injury of this vessel during Le Fort I osteotomy is not uncommon.

Which is the most mobile carpometacarpal joint?

The CMCJ of the thumb is a saddle joint with motion in three axes, giving the thumb unique mobility

What is the smallest extrinsic flexor tendon?

The FDS to the little finger not only is the smallest tendon but also is frequently nonfunctional or even missing. Its consistently small size helps to identify the individual cut ends in the spaghetti wrist.

Why is extension the safe position for the IP joints?

The IPJ collateral ligaments tend to have the same tightness in flexion & extension. Two other points are important instead (1) The volar plate - overlies cartilaginous surface of phalangeal condyles in extension, but in flexion slides proximal to the condyles, where it readily becomes adherent to the filmy soft tissue between the tendon sheath and periosteum. Maintenance of this position produces a flexion contracture. (2) Extensor mechanism near PIPJ - is highly stable in extension but is under stress in flexion. This problem is particularly significant when the PIP joint is injured, as in a burn injury. Inflammation may cause attenuation of the delicate extensor mechanism, resulting in disruption of the transverse retinacular ligaments when the joint is stressed in flexion. The lateral bands then slip volarly, creating a boutonnière deformity.

Why is flexion the safe position for the MP joint?

The MCPJ head is ovoid in sagittal plane (creating a cam effect) and possesses a palmar flare in the transverse plane, which requires the collateral ligaments to span a greater distance in flexion than extension. Therefore the collateral ligaments are stretched tight in flexion but lax in extension, & lax ligaments shorten.

What does the oblique retinacular ligament do?

The ORL controls and coordinates flexion and extension between the IP joints. It courses beneath the PIPJ and over the DIPJ. As the DIP begins to flex, the ORL tightens, delivering flexor tone to the PIP joint. When the PIP begins to extend, the ORL tightens, delivering extensor tone to the DIP joint. Thus it ensures smooth, modulated, coordinated flexion and extension to the IP joints. It has been called the "cerebellum" of the finger.

How, then, can the DIP joint be flexed while maintaining extension of the PIP joint, which would have to stretch the ORL?

The ORL is a very subtle, light structure that stretches and deforms somewhat to allow this type of finger motion.

Which tissues contribute to growth of the nail plate?

The entire nail bed, including the overlying eponychial fold, contributes material to the developing and growing nail. The proximal nail bed (germinal matrix) forms the early developing nail, the overlying fold contributes the smooth surface, and the distal bed (sterile matrix) continues to add bulk so that the nail plate does not become too thin from wear.

If the two primary tendon graft donors are missing, what is still available?

The extensors of the toes can be used as graft material if necessary

What is the primary extender of the MP joint?

The extrinsic system extends the MP joint.

How is the long vinculum of the profundus tendon related to the short vinculum of the superficialis?

The vincula are folds of mesotenon carrying blood supply to both tendons. Normally, each of the profundus and superficialis tendons has a short vinculum (breve) and a long vinculum (longum). The vinculum longum of the profundus tendon traverses the vinculum breve of the superficialis tendon.

How does delay of a muscle flap work?

Venous valves in the area become imcompetent. Eg cut DIEA/V before superior pedicled TRAM may ensure greater skin paddle survival. Venograms show direction of venous outflow is redirected away from the groin unencumbered because the venous valves have become incompetent.

Which are the most important pulleys in the fibroosseous tunnel?

The finger flexor unit functions well if the A2 and the A4 pulleys are preserved. Both are needed to prevent tendon bowstringing. The A2 pulley is located at the proximal portion of the proximal phalanx ("proximal proximal"). The A4 pulley is located at the middle portion of the middle phalanx ("middle middle").

Which interosseous muscles have insertions into the bases of the proximal phalanges?

The first, second, and fourth dorsal interosseus muscles have bony insertions from their superficial bellies/medial tendons.

Which of the interosseous muscles abduct the fingers? Which adduct them?

The four dorsal interossei, which arise from the adjacent surfaces of the shafts of the first, second, third, and fourth metacarpals and insert on the proximal phalanges of the index, middle, and ring fingers, abduct the digits from the midline of the hand. The three volar interossei, which arise from the second, fourth, and fifth metacarpals and insert on the respective proximal phalanges, adduct the digits toward the midline. The tendons from these muscles lie volar to the axis of MP motion but dorsal to the transverse metacarpal ligament (TMCL).

What is the primary flexor of the MP joint?

The intrinsic muscle tendons course volar to the MP joint axis of rotation and are the primary flexors of the MP joint.

Which extends the IP joint: the extrinsic system or the intrinsic system?

The intrinsic system extends the IPJ when the MP joint is in hyperextension. The extrinsic system extends the IP joint when the MP joint is in flexion.

How do the lumbricals assist in IP joint extension?

The lumbricals originate on the radial side of the FDP tendons. As they contract they simultaneously extend the IP joints by directly pulling on the lateral band and pulling the FDP distally, relaxing the flexion antagonist to extension.

Name the three planes of the palmar fascia.

The palmar fascia is aligned in longitudinal, vertical, and transverse components

How are the flexor tendons arranged in the carpal tunnel?

The profundus tendons lie side by side on its floor. The FPL is the radialmost member of this group. The superficialis tendons lie on the profundus tendons arranged two by two; the middle and ring finger tendons (third and fourth) are superficial; the index and small finger tendons (second and fifth) lie between them and the profundus row. Remember, 34 (third and fourth) is higher (more superficial) than 25 (second and fifth)

Which are the least mobile CMC joints?

The second and third metacarpals are bound firmly to the trapezoid and capitate, forming a stable structure known as the "fixed unit of the hand." Thus the second and third CMC joints are the least mobile.

Which side of a thumb duplication should be preserved?

The side with the better parts. Usually the radial partner is the more hypoplastic & is ablated. In some more proximal type V and type VI varieties at the metacarpal level, the distal portion of the ulnar partner is transposed on top of the proximal portion of the radial partner

When is the ECU not primarily an extensor of the wrist?

