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Above Knee amputation-Burgess Long posterior flap technique

The Burgess technique is the most frequently used technique in BK amputation.The well vascularized myocutaneous flap consists of gastrocnemius, partial soleus and posterior skin.

Technique

Incision

Anterior skin incision should be located 12 cm (one handbreadth) below tibial tuberosity, skin incision should be continued transversley for a distance approximately 1/3rd of calf circumference to minimize formation of dog ears. Skin incision should be extended vertically for a distance approx one and half times the length of transverse incision. The posterior flap is then completed with a transverse incision at this level.The skin incision is then extended through the fascia throughout, with division of great saphenous vein.

Division of muscles

The anterior compartment muscles(Tibialis anterior.EHL,EDL and fibularis longus) are divided at the same level as the anterior incision.Central in the anterior compartment is anterior tibial artery and vein and deep peroneal nerve.The vessels are suture ligated and nerve is transected under tension.The tibia is then cleared and interosseus membrane is incised sharply.The tibia is divided at or just proximal to the skin incision with an anterior bevel.The lateral compartment muscles(fibularis longus and brevis) are divided to expose fibula.Fibula is divided 1-2cm proximal to level of  tibial transection.

Flap closure

The posterior compartment muscles( Soleus and Gastrocnemius) are divided obliquely to create a posterior muscle flap.Enough soleus should be removed to allow flap closure. The posterior tibial and peroneal vessels are suture ligated .The fascial edges are closed with interrupted sutures and skin closed with mattress sutures.Elasto crepe bandage should be applied to mould the stump.

What is the point in learning medicine?

Learning to sail-1=

Learning to sail-1= (Photo credit: Sheba_Also)

My question is to the medical graduates who study for a major part of their lives.What is the point in learning ?. After all our lifespan is limited and our learning period is too long. How can any medical student stride forward in his aim for excellence?

 

Without an aim there is no point studying, or learning as such. So we all need to have an aim, which should not be to replicate the past success of our ancestors, but to create history by our own efforts. Once you recognize that you can achieve it through practice or by learning, the whole process of life become interesting.

 

So you have to introspect and find out: what your life is for? Is it just for living and to enjoy the nature, with the health endowed upon us? There are less fortunate people who suffer without any reason of their own. Doctors cannot alleviate the pain of a whole generation of people, but we can give hope to a new generation with our efforts.People have done it in the past, and it can be done in the present and it will be repeated in the future too. So don’t stand back, start your learning process now and reap the benefits for yourselves and for a whole lot of people who deserve your help

 

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Skin Grafting-Types of skin grafts

Anatomy of the human skin with English languag...

Anatomy of the human skin with English language labels. Arabic language description translated by: Tarawneh (Photo credit: Wikipedia)

Split thickness skin grafts

 

Also known as thiersch graft,split-thickness grafts consist of epidermis and a variable thickness of dermis. Thinner grafts (<0.016 in.) have a higher rate of engraftment, whereas thicker grafts, with a greater amount of dermis, are more durable and aesthetically acceptable. Common donor sites are the thigh, buttock, and scalp.

 

Full thickness skin grafts

 

Also known as Wolfe graft ,full-thickness grafts include epidermis and a full layer of dermis. Common donor sites include groin and postauricular and supraclavicular sites, but the hypothenar eminence and instep of the foot can also be used. The donor site is usually closed primarily. These grafts are generally used in areas for which a high priority is placed on the aesthetic result (e.g., face and hand).

 

Thinner grafts have greater secondary contraction and do not grow commensurate with the individual. They have fewer adnexal cells and therefore have variable pigment, less hair, and less sebum, with a proclivity toward dryness and contractures. Full-thickness grafts, with more dermis and the requisite adnexal structures, exhibit less contraction and better cosmesis.

 

Graft meshing

 

Grafts can be meshed in expansion ratios from 1.5:1 to 6:1. Meshing a graft allows coverage for a wider area using the same-size donor site and decreases the risk of serous fluid accumulating under the graft without a method of egress. The interstices are covered within 1 week by advancing keratinocytes. However, because the entire area is not covered by dermis, meshed grafts are less durable, and the meshing pattern remains after healing, making them inappropriate for aesthetically important areas, such as the face.
Graft healing.

 

Factors affecting graft take

 

Initial metabolism is supported by imbibition or diffusion of nutrients from the wound bed. Revascularization occurs between days 3 and 5 by ingrowth of recipient vessels into the graft (inosculation).

 

Therefore, for a graft to take, the bed must be well vascularized and free of infection, and the site must be immobilized for a minimum of 3 to 5 days. Prevention of shear forces is particularly important during this period of inosculation.

