Plastic, Reconstructive and Hand Surgery
Plastic, Reconstructive and Hand Surgery tests reconstructive decision-making - the ladder, graft versus flap, and hand emergencies with a hard time limit.
Grafts
- Split-thickness grafts (0.2-0.4 mm) survive on less vascular beds and are meshed for large areas; they contract more.
- Full-thickness grafts include dermis and are used on the face and hands, over joints and tendons; they contract less but need a well-vascularised bed.
- Graft take proceeds by plasmatic imbibition (0-48 hours), inosculation (48 hours) and revascularisation (days 4-7). Haematoma or shear is the commonest cause of failure.
- Grafts do not survive on bare bone, tendon or cartilage without periosteum or paratenon.
Flaps
A flap carries its own blood supply. Random pattern flaps rely on the subdermal plexus and should respect a length-to-breadth ratio of about 1:1; axial flaps have a named vessel (groin, radial forearm); free flaps need microvascular anastomosis. Local options include Z-plasty, which lengthens a contracture and redistributes tension, and V-Y advancement.
Burns reconstruction and scarring
Contractures are released and grafted or flapped once scars mature. Hypertrophic scars stay within the wound and respond to pressure, silicone and intralesional steroid; keloids extend beyond the original wound.
Hand
- Flexor tenosynovitis: Kanavel's four signs - fusiform swelling, finger held in slight flexion, tenderness along the sheath, pain on passive extension. Treatment is surgical sheath washout.
- Nerve injury: median - loss of thumb abduction and opposition; ulnar - claw hand with loss of adduction; radial - wrist drop.
- Compartment syndrome of hand or forearm: pain on passive stretch with a tense compartment means fasciotomy, not observation.
Worked example
A 30-year-old has a circular saw injury with a 4 cm palmar laceration, the finger held flexed, pain on passive extension and tenderness along the sheath. That is flexor sheath infection: IV antibiotics and urgent operative sheath irrigation through a mid-axial approach, not simple suture.
Traps
Placing a skin graft on bare tendon; missing a nail bed injury by not removing the nail; treating a hand infection with antibiotics alone.