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A-Z of Plastic Surgery

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The A-Z is a quick reference guide to the ever expanding specialty of Plastic Surgery. The succinct bullet pointed references will enable the reader to rapidly assimilate the essentials of each entry. The cross referencing links will allow the reader the look up related entries. It will be particularly relevant to trainees in Plastic Surgery as a working reference book and as an invaluable resource during preparation for final exams.
Year:
2008
Edition:
1
Publisher:
Oxford University Press
Language:
english
Pages:
352
ISBN 10:
0199546576
ISBN 13:
9780199546572
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A–Z of Plastic Surgery

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A–Z of Plastic
Surgery
Andrew Hodges

1

1

Great Clarendon Street, Oxford ox2 6dp
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Oxford University Press, at the address above
You must not circulate this book in any other binding or cover
and you must impose the same condition on any acquirer
British Library Cataloguing in Publication Data
Data available
Library of Congress Cataloging in Publication Data
Hodges, Andrew, 1962A-Z of plastic surgery / Andrew Hodges.
p. ; cm.
ISBN-13: 978-0-19-954657-2 (alk. paper) 1. Surgery, Plastic—Handbooks,
manuals, etc.
[DNLM: 1. Reconstructive Surgical Procedures—Handbooks. 2. Cosmetic
Techniques—Handbooks. 3. Surgery, Plastic—Handbooks. WO 39 H688a
2008] I. Title: A to Z of Plastic Surgery. II. Tit; le.
RD118.H63 2008
617.9′5—dc22
2008004569
Typeset by Cepha Imaging Private Ltd, Bangalore, India
Printed in Great Britain
on acid-free paper by
Ashford Colour Press, Gosport, Hampshire
ISBN 978-0-19-9546-572
1 3 5 7 9 10 8 6 4 2

To my wife Sarah and
my children Naomi, Sam and Rachel

Preface
Plastic Surgery is an extremely broad subject
and the trainee in this specialty is required to
assimilate a large amount of information.
The A–Z of Plastic Surgery has been written as
an aid to learning and revising this material
and as a reference book. Although it is written
in an encyclopaedic format, it does not claim
to be a complete text. The concise style should
enable subjects to be grasped rapidly. However,
this book does not replace, but rather complements fuller chapter-based texts. The primary focus is for Plastic Surgery trainees,
but it will also be of value to the specialist as
a reference text and to medical workers in

allied specialties. In a book of this scope and
size there will inevitably be controversy as to
what should be included or omitted, and
under which heading. In this rapidly changing
and expanding specialty, the author would
welcome contributions and comments from
readers – particularly to augment existing
entries or to suggest new entries. These will be
incorporated into the second edition.
Andrew Hodges
Consultant Plastic Surgeon
Mengo Hospital, Kampala, Uganda
Andrewhodges3001@yahoo.co.uk

Acknowledgements
I am grateful to the Plastic Surgeons who
have inspired and taught me. In particular, I
would like to acknowledge Tim Goodacre, who
first introduced me to this exciting specialty,
and to my consultants in Exeter, Peter Saxby,
John Palmer, Vik Devaraj and Chris Stone,
who helped me throughout my training and

particularly in preparation for the final Plastic
Surgery examinations. I am grateful to Oxford
University Press and Rose James for their
assistance in publishing this book, and for
their valuable comments and suggestions.
The publisher is grateful to Lucy Cogswell
for her help in reviewing the final manuscript.

How to use this book
●

●
●

Entries are arranged in alphabetical order. Some subjects are grouped under one main
heading (e.g. burns).
Words that are italicized and underlined are cross references to other entries.
Abbreviations have been used to maintain the concise style. A list of abbreviations is available at the end of the book.

A

Abbé flap to Axonotmesis

Abbé flap
Useful flap for reconstructing moderatesized defects (too big to close directly) of
the lip.
● Pedicled flap, usually taken from the lower
lip to reconstruct a defect on the upper lip,
although this can be reversed.
● Blood supply is from the inferior labial artery.
● The flap is positioned so that the width of
the vermilion matches the lip segment being
replaced.
● The Abbé flap may be quadrilateral, forked or
winged to assist closure of the lower lip defect
● The lower lip can sacrifice 25–35% of its
length.
● While pedicle remains attached the patient
requires a soft diet.
● Divide the flap in 1–2 weeks.
● A similar principle can be used for upper
eyelid reconstruction.
See Lip reconstruction. See Secondary lip and
nasal deformities.
●

the internal oblique splits and half passes deep
to rectus. Below this the posterior sheath is
only composed of transversus abdominus.
Neurovascular structures lie between internal
oblique and transversus abdominus.

Blood supply:
● Superior epigastric artery: terminal branch
of the internal mammary artery.
● Thoracic and lumbar intercostal arteries: run
between internal and external oblique.
● Deep inferior epigastric artery: from the external iliac artery, enters rectus abdominus and
supplies it and the overlying skin.
● Deep circumflex iliac artery: from the external iliac artery to the inner ileum and skin.
● Superficial inferior epigastric artery: from
the femoral artery, to the skin of the lower
abdomen.
● Superficial circumflex iliac artery: from the
femoral artery to the lower abdomen.
● Superficial external pudendal artery: from
the femoral artery to the skin over the pubis.

Abdominal wall

Abdominal wall reconstruction

Function: Abdominal wall muscles important
for posture, standing, walking and bending.

Indications:
● Trauma.
● Tumour:
Desmoid, Dermatofibrosarcoma
protuberans.
● Radiation.
● Infection: Gas gangrene, Necrotizing fasciitis.
● Iatrogenic: Incisional hernia.
● Congenital:Omphalocoele,Gastroshisis,Prune
belly syndrome.

Anatomy:
Muscles:
● External oblique: from lower 8 ribs, inserts
into iliac crest and forms inguinal ligament.
● Internal oblique: deep to external oblique.
From lumbodorsal fascia, iliac crest and
inguinal ligament. Lower fibres form conjoint tendon. Superior fibres insert into
linea alba and 7–9 cartilage.
● Transversus abdominus: deep to internal
oblique. From lower 6 ribs, lumbodorsal
fascia and iliac crest into linea alba and conjoint tendon.
● Rectus abdominus: Longitudinal from symphysis to xiphoid and 5–7 ribs.
● Pyramidalis: small triangular muscle superficial to rectus. From pubis to linea half way
between symphysis and umbilicus.
Linea semicircularis or arcuate line lies midway between umbilicus and pubis. Above this

Management of acute loss: After aggressive
debridement, avoid closure under tension and
avoid raising flaps acutely. Cover viscera with
synthetic mesh.
Objectives: Cover abdominal contents, prevent herniation and restore the appearance.
When direct closure is not possible, closure
may be achieved with fascial releases and component separation. If a defect remains, then
closure will require alloplastic material or
musculofascial flaps for strengths, and skin
grafts or flaps for cover.

2

abdominoplasty

Procedures:
● Ramirez Component separation.
● Local flaps: based on vessels supplying
abdominal skin. The external oblique can be
used as a turn over flap. Rectus can be used.
● Regional flaps: pedicled tensor fascia lata
(TFL), Rectus femoris, anterolateral thigh
flap. Gracilis is less useful as it only reaches
to the perineum.
● Distant flaps: omentum, latissimus dorsi.
● Mesh: apply over omentum to prevent adhesions. Suture under tension.

Abdominoplasty
An aesthetic procedure which aims to provide a flatter, narrower abdomen by excising skin and fat excess and addressing rectus
divarication, generally by using a lower transverse abdominal scar.

Classification:
● I: Excess fat, liposuction.
● II: Lax skin infra-umbilical, resect lower abdo
skin.
● III: Lax skin and muscle with fat infraumbilical mini-abdominoplasty with muscle
plication.
● IV: Lax muscle, complete abdominoplasty
without umbilical translocation.
● V: Lax skin and fat, complete abdominoplasty with umbilical translocation.
● VI: Circumferential laxity, circumferential
abdominoplasty.
Operation: Mark skin incision with a large
ellipse. The lower line passes just above the
pubic hairs and is flattened centrally. For
a full abdominoplasty, the upper line will be
around the level of the umbilicus. Dissect out
umbilicus. Elevate flap leaving thin layer of
fascia intact. Proceed up to xiphoid if needed.
Limit lateral dissection. Tighten aponeurosis.
Flex the back. Skin excision should be generous laterally – high-tension abdominoplasty
(HTA). Suture flap and find new location for
the umbilicus. If there is significant lateral laxity add a vertical component to produce a
Fleur-de-Lys abdominoplasty.
Complications: Thrombo-embolism, respiratory difficulties, skin necrosis, wound dehiscence, wound infections, haematoma, seroma.

Abductor pollicis brevis
APB: Most superficial muscle of thenar
eminence.
Origin: Transverse carpal ligament, palmaris
longus and there may also be another slip from
abductor pollicis longus.
Insertion: The tendon is adherent to the radial
side of the MCP joint capsule. A few fibres join
FPB and radial sesamoid. The rest join the
extensor expansion.
Nerve supply: Median nerve.
Action: Abduction of the thumb at the carpometacarpal and MCP joint. This is a forward
movement in the anteroposterior plane. See
Muscles.

Abductor pollicis longus
Origin: Dorsum of radius, ulnar and interosseous membrane. It runs obliquely around the
radius coursing over the wrist extensors. It
runs in the 1st extensor compartment with
extensor pollicis brevis and may have several
slips.
Insertion: Lateral 1st metacarpal. It gives off a
slip to trapezium and another to APB.
Nerve supply: Posterior interosseous nerve.
Action: Abducts the thumb through slip to
APB. Extends the thumb and radially deviates
the wrist. See Muscles.

Absorbable polymers
Synthetic:
● Used
for sutures and investigated for
other devices such as plates and screws
(LactoSorb).
● One class of polymers used is the alphahydroxy acids including L-lactic acid, glycolic
acid, and dioxanone.
● As polymers these are
● PLLA: poly-l-lactic acid;
● PGA: polyglycolic acid;
● polydioxanone.
● PLLA and PGA are used together. Breakdown
is by hydrolytic scission of the ester bond.
● PGA is degraded more rapidly than PLLA.
● Dexon is pure PGA. Vicryl is 8% PLA, 92%
PGA.

adductor pollicis 3

Natural:
● Many materials are produced from Collagen.
● Haemostatic properties can be reduced by
isolating collagen into fibrils.
● The haemostatic properties can also be
utilized.
See Alloplasts.

Occur mainly on neck, upper chest and axilla.
The only symptoms relate to local irritation.
● Excise with scalpel or scissors.
See Mesodermal tumours.
●
●

Acrosyndactyly
●
●

Acanthosis

●

Hyperplasia of epithelium. See Skin.

●
●

Accutane
Isotretinoin. The synthetic retinoid derivative 13-cis-retinoic acid (Accutane) used for
severe Acne vulgaris. The dose is 1 mg/kg body
weight for an initial 4–5-month course of
therapy. It reduces sebum excretion and is
anti-inflammatory.

Acne vulgaris
●

●

●

Acne vulgaris is a common skin disorder
seen in adolescents and young adults.
Seborrhoea, small comedones, and inflammatory papulopustules found.
Acne conglobata is the severe form with deep
cysts and sinuses with extensive scarring of
face back and chest.

Management:
● Incision of the cystic lesions reduces the
inflammation that produces the scarring.
● Dietary control does not appear to be
beneficial.
● Topical medications with benzoyl peroxide,
topical antibiotics or tretinoin (retinoic acid).
● Skin hygiene and long-term administration
of antibiotics, such as tetracycline, has been
helpful.
● Ultraviolet rays and superficial X-ray therapy are effective, but with unacceptable longterm effects.
● Accutane is effective for severe acne.
● Dermabrasion, laser resurfacing and collagen injections may help reduce the scarring.
● A facelift procedure may reduce skin laxity,
which may improve the appearance of the
acne scarring.

Acrochordon
●

●

Common papillomatous lesion occurring
in middle adult life.
Multiple, fleshy, skin-coloured tags.

●

One of the Congenital hand anomalies.
Fusion of digits distally.
Mainly sporadic, non-hereditary occurrence.
Associated with Constriction ring syndrome.
Bilateral in 50%, but asymmetric.
Also associated with craniofacial syndactyly,
such as Apert’s syndrome, in which it is
symmetrical.