The sixth dorsal compartment is fixed on the ulnar head. When the radius pivots around the ulnar head in pronation and supination, the ECU assumes different positions relative to the wrist. In full pronation it is ulnar to the wrist and thus primarily an ulnar deviator.

How is symphalangism treated?

The stiff fingers will always be stiff. Angulation and especially rotation should be corrected early in life without damage to growth centers.

Why can you not pull a superficialis tendon out through a palmar incision if you release it from its insertions in the middle phalanx?

The superficialis tendon does not simply divide when the profundus passes superficial to it; it reconstitutes itself beneath the profundus (chiasm of Camper) before dividing finally to its two insertions. This structure prevents the superficialis from being pulled out because it completely encircles the profundus tendon.

What are the boundaries of the carpal tunnel?

The transverse carpal ligament (TCL) forms roof of carpal tunnel & provides a pulley mechanism for the flexor tendons. The TCL courses on radial side from scaphoid tubercle & crest of trapezium, to the pisiform and hamate on ulnar side

Which of the three palmar fascia planes is never involved in Dupuytren's?

The transverse fibers, located over the metacarpophalangeal joints, are never involved in Dupuytren's disease.

The IP joint can be thought of as a box, with the articular surfaces of the phalanges forming the proximal and distal ends. What forms the other sides?

The volar plate forms the bottom and collateral ligaments the sides. The collateral ligaments extend from their points of origin into a broad, fan-shaped insertion into the phalanx distally and the sides of the volar plate volarly. The volar portion of the collateral ligament is referred to as the accessory collateral ligament. The top or lid of the box is formed by the extensor mechanism, which contributes little to the structural stability of the joint

What is the lunula?

The white arc just distal to the eponychium, called the lunula, is a result of persistence of nuclei in the cells of the germinal matrix as they flow distally, creating the nail. As the nuclei disintegrate distal to the lunula, the nail becomes transparent.

CO2 lasers indications & contraindications -CO2 laser is gold standard in ablative lasers -emits invisible IR beam at 10,600 nm, targeting both intracellular and extracellular water. When light energy is absorbed by water-containing tissue, skin vaporization occurs.

Therapeutic -actinic & seborrheic keratosis, warts, moles, skin tags, epidermal and dermal nevi, xanthelasma -also dermatofibroma, rhinophyma, severe cutaneous photodamage, sebaceous hyperplasia, syringomas, actinic cheilitis, angiofibroma, scar treatment, keloid, skin cancer, neurofibroma, diffuse actinic keratoses, granuloma pyogenicum, penile papule Aesthetic -Periorbital and perioral wrinkles, facial resurfacing, acne scars, dyschromias including solar lentigines Contraindications -Isotretinoin in prev 6/12, keloid/hypertrophic scarring Hx, ongoing UV exposure, prior XRT to area, collagen vascular disease, chemical peel and dermabrasion.

What is ideal age for CS correction?

Thickness of skull is adequate between 3-12 months age to permit osteotomies, yet soft enough for remodelling. Delayed recon >2yrs is technically more difficult.

What effect does the intraorbital/intranasal exoneration have on future growth of the midface?

This is controversial. McCarthy reports normal development of the midface after OHT reconstruction in pediatric patients. However, Mulliken and others demonstrated an adverse effect on anterior facial growth in young children who underwent OHT correction. Ortiz Monasterio reported no significant growth disturbances following facial bipartition.

What is Bonnet-Dechaume-Blanc syndrome?

Very rare syndrome comprised of facial staining and intracranial AVM involving the mesencephalon

How is OHT surgically managed?

Three fundamental approaches have been accepted to surgically correct OHT 1) combined intracranial/extracranial approach 2) subcranial approach 3) facial bipartition.

How are Apert hands classified?

Three specific types of hand configurations with varying degrees of severity have been described. -Type I: Central digital mass, thumb and little finger free (spade hand) -Type II: Thumb only free (mitten/spoon hand) -Type III :Thumb and digital mass share a common nail (rosebud/hoof hand)

What is the purpose of skeletal analysis?

To classify facial types & establish relative AP relation of basal arches. •Angle SNA indicates AP position of basal arches. Normal is 82 degrees, >82 indicates maxillary protrusion, <82 is retrusion •Angle SNB indicates AP relation of mandible to cranial base. Normal is 80 degrees.

How do you design a rhombic flap?

To reduce tension, close donor site in parallel with LME

Main reasons for radius # after osteocutaneous FRFF?

Took too much bone, perpendicular osteotomies w crosscutting of radius weakens it, too short in POP, POP wasnt long arm cast so didnt prevent pronation/supination

why is no 4 facial cleft aka meloschisis

cleft involves cheek therefore meloschisis from lat to cupids bow & philtrum, cheek, to lower lid nasolacrimal system normal

Mycobacterium - ?corosum found in tropical / chronic wounds

Tropical ulcer by mycobacterium ulcerans -painless erythematous nodule develops, usually on the leg or forearm, gets necrotic and ulcerates. -can cause major infective problems, contractures, req amputation -spread by ?infected aquatic insects -Rx w aggressive surgery & rifampicin/clarithromycin

What is melanoma?

Tumor arising from the transformation of melanocytes. Heterogenous disease which suggests richly complex aetiology.

FDP avulsion classification (leddy packer)

Type 1. Profundus retracts into Palm, both vinculae also ruptured Type 2. Distal tendon held by long vinculum at PIPJ level (A3) Type 3. Fracture fragment large trapped at level of A4 pulley

Hyaline

Type 2 collagen in cartilage T Chondrocytes cause immune respone Allograft dissapears if scored

M&N muscle classification

Type I: Single pedicle Type II: Dominant pedicle(s), with minor pedicle(s) Type III: Dual dominant pedicles Type IV: Segmental pedicles Type V: Dominant pedicle, with secondary segmental pedicles

What influences voltage req to cause injury

Type of current (need less AC than DC), its frequency, its magnitude. 10mA can cause 'no-let-go' phenomenon, while 50mA >2secs can cause VF

How do you trace a cephalogram?

