*** Reconstruction Surgery  of Tissue Defect!:

I-Local Plasty( Plasty with Local Tissue)
-In Case of Nevus(mole) excise the borders & mobilize
 the surrounding tissue.
-speration of Subcutanous from the Fascia 
-Suture the Edges!

in Case of Dog Bite:
-inflatable Balloon with a specific valves  that can be filled durign surgery preparation!

II-REconstruction with Rotated Flap:
-No Major Vessels
-Excisr the Nectortic Tissue( electrical injuty)
-Using the near Tissue —-> rotate & Close!

III-Axillary Flap!:
-Contain Major Vessel
-Ex patient develops osteomyelitis After Cardiac Surgery!

IV-Free thickness Grafting:
-skin graft harvesting -.2-0.3 mm 
—> will heal spontanously after 10-14 days!
-Using Dermatome we mash the Graft!
-Craft is vasculairzed after 3 days!

V-Fiber Plasty
-Old technique rarely used!

***Nerve lesions, Suture Reconstruction /Regeneration!:


-Temporary Damage
-Function return after 2-3 W
-Epineurium isnt Damaged!

2- Axonotmesis:
-Part of nerve is damaged due to Glass/Knife
-Spontenous regeneration around 1mm/day
-distal part after the injuty degenerates,then regenerates as root from central part

-Most Severe
-Full nerve Damage(all bundles damaged)
-Epineurom laso daaged!
-Surgery is needed , Excision of Ends First & Then suture!

Suture Line is small 8/0 or 10/0 proline
External pineurium is only sutured and holds the axon ends together!

***Injury of Median/Ulnar/Radial Nerve!

^^Median Nerve:
-Injury At the level of elbow result results in Loss of pronation &   Flexion!

-Entrapt at level of elbow/forarm—->Pronator teres Syndrome

-Compression ——->median nerve Plasty

-Injury of anterior interosseous branch—–>Anterior Interosseous syndrome

-Compression at Carpel Tunnel—–>Carpel tunnel Sydrome!

-cutting median nerve—-> Median Claw hand!(Benedictine Hand)
-In the Hand thenar muscle are parayzed+ will atrophy!

^^Ulnar nerve:
-lesion—–>los of sensation on medial aspect of hand
-Elbow compression——–> Cubbital Tunnel Sundrome  
(causes numbness)
-Claw habd gets worse for Guyon Canal Stenosis/Nerve Compresison @ wrist!

^^Radial Nerve Injury :
-Wrist Drop
 (inability to extend wrist upward when hand is palm down)
-Numbness on banck of the Hand & Wrist and inability to colunatry Straighten the finger!
-Losss of Extension due to paralysisof posterior Compartment of forarm!

***Tendone sutures/ Hand Tendon Healing Deatures/Dynamic immobilization!

^^Tendon Sutures:
-When Tendon is Damaged, Fibers are Spread to different ways
-adhesion fix tendon to surrounding Tissue
-Task During Surgery is to make suture of the Tendon and to insure proper sliding!
-We Place suture Knots inside the Lumen of the enon /Between Tendon & Adhesion!

^^Tenson Healing :
-3 Stages of healing are : Inflammation/repair or Prolfieration/ & Remodelling!(The stages overlap)

Stage 1:
-inflammatory cells such as Neutrophils+ Erythrocyte Are recruited to injury Site
-Monocyte & macropahges come to in 24 hours , they phagocyte necotric material at site of injury!
-Vasoactie& Chemotactic Facotr——->Angiogeneis &Proligeration of tenocytes!
-Tenocytes move in and synthesize collagen III
-Inflamamtion last for few ats
-Repair & Proliferation stage last around 6 W

Stage 2:
After 6 W ,Remodelling Stage begins
-first PArt i Consolidation  6-10 W
(Syntehsis of Collages &GAG is    & tisue becomes more fibourous
Due to icnreased Collagen Production)

Stage 3: Maturation
-after 10 W
-increase in crosslinks of collagen Fibrils ,causing Tissue ot be Stifer!
-Over 1 Year we will have Scar tissue!

***First Aid In Case of Traumatic Amputation of Extremities:
Retention of Fragments!

^^First Aid:

1- Stay Sfe
universal protection/Wear Protective Equipment!
2-Call 911/Help immediatly+ Say Location
3- Make sure the the airway & breathing is present
—> If Not Begin CPR!
-Control Bleeding on the Stmp( amputed part)
by using pressure over the wound & elevate Limb above Heart!
-DO Not use tourinuqet unless med Care is delayed 

4-Collct amputed Limb in a bag ON  top of ICE!
-Do not Wash the amputed Part 

5-I ambulance is not available get the victim to med care ASAP

6- Check for Shock signs!

