Oxford Handbook of Clinical Surgery (4 edn)
Annotate
Cite
Suturing wounds 590
Skin grafts 594
Surgical flaps 596
Management of scars 598
Excision of simple cutaneous lesions 600
Skin cancer 602
Burns: assessment 604
Burns: management 606
Soft tissue hand injuries 610
Hand infections 612
Dupuytren's disease 614
Breast reduction 616
Breast augmentation 617
Breast reconstruction 618
Suturing wounds
Key facts
A correctly orientated incision, adequate haemostasis, and minimal tissue handling are prerequisites for an ideal scar. When closing wounds, bear in mind the following:
All wounds leave scars. You must warn your patient of this.
Hypertrophic scars are more likely on the sternum and deltoid area.
Speed of healing depends on site. The face heals more quickly than the trunk and limbs.
Children and young adults heal more quickly and achieve stronger scars than the elderly, the chronically ill, and those on steroids.
Stitch marks (‘tramline effect’) are caused by epithelial growth into suture tracks and occur when sutures are left in longer than 7 days.
Cross-hatching is more common when tight sutures cause ischaemia.
If sutures are removed too early, the wound may dehisce, leaving a worse scar.
Suture techniques
Eliminate dead space with deep sutures or a drain, but avoid suturing fat, which contributes no strength and may lead to fat necrosis.
Consider buried, interrupted dermal sutures to reduce skin tension.
Dermal sutures can be combined with a subcuticular running suture or skin tapes to avoid suture marks.
Use the finest suture possible to maintain wound closure—5/0 or 6/0 for the face; 4/0 or 5/0 for the hand; 2/0 to 4/0 for the trunk.
Evert the wound to reduce dead space and allow rapid healing.
Approximate wound edges without strangulating the skin.
Dressings can be used to splint a wound or immobilize a limb during healing.
Elevation will reduce post-operative swelling, bleeding, and pain.
In a low tension wound closure, sutures may be removed at 5–7 days on the face, 7–10 days on the arm and anterior trunk, and 14 days on the back and lower limb.
Most wounds benefit from being splinted with skin tape after removal of sutures.
Interrupted skin suture
(see Fig. 16.1(a))
Use fine-toothed Adson forceps or a skin hook to evert the skin.
Pass the needle perpendicular to the skin through its full thickness.
Either remove the needle through the wound or continue in one sweep to the other side of the wound, using the forceps for counter pressure so the needle passes perpendicular to the skin on its way out.
Tie the knot so the skin edges are just apposed, bearing in mind the wound will swell post-operatively.
Place the sutures evenly, approximately twice as far apart as they are from the wound margins.
The distance between the suture and the wound margin should be similar to the thickness of the skin.
Types of suture. (a) Interrupted suture. (b) Mattress suture. (c) Deep dermal suture. (d) Continuous suture. (e) Subcuticular suture.
Mattress suture
(see Fig. 16.1(b)) Pass the needle as above across the wound, then turn it around and pass it back as if doing another interrupted suture in the opposite direction. The second pass can be along the wound from the first (a horizontal mattress) or nearer the wound margin than the first pass (a vertical mattress suture).
Deep dermal suture
(see Fig. 16.1(c)) Use the forceps or skin hook to evert the skin and pass the needle from deep to superficial on the dermal surface of the wound. Move to the other side of the wound and pass the needle from superficial to deep within the dermis. Tie a knot which should be buried deep in the wound.
Continuous suture
(see Fig. 16.1(d)) A combination of repeated interrupted-type sutures or interrupted, then mattress sutures.
Subcuticular suture
(see Fig. 16.1(e)) The suture is passed continuously within the dermis, usually near the dermo-epidermal junction, from one end of the wound to the other, and pulled tight. It may be secured with a knot buried deeply at either end or with skin tapes laid over the suture ends and the wound surface.
Skin grafts
A skin graft is a piece of dermis and epidermis that is completely removed from its original bodily attachment (the donor site). It is fixed to a recipient site and develops a new blood supply from the underlying tissue.
Autograft. Transfer from one part of a person's body to another part.
Isograft. Transfer between genetically identical individuals.
Allograft. Transfer between individuals of the same species.
Xenograft. Transfer between individuals of different species.
Full thickness skin grafts (Wolfe grafts)
(see Table 16.1)
Contain epidermis plus the entire thickness of dermis.
Adnexal structures, e.g. hair, are included.
Harvested by elliptical excision from sites of skin laxity, e.g. post-auricular skin crease, supraclavicular, preauricular, groin, or medial upper arm skin.
Graft secured with a tie-over dressing, e.g. proflavine-soaked cotton wool, and inspected after a week.