Use lead pencil on acetate paper. Side closest to film is traced. Any double image is traced by bisecting the two.

Is any special workup needed in newborns with a duplication?

Usually no - but if opposite of usual occurs then consider referring in genetics, eg preaxial in Blacks or postaxial in Whites. More than 30 syndromes are associated with postaxial duplications, mainly in non-blacks.

Polands syndrome - LD 'usually there'?

Usually presents as unilateral absence of pec major +/- ipsilateral syndactyly. Variable spectrum can #Muscles: Partial or complete absence of PM; also pec minor, LD, serratus anterior, EO #Breast: mammary hypoplasia/aplasia, small nipples #Bones: absent ribs & costal cartilages, smaller scapula #Hand: brachysyndactyly; hypoplasia of forearm, hand, digits

Mandibular nerve - what muscle would not be paralysed

VC MOTOR 1) Main branch: medial pterygoid, tensor tympani, TVP 2) Ant branch: masseter, temporalis, lat pterygoid 3) Post branch: mylohyoid, anterior belly of digastric VC SENSORY = BALI 1) Buccal n. 2) Auriculotemporal n. 3) Lingual n. 4) Inferior Alveolar n.

Which CMF syndrome has lower lip pits?

Van der Woude. Lower lip pits in 80%, may be missing teeth, CL > CP, & autosomal DOMINANT (everything else is AR)

Vasodilation of skeletal muscle caused by H, HCO3, K, pO2, CO2 levels that contribute?

Vasodilation occurs with -decreased O2 -elevated lactate, adenosine, K+, osmolarity, PCO2, H+

Difference in venous and arterial haematocrit?

Venous haemotcrit is 3% higher than arterial If we review Co2 transport from tissues to venous blood: there is formation of HCO3 ion, which exits from RBC and is followed by entry of Chloride ions (aka Chloride Shift). Presence of Bicarbonate and entry of Chloride ions increase the osmotic pressure of venous RBC and water follows inside RBC. Therefore Vol of Venous RBC > Vol of Arterial RBC and hence HCt of Venous blood is higher

What is the "assembly line"?

Volar lateral ridges of the proximal phalanx, in which nestle the flexor tendons and which give attachment to the fibroosseous tunnel, the oblique retinacular ligament, and Grayson's and Cleland's ligaments

When does the face develop?

W4-W8

Breast development

W5 milk line develops from ectoderm Milk line --> milk ridge --> milk hill Milk hill vascularises into mammary structures Incomplete involution of milk ridge causes accessory nipples & breast tissue

Low UN palsy has permanent LF abduction

Wartenberg's sign. EDM has 2 bundles - radial one passes over centre of MCPJ, while ulnar one runs ulnar & attaches to tendon of AbDM.

How are preaxial duplications classified?

Wassell thumb duplication classification In duplicated thumbs *bones are odd* (odd #s have bifid bones) Type 1. Bifid distal phalanx Type 2. Duplication starting at the DIPJ Type 3. Bifid proximal phalanx Type 4. Duplication starting at the MCPJ (commonest) Type 5. Bifid metacarpal Type 6. Duplication starting at the CMCJ Type 7. Thumb duplication with a triphalangeal thumb

in zygoma # what incisions used access to a) infraorbital rim/floor b) lat orbit wall c) ZM buttress

a) infraorbital rim/floor: transconj or mid lid >> subciliary b) lat orbit wall: lat brow, lat extension of bleph incision, coronal c) ZM buttress: upper buccal sulcus

What is the Tennison Randall repair?

Z plasty of CL edges that positions the Cupid's bow but at expense of unnatural lip scar across philtrum column & partial flattening of philtral dimple

Z plasty angle and gain in length

Z-plasty angle & Gain in Length 30/30° = 25% 45/45° = 50% 60/60° = 75% 75/75° = 100% 90/90° = 120%

What are the basic requirements in designing a Z-plasty?

Z-plasty consists of central limb & two limbs that resemble a Z or reverse Z -All limbs must be equal in length -Angles of Z vary from 30° to 90°, but usually 60 -Sufficient laxity must be available transversely to achieve the appropriate lengthening perpendicular to it -The limbs of the Z-plasty should follow the RSTLs

What happens to the ORL in a boutonnière deformity?

With the PIP joint in flexion and the DIP joint in extension (the boutonnière position), the ORL is lax. Therefore the ORL shortens (as do all ligaments in a lax position) and helps to maintain the deformity.

How does a sclerosing BCC behave?

Yellow-white, morpheaform, ill-defined borders, looks like a scar or scleroderma, indurated. A/w recurrent dz.

Does the palmar fascia extend into the fingers?

Yes - the longitudinal fibers of palmar fascia extend into the fingers - Webspace: natatory ligaments - PP & MP: Cleland's (dorsal to NVB) & Grayson's (volar) attach along the ridge giving rise to the fibroosseous tunnel - DP: vertical fibers are attached directly to the underlying DP and form a honeycomb series of compartments, similar to that in the palm between the skin and palmar fascia

Is there an association between torticollis & DP?