Actinic keratosis
Also called senile keratosis and solar keratosis.
● The most frequently occurring premalignant
cutaneous condition.
● Due to the cumulative effect of UV exposure.
● Occur on exposed skin and often multiple
lesions.
● Lesions may regress if sun exposure is
limited.
● They occur in genetically predisposed people.
● Arsenic keratosis occurs secondary to exposure to inorganic arsenic compounds.
● Get well circumscribed, erythematous and
maculopapular lesions, red to light brown
and scaly.
● Microscopically
get hyperkeratosis with
dyskaryosis and acanthosis. In the dermis
there is an actinic elastosis with inflammatory infiltrate.
● Over time many progress to SCC and 20–25%
become invasive. SCCs arising from actinic
keratosis rarely metastasize.
● Treat with excision, curettage, liquid nitrogen, 5-fluorouracil (efudex), chemical peel,
dermabrasion and photodynamic therapy
(PDT).
See Cutaneous horn.

Adductor pollicis
See Muscles.

Origin:
● Oblique head: transverse carpal ligament,
anterior surface base of 2nd and 3rd
metacarpal.
● Transverse head: from anterior surface of
shaft of 3rd metacarpal. Two heads join.

4

adipofascial flaps

The transverse fibres insert mainly into the
medial sesamoid and the oblique into the
extensor expansion.

Insertion: With the 1st palmar interosseous
into medial side of base of proximal phalanx.

●

●

Nerve: Deep branch of ulnar nerve.
Action: Adduction of the thumb at the carpometacarpal and metacarpophalangeal joint.
This is a backward movement in an anteroposterior plane.

Adipofascial flaps
A flap comprised of fascia and overlying fat.
Essentially, the same as a fasciocutaneous flap
with the skin dissected away from the flap.

Anatomy:
● Dermal and fascial plexuses exist in subcutaneous tissues. Both gain their blood supply from perforators.
● In adipofascial flaps the tissues are divided
between plexuses leaving the dermal and
subdermal plexuses to supply the skin and
the fascial plexuses are taken with the flap to
supply it.
● Three perifascial plexuses are described –
sub-, intra- and prefascial plexuses. All
anastomose, but only pre- and subfascial
plexuses receive branches from perforators.
The prefascial plexus (superficial to fascia)
is dominant.
Properties: Adipofascial flaps are easy to raise,
are more malleable and conform better than
fasciocutaneous flaps. They are not so robust
and require a skin graft onto the flap.
Indications:
● Lower limb: medial flaps use posterior tibial perforators. Usually 2–5 of these, fairly
constant. There are usually 4–5 anterior tibial perforators. The perforators to the peroneal artery are less predictable, but usually
number 4–5.
● Upper limb: small adipofascial flaps can be
raised from the dorsum of the finger to
cover finger tips or exposed bone.

Adnexal tumours
●

In adnexal tumours, the relationship
between stromal and epithelial components

●

●

●

is maintained though distorted to varying
degrees.
They are classified by the degree and the
direction of differentiation to sweat and
sebaceous glands, and hair follicles.
They are also termed organoid or appendageal tumours or Hamartomas.
A tumour with fully developed appendageal
structures is called a Naevus.
A tumour with incomplete development of
structures is an Adenoma.
A poorly organized tumour is an Epithelioma.

Adrenaline
●

●

●

●
●

●

●

Extensively used in plastic surgery to produce vasoconstriction, which reduces blood
loss during surgery, although there is some
concern that this may increase the risk of
post-operative haematoma.
Adrenaline can cause cardiac arrhythmias
especially in conjunction with halothane.
The maximum recommended dose is 10 ml
of 1:100 000 (100 µg) over 10 minutes or
30 ml (300 µg) over 1 hour.
1 ml 1:1000 in 200 ml = 1:200 000.
Topical soaks for haemostasis can be 1:10
000.
The total dose of adrenaline should not exceed
500 µg and it is essential not to exceed a concentration of 1 in 200 000 (5 µg/ml) if more
than 50 ml of the mixture is to be injected.
Generally avoided in end arteries, such as
digital vessels, although several trials have
shown no adverse effects in such situations.

Adson’s test
Adson’s test arm adducted. A test used in the
assessment of Thoracic outlet syndrome.
● Patient stands with arm adducted against
front of trunk. Feel radial pulse.
● Extend neck and turn chin to affected side.
This stretches and tightens the Scalene muscles causing neural or arterial compression
by scissoring effect.
● Now take a deep breath. This depresses
the first rib. Hold breath while traction is
applied to arm and feel the pulse. Loss of
pulse volume or neurological signs gives a
positive result.
● Reverse Adson’s test: patient in same position, but patient flexes neck and rotates chin

alexithymia

to contralateral side to shorten the scalenes.
Push down with chin against chest to contract scalenes. This may reproduce symptoms when there is scalene hypertrophy.

Advancement flaps
●

●

●

●
●

A local random pattern flap where tissue is
advanced to fill an adjacent defect. Examples
include
Single pedicle: raised as a square or rectangle
with two parallel cuts along the sides of the
defect. Burow’s triangles are excised from
the base of the flap to help advancement.
Bipedicled advancement flap: useful for long
defects in extremities. An incision is made
parallel to the defect and the flap attached at
either end is advanced. As there is a blood
supply from either end a longer length to
width ratio is possible. The donor defect can
be grafted.
V–Y advancement flap.
Y–V advancement flap.

●
●

5

50s: neck rhytids, jowls.
60s+: skin atrophy with increasing wrinkles.

Retaining ligaments:
● Zygomatic osteocutaneous ligaments.
● Mandibular osteocutaneous ligaments (these
two are the most important).
● Platysma-auricular ligaments.
● Anterior platysma-cutaneous ligaments.

Air embolus
Air entering the circulation, usually through
the veins. Complication seen in Neck dissection
and neurosurgery from air entering the internal jugular vein. Air enters the heart and is
compressed, rather than expelled. Air froths
in the chamber and reduces cardiac output.

Treatment:
● Fill the wound with fluid to reduce further
embolisms.
● Lie the patient on the side with head down
and aspirate the heart directly or aspirate
through a central line.

Aesthetic unit
Gonzalez-Ulloa in 1956 divided the face into
regions or units to aid in the planning of reconstruction. Some principles of reconstruction
by units are:
● Patients wish to look normal.
● The normal is defined by regional units,
adjacent three-dimensional areas of characteristic skin quality, surface outline and
contour.
● The surgeon must restore regional units not
fill defects if the normal is the goal.
● The wound may need to be enlarged and
normal tissue may be discarded to allow a
whole subunit to be reconstructed.
● Scars are best positioned in the borders
between units where they will be less
apparent.
● Donor material should be chosen for similar quantity and quality.
● Restoring three-dimensional contour not
just filling a hole is important for good
reconstruction.

Albinism
●
●

●
●
●

Characterized by the absence of melanin.
Due to mutation of genes, which regulate
melanin synthesis.
Equal incidence in sex and race.
Most are autosomal recessive traits.
The skin is very sensitive to the carcinogenic
action of UVB radiation.

Albright’s syndrome
●
●
●
●

●

Polyostotic Fibrous dysplasia.
Pseudohypoparathyroidism.
Autosomal dominant disorder.
Deficiency of regulatory protein required
to couple membrane receptors to adenyl
cyclase.
Present with:
● rounded low nasal bridge;
● short neck;
● cataracts;
● short metacarpals and metatarsals;
● hypocalcaemia with raised phosphate;
● pigmented skin lesions.

Ageing face
Chronology:
● 30s: redundant eyelid skin, crows feet.
● 40s: prominent nasolabial folds, forehead
furrows.

Alexithymia
Lack of words for mood or emotion. Seen in
patients with Reflex sympathetic dystrophy
(RSD).

6

alginates

Alginates

●

Derived from seaweed.
● They contain calcium, which activates the
clotting cascade when exchanged with
sodium in the wound.
● They are very absorbent and become gelatinous upon absorbing moisture.
● They are used clinically for both their haemostatic and absorbent properties.
● Examples include sorbsan and kaltostat.
See Dressings.

●

●

Allen’s test
●

●

●

●

To test the integrity of arterial anastomotis
between the radial and ulnar side of the hand.
Occlude radial and ulnar artery and empty
hand by making a fist.
Release one artery, the hand should fill with
blood immediately.
A similar test can be applied to the finger to
confirm the presence of two digital arteries.

Alloderm
An immunologically inert dermis derived from
human cadaver.

Allodynia
Marked pain from a usually non-noxious
stimulation. See RSD.

Alloplasts
An alloplast is a relatively inert foreign body
implanted into tissue.

Advantages: No donor site morbidity, quick,
unlimited supply, can be prefabricated, selected
resorption.

Sterile.
Withstands stress.

Goal: To achieve the goal of reconstruction,
the implant should be well covered and scars
should be concealed.
Liquids:
● Injectable collagens.
● Hyaluronic acid preparations.
● Silicone.
Solids:
Metals:
● Stainless steel.
● Vitallium.
● Titanium.
● Gold.
Polymers:
● Polyethylene.
● Polypropylene.
● Methylmethacrylate.
● Cyanoacrylates.
● Fluorocarbons.
Ceramics:
● Hydroxyapatite.
● Others: calcium sulphate and calcium phosphate. Absorbable polymers, sutures.
Oppenheimer effect.

Fibrous tissue interface: Around an implant
there is a dead space into which fibroblasts
and macrophages migrate. As a result of
this chronic inflammatory response, fibrous
encapsulation occurs. This is termed implant
bursitis.

Classification:
● Liquid or solid. The physical form determines whether it will be encapsulated or
whether fibrous tissue will penetrate the
implant.
● Biological or synthetic.
● Permanent or absorbable.

Bonding and Osseointegration: Bonding can
be mechanical or chemical. Mechanical bonding occurs when there is in-growth into a
porous substance. Chemical bonding occurs
by molecular adsorption and is poorly understood. Osseointegration refers to bone on an
implant surface with no intervening fibrous
tissue.

Properties: Ideal properties of an alloplast
are:
● Inert.
● Strong.
● Ability to shape.
● Non-toxic, non-carcinogenic, non-allogenic.

Carcinogenicity: Chromium and nickel are
known carcinogens. There are few reports
of tumours around implants. Some studies
following hip implants have suggested an
increase in lymphatic and haemopoietic cancers, but a decrease in breast and colon cancer.

ambiguous genitalia 7

Biomaterial failure: Due to wear, e.g. by abrasion and fatigue, or corrosion, where the
implant is lost by chemical reaction.

●

●

Alopecia
Primary excision with rotation flaps such as
the Ortichochea flap are useful to correct
defects covering 15–20% of the hair-bearing
scalp.
● Also Juri flaps.
● Tissue expansion.
See Hair restoration with flaps. See Burns
reconstruction.
●

Alveolar carcinoma
See Head and neck cancer.
● Third most common site.
● Usually over 50 years.
● Lower jaw is more common than upper jaw,
particularly behind the bicuspid teeth.
● Less directly related to tobacco and ethanol.
● Sometimes linked to poor dental hygiene
and dentures.
● Commonly present with ulcers without pain.
● Spread is initially lateral. Dental caries can
be a site of invasion. If bone is invaded the
neurovascular bundle (NVB) is at risk. Direct
mandibular invasion is common.
● Regional node metastasis is more common
with carcinoma of the lower alveolus than
of the upper alveolus mainly to levels I–III.

Treatment:
● For T1N0 lesions, a localized excision with
marginal mandibular resection can be
accomplished through the mouth.
● More extensive lesions with more significant mandibular involvement require a lip
split, cheek flap, and mandibular resection.
● In the upper jaw, a partial maxillectomy
is performed through a modified WeberFergusson incision. With more invasive
lesions that have broken into the maxillary
antrum, total maxillectomy is indicated.
More extensive involvement (e.g. ethmoid
sinus) will require an anterior cranial fossa
approach.
● If access to the neck is required for reconstruction, perform a selective neck dissection for an N0 neck. Palpable nodes make
this procedure mandatory.

Small tumours may be treated with external
beam irradiation. Osteoradionecrosis may
occur if larger tumours are irradiated.
Large tumours or node positive tumours
are irradiated after resection.

Results: Overall 5-year survival rate is 65%.
● Stage I: 78%.
● Stage II: 65%.
● Stage III: 35%.
● Stage IV: 15%.

Ambiguous genitalia
See Embryology. In cases of ambiguous genitalia, assign patients sex before the age of 2.
Assess by a geneticist and paediatrician. The
most common cause is congenital adrenal
hyperplasia.

