Practical Plastic Surgery for Nonsurgeons

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$finger fractures and dislocations - Practical Plastic Surgery$

34 Practical Plastic Surgery for Nonsurgeons Nerve Blocks In some areas of the body, discrete nerves that are responsible for sensation to the injured area are easy to locate. In these instances, local anesthesia can be infiltrated around (not into) the sensory nerve for pain control to the area around the wound. This approach is advantageous because the patient needs to undergo fewer injections than if you anesthetize the entire wound margins directly. Nerve blocks are also a good choice when the wound is deep, because they often give a more complete block of the entire area, not just the skin. This approach is especially appropriate for larger wounds, because it usually requires less anesthetic agent than direct infiltration. Whenever possible, use a relatively small needle (23- or 25-gauge) for the injection. Always draw back on the syringe before injecting the anesthetic. The nerves that you are blocking often are located near blood vessels. Caution: You are probably injecting the anesthetic directly into the nerve if the patient complains of strong electric shocks or severe pain radiating along the distribution of the nerve. Stop the injection immediately and reposition the needle. It usually takes a few minutes longer for the anesthetic to take effect than with direct wound injection. Often you must wait 10–15 minutes after giving a nerve block before proceeding with the procedure. NNeerrvvee BBlloocckkss ffoorr HHaanndd IInnjjuurriieess Lidocaine, bupivacaine, or a combination of the two solutions can be used. Add bicarbonate if it is available. Epinephrine should not be used for anesthetizing the hand and fingers. Digital Block A digital block is the best way to evaluate and treat a wound on the finger. The digital nerves supply sensation to the volar and dorsal surfaces of the finger. Anatomy. Each finger and the thumb have two digital nerves that travel with the digital vessels along the lateral and medial sides of the digit. Look at your own finger from the side, bend it at the two joints (distal interphalangeal [DIP] and proximal interphalangeal [PIP] joints). The line that connects the joint creases is a good estimate of where each digital nerve runs.
Local Anesthesia 35 Digital nerve block, dorsal approach. Care must be taken to ensure that the anesthetic is not injected entirely circumferentially around the finger. (Illustration by Elizabeth Roselius. From Green DP, et al: Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, with permission.) Procedure 1. The injection is done from the dorsal (not volar) surface near the metacarpophalangeal (MCP) knuckle. 2. Insert the needle into the web space, when present (the thumb and little finger are not bordered on both sides by web spaces). 3. Aim the needle toward the MCP joint of the affected finger, moving in a volar direction. 4. Be careful not to inject too superficially on the volar side, or your injection will miss the area around the nerve. 5. Inject 2–3 ml of solution into each side of the affected finger. 6. Infiltrate 1–2 ml along the dorsal skin of the digit, just distal to the MCP knuckle.
Page 1 and 2: Practical Plastic Surgery for Nonsu
Page 3 and 4: Dedication To Chris and Jenny McCon
Page 5 and 6: Table of Contents Chapter 1 Suturin
Page 7: Contents vii Chapter 33 Nerve and V
Page 10 and 11: Chapter 1 SUTURING: THE BASICS KEY
Page 12 and 13: SSuuttuurree MMaatteerriiaall Sutur
Page 14 and 15: Instruments Needed Suturing: The Ba
Page 16 and 17: Placing the Sutures Suturing: The B
Page 18 and 19: Interrupted or Continuous Closure A
Page 20 and 21: The vertical mattress suture. Sutur
Page 22 and 23: Figure-of-eight suture. This techni
Page 24 and 25: Suturing: The Basics 15 8. Bring th
Page 26 and 27: Suturing: The Basics 17 Close the s
Page 28 and 29: Suturing: The Basics 19 A, Closing
Page 30 and 31: Chapter 2 BASIC SURGICAL TECHNIQUES
Page 32 and 33: Basic Surgical Techniques 23 Make t
Page 34 and 35: Regular Tie Basic Surgical Techniqu
Page 36 and 37: Basic Surgical Techniques 27 that a
Page 38 and 39: 30 Practical Plastic Surgery for No
Page 74 and 75: Chapter 7 GUNSHOT WOUNDS KEY FIGURE
Page 76 and 77: Gunshot Wounds 69 Feel for the dist
Page 78 and 79: Gunshot Wounds 71 loosely closed to
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86 Practical Plastic Surgery for No
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88 Practical Plastic Surgery for No
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Chapter 11 PRIMARY WOUND CLOSURE KE
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HHooww ttoo SSuuttuurree tthhee WWo
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Primary Wound Closure 95 If the wou
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Chapter 12 SKIN GRAFTS KEY FIGURES:
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Skin Grafts 99 alive for, at most,
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Procedure for Taking the Graft Skin
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Skin Grafts 103 blade edge. You may
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Skin Grafts 105 3. Scraping the wou
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Indications Skin Grafts 107 FTSGs a
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Skin Grafts 109 4. Keep the dressin
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112 Practical Plastic Surgery for N
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Chapter 15 SCAR FORMATION KEY FIGUR