-DO not let the Victim Eat or Drink!
-Reattachment requires surgery!

Pts & Amputed limb need attention

I-Pts—>Xray/NPO/Cleanwound/irrigate/Dress Stump with nonadherent Cover!/Ax/Tetanus Ax

II-Amputated Limb:ray/irrigate/Sterile solution/Ice !

III-Reimplant Indication:
-Age(children better then adults)
-level of injury!
-Proximal limb thumb and digits have higher priority!
-if CI manage stump with revision amputation !

***First Aid in Burn:

^^Burn Specific Care:
-Relieve Resp Distress( Eschartomy /Intubation)
-Prevent & Burn Shock!-2 large Bore IVs
-ID & Tx Life threatening Condition!
-Determien BSA affeted 1st!(Depth is difficult to asses)
-Tetanus prophylaxi!
-ts with burns >10% TBSA or deper need 0.5 ml tetanus toxoid!
-250 U of Tetanus Ig if perior immunization is abscent/unclear!
-Basline Laboratory Studies
-Cleanse Debride
-Burn wound should be elevated!

^^Resp Problems:
-3 Causes:
1-Burn Eschar Encircling chest!—-< Perform Esharotomy!
2-Carbon Monoxide Posion—>100% O2
3-Smoke Inhalation leading to  Pulmonary injury!

-If Humidified O2 is not succesful —>intubate & Ventilate!
-Risk of Pul insuff Pul & Pul edema
-look out for 2nd BronchoPn(3-25 Days)

^^Burn Shock:
-Hypovolemia due to Movement of H2o & Na in zone of Stasis !
+Increase in Cappillary permeability to all organs!

-resusctation with parkland Formula to restore Plasma Volume& Cardiac output!

-4 cc Reingers OVer 24 H
(50% first 8 hours) 505 in net 16 hours)

^^Extra Fluid adminsitration required if:
1-Burn ?80% of BSA
2-4 th degree burn!
3-Trauamtiv injury(pediatric burn)
4- Electrical burn!

-Moniter resusitation:
Urine outpur if best measure >0.5 cc/kg/hours! 
1 cc.kg/hours (Children>12 YO)

-commercial dressing with silver
-biosynthetic Wound dressing
-Topical Salves must be changed daily!
-Silver udressing must be kept moist chnge onl after 3 days!
-artifical skin products are not changed routinely 

***Classification of Burn Depth , Etiology , Severity of Burn:

^^Burn Wound Area:
-Coagulation /Necrosis =No Viable Tissue
-Ischemia/Stasis=Tissue  is Viable But inpropragatable!
(Most important zone)
-Hyperemic= Health tissue able to regenerate!

^^Depth Classification:
1 Degree= superficilail Epidermal
2nd Degree= Partial-thickness/ Dermal
3rd Degree= Full Thickness
4th Degree= Burns Extend Beneth The Subcutanous tissue & Involve Fascia/Muslce/Bone


-Dry /Red
-Blacheswith prssure

2-6 Days
Deep -Partial thickness
-Variable color
Perceptive of pressure
>31 days
Full thickness
Deep Pressure only!
Rare unles surgical
4th degree
into dacia/Muscle
Deep Pressure
NEver unless Surgical Treated

-Most common Burn in Children is Scald Injury!
-Adult most common burn from Flame!

-depth of burn is related to contact Temperature
-involves epidermis and part of dermis
-Causes: Flames/Hot Liquies/Hot Solids/Steams!

2-Cold Exposure(Frostbite):
-Damage in Skin + underlying tissue!
-when Ice Crutsale Puncture the cell /Creation of hypertonic tissue Environment!

3-Chemical burns:
-Causes: Change in Ph /Distrubs of cellular membrane/ Toxic efect on metabolic process

-when electircal energy becomes thermal
-Electroporation(injury of cell membrane)

-Toxic products  of combustion injury airways!
-Causes: Flash burns/ Fire/Steam!/Hot smoke

Radio Frequency energy/ ionizing Radation

-Estimation of burn size is needed  to know when to trasnfer pts to burn Center!
-is it how much % of total body Surface area the Pts is burned(TBSA, Does not include superficial burns)

^^Technique used in burns assesment:
1-CLinical appreciation
3- Laser doppler Velocimetry!