Female pseudohermaphroditism:
● 46XX
usually with congenital adrenal
hyperplasia.
● Increased androgen production due to a
deficiency of the enzyme 21-hydroxylase.
● The appearance of the external genitalia
varies from a mildly enlarged clitoris to a
normal penis with terminal meatus.
● These children should be raised as female
and can be fertile.
● Surgical
correction may be necessary.
Perform at 3–6 months, clitoral recession
and vaginoplasty.
Male pseudohermaphroditism:
● 46XY.
● Have defects in androgen synthesis and
other causes of incomplete virilization.
● It may be advisable to raise as a female as
there will always be an inadequate phallus.
Orchidectomy and vaginal reconstruction
will be required. May be due to:
● enzyme
5-α reductase resulting in
decreased testosterone production;
● testicular feminization syndrome, with
absence of androgen receptors.
True hermaphrodite:
● 46XX or 46XY or mosaic karyotype with
both testicular and ovarian tissue.
● Very rare.
● Patients have an ovary one side and a testis
on the other or bilateral ovotestes.

8

ameloblastoma

Raise as female as they will have an inadequate phallus. Remove the testes.

more distal than mid-proximal phalanx will
get equivalent function by terminalizing.

Mixed gonadal dysgenesis:
● Most have 46XY/46XO karyotype with testes
on one side and streak gonad on the other.
● The normal testes has a high risk of developing gonadoblastoma.
● These patients should be raised as female.
Perform gonadectomy, clitoral recession
and vaginoplasty.

Index ray amputation: A racquet incision is
made. Divide extensors. Expose metacarpal.
Preserve insertions of FCR and ECRL. Cut
flexors. Divide NVBs and bury nerves. Similar
technique for little finger.

●

Pure gonadal dysgenesis:
● 45X0, 46XX or 46XY karyotype.
● Usually present with delayed adolescence.
● Bilateral streak gonads. High malignant
potential and gonadectomy is recommended.

Ameloblastoma
An aggressive odontogenic tumour thought
to form from ameloblasts that do not differentiate to the stage of enamel formation.

Amplitude: of tendon excursion
See Tendon transfers. Donor muscles should
have similar excursion to that which is replaced.
● Excursion of wrist flexors and extensors is
3 cm, finger extensors is 5 cm, finger flexors
is 7 cm.
● Increase amplitude of donors by tenodesis
effect and by freeing fascial attachments.

Amputation – upper limb
Digital amputation: Most commonly for
complex traumatic injuries. Also vascular disorders, tumours and congenital anomalies.
A single finger amputation should usually be
terminalized, rather than replanted. The aim
is stump coverage with sensate skin and length
preservation. Perform bone shortening and
trim back tendons. Extensor tendons should
not be sutured to flexor tendons to avoid the
Quadrigia effect. Nerves are cut back and soft
tissue opposed without tension. The retracted
FDP can pull on the lumbrical giving an
intrinsic plus position. This can lead to PIP
joint extension with grasp. Treat by partial or
complete excision of the lumbrical.
Thumb: Loss of proximal to mid-proximal
phalanx results in loss of pinch. Thumb amputations should be replanted if possible though

3rd and 4th ray amputation: Either excise
metacarpal and narrow the space or transpose
ulnar metacarpals to close the cleft. Perform a
dorsal longitudinal and volar Bruner incision.
Remove the metacarpal and two interossei.
Section the border MC and translocate to a
central position. Repair deep intermetacarpal
ligament.
Wrist disarticulation: Preserves normal pronation and supination 50% of which is transferred to the prosthesis. Progressively more
supination and pronation is lost with more
proximal amputations. A more distal prosthesis has less padding and is more of a challenge
for prosthetics.
Shoulder disarticulation: Amputation through the glenohumeral joint, clavicle acromion
and scapula are preserved.
Forequarter amputation: Removal of entire
shoulder girdle with clavicle and scapula.

Amyotrophic lateral sclerosis (ALS)
●

●
●

●
●
●

A type of motor neuron disease with atrophy of skeletal muscles of the body.
Causes degeneration of motor neurons.
Patients with ALS have weakness, atrophy
and fasciculations.
Often asymmetric.
No loss of sensation.
One-third of patients present with upper
limb symptoms.

Anaesthesia
SeeASA classification,Local anaesthetics,Tumescent anaesthesia.

Andre-Thomas sign
●
●

In Ulnar nerve palsy.
The deformity of clawing is made worse by
an unconscious effort to extend the fingers
by tenodesing the extensor tendons with
palmar flexion of the wrist.

angiosome

Aneurysmal bone cyst
●
●
●
●

Blood-filled cysts lined with fleshy membrane.
50% occur secondary to other tumours.
20s–30s.
Tendency to recur, can be aggressive.

XR: Metaphyseal expansile lesion with a thin
rim of reactive bone.
Treatment is bloc bone excision and strut
graft.
See Bone tumours.

Aneurysms – upper limb
See Vascular injuries.
● Most are due to trauma and infection.
● Traumatic aneurysms are most commonly
found in the thenar and hypothenar eminence, and the superficial arch.
● True aneurysms contain all layers of the vessel wall. False aneurysms are pulsating haematomas and occur after penetrating injury.
● Most patients complain of a pulsatile mass.
It may be difficult to distinguish from a
ganglion.
● Arteriography may be useful.

Treatment: Resect and repair pseudoaneurysms. Ligation may be adequate if there
is no vascular compromise.

Angel kiss
See Nevus flammeus neonatorum. A macular
vascular birthmark seen on the upper lip,
which fades spontaneously.

Angioblastoma of Nakagawa

Angiogenesis
Angiogenesis is the process of forming new
blood vessels.
● Platelets secrete PDGF, which attracts macrophages and granulocytes and promotes
angiogenesis.
● The macrophage plays a key role in angiogenesis by releasing a number of angiogenic
substances, including tumour necrosis factoralpha (TNF- α) and basic fibroblast growth
factor (bFGF).
● VEGF, released by keratinocytes is also a
potent stimulator of angiogenesis.
See Wound healing. See Cytokines and growth
factors.
●

Angiosarcoma
See Sarcoma.
● Rare vascular neoplasm.
● Aggressive, recurs locally, spreads widely and
has a high rate of vascular and lymphatic
metastasis.
● 50% occur in the head and neck.
● Male:female, 8:1, elderly.
● Associated with irradiation and some environmental carcinogens.
● Soft violaceous painless compressible mass.
● Treat with wide excision and radiotherapy.

Angiosome
●

●

See Tufted angioma.

Angiofibroma
●

●

●

●

●

Skin lesions usually found on the lower central face.
Fibrous, erythematous papule 1–3 mm in
size.
When multiple they are associated with the
Tuberous sclerosis complex (Bourneville’s
disease), and occur on the cheeks and chin.
Treatment is by dermabrasion, laser, or
excision.
Peri-ungual angiofibromas (Koenen’s periungual tumours) also are often present in
this syndrome.

9

●

●

●

●

●

Manchot studied skin territories in 1889.
Salmon expanded this in 1930s, and Taylor
and Palmer developed the angiosome concept in 1987.
An angiosome is a three-dimensional composite block of skin, soft tissues and bone
supplied by branches of a single source artery.
Choke vessels link adjoining angiosomes
and may regulate flow between them. The
veins do not contain valves and are called
oscillating veins as blood may flow in either
direction.
The anatomic territory is the area of tissue
supplied by an artery before anastomosing
with adjacent vessels.
The dynamic territory of an artery is that
which stains with fluoroscein.
The potential territory is that which can be
included if the flap is delayed.
Flap principles are that a random flap can
support one angiosome. An axial pattern

10 Angle classification

flap can support another angiosome perfused via a choke vessel in a random cutaneous fashion.

Anatomic concepts of blood supply
developed by Taylor and Palmer:
● Blood supply detours through muscles.
● Arteries link to form continuous unbroken
network.
● The intramuscular territories of arteries and
veins match.
● The viability of a muscle flap is dependent on the size and number of its vascular
territories.
● The vessels hitchhike with nerves.
● The
vessels follow connective tissue
framework.
● Vessels radiate from fixed to mobile areas.
● There is a direct relationship between muscle mobility, and the size and density of the
supplying vessels.
● Vessels tend to have a constant destination,
but a variable origin.
● The territory of the intramuscular arteries
obeys the law of equilibrium.
● Vessel size and orientation are the product
of tissue differentiation in the area.
● The muscles are the prime movers of venous
return.
● As arterial territories are linked by choke
vessels, so the venous territories are linked
by oscillating veins, which are devoid of
valves.

Angle classification
●

●

●

●

●

System for describing dental occlusion in
the anteroposterior plane developed by
Edward Angle.
The upper first molar is the point of reference in describing the anteroposterior relationship of the mandible and maxilla.
This classification only tells of the relationship of mandible to maxilla. It doesn’t say
which is malpositioned or what the cause is.
Class I occlusion: The mesiobuccal cusp of
the maxillary first molar articulates within
the mesiobuccal groove of the lower first
molar.
Class II malocclusion: the lower first molar is
distal to the upper first usually ½ to a full
cusp. In II1 the upper anterior teeth are

flared forward, in II2 the anterior upper and
lower teeth are retruded with overbite.
● Class
III malocclusion: the mandibular
dentition is positioned mesial to maxillary
dentition.
(NB Mesial means situated toward the middle
of the front of the jaw along the curve of the
dental arch.)
See Orthognathic surgery, Teeth.

Anterior interosseous syndrome
●

●

●

●
●
●
●

Anterior interosseous nerve is a branch
of the median nerve supplying FPL, FDP
(index and middle) and pronator quadratus.
Compression produces pain in the forearm
and a weak pinch grip (O sign).
Test pronator quadratus by strength of
resisted forced supination with elbow flexed
to eliminate humeral head of pronator teres.
EMG may be helpful.
Incomplete syndromes can occur.
Distinguish from Parsonage–Turner syndrome.
Plan to explore if there is confirmation on
nerve conduction studies and if there is no
improvement after 2–3 months.

Compression points:
● Fibrous bands of pronator teres muscle
between the superficial and deep heads.
● FDS bands.
● Gantzer’s muscle, an accessory head of FPL.
● Aberrant radial artery.
● Thrombosis of the ulnar collateral vessel.
● As a complication of forearm fracture.
● Accessory bicipital aponeurosis.
● Enlarged communicating veins.
Treatment:
● Surgical exposure as for Pronator syndrome.
● Release the deep head of pronator teres and
suture the deep head to the superficial head.
● Interfascicular neurolysis of the anterior
interosseus nerve 2–7.5 cm below the elbow
is probably warranted if no obvious compression identified.

Anterolateral thigh flap
●

●

A fasciocutaneous flap raised from the anterolateral aspect of the thigh.
Supplied by musculocutaneous perforators from descending branch of the lateral

Apert’s hand

●

●

●

●

circumflex femoral system through TFL and
rectus femoris.
The perforators reach the skin via intermuscular septum between vastus lateralis
and rectus femoris or traverse through the
muscle.
The largest perforator reaches the deep fascia 2 cm inferolateral to the mid point of
a line between the ASIS and the superolateral corner of the patella. Occasionally
the descending branch is in two parts running parallel to the intermuscular septum.
Elevate medial edge of flap and fascia.
Preserve lateral cutaneous nerve of thigh.
Expose the intermuscular septum and look
for descending branch.
This flap can be raised as a proximally or
distally based pedicled flap or more commonly as a free flap. It can be raised below
the fascia or suprafascially if a thin flap is
required. Thinning of the flap has been
described.

Apert’s hand
See Apert’s syndrome.
● All involved portions of upper limb have
skeletal unions, incomplete joint segmentation and incomplete separation of rays.
● All hands have skeletal coalitions, distal
bifurcation of tendons, nerves and vessels,
distal intrinsic insertions and complex
syndactylies.
● Shoulder and elbow synostosis may occur
especially with type 1 and 2 hands. A discrepancy in size in shoulder may cause
reduced ROM with growth. Most have normal elbow motion.
● Hand features are short radially deviated
thumb, osseous syndactyly and symbrachydactyly of central 3 rays, simple syndactyly
of 4th web and variable syndactyly of 1st
web. Carpal coalitions occur, particularly
between capitate and hamate, and 4th and
5th metacarpal.
● Ideally treatment is performed bilaterally
between 4–12 months of age. Earlier treatment leads to relapse.
● Ideally perform two bilateral releases before
the age of 2, mobilize 5th ray, and lengthen
and realign thumb when 4–6 years.