Donor site sutured closed.
| Split skin graft | Full thickness skin graft | |
|---|---|---|
Cosmesis | Thin, often hypertrophic skin | Good cosmesis |
Contracture | Frequent | Less frequent |
Availability | Plentiful; can re-harvest after 14 days | Limited by skin laxity |
Take Donor scar | Good—low metabolic needs Minimal—colour change only | Needs optimal bed Linear scar |
Contraindications | Inadequate bed, e.g. exposed bone, tendon, cartilage (in which case flap needed) Infected bed Areas where cosmesis is paramount | Large area to be covered Inadequate bed |
| Split skin graft | Full thickness skin graft | |
|---|---|---|
Cosmesis | Thin, often hypertrophic skin | Good cosmesis |
Contracture | Frequent | Less frequent |
Availability | Plentiful; can re-harvest after 14 days | Limited by skin laxity |
Take Donor scar | Good—low metabolic needs Minimal—colour change only | Needs optimal bed Linear scar |
Contraindications | Inadequate bed, e.g. exposed bone, tendon, cartilage (in which case flap needed) Infected bed Areas where cosmesis is paramount | Large area to be covered Inadequate bed |
Split thickness skin grafts (Thiersch grafts)
(see Table 16.1)
Consist of epidermis plus a variable thickness of dermis.
Harvested by shaving off a layer of skin with a skin graft knife or dermatome. Can be taken from any area of the body (thigh skin most often used—plentiful and easy to access).
Graft is often fenestrated (to stop blood or serous fluid collecting under it) or meshed (to expand the graft and allow it to contour to the wound bed).
Graft secured with glue, sutures, or staples, then a non-adherent, compressive dressing. Inspected after 5 days.
Defect heals by re-epithelialization from skin appendages.
Graft healing
Stages of graft take
Adherence (immediate). Fibrin bond between graft and recipient bed.
Serum imbibition (days 2–4). Graft absorbs fluid and nutrients from bed.
Revascularization (after day 4). Blood enters the graft, either by flowing directly into the graft vessels (inoculation) or by new vessel ingrowth.
Reasons for graft failure
Shearing. Revascularization cannot occur if the graft is mobile.
Infection. Either of the bed or the graft tissue.
Separation of graft from its bed. By haematoma or seroma.
Inadequate bed, e.g. bare cortical bone; tendon without paratenon.
Damage to the graft, e.g. poor surgical technique, excessive dressing pressure.
Vacuum dressings
These are dressings that apply negative pressure via a sponge placed in the wound cavity, covered with an airtight adhesive silicone sheet and connected to a vacuum pump. They increase the initial rate of granulation in a variety of wounds, including dehisced or infected sternotomy and laparotomy wounds, pressure sores, chronic open wounds, flaps, grafts, and burns. The dressing is changed every 48–72h. Fluid from the wound bed is collected in a disposable canister. Chronic wounds may heal by secondary intention (see 
p. 146) or be closed primarily.
Surgical flaps
A scar is an area of fibrous connective tissue, produced by healing.
Classification of flaps
Also see Fig. 16.2.
Types of surgical flaps. (a) V-Y flap. (b) Rhomboid flap.
By blood supply
Random pattern. Survive on blood vessels in dermal and subdermal plexuses which have no specific anatomical pattern. Length to breadth ratio is therefore limited to 1:1 (or 3:1 on the face).
Axial pattern. Have at least one specific artery running longitudinally within the flap, so length to breadth ratio can be greatly increased.
All composite flaps and all free flaps have an axial blood supply.
By mode of transfer (for local flaps)
Advancement. The base of the flap advances in the direction of the flap axis, e.g. V-Y flap of perianal skin into anal canal for anal stenosis.
Pivot. Rotation or transposition. The flap rotates around a single pivot point, e.g. scalp rotation flap to cover facial defect after tumour excision.
Interpolation. The flap pedicle passes over or under adjacent skin to inset the flap into a nearby defect, e.g. deltopectoral flap for head and neck reconstruction after radical tumour surgery.
Transfer of distant flaps
Direct. Flap moved directly to non-adjacent area, e.g. cross finger flap.
Tubed. Pedicle curled inwards to form a tube until base of flap divided, e.g. tubed flap from upper arm for nose reconstruction.
Free. Artery and vein to flap are completely divided, then reattached with microvascular anastomoses to a suitable artery and vein at the recipient site, e.g. radial forearm flap to release neck scar contracture.
By composition
Cutaneous. Skin and subcutaneous tissue only, e.g. groin flap.
Fasciocutaneous. Includes deep fascia, making flap vascularity more reliable and allowing length to breadth ratio to be increased.
Fascial or adipofascial. The fascia (and subcutaneous fat) is transferred, but the skin, still attached, is replaced on the donor site, e.g. temporalis fascial flap. The transposed flap can then be skin grafted.
Muscle. Useful for infected or traumatic wounds. The flap is skin grafted, e.g. gastrocnemius flap for exposed knee prostheses.
Myocutaneous. Used in reconstructive surgery. The muscle carries the blood supply to the skin, e.g. latissimus dorsi myocutaneous flap.
Perforator flaps. Modified myocutaneous flaps. A single artery and vein are dissected from skin, through muscle, to the parent vessels. The muscle remains in situ, so its function is retained, e.g. deep inferior epigastric perforator (DIEP) flap.
