This document discusses syndactyly, a congenital hand anomaly where adjacent digits are fused. It describes the typical surgical techniques used to correct syndactyly, including the use of local flaps and skin grafts. Recently, some reconstructive techniques have been developed that do not require skin grafts. The document outlines the steps of syndactyly release surgery, including flap design and elevation, separation of digits, and use of skin grafts if needed. Postoperative complications are also discussed, such as web creep caused by scar contracture.
MEDIAL EPICONDYLE FRACTURE BY DR. VASU SRIVASTAVAVasu Srivastava
A medial epicondyle fracture is an avulsion injury to the medial epicondyle of the humerus; the prominence of bone on the inside of the elbow. Medial epicondyle fractures account for 10% elbow fractures in children. 25% of injuries are associated with a dislocation of the elbow.
Medial epicondyle fractures are typically seen in children and usually occur as a result of a fall onto an out-stretched hand. This often happen from falls from a scooter, roller skates, or monkey bars, as well as from injuries sustained playing sports. The peak age of occurrence is 10–12 years old.[1]
Symptoms include pain, swelling, bruising and a decreased ability to move or use the elbow. Initial pain may be managed with NSAIDs, opioids, and splinting. The management of pain in children typically follows guidelines, such as those from the Royal College of Emergency Medicine.[2]
The diagnosis is confirmed with X-rays and occasionally with a CT scan.
The treatment of these injuries is controversial, and there are currently ongoing international randomised studies. The SCIENCE study is an ongoing study funded by the National Institute for Health Research (UK). A similar study is being planned in the US, funded by the National Institutes for Health (US). These studies both seek to determine if surgery to restore the natural position of the elbow is better than allowing the bone to heal in a cast without restoring the natural position. Children and families internationally are being encouraged to participate in these research studies to resolve the uncertainties.
Videoscopic assisted thoracoscopic surgery in correction of thoracic scoliosisLibin Thomas
This document discusses thoracoscopic scoliosis correction, a minimally invasive surgical technique. It describes how thoracoscopic spine surgery uses small incisions and an endoscopic camera to correct scoliosis through a single-lung ventilation technique. The advantages over traditional thoracotomy include less invasiveness, earlier return to work, and less postoperative morbidity. The document also presents a case study of an 11-year-old female patient who underwent successful thoracoscopic instrumented correction of her scoliosis.
This document describes several posterior surgical approaches to the elbow. It provides details on the techniques for the posterolateral extensile approach, the posterolateral approach in elbow contracture, the Wadsworth extensile posterolateral approach, the Macausland & Müller posterior approach using an olecranon osteotomy, and the Bryan and Morrey extensile posterior approach. Key steps common to many of the approaches include exposing the triceps tendon, retracting the ulnar nerve, reflecting the triceps mechanism or tendon, and exposing the posterior aspect of the elbow joint.
Spondylolisthesis is the anterior or posterior displacement of one vertebra over another. It is caused by defects in the pars interarticularis region which is the weakest part of the vertebra. Spondylolisthesis can be developmental, traumatic, pathological, or degenerative in nature. It is classified based on its etiology and grade. Low grade spondylolisthesis can be managed conservatively while high grade or progressive cases may require surgical intervention like fusion to prevent neurological complications.
Apply gentle pressure proximally
Surgeon: Check distal pulses and capillary refill
If no improvement:
Consider temporary arteriotomy or venous shunt
Delay closure and observe
Flap or graft may be needed
Dr Bipin Ghanghurde, hand surgeon, Mumbai, +917738729068,
Bipinghanghurde@gmail.com
Syndactyly is a common hereditary digit malformation where
adjacent fingers are webbed due to a failure to separate during limb development. Surgical release is indicated in almost every case except for a mild, incomplete syndactyly without functional impairment.
References
Braun TL, Trost JG, Pederson WC: Syndactyly Release. SeminPlastSurg 30:162-70, 2016.
2. Cronin TD. Syndactylism: results of zig-zag incision to prevent postoperative contracture. PlastReconstrSurg (1946) 1956;18(6): 460–468.
3. Dao KD, Shin AY, Billings A, Oberg KC, Wood VE: Surgical treatment of congenital syndactyly of the hand. J Am AcadOrthopSurg 12:39-48, 2004.
4. Malik S: Syndactyly: phenotypes, genetics and current classification. Eur J Hum Genet 20:817-24, 2012.
5. Tonkin MA: Failure of differentiation part I: Syndactyly. Hand Clin 25:171-93, 2009.
6. Withey SJ, Kangesu T, Carver N, Sommerlad BC. The open finger technique for the release of syndactyly. J Hand Surg [Br] 2001; 26(1):4–7.
This document provides an overview of fractures of the calcaneus bone. It begins with background, noting that calcaneus fractures make up about 2% of fractures and most commonly occur in males aged 21-45 from falls or car accidents. While treatment results have historically been poor, operative fixation can provide better long-term outcomes than conservative care for displaced intra-articular fractures. The document then covers anatomy, classifications, mechanisms of injury, imaging, treatment approaches including closed reduction, open reduction and internal fixation, complications, and take-home points.
Charcot joint, or neuropathic arthropathy, is a destructive joint disorder caused by trauma to a neuropathic extremity, most commonly the foot, and is initiated by nerve damage. It results in bone fragmentation, joint dislocation, and foot deformity. The main treatments are immobilization with a total contact cast or custom boot to stop inflammation and preserve foot architecture until healing is complete. Later stages may require surgery like joint fusion or bone excision to prevent ulcers and correct deformities.
MEDIAL EPICONDYLE FRACTURE BY DR. VASU SRIVASTAVAVasu Srivastava
A medial epicondyle fracture is an avulsion injury to the medial epicondyle of the humerus; the prominence of bone on the inside of the elbow. Medial epicondyle fractures account for 10% elbow fractures in children. 25% of injuries are associated with a dislocation of the elbow.
Medial epicondyle fractures are typically seen in children and usually occur as a result of a fall onto an out-stretched hand. This often happen from falls from a scooter, roller skates, or monkey bars, as well as from injuries sustained playing sports. The peak age of occurrence is 10–12 years old.[1]
Symptoms include pain, swelling, bruising and a decreased ability to move or use the elbow. Initial pain may be managed with NSAIDs, opioids, and splinting. The management of pain in children typically follows guidelines, such as those from the Royal College of Emergency Medicine.[2]
The diagnosis is confirmed with X-rays and occasionally with a CT scan.
The treatment of these injuries is controversial, and there are currently ongoing international randomised studies. The SCIENCE study is an ongoing study funded by the National Institute for Health Research (UK). A similar study is being planned in the US, funded by the National Institutes for Health (US). These studies both seek to determine if surgery to restore the natural position of the elbow is better than allowing the bone to heal in a cast without restoring the natural position. Children and families internationally are being encouraged to participate in these research studies to resolve the uncertainties.