Methods for TBSA assesment in Adults:

Lung -Browder
Rule of Nine
PALM method(small)
-Each Leg =18% of TBSA

-Each Arm =9% o TBSA

-Anterior & Poserior Trunk 18% of TBSA

-Head Represent 9 % of TBSA
-Small patchy
burns are approciamted using the surface area of Patients Paslm
Excluding the Fingers =0.5% o TBSA

***Types of Reconstruction Operations or Burns And their Deadlines:

^^Goal general:
-To Restore Function + Cosmetic appearance
-Blaance must be achieved between immoblization for Skin Grad (Tissue Fla) and Mobilization to Restore Function!

^^Burn Period:
-Shock Phase
-Acute Phae(1-2 M)
-Recovery Phase

^^Goal OF Local Tx:
-Infection PRevention& Tx
-Removal of Necrotic tissue
-Antiseptic , H2O(+) Cream/Silver suldafiazine!
-Early wqound plastics
(fat dressing should not be used )
(Fatty oil–>+ Inflammation)
(Ax insuff concentration)

^^Dressing of Burn Wound:
Hydrophilic antiseptic Lubricant:
1-Tx of Choice—->Siver sulfadiazine /Falmmaine Sulfargine!
2-Other X: Betadine /POVIDON-IOD!
3-Antiseptic solution : Povidon-Iodine/Oktendinio/Furaciline
4-Antiseptic Bandage:
-Aquacel Ag

1-Necrotomy: Removal of all Dead tissue/ ascitiomy for Decompression
2-Necrotomy: removal of vialbe& Non viable Withing the tissue
3- Reconstructie Surgery!

^^Surgery Timing:
-Urgent (1-3 days)
-Essential(4-10 Days)
-Delayed(11-20 Days)
-Desirable(2 Day)

Burns required immediate reconstruction while scar can remains for over a year!

-Burns where there is No other suitable Tx!
-Cover for exposed /damaged structures!
-Done to PReserve FUNCTION of the vital Area
-Done after all open wounds are closed &Onset of Sx of Vital Sturcture:
1-Release of eyelid to protect the cornea to avoid extropion
2-Release of Microstomia

-To Improve burn Care
-Done For mature burn Sars Contractures  That No Not Respons to Splinting/Physical therapy!
-Example( Non-synechial neck cotnraction/Hand contracture)

III-Desirable(late) Procedure:
-Most common
-Procedure is Done after Scar Matured!
-adress size & Shape of mature scar
-example : Reconstructive Passive Area /Esthetics!

^^Burn Reconstrcution Procedure:
-To Cover woudns and restore Function & Aesthetics!

1-Primary Closure :
-Used for Small burn Scars
-scar are excised and closed by immediate approximation of wound edges!
-There Must be No Tension on the Wound
-Closure with 5 Day is Optimal

2- Early Excison & Skin Grafting:
-Acute coverage of Burns 
Imp for managing burn Reconstruction wounds As Early Excision and skin Grafing reduces the presence of potentially necrotix & Infected Tissue!

3-Dermal Regeneraion(Free skin grafts):
Split/Full Thicness
-Conventional Option for burn Coverage!
-used to cover exposed Bone & Tendons!
4-Tissue Expansion
5-Tissue Transfer: Local /Regional /Distant
Grafts can be secured to burn with Staples/Sutures/Tissue glue!

-Staples:Fasted Method/  Straightforward/Inexpensive!
-Suturing: For small Grafts  in sensitie areas!
-Glue Fixation:with use of Cyancrtystales !

***Sx of skin Injury & Regeneration options/ Regentaion of Donor Wound!:

-Wound Can be Caused by Different Mechanism: Incision/Bites/ Lacerations/ Burns/Ulcers!

^^Sx of skin Injury :
-Acute Inflammation (Tumour/Rubour/Calor)
-Spread of Inflammation to Healthy tissue

^^Regenration Option:
-Stop inflammation & Protects agaisnt infection!
-allows healing!
-Bandage needs to be rmevoed after 1 Day to Reasses !
-Sufficient Moisture condition to allow healing!
-Change dressing every 3-4 day if no infection
-Change 1-4 /Day if Infection Present!