11

Classification: Upton.
● Type I: spade hand. Complex syndactyly of
digits 2–5 with the thumb and little fingers
free.
● Type II: spoon or mitten hand. Complex
syndactyly of digits 2–5 with simple syndactyly of thumbs or thumbs free.
● Type III: rosebud hand. All 5 digits involved
in complex syndactyly.
See Apert’s syndrome.
Type I:
● Least severe and most common.
● Thumb radial clinodactyly and shallow web.
● Side to side fusion of fingers 2–4 with
phalangeal fusion at DIPJ, spade hand.
● Simple syndactyly of 4th and 5th finger.
● Mobile MPJs, stiff IPJs.
Treatment:
● 4–12 months separate index and 5th finger,
after 6/12 separate 3rd web. Division of transverse metacarpal ligaments will increase
mobility.
● Get
frequent tendon, nerve and vessel
anomalies.
● Perform osteotomies, which may be through
cartilaginous bars of IPJs at time of releases.
● Age 3–5, correct thumb clinodactyly with
opening-wedge osteotomy through middle
of proximal phalanx. Use bone from iliac
crest. Release 4–5th metacarpal synostosis
with interposition of dermal graft.
Type II:
● Thumb joined to index in complete simple
syndactyly, but have separate nails.
● Central fusion gives concave palm, mitten
or spoon hand. Conjoined nail. Abnormalies
of index proximal phalanx.
● Complete syndacyly between 4th and 5th
fingers.
Treatment:
● Release 2nd and 4th web at the same time as
1st web. Need to excise fascial bands between
thumb and index.
● If not too tight use 4-flap Z-plasty, otherwise use Y-V. Perform capsulotomy of CMCJ.
● If index finger proximal phalanx is abnormal and radially deviated it may be better to
ablate early.

12 Apert’s syndrome

●

Later correction of thumb clinodactyly as
for type I

Type III:
● Most severe, least common.
● Tight
osseous and cartilaginous union
between fingers 1–4 with single conjoined
nail with index and thumb being indistinguishable, hoof or rosebud hand.
● Thumb radial clinodactyly less severe, but
thumb is smaller.
Treatment:
● Perform index ray resection at time of 1st
web release. Use dorsal advancement flap,
and re-advance with subsequent procedures. Release 4th web at the same time.
● At time of 1st web release perform osteotomy across DIPJs with a transverse K wire,
which converts this to a type I hand.

Apert’s syndrome
Acrocephalosyndactyly with bicoronal synostosis, Midface hypoplasia, cleft palate, and
complex syndactyly. See Apert’s hand.
● Most are sporadic, but also autosomal dominant inheritance.
● Mutation in Fibroblast growth factor receptor
2 (FGFR2).
● Incidence is 1/160 000 live births.
● Only the lambdoidal suture is present. The
coronal suture is absent. Possibly primary
cranial base synostosis delays the approximation of bones and suture induction
doesn’t occur.
● The face has a steep forehead and a groove
above the supra-orbital ridge. Orbits are
shallow with hypertelorism and down slanting of palpebral fissures.
● The mid-third of the face is hypoplastic with
a normal mandible.
● The nose is beaked.
● Decreased patency of posterior nasal choanae may result in obstructive apnoea.
● 30% have a cleft palate or uvula.
● Mental retardation is frequent.
● Mirror image abnormalities of hands and
feet with an inverse relationship between
the severity of craniofacial abnormality and
the severity of hand anomalies.
● Syndactyly of fingers 2, 3 and 4 is present
and the whole hand may be fused. If the

thumb is free, it is broad and radially deviated. The feet are similarly involved.
Acrosyndactyly of hands graded from I–III
with increasing severity.
● Class 1: the little finger and thumb are
separate;
● Class 2: only the thumb is free;
● Class 3: the whole hand is involved.
See Craniosynostosis.

Aplasia cutis congenita
●

●

●

●

Rare, sporadic congenital deformity most
often in first-born females.
Get failure of differentiation of skin ranging
from total absence of skin, fat, skull, dura
and occasionally underlying brain. Scalp is
involved in 60% of cases and ulcers may be
multiple.
Mostly occurs in the midline in the area of
the posterior fontanelle.
Ulcers are sharply marginated with a red
base and usually heal rapidly by secondary
intention.

Aetiology: May be chromosomal, placental infarcts, amniotic adhesions or pressure
necrosis. Also associated with hydrocephalus,
facial clefts and spina bifida.
Management:
● May heal with dressings, which should be
kept moist.
● For large defects with exposed brain, dura
or skull, provide soft tissue cover and reconstruct bone later.
● Use local flaps and possibly tissue expansion.
See Scalp reconstruction.

Apocrine cystadenoma
●

●

●

A small, benign, translucent nodule, usually
appearing on the face.
Often pigmented and may contain brownish fluid.
It may be confused with melanoma or pigmented basal cell naevus.

Apocrine glands
●
●

●

Sweat glands found in axilla and groin.
They start to function in puberty and give
an odour due to bacterial decomposition.
They have a sympathetic adrenergic nerve
supply.

arthrodesis hand

Apocrine tumours
SeeApocrine cystadenoma,Syringocystadenoma
papilliferum, Chondroid syringoma.

●

●

Arachnodactyly
Unusually long slender fingers.

●

Arcade of Frohse
See Radial tunnel syndrome. A fibrous band on
the surface of supinator. One of the structures
implicated in compression of the radial nerve
at the elbow.

●

Arcade of Struthers
See Cubital tunnel syndrome. Fascial band
above elbow.

Arnez and Tyler classification
Classification for Degloving injuries.
● Type 1: non-circumferential degloving.
● Type 2: abrasion, but no degloving.
● Type 3: circumferential degloving.
● Type 4: circumferential degloving plus avulsion between deep tissue planes. Requires
serial conservative debridement and delayed
reconstruction.

Arteriovenous fistulae
Rare in the upper extremity with the exception of high flow AV malformations and surgically made AV fistulae. High output failure
rarely occurs distal to the elbow. Most become
manifest in the first 10 years of life. Most traumatic fistulae are due to penetrating Vascular
injuries. An arteriogram will help guide treatment. Fistulae with bony involvement are
poorly controlled by excision. Diffuse digital
masses respond poorly to simple excision.
Amputation may be required.

Arteriovenous malformations
●

●

●

●

These are the most difficult Vascular malformations to treat.
They can be high flow and haemodynamically active.
Pure arterial malformations such as aneurysms are rare but they can occur with AVMs.
The epicentre of an AVM is called the
nidus and consists of arterial feeders, microand macro-arteriovenous fistulas (AVFs),
and enlarged veins.

13

AVM is present at birth and can either manifest in infancy, or appear later.
Intracranial AVM is more common than
extracranial AVM, followed in frequency by
AVM of the limbs, trunk, and viscera.
Some may be hormonally active. The fastflow nature may not be recognized until
trauma or puberty stimulate expansion.
AVMs develop ischaemic skin changes,
ulceration, intractable pain, and intermittent bleeding. Low-flow lesions may be associated with skeletal hypertrophy, high-flow
with destruction. May present as emergency
with haemorrhage or cardiac failure.

Staging: Clinically by Schobinger;
● Stage
I: blush/stain, warmth and AV
shunting.
● Stage II: stage I with enlargement, tortuous
veins, pulsations, thrill and bruit.
● Stage III: stage II with either dystrophic
changes, ulceration, bleeding, persistent
pain or destruction.
● Stage IV: stage II with cardiac failure.
Treatment: See Vascular malformations.

Arthrgryposis
Greek meaning curved joint.
Many causes but all have in common immobility of the joints in utero.
● This may be due to abnormal muscles,
abnormal neurology or crowding due to oligohydramnios, bicornuate uterus etc. Beal’s
syndrome is a contractural arachnodactyly.
● Findings:
contractures, usually bilateral,
adduction and internal rotation of shoulders, fixed flexion or extension of elbows
and knees. Club-like hands and wrists, thin
waxy skin.
● Treatment: dynamic and static splintage,
occasionally surgery.
See Congenital hand anomalies.
●
●

Arthrodesis hand
Wrist:
● For pain, reconstruction following tumour
resection, instability.
● Remove all articular surface, maintain carpal alignment and height, use internal fixation, bone graft and splint until radiological
union.

14 arthroplasty

Optimal position is 15º extension 5º ulnar
deviation. If both wrists are being fused
place dominant hand in extension and nondominant in flexion for personal hygiene.
● Use bone graft, bone blocks, intramedullary
rods, interosseus wires, external fixators and
dorsal plates.
See Proximal row carpectomy.
●

Limited fusions:
● Triscaphe
arthrodesis (STT): for rotary
subluxation of the scaphoid, non-union,
Kienböcks, triscaphe arthritis, DISI.
● Lunotriquetral arthrodesis: for lunotriquetral ligament tears and instability.
● Capitolunate arthrodesis: mid-carpal degenerative arthritis.
● Scaphocapitate arthrodesis: for rotary subluxation of the scaphoid, Kienböcks, midcarpal instability.
● Capitate-lunate-hamate-triquetral
(four
corner): for ulnar mid-carpal instability,
SLAC, scaphoid non-union.
Fusion across radio-carpal joint gives the
greatest loss of movement. A single row fusion
gives the least loss of motion.
Small joint arthrodesis:
● Indications: pain, instability, deformity and
loss of neuromuscular control.
● Position: individualize to particular patient.
● MCP joints cascade radial to ulnar, 25º for
the index and add 5º for each digit;
● PIPJ cascade from 40º in index to 55º;
● DIPJ fuse in 0º flexion, possibly 5-10º
supination for index and middle to
achieve pinch grip;
● thumb, keep length. IPJ fuse in slight flexion (recommended between 0–15º). MPJ
5–15º. CMC fuse with 40º palmar abduction and 20º of radial abduction.
● Surface preparation:
● avoid shortening;
● cup and cone method enables accurate
positioning;
● remove all the articular cartilage.
● Fixation:
● K wires: crossed;
● Interosseous wiring: stronger than K wires;
● Tension band wiring: use for MCP joints
and pip joints. Compression is produced
by the dorsally placed tension band.

DIPJ: Approach through H incision. Section
extensor tension. Flex joint and excise collateral ligaments to increase exposure. Fix with
either Herbert screw or interosseous wire and
oblique K wire. For the IPJ can use 90-90 wires
or if bone stock poor use K wire.
PIPJ: Dorsal longitudinal incision. Split
extensor tendon and elevate to either side. Cut
central tendon and collaterals. Use 90-90 or
tension band wiring.
MPJ: Expose through longitudinal incision
in skin and on radial side of finger. Excise
collaterals. Fix with mini plate.

Arthroplasty
●

●

●

Wrist: inflammatory, degenerative and posttraumatic arthritis. Arthroplasty most commonly performed in RA. Contraindicated if
there are poor wrist motors.
PIP joint: silicone implant arthroplasty may
be performed through a palmar, lateral or
dorsal approach. For a dorsal approach the
extensor mechanism is opened. Collateral
ligaments and volar plate are released. The
articular surfaces are removed, osteophytes
are removed, the medullary canal reamed
and the implant inserted. Repair the collateral ligament. Commence active motion
immediately. Protect finger from lateral
stress.
MCP joint: Swanson’s arthroplasty.

Arthroscopy – wrist
Indications: Diagnose and treat pain, tears of
ligaments and TFCC. Remove loose bodies.
Portals:
● Named by the extensor compartments, e.g.
3–4 portal is between 3rd and 4th dorsal
compartment.
● The 5 used are 1–2, 3–4, 4–5, 6R and 6U –
radial and ulna to FCU.
● 3–4 and 4–5 most commonly used, the
former for visualization and the latter for
instrumentation.
● With 1–2 the nerve and artery are at risk.
With 6U dorsal branch of ulnar nerve at
risk
● Some surgeons pre-inflate the joint. Lunotriquetral ligament is best seen through 6R.

axilla 15

●

Mid-carpal joint: three mid-carpal portals –
mid-carpal radial (MCR), ulnar (MCU)
and scaphotrapeziotrapezoid (STT).

ASA classification
Classification adopted by the American Society
of Anaesthesiologists for assessing preoperative physical status.
● I: healthy.
● II: mild systemic disease.
● III: moderate systemic disease, some functional limitation.
● IV: severe systemic disease, constant threat
to life.
● V: moribund patient, unlikely to survive
24 hours.

minimizing morbidity and mortality in the
3rd peak (days–weeks) by optimizing initial
trauma care.
● Prehospital management.
● Triage
● Primary survey:
● A: airway and cervical spine control;
● B: breathing and ventilation;
● C: circulation haemorrhage control;
● D: disability; AVPU – Alert, Vocal stimulus,
Painful stimulus, Unresponsive;
● E: exposure and environmental control.
● Resuscitation and repeat primary survey
until stabilized.
● Secondary survey.
● Post-resuscitation monitoring.
● Definitive care.