Bone, osseocutaneous. Bone with or without skin, e.g. fibular flap for reconstruction of mandible. Muscle may also be included.
Management of scars
A flap is a unit of tissue that maintains its own blood supply while being transferred from donor to recipient site.
Clinical features
A normal scar is initially flat and pale, then becomes red, itchy, and raised. Over months to years, it settles back to a flat, pale, slightly shiny patch. Scarring is more pronounced if infection intervenes during healing or in the presence of foreign bodies. Scars settle more slowly in children and will improve over 2–3y, but resolve rapidly in the elderly.
There are several types of abnormal scar.
Hypertrophic scars. Firm, red, itchy, and elevated above the skin surface, but within the boundaries of the injury. More common over presternal and deltoid regions. Regress with time.
Keloid scars. Extend beyond wound boundaries. Do not regress spontaneously. Painful and itchy. Common in dark skins and sites as above.
Stretched scars. Due to dehiscence of dermis under intact epidermis. Common on the back.
Scar contractures. Common over flexor surfaces of joint. Occur when wounds heal by secondary intention, after split skin grafting, or when incisions cross a joint perpendicular to the crease.
Treatment
Treatment aims to improve poor cosmesis, relieve local symptoms (pain, itch, irritation), or reduce restriction of associated joint movement.
Medical/conservative treatment
Observation. ‘Benign neglect’.
Massage. Scar achieves flat, pale state more quickly. Relieves itch.
Pressure. Pressure garments for large areas, e.g. skin-grafted burns. Pressure devices, e.g. clip earrings for earlobe keloids. Worn continuously till scars mature. Reduce hypertrophy and contracture.
Silicone gel. Either a sheet of gel tape worn on the scar or a jelly rubbed into it scar. Reduces hypertrophy and relieves itch.
Lasers. Pulsed dye lasers used to reduce redness and hypertrophy. Carbon dioxide laser resurfaces depressed scars.
Intralesional injections. Steroids and cytotoxics (e.g. bleomycin, 5-FU) reduce excess collagen formation; used to flatten hypertrophic and keloid scars and reduce pain and itch. Usually need repeated injections at 1–2-month intervals.
Radiotherapy. Occasionally given immediately post-operatively to wounds in patients known to be prone to hypertrophic or keloid scarring.
Surgical treatment
Excision and closure. For stretched scar or scar with ‘tramlines’. Usually restretch to some extent. Keloid or hypertrophic scars are likely to recur if excised and may be much larger than the original scar. Keloids should only be excised in combination with a post-operative course of steroid injections.
Z-plasty (see Fig. 16.3(a)). Lengthens scar. Can re-orientate scar into lines of relaxed skin tension, or break up the line of the scar and make it less noticeable.
W-plasty (see Fig. 16.3(b)). Breaks up line of scar. Used on scalp to avoid a hairless linear scar.
Scar release and resurfacing. Used when Z-plasty inadequate for scar release, either because there is insufficient laxity adjacent to the contracture or if adjacent skin is of poor quality. Resurfacing may include skin grafting, local flaps, or free tissue transfer.
Surgical techniques for managing scars. (a) Z-plasty. (b) W-plasty.
Excision of simple cutaneous lesions
Planning
Under good light and before infiltration of anaesthesia, mark the borders of the lesion. Mark the appropriate margin of excision: 2–5mm for basal cell carcinoma (BCC), 4–6mm for squamous cell carcinoma (SCC), 1–2mm for biopsy of a pigmented lesion.
Incision biopsies should include a border of the lesion and normal skin.
For direct closure, convert the excision to an ellipse, using lines of relaxed skin tension as the long axis. Be guided by wrinkles and line of hair growth (hair generally grows in the direction of relaxed skin tension lines (RSTLs)).
Wedge excisions are used on the borders of the ear, eyelid, and lip. Circular excisions are used where there is little skin laxity, using flaps or grafts to close the defect.
Anaesthesia
Calculate the maximum safe dose for your patient (see p. 218).
Consider a mixture of bupivacaine 0.25% with lidocaine 1% to provide longer acting anaesthesia. Adding sodium bicarbonate makes the injection less painful.
Using adrenaline with the infiltration reduces intraoperative bleeding, but should not be used near anatomical ‘end’ arteries (e.g. the digital arteries) due to the risk of distal ischaemic necrosis.
In the face, nerve blocks (e.g. mental, infraorbital, supraorbital, and supratrochlear) may reduce the pain of infiltration, the volume of anaesthetic needed, and distortion of the tissues by the anaesthetic fluid.
Check the anaesthetic is working before starting excision.
Shave excision
For benign, non-pigmented naevi and seborrhoeic keratoses. Use a number 10 blade to cut horizontally across the lesion at mid-dermal level.
Excision
Be aware of underlying structures (e.g. the frontal branch of the temporal nerve when excising lesions from the temple). Ask your assistant to stretch the skin.