Yes - true torticollis where head tilts towards abnormal side is present in 64% of DP kids. Ocular torticollis, where child attempts to correct for strabismus induced diplopia by tilting head towards normal side, is present in 50% kids with CS plagiocephaly

typical zygoma # pattern

ZF suture Into orbit at zygomaticosphenoidal suture to inferior orbital fissure Orbital floor & infraorbital rim Infraorbital foramen ZM buttress Lateral wall of maxillary sinus Zygmomatic arch 1.5cm posterior to zygomaticotemporal suture Most displaced #s are depressed and rotated laterally, resulting in asymmetric pupil levels/orbital dystopia, ZF step, antimongoloid slant

What conditions are included under failure of formation?

a) Longitudinal: radial/ulnar /central deficiencies ('club/cleft hand'). -b) Transverse: amelia, brachymetacarpia. c) Mixed: phocomelia, symbrachydactyly (terminal differentiation)

what is an oronasocular cleft

aka oblique facial cleft no3 cleft from cupids bow, nasal ala, lower eyelid coloboma (eyelid cleft) is medial to punctum nasolacrimal system disrupted

Gentamicin

aminoglycoside bactericidal need O2 so crap vs anaerobes good for GNR synergistic w beta lactams SE are nephro, ototoxicity, teratogen

how do you block lower lid & upper lip?

block infraorbital n (V1) at its foramen just before it divides into 4 branches: inf palpebral, external nasal, int nasal, sup labial nerves

commonest facial cleft

cleft no 7 aka hemifacial microsomia -1 in 3000 -variable expression -from macrostomia at oral commissure & continues across cheek towards a microtic ear -hypoplastic zygoma, mandible, temporal bone -may have skin tag only in "form fruste" version

blepharoptosis classification

congenital myogenic (abnormal levator) neurogenic (abn CN III or SANS) involutional/senile mechanical ciccatricial

aging changes in face hard tissue

decreased height in mid and lower face increased facial width less chin prominence increased frontal sinus prominence increased zygomatic arch prominence increased facial depth

indications for surgery on frontal sinus #

depends on state of ant & post table & nasofrontal ducts -displaced ant table may req OT -displaced post table #s >1 wall thick req OT -suspicion of NF duct involvement may req OT -nondisplaced post table #s may be observed if theres no CSF leak

how is HA used in PRS?

eg Bonesource, Norian, Mimix -facial skeletal augmentation -cranioplasty defects up to 25cm2

how much do facial implants augment the face? in what plane do you place them?

facial soft tissue response to facial skeleton change is 0.66, ie implant w 1cm projection gives 0.66cm, due to overlying soft tissue thinning place them subperiosteally

pedicle of great toe transfer

first dorsal intermetatarsal artery, usually from DPA but sometimes from deep plantar system

what syndrome is hemifacial microsomia plus epibulbar ocular dermoids and vertebral anomalies

goldenhar syndrome

risks of breast implant insertion

hematoma 1.5% infection 2.2% capsule contractures 5% saline nerve injury* 15% malposition unsightly scars *Anterior branch of T4 enters breast 2cm from lateral edge of gland to supply NAC. Injured from aggressive lateral dissection

commonest complication after any nerve compression release

injury to nearby nerve eg CTR = PCB eg cubital tunnel = MCN forearm eg tarsal tunnel = post br saphenous nerve

What is more common, intracranial or extracranial AVMs?

intracranial AVMs are 20x commoner

Brachytherapy Qs

isotopes should be inserted at surgery - involves external beam radiation - reduced treatment time with more tissue damage

benefits of textured implants

less contracture (textured area diverts linear scar) less mobile from tissue intregration (can lead to rippling from overlying mobile skin)

compare omphalocele & gastrocele

omphalocele -failure of 4 folds of abdo wall to fuse -midline defect -sac covers eviscerated organs eg SI, liver -umbi is attached to apex of sac -underlying gut is normal -associated sternal probs, heart defects, etc gastrocele -full thickness abdo wall defect -lateral defect -no sac covers the herniated viscera -umbi is in usual spot -intestines abnormal becuase of prolonged contactw amnion -less a/w syndrome

retaining ligs of face - types, names

osteocutaneous ligs - zygomatic ligs: suspend malar fat pad; weakness a ageing causes prominent NLF - mandibular ligs supporting ligs - run from deep to superficial fascia eg parotidocutaneous

thumb recon options

osteoplastic recon finger pollicisation toe transfer prosthetic

incidence of hernia after TRAM

pedicled TRAM 0.2-16% free TRAM 1-5%

mandible subcondylar #s present w...

premature contact on ipsilateral side (as ramus is shorter on this side) with resultant contralateral open bite

SOF syndrome

ptosis eyelid proptosis of globe paralysis of nerves III, IV, VI anesthesia in V1 above + blindness = orbital apex syndrome

cmn classsification

small <1.5cm * medium 1.5-19.9cm* large >20cm* *or predicted to be that size if kept growing

collar button abscess

subfascial palmar space abscess cant go volar, so goes into dorsal subcut space between fingers

classic hyperparathyroid changes in hands

subperiosteal resorption at radial sides of middle phalanx

BCC in situ

superficial bcc -approved Rx is imiquinoid -clears 82% -need Bx first to r/o psoriasis etc

how do you block a forehead?

supraorbital n (V1) & supertrochlear n can both be blocked by infiltration along horizontal line extending 2cm above eyebrow from lateral orbital rim to midline

skin substitutes classification

temporary or permanent biological or biosynthetic dermal or epidermal or combined

facial buttresses - transverse, vertical

transverse: mandible, palate, orbital rims, frontal bar vertical: nasomaxillary, zygomaticomaxillary, pterygomaxillary, posterior (mandible ramus)

What is a "blowout" fracture?

traumatic force applied to rim >> globe --> sudden increase in IOP --> incompressible intraorbital contents are displaced posteriorly & traumatic force is transmitted to thin orbital floor & medial orbital wall, which are the first to fracture

bilateral 6, 7, 8 facial clefts is...

treacher collins -3 clefts involve maxiloozygomatic, temporozygomatic, frontozygomatic sutures -no 6 cleft = lower lid coloboma -no 7 cleft = absent zygoma (hallmark of TCS) -no 8 cleft=absent lat orbit wall

preRx for trichloroacetic acid chemical peeling?