Aspergillosis
An opportunistic fungal infection seen in
immunocompromised patients, e.g. aplastic
anaemia, leukaemia and major burns.
● It is not seen in healthy individuals.
● Invasive aspergillosis usually requires surgical debridement in addition to anti-fungal
agents to eradicate infection.
See Fungal hand infections.
●

Atypical fibroxanthoma

Has an inhibitory effect on platelet
aggregation.
● Cyclo-oxygenase is acetylated, which blocks
thromboxane A2 production.
See Microsurgery.

A small, firm nodule with crusting. Similar
in appearance to a BCC.
● Occurs in the elderly on the head and neck.
● Histologically see atypical spindle and giant
cells with a lot of mitoses.
● Treat with simple excision and it rarely
recurs.
● If it invades deeply it is called a Malignant
fibrous histiocytoma and can resemble basal
cell epithelioma. Appears on chronically
sun-exposed parts of the head and neck, particularly in the pre-auricular area in older
persons.
See Pseudosarcomatous lesions.

Atasoy volar V–Y flap:

Axial flaps

Aspirin
●

●
●

●

●

Used in the treatment of Fingertip injuries.
Volar Y–V flap taken from defect down to
DIP joint.
Raise with NVB and free fibrous septa.
Tension free closure.
Also known as Tranquilli–Leali flap.

Ataxia-telangiectasia
See Louis–Bar Syndrome.

●

A flap raised with a known vessel that increases
the length to width ratio available.
● Direct: contain a named artery in the subcutaneous tissues. Examples include the Groin
flap and Deltopectoral flap. They may include
a random element in the distal portion.
● Fasciocutaneous flap: based on vessels running within or near the fascia.
● Musculocutaneous flaps.
● Venous flaps:

ATLS
Advanced Trauma Life Support
A system of trauma care that involves systematic prioritized evaluation and treatment
aimed specifically at preventing deaths in the
2nd peak (minutes to hours after trauma) and

Axilla
Boundaries:
● Anterior: pectoralis major, subclavius, pectoralis minor.
● Posterior: subscapularis, lat dorsi, teres major.

16 axillary dissection

●
●

Medial: 4–5 ribs, serratus anterior.
Lateral: coracobrachialis and biceps.

Nerves:
● Intercostobrachial nerve: sensory innervation to upper medial arm.
● Long thoracic nerve: to serratus anterior.
From C5,6,7. Division cause winging of the
scapula.
● Thoracodorsal nerve: from posterior cord to
lat dorsi.
● Medial pectoral nerve: pectoralis major and
often wraps around the lateral border of
pectoralis minor.

Axillary dissection
Three levels of axillary nodes:
● I: lateral to lateral border of pectoralis
minor.
● II: under pectoralis minor.

B

III: medial to pectoralis minor muscle.
Make inverted U incision in axilla. Raise skin
flaps and stitch back. Define borders of axilla
anteriorly and posteriorly. Leave fascia on
muscle. Find and preserve long thoracic nerve
and NVB to lat dorsi. Having identified these
structures and axillary vein, start distally and
work proximally from an anterior and posterior front to converge on axillary vein and
continue up behind pectoralis minor.
Anatomy of axilla.

●

Axillary nerve
C5, C6 roots from the posterior cord. Supplies
deltoid and teres minor.

Axonotmesis
Axonal damage with Wallerian degeneration.
See Seddon classification.

Bactigras to Byrd and Spicer classification of fractures

Bactigras
Paraffin
gauze
chlorhexidine.
See Dressings.

●

impregnated

with
●

Bakamjian
1965: Described the deltopectoral flap.

Baker classification
Classification of capsular contracture (1975).
● I: soft.
● II: minimal, implant palpable not visible.
● III: moderate, palpable and visible.
● IV: severe, hard, painful with distortion.
See Breast augmentation, Breast implants.

Balanitis xerotica obliterans
(BXO)
●

●
●

●

Male genital form of lichen sclerosis, which
is a chronic, progressive, sclerosing inflammatory dermatosis of unclear aetiology.
Chronic BXO predisposes to SCC.
There may be a viral association and HLA
association.
Increased in obese patients.

Dyskaryosis and inflammatory changes in
the early stages lead to fibrosis and skin
atrophy.
The prepuce becomes adherent to the glans
with a white stenosing band at the end of
the foreskin and a haemorrhagic response
to minor trauma leading to phimosis and
stenosis.

Treatment:
● Steroid creams for early disease in children.
● Circumcision, meatoplasty.
● Excise advanced disease and apply a buccal
mucosal graft in which BXO does not recur.

Balding
See Hair restoration with flaps.

Bannayan syndrome
Microcephaly, multiple vascular malformations and multiple lipomas.

Basal cell carcinoma
●

95% of BCCs occur between 40–80 years,
85% in the head and neck.

Bayne and Klug classification of radial dysplasia 17

●

●

●
●

It is the most common malignancy in
Caucasians.
BCCs arise from pluripotential cells of the
basal layer of the epithelium or pilosebaceous follicles.
Directly related to sun exposure.
Almost never metastasize.

Carcinogens:
● Ultraviolet radiation (UV).
● Ionizing radiation.
● Chemicals: arsenic, psoralens, nitrogen mustard and atmospheric pollutants have been
implicated.
Inherited conditions:
● Xeroderma pigmentosa.
● Gorlins syndrome.
● Albinism with increased risk of BCC and
SCC.
● Epidermodysplasia verruciformis.
● Muir–Torre syndrome.
● Porokeratosis.
● Bazex–Dupre–Christol syndrome.
Types:
● Nodular: most common. Usually single on
face. Translucent papules. Grow slowly and
ulcerate.
● Superficial: often multiple, usually trunk,
erythematous, scaly.
● Infiltrative: also morphoeic, yellow-white,
morpheaform, and ill-defined borders. More
often recur.
● Pigmented: like nodular with pigment.
● Trabecular: See Merkel cell tumour.
● Adnexal: arise from sebaceous sweat glands.
Uncommon and appear as solitary tumours
in older patients. No particular features,
grow slowly, tend to recur locally and metastasize regionally.
Histology:
● Oval cells with deeply staining nuclei and
scant cytoplasm.
● Irregular masses of basaloid cells in the dermis, with the outermost cells forming a pallisading layer on the periphery.
● A
fibrous reaction in the surrounding
stroma.
● 95% are attached to the epidermis, the rest
are attached to a hair follicle.

●

Broder’s classification.

Treatment:
● Surgery:
● excise with 2–3 mm margin, wider if
indistinct;
● 5% are incompletely excised;
● Treatment of incomplete excision is controversial between authors; some advise
all to be re-excised, others suggest observation as 2/3 don’t recur; other than surgery, can use.
● Radiotherapy.
● Photodynamic therapy.
● Cryotherapy.
● Curettage.
● Moh's micrographic surgery.
● Intralesional interferon or BCG vaccine.
Recurrence: 36% of patients with a BCC
develop a second primary within 5 years.
See Squamous cell carcinoma. See Naevus
sebaceous.

Basal osteotomy
For 1st CMC joint OA.
● Can provide good stable pain free CMC
movement.
● Closing wedge osteotomy.
● 4-cm incision centred on prominence of 1st
CMC joint in line with shaft. Retract EPL,
expose proximal third of metacarpal.
● Site of osteotomy should be 1 cm from
joint. Strip periosteum circumferentially
and insert levers. Mark osteotomy – 5 mm
wide for 20–30° abduction.
● Wide part of wedge is directed so as to
cause abduction on closing the wedge, insert
interosseous wire.
● Excise bone wedge keeping far cortex intact.
Close wedge. Insert wire and plaster in corrected position for 6/52 (Journal of Bone and
Joint Surgery 1983;65:179).

Bayne and Klug classification of
radial dysplasia
I: short radius.
II: hypoplastic radius.
● III: partial absence of radius.
● IV: total absence of radius.
See Radial club hand.
●
●

18 Bazex–Dupre–Christol syndrome

Bazex–Dupre–Christol syndrome
●
●

X-linked disorder.
Follicular atrophoderma, congenital hypotrichiosis, basal cell naevi and Basal cell carcinomas.

●

●

Beal’s syndrome
Contractural arachnodactyly syndrome. Initially thought to be Marfan’s with Arthrgryposis.

BEAM
Bulbar Elongation and Anastomotic Meatoplasty.
● One stage treatment for Hypospadias.
● The whole length of urethra is dissected and
advanced to lie at the level of the normal
meatus.
● Up to 5 cm advancement can be achieved.

Bean syndrome
See Blue rubber bleb syndrome.

Becker’s flap
●

●

Based on a fairly constant dorsal branch of
the ulnar artery supplying the dorsal ulnar
border of the forearm.
It pierces the deep fascia a few centimetres
proximal to the pisiform so it can be used as
a distal island flap without sacrificing the
ulnar artery.

Becker’s naevi
Acquired pigmented patches.
Incidence of 1:200, M:F 5:1.
● Appears in adolescence, exaggerated by
sunshine.
● Occurs on the upper trunk and arms.
● It gradually spreads, and becomes darker
and hairy with acne lesions within it. The
melanocytes are excessively active and the
epidermis is thickened with enlarged sebaceous glands.
● Q-switched ruby (694 nm) and pulsed dye
Lasers (510 nm) may be effective.
See Naevus.
●
●

Beds – for pressure sores
●

●

Patients are assessed for the risk of developing
a pressure sore by using the Waterlow score.
10+ risk: foam mattress such as soft foam premier which contains a contoured insert pad.

15+ risk: alpha excel has an overlay pressurerelieving mattress.
20+:
● dynamic floatation: Nimbus 3;
● alternating pressure system: Pegasus;
● air fluidized bead bed: Clinitron;
● low air loss: mediscus, cells inflate and
deflate independently.

Belfast regime
A regime of early active mobilization after
flexor tendon repair.
● A dorsal splint is worn, which leaves the fingers free to flex.
● The wrist is held between neutral and 30º
flexion. MCP extension limited to 70º flexion. Hyperextension of IPJs is prevented
beyond neutral.
● Active mobilization consists of:
● passive flexion;
● passive flexion and hold, to maintain
muscle function;
● active flexion, to create tendon glide and
limit adhesions.
See Tendon, Flexor repair.
●

Bell’s palsy
Paralysis of the facial nerve.
Described by Charles Bell in 1814.
● Originally referred to facial nerve paralysis
from any cause.
● Now
refers to idiopathic facial nerve
paralysis.
● A diagnosis of exclusion.
● It may be a viral infection with swelling
of the nerve in the tight intratemporal
course.
● 80% recover full function, which begins
within 4 weeks.
See Facial nerve
●
●

Bell’s phenomenon
Upward movement of eye with closure of
eyelid.
● Test by holding upper lid open, while patient
attempts gentle closure of the eye.
See Ptosis.
●

Below knee amputation
See Skew flap, Long posterior flap.

biobrane

Benelli mastopexy

Bilhaut–Cloquet operation

Treatment for mastopexy with excision of
peri-areolar skin.
● Concentric skin excision around the areolar,
which moves the nipple superiorly. Dimensions may be up to 14 cm vertically and
12 cm horizontally.
● Breast may be sutured to periosteum and crisscross flaps may help increase projection.
● Tendency for the scar to stretch is combated
with a non-absorbable purse string suture,
as well as nylon cross sutures to reduce areolar herniation.
● It may help in the constricted or tuberose
breast with mild to moderate laxity.
● Three problems may occur:
● the areola may enlarge;
● the scar may be hypertrophic;
● breast contour may be flattened.
See Mastopexy.

●

●

Bennet’s fracture
Intra-articular fracture-subluxation of base of
thumb metacarpal. Oblique fracture through
volar beak, which is held by beak ligament.
APL pulls metacarpus radially causing subluxation. Reverse Bennet’s fracture occurs in
the base of the 5th metacarpal.

Bernard operation
●

●

●

Used for Lip reconstruction with significantsized defects.
Advances full thickness flaps with triangular
excision to allow proper mobilization.
May have diminished sensation and mobility which may be lessened in Webster modification.

Biers block
●

●

●

●

●

Intravenous regional anaesthesia which lasts
90 minutes.
Cannula placed in arm which is exsanguinated and a tourniquet applied.
4–6 mg/kg of 0.5% lignocaine without
adrenaline (not bupivicaine, which is cardiotoxic) is injected slowly.
The tourniquet should be on for at least
25 minutes to reduce the risk of generalized
spread of lignocaine.
If tourniquet pain is a problem, inflate a second more distal.