Use a size 15 blade on the face; consider a larger size 10 blade on the thicker skin of the back.
Cut the margins of the lesion perpendicular to the skin; this will aid closure.
Cut away from the corners of the wound to avoid X-shaped overcuts. Cut the lower edge before the upper one; blood trickling down may obscure your view.
Lift one corner of the lesion gently with a skin hook or fine-toothed (Adson's) forceps and cut along the base of the lesion in horizontal lines at the level of the subcutaneous fat. Avoid traumatic handling of the lesion, which may compromise histological analysis.
Perform accurate haemostasis.
Close and dress the wound.
Post-operative care
All lesions should be sent for histological analysis, clearly labelled (if necessary with a marking stitch for orientation).
Elevate the wound.
Keep the wound dry until the skin is healed.
Paracetamol, ibuprofen, and codeine are suitable analgesics; aspirin is best avoided due to risk of bleeding.
Patients should not drive on the day of surgery.
Skin cancer
Key facts
BCC, a neoplasm of the basal cells of the epidermis affects 20–40% Caucasians. It almost never metastasizes, but can invade deeply and may therefore be fatal.
SCC is a malignant neoplasm of the keratinizing cells of the epidermis affecting 1 in 2000 Caucasians per year.
Melanoma is a malignant neoplasm of melanocytes, with a lifetime risk of about 1 in 70 for Caucasians. The incidence has doubled over the past 20 y.
Clinical features
Melanoma presents with a change in a pre-existing or new mole (naevus). Remember Asymmetry; Border irregularity; Colour change or variegated colour; Diameter >6mm; Elevation, itch, or bleeding. All these features are suspicious of melanoma.
The typical BCC is a skin ulcer with a pearly edge and telangectasia; however, there may not be any of these features. A persistent, itchy; scaly patch in a sun-exposed area may also be a BCC.
SCC typically presents as an ulcer with a raised, rolled edge, but also may take many forms from scaly patch to keratotic horn.
Risk factors
Fair skin and blue eyes.
Sun exposure, both adult and childhood, especially sunburn.
Family history.
Previous skin cancer.
Immunosuppression, especially post-organ transplantation.
Xeroderma pigmentosum.
Pre-malignant lesions. Multiple atypical naevi and giant congenital naevi for melanoma; sebaceous naevus of Jadassohn for BCC; Bowen's disease, solar keratosis, and chronic ulcers for SCC.
Radiotherapy.
A variety of chemicals, e.g. arsenic and coal, predisposes to SCC and BCC.
Assessment
History includes sun exposure, previous skin lesions, drug history, and family history.
Examine the entire skin and palpate draining lymph nodes.
Dermatoscopy is used to improve accuracy of clinical diagnosis of melanoma.
Management
Melanomas and SCCs are managed by skin cancer MDTs.
Melanoma
All suspicious pigmented lesions are biopsied with a 2mm margin to include subcutaneous fat and sent for histological analysis.
Surgery aims to cure melanoma. Radiotherapy and chemotherapy are used for palliation only. Wide local excision margins depend on the depth of invasion (Breslow thickness) of the tumour and are typically 1cm for lesions <1mm thick, 2cm for lesions 1–2cm thick, and 2–3cm for lesions >2cm thick.
Sentinel lymph node biopsy may be considered, with lymph node dissection of the neck, axilla, or groin if positive.
Prognosis depends on Breslow thickness, ulceration of the tumour, and lymph node involvement.
SCC
Lesions are excised with a 4–6mm margin depending on the site; 95% of tumours are cured by this treatment.
Moh's micrographic surgery probably gives the highest cure rate.
Radiotherapy is used as an adjuvant treatment for metastatic tumours or as primary treatment if the tumour or the patient mean that surgery is not possible.
Palpable lymph nodes in the draining basin are investigated by FNA, with lymphadenectomy if positive.
Prognosis depends on diameter of lesion, depth of invasion, nerve or vessel invasion on histology
BCC
Margins of 3–4mm are suitable for well-defined BCCs, but wider margins are used when margins are unclear and in recurrent tumours.
Moh's micrographic surgery is also used, particularly when wide excision would leave an unacceptable defect, e.g. around the eye.
Other treatment modalities include curettage and cautery, cryotherapy, radiotherapy, efudix, imiquimod.
Ninety-five per cent of lesions are cured by complete excision, 99% with Moh's surgery. Radiotherapy cures 90%.
Burns: assessment
Assessment and management of burns go hand in hand and are simultaneous in practice. They have been divided here only for ease of reading.
Causes
Most burns are due to flame or contact with hot surfaces; scalds are more common in children and the elderly. Chemical, electrical, irradiation, and friction burns are rare.
History
Find out the exact mechanism, including temperature of water, duration of contact, concentration of chemical, voltage.
Record factors suggesting inhalation injury, e.g. burns in a confined space, flash burns.
Enquire about other injuries.
Document first aid given so far.