Videoscopic assisted thoracoscopic surgery in correction of thoracic scoliosisLibin Thomas
This document discusses thoracoscopic scoliosis correction, a minimally invasive surgical technique. It describes how thoracoscopic spine surgery uses small incisions and an endoscopic camera to correct scoliosis through a single-lung ventilation technique. The advantages over traditional thoracotomy include less invasiveness, earlier return to work, and less postoperative morbidity. The document also presents a case study of an 11-year-old female patient who underwent successful thoracoscopic instrumented correction of her scoliosis.
This document describes several posterior surgical approaches to the elbow. It provides details on the techniques for the posterolateral extensile approach, the posterolateral approach in elbow contracture, the Wadsworth extensile posterolateral approach, the Macausland & Müller posterior approach using an olecranon osteotomy, and the Bryan and Morrey extensile posterior approach. Key steps common to many of the approaches include exposing the triceps tendon, retracting the ulnar nerve, reflecting the triceps mechanism or tendon, and exposing the posterior aspect of the elbow joint.
Spondylolisthesis is the anterior or posterior displacement of one vertebra over another. It is caused by defects in the pars interarticularis region which is the weakest part of the vertebra. Spondylolisthesis can be developmental, traumatic, pathological, or degenerative in nature. It is classified based on its etiology and grade. Low grade spondylolisthesis can be managed conservatively while high grade or progressive cases may require surgical intervention like fusion to prevent neurological complications.
Apply gentle pressure proximally
Surgeon: Check distal pulses and capillary refill
If no improvement:
Consider temporary arteriotomy or venous shunt
Delay closure and observe
Flap or graft may be needed
Dr Bipin Ghanghurde, hand surgeon, Mumbai, +917738729068,
Bipinghanghurde@gmail.com
Syndactyly is a common hereditary digit malformation where
adjacent fingers are webbed due to a failure to separate during limb development. Surgical release is indicated in almost every case except for a mild, incomplete syndactyly without functional impairment.
References
Braun TL, Trost JG, Pederson WC: Syndactyly Release. SeminPlastSurg 30:162-70, 2016.
2. Cronin TD. Syndactylism: results of zig-zag incision to prevent postoperative contracture. PlastReconstrSurg (1946) 1956;18(6): 460–468.
3. Dao KD, Shin AY, Billings A, Oberg KC, Wood VE: Surgical treatment of congenital syndactyly of the hand. J Am AcadOrthopSurg 12:39-48, 2004.
4. Malik S: Syndactyly: phenotypes, genetics and current classification. Eur J Hum Genet 20:817-24, 2012.
5. Tonkin MA: Failure of differentiation part I: Syndactyly. Hand Clin 25:171-93, 2009.
6. Withey SJ, Kangesu T, Carver N, Sommerlad BC. The open finger technique for the release of syndactyly. J Hand Surg [Br] 2001; 26(1):4–7.
This document provides an overview of fractures of the calcaneus bone. It begins with background, noting that calcaneus fractures make up about 2% of fractures and most commonly occur in males aged 21-45 from falls or car accidents. While treatment results have historically been poor, operative fixation can provide better long-term outcomes than conservative care for displaced intra-articular fractures. The document then covers anatomy, classifications, mechanisms of injury, imaging, treatment approaches including closed reduction, open reduction and internal fixation, complications, and take-home points.
Charcot joint, or neuropathic arthropathy, is a destructive joint disorder caused by trauma to a neuropathic extremity, most commonly the foot, and is initiated by nerve damage. It results in bone fragmentation, joint dislocation, and foot deformity. The main treatments are immobilization with a total contact cast or custom boot to stop inflammation and preserve foot architecture until healing is complete. Later stages may require surgery like joint fusion or bone excision to prevent ulcers and correct deformities.
- Limb development begins in the 4th week of gestation from lateral plate mesoderm under the guidance of three signaling centers: the AER, ZPA, and dorsal/ventral ectoderm.
- The AER guides proximal-distal growth through FGF signaling, the ZPA patterns anterior-posterior development using SHH, and the ectoderm determines dorsal-ventral fates through WNT7a.
- Failure of limb formation can result in transverse or longitudinal deficiencies, where parts of the limb fail to develop fully, such as in radial club hand where the radius is absent. Classification systems aim to describe the spectrum of abnormalities.
This document discusses compartment syndrome, beginning with definitions, pathogenesis, and a historical review. It then covers pathophysiology, including normal and elevated tissue pressures. Tissue survival times are provided for muscle and nerve damage. Etiologies and diagnostic criteria are outlined. Pressure measurement techniques and indications for fasciotomy surgery are described for various body areas like the forearm, leg, thigh, and foot. Post-operative care and potential medical-legal issues are also summarized.
This document provides information about syndactyly, including its definition, embryology, etiology, types, evaluation, management, surgical techniques, complications, and its association with certain genetic syndromes. Syndactyly is a fusion of soft tissue or skeletal elements of adjacent digits. It occurs when normal digital separation fails during development. Surgical correction aims to separate the digits and reconstruct the intervening skin and tissues. Timing, flap design, and postoperative care require consideration to optimize outcomes and prevent contractures. Syndactyly can be an isolated anomaly or part of genetic syndromes like Apert syndrome or Poland syndrome.
Can read freely here
https://sethiortho.blogspot.com/
Thoracic outlet syndrome
Neurovascular symptoms in the upper extremities due to pressure on the nerves and vessels in the thoracic outlet area
The specific structures compressed are usually the nerves of the branchial plexus and occasionally the subclavian artery or subclavian vein
Anatomy
Thoracic outlet
Entrance/ Exit region of the upper limb
The thoracic outlet is defined as the interval from the supraclavicular fossa to the axilla that passes between the clavicle and the first rib
Anatomy - Scalane triangle
Anatomy of the costoclavicular space
Pectoralis minor space
Located inferior to the coracoid process
anterior to the second through fourth ribs
posterior to the pectoralis minor muscle
The cords of the brachial plexus
Axillary artery
Axillary vein.
Soft-tissue Causes (70%)
Scalene muscle
Variations in insertion
Hypertrophy
Accessory scalenus minimus muscle
Anomalous ligaments or bands
Soft-tissue tumors
Osseous Causes
Cervical rib
Prominent C7 transverse process
Displacement or callus from first rib fracture
Malunited clavicle or first rib fracture
AC or SC joint injury or dislocation
Osseous tumor
Poor posture
Drooping the shoulders
Holding the head in a forward position
Repetitive activity
Athletes and swimmers
Neurogenic TOS
Compression – scalene triangle and costoclavicular space
May be associated with normal anatomy
Traction of the lowest trunk of the brachial plexus
Often in association with arterial TOS
Features of Lower brachial plexus compression - Common
Female predominance
Appearance of Amedio Modigliani painting
Complains of pain and paresthesia extending from the shoulder /down the ulnar aspect of the arm into the medial two fingers
Neurogenic TOS
Upper brachial plexus compression C5,C6 and C7
Less common
Compression mainly occurs in scalene triangle
Symptoms
Unilateral occipito-frontal headache
Facial or jaw pain
The Gilliatt-Sumner hand
A characteristic finding of neurogenic TOS, is described as atrophy of the abductor pollicis brevis and, to a lesser degree, the hypothenar musculature and the interossei.