●

●

●

19

Used to correct distal Thumb duplication.
Both elements of the duplicated thumb are
reduced and joined.
Nails are removed, the outer segments
approximated and the nail bed repaired.
It can be modified by taking unequal portions of each finger. This avoids the central
longitudinal nail bed repair and reduces the
risk of susequent nail irregularities.

Bilobed flap
●
●

A transposition flap with 2 lobes 50º apart.
The first lobe is the same size as the defect
and the second is half the size. The defect
left by the second lobe is closed directly. The
angle of rotation of each flap should be 50º.

Principles:
● No more than 50º for each lobe.
● Excise a triangle of dog-ear between defect
and flap pivot point before the flap is rotated.
● Make the first lobe the same size and thickness as the defect and undermine to enable
it to inset without pin-cushioning.
● For the nose it can be used for a defect up to
1.5 cm.
See Nasal reconstruction.

Binder’s syndrome
●

●

●

●

A congenital malformation with nasomaxillary hypoplasia.
M = F, most sporadic but there may be a
hereditary component.
It may be due to an inhibition of the ossification centre that would have formed the
lateral and inferior borders of the piriform
apertures.
The nose appears pushed in with
malocclusion.

Treatment:
● Le Fort 3 osteotomies with advancement of
maxilla until teeth occlude.
● Gaps are filled with bone chips.
● Augmentation rhinoplasty with costal cartilage grafts can be performed.

Biobrane
●
●

A dressing used for partial thickness wounds.
A bilaminate semi-permeable silicone membrane bonded to a thin layer of nylon fabric

20 biological skin substitutes

●

●

which is bound to modified porcine dermal
collagen.
It is available as a glove, which allows active
movement during healing.
It can’t be used for deeper or full thickness
wounds.

●
●

Eyelid skin remains excessive.
The term Dermatochalasis should be used
for involutional skin excess.

Blepharomelasma
Dark discolouration of eyelid skin.
See Blepharoplasty.

Biological skin substitutes
Allograft: Cadaver skin.
Xenograft: pigskin. Less expensive, doesn’t
last as long, and doesn’t cause wound bed
vascularization.
● Biobrane.
● Human amniotic membrane.
● Transcyte.
● Integra.
See Burns. See Transplant immunology.
●
●

Blepharopachynsis
Thickening of eyelid skin.
See Blepharoplasty.

Blepharophimosis
Congenitally small palpebral fissures caused by
a triad of Ptosis, Epicanthal folds and Telecanthus.
See Ptosis – eyelid.

Blepharoplasty
Biomaterials
See Alloplasts.

Bites
●

●

Human: aerobic pathogens include Staph.
aureus and epidermidis, and Strep. Anaerobic bacteria include Peptostrep. peptococci,
Eikenella corodens and bacteroides.
Animal: dogs and cats also have Pasteurella
multocida. Only 20% of dog bites get infected,
whereas 80% of cat bites get infected due to
the depth of the wound.

Blauth classification for thumb
hypoplasia
See Thumb hypoplasia.

Blauth and Gekeler classification of
symbrachydactyly
Short finger: four short stiff coalesced fingers, normal thumb.
● Oligodactylic: central aplasia and cleft.
● Monodactylic: aplasia of all fingers, thumb
preserved.
● Peromelic: transverse absence of all digits at
metacarpal level.
See Symbrachydactyly.
●

Blepharochalasis
●

●

A rare inherited condition with recurrent
episodes of eyelid oedema.
This results in ptosis due to an attenuated
levator aponeurosis.

The procedure to shape the appearance of
the eyelids and create lid creases. Usually
skin, some muscle and excessive orbital fat is
removed.

Assessment: Ask whether the patient wears
contact lenses, suffers from dry eyes or diplopia.
Examination: Assess position of the eyebrow,
eyelid pathology, fat pads, lagophthalmos,
position of eyelid in relation to the eye.
● Tests:
● compensated brow ptosis: as the patient
opens the eyes the eyebrow moves up;
● snap test: distract eyelid, >1 second to
return is abnormal;
● distraction test: lax if the lower lid can be
pulled more than 7 mm from the globe;
● fat pads: push on globe and look for
herniation;
● lateral herniation may be lacrimal gland;
● Bell’s phenomenom;
● enopthalmos: look at position of globe
from above;
● visual fields;
● visual acuity.
Operation:
● Upper blepharoplasty: while patient is supine
design upper eyelid incisions. Elevate the eyebrow manually. Make caudal incision first. In
the crease in younger patients, 1 mm above
in older patients. Gently stretch the skin.
Pinch the skin and mark the upper incision.
Extend the upper mark laterally and medially.

blood supply to upper limb 21

●

●

●

Examine and mark the fat pads. Excise skin
with orbicularis if required. Incise orbital
septum to expose the pre-aponeurotic fat
pad and remove with careful haemostasis.
Inject with local anaesthetic to reduce the
oculocardiac reflex. If the lacrimal gland is
prominent it may need to be elevated. A lateral canthopexy may be required.
Lower blepharoplasty: incise just inferior to
the lid margin. Stop before the punctum.
Dissect orbicularis leaving the pretarsal portion attached to the tarsus. Continue
submuscularly until the orbital rim is
reached. Here, incise septum to expose and
remove the fat. Gently press the globe to
asses the amount of fat excess. Drape the
skin back and pull downwards to simulate
gravity. Excise 2–3 mm skin with orbicularis.
Transconjunctival lower blepharoplasty: this
enables fat pads to be excised without an
external incision. Skin excess may be address
with laser resurfacing.
Compensated brow ptosis: If the resting
position of the brow has dropped, frontalis
contracts to elevate brow and lid. Lid resection allows relaxation of frontalis and the
position of the eyelid remains unchanged.
A brow lift may be required prior to performing a blepharoplasty.

blisters are rich in prostaglandins, particularly thromboxane, which may increase burn
wound depth by increasing the zone of stasis.

Blood flow
Muscular tone of vessels is controlled by:
● Sympathetic nerve supply: these regulate
flow by:
● increasing arteriolar tone and precapillary sphincter tone which decreases blood
flow;
● decreasing AVA tone enabling blood to
bypass the capillary bed.
● Pressure: an increase in intraluminal pressure results in vasoconstriction and a
decrease causes vasodilatation. This is the
explanation for hyperaemia after releasing
the tourniquet.
● Humeral factors:
● adrenaline
and noradrenaline cause
vasoconstriction;
● histamine
and bradykinin cause
vasodilatation;
● low O , high CO
2
2 and acidosis result in
vasodilatation.
● Temperature: increase in temperature produces cutaneous vasodilatation and flow,
which bypasses the capillary beds.

Blood supply to skin
Complications:
● Immediate:
● loss of vision;
● retrobulbar haematoma – if this occurs
decompress as an emergency; acetazolamide and mannitol can be given;
● injury to inferior oblique muscle;
● wound dehiscence.
● Late:
● over or under correction;
● dry eye syndrome;
● epiphora,
Drooping of the upper lid.
See Ptosis – eyelid.

Six layers of vascular plexuses
● Subfascial plexus: small plexus under the
fascia.
● Prefascial plexus: larger plexus, prominent
on limbs, predominantly supplied by fasciocutaneous vessels.
● Subcutaneous plexus: in superficial fascia.
Predominant in torso, supplied by musculocutaneous vessels.
● Subdermal plexus: main plexus supplying
skin.
● Dermal plexus: arterioles, important for
thermoregulation.
● Subepidermal plexus: contains small vessels
without muscles. Predominantly nutritive
and thermoregulatory.

Blisters – in burns

Blood supply to upper limb

The management of burns blisters is controversial. Some advocate leaving blisters intact
to provide sterile wound coverage. However,

●

Blepharoptosis

●
●

Radial artery.
Ulnar artery.
Dorsal carpal arch.

22 blood vessels

●
●

Superficial palmar arch.
Deep palmar arch.

Blood vessels
Anatomy:
● The inner layer consists of basement membrane with endothelial cells sitting on it.
● The next layer is the intima composed of
elastin.
● Next is the media made of collagen and
smooth muscles.
● The outer layer is the adventitia with the
vasa vasorum.
Injury and repair:
● After injury endothelium is regenerated
from endothelial cells from the edge.
● At an anastomosis get healing of all layers.
● Initially platelets aggregate on exposed collagen, but by the end of a week the endothelium proliferates and sutures are covered by
2 weeks.

Blue naevus
Round, solitary bluish naevus.
Found on dorsum of extremities or buttocks and often present at birth.
● Female: Male 2:1.
● Very low malignant potential.
● Due to arrested migration of melanocytes
bound for the dermo-epidermal junction.
● Naevus of Ota occurs in area of 1st and 2nd
trigeminal nerve.
● Naevus of Ito occurs in the dermatome of
the upper chest.
● Current treatment is excision though lasers
should be effective.
See Naevus. See naevus of Ota and Ito.
●
●

Blue rubber bleb nevus
Sporadic combination of cutaneous and
visceral VMs.
● The skin lesions are soft, blue and nodular;
they can occur anywhere, but are typically
located on the hands and feet.
● The gastrointestinal lesions are best seen by
endoscopy.
● Recurrent intestinal bleeding can be severe,
requiring repeated transfusions.
See Venous malformations (Bean syndrome).
●

Body dysmorphic disorder (BDD)
Preoccupation with an imagined defect in
one’s appearance.
● If a physical anomaly is present, the person’s
concern is markedly excessive. Patients
with BDD have a high risk of committing
suicide.
● The most common preoccupation is with
the nose.
● Surgery tends to increase the preoccupation
and the dissatisfaction.
● Patients turned down for surgery may
attempt DIY surgery.
● BDD begins in adolescence.
● Men and women show differing concerns
for different body parts.
See Psychology and plastic surgery.
●

Body Mass Index (BMI)
Measured by body wt (kg) divided by height2
(m)
● Normal
20–25 kg/m2
● Overweight
25–30 kg/m2
● Obese
30–35 kg/m2
● Morbidly obese
35–55 kg/m2
● Super morbidly obese
>55 kg/m2
See Obesity.

Bolan case
Bolan versus Freean Hospital Management
Committee 1957: by this ruling, doctors defending negligence actions could rely on evidence
of opinion from colleagues to justify their
actions even if there is a body of opinion that
would take the contrary view.
●
‘I myself would prefer to put it this way,
that he is not guilty of negligence if he has
acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art ...
Putting it the other way round, a man is not
negligent, if he is acting in accordance with
such a practice, merely because there is a
body of opinion who would take a contrary
view.’
See Ethics.

Bolitho case
Bolitho versus city and Hackney Health
Authority, 1997. Based on a case of a child admitted for observation with respiratory difficulties.

bone graft

The registrar did not come when called and
the medical experts were divided on whether it
would have made any difference.
● Basic premise: the body of opinion relied
upon must be logical, and the judge must be
satisfied that the experts have considered
the question of comparative risks and benefits, and reached a defensible conclusion.
● In other words: it is no longer enough for the
defence to put up experts to say they genuinely believe a doctor’s actions conformed
with accepted practice. The defence now has
to show a logical basis for the opinion.
See Ethics.

Bone
To maintain function, bone must regenerate.

Anatomy: Bone is generated by osteoblasts.
They are surrounded by their matrix and they
are trapped. Once trapped they become
smaller and become osteocytes.
● Enchondral bone (long bones) starts as cartilage, which ossifies.
● Membranous bones in the facial skeleton lay
down bone directly. Membranous bones are
more vascular but less strong.
● Cortical bone has concentric lamellae around
Haversian canals containing blood vessels.
● Cancellous bone has large and small units of
bone – trabeculae and spicules. Also have
osteocytes, though not as compact as cortical bone. Bone is only 8% water. The matrix
is 98% collagen (type I).
● Blood supply: of long bones from a primary
nutrient artery, proximal and distal metaphyseal vessels and the periosteum. Though
the endosteal circulation is dominant in
undisplaced fractures, in displaced fractures, the main blood supply is derived from
the periosteum.
Healing:
● Primary healing: if bone is rigidly fixed. Get
restoration of normal bone structure without the inflammatory and proliferative phase.
Callus is not formed. Osteoclasts first cross
the fracture line followed by osteoblasts.
● Secondary healing: occurs if fragments are
not rigidly fixed or if there is a gap. If the fracture is widely displaced or mobile then scar
tissue bridges the gap forming a non-union.

23

In more favourable conditions, new bone
formation occurs.