 

Although bare bone and tendon do not engraft, periosteum and peritenon can support skin grafts, especially if they are first left to form a layer of granulation tissue. Graft failures are most often the result of hematoma, seroma, or shear force prohibiting diffusion and vascular ingrowth.

 

Source:Washington manual of surgery

Sister Mary Joseph Nodule

Main sites of metastases for some common cance...

Main sites of metastases for some common cancer types. Primary cancers are denoted by “…cancer” and their main metastasis sites are denoted by “…metastases”. List of included entries and references is found on main image page in Commons: (Photo credit: Wikipedia)

Sister Mary Joseph Dempsey (born Julia Dempsey; 1856-1939) was the surgical assistant of William J. Mayo at St. Mary’s Hospital in Rochester, Minnesota,USA from 1890 to 1915. She drew Mayo’s attention to the phenomenon, and he published an article about it in 1928. The eponymous term Sister Mary Joseph nodule was coined in 1949 by Hamilton Bailey.

What is Sister Mary Joseph Nodule?

Sister Mary Joseph nodule or node, also called Sister Mary Joseph sign, refers to a palpable nodule bulging into the umbilicus as a result of metastasis of a malignant cancer in the pelvis or abdomen.

Etiology

1.Gastrointestinal malignancies account for about half of underlying sources (most commonly gastric cancer, colonic cancer or pancreatic cancer, mostly of the tail and body of the pancreas)

2.Gynecological cancers account for about 1 in 4 cases (primarily ovarian cancer and also uterine cancer).

3.Unknown primary tumors and rarely, urinary or respiratory tract malignancies cause umbilical metastases.

Mechanism of spread

Proposed mechanisms for the spread of cancer cells to the umbilicus include direct transperitoneal spread, via the lymphatics which run alongside the obliterated umbilical vein, hematogenous spread, or via remnant structures such as the falciform ligament, median umbilical ligament, or a remnant of the vitelline duct.

Importance of the finding

Sister Joseph nodule is associated with multiple peritoneal metastases and a poor prognosis.So once you find a Sister Mary Joseph nodule in a patient you can brace for a bad outcome.
Source:Medcosmos surgery

Cardinal Signs of Kanavel

Seen in suppurative tenosynovitis,which involves infection of the flexor tendon sheath, which is usually caused by a puncture wound to the volar aspect of the digit or palm.

Diagnosed by:Cardinal Signs of Kanavel

  • Finger held in flexion.
  • Fusiform swelling of the finger.
  • Tenderness along the tendon sheath.
  • Pain on passive extension.

Classification of nerve injuries

Sunderlanda Seddonb Structure injured Prognosis
First degree Neurapraxia Schwann cell (demyelination) Complete recovery within 12 wk
Second degree Axonotmesis Axon (wallerian degeneration) Complete recovery regeneration 1 mm/day
Third degree Endoneurium Incomplete recovery
Fourth degree Perineurium No recovery
Fifth degree Neurotmesis Epineurium No recovery
Sixth degree Mixed injury, neuroma, incontinuity Unpredictable recovery

Compartment Syndrome

English: This is a picture of compartment synd...

English: This is a picture of compartment syndrome of the lower leg (Photo credit: Wikipedia)

Compartment syndrome results from increased pressure within an osseofascial space, leading to decreased perfusion pressure. If it is left untreated, muscle and nerve ischemia may progress to necrosis and fibrosis, causing Volkmann ischemiccontracture.Compartment syndrome is usually seen in hand and forearm

  • Etiology. Fractures that cause bleeding, crush and vascular injuries, circumferential burns, bleeding dyscrasias, reperfusion after ischemia, or tight dressings can lead to the syndrome.
  • Diagnosis is based on a high index of suspicion, clinical examination, and symptoms of pain that are exacerbated with passive stretch of the compartment musculature, paresthesias, paralysis, or paresis of ischemic muscles. Pulselessness may occur and indicates a late finding (and is usually also a sign of irreversible damage) or the presence of major arterial occlusion rather than compartment syndrome. Measurement with a pressure monitor of a compartment pressure of greater than 30 mm Hg confirms diagnosis.
  • Treatment for incipient compartment syndrome involves close observation and frequent examinations and should include removal of tight casts and dressings. Elevation of the extremity to, or slightly above, the level of the heart is recommended. Acute or suspected compartment syndrome requires urgent fasciotomies of the involved areas. Decompression within 6 hours of established compartment pressures is necessary to prevent irreversible muscle ischemia. Forearm fasciotomies involve volar, carpal tunnel, and dorsal compartments. Hand fasciotomies include dorsal incisions for interossei and adductor pollicis, thenar, and hypothenar compartments, as well as midaxial incisions of the digits (ulnar for the index, long, and ring fingers and radial for the thumb and small finger).
Source:Washington Manual of surgery

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