Venous TOS
Causes
Hypertrophy of the subclavius muscle,
Chondroma formation
Clinical presentation
Most patients are sportsmen, musicians or manual workers undertaking repetitive arm movements.
The condition occurs more commonly in the dominant limb
Male predominance
Clinical presentation
Acute presentation -
Swollen and tensed upper limb
Upper limb aching pain
blueish- purple arm due to venous engorgement
Collateral veins may be visible
Feeling of heaviness that is worse after activity
Symptoms are precipitated by working with the arms elevated and are relieved by dependency, a pathognomonic feature of vTOS.
Arterial TOS
Rare but has more devastating consequences
Caused by
Intermittent subclavian arterial compression - Costoclavicular compression with normal anatomy.
This document discusses congenital anomalies of the upper limb, including definition, incidence, embryology, classification, and specific anomalies such as club hand, Madelung deformity, Apert's syndrome, cleft hand, and thumb abnormalities. Upper limb anomalies can occur due to arrest of development during crucial embryonic stages between 4-8 weeks. Common types include transverse or longitudinal arrest of parts, failure of differentiation, duplication, and overgrowth/undergrowth. Radial and ulnar club hands are described in detail along with associated syndromes and treatment approaches.
This document discusses early and delayed complications that can arise from fractures. Early complications include visceral injuries to organs like the brain, chest, abdomen, and pelvis. Vascular injuries such as cuts, compression, thrombosis, or spasm of major arterial vessels can also occur. Compartment syndrome, which is an increase in pressure within a closed muscle compartment, is another potential early complication. Delayed complications include delayed union, malunion, non-union, avascular necrosis, joint instability, growth disturbances, and osteoarthritis.
The document discusses the decision between limb salvage and amputation for severely injured extremities. It outlines factors to consider like injury classification, soft tissue damage, vascular and nerve injury. Scoring systems like MESS, LSI and PSI are mentioned but have limitations. With advances in wound care, fixation and reconstruction, more limbs can now be salvaged that would have previously required amputation. The optimal decision involves a multidisciplinary team at an experienced trauma center tailored to each patient's injuries and prognosis.
This document provides information on nerve injuries, specifically those involving the brachial plexus. It describes the anatomy of the brachial plexus and its branches, then discusses various types of nerve injuries including locations, causes, affected muscles and functions, sensory loss, and resulting deformities. Key injuries summarized are Erb's palsy from upper trunk injury, Klumpke's palsy from lower trunk injury, injuries to specific nerves like the radial and ulnar nerves, and common sites of median nerve injury.
Supraspinatus tear - medial information martinshaji
A supraspinatus tear is a tear or rupture of the tendon of the supraspinatus muscle. The supraspinatus is part of the rotator cuff of the shoulder.
please comment
thank you ....
Back pain is common in adolescents, with incidence higher in girls than boys. Associations exist with heavy school bags, lack of lockers, and family history. Red flags include younger age, persistent or worsening pain, fever, and neurological symptoms. MRI is most valuable for imaging. Rehabilitation and back education are the mainstay of treatment.
Rheumatoid arthritis is a common inflammatory joint disease characterized by symmetric joint swelling, pain, and erosion. It affects around 1% of the population, predominantly women aged 40-60. Genetic and environmental factors contribute to disease risk. Early treatment with disease-modifying drugs like methotrexate can help control symptoms, prevent bone erosion, and reduce joint damage and loss of function. The goal of treatment is clinical remission to minimize long-term effects of the disease.
Various ankle injuries and it’s managementAmol Gaikwad
This document provides information on various ankle injuries and their management. It begins with an introduction to ankle injuries and anatomy of the ankle joint. It then describes the classification systems for ankle injuries including Lauge-Hansen and Danis-Weber classifications. Specific injury mechanisms such as supination adduction, pronation abduction, and pronation external rotation injuries are explained. Evaluation, diagnosis and treatment approaches for different types of ankle injuries like sprains, lateral malleolus fractures, and bimalleolar fractures are covered. Radiographic tests and surgical fixation options are also summarized.
This document summarizes several developmental disorders categorized into chondro-osteodystrophies (disorders of cartilage and bone growth), connective tissue disorders, and metabolic defects. It describes specific conditions such as achondroplasia (the most common short stature disorder), osteogenesis imperfecta (brittle bone disease), and mucopolysaccharidoses (disorders caused by a lack of enzymes needed to break down sugars). The document provides diagnostic features and radiographic findings for each condition.
1. The document discusses various congenital hand anomalies classified using the Swanson and modified classifications.
2. Key classifications include failures of formation (transverse arrest, longitudinal arrest), differentiation (syndactyly, contractures), duplication (polydactyly), overgrowth (macrodactyly), undergrowth (hypoplastic thumb), and generalized skeletal abnormalities (Apert syndrome, Poland syndrome).
3. The modified classification organizes anomalies by malformations involving the entire limb, hand plate, or unspecified structures, as well as deformities and dysplasias. Specific conditions like symbrachydactyly, triphalangeal thumb, and brachydacty
This document discusses common shoulder and humerus injuries seen in the emergency department. It covers AC separation, clavicle fractures, scapula fractures, shoulder dislocations, and humeral fractures. For each injury, the mechanism of injury, physical exam findings, diagnostic imaging, classification, and management approach are described. Complications for certain injuries like shoulder dislocations are also outlined.
Syndactyly is a condition where two or more digits, such as fingers or toes, are fused together. It can be classified as simple or complex based on whether the soft tissue or bones are fused. Syndactyly is usually congenital and occurs when the webbing between digits fails to dissolve during early fetal development. While syndactyly surgery is generally indicated, risks include hypertrophic scarring and skin flap sloughing, especially in lower limb procedures on young children. Post-operative scar management may include massage, splinting, ultrasound therapy, or laser treatment.
Spondylolisthesis is the forward or backward slipping of one vertebra over another. This document discusses various types and classifications of spondylolisthesis. The key classifications discussed are the Wiltse, Newman, and Macnab classification (which categorizes spondylolisthesis based on its location and cause), the Meyerding classification (which grades the severity of slip based on percentage of vertebral translation), and the Marchetti-Bartolozzi classification (which categorizes spondylolisthesis as developmental or acquired based on etiology). Risk factors for progression include young age at presentation, female gender, high slip angle, and high grade slip.