Phases of healing:
● Haematoma
● Inflammation: osteoclasts remove debris.
Associated with pain.
● Cellular
proliferation: periosteal and
endosteal.
● Callus formation: immature woven bone,
osteoid laid down by osteoblasts and mineralized with hydroxyapatite.
● Soft callus: neovascularization mainly from
periosteum. Precursor cells differentiate
into fibroblasts, chondroblasts, and osteoblasts. These produce collagen, cartilage
and osteoid that makes up callus. Mainly
type II collagen.
● Hard callus: soft callus is mineralized.
3–4 weeks after injury. Osteoclasts remove
all dead bone and type II collagen is
replaced by type I collagen. Calcium
hydroxyappatite is deposited. Initially get
woven bone.
● Remodelling: cortical structure and medullary cavity are restored. Fibres are reorientated along stress lines (Wolf ’s law). Woven
bone is remodelled into lamellar bone.
Guided bone regeneration: Controlled stimulation of new bone into a defect by osteoconduction, osteo-induction or osteogenesis.
Periosteum provides a source of osteoprogenitor cells and blood supply. The periosteum
may also provide a barrier to the in-growth of
fibrous tissue. Other membranes have been
tried in place of periosteum. PTFE sheets have
been used. Resorbable barriers are being
evaluated.
See Ilizarov.

Bone graft
Source:
● Autogenous: preferred due to improved take.
Autogenous grafts contain cells and growth
factors. Cancellous bone has these in greater amounts. Cortical bone provides bulk.
Grafts can be vascularized or free, inlay or
onlay.
● Allogenic
implants: bone transplanted
between individuals. As the cells are killed
it is not an allograft, but an implant. Less

24 bone morphogenetic proteins (BMPs)

●

predictable than autografts. Get delayed
vascularization, resorption and poor osteogenic capacity.
Xenogenic transplant: first performed in
1668 when a Dutch surgeon put pig calvaria
into a Russian soldier. The Russian church
demanded its removal 2 years later during
which he died. Xenogenic grafts are presently not performed.

Heal by:
● Osteogenesis: formation of new bone by surviving cells in the bone graft. This only
occurs in vascularized bone grafts.
● Incorporation: graft adheres to the host tissue.
● Osseoconduction: cells migrate from the
bone ends into the graft, which acts as a
scaffold.
● Osseoinduction: precursor cells are stimulated to become osteocytes, which move
into the graft. Osseo-induction is controlled
by bone morphogenic proteins (BMPs).
Graft survival:
● Systemic factors are similar to those affecting
Wound healing.
● Intrinsic graft factors: grafts with intact periosteum and membranous bones undergo
less absorption.
● Graft placement factors: particularly if in a
normal bone site, quality of bed, graft
fixation.
Bone substitutes: Polymethylmethacrylate,
Polytetrafluoroethylene.

Bone morphogenetic proteins
(BMPs)
●
●

●

●

BMPs are responsible for bone regeneration
Multiple BMPs exist. 15 have been identified, and all apart from BMP-1 belong to the
TGF-β family.
Bone produced at non-bony sites may be
caused by the presence of BMPs.
There are pathological and oncological concerns about the presence of BMPs, which
may limit clinical use.

Bone tumours
Hand bone tumours account for 5% of bone
tumours and 2% of malignant bone tumours.
● Aneurysmal bone cyst.
● Chondroblastoma.

●
●
●
●
●
●
●
●
●
●
●
●
●
●
●

Chondromyxoid fibroma.
Chondrosarcoma.
Enchondroma.
Ewing’s sarcoma.
Fibrous dysplasia.
Giant cell tumour of bone.
Histiocytosis.
Osteochondroma.
Osteogenic sarcomas.
Osteoid osteoma.
Osteoblastoma.
Unicameral bone cyst.
Metastatic carcinoma.
Myeloma.
Non-ossifying fibroma.

Classification: Enneking’s system.
Clinical presentation: pain is a common
symptom. Family history is important for some
diseases with a high association with tumours.
Investigations:
● Hypercalcaemia is common.
● Alkaline phosphatase is elevated in 50% of
patients with osteosarcoma.
● Lactate
dehydrogenase is elevated with
Ewing’s sarcoma.
● Perform plain XRs. Assess the bone, the
tumour and the matrix. Bone scans are not
very useful.
● MRI is useful to assess intramedullary extent.
● CT is useful to detect matrix calcification.
CT of the chest is important.
● USS differentiates cystic from solid masses.
● PET is useful for some carcinomas such as
hepatic carcinoma and melanoma.
Principles: Without surgery, the tumour will
recur. The options for resection are intracapsular, marginal, wide (intracompartmental)
and radical (extracompartmental). The aim is
to cure the patient of the tumour, preserve the
limb and preserve function if possible.
● Biopsy: a tissue diagnosis is important.
Perform an incision longitudinally over the
tumour closest to the skin within one compartment. Frozen section may be used to
ensure a good sample of the tumour has
been taken. FNA and core biopsies can be
used if the pathologist is confident. The
incision or core tract will require complete
excision at the time of definitive surgery.

Bouvier’s manoeuvre

●

●

Curettage: this is not curative and is reserved
for recurrent or stage 3 tumours. The cavity
can be filled with bone cement or treated
with liquid nitrogen. Bone graft or allograft
can be used to fill the defect.
Resection/amputation: most primary tumours
are located in the metaphysis and require
sacrifice of the joint.

●

●

25

paralysis appears within 24–48 hours of
injection.
Botox can be used for hyperhidrosis, rhytids,
facial asymmetry and focal hand dystonia
when EMG may be useful in helping to
locate the muscle.

Bouchard’s node
Osteophyte developing at the PIP joint.

Bonnet–Dechaume–Blanc
Telangiectatic facial birthmark with intracranial AVM.
See Vascular malformations.

Boutonnière deformity
●

●

Boss – carpometacarpal
●

●

●
●

Bony prominence usually arising at the base
of the second and third metacarpal.
The joint becomes hypertrophic with an
overlying bursa, and tendons may bowstring
over the swelling.
Possibly secondary to trauma.
XR: use a carpal boss view taken in 30–40º
supination and 20–30º ulnar deviation.

Treatment:
● Conservative with splint, NSAIDS and steroid injection, surgery if symptoms persists.
● Excise the boss through a longitudinal or
transverse incision. Retract extensors. Make
a longitudinal incision over the boss. Expose
the boss subperiosteally. Elevate part of
ECRB from the bone. Excise the boss with
an osteotome until normal cartilage is seen.
Inadequate excision results in persistent
pain and swelling, so the entire boss needs
to be excised, exposing the CMC joint. A
ganglion at this site will require excision of
the ganglion and the boss.

Botulinum toxin
●

●

●

Botulin was first used clinically to attenuate
extra-ocular muscle in the 70s and also used
for blepharospasm.
Clostridium botulinum produces eight serologically distinct exotoxins. These release
acetylcholine at the neuromuscular junction resulting in flaccid paralysis.
Type A toxin is the only one available. It is
supplied dry in vials containing 100 MU.
It is unstable and must be kept in a freezer. It
is dissolved in 2 ml of saline.

Flexion of the PIP joint and extension of the
DIP joint.
Due to a disruption of the extensor mechanism. The central slip is often disrupted and
the lateral bands move volarly and become
flexors of the PIP joint. The FDS tendon
now has nothing to resist it and unopposed
flexion occurs. With time the lateral bands
contract and their pull on the oblique retinacular ligament (ORL) pulls the DIP joint
into hyperextension. The MCP joint also
moves into hyperextension.

Assessment:
● Active and passive ROM of DIP joint and
PIP joint.
● Check tightness of ORL by extending PIP
joint and assessing tension at DIP joint.
Classification:
● Stage 1: dynamic, passively correctable.
● Stage 2: established deformity which cannot
be passively corrected.
● Stage 3: established deformity with secondary PIP joint changes.
Treatment:
● Acute
central slip divisions should be
repaired.
● Stage 1and 2 problems should be splinted to
stretch volar structures, lateral bands and
the ORL.
● Stage 3 problems are difficult to correct.
Joint release may be performed. Central slip
reconstruction, lateral band release, arthrodesis or arthroplasty may be required.

Bouvier’s manoeuvre
●
●

A test for ulnar nerve palsy.
When hyperextension is passively prevented
by dorsal pressure, EDC can extend the middle and distal phalanx.

26 Bowen’s disease

Bowen’s disease
●

●

●

●
●

●

●
●

Squamous cell carcinoma in situ. 10% become
invasive after many years with 1/3 of these
developing metastatic disease.
Seen in older patients in sun exposed and
covered areas.
Found on skin or mucous membrane (Bowen’s
of mucous membranes). Most are solitary
with a long clinical course.
More common in men than women.
Appearance of sharply defined erythematous reddish scaly plaque with pruritus and
superficial crusting.
Histologically see hyperkeratosis and acanthosis with disordered epithelium and frequent mitoses, but no dermal invasion.
Treat with excision or curettage.
There is also a relation between Bowen’s disease and internal malignancies.

Boyes sublimis transfer
For Radial nerve palsy.
● PT
→
● FDS middle
→
● FDS ring
→
● FCR
→

ECRB
EDC 2–5
EPL, EIP
APL, EPB

Bra
See Cup size.

Brachial plexus – anatomy
●
●
●
●
●

●

●

●

5: nerve roots (C5–T1).
3: trunks (upper, middle, lower).
6: divisions (3 posterior, 3 anterior).
3: cords (lateral, medial and posterior).
4: major nerves (median, ulnar, radial and
musculocutaneous.
Dorsal root: sensory afferents, cell bodies in
the dorsal root ganglion.
Ventral root: motor efferents (relay in anterior horn cells).
Dorsal and ventral roots combine to form
spinal nerves which split into anterior and
posterior rami. The major plexuses are
formed from the anterior rami. The posterior rami become the posterior intercostal
nerves.

Roots: C5–T1, variably C4 and T2. lie behind
scalenus anterior.

Trunks: Upper, middle, lower between the
anterior and middle scalenes. Cross lower part
of posterior triangle.
Division: Anterior and posterior. Each trunk
divides at the lateral edge of first rib. Lie behind
clavicle.
Cords: Lateral, medial and posterior. Formed
by the combinations of divisions and named
in relation to the axillary artery. The anterior
division of lower trunk continues to become
the medial cord, the posterior divisions join to
become the posterior cord and the anterior
division of lower joins with anterior division
of upper to become the lateral cord.
Nerves: Commence at the lateral border of
pectoralis minor.
Examination based on anatomy
C5 and C6 roots and upper trunk:
● Dorsal scapular nerve supplies rhomboids:
squeeze shoulder blades and palpate.
● Long thoracic nerve supplies serratus anterior:
push wall.
● Suprascapular nerve supplies supra- and
infraspinatus: look at muscle bulk and test
for external rotation of the shoulder.
● Third branch joins middle trunk to form axillary nerve: test abduction of shoulder, palpate deltoid.
● Lateral pectoral nerve: clavicular head of
pectoralis major, don’t examine.
● Musculocutaneous nerve: biceps and sensation lateral arm
● Upper trunk contribution to median nerve:
supplies FCR and pronator teres. Test FCR
with wrist flexion and palpation. Test PT
with pronation against force at 90º.
C7 root:
This is like examining the radial nerve with
subscapularis.
● Assess internal rotation and latissimus dorsi:
push down on hips and palpate.
● Axillary nerve has already been tested.
● Final branch is radial nerve. Brachioradialis
and ECRL/B are supplied by C6, EPL and
EDC supplied by C7 and 8. Test sensation.
C8–T1 root:
● Medial pectoral nerve: supplies pectoralis
major.

brachial plexus injury 27

Medial cutaneous nerve of the arm and forearm: test sensation.
● Contribution to median nerve supplying
FDS, FDP index and middle, FPL, APB.
● Terminates as ulnar nerve.
Also note pain, fractures, phrenic nerve palsy
and Horner’s syndrome.
●

Brachial plexus injury
Obstetric brachial plexus palsy
Incidence 1:1000. Most recover, 10% are
severe.
Aetiology:
● Lateral distraction of the head from shoulder with injuries to upper roots.
● C5 has strong dural attachment so ruptures.
● C6 and C7 will avulse at the roots.
● C8 and T1 are usually only injured once the
other roots are completely avulsed.
● However, Klumpke’s is lower root due to
hyperabduction in breech delivery.
Classification: by Narakas.
Prognosis:
● Any partial lesion has a better prognosis.
● Good grasp at 8/52 is likely to recover well.
● No recovery by 6/12 is unlikely to improve
much.
● Breech delivery gives the most severe injuries.
Indications for operation:
● Groups 1 and 2 with no recovery in 3/12.
● Group 3 no biceps recovery in 3/12.
● Group 4 lesions.
Management:
● Once the diagnosis is made, assess at 6 weeks
then every 6 weeks after. Maintain supple
joints. Explore:
● complete injuries.
● C5 and C6 injuries, where there is evidence of phrenic nerve palsy.
● If no biceps and wrist extension by 3 months.
This is controversial and some may observe
for longer.
Surgery:
● Nerve repair: direct or with grafts, or intraplexural or extraplexural neurotization.
● Secondary surgery may be required, e.g. to
improve external rotation.