tretinoin decreases stratum corneum thickness so more permeable to TCA hydroquinone decreases melanocyte activity so less postpeel hyperpigmentation

difference in true collateral and accessory collateral ligaments

true collateral: condyles of proximal bone->palmar third of distal bone accessory collateral: condyles of proximal bone-> volar plate

Palmar fat pads

tubiana

classification of mandible defects in hemifacial microsomia

type I - all parts there just hypoplastic type IIA - condylar process only allows hinge movement, no translatory movement type IIB - no condylar process articulates w TMJ type III - entire mandible ramus absent

angle classification of malocclusion

uses upper 1st molar as point of reference & describes the ant/post (mesial/distal) relationship between teeth -class I neutroocclusion: mesiobuccal cusp of maxillary first molar articulates within buccal groove of lower first molar -class II malocclusion: lower arch is posterior, ie mesiobuccal cusp of maxillary first molar articulates with distal portion of mandibular second bicuspid and mesial cusp of first molar. -class III malocclusion: mandibular dentition is positioned mesially in relation to the maxillary dentition. Thus the mesiobuccal cusp of the first upper molar intercuspates with the distobuccal groove of the lower first molar.

list high MN tendon transfers

want... *thumb opposition: EIP to APB *thumb IP flexion: BR to FPL *IF & MF DIP flexion: tenorrhaphy of IF/MF to RF/LF FDP

best xray for frontal sinus #

waters view (posteroanterior oblique) ct is toc - floor # that run near midline, cross midline, run near posterior wall, or involve NOE complex are indirect evidence of ductal injury

what are some anaesthetic considerations for sickle cell disease

well hydrated; transfuse only if Hb <70; well oxygenated; normothermic; inspired O2 40-50%; TQ's are safe as long as well hydrated & oxygenated

Non surgical options for facial rejuvenation

what type for what indication -dermabrasion of eyelids -Botox for rhytids -Hyaluronic acid for contour irregularities

tenolysis indications

when PROM >>> AROM at same joint, and all wounds etc healed

What is collagen

• 30% of total body protein. • Formed by hydroxylation of aminoacids lysine and proline. • Procollagen is initially formed within the cell. • Procollagen is transformed into tropocollagen after it is excreted from the cell. • Collagen formation is inhibited by colchicine, penicillamide, steroids, vitamin C and iron deficiency. • Each type of collagen shares same basic structure but differs in relative composition of hydroxylysine and hydroxyproline & degree of cross-linking between chains. • Ratio of type 1 : type 3 in normal skin is 5 : 1. • Hypertrophic & immature scars contain a ratio of 2 : 1 or less. • 90% of the total body collagen is type 1.

What other terms have been used to describe CRS?

• Acrosyndactyly refers to digits joined together at tips, creating appearance of peak (Greek: acro = peak). • Anular band is a ring around a body part; constriction ring is the preferred term to describe the same phenomenon. • Fenestrated syndactyly refers to the sinuses at the base of the webbed digits. At the time of ischemic insult caused by the constricting band, separation of the digit via programmed cell death has started. Although the webbing recurs as a result of the distal inflammatory process, the separation may persist and presents as a dorsal-to-palmar epithelial-lined sinus that can be easily probed. The actual level of the sinuses is always distal to the level of the normal commissure. •Placental bands and amniotic bands refer to the strands that wrap around body parts. At birth, desiccated strands wrapped around digits represent the loose strands of the chorionic sac that have separated and become entangled around fingers, toes, and other body parts. • Congenital amputations refer to transverse loss of tissue or failure of formation. They are commonly seen in CRS but are not exclusive to it.

stages of CRPS

• Acute: few weeks - 3 months. Diffuse disproportionate burning pain, oedema & reduced ROM, skin hyperthermic or hypothermic, XRs may show early bony changes. • Dystrophic: 3-12 months. Pain - constant, worse w any stimulus, indurated skin & fascia, cool sweaty skin, dry hands, atrophic soft tissue esp fingertips. XR may see osteoporosis, triple-phase bone scan positive. •Atrophic: chronic. Pain - spreads proximal, may reduce severity but still constant. Irreversible tissue damage, skin thin & shiny, no oedema, atrophic muscles, joint contractures, cool skin. XR shows demineralization.

What is a four-flap Z-plasty?

• An effective technique to elongate an area of tissue, used well in 1st webspace & axillary contractures • Essentially is two indepedent Z plasties • A 90°/90° angle or 120°/120° angle Z-plasty is designed • This two-flap Z-plasty is then converted to a four-flap by bisecting the angles, creating flaps that are 45° or 60° • Transposition results in outer flaps becoming inner flaps, & inner flaps becoming the outer flaps • Eg 'ABCD' becomes --> 'CADB' (CADBury). • This produces greater lengthening (124%) with less tension

what is glomus tumour

• Glomous is an arteriovenous anastomosis involved in thermoregulation. Large number are present beneath nails and in finger pulps. • Patients with glomus tumours typically present with the triad of pain, tenderness, cold insensitivity. • Love's sign is presence of one exquisitely painful spot on palpation. • Hildred's sign is reduction of pain on exsanguination of affected part. • Treatment is by surgical excision

indications for operation in dupuytrens

• MCPJ flexion > 20-30° • Any IPJ contracture • Painful nodules • Rapidly progressive disease • A strong family history of aggressive disease

What is actinic or solar keratosis?

•Caused by UV damage so in sun exposed areas •Multiple, discrete, reddish, maculopapular, dry, scaly •Almost all progress to SCC, w 20% invasive SCC •Rx currettage, ED, nitogen, 5-fluorouacil (Efudex)

Incidence of CS?

•Common CS: Europe 1 in 2200 live births, or 343 in 1000,000. •Rare facioCS eg Aperts 1 in 150 000 •Most nonsyndromic single suture CS is sporadic •Most syndromic are AD or AD, w variable penetrance

What is different about cleft 7?