Adequte mositure?
—>reduces O2 contect/Stops Bleeding and phagocutes/ Protect from Bacteria!
-Decrease Blood glucose
-increase of LA

^^Regeneration of donor wound:
-Occurs by epithlization as soon as epdermis is removed!
Grnaultion issue form in open wound to allow Re-Epithlization
Epithlial Cell migrate across the new tissue ot Form barrier between Wound and neviroment
-Cell Resp for Epithlization: Basal Keratinocytes/Dermal appendages(hair ollices,Sweat glands)
-Advance in sheet across wound site and proliferate at the edges then meet in them middle!

^^Wound Healing Types:

-Acute: ussually ater Trauma , esily defined mechanism of Injury !
Chronic :Caused by physiological Impariments that slows/Prevents Wound healing

^^Stages of Wound Healing:
Seps involves (+) of keratinoutes /Fibroblast/Endothlial Cells/ Macrophages. platlets.
-Cells Migrates& recruitments of endotheial Cell for angiogensis

-Immediate after injury
-BV constirct
Platlets aggregate  and triger  cloting cascade & Release Essential GF & Cytokines which are imp for Wound healing!
Fibirn matrix that result stabilizes the wound & provides Scaffold
-3 days 
-Key components:
1-Increase vascular permeability 
2-cellular recruitment

Chronic wounds Stop  in this Stage
-Necotric tissue /foreign bodues –>abnormal prodcion of metalloproteat which alter balance of inflammation! & (-) Cytokines
III-Epithlization(cell migration):
-Basal cell proliferation & epithlial cell migration inside the fibrin brdigework inside a clot
Prolfieration contnues untril individual cell are surrounded buy cell of similar Tpes
-Problems arise if woudns are not primarly closed!
-biofilm also (-) this process

IV- Fibroplasia:
-Fibroblast prolieration
-accumilation of ground substance
-Collagent Production

-Fibroblast are trasnformed from Local mesenchymal
atach fibrin matrix of clot /Multiple & produce Glycoprotiens which makes gorund substance

Collagen/Crosslinking/Remodelling /Wound contraction!

^^Wound Dressing:
Affects: Speed of wound healingWound Strength & Function / Function of Repaired Skin / Cosmetic appearance!
-No 1 Dressing is perkect for all wounds, All must be monitered and dressing requirment changes over time
-General Principle:
1-Hydrogels For debridments stage
2-Foam and Low Adherence dressing for Granulation
3-Hydrocolloid and low adherense for Epithlization Stage!

-Ideal Dressing:
1-Absorbs Excessive Wound Fluid /while keepng moist enviroment
2-Protect Wound from more mechnical Damage
3-PRevents bacterial Invation
4-Debrides Necrotic Tissue
5-Achieves Homeostasi an minimzies the edema through compression
6-liminate Pain during and between changes of dressing
7-Minimal Dressing Change
8-Inexpensive And readily avlaible/ Long shelf Life
9-Transparent For Moniterong!

***Wound clasification according to contmination, Criteria For wound Infection & Treatment Priorities:

^^Wound Classification :

I-Clean Wound(aseptic):
-uninfected Operative Wounds
-No inflammation
Primarly Closed
II-Clean -Contmaind(<10 8ORgamigns):
-operative wound where viscus has entered
-Immune sustem is Active and able to control ifnection
-No Ax needed
III-Contamine Wound (>10 ????
-Open/Fresh /accidental wounds
-Operation with major breaks in steril techniques
prulent inflammation 
-Needs to be cleaned to make it II
IV-Dirty Wounds:
-Old Traumatic wounds
Devitalzied tissue
Forirngn bodies/ Fecal contmaination
-We need Systemic Ax!!

Sign of wound contmination:
1-Slow healing
2- Smell
5- Chronic inflammation

^^Contamination :
1- conditional Pathogens: S.aureus, E. coli, Acinetobacter, Citrobacter, Pseudomonas aeruginosa, Enterococcus and

2-Absolute Pathogens:
Streptococcus haemolytica,Streptococcuspyogenes, and Clostridium, other anaerobes

^^Wound healing Depens on :
1- Nutriton an anabolic  Rxn ( bedsores.trohpic ulcer, & infection)
2-Localized condition (art infow)

***Types of Dressing & indications:

I-Common Dressing:
-Water etaining abilities!
-Main goal is to : maintain the moisture in the wound enviroments!
-Classifcited as Open & Semiopen/Semi occlusive!

-Primary Gauze!
-mositured with Salien before Placing it on Wound!
Semi open:
-Mesh Gauze Impregnated with petroleum.gaffin wax/ Ointment!
-Seconds lauers o absorbent gauze!