Complete Information Synthesized (Summary Part III)

Hand Injuries and Conditions

Hand injuries and conditions—from injuries to carpal tunnel syndrome to rheumatoid arthritis—can be mildly irritating or severely debilitating. Whether mild or severe, they often inhibit a person’s ability to live his or her life fully. In some cases, a person may not be able to work, play with children or grandchildren, enjoy recreational activities, or get dressed or do other types of daily living activities.

When the injury or condition becomes severe, surgery may be the solution that can best restore function to the affected area and alleviate pain. A hand surgeon operates on the hand and the lower arm up to the elbow. Many conditions and injuries may call for hand surgery, including:

• Abnormally shaped fingers or hands
• Amputations
• Arthritis
• Carpal tunnel syndrome
• Ganglion cysts
• DeQuervain’s disease
• Dupuytren’s contracture
• Flexor tendon injuries
• Fractures
• Lacerations
• Mallet finger
• Missing fingers, thumb
• Nailbed injuries
• Polydactyly (extra fingers)
• Reflex sympathetic dystrophy
• Syndactyly (webbed fingers)
• Tendonitis
• Trigger finger
• Ulnar nerve compression
• Vascular disorders

Most Common Hand Conditions

Carpal Tunnel Syndrome

The most common condition requiring surgical intervention is carpal tunnel syndrome, which is caused by pressure on the median nerve in the wrist. Symptoms may include tingling, pain, numbness, or weakness in the thumb through ring fingers of the affected hand. Nerve compression can be caused by a number of things, including repetitive motions, injury, cysts, and tumors. For many patients, there may not be an identifiable source of the nerve compression. To relieve the symptoms of carpal tunnel syndrome or other nerve compression conditions through surgery, the reconstructive surgeon makes an incision in the elbow or wrist and relieves the compression, either by giving the nerve more room, removing a cyst or tumor, or moving the nerve. Read more about carpal tunnel syndrome in Johns Hopkins Health, our community newsletter about the latest advances in medicine.

Arthritis

When the normally smooth surfaces of a joint become irregular and don’t glide well anymore, the joint wears out, resulting in arthritis—or painful joints. Several kinds of surgery can relieve the inflammation and pain caused by arthritis and, in some cases, can also restore mobility.

With joint fusion surgery, the reconstructive surgeon will remove the arthritic surface and fuse the bones on each side of the joint together. While this type of surgery keeps the joint from moving, it does relieve pain and correct deformities that may interfere with daily living activities. Read more about joint reconstruction surgery in Cutting Edge, a Department of Surgery publication. 

Joint reconstruction surgery replaces the arthritic surface with soft tissue, like a tendon, or a joint replacement implant. This surgery can relieve the pain of arthritis while preserving mobility of the joint. The reconstructive surgeon consults with the patient and other doctors to determine what type of surgery would be the best solution for the patient’s needs.

Complete Information Synthesized (Summary Part II)

Body Injuries and Conditions

Brachial plexus injuries

The brachial plexus is a network of nerves that sends signals from the spinal cord to the shoulder, arm and hand. When those nerves are damaged, it is considered a brachial plexus injury. Injury can occur during birth, from tumors putting pressure on nerves, trauma (such as an accident), or inflammation. If you have a brachial plexus injury, you may experience pain or numbness, an inability to move your arm or hand, or a feeling of limpness.

Obstetric brachial plexus injury: In infants, brachial plexus injury most often occurs during an abnormal or difficult birth, causing damage to the brachial plexus nerves (shoulder dystosia). You can find out more about brachial plexus injuries on our Pediatric Injuries and Conditions page. 

Lymphedema

Lymphedema is caused by the buildup of lymph fluid, which causes nearby body parts, such as the arm or leg, to swell. This condition most often occurs due to injury, when lymph nodes are removed or become scarred, or if there is trauma to the lymphatic system. For example, some women who have undergone treatment for breast cancer develop lymphedema after the treatment.

While older surgical techniques have not successfully cured lymphedema, Johns Hopkins reconstructive surgeons have experience in new techniques that show promise in effectively treating it. In vascularized lymph node transfer, or lymphovenous bypass, the reconstructive surgeon moves lymph nodes from the groin area to the armpit and reconnects them to blood vessels. The new lymph nodes remove the excess fluid returning it to the lymphatic system. In lymphaticovenous anastomosis, the reconstructive surgeon uses microsurgery to join lymphatic channels in the affected area to nearby veins.

This surgical treatment of lymphedema is not a cure-all, according to plastic and reconstructive surgeon Justin Sacks, but it has a low risk of complications and may alleviate discomfort for some.

Peripheral nerves are those located outside of your brain and spinal cord. When there is something wrong with peripheral nerves in some part of the body, it interrupts the signals between the spinal cord and brain and that part of the body. There are more than 100 kinds of peripheral nerve disorders.

One of the most common and well-known peripheral nerve disorders is carpal tunnel syndrome, which is caused by nerve compression on the median nerve in the wrist and often occurs in people who do repetitive motions involving their wrists and hands. If you have carpal tunnel syndrome, your symptoms may include pain, weakness, numbness, or tingling in your hand or wrist, or up your arm. Other types of peripheral nerve injuries may stem from illnesses like viral infections and diabetes. In other cases, people are born with peripheral nerve disorders.

The decision to repair a peripheral nerve disorder through surgery is one that may be quite complex, depending on the type of problem, the severity of the pain, the severity of neurological symptoms associated with the problem, and how well other kinds of treatment have worked.

