Oral exam Case 1 Hand tumour A 73-year-old woman presents with a rapidly growing lesion on the dorsum of her right wrist
Objective 3: The candidate can develop a management plan Questions 3: Biopsy of these lesion shows it to be a Merkel cell carcinoma. The lesion feels relatively mobile and the remainder of the hand examination is normal. MRI shows no invasion of underlying structures. There is one palpable node in the axilla. How would you surgically manage this patient? • Excision of lesion with 2 cm margin • Sacrifice of involved important structures (tendon, nerve, vessel) as required • Additional deep margin • Sentinel lymph node biopsy/axillary node dissection • Await histopathologic confirmation of margins • Reconstruction of defect Question 4: The patient undergoes resection with two cm margins. There is now a 9 cm × 7 cm defect on the dorsum of the right wrist with exposed extensor digitorum communis and extensor pollicis longus. What are your options for coverage of this defect?
Objective 1: The candidate can formulate a differential diagnosis for a tumour of the hand Question 1: What is your differential diagnosis?
• Split thickness skin graft if paratenon intact • Reverse radial forearm flap • Groin flap • Free flap (contralateral RFFF, ALT) Additional Photo
Malignant: • SCC • BCC • Melanoma • Merkel cell carcinoma • Cutaneous metastasis Benign • Keratoacanthoma • Dermatofibroma • Kaposi’s sarcoma Objective 2: The candidate can appropriately examine a patient with a hand tumour Question 2: Describe your focused physical examination of this patient • Inspection of lesion – dimensions, appearance, borders, homogeneity, ulceration • Palpation of lesion – mobile/fixed, fluctuant/firm, painful, pulsatile • Sensation of the hand • Vascularity of the hand • Function of the hand (extensor lag, full flexion, wrist ROM, etc) • Adenopathy (epitrochlear, axillary) • Cutaneous lesions elsewhere on the body
Correspondence: Dr Kirsty U Boyd, Dr Daniel A Peters, University of Ottawa, Box 213, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9. E-mail [email protected] Plast Surg Vol 23 No 2 Summer 2015
©2015 Canadian Society of Plastic Surgeons. All rights reserved
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Case 2 Thumb amputation A 43-year-old right hand dominant mechanic amputated his right thumb just distal to the metacarpal-phalangeal joint with a wire 2 h previously
Objective 2: The candidate can manage complications in replantation Questions 3: The digit is successfully replanted with excellent arterial inflow. Due to a component of ring avulsion injury, the dorsal veins are friable. You are called by the nurses in the recovery room 1 hour after replantation with concerns about venous congestion. What are your options for management of this complication? • Removal of nail plate • Heparin soaks of nail bed • Leeches • Re-exploration in operating room • Removal of stiches potential compressing vein • Elevation of the extremity Question 4: The patient presents with the following complication (additional photo 2) and the decision is made to remove the replanted digit. Coverage of the exposed bone is obtained with a rotation flap from the dorsum of the thumb. What potential options are there to improve thumb function at a later date?
Objective 1: The candidate can formulate an approach to finger replantation Question 1: Describe your assessment of this patient as a candidate for replantation. • History • Mechanism of injury • Time since injury • Treatment at other institutions (including management of amputated part) • Comorbidities (smoking, diabetes, vascular disease)
• Toe-to-thumb transfer • Distraction and bone grafting of the remaining thumb metacarpal • Deepening of the first webspace • Removal of remnant thumb and pollicization of index • External prosthesis
Additional Photo 1
Physical examination: • Examination of amputated part for potential viable vessels • Examination of recipient hand Investigations: • X-ray of hand and amputated part Question 2: The amputated part is deemed to be potential replantable (see additional photo 1). Describe your operative approach • Main operating room, emergent case • Loupes/Operating microscope • Identification of structures in amputated part (artery, vein, nerves, tendons, bone) • Identification of structures in recipient hand (artery, vein, nerves, tendons, bone) • Achieve bony fixation with fluoroscopy • Repair tendons (flexor and extensor) • Reestablish arterial inflow • Anastamosis of nerves and veins
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Additional Photo 2
Plast Surg Vol 23 No 2 Summer 2015
Objective 3: The candidate can develop a management plan Questions 3: Biopsy of these lesion shows it to be a Merkel cell carcinoma. The lesion feels relatively mobile and the remainder of the hand examination is normal. MRI shows no invasion of underlying structures. There is one palpable node in the axilla. How would you surgically manage this patient? • Excision of lesion with 2 cm margin • Sacrifice of involved important structures (tendon, nerve, vessel) as required • Additional deep margin • Sentinel lymph node biopsy/axillary node dissection • Await histopathologic confirmation of margins • Reconstruction of defect Question 4: The patient undergoes resection with two cm margins. There is now a 9 cm × 7 cm defect on the dorsum of the right wrist with exposed extensor digitorum communis and extensor pollicis longus. What are your options for coverage of this defect?