This document discusses the history, pathophysiology, diagnosis, and management of compartment syndrome. It notes that compartment syndrome is characterized by increased tissue pressure within a closed anatomical space that compromises circulation and function. Key points include:
- Compartment syndrome was first described by Richard von Volkmann in 1881 and the term was coined by Hildebrand in 1906.
- The most common causes are fractures and soft tissue injuries, which can lead to bleeding inside an anatomical compartment.
- Diagnosis involves evaluating the patient for pain out of proportion, tense compartments, sensory changes, and measuring compartment pressure.
- Untreated, it can lead to permanent muscle and nerve damage within hours; fasciotomy is
1) Soft tissue management is an important consideration in endodontic surgery. The choice of flap design impacts surgical access, blood supply, and post-operative healing.
2) Key factors in flap design include the position of the tooth, underlying bone quality, and avoiding incisions that sever vertically-oriented blood vessels and collagen fibers.
3) Common flap types include triangular, rectangular, and papilla-base flaps. Limited flaps like submarginal designs disrupt more tissue but provide less access than full-thickness flaps.
This document summarizes flexor tendon injuries and repairs. It describes tendon nutrition, zones of ischemia, tendon healing phases, factors that cause adhesions, examination techniques, and types of tendon repairs. Flexor tendon injuries are evaluated based on the location of the injury (Verdan zones I-V) and repaired accordingly. Primary repair is preferred if possible, while complications like adhesions or gap formation require techniques like tenolysis. Postoperative rehabilitation aims to restore tendon gliding and function while avoiding issues like bowstringing.
- Limb development begins in the 4th week of gestation from lateral plate mesoderm under the guidance of three signaling centers: the AER, ZPA, and dorsal/ventral ectoderm.
- The AER guides proximal-distal growth through FGF signaling, the ZPA patterns anterior-posterior development using SHH, and the ectoderm determines dorsal-ventral fates through WNT7a.
- Failure of limb formation can result in transverse or longitudinal deficiencies, where parts of the limb fail to develop fully, such as in radial club hand where the radius is absent. Classification systems aim to describe the spectrum of abnormalities.
This document discusses compartment syndrome, beginning with definitions, pathogenesis, and a historical review. It then covers pathophysiology, including normal and elevated tissue pressures. Tissue survival times are provided for muscle and nerve damage. Etiologies and diagnostic criteria are outlined. Pressure measurement techniques and indications for fasciotomy surgery are described for various body areas like the forearm, leg, thigh, and foot. Post-operative care and potential medical-legal issues are also summarized.
This document provides information about syndactyly, including its definition, embryology, etiology, types, evaluation, management, surgical techniques, complications, and its association with certain genetic syndromes. Syndactyly is a fusion of soft tissue or skeletal elements of adjacent digits. It occurs when normal digital separation fails during development. Surgical correction aims to separate the digits and reconstruct the intervening skin and tissues. Timing, flap design, and postoperative care require consideration to optimize outcomes and prevent contractures. Syndactyly can be an isolated anomaly or part of genetic syndromes like Apert syndrome or Poland syndrome.
Can read freely here
https://sethiortho.blogspot.com/
Thoracic outlet syndrome
Neurovascular symptoms in the upper extremities due to pressure on the nerves and vessels in the thoracic outlet area
The specific structures compressed are usually the nerves of the branchial plexus and occasionally the subclavian artery or subclavian vein
Anatomy
Thoracic outlet
Entrance/ Exit region of the upper limb
The thoracic outlet is defined as the interval from the supraclavicular fossa to the axilla that passes between the clavicle and the first rib
Anatomy - Scalane triangle
Anatomy of the costoclavicular space
Pectoralis minor space
Located inferior to the coracoid process
anterior to the second through fourth ribs
posterior to the pectoralis minor muscle
The cords of the brachial plexus
Axillary artery
Axillary vein.
Soft-tissue Causes (70%)
Scalene muscle
Variations in insertion
Hypertrophy
Accessory scalenus minimus muscle
Anomalous ligaments or bands
Soft-tissue tumors
Osseous Causes
Cervical rib
Prominent C7 transverse process
Displacement or callus from first rib fracture
Malunited clavicle or first rib fracture
AC or SC joint injury or dislocation
Osseous tumor
Poor posture
Drooping the shoulders
Holding the head in a forward position
Repetitive activity
Athletes and swimmers
Neurogenic TOS
Compression – scalene triangle and costoclavicular space
May be associated with normal anatomy
Traction of the lowest trunk of the brachial plexus
Often in association with arterial TOS
Features of Lower brachial plexus compression - Common
Female predominance
Appearance of Amedio Modigliani painting
Complains of pain and paresthesia extending from the shoulder /down the ulnar aspect of the arm into the medial two fingers
Neurogenic TOS
Upper brachial plexus compression C5,C6 and C7
Less common
Compression mainly occurs in scalene triangle
Symptoms
Unilateral occipito-frontal headache
Facial or jaw pain
The Gilliatt-Sumner hand
A characteristic finding of neurogenic TOS, is described as atrophy of the abductor pollicis brevis and, to a lesser degree, the hypothenar musculature and the interossei.
Venous TOS
Causes
Hypertrophy of the subclavius muscle,
Chondroma formation
Clinical presentation
Most patients are sportsmen, musicians or manual workers undertaking repetitive arm movements.
The condition occurs more commonly in the dominant limb
Male predominance
Clinical presentation
Acute presentation -
Swollen and tensed upper limb
Upper limb aching pain
blueish- purple arm due to venous engorgement
Collateral veins may be visible
Feeling of heaviness that is worse after activity
Symptoms are precipitated by working with the arms elevated and are relieved by dependency, a pathognomonic feature of vTOS.
Arterial TOS
Rare but has more devastating consequences
Caused by
Intermittent subclavian arterial compression - Costoclavicular compression with normal anatomy.
This document discusses congenital anomalies of the upper limb, including definition, incidence, embryology, classification, and specific anomalies such as club hand, Madelung deformity, Apert's syndrome, cleft hand, and thumb abnormalities. Upper limb anomalies can occur due to arrest of development during crucial embryonic stages between 4-8 weeks. Common types include transverse or longitudinal arrest of parts, failure of differentiation, duplication, and overgrowth/undergrowth. Radial and ulnar club hands are described in detail along with associated syndromes and treatment approaches.
This document discusses early and delayed complications that can arise from fractures. Early complications include visceral injuries to organs like the brain, chest, abdomen, and pelvis. Vascular injuries such as cuts, compression, thrombosis, or spasm of major arterial vessels can also occur. Compartment syndrome, which is an increase in pressure within a closed muscle compartment, is another potential early complication. Delayed complications include delayed union, malunion, non-union, avascular necrosis, joint instability, growth disturbances, and osteoarthritis.