Document timings of injury, first aid, and resuscitation.
Examination
Estimate area of burn Do not include areas of unblistered erythema.
Rule of nines.
Lund and Browder chart.
Epidermal. Erythema only.
Superficial dermal. Pink, wet or blistered, sensate, blanches and refills.
Deep dermal. Blotchy red, wet or blistered, no blanching, insensate.
Full thickness. White or charred, leathery, no blanching, insensate.
Signs of inhalation injury
Singed nasal hair.
Burns to face or oropharynx. Look for blistered palate.
Sooty sputum.
Drowsiness or confusion due to carbon monoxide inhalation.
Respiratory effort, breathlessness, stridor, or hoarseness are signs of impending airway obstruction and require immediate intubation.
Features of non-accidental burns injury
Refer to paediatric burns unit if suspected in a child. Features include:
Delayed presentation.
History inconsistent or not compatible with injury.
Other signs of trauma.
Suspicious pattern of injury, e.g. cigarette burns, bilateral ‘shoes and socks’ scalds.
Burns: management
Immediate first aid
Stop the burning process (do not endanger yourself ).
Cool the wound. Running water at 2–15°C for 20min (beware risk of hypothermia in infants, young children, and adults with >25% TBSA).
Resuscitation
A. Airway maintenance with C-spine control. Intubate if suspected inhalation injury; airway oedema can be rapidly fatal.
B. Breathing and ventilation.
C. Circulation with haemorrhage control.
D. Disability and neurological status.
E. Exposure and environmental control.
F. Fluid resuscitation: child, >10% TBSA; adult, >15% TBSA burned.
Two large peripheral IV lines, preferably through unburned skin.
Send blood for FBC, U&E, clotting, amylase, carboxyhaemoglobin.
Give 3–4mL Hartmann's solution/kg/% TBSA burned. Half of this is given over the first 8h following injury, half over the next 16h.
Children need maintenance fluid in addition.
Monitor resuscitation with urinary catheter (aim for urine output 0.5–1mL/kg/h in adults and 1–1.5mL/kg/h in children).
Consider ECG, pulse, BP, respiratory rate, pulse oximetry, ABGs.
Perform secondary survey.
Referral to a burns unit
(see Box 16.1) Intubate before transfer if inhalation injury suspected. Give humidified 100% O2 to all patients. Wash the burn and cover with cling film. Give IV morphine analgesia. Discuss NGT and catheter insertion with burns unit. Give tetanus prophylaxis if required.
>10% TBSA burn in adult; >5% TBSA in child.
Burns to face, hands, feet, perineum, genitalia, major joints.
Full thickness burns >5% TBSA.
Electrical or chemical burns.
Associated inhalation injury—always intubate before transfer.
Circumferential burns of limbs or chest.
Burns in very young or old, pregnant women, and patients with significant comorbidities.
Any burn associated with major trauma.
Management of the burn wound
Superficial dermal burns will heal without scarring within 2 weeks as long as infection does not deepen the burn.
For small burns, outpatient treatment with simple, non-adherent dressings and twice weekly wound inspection is sufficient.
Wash burns with normal saline or chlorhexidine.
Debride large blisters. Elevate limbs to reduce pain and swelling.
Dress hands in plastic bags to allow mobilization.
Topical silver sulphadizine is used on deep burns to reduce risk of infection (but should not be applied until the patient has been reviewed by a burns unit as it makes depth difficult to assess).
Escharotomy
Performed for circumferential full thickness burns to the chest that limit ventilation or to the limbs that limit circulation. Loss of pulses or sensation is a late sign. In the early stages, pain at rest or on passive movements of distal joints indicates ischaemia. Patients may also need fasciotomies.
Excision and skin grafting
Performed for deep dermal or full thickness burns that are too large to heal rapidly by secondary intention.
Electrical injuries
Low voltage (<1000V). Domestic electrical supply. Causes local contact wounds, but no deep injury. May cause cardiac arrest.
High voltage (>1000V). High tension cables, power stations, lightning. Causes cutaneous and deep tissue damage with entry and exit wounds.
ECG on admission for all injuries. Continuous cardiac monitoring for 24h for significant injuries.
In high voltage injury, muscle damage may require fasciotomy.
Myoglobinuria can cause renal failure. Urine output >75–100mL/h.
Chemical burns
Treat with copious lavage for at least 30min until all chemical has been removed and skin pH is normal.
Acid. Causes coagulative necrosis; penetrates skin rapidly, but is easily removed.
Alkali (includes common household chemicals and cement). Causes liquefactive necrosis so needs longer irrigation (>1h).
Hydrofluoric acid. Fluoride ions penetrate burned skin, causing liquefactive necrosis and decalcification; 2% TBSA burn can be fatal.
Irrigate with water.
Trim fingernails.
Topical calcium gluconate gel, 10%.
Local injection of 10% calcium gluconate.
IV calcium gluconate.
May need urgent excision of burn.