Objective 1: The candidate can formulate a differential diagnosis for a tumour of the hand Question 1: What is your differential diagnosis?
• Split thickness skin graft if paratenon intact • Reverse radial forearm flap • Groin flap • Free flap (contralateral RFFF, ALT) Additional Photo
Malignant: • SCC • BCC • Melanoma • Merkel cell carcinoma • Cutaneous metastasis Benign • Keratoacanthoma • Dermatofibroma • Kaposi’s sarcoma Objective 2: The candidate can appropriately examine a patient with a hand tumour Question 2: Describe your focused physical examination of this patient • Inspection of lesion – dimensions, appearance, borders, homogeneity, ulceration • Palpation of lesion – mobile/fixed, fluctuant/firm, painful, pulsatile • Sensation of the hand • Vascularity of the hand • Function of the hand (extensor lag, full flexion, wrist ROM, etc) • Adenopathy (epitrochlear, axillary) • Cutaneous lesions elsewhere on the body
Correspondence: Dr Kirsty U Boyd, Dr Daniel A Peters, University of Ottawa, Box 213, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9. E-mail [email protected] Plast Surg Vol 23 No 2 Summer 2015
©2015 Canadian Society of Plastic Surgeons. All rights reserved
111
Boyd and Peters
Case 2 Thumb amputation A 43-year-old right hand dominant mechanic amputated his right thumb just distal to the metacarpal-phalangeal joint with a wire 2 h previously
Objective 2: The candidate can manage complications in replantation Questions 3: The digit is successfully replanted with excellent arterial inflow. Due to a component of ring avulsion injury, the dorsal veins are friable. You are called by the nurses in the recovery room 1 hour after replantation with concerns about venous congestion. What are your options for management of this complication? • Removal of nail plate • Heparin soaks of nail bed • Leeches • Re-exploration in operating room • Removal of stiches potential compressing vein • Elevation of the extremity Question 4: The patient presents with the following complication (additional photo 2) and the decision is made to remove the replanted digit. Coverage of the exposed bone is obtained with a rotation flap from the dorsum of the thumb. What potential options are there to improve thumb function at a later date?
Objective 1: The candidate can formulate an approach to finger replantation Question 1: Describe your assessment of this patient as a candidate for replantation. • History • Mechanism of injury • Time since injury • Treatment at other institutions (including management of amputated part) • Comorbidities (smoking, diabetes, vascular disease)
• Toe-to-thumb transfer • Distraction and bone grafting of the remaining thumb metacarpal • Deepening of the first webspace • Removal of remnant thumb and pollicization of index • External prosthesis
Additional Photo 1
Physical examination: • Examination of amputated part for potential viable vessels • Examination of recipient hand Investigations: • X-ray of hand and amputated part Question 2: The amputated part is deemed to be potential replantable (see additional photo 1). Describe your operative approach • Main operating room, emergent case • Loupes/Operating microscope • Identification of structures in amputated part (artery, vein, nerves, tendons, bone) • Identification of structures in recipient hand (artery, vein, nerves, tendons, bone) • Achieve bony fixation with fluoroscopy • Repair tendons (flexor and extensor) • Reestablish arterial inflow • Anastamosis of nerves and veins
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Additional Photo 2
Plast Surg Vol 23 No 2 Summer 2015