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MMeetthhoodd ooff WWoouunndd CClloo
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Scar Formation 141 How to use the s
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Scar Formation 143 area may become
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Chapter 16 FACIAL LACERATIONS KEY F
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Facial Lacerations 147 Bupivacaine
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Suture Removal Facial Lacerations 1
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Facial Lacerations 151 1. It often
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Skin Facial Lacerations 153 • It
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Full-thickness Forehead Lacerations
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Anterior Side of the Ear Facial Lac
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BBiibblliiooggrraapphhyy Facial Lac
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Chapter 19 SOFT TISSUE INFECTIONS S
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Soft Tissue Infections 185 Cuts fro
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Soft Tissue Infections 187 1. Remin
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Soft Tissue Infections 189 Temporiz
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Chapter 22 SKIN CANCER KEY FIGURES:
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Skin Cancer 223 Most melanomas aris
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Skin Cancer 225 History of sun expo
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How to Do the Biopsy Skin Cancer 22
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Skin Cancer 229 approach is especia
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Skin Cancer 231 Performing a shave
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Re-excision for Melanoma Skin Cance
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Chapter 23 CLEFT LIP/PALATE KEY FIG
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PPrreesseennttaattiioonn aanndd IIn
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Helpful Strategies Cleft Lip/Palate
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Optimally, a pediatric dentist or o
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Cleft Lip/Palate 243 palate forms t
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246 Basic Surgical Procedures for t
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Chapter 28 HAND SPLINTING AND GENER
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Hand Splinting and General Aftercar
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Splinting the hand with an extensor
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Hand Splinting and General Aftercar
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Chapter 29 FINGERTIP AND NAIL BED I
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Treatment Fingertip and Nail Bed In
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Subungual Hematoma Fingertip and Na
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Fingertip and Nail Bed Injuries 289
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Nail bed lacerations are often mult
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Chapter 31 TRAUMATIC HAND AND FINGE
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Traumatic Hand and Finger Amputatio
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Chapter 32 TENDON INJURIES OF THE H
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Repair of the Extensor Tendon Tendo
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Tendon Injuries of the Hand 311 Spl
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Chapter 33 NERVE AND VASCULAR INJUR
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Nerve and Vascular Injuries of the
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Chapter 37 SPECIFIC TYPES OF HAND I
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Specific Types of Hand Infections 3
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Chapter 38 CHRONIC HAND CONDITIONS
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Chronic Hand Conditions 357 On phys
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Chronic Hand Conditions 359 of the
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Chronic Hand Conditions 361 The car
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Chronic Hand Conditions 363 Also, u
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Chronic Hand Conditions 365 gentle
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Chapter 39 EXPLORATION OF AN INJURE
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Exploration of an Injured Hand or F
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Proper placement of incisions is im
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Dorsal Surface Exploration of an In
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Index Page numbers in boldface type
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Burns (cont.) subsequent care for,
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Dressings (cont.) wet-to-wet, 83 an
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Fractures (cont.) of fingers, 63, 2
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Instruments sharp disposal of, 47 s
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Nutritional support, for burn patie
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Shotgun injuries, 71 Silicone breas
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Tendon injuries (cont.) traumatic a
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