•Commonest facial cleft, 1 in 3000 births •Usually occurs alone, ie not with any other pair, but can be bilateral

anatomy of palmar fascia

• Palmar aponeurosis has 3 layers: 1 A superficial layer containing longitudinal fibres 2 An intermediate layer containing transverse fibres 3 A deep layer containing vertical fibres binding it to the metacarpals. • Distally the longitudinal fibres split into three layers and insert: 1 Superficially into skin of palm 2 Into spiral band of Gosset which passes into lateral digital sheet 3 Deeply into middle phalanx & flexor sheath. • The spiral band is normal condensation of fascia that extends from the longitudinal fibres of palmar fascia to natatory ligament. • The natatory ligament passes transversely across the web space; its contracture limits separation of the fingers. • The lateral digital sheets are condensations of fascia that run vertically along the finger outside the neurovascular bundle. • Grayson's ligaments pass laterally from the proximal and middle phalanx to skin volar to NVB • Cleland's ligaments pass laterally from proximal and middle phalanx to the skin dorsal to NVB & are never involved in DD • Aide-mémoire: ClelanD's ligaments are Dorsal.

pathological anatomy of palmar fascia

• Pretendinous cord is contracture of superficial longitudinal layer of the palmar fascia • Central cord is continuation of pretendinous cord into finger (it has no band precursor) • Lateral cord is a contracture of the lateral digital sheets. • An abductor digiti minimi cord is often present on the ulnar side of the little finger. • A spiral cord is made up of 4 elements (PSLG) from proximal to distal: Pretendinous cord, Spiral cord, Lateral digital sheet, Grayson's ligament. Forms a tight cord attached proximally to palmar fascia and distally to middle phalanx. As it contracts it pulls NVB medially & superficially

What is leukoplakia?

•"White patch" on oral, vulval, vaginal mucosa •In old men, smokers, ill fitting dentures, bad teeth •20% become SCC - more aggressive than SCC from AK's

What is Virchows law?

•1851 Virchow noticed cessation of growth prependicular to affected suture, resulting in compensatory growth *parallel* to affected suture

What is von Langenbeck operation?

•1859, elevation of bilateral bipedicled mucoperiosteal flaps w lateral relaxing incisions. Need to do IVV as well. Doesn't lengthen palate.

What operations are done before 1 year? After 1 year?

•1st year: Frontal bone advancement with or without strip craniectomies, vault remodeling, shunt surgery for hydrocephalus. •>1 year: Le Fort III advancement +/- frontal bone advancement, monobloc advancement, jaw surgery (usually early adolescence), which may include Le Fort I osteotomy & genioplasty

What is likelihood of having second child with CP?

•2% if 1 sibling affected, 13% if 2 siblings •7% if 1 parent •17% if 1 parent & sibling

What is a monobloc advancement? Is it safe?

•30yrs ago, Ortiz-Monasterio popularized a method of increasing orbital volume for correction of severe exorbitism by simultaneous advancement of forehead, orbits, and midface. •Osteotomy lines are similar to those for combined Le Fort III/FOA except nasofrontal junction & ZF are not osteotomized. Inclusion of orbits with advancement results in a considerable expansion of orbital volume •Main issue is increased risk of infx & CSF leak due to communication created between nasal intracranial cavities by osteotomy design

Where do BCCs occur?

•93% in H&N - see pic (nodular mainly in H&N) •7% in trunk & limbs (superficial BCC mainly in trunk)

What is erythroplasia?

•Aka Bowens of mucous membranes •Affects glans, in uncircumised older men •Defined, moist, velvety lesions •Histo similar to Bowens dz, but erythroplasia is more likely to invade & metastasise

What is the Wardill-Kilner-Veau repair?

•Aka pushback, is VY advancement of HP mucoperiosteum, designed to lengthen palate but leaving exposed bare membranous bone. This granulates & epithelise in 2-3/52, but fibrous scar tissue can cause later maxillary growth restriction

What CMF syndrome has a metabolic disorder?

•Albright syndrome (pseudohypoparathyroidism). Rounded low nasal bridge, short neck, cataracts, short MCs. May also have hypoCa+, hyperPO4

Which craniofacial syndromes affect the limbs?

•Aperts: syndactyly of feet & hands •Saethre-Chotzen: brachydactyly •Pfeffer: large broad great toes & thumbs •Carpenter: short hands & polysyndactyly of feet •Nagar: missing digits, syndactyly, hypoplastic radial side

Describe timing in Millards CL protocol

•At 10 pounds weight, put Latham device in •When segments aligned, GVP & lip adhesion is done •At 6/12 CLR w primary rhinoplasty •At 18/12 CPR w any lip touch ups

When does brain volume & cranial capacity approximate 50% of adult?

•At 6 months of age. Brain volume triples in 1st year, quadruples by 2nd. Sutures must remain open for this to occur, so CS is an obstacle to normal vault growth

How is a BCL repaired?

•At GVP a lip adhesion is done, joining lateral lip elements (LLE) to prolabium. •LLE's are freshed by turndown of mucocutaneous flaps, which are overlap turndown flap from inferior prolabium vermillion •This hides the unnatural prolabium & creates a natural looking Cupids bow •During CPR at 18/12 the prolavium has stretched enough to accept a forked flap that was banked in whisker position beneath the alar. Nasal tip is released, alar cartilages are freed & sutured to recontruct the medial crura, & columella is lengthened

When should pts w BCC or SCC be re-examined?

•BCC 6 monthly for 5 yrs, as 36% will get another in 5 years •SCC 3 monthly for several yrs, then 6 monthly indefinitely, due to risk of spread. 18% get 2nd SCC within 3 years

Compare growth of brain & skull in 1st 2 years of life

•Brain size doubles in 1st year •2yo the ant BOS is 70% adults size, while brain has increased 4x since birth

What is CS & who first described it?

•CS is premature fusion of one or more sutures in either cranial vault or cranial base. •Hipporcrates described it in 100BC

What is the main feature of faciocraniosynostosis cf CS?