The document discusses the decision between limb salvage and amputation for severely injured extremities. It outlines factors to consider like injury classification, soft tissue damage, vascular and nerve injury. Scoring systems like MESS, LSI and PSI are mentioned but have limitations. With advances in wound care, fixation and reconstruction, more limbs can now be salvaged that would have previously required amputation. The optimal decision involves a multidisciplinary team at an experienced trauma center tailored to each patient's injuries and prognosis.
This document provides information on nerve injuries, specifically those involving the brachial plexus. It describes the anatomy of the brachial plexus and its branches, then discusses various types of nerve injuries including locations, causes, affected muscles and functions, sensory loss, and resulting deformities. Key injuries summarized are Erb's palsy from upper trunk injury, Klumpke's palsy from lower trunk injury, injuries to specific nerves like the radial and ulnar nerves, and common sites of median nerve injury.
Supraspinatus tear - medial information martinshaji
A supraspinatus tear is a tear or rupture of the tendon of the supraspinatus muscle. The supraspinatus is part of the rotator cuff of the shoulder.
please comment
thank you ....
Back pain is common in adolescents, with incidence higher in girls than boys. Associations exist with heavy school bags, lack of lockers, and family history. Red flags include younger age, persistent or worsening pain, fever, and neurological symptoms. MRI is most valuable for imaging. Rehabilitation and back education are the mainstay of treatment.
Rheumatoid arthritis is a common inflammatory joint disease characterized by symmetric joint swelling, pain, and erosion. It affects around 1% of the population, predominantly women aged 40-60. Genetic and environmental factors contribute to disease risk. Early treatment with disease-modifying drugs like methotrexate can help control symptoms, prevent bone erosion, and reduce joint damage and loss of function. The goal of treatment is clinical remission to minimize long-term effects of the disease.
Various ankle injuries and it’s managementAmol Gaikwad
This document provides information on various ankle injuries and their management. It begins with an introduction to ankle injuries and anatomy of the ankle joint. It then describes the classification systems for ankle injuries including Lauge-Hansen and Danis-Weber classifications. Specific injury mechanisms such as supination adduction, pronation abduction, and pronation external rotation injuries are explained. Evaluation, diagnosis and treatment approaches for different types of ankle injuries like sprains, lateral malleolus fractures, and bimalleolar fractures are covered. Radiographic tests and surgical fixation options are also summarized.
This document summarizes several developmental disorders categorized into chondro-osteodystrophies (disorders of cartilage and bone growth), connective tissue disorders, and metabolic defects. It describes specific conditions such as achondroplasia (the most common short stature disorder), osteogenesis imperfecta (brittle bone disease), and mucopolysaccharidoses (disorders caused by a lack of enzymes needed to break down sugars). The document provides diagnostic features and radiographic findings for each condition.
1. The document discusses various congenital hand anomalies classified using the Swanson and modified classifications.
2. Key classifications include failures of formation (transverse arrest, longitudinal arrest), differentiation (syndactyly, contractures), duplication (polydactyly), overgrowth (macrodactyly), undergrowth (hypoplastic thumb), and generalized skeletal abnormalities (Apert syndrome, Poland syndrome).
3. The modified classification organizes anomalies by malformations involving the entire limb, hand plate, or unspecified structures, as well as deformities and dysplasias. Specific conditions like symbrachydactyly, triphalangeal thumb, and brachydacty
This document discusses common shoulder and humerus injuries seen in the emergency department. It covers AC separation, clavicle fractures, scapula fractures, shoulder dislocations, and humeral fractures. For each injury, the mechanism of injury, physical exam findings, diagnostic imaging, classification, and management approach are described. Complications for certain injuries like shoulder dislocations are also outlined.
Syndactyly is a condition where two or more digits, such as fingers or toes, are fused together. It can be classified as simple or complex based on whether the soft tissue or bones are fused. Syndactyly is usually congenital and occurs when the webbing between digits fails to dissolve during early fetal development. While syndactyly surgery is generally indicated, risks include hypertrophic scarring and skin flap sloughing, especially in lower limb procedures on young children. Post-operative scar management may include massage, splinting, ultrasound therapy, or laser treatment.
Spondylolisthesis is the forward or backward slipping of one vertebra over another. This document discusses various types and classifications of spondylolisthesis. The key classifications discussed are the Wiltse, Newman, and Macnab classification (which categorizes spondylolisthesis based on its location and cause), the Meyerding classification (which grades the severity of slip based on percentage of vertebral translation), and the Marchetti-Bartolozzi classification (which categorizes spondylolisthesis as developmental or acquired based on etiology). Risk factors for progression include young age at presentation, female gender, high slip angle, and high grade slip.
This document discusses the history, pathophysiology, diagnosis, and management of compartment syndrome. It notes that compartment syndrome is characterized by increased tissue pressure within a closed anatomical space that compromises circulation and function. Key points include:
- Compartment syndrome was first described by Richard von Volkmann in 1881 and the term was coined by Hildebrand in 1906.
- The most common causes are fractures and soft tissue injuries, which can lead to bleeding inside an anatomical compartment.
- Diagnosis involves evaluating the patient for pain out of proportion, tense compartments, sensory changes, and measuring compartment pressure.
- Untreated, it can lead to permanent muscle and nerve damage within hours; fasciotomy is
1) Soft tissue management is an important consideration in endodontic surgery. The choice of flap design impacts surgical access, blood supply, and post-operative healing.
2) Key factors in flap design include the position of the tooth, underlying bone quality, and avoiding incisions that sever vertically-oriented blood vessels and collagen fibers.
3) Common flap types include triangular, rectangular, and papilla-base flaps. Limited flaps like submarginal designs disrupt more tissue but provide less access than full-thickness flaps.
This document summarizes flexor tendon injuries and repairs. It describes tendon nutrition, zones of ischemia, tendon healing phases, factors that cause adhesions, examination techniques, and types of tendon repairs. Flexor tendon injuries are evaluated based on the location of the injury (Verdan zones I-V) and repaired accordingly. Primary repair is preferred if possible, while complications like adhesions or gap formation require techniques like tenolysis. Postoperative rehabilitation aims to restore tendon gliding and function while avoiding issues like bowstringing.
Gingivectomy is the surgical excision of gum tissue to eliminate periodontal pockets and create a favorable environment for gum healing. It involves marking pockets, making internal bevel incisions, removing gum tissue and granulation, and root planing. Healing occurs through clot formation, granulation tissue growth, and epithelialization over 2-7 weeks. While it effectively eliminates pockets, gingivectomy risks reducing attached gum and exposing root surfaces.