Injury:
Most occur in birth or are post-traumatic most
commonly from RTAs. Obstetric palsies have
a functional deficit and a growth deficit.
Diagnosis:
● History: the nature of the force. The position of head and arm. Shoulder abduction
will suggest lower root injury. If the arm is
pulled down it is more likely to involve
upper roots. Traction will cause a central C7
injury.
● Examination:
look for muscle atrophy.
Wasting of paraspinal muscles indicates
high cervical nerve avulsion injury.
● Electrodiagnostic studies: Repeat 6 weekly
and if there is no recovery after 3 months
and no evidence of root avulsion, explore
surgically:
● low
amplitude potentials suggest
re-innervation;
● diminished fibrillations and sharp waves
and activated muscle units suggest reinnervation, but don’t correlate with
function;
● sensory nerve action potential (SNAP)
and normal conduction velocity indicate
root avulsion with a preserved dorsal root
ganglion.
● Neuroradiology:
● CT myelograms can be helpful to diagnose root avulsions;
● MRI can reveal the roots beyond the spinal foramina. So CT for proximal, MRI
for distal lesions;
● angiogram may also be required.
Classification: Millesi.
Timing:
● For acute trauma, re-establish blood supply
and examine.
● Some advocate early repair if possible, others wait for 4–6 weeks to allow for Wallerian
degeneration, which helps identify the level
of injury.
● Closed injuries should be explored before
2 years after. Preferably from 6 weeks to
3 months.
Priorities: Aim is to restore use and prevent
amputation.

28 brachioplasty

●

●

●

●

Shoulder: stabilizing the shoulder prevents
subluxation – by neurotization of the suprascapular nerve with intraplexus nerve
donor or accessory nerve.
Elbow: flexion is the first priority. Musculocutaneous nerve is restored with intraplexus donors or extraplexus donors such as
intercostals.
Sensation: median nerve neurotization from
sensory intercostals or cervical plexus.
Hand function: priorities are finger flexion
and extension, then intrinsics and thumb
opposition and abduction.

Prognosis: Determined by the type of
lesion, age, denervation time, degree of root
involvement, surgical technique and patient
compliance.
Operative procedures: The final diagnosis
can only be made at exploration. After an
extensive exploration, perform intra- and
extraplexus ipsilateral and contralateral
neurotizations with nerve grafts and freefunctioning muscle transfers.
● Microneurolysis: either perform epineuriotomy or interfascicular dissection. Use methylene blue to delineate the fascicles. Use
palpation to assess the extent.
● Direct nerve repair: usually only possible for
a fresh cut.
● Nerve grafting: the graft can be split into fascicles to increase the chance of survival. Also
free vascularized nerve grafts such as ulnar
nerve can be used.
● Neurotization: aims to reconstruct the peripheral nerve when the stump is unavailable
e.g. in root avulsion. Examples of donors
are intraplexus donors, intercostal nerves,
spinal accessory nerve, cervical plexus,
phrenic (partial), hypoglossal, contralateral
pectoral, contralateral C7. May be end-toend or with nerve grafts. Contralateral C7
provides a powerful motor donor and is
useful for global avulsions.
Secondary reconstruction: These are necessary as only partial recovery will occur with
the above procedures.
● Shoulder: aim for abduction and external
rotation with tendon transfers such as latissimus dorsi for external rotation and
trapezius advancement for abduction. Free

●

●

muscle transfer can be used, e.g. gracilis and
adductor longus on a single pedicle.
Elbow: pedicled latissimus dorsi can restore
elbow flexion. Use local muscles first before
free flaps. Forearm flexors have been moved
proximally to act on the elbow. Free transfers used are lat dorsi, gracilis (but not very
strong), vastus lateralis and rectus femoris
for biceps.
Wrist: fuse in global avulsion as restoration
of wrist function is not feasible.

Brachioplasty
Many patients seeking improvement in arm
contour have significant skin excess. This will
leave a scar from axilla to elbow. This is a significant disadvantage as the scar is very visible.
Most patients have therefore had marked
weight loss with severe skin excess.

Brachioradialis
See Muscles.

Origin: Proximal 2/3 of lateral supracondylar
ridge of humerus and intermuscular septum
proximal to ECRL. It lies on the radial aspect
of forearm, crossing ECRL and PT.
Insertion: Styloid process of radius and antebrachial fascia. The latter is divided if the tendon is used as a tendon transfer.
Nerve supply: Radial nerve.
Action: Flexes elbow joint, supinates the pronated forearm, weak pronator of supinated
forearm.

Brachydactyly
Unusually short fingers.

Brachytherapy
●

●

●

●

●

Radiotherapy treatment by implantation of
radioactive material.
Originally radium needles were used but
now iridium 192 is implanted in wires.
Plastic tubes are inserted at the time of
operation.
These are then loaded with radioactive
seeds. This can be performed manually or it
can be automated to reduce radiation exposure to the technicians.
Useful in tongue and mouth lesions.

breast 29

May be preferable for posterior 1/3 of
tongue tumours, which cross the midline
which would otherwise require a debilitating total glossectomy.
● High risk of osteoradionecrosis.
See Radiation.
●

●

●

●

Bracka repair

●

This is a modification of the original Cloutier
operation for Hypospadias repair.

●

First stage: Aims are to correct chordee, excise
the urethral plate and apply a FTSG. Perform
at 3 years. Place penis on board. Tourniquet to
root of penis. Horton erection test. Excise urethral plate well laterally (1.2–1.5 cm width).
Excise chordee down to corpus cavernosum.
At glans/shaft junction split glans transversely
to correct glandular tilt. Split glans to level of
new meatus. If foreskin is present take graft
from inner surface, leave the rest of the foreskin intact. Meticulously suture on graft with
fine absorbable suture to floor of shaft, not to
edge of skin. Use quilting sutures particularly
at shaft/glans junction. Catheterize. Once well
sutured roll jelonet and tie over with 3 firm
4/0 nylon. Take tourniquet off. Post-op remove
dressing and catheter at 5 days.
Second stage: Aims to tubularize the skin
graft to form a neo-urethra. Perform when the
graft is well healed and softened. Tourniquet,
glans stitch, catheterize, penile board. Incise
around graft at a width adequate to create tube
around size 8 Foley catheter. Mobilize minimally and suture over catheter with fine
absorbable suture. Incise around corona lifting skin and preputial fascia with dorsal veins
off shaft. Dissect out a preputial flap and pedicle over suture line as a waterproofing layer.
Achieve haemostasis then suture the skin.
Results: Fistula rate of 5% reported by Bracka,
but 15% by trainees in the same unit.

week. If they persist they become a sinus
or cyst.
They occur along the anterior border of the
sternocleidomastiod.
May occur at any age, usually present by
8 years of age.
Cysts are soft non-tender.
They often become infected which should
be treated prior to excision.
Require imaging prior to surgery.

Cysts:
● First branchial cleft cysts: very rare. Get dimple or tract close to parotid, associated with
facial nerve.
● Second branchial cleft cysts: more common.
Occurs at the junction of middle and lower
thirds of sternocleidomastiod in the direction of the tonsillar fossa between internal
and external carotid artery.
● Third branchial cleft cysts: rare.
● Fourth branchial cleft cysts: runs behind
the internal carotid artery then beneath
the subclavian artery on the right and aortic arch on the left, opening into upper
oesophagus.
See Head and neck embryology.

Branemark implant
See Osseointegration.

BRCA
●

●

●

●
●
●

BRCA1 and BRCA2 are tumour suppressor
genes present in all women.
Mutations in these genes increase the risk of
developing Breast cancer.
1:300 women are carriers of mutations of
BRCA1 gene.
Autosomal dominant.
Present in 2% of women with breast cancer.
85% risk of developing breast cancer and
65% risk for ovarian cancer.

Breast
Branchial cysts
●

●

●

Branchial cleft anomalies are the most frequently occurring masses in the lateral neck.
They occur because of failure of maturation
of the first and second branchial arches. The
remnant remains trapped in the neck.
Between the arches are clefts. The 2nd, 3rd,
4th clefts are usually obliterated by the 6th

Anatomy:
● The breast develops from ectoderm. The
milk line forms in the 5th week of gestation.
Incomplete involution of the milk ridge
produces accessory nipples.
● At adolescence the breast grows and differentiates with ptosis developing after the age

30 breast

●

of 16. At menopause glandular involution
occurs.
The breast is mainly fibrous with around
15 main ducts running through to drain at
the nipple. Each duct drains a lobe and lobes
are separated by fibrous septae. The ligaments of Astley Cooper attach deep fascia to
skin and provide support.

Boundaries: 2nd to 7th rib, sternal edge to
anterior axillary line overlying the pectoral
fascia and serratus anterior, external oblique,
and rectus abdominus.
Blood supply:
● From perforating branches of the internal
thoracic artery (60%): medial portion.
● The lateral thoracic artery: lateral portion.
● Highest thoracic artery.
● Lateral branches from the 3rd, 4th and 5th posterior intercostal arteries: lower outer portion.
● Veins follow arteries.
Lymphatics: Parallel the venous system,
though most is to the axilla. The internal thoracic may carry 3–20% of lymph.
Nerve supply: Sensory innervation from:
● The supraclavicular nerves of the 3rd and
4th branches of the cervical plexus.
● The anterior cutaneous nerves from the
2nd–6th intercostal nerves.
● The anterior branches of the lateral cutaneous nerves from the 3rd–6th intercostal
nerves. Sensation to the nipple is from the
lateral cutaneous branch of the 4th intercostal nerve.
Shape:
● The shape varies but in the mildly ptotic breast, most of the fullness is in the inferior half.
● The nipple to inframammary fold distance
measures 5–6 cm in the ‘ideal’ breast.
● The nipple-areolar complex is the point
of maximum projection and measures 35–
45 mm in diameter.
Accessory breast tissue:
● Due to failure of regression of ectoderm or
mesoderm along the mammary line. <2%
of children.
● M:F 1:2.
● Accessory nipples are confused with pigmented naevi and breast tissue with lipomas.

●

May develop the same pathological diseases
as breast.

Breast augmentation:
History:
● Czerny transplanted a lipoma in 1895.
● Cronin and Gerow inserted a silicone prosthesis in 1962.
Incisions:
● Peri-areolar: with good scar, but possibly
nipple paraesthesia.
● Inframammary with good exposure but more
noticeable scar.
● Axillary with no scar on the breast but
decreased exposure.
● Endoscopic placement through umbilical
or axillary route.
Position:
● Subglandular: below breast tissue, above
fascia.
● Submuscular: below pectoralis and rectus
abdominus.
● Subpectoral: below pectoralis major superiorly and subglandular inferiorly.
Infection: Incidence is 2.2%, most commonly
with Staph. epidermidis. Prophylactic antibiotics are required.
Complications:
● Nerve injury to Nipple with decreased sensation in 15%.
● Capsular contracture.
● Rupture: around 2% per year, but less with
newer implants.
● Autoimmune disease and cancer: no evidence
of increased risk.
Breast cancer:
● Incidence: 1:8. The most common cancer in
women. 25 000–33 000 new cases per year in
Britain.
● Risk factors: Age, family history, DCIS, First
pregnancy >40 years, early menarche and
late menopause.
● Inheritance Linked to BRCA carriers.
Pathology: WHO classification – non-invasive
and invasive.
● Non-invasive:
● ductal carcinoma in situ (DCIS):
■ dysplasia in the epithelial cells of the
mammary ducts;

breast 31

10% bilateral. 20% multicentric. 30%
become invasive;
■ Small, local excision; larger, mastectomy;
● lobular carcinoma in situ (LCIS):
■ a marker of breast cancer;
■ 40% bilateral, 60% multifocal;
■ 1% chance per year of developing invasive breast cancer;
■ treat by observation or bilateral mastectomy.
Invasive:
● ductal, lobular, medullary, tubular, papillary, mucinous, adenoid cystic;
● 75% are ductal, 10% are