576 Section III / Subspecialty Surgery

SKIN GRAFTS

What is an STSG?	Split thickness: includes the epidermis
	and a variable amount of the dermis
How thick is it?	10/1000 to 18/1000 of an inch
What is an FTSG?	Full thickness: includes the entire
	epidermis and dermis
What are the prerequisites	Bed must be vascularized; a graft to a
for a skin graft to take?	bone or tendon will not take
	Bacteria must be 100,000
	Shearing motion and fluid beneath the
	graft must be minimized

What is a better bed for a skin graft: fascia or fat?

How do you increase surface area of an STSG?

How does an STSG get nutrition for the first 24 hours?

FLAPS

Fascia (much better blood supply)

Mesh it (also allows for blood/serum to be removed from underneath the graft)

Imbibition

Where does a random skin	From the dermal-subdermal plexus
flap get its blood supply?
Where does an axial skin	It is vascularized by direct cutaneous
flap get its blood supply?	arteries
Name some axial flaps and	Forehead flap—superficial temporal
their arterial supply.	artery; often used for intraoral lesions
	Deltopectoral flap—second, third, and
	fourth anterior perforators of the
	internal mammary artery; often used
	for head and neck wounds
	Groin flap—superficial circumflex iliac
	artery; allows coverage of hand and
	forearm wounds

	Chapter 68 / Plastic Surgery 577
What is the most common	Venous thrombosis
cause of flap loss?
What is a simple
advancement flap?

Defect

What is a rotational flap?

What is a “free flap”?

What is a TRAM flap?

What is a “Z-plasty”?

Pivot

point

Defect

Flap separated from all vascular supply that requires microvascular anastomosis (microscope)

Transverse Rectus Abdominis Myocutaneous flap (see page 410)

578 Section III / Subspecialty Surgery

What is a “V-Y advancement flap”?

Defect

C h a p t e r 69

Who operates on hands?

What are the bones of the hand?

What is the distal finger joint?

What is the middle finger joint?

What is the proximal finger joint?

What are the “intrinsic” hand muscles?

What is ADDuction and ABDuction of the fingers?

Hand Surgery

Plastic surgeons and orthopaedic surgeons

Phalanges (fingers)

Metacarpal bones

Carpal bones

Distal InterPhalangeal (DIP) joint

Proximal InterPhalangeal (PIP) joint

Metacarpal Phalangeal (MP) joint

Lumbricals, interosseous muscle

ADDuction is to midline and ABDuction is separation from midline

		n	A
		t	D	D
		io		u
		c
		u		c
				t
		D		o
	B			i
A				n

Midline

Chapter 69 / Hand Surgery 579

What are the trauma zones of the hand?

1

2

3

1

2

3

4

5

Where is “no man’s land”?

Zone extending from the distal palmar crease to just beyond the PIP joint (zone 2)

Zone 2:

“No Man’s Land”

1

1

2

2

3

3

4

5

What is the significance of the “no man’s land”?

Flexor tendon injuries here have a poor prognosis; a hand expert needs to repair these injuries

SENSORY SUPPLY TO THE HAND

What is the ulnar nerve distribution?

580 Section III / Subspecialty Surgery

What is the radial nerve distribution?

What is the median nerve distribution?

How can the radial	1.	Wrist and MCP extension
nerve motor function be	2.	Abduction and extension of thumb
tested?
How can the ulnar nerve	1.	Spread fingers apart against
motor function be tested?		resistance
	2.	Check ability to cross index and
		middle fingers

How can the median nerve function be tested?

1.Touch the thumb to the pinky (distal median nerve)

2.Squeeze examiner’s finger (proximal median nerve)

Chapter 69 / Hand Surgery 581

How can the flexor digitorum profundus (FDP) apparatus be tested?

Check isolated flexion of the finger DIP joint

	FDP
How can the flexor	Check isolated flexion of the finger at the
digitorum superficialis	MP joint
(FDS) apparatus be tested?

FDS

f r h

Where do the digital	On medial and lateral sides of the digit
arteries run?
What hand laceration should	Lacerations from human bites or animal
be left unsutured?	bites
Should a clamp ever be used	No; use pressure and then tourniquet for
to stop a laceration bleeder?	definitive repair if bleeding does not cease
	because nerves run with blood vessels!

582 Section III / Subspecialty Surgery
What is a felon?	Infection in the tip of the finger pad
	(Think: felon fingerprints infection
	in pad); treat by incision and drainage
What is a paronychia?	Infection on the side of the fingernail
	(nail fold); treat by incision and drainage
What is tenosynovitis?	Tendon sheath infection
What are Kanavel’s signs?	Four signs of tenosynovitis:
	1. Affected finger held in flexion
	2. Pain over volar aspect of affected
	finger tendon sheath upon palpation
	3. Swelling of affected finger (fusiform)
	4. Pain on passive extension of
	affected finger
Most common bacteria in	Staphylococcus aureus
tenosynovitis and paronychia?
How are human and animal	Débridement/irrigation/administration of
hand bites treated?	antibiotics; leave wound open
What unique bacteria are	Eikenella corrodens
found in human bites?
What unique bacteria are	Pasteurella multocida
found in dog and cat bites?
What is the most common	Ganglion cyst
hand/wrist tumor?
What is an extremely painful	Glomus tumor (subungual: under the nail)
type of subungual tumor?
What is a “boxer’s fracture”?	Fracture of the fourth or fifth metacarpal
What is a “drop finger” injury?	Laceration of extensor tendon over the
	MP joint
	Cut

Chapter 69 / Hand Surgery 583

What is the classic deformity Mallet finger resulting from laceration of

the extensor tendon over the	Cut
DIP joint?

What is the classic deformity Boutonniere deformity resulting from laceration of

the extensor tendon over the PIP joint?

Cut

Which fracture causes pain Scaphoid fracture; often not seen on

in the “anatomic snuffbox”? x-ray at presentation, usually seen at a later date (2 weeks) on x-ray

Can result in avascular necrosis Place in a cast if clinically suspected,

regardless of x-ray findings

What is the “safe position” of hand splinting?