•CS: skull + forehead/orbital deformities •FCS: above + midface hypoplasia w centrofacial retrusion & class III malocclusion

Blepharophimosis syndrome

•Congenital syndrome w B-PET -blepharophimosis: horizontal narrowing eyelid fissure -Ptosis from poor levator fxn. Rx w frontalis sling -Epicanthus inversus (~fold). Rx w 5 flap Zplasty -Telecanthus. Rx w transnasal wire •Unknown cause, AD inheritance •May get other facial & systemic abnormalities eg lateral ectropion (may req lateral canthoplasty and lower eyelid skin grafting) •Rx before school age

What is syndromic CS?

•Constellation of congenital abnormalities including CS. Most commonly coronal CS, eg Aperts, Crouzons. •Makes up 20% of CS cases, or 2 in 100,000 live births

Benefits of Millard repair?

•Creates symmetrical cupids bow •Scar along philtrum column & preserves philtral dimple •No interlocking flaps mean secondary correction easier

Name factors assoc w SCC recurrence

•Differentiation: poor 28% vs well 7% •Depth of invasion •PNI •Overall SCC twice likely as BCC to recur

Summarise the evolution of unilateral CL repair

•Early: freshened edges & closed •Later: lengthen cleft side w flaps

What is the Tessier classification of facial clefts?

•Face is cut in half, each side is clock from 0 (inf) to 14 (sup) •O cleft is through midnose •14 is through nasofrontal suture & midfrontal region •1,2,3 through piriform aperture •4,5,6 through media, middle, lateral 1/3s lower eyelid •7 through lateral oral commissure •8 through lat commissure palp fissue & into temple •8-14 are extensions of their midfacial counterparts •Usually clefts occur in pairs that equal 14, eg 0 & 14

What is Passavant's ridge?

•Forceful contraction of both LVP & superior pharyngeal constrictors may produce bulge or ridge on posterior pharynx above atlas •Can occur normally in gagging, or abnormally in VPI as compensatory mechanism to help palate closure

What are clinical signs of BCC recurrence?

•Healed scars that intermittently ulcerate or get infected •Scar that becomes red, scaled, crusted •Enlarging scar w surrounding telangiectasia •Nodule within scar •Frank tissue destruction

What investigations are helpful for stage III melanoma disease?

•Heterogenous group so need to tailor investigations to how pt presents i) SLNB +ve but clinically -ve LNs (stage IIIA/B, microscopic disease): Routine Ix not recommended (true +ve rate of CT chest/abdo/pelvis & MRI is <2%) unless being Ix for therapeutic LND and Dx of occult mets would influence Rx. ii) Clinically +ve LNs (stage IIIB/IIIC, macroscopic disease): Investigate with blood tests (incl LDH), and CT/PET (with macroscopic disease will Dx occult mets in 20%, influence Rx 50%, but can have false positives to 20%) iii) In-transit mets. There's no evidence for in-transit mets so recommendations are same as the clinically +ve LN group

What is VPI?

•Inability of SP to make contact with posterior pharyngeal wall during speech, resulting in abnormal speech eg hypernasality, decreased vocal intensity. •Evaluation of palatal fxn begins once speech begins eg 4yo, is ongoing, w incidence of 7-30%

What common mistakes are made in Millard repair?

•Inadequate rotation from no cut-back on rotation incision •Inadequately paring of cleft edge •Not using C flap to reduce cutback gap in upper lip & to lengthen columella on CS •Vertical lengthening of entire lip by extending cutback across normal philtrum column •Too much reduction of nostril size incomplete clefts

What are the features of a nodular BCC?

•Initially - single, small, firm, translucent (pearly), papule or nodule, telangiectasia •Grow slowly & ulcerate, can cause local tissue destruction •Commonest subtype

What cells does an SCC arise from?

•Keratisining or malphigan (spindle) cell layer of epithelium •1st is smooth, verrucous, papillomatous, or ulcerative •Later is indurated, inflammed, ulcerated

What muscles contribute to velopharyngeal closure?

•LVP most important: pull SP sup & post to knuckle vs pharyngeal wall •Palatopharyngeus pull SP posteriorly •Uvulae cause uvula to thickken centrally w contraction •Sup pharyngeal constrictors move lat pharyngeal walls medially or posterior pharyngeal wall anteriorly

What is most important abnormality seen in CP?

•LVP normally joins in midline w transverse orientation by inserting into middle of SP via palatal aponeurosis •In CP LVP is longitudinally orientated & inserts along the bony cleft

what anatomical structures are responsible for various MCPJ, PIPJ, DIPJ contractures

•MCPJ contracture: by pretendinous cord, which attaches to skin & tendon sheath distal to MP joint. •PIPJ contracture: central cord > spiral cord > lateral cord, with all 3 attached to base of MP •DIPJ contracture: retrovascular > lateral cord, with both attaching to DP •Natatory cord contracts web space & prevents fingers from separating. •Thumb MCPJ contracture is pretendinous cord, natatory cord, and termination of transverse fibers of palmar aponeurosis

What are advantages of early orthodontic manipulation & GVP of the alveolar cleft?

•Minimises fistulas •Creates bone bridge across cleft that will accept teeth & not req ABG •Creates stable platform for CLR

What is the argument of timing of CP closure?

•Most agree CPR should be 6-9 months. •Earlier gives better speech, but more growth restriction. •Late closure means poor speech -difficulty building up pressure for sounds like P & T -difficulty sustaining pressure for sounds like S & H -can speak w these sounds missing/distorted -can speak w *compensatory articulation* eg glottal stop, pharyngeal fricative

What are the different types of BCCs?

•Nodular ulcerating •Superficial •Sclerosing/morpheic •Pigmented •Trabecular (Merkel) •Adnexal

What is the incidence of clefts?