The document provides an overview of hand anatomy including terminology, skin, fascia, muscles, tendons, bones, joints, nerves and vasculature. Key points include descriptions of various hand incisions and their purposes, fascial layers and spaces of the hand, flexor tendon anatomy and zones of injury, and anatomy of important muscles like the thenar and hypothenar muscles. The document covers the detailed functional anatomy of the hand.
This document discusses various options for non-microsurgical coverage of soft tissue defects in the hand, including healing by secondary intention, vacuum-assisted closure, skin grafting, and various local, regional, and distant flaps. It provides details on techniques such as the Moberg flap, Tranquilli-Leali flap, cross-finger flap, and their indications. It also discusses the vascular anatomy of the hand and design principles for different types of flaps used in hand reconstruction.
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This document provides information about syndactyly, including:
- It is the most common congenital hand malformation, occurring in about 1 in 2,000 live births.
- It can range from simple incomplete fusions to complex fusions involving bones and other structures.
- Treatment involves carefully separating the fingers while reconstructing skin and other tissues to form new web spaces. Multiple flap techniques may be used depending on the specifics of each case.
- Proper postoperative immobilization and splinting is important to maintain the results long term and prevent web creep.
This document discusses the principles and management of various congenital hand anomalies. It covers topics such as:
- Surgical management should aim to improve function and appearance with minimal risk. Hand function depends on thumb mobility and pinch grip.
- Timing of surgery depends on technical difficulty and cortical plasticity. Surgery may be delayed to treat other conditions.
- Transverse deficiencies are often managed non-surgically with prosthetics. Longitudinal deficiencies often benefit from surgery.
- Specific procedures are described for conditions like symbrachydactyly, radial hypoplasia, central ray deficiency, thumb and finger hypoplasia/aplasia. Syndactyly and poly
This document discusses various flap techniques used in periodontal surgery. It defines flaps as sections of gingiva and mucosa surgically separated from underlying tissues to provide access to bone and roots. Full and partial thickness flaps are classified based on the depth of tissue reflection. Techniques include the modified Widman flap, undisplaced flap, apically displaced flap, papilla preservation flap, and techniques for distal molar surgery. Healing after flap surgery is described in stages from initial clot formation to establishment of new connective tissue attachment after 4 weeks.
The objective in the management of soft-tissue injuries of the hand is to achieve primary wound healing.
The choice of treatment of fingertip is based on the
mechanism of injury ,
the size of the defect,
location and status of the wound
injuries to other parts of the hand
other factors(patient’s age, sex, general health, and occupation)
This document discusses different types of periodontal flaps used in periodontal surgery. It defines a periodontal flap as a section of gingiva and/or mucosa surgically separated from underlying tissues to provide visibility and access to the bone and root surfaces. It then classifies periodontal flaps based on bone exposure, placement after surgery, and management of the papilla. Specific flap techniques discussed include the modified Widman flap, undisplaced flap, apically displaced flap, and palatal flap. The objectives, incisions, and procedures for each flap type are described in detail.
Gingivectomy and gingivoplasty are procedures to remove gum tissue and reshape the gum line. Gingivectomy removes gum tissue from deep pockets, while gingivoplasty contours gum tissue without eliminating pockets. The document outlines the indications, contraindications, techniques, and healing process for gingivectomy. Surgical gingivectomy uses knives and curettes to remove gum tissue in pockets and reshape the gum line. Healing occurs through granulation tissue formation and re-epithelialization over 1-2 weeks. Other techniques include electrosurgery, laser gingivectomy, and chemo surgery.
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Flexor tendons - enclosed by synovial sheaths.
Tendons - blood supply through synovial folds known as vincula, each
tendon having two, vincula longa and vincula brevia.
The sheath of the little finger is continuous with the ulnar bursa covering
the flexor tendons in the palm.
The flexor pollicis longus is covered by a single sheath throughout, the
radial bursa.
Synovial sheaths can be infected producing tenosynovitis. Infection can
spread throughout the sheath. Infection of the sheath of the little finger can thus spread up the distal aspect of the forearm into the space of Parona.
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This document describes various types of abdominal incisions including:
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2. Joel-Cohen incision - straight incision higher than Pfannenstiel that involves sharp dissection of skin and blunt separation of deeper layers, leading to better outcomes than Pfannenstiel.
3. Midline incisions - provide excellent exposure but are more prone to wound complications compared to transverse incisions.
It also discusses closure techniques like absorbable sutures and staples that minimize infection risks and wound healing considerations.
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The skin is composed of two main layers, the epidermis and dermis. Various types of incisions can be made through the skin for surgical procedures, with considerations including accessibility, extensibility, security, and following natural lines of tissue tension. Different suturing methods can be used to close wounds, including everting, inverting, interrupted, running, and locking stitches.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
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These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
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Mercurius is named after the roman god mercurius, the god of trade and science. The planet mercurius is named after the same god. Mercurius is sometimes called hydrargyrum, means ‘watery silver’. Its shine and colour are very similar to silver, but mercury is a fluid at room temperatures. The name quick silver is a translation of hydrargyrum, where the word quick describes its tendency to scatter away in all directions.
The droplets have a tendency to conglomerate to one big mass, but on being shaken they fall apart into countless little droplets again. It is used to ignite explosives, like mercury fulminate, the explosive character is one of its general themes.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
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SYNDACTYLY RELEASE..pptx
1. Department of plastic, Reconstructive and aesthestic surgery. Udayana University/RSUP Prof Dr IGNG Ngoerah Hospital, Indonesia
2. • Syndactyly is one of the most common
congenital hand anomalies treated by pediatric
plastic surgeons.
• Numerous surgical methods have been
described, many of which involve the use of
local flaps to reconstruct the commissure and
full-thickness skin grafts for coverage of raw
areas.
• Recently, reconstructive techniques without the
use of skin grafts have been devised, which work
well for certain indications. Special
considerations are described for complete,
complex, and syndromic syndactylies
3. Syndactyly is a congenital anomaly in which there is
fusion of adjacent digits due to failure of separation of
developing phalanges during organogenesis.
Normally, webbing between the digits regresses
during 6 to 8 weeks of gestation in a distal to
proximal direction.
Dependent on apoptosis of some portions of the apical
ectodermal ridge, and is mediated by cytokines such as bone
morphogenetic proteins, transforming growth factor-β,
fibroblast growth factors, and retinoic acid.
4. Syndactyly occurs in approximately 1 in every 2,000 to
3,000 births.
Syndactyly is bilateral in half of the patients and may be
symmetrical or asymmetrical.
Males are affected twice as frequently as females.
