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![Outline of Topics General overview of service Expectations Plastic surgery](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-1.jpg)
Outline of Topics
General overview of service
Expectations
Plastic surgery “Emergencies”
Hand
Face
Soft tissue injuries
Decubitus ulcers
V.A.C.
system
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![General Overview Plastic surgery at the VA and Elmhurst is](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-2.jpg)
General Overview
Plastic surgery at the VA and Elmhurst is a relatively
small service staffed soley by the plastic surgery chief resident or senior resident
A general surgery junior resident is responsible for covering the service during off-hours and weekends. This includes the in-patients (which are rare) and the ED consults
YOU ARE NOT ALONE – the plastic surgery resident is always reachable by pager or phone, and ALWAYS available to come in to assist you with complex questions
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![VA is a light service and most ED consults are](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-3.jpg)
VA is a light service and most ED consults are facial
lacerations or hand injuries
Elmhurst is significantly busier especially during “hand” weeks
Plastic surgery and Ortho alternate hand coverage weekly. You should know what service is covering when you are on call
Plastic surgery/ENT/OMFS alternates “face” call. You should refer to the call schedule for the coverage details
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![Expectations You are not expected to know everything about plastic](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-4.jpg)
Expectations
You are not expected to know everything about plastic surgery
YOU SHOULD:
be
competent in the basic physical exam (hand, face)
Be able to assess severity of injuries
Be able to clearly describe injury to the plastic surgery resident
Be able to identify plastic surgery “emergencies”
Be comfortable with digital nerve blocks, splinting, and suturing
Know when to call for help
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![Plastic Surgery “Emergencies” Hand/Extremity: amputation, near amputation, vascular compromise compartment](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-5.jpg)
Plastic Surgery “Emergencies”
Hand/Extremity:
amputation, near amputation, vascular compromise
compartment syndrome
Uncontrolled bleeding
Face:
Entrapment of ocular
muscles
Septal hematoma
Complex multifacial trauma
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![Hand Includes soft tissue distal to the elbow and bones](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-6.jpg)
Hand
Includes soft tissue distal to the elbow and bones on wrist
and distal
Radius/Ulnar fractures are always orthopedics
Most common injuries include:
Fractures
Lacerations
Tendon injuries
Nerve injuries
Nailbed injuries
Cellulitis
IV infiltrate
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![“Hand History” Specifics about “hand history” Mechanism of injury (crush,](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-7.jpg)
“Hand History”
Specifics about “hand history”
Mechanism of injury (crush, laceration, fall)
Right-handed or
left-handed
Occupation (piano player, construction)
Tobacco use
Diabetes
Injury at work or at home
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![](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-8.jpg)
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![Amputations This is an emergency - the clock is ticking…](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-9.jpg)
Amputations
This is an emergency - the clock is ticking…
Call the plastic
surgery resident
Also, facilitate the following in the ED:
Tetanus, IV ABx
Xray of hand (yes this is important)
Pre-op labs – results should be printed and sent with patient
Let the ED attending know that patient shold be transported to Sinai
Packaging of part – place in plastic bag, then place that on ice. NEVER PUT PART DIRECTLY IN ICE
If part is “hanging” by small skin bridge, NEVER COMPLETE THE AMPUTATION. Wrap bag of ice around hand and secure with ace bandage.
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![Fractures 95% of time will simply advise to place in](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-10.jpg)
Fractures
95% of time will simply advise to place in splint
Splint options:
Phalanx,
metacarpal, carpals- volar splint
“boxer” fracture, 4th/5th metacarpal - ulnar gutter splint
Thumb- thumb spica splint.
NO CASTS
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![Thumb spica Basic Splinting Position of “safety”](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-11.jpg)
Thumb spica
Basic Splinting
Position of “safety”
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![Flexor Tenosynovitis Infection in flexor sheath 4 classic Knavel Signs](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-12.jpg)
Flexor Tenosynovitis
Infection in flexor sheath
4 classic Knavel Signs
Pain with passive motion
Fusiform
swelling
Fixed in flexion
Pain along tendon sheath
Treatment is operative drainage
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![Tendon Injuries You are not expected to know how to](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-13.jpg)
Tendon Injuries
You are not expected to know how to repair these
You
must be able recognize the injury
Know anatomy
FDP flexes at DIP joint
FDS flexes at PIP joint
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![FDS tendon – flexes PIP joint](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-14.jpg)
FDS tendon – flexes PIP joint
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![FDP tendon – flexes DIP joint](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-15.jpg)
FDP tendon – flexes DIP joint
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![Extensor tendon](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-16.jpg)
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![Nerve Injury Must have high degree of suspicion given location](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-17.jpg)
Nerve Injury
Must have high degree of suspicion given location of laceration
Most
of the time, patient will say that it feels “a little weird at the tip”. This is more common then complete numbness.
