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Microsurgery Dr. Çağatay Uluçay Yeditepe Üniversitesi Tıp Fakültesi Ortopedi ve Travmatoloji AD Gentle & Powerful – Sensitive & Skillful Normal hand position Position of rest Hand – Edema(Swelling) Elevation? Position of immobilisation Hand functional positions Hand incisions Hand incisions Normal alignment and rotational deformity Mallet deformity Flexor tendon injury Zones for tendon repair Flexor Tendon Anatomy Methods of tendon repair Open fractures - classification Type I tidy wound < 1cm Type II tidy wound 1-2 cm Type IIIA >2cm; soiled Type IIIB IIIA + periosteal stripping Type IIIC neurovascular damage Severe hand injury survey Blood supply Stable skeleton Viable skin cover Basic function Occupation Serious hand trauma -after debridement Longitudinal/ extensile exposures Compartment decompression Skeletal alignment/ fixation Musculo-tendon repair Vessel repair/ graft Nerve repair Replantation - indications All amputations at the level of the arm, forearm, carpus and metacarpus All amputations of thumb prox to mid distal phalanx In multiple digits replant as many as possible Most digits amputated distal to prox phalanx Children Think about avulsed digits and crushed distal parts Hand Replantation 7 months off work 50% get only protective sensation 50% range of movement 60% need > 2 operations Medical cost 5-15 times amputation Nerve Repair Partial nerve Full nerve Regrow at 1mm per day Splintage rehabilitation Gracillis free flap Thoracodorsal artery perforator flap Radial forearm free flap Hand Infection Bacterial Viral Fungal Protozoal 64% grow multiple organisms Hand Infection: anatomical compartments Nail fold (paronychia) Pulp space Tendon sheath Web space Deep palmar space Septic arthritis Infection: history Time lapse cellulitis tendon sheath web space deep palm paronychia pulp space septic arthritis 24 hours 48 hours days 4-5 days <2 weeks Web space infection Deep palmar infection Infection: tendon sheath Finger in slight flexion Uniformly red and swollen Intense pain on attempted extension Tenderness along line of sheath Drainage of tendon sheath Drainage of mid-palmar space Infection: septic arthritis Usually secondary to human bite Swelling out of proportion to inflammation Restricted motion Instability Discharging sinus X-ray changes Paronychia Pulp space infection Herpetic whitlow Hand trauma and IV Drug Abuse