Oral exam Case 1 Wrist injury A 26-year-old right hand dominant engineering student injured his dominant wrist while dirt biking
Objective 3: The candidate can develop a management plan Questions 3: With this additional view (Additional Photo 1) what is your initial management plan? • Pain relief • Attempt closed reduction under local anaesthesia (Tavernier’s manoeuvre) • Consider conscious sedation for closed reduction • Splinting/elevation • Book for OR (urgent if signs of acute carpal tunnel syndrome) Question 4: You are unable to reduce the injury via closed reduction. You elect to take this patient to the operating room. Please describe your surgical approach to address this injury. • Open reduction, internal fixation • Main operating room – General anaesthesia • Tourniquet control, loupe magnification, fluoroscopy • Volar and dorsal approaches • Volar: extended open carpal tunnel release, visualize rent in volar wrist capsule (space of Poirier), repair capsule, repair wrist ligaments • Dorsal: midline longitudinal, incise extensor retinaculum, retract tendons, ligament-sparing capsulotomy, reduce perilunate dislocation (joystick), K-wires across scapholunate interval ×2, across lunotriquetral interval ×2
Objective 1: The candidate can formulate a provisional diagnosis for an acute wrist injury Question 1: What is your provisional diagnosis? • Perilunate dislocation Objective 2: The candidate can describe a focused physical examination Question 2: Describe your focused physical examination of this patient’s wrist. • Comparison to contralateral hand • Inspection – obvious deformity, assess for open fracture, bruising, swelling • Assessment of vasculature, nerve function (motor and sensory) • Function – wrist ROM (flexion, extension, pronation, supination), finger and thumb ROM
Additional Photo 1
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 3 Autumn 2015
©2015 Canadian Society of Plastic Surgeons. All rights reserved
203
Boyd and Peters
Case 2 Delayed breast reconstruction A 40-year-old woman presents to discuss breast reconstruction. Three years ago, she underwent neoadjuvant chemotherapy, left mastectomy, and sentinel lymph node biopsy and radiation
Objective 3: The candidate can describe a management plan. Question 3: The patient decides to proceed with a free autologous DIEP flap and a contralateral prophylactic mastectomy and tissue expander reconstruction. Please describe your preoperative markings for this patient. Breast • Contralateral breast as a footprint • Breast borders (inframammary fold, superior pole, medial and lateral) • Planned incision for prophylactic (horizontal ellipse) Abdomen • Lower abdominal ellipse extending from supraumbilical to ASIS bilaterally • Inferior mark is based on ability to close abdomen • Midline Objective 4: The candidate can manage a perioperative complication. Question 4: Unbeknownst to you, your patient leaves the floor on postoperative day 1 and smokes crack cocaine, cigarettes and has a coffee. You are called the following morning with concerns about her wounds. How would you manage these complications (additional photo 1) • Investigation (physical examination, imaging, blood tests) • Patient counseling • Avoidance of further cocaine, nicotine, caffeine • Supportive management (fluids, antibiotics, dressing changes) • Delayed management as required once wounds declare themselves
Objective 1: The candidate is familiar with the options for delayed breast reconstruction Question 1: What options are available for reconstruction of this breast? Autogenous: • Pedicled TRAM • Free flap (TRAM, muscle-sparing TRAM, DIEP, SIEA, TUG, SGAP, IGAP) Combined alloplastic and autogenous • Latissimus dorsi plus tissue expander/implant Alloplastic (depending on quality of radiated skin envelope) • Tissue expander • Dual saline/silicone implant Objective 2: The candidate can obtain a focused history for delayed breast reconstruction. Question 2: What questions would you ask this patient when obtaining a medical history? Patient factors: • Comorbidities • Allergies, medications, illicit drug use, smoking history • Height, weight, body mass index • Previous surgeries (potential donor sites) • Goals and expectations Cancer factors • Previous surgery and adjuvant therapies (including timing, complications) • Ongoing treatments • Surveillance • Family history