Repair not emergent. Should be fixed in 7-10 days for optimal results.
Important to test BEFORE giving anesthesia
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![Lacerations Close in 1 layer with 4.0 nylon sutures Not](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-18.jpg)
Lacerations
Close in 1 layer with 4.0 nylon sutures
Not too tight –
it will swell
Bacitracin/xeroform/dry dressing
May place splint for comfort
Elevation
ABx – 1 dose IV in ED and 5-7 days oral
Tetanus booster
Sutures remain for 2-3 weeks
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![Digital Block 1% lidocaine – NO EPINEPHERINE 2 nerves –](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-19.jpg)
Digital Block
1% lidocaine – NO EPINEPHERINE
2 nerves – must block both
for each finger
2 techiques:
Individually block each nerve (in web space)
Trans-thecal – inject into tendon sheath and anesthetic diffuses out sheath into nerves
You can always inject directly into wound
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![Individual Nerves – inject in each web space Trans-thecal –](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-20.jpg)
Individual Nerves – inject in each web space
Trans-thecal – inject in
tendon sheath at A1 pulley
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![Nailbed injury Typical injury is “crushed finger in door” Remove](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-21.jpg)
Nailbed injury
Typical injury is “crushed finger in door”
Remove nail-plate
Assess nail-bed injury
(below plate)
Nail-bed repaired with 6.0 chromic
Nail-plate replaced under eponychial fold and secured in place with a suture
If no nail-plate, may use foil from suture wrapper
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![](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-22.jpg)
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![Sub-Ungal hematoma Hematoma under nail plate Should be drained if](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-23.jpg)
Sub-Ungal hematoma
Hematoma under nail plate
Should be drained if > 50% nail
surface
Drain by boring a hole in nail with 18 gauge needle. This should not be painful to patient.
If hematoma and nail-plate is partially avulsed, you can simply remove the nail
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![](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-24.jpg)
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![Facial lacerations Rule out other injuries based on location Lacrimal](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-25.jpg)
Facial lacerations
Rule out other injuries based on location
Lacrimal duct
Parotid duct
Facial nerve
Vascular
injury
6.0 nylon or prolene
Sutures removed in 3-5 days
Bacitracin ointment, keep dry
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![Facial Fractures CT scan – axial and coronal with fine](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-26.jpg)
Facial Fractures
CT scan – axial and coronal with fine cuts through
orbits (3mm)
Protect airway if multiple fractures or mandible/maxilla fractures
10 % incidence of C-Spine injury in setting of mandible fracture or multiple facial fractures
All patients need spine cleared if significant facial injury.
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![Orbit Fracture Opthamology must see the patient Assess gross vision](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-27.jpg)
Orbit Fracture
Opthamology must see the patient
Assess gross vision
Assess occular muscles
Entrapment is
emergency
Check for forehead parathesia (supra-orbital N.) and cheek parathesia (infra-orbital N.)
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![Nasal Fracture Look for septal hematoma Must be drained if](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-28.jpg)
Nasal Fracture
Look for septal hematoma
Must be drained if present to prevent
septal necrosis
Is fracture stable or unstable (“crunches” when palpated)
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![Septal Hematoma](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-29.jpg)
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![Complex Soft Tissue Injuries Assess wound Irrigate copiously Xray to](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-30.jpg)
Complex Soft Tissue Injuries
Assess wound
Irrigate copiously
Xray to rule out fractures or
foreign bodies
Most do not need “coverage” or “repair” in the acute setting
Priority is bone/vascular/nerve injuries
Must assess neurologic function before injecting local anesthetic
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![Decubitus Ulcers Only “emergent” if source of sepsis If wound](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-31.jpg)
Decubitus Ulcers
Only “emergent” if source of sepsis
If wound is open and
draining, very unlikely to be septic source
Look for other sources (urine, lungs, etc.)
If “boggy” and fluctuant, need to open wound and allow drainage
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![V.A.C. system Know how to troubleshoot system if called because](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-32.jpg)
V.A.C. system
Know how to troubleshoot system if called because it is
“beeping”
Usually it is a leak in the dressing. Can patch leaks with Tegaderm
If machine says cannister is full…but clearly it is not, most likely because clogged tubing
Change cannister first
If still not working, change tubing on dressing next. Can simply replace “disk”and tube without removing sponge. Cut out disk, replace it, and patch over top of it.
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![](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-33.jpg)
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![Clinic Schedule Elmhurst Plastic surgery – Tues 1 PM, Friday](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/5322/slide-34.jpg)
Clinic Schedule
Elmhurst
Plastic surgery – Tues 1 PM, Friday 9 AM
Hand –
Friday 1 PM
VA
Plastic/Hand – Thursday 1 PM