Surgical Reconstruction: Tissue Repair, Nerve & Tendon Sutures, Burn Care
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*** Reconstruction Surgery of Tissue Defect!:I-Local Plasty( Plasty with Local Tissue)
***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 part3-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 prolineExternal pineurium is only sutured and holds the axon ends together!***Injury of Median/Ulnar/Radial Nerve!^^Median Nerve:
***First Aid In Case of Traumatic Amputation of Extremities:Retention of Fragments!^^First Aid:1- Stay Sfeuniversal protection/Wear Protective Equipment!2-Call 911/Help immediatly+ Say Location3- 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 ASAP6- Check for Shock signs!Tips:-DO not let the Victim Eat or Drink!-Reattachment requires surgery!^^ER:Pts & Amputed limb need attentionI-Pts--->Xray/NPO/Cleanwound/irrigate/Dress Stump with nonadherent Cover!/Ax/Tetanus AxII-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% O23-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 BSA2-4 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
-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 part3-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 prolineExternal 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! |
***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 patchyburns are approciamted using the surface area of Patients PaslmExcluding the Fingers =0.5% o TBSA |
| 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 |
-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 recruitmentChronic 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! |