5. It can be inherited autosomal dominantly with variable
expression or reduced penetrance, and can also occur
sporadically
Environmental factors associated with syndactyly
include maternal smoking, lower nutritional status,
lower socioeconomic status, and increased meat and
egg consumption during pregnancy
The most commonly involved interspace in isolated
syndactyly is between the middle and ring finger,
followed by the interspace between the ring and little
finger
6. when the fingers are fused along the full length of the
digits including the nailfold
Complete Syndactyly
Incomplete Syndactyly when the nailfold is not involved
7. When fingers are connected by only skin and soft
tissue, and “complex syndactyly” when osseous or
cartilaginous unions are present between adjacent
digits
Simple Syndactyly
Complicated syndactyly is useful to describe abnormalities that extend
beyond simple side-to-side fusion of digits, such as
accessory phalanges or abnormal tendons, muscles,
and nerves interposed within the fused interspaces.
8. when osseous or cartilaginous unions are present
between adjacent digits
Complex syndactyly
Incomplete Syndactyly Describe abnormalities that extend beyond simple
side-to-side fusion of digits, such as accessory
phalanges or abnormal tendons, muscles, and
nerves interposed within the fused interspaces
9. Syndactyly associated with syndromes is often
classified as complicated syndactyly; examples include
central polysyndactyly and typical cleft hand
Syndactyly may occur in isolation or as a common
feature of at least 28 syndromes.
10. • Physical examination is performed that includes
the entire affected upper limb, contralateral
hand, chest wall, and feet to search for additional
anatomical differences.
• Radiographs of the hand are taken to confirm the
skeletal deformities and detect any concealed
extra digits or articular deformities.
• In the case of complex syndactyly, magnetic
resonance imaging or ultrasound can determine
flexor tendon and vascular anatomy.
11.
12. • Surgery is indicated for nearly all cases of
syndactyly, as the potential for improved
functionality outweighs the risks of the procedure
• a mild, incomplete syndactyly that does not impair
function, medical conditions that preclude surgery,
or complex syndactyly thst risk further functional
impairment
13. • The goal of surgery is to create a
normalwebspace and improve the appearance of
the involved fingers.
• Soft tissue deficits usually require skin grafting,
although many techniques have been described
to avoid skin grafting.
• Smallerdeficits may alternatively be allowed to
heal by secondary intention.
14. • We generally perform surgery around 12 months
of age.
• Surgery before 12 months of age is generally
associated with a higher incidence of scar
contracture
• If the defect is bilateral, procedures should be
performed on both hands simultaneously in non
ambulatory children younger than 12 to 14
months
• If both sides of a finger are involved, multiple surgical procedures are required.
• All releases should be performed before school age when fine motor skills of the hand are
essential, and preferably before 24 months
15. • Operating on both sides of the finger at one time
puts the patient at risk for neurovascular
compromise. In addition, the bordering digits are
typically operated on first given the greater
degree of size discrepancies and the potential for
tripod pinch following release.
16. • The most common reconstructive design for the
commissure, and that used at our institution,
involves a rectangular, proximally-based dorsal
flap.
• Flap design is heavily dependent on training and
surgeon preference, and can be easily modified
to attempt a more anatomical webspace
reconstruction.
• In cases where construction of a commissure flap
is not needed, such as very mild syndactylies or
mild constriction of the first webspace, a z-plasty
can be employed to simplylengthen the soft
tissue and increase range of motion
17. • The incision location and pattern must also be
determined, though most surgeons prefer a
zigzag pattern.
• Cronin’s technique of matched zigzag incisions on
the flexor and dorsal surfaces was developed
after his observation that all postoperative
contractures arose from straight incisions on the
flexor surface
• An alternativemethod uses straight-line
midlateral incisions, which are closed with skin
grafts, splinted to prevent contracture, and then
medially excised
18. Skin grafting has been used to resurface these rawareas for the last century,
and its introduction greatly decreased the contracture rate that resulted
from large raw surfaces left to heal secondarily
Table-21Syndactyly release with skin grafting
19. Issues with skin grafts include the need for postoperative immobilization, contraction
leading toweb creep and flexion contractures, hyperpigmentation, hair growth, and
donorsite morbidity
Table-1 Syndactyly release with skin grafting
20. • Grafts are frequently obtained from the groin,
which allows full-thickness harvest with minimal
morbidity.
• Grafts from this region should be taken lateral to
the femoral artery to avoid hair growth at
puberty.
• Grafts from the groin tend to be darker than the
normal hand skin, however, and this may become
an issue as the child becomes older.
• Other possible donor sites are the distal wrist
crease or medial upper arm
21. • Grafts from the dorsal metacarpal region leave a
visible scar on the hand
• Foreskin has been used, but tends to take poorly
and pigments.
• Patients must be consented before skin grafting,
as the scar at the donor site might hypertrophy.
22. • Surgery is performed under general
anesthesia with a tourniquet and loupe
magnification.
• The hand and ASIS area are both
prepped and draped.
• The rectangular flap is designed,
extending from the metacarpal heads to
two-thirds the length of the proximal
phalanx.
• The longitudinal edges of the flap can be
curved to fit the roundness of the finger.
Figure 4 (A) The dorsal rectangular flap for
reconstruction of the commissure extends from
the metacarpal heads to two-thirds the length of
the proximal phalanx. A zigzag incision is used to
separate the digits.
23. • . The dorsal zigzag incision begins at the
apex of the flap, and then extends to the
midline of the proximal interphalangeal
(PIP) joint of the adjacent finger.
• It traverses to the midline of the
neighboring middle phalanx, and back
across to the midline of the distal
interphalangeal joint.
• The palmar zigzag is designed in the
opposite manner so they are mirror
images, with a proximal midline vertical
incision extending from the proximal
zigzag to the level of the desired
webspace
(Figure 4 B) The palmar zigzag incision is a mirror
image of the dorsal incision, with a proximal
midline incision extending to the neo-webspace. A
T incision will be added at the proximal end of the
straight incision to allow insetting of the flaps.
24. • The proximal palmar incision will have a
small T incision added at the end to
allow insetting of the flap. The T incision
can be adjusted during surgery to allow a
better fit between the flaps
• Once this is done, the hand is
exsanguinated with a Martin bandage
and the tourniquet elevated to 250 mm
Hg pressure
(Figure 4 B) The palmar zigzag incision is a mirror
image of the dorsal incision, with a proximal
midline incision extending to the neo-webspace. A
T incision will be added at the proximal end of the
straight incision to allow insetting of the flaps.
25. • The proximal palmar incision will have a small T incision
added at the end to allow insetting of the flap. The T incision
can be adjusted during surgery to allow a better fit between
the flaps
• Once this is done, the hand is exsanguinated with a Martin
bandage and the tourniquet elevated to 250 mm Hg pressure
26. • The dorsal triangular flaps are raised first with
sharp dissection, while controlling bleeding
points with bipolar cautery.
• Attention is then turned to the volar flaps, which
are raised, and neurovascular bundles are
identified. Next, the separation of digits occurs in
the distal to proximal direction.
• During the separation, neurovascular bundles
and venous plexuses on the dorsum of digits and
within the flaps are preserved.