•Overall incidence of CP is 0.5 per 1000 live births •Unlike CL, CP has no racial heterogenity •Overall cleft ratio is CLP 50%, CPO 30%, CL 20%, •CL is L:R:Bilateral 6:3:1, & 86% bilateral CL have CP also •Commonest is bifid uvula (2% popn): usually ASx, but VPI in 20%

What is clinical significance of PNI or mucoperiosteal invasion?

•Perineural, lymphatic, mucoperiosteal invasion indicate advanced disease, more risk of metastasis, less risk of local cure •Eg SCC in mucoperiosteum of piriform aperture is very hard to cure

How does Rx of UCS (plagiocephaly) differ from Rx of BCS (brachycephaly)?

•Plagiocephaly Rx is *unilateral* problem Rxed w *bilateral* forehead remodeling & removal & modification of single supraorbital bandeau extending across both orbits. This corrects forehead symmetry, AP position & superoinferior discrepancy of supraorbital rims. •Plagiocephaly is similar to brachycephaly Rx (eg bilateral FOA) but orbital symmetry is bigger problem in plagiocephaly, requiring anteroinferior and slight medial translocation of the affected supraorbital rim. •In mild cases only unilateral Rx is required, w supraorbital bandeau on affected side osteotomized and advanced. The anterior cranial vault is contoured to accommodate both sides of supraorbital bar & yield a seamless reconstruction

What cells does BCC arise from?

•Pluripotential cells of basal layer of epithelium or from external root sheath of hair follicle •Occurs most where high % of pilosebaceous follicles •Reqs stroma for survival: doesnt arise from abn mature cells like SCC

Why is lip adhesion done?

•Pre-PSO it served as crude orthodontic molding device to align segments & narrow cleft width

What are the specific deformities in bilateral cleft lip?

•Premaxillary vomer segment grows anterior •Shortage of columella skin •Prolabium lacks muscle, philtral columns, dimple, Cupids bow •Alae are spread wide, alar cartilages are dislocated, nasal tip is depressed from short columella

What are the key steps to keep in mind during surgical planning for OHT correction?

•Remember average IOD is 25 mm females & 28 mm males. •Check level of the cribriform plate prior to surgery. •Preserve continuity of nasal mucosa to cribriform plate to minimize loss of smell. •Choose the surgical procedure that best suits the pts anatomy (facial bipartition, U-shaped osteotomies, or box osteotomies). •Discuss postsurgical redundant nasal skin with family and the options for correction.

What is the main risk of early alveolar construction, & how can this be avoided?

•Retrusion of premaxilla - can prevent & also fix w orthodontics

What is the Millard repair?

•Rotation incision releases lip tissue incl Cupids bow, down into normal symmetrical position w opposite side •Advancement of lateral lip into rotation gap to complete lip reconstruction; advancement helps correct flaring alar •Scar is along line of natural philtrum column & preserves any philtral dimple

Bowen disease

•SCC insitu •Occurs in both SEA & nonSEA, in skin or mucous membrane •Solitary, defined, dull, scaly plaque •Long clinical course, Rx curettage or ED •If SCC develops is more aggressive than SCC from AK

What is Bowens disease?

•SCC insitu •Occurs in both SEA & nonSEA, in skin or mucous membrane •Solitary, defined, dull, scaly plaque •Long clinical course, Rx curettage or ED •If SCC develops is more aggressive than SCC from AK

How does adnexal carcinoma behave?

•Solitary lump in old people •Arises from sebaceous sweat glands •Grow slowly, recur locally, can metastasise

What is a sebaceous naevi?

•Superficial congenital head & neck skin lesion •Well defined, irregularly raised plaque •Has no hair •10% become BCC

What is primary stimulus for growth at the cranial suture?

•Suture growth is a secondary compensatory & mechanically obligatory event following the primary growth of enclosed brain & ocular globes. Expanding brain bulges the skull out, & each bone responds by depositing new bone at contact edges of sutures

Summarise the evolution of bilateral cleft lip surgery

•To help closure surgeons amputated the premaxilla, creating an oral cripple •Brophy used circumferential wire to encircle 3 maxillary elements & crunch them together to help lip closure •Lip closure over the premaxilla caused ventroflexion of septum •PSO to retract premaxilla & align arch

What is "tower skull"?

•Towerskull: acrocephaly & turricephaly are unRxed brachycephaly w excess of skull height & vertical elongation of forehead

What is Furlow repair?

•Two double opposing Z plasties to repair the SP, one on palate side & other on nasal side •Levator muscle is included on both oral & nasal posteriorly based flaps, while anterior flaps are mucosa only •Results in reorientation of levator muscles, permits overlap in their repair, & lengthens the palate

What are the key deformities in unilateral cleft nose & how are they corrected?

•Unilateral short columella: lengthened w C flap •Septal deviation: PSO •Alar cartilage dislocated & slumped: dissect medial crus then insert sutures to normal side •Alar base flaring: alar cinch procedure

What are the histopathology features of BCC?

•Varies w subtype •Common chx are irregular basal cells, w peripheral cells forming palisading layer, & stroma has fibrous reaction

What are the 2 regions of the skull

•Viscerocranium or splanchnocranium: facial skeleton •Neurocranium: houses brain & consists of vault (roof & walls) & base (floor)

why are LHS clefts commoner than RHS?

•W7: palatal shelves swap from vertical to horizontal position •R becomes horizontal before L, so L more vulnerable to problems

What are 3 inherited condition that predispose to skin cancers?

•Xeroderma pigmentosum: AR; acute UV sensitivity from defective DNA repair; many epitheliomas --> NMSC •Gorlin syndrome: AD w multiple BCC, jaw cysts, palm/sole pits. Also pseudohypotelorisim, frontal bossing, syndactyly, spina bifida •Albinism: hypopigmented skin, hair, eyes w inc NMSC risk

What is the premaxilla?

•alveolar segment of maxilla, anterior to incisive foramen •contains nasal spine & 4 incisors