Elemental Na, K, Mg, Li. Do not irrigate initially; they ignite in water. Brush off particles and direct high pressure jet of water to wound.
Phosphorus. Irrigate with water, then debride particles which will otherwise continue to burn. Apply copper sulphate which turns particles black so they are easier to identify.
Bitumen. Burns by heat; treat by cooling with water. Remove cold bitumen with peanut or paraffin oil.
Tar. Burns by heat. Treat by cooling with water; no need to remove tar as it gradually gets emulsified with topical ointments used for treatment.
Soft tissue hand injuries
History
Mechanism of injury.
Dominant hand, occupation, hobbies.
Medical and smoking history, previous hand injuries, social history.
Examination
Use local anaesthetic block if needed for pain (check sensation first).
Look
Posture of hand and digits. Site of laceration(s) and tissue loss.
Feel
Perfusion of hand and digits, pulses. Sensation in distribution of radial, ulnar, median, and digital nerves. Pain over bones.
Move
Long extensors extend MCPJs.
EPL extends thumb dorsal to plane of hand (i.e. up off a table).
FDP tendons flex DIPJs.
FDS tendons flex PIPJs. Isolate FDS by holding all digits except the one under examination extended.
Testing wrist flexors and extensors is unreliable as finger flexors and extensors may mimic function, but pain on movement suggests injury.
Examine intrinsics, hypothenar and thenar muscles, particularly abductor pollicis brevis (supplied by median nerve) and Froment's sign (for adductor pollicis supplied by ulnar nerve).
Check stability of joints. Pain or abnormal movement on lateral deviation suggests collateral ligament damage.
Investigations
X-ray for fractures of foreign bodies. Photographs.
Treatment
Finger pulp injury. Debride under tourniquet. If there is no bone exposed, it will heal by secondary intention. Exposed bone may need surgery to shorten bone or cover it with a local flap.
Subungual haematoma. Painful bruise under nail. Trephine nail with sterile needle to evacuate haematoma.
Nailbed injury. Often with distal phalanx (DP) fracture. Remove nail under tourniquet; irrigate wound; repair nail with absorbable 7/0 suture using loupe magnification. Replace fenestrated nail as splint for eponychial fold.
Mallet finger. Immobilize in stack splint for 6–8 weeks unless large bony fragment present which may require surgical fixation.
Foreign bodies. Remove organic matter and painful foreign bodies.
Lacerations and puncture wounds.
Always explore with anaesthetic and tourniquet to determine underlying structural damage.
Irrigate wounds and debride as necessary.
Tetanus prophylaxis (see p. 175).
Co-amoxiclav (500mg tds PO) for bites.
Repair tendons, ideally primarily. Post-operative regimes typically involve splints for 6 weeks and 6 more weeks without heavy lifting.
Repair nerves under magnification. Axonal regeneration progresses at 1mm/day after 1 month from repair.
Thoroughly irrigate open joints due to the risk of septic arthritis. Collateral ligaments may need to be repaired and are splinted for around 4 weeks post-repair.
Complications. Haematoma, infection, tendon or ligament rupture, stiffness, painful scars, neuroma, complex regional pain syndrome, scar contracture, cold sensitivity.
Hand infections
Key facts
Usually follows a penetrating injury (which may seem insignificant) or a bite. Haematogenous spread of infection to the hand is rare.
Infecting organisms. After penetrating injury, Staphylococcus aureus is the most common, followed by streptococci. Human bites are often also contaminated with Eikenella corrodens. Viruses (hepatitis B and C, HIV) are rarely transmitted. Pasteurella spp. are common in infected cat and dog bites.
Paronychia. Infection of nailfold. Candida albicans causes chronic paronychia and may require excision of crescent of epinychium and topical antifungals. Herpes simplex causes whitlow with vesicles or bullae around the nail, but no pus. Avoid surgery in these cases.
Felon. Finger pulp infection.
Palmar space infection. There are four fascial compartments in the palm (web space, hypothenar, mid-palm, and thenar). They usually confine infection initially. Pain, swelling, and reduced movement are features. Swelling is often more prominent on the dorsal surface of hand.
Flexor sheath infection. The cardinal signs are flexed posture of finger, pain on passive extension, fusiform swelling, pain along flexor sheath. Often requires continuous saline irrigation for 24–48h post-drainage.
Bites. High risk of infection so always irrigate, give antibiotic prophylaxis (co-amoxiclav 500mg PO tds), and refer for surgical exploration.
Treatment
Delay can be disastrous, resulting in stiffness, contracture, and pain. Early cellulitis (24–48h after onset) may be treated by elevation, splints, and antibiotics. Any collection of pus must be drained urgently.
Initial treatment
Tetanus prophylaxis if indicated.
Elevation and splintage.
IV co-amoxiclav 1g tds (unless penicillin allergy) till sensitivities known.
Plain X-ray may be useful to exclude associated fractures, foreign bodies, underlying osteomyelitis, and evidence of gas-forming infection.