204
Additional Photo 1
Plast Surg Vol 23 No 3 Autumn 2015
Objective 3: The candidate can develop a management plan Questions 3: With this additional view (Additional Photo 1) what is your initial management plan? • Pain relief • Attempt closed reduction under local anaesthesia (Tavernier’s manoeuvre) • Consider conscious sedation for closed reduction • Splinting/elevation • Book for OR (urgent if signs of acute carpal tunnel syndrome) Question 4: You are unable to reduce the injury via closed reduction. You elect to take this patient to the operating room. Please describe your surgical approach to address this injury. • Open reduction, internal fixation • Main operating room – General anaesthesia • Tourniquet control, loupe magnification, fluoroscopy • Volar and dorsal approaches • Volar: extended open carpal tunnel release, visualize rent in volar wrist capsule (space of Poirier), repair capsule, repair wrist ligaments • Dorsal: midline longitudinal, incise extensor retinaculum, retract tendons, ligament-sparing capsulotomy, reduce perilunate dislocation (joystick), K-wires across scapholunate interval ×2, across lunotriquetral interval ×2
Objective 1: The candidate can formulate a provisional diagnosis for an acute wrist injury Question 1: What is your provisional diagnosis? • Perilunate dislocation Objective 2: The candidate can describe a focused physical examination Question 2: Describe your focused physical examination of this patient’s wrist. • Comparison to contralateral hand • Inspection – obvious deformity, assess for open fracture, bruising, swelling • Assessment of vasculature, nerve function (motor and sensory) • Function – wrist ROM (flexion, extension, pronation, supination), finger and thumb ROM
Additional Photo 1
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 3 Autumn 2015
©2015 Canadian Society of Plastic Surgeons. All rights reserved
203
Boyd and Peters
Case 2 Delayed breast reconstruction A 40-year-old woman presents to discuss breast reconstruction. Three years ago, she underwent neoadjuvant chemotherapy, left mastectomy, and sentinel lymph node biopsy and radiation
Objective 3: The candidate can describe a management plan. Question 3: The patient decides to proceed with a free autologous DIEP flap and a contralateral prophylactic mastectomy and tissue expander reconstruction. Please describe your preoperative markings for this patient. Breast • Contralateral breast as a footprint • Breast borders (inframammary fold, superior pole, medial and lateral) • Planned incision for prophylactic (horizontal ellipse) Abdomen • Lower abdominal ellipse extending from supraumbilical to ASIS bilaterally • Inferior mark is based on ability to close abdomen • Midline Objective 4: The candidate can manage a perioperative complication. Question 4: Unbeknownst to you, your patient leaves the floor on postoperative day 1 and smokes crack cocaine, cigarettes and has a coffee. You are called the following morning with concerns about her wounds. How would you manage these complications (additional photo 1) • Investigation (physical examination, imaging, blood tests) • Patient counseling • Avoidance of further cocaine, nicotine, caffeine • Supportive management (fluids, antibiotics, dressing changes) • Delayed management as required once wounds declare themselves
Objective 1: The candidate is familiar with the options for delayed breast reconstruction Question 1: What options are available for reconstruction of this breast? Autogenous: • Pedicled TRAM • Free flap (TRAM, muscle-sparing TRAM, DIEP, SIEA, TUG, SGAP, IGAP) Combined alloplastic and autogenous • Latissimus dorsi plus tissue expander/implant Alloplastic (depending on quality of radiated skin envelope) • Tissue expander • Dual saline/silicone implant Objective 2: The candidate can obtain a focused history for delayed breast reconstruction. Question 2: What questions would you ask this patient when obtaining a medical history? Patient factors: • Comorbidities • Allergies, medications, illicit drug use, smoking history • Height, weight, body mass index • Previous surgeries (potential donor sites) • Goals and expectations Cancer factors • Previous surgery and adjuvant therapies (including timing, complications) • Ongoing treatments • Surveillance • Family history
204
Additional Photo 1
Plast Surg Vol 23 No 3 Autumn 2015
