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*** 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!:
^^Lesions:
1-Neurapraxia:
-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
3-Neurotomesis:
-Most Severe
-Full nerve Damage(all bundles damaged)
-Epineurom laso daaged!
-Surgery is needed , Excision of Ends First & Then suture!
^^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!
Tips:
-DO not let the Victim Eat or Drink!
-Reattachment requires surgery!
^^ER:
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
(Hb/UA/BUN /CXR)
-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)
^^Dreassing:
-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
(TABLE)
Superficilial | -Dry /Red -Blacheswith prssure | Painful | 2-6 Days |
Deep -Partial thickness | -Blisters -Wet -Variable color | Perceptive of pressure | >31 days |
Full thickness | Waxy – | Deep Pressure only! | Rare unles surgical |
4th degree | into dacia/Muscle | Deep Pressure | NEver unless Surgical Treated |
^^Etiology:
-Most common Burn in Children is Scald Injury!
-Adult most common burn from Flame!
1-Thermal:
-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
4-Electircal:
-when electircal energy becomes thermal
-Electroporation(injury of cell membrane)
5-Inhalaton:
-Toxic products of combustion injury airways!
-Causes: Flash burns/ Fire/Steam!/Hot smoke
6-Radiation:
Radio Frequency energy/ ionizing Radation
^^Severity:
-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
2-biopsy
3- Laser doppler Velocimetry!
Methods for TBSA assesment in Adults:
Lung -Browder | Rule of Nine | PALM method(small) |
CHART in Q | -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:
-Silver
-Anticoat
-Silverolne
-Aquacel Ag
^^Surgery:
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!
I-Urgent:
-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
II-Essential
-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!
-Steps:
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)
-Suppuration
-Spread of Inflammation to Healthy tissue
^^Regenration Option:
1-Dressing:
-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
I-Homeostasis: -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 |
II-Inflammation: -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 |
V-Maturation: 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
3-Osteonectsis
4-Discharge
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!
OPEN: -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! |