Surgical treatment
Use a tourniquet, but elevate rather than exsanguinate the limb.
Send pus swabs and tissue samples for culture.
Debride and irrigate wounds; fully explore pockets of pus.
Leave wound open for delayed primary closure.
Post-operative care
Continue elevation.
Daily saline soaks or irrigation of the wound.
Splint for comfort with wrist extended, MCPJs flexed, and interphalangeal joints (IPJs) extended. Mobilize with physiotherapists.
Antibiotics until infection resolved.
Dupuytren's disease
Key facts
A progressive thickening of the palmar and digital fascia that may lead to contractures. Aetiology is unknown, but there is a higher incidence among relatives of affected patients. Associated conditions include diabetes and epilepsy. Alcoholism, TB, HIV, hand trauma, and tobacco have all also been implicated. Incidence is 1–3% of northern Europeans, but it is uncommon in Africa and Asia. It increases with age; ♂ > ♀, approximately 7:1.
Pathogenesis
Disease classified by Luck into three phases: proliferative, involutional, and residual.
In the proliferative phase, immature fibroblasts, many of which are myofibroblasts, produce extracellular matrix containing type IV collagen. Resembles a healing wound histologically.
Mechanical tension appears to play a role in contractures.
Clinical features
Thickened palmar and digital fascia forms nodules and cords.
Progresses to contractures of the MCPJs and PIPJs of the affected rays.
Tends to affect digits in order: ring, little, thumb, middle, index.
Normal fascia is referred to as bands; diseased bands are called cords.
A spiral cord may be a feature, wrapping around the neurovascular bundle (NVB) and displacing it to the midline and superficially, putting it at risk during surgery.
The disease affects longitudinal fascial structures; the transverse palmar fascia is never involved and provides a landmark for dissecting NVBs.
Garrod's pads. Thickening over dorsal aspect of PIPJs.
Peyronie's disease. Thickened plaques in the shaft of the penis.
Ledderhose's disease. Thickened plantar fascia.
Treatment
Indications for surgery
Over 30° fixed flexion contracture at MCPJ or any PIPJ contracture. Also any rapidly progressing contracture. Results are better for release of MCPJs than PIPJs.
Tabletop test. Surgery indicated when hand will not lie flat on table.
Pain in nodules or Garrod's patches. Injection with steroid or excision.
Many people with Dupuytren's disease never require surgery.
Surgical considerations
Skin
Typical incisions include the following.
Linear incisions with Z-plasties.
Bruner incisions.
Multiple V to Y incisions.
Lazy ‘S’ incisions.
Transverse palmar incision with longitudinal extensions.
Multiple short curved incisions.
Multiple Z-plasties.
Closure may be direct with skin grafts (split or full thickness) or palm left open to heal by secondary intention.
Fascia
This may be incised (fasciotomy) or excised (fasciectomy).
Radical fasciectomy removes the entire palmar fascia.
Regional or limited fasciectomy removes only the diseased fascia.
Segmental fasciectomy excises sections of the diseased cord.
Fasciotomy via a percutaneous approach using a needle provides temporary relief from contracture.
Dermofasciectomy. Excision of fascia with overlying skin, used for severe skin involvement and where risk of recurrence is high, e.g. surgery for recurrent disease.
Specimens are sent for histological analysis to rule out the rare differential diagnosis of epithelioid sarcoma.
Joint contractures
Release of fascia usually resolves contracture at the MCPJ. Fixed flexion at the PIPJ is more difficult to release and contracture often recurs. Consider releasing the check-rein and accessory collateral ligaments. DIPJs are rarely involved except in recurrent disease.
Post-operative care
The affected fingers are splinted in extension and active exercises begun in the first week, unless a skin graft has been used. Night splints are used for at least 3 months.
Complications
Early. Damage to neurovascular structures (1–3%), PIPJ hyperextension, haemorrhage.
Intermediate. Infection, skin flap necrosis.
Late. Complex regional pain syndrome; recurrence (25% of patients treated surgically will need further surgery for Dupuytren's disease).
Treatment of recurrence
Recurrence may be treated by repeat surgery although this tends to be less successful and more extensive at each event. Amputation of a fixed flexed digit is occasionally an option, particularly if the digit hampers work or leisure activities.
Breast reduction
To reduce the volume and weight of the hypertrophied breast while maintaining a blood supply to the nipple and creating an aesthetically pleasing breast.
Indications
Neck, back, or shoulder pain.
Indentation of shoulder skin by bra straps.
Persistent infections or soreness in the inframammary crease.
Restriction in activity, especially sport.
Inability to find clothes that fit.
Psychological. Embarrassment, low self-esteem, loss of sexual appeal.
Operative considerations
Blood supply to the nipple
In order to lift the nipple, skin around it is de-epithelialized or excised. The base of the nipple is left attached to a mound of breast parenchyma (the pedicle) through which its blood supply travels. Due to the rich vascular anastamoses in the breast, numerous techniques are possible. Pedicles can be based inferiorly, superiorly, supero-medially, laterally, or centrally. Alternatively, the nipple can be removed before the breast is reduced and replaced as a full thickness graft.