27. • The proximal dissection is limited by the
bifurcation of the digital artery, which
thereby limits the location of the new
webspace.
• Each digit must have one viable digital
artery.
• The digital artery can be ligated as long
as the other side of the digit has not
been operated on, or the other artery is
known to be intact
• It is thus essential to keep proper
documentation of the digital vasculature
during all surgeries for future reference.
(Fig. 5 )Dorsal and palmar interdigitating zigzag flaps
will resurface the lateral aspects of the digits. After
triangular flaps are lifted, the dorsal rectangular flap
is raised and all flaps judiciously defatted.
28. • Instead of ligating the artery, a vein graft can be
used to extend the artery and allow a more proximal
webspace, though thiswould rarely be necessary.
• If the digital nerve bifurcates distal to the webspace,
microdissection is used to separate it.
• Attention is then returned to the dorsal side to
elevate the rectangular flap, which is partially
defatted
(Fig. 5 )Dorsal and palmar interdigitating
zigzag flaps will resurface the lateral aspects
of the digits. After triangular flaps are lifted,
the dorsal rectangular flap is raised and all
flaps judiciously defatted.
29. • On the volar side, a vertical incision ismade
proximally and extended to overcorrect the
webspace.
• A small T incision is then made at the proximal
palmar incision to bring up the flaps on the sides.
Wounds are then irrigated and bleeding
controlled.
• All flaps in the finger are defatted carefully, and
then tacked down in place at the tips with 4–0
chromic suture to ensure they fit properly. If
necessary, the T incision can be lengthened to
allow the flaps to fit better.
30. • The tourniquet is then let down,
bleeding controlled, and the remaining
flaps sutured in place with interrupted
4–0 chromic sutures.
• To cover any remaining skin defects, an
appropriately sized graft is marked over
the ASIS.
• The full-thickness skin graft is elevated
using the knife and hemostasis achieved.
(Figure 6 (A) Grafts from anterior to the anterior
superior iliac spine covering skin deficits at the
proximal aspect of the
lateral fingers.
31. • The donor site is closed by advancing
the skin and then closing with
interrupted 4–0 Vicryl (Xeroform, Inc.)
and running subcuticular 4–0 Monocryl
(Ethicon, Inc.) sutures.
• Steri-Strips (3M, Inc.) are placed over the
closure.
• The graft is then defatted and trimmed,
and sutured in place over the skin
defects with interrupted 4–0 chromic
sutures.
Figure 6. (B) (B) The dorsal rectangular flap is
advanced to reconstruct the commissure.
32. Surgical methods using grafts need both compression and
immobilization to allow for graft take.
Grafts and incisions are covered with one layer of Xeroform
gauze followed by cotton in thewebspace,with the fingers in
abduction to avoid kinking of commissuralflaps.
In young children, the compressed dressing is reinforced with
an above-the-elbow plaster castwith the elbowflexed at 90
degrees to prevent the cast from slipping off the arm.
33. • Graft-free reconstruction improves overall skin match and decreases
operative time.
• However, not all cases are amenable to primary closure.
Table-2 Syndactyly release without skin grafting
36. • Simple syndactylies do not extend beyond the
PIP joint may allow for adequate separation of
the digits and deepening of the webspace
without the need for a graft.
• In the complex syndactyly (extend more distally),
local tissue becomes too scarce for adequate
circumferential coverage, regardless of flap
design.
• Primary closure without grafting can be achieved
using two major principles: importation of excess
dorsal tissue and/or extensive defatting of the
involved digits.
37. • No single technique has been identified as a gold
standard for surgical correction.
• However, the most common techniques involve a
pedicled dorsal metacarpal artery flap that
receives numerous small contributory vessels
• The common disadvantage of a graft-free
syndactyly release is a more conspicuous scar on
the dorsum of the hand.
38. • Defatting, rather than flap design, has been
suggested as the more important determinant of
whether primary closure can be accomplished.
• Fat tissue is judiciously dissected fromthe
commissure to the distal end of fusion and must
be removal laterally along the syndactylized
digits to the middorsal line.
• However, excess fat removal can lead to
complications such as neurovascular injury, poor
venous drainage, and a withered finger
appearance.
39. • Inadequate defatting can lead to tight sutures
and ischemia.
• After defatting, if the skin is still unable to be
closed primarily without tension, small areas
(preferably < 2 mmin size) may be left open to
heal secondarily.
• In general, very young patients, from 3 to 6
months old, exhibit the most digital fat and are
the most amenable to defatting.
• Older patients and syndromic patients have less
digital fat and are more likely to require grafting
or healing by secondary intention
40. • Simple syndactyly release usually successfully improves hand appearance and creates independent digits
that are freely mobile , On the contrary, complex syndactyly release is often associated with loss of mobility
due to the higher risk of contracture and scarring and also has a higher reoperation rate.
41. • Short-term complications including infection, graft or flap maceration, and graft failure are frequently related to the child’s
activity or inadequate immobilization. Causes of graft failure, which are more common in infants, include hematoma, seroma, and
loss of postoperative bandages
• Web creep is defined as the distal migration of the web- space with growth and is due to scar contracture (►Fig. 8). Incidence ranges in studies from 7.5 to
60% and is more common when the patient is under 18 months old at the time of surgery. Factors that increase incidence of web creep include complex
syndactyly, use of split-thickness skin graft, secondary intention healing after graft loss, poor flap design with longitudinal scars at base of finger
42. • Short-term complications including infection, graft or flap maceration, and graft failure are frequently related to the child’s activity or
inadequate immobilization. Causes of graft failure, which are more common in infants, include hematoma, seroma, and loss of postoperative
bandages
• Web creep is defined as the distal migration of the web- space with growth and is due to scar contracture (►Fig. 8). Incidence ranges in studies from 7.5 to 60% and is more
common when the patient is under 18 months old at the time of surgery. Factors that increase incidence of web creep include complex syndactyly, use of split-thickness skin
graft, secondary intention healing after graft loss, poor flap design with longitudinal scars at base of finger
43. • Web creep can be prevented with full- thickness skin grafts, early release of border digits, and
overcompensating the webspace deepening by recessing the webspace more proximally.
• The release of complex syndactyly can result in joint instability from insufficient collateral ligaments, and can be
corrected with arthrodesis as a revision procedure at skeletal maturity.
44. • Syndactyly is a common congenital hand deformity that
can manifest in an isolated or syndromic form.
• Patients can present with simple syndactyly, which
occurs when the web space moves distally and there is a
fusion of the soft tissue and skin but not of the nail bed,
or with complex syndactyly, where there is bone
involvement in addition to skin and soft tissue
involvement.
• There should be several separate surgeries if one digit is
involved in multiple fusions, as performing both releases
in one surgery can lead to neurovascular compromise.