Skin excision and scars
An anchor shape (Wise pattern) excision leaves an inverted ‘T’-shaped scar. It runs around the areola, vertically down to the inframammary fold and horizontally along the fold. Other options include periareolar incision only or periareolar incision with a vertical scar. These techniques limit the amount of breast tissue that can be resected. L-shaped and horizontal scar techniques are also possible, but more rarely used.
Post-operative care
The patient usually stays in hospital overnight or longer if drains are used. She should wear a supportive bra and avoid heavy lifting for 4–6 weeks post-operatively.
Complications
Early. Haematoma, infection, altered nipple sensation, skin loss or necrosis, fat necrosis, delayed wound healing, asymmetry.
Late. Unsightly scar, inability to breastfeed, pseudoptosis (‘bottoming out’), recurrence (if done before breast fully grown).
However, most patients are happy with the result, even if they do suffer complications.
Breast augmentation
To enhance breast size by placing an artificial implant beneath the breast.
Indications
Performed for asymmetry, hypoplasia, and psychological reasons, e.g. self-consciousness or problems with sexual relationships. Inadequate breast volume may be due to hypoplasia or involution following childbirth or menopause.
Operative considerations
Incision
Inframammary fold. Good visualization of implant pocket; visible scar.
Periareolar. Semicircular incision at the border of the areolus. Scar fades well, but access is limited. More likely to alter nipple sensation.
Transaxillary. Eliminates scars on breast. Limited access improved by using endoscope. Better for subpectoral implants.
Transumbilical. Only used for saline-filled implants, inserted along a tunnel created superficial to rectus sheath. Endoscope confirms position of implant pocket. Implant inflated once in position.
Position of implant
Submammary. Under the normal breast.
Subpectoral. Under the pectoralis major (slightly less obvious upper border in the thin; have lower rates of capsular contracture, but may move when the pectoralis contracts).
Type of implant
Size. Depends on patient's choice.
Shape. Round implants are low or high profile (depending on how much they project forwards); anatomical implants are teardrop-shaped.
Shell. Implants are made of a silicone shell that is smooth or textured. Textured implants have lower rates of capsular contracture.
Implant filling. Saline-filled implants allow for fine adjustment of volume and can be filled or emptied post-operatively. Silicone gel-filled implants feel more like normal breast tissue. No current evidence to support implication of silicone in causing autoimmune diseases.
Post-operative care
Usually an overnight stay procedure (longer if drains are used).
A supportive bra is worn and heavy lifting avoided for 4–6 weeks.
Complications
Early. Haematoma, infection, nerve injury (altering sensation to the nipple), incorrect position of implant.
Late. Capsular contracture, rupture, or deflation; silicone gel bleed.
Implants have a limited lifespan, up to about 20y. The likelihood is that they will need to be removed or replaced at some time. Patients can usually breastfeed after augmentation. Patients are warned that mammography is technically more difficult, requiring different views.
Breast reconstruction
Aims
To recreate a breast mound resembling the contralateral breast with minimal donor deficit, using a technique appropriate for the patient. After mastectomy, breast reconstruction is of psychological benefit. It is technically easier to perform it at the same time as mastectomy, rather than as a delayed procedure as there is no scarring around the breast and original landmarks are present. It also reduces the number of operations required. However, there may be logistical difficulties if a combined breast surgery/plastic surgery team is needed. Also, some patients prefer to wait.
Surgical options
Tissue expander
Placed in the subpectoral position. Inflated with saline once the wounds are healed (2–4 weeks post-operatively) via a subcutaneous port. The skin is slowly stretched until a satisfactory size is reached. The implant can later be changed for a silicone gel-filled implant.
Latissimus dorsi myocutaneous flap
A pedicled flap based on the thoracodorsal vessels. The latissimus dorsi muscle, with an ellipse of overlying skin and fat, is tunnelled under the intervening skin bridge into the breast defect. Depending on the size of the contralateral breast, an implant may be used under the flap.
Abdominal flaps
The transverse rectus abdominis myocutaneous (TRAM) flap consists of a transverse ellipse of skin on the lower abdomen, plus one of the two rectus abdominis muscles. This versatile flap may be based on either its upper (deep superior epigastric) or lower (deep inferior epigastric) vascular pedicles. The upper pedicle is used as a pedicled flap, tunnelled under the abdominal skin into the breast. The lower pedicle is used as a free tissue transfer. If a sizeable muscular perforator vessel is identified, a DIEP flap can be used, leaving the muscle behind. This flap is usually large enough not to need an implant.
Nipple reconstruction
At a later stage, the reconstructed breast can be tattooed with a picture of a nipple or a nipple formed with a combination of local flaps, skin graft, and grafts from the contralateral nipple.
Surgery to the contralateral breast
The opposite breast may be reduced, augmented, or lifted to improve symmetry.