Complete Information Synthesized (Summary)

Maxillofacial injuries are commonly encountered in the practice of emergency medicine. More than 50% of patients with these injuries have multisystem trauma that requires coordinated management between emergency physicians and surgical specialists in oral and maxillofacial surgery, otolaryngology, plastic surgery, ophthalmology, and trauma surgery.

Trauma to the maxillofacial anatomy mandates special attention. Contained within the face are systems that control specialized functions including seeing, hearing, smelling, breathing, eating, and talking. Also, the vital structures in the head and neck region are intimately associated. Lastly, the psychological impact of disfigurement can be devastating.

The maxillofacial region is divided into 3 parts.

• The upper face: Here, fractures involve the frontal bone and frontal sinus.
• The midface: The midface is divided into upper and lower parts. The upper midface is made up by the zygoma, nasal bones, ethmoid bone, and non-tooth–bearing segment of the maxillary bone. This is where maxillary LeFort II and LeFort III fractures occur and/or where fractures of the nasal bones, nasoethmoidal complex (NOE) or zygomaticomaxillary complex (ZMC), and the orbital floor occur. The lower midface is composed of the maxillary alveolus, teeth, and the palate and is where LeFort I fractures occur.
• The lower face: This is composed of the mandible, where fractures can occur

More than 3 million facial injuries occur in the United States each year. Most are secondary to assaults and motor vehicle accidents. Information about the causes of facial fractures depends on the country and location of the trauma center; therefore, reported statistics vary widely.

Etiology of MI

Facial trauma in an urban setting is most often caused by assaults, followed by motor vehicle and industrial accidents.

The nasal bones, mandible, and the zygoma are the most commonly fractured bones during assaults. Facial trauma in the community setting is most often due to motor vehicle accidents, followed by assaults and recreational activities. Motor vehicle accidents produce fractures that often involve the midface, especially in patients who were not wearing their seatbelts. Other important causes of facial trauma include penetrating trauma (knife and gunshot wounds), domestic violence, and the abuse of children and elderly persons.

Pathophysiology 

The kinetic energy present in a moving object is a function of the mass multiplied by the square of its velocity. The dispersion of this kinetic energy during deceleration produces the force that results in injury. High-impact and low-impact forces are defined as greater or lesser than 50 times the force of gravity. These parameters impact on the resultant injury because the amount of force required to cause damage to facial bones differs regionally. The supraorbital rim, the maxilla and the mandible (symphysis and angle), and frontal bones require a high-impact force to be damaged. A low-impact force is all that is required to damage the zygoma and nasal bone.

• Frontal bone fractures: These result from a severe blow to the forehead. The anterior and/or posterior table of the frontal sinus may be involved. Assume a dural tear is present if the posterior wall of the frontal sinus is fractured. The nasofrontal duct often is disrupted.
• Orbital floor fractures: Injury to the orbital floor can result in an isolated fracture or can be accompanied by a medial wall fracture. When a force strikes the globe or orbital rim, the intraorbital pressure increases with transmission of this force and damages the weakest aspects of the orbit, the floor and medial wall. Herniation of the orbital contents into the maxillary sinus is possible. The incidence of ocular injury is high, but globe rupture is rare.
• Nasal fractures: These are the result of the forces transmitted during direct trauma.
• Nasoethmoidal fractures (NOE): These extend from the nose to the ethmoid bones and can result in damage to the medial canthus, lacrimal apparatus, or nasofrontal duct. They also can result in a dural tear at the cribriform plate.
• Zygomatic arch fractures: A direct blow to the zygomatic arch can result in an isolated fracture involving the zygomaticotemporal suture.
• Zygomaticomaxillary complex fractures (ZMC): These fractures result from direct trauma. Fracture lines extend through zygomaticotemporal, zygomaticofrontal, and zygomaticomaxillary sutures and the articulation with the greater wing of the sphenoid bone. The fracture lines usually extend through the infraorbital foramen and orbital floor. Concurrent ocular injuries are common.
• Maxillary fractures: These are classified as Le Fort I, II, or III
  

  • LeFort I fracture is a horizontal maxillary fracture across the inferior aspect of the maxilla and separates the alveolar process containing the maxillary teeth and hard palate from the rest of the maxilla. The fracture extends through the lower third of the septum and includes the medial and lateral maxillary sinus walls extending into the palatine bones and pterygoid plates.
  • LeFort II fracture is a pyramidal fracture starting at the nasal bone and extending through the ethmoid and lacrimal bones; downward through the zygomaticomaxillary suture; continuing posteriorly and laterally through the maxilla, below the zygoma; and into the pterygoid plates.
  • LeFort III fracture or craniofacial dysjunction is a separation of all of the facial bones from the cranial base with simultaneous fracture of the zygoma, maxilla, and nasal bones. The fracture line extends posterolaterally through ethmoid bones, orbits, and pterygomaxillary suture into the sphenopalatine fossa. See the image below.
    
• Mandibular fractures: These can occur in multiple locations secondary to the U-shape of the jaw and the weak condylar neck. Fractures often occur bilaterally at sites apart from the site of direct trauma.
• Alveolar fractures: These can occur in isolation from a direct low-energy force or can result from extension of the fracture line through the alveolar portion of the maxilla or mandible.
• Panfacial fractures: These usually are secondary to a high-energy mechanism resulting in injury to the upper face, midface, and lower face. These fractures must be composed of at least 3 of the possible 4 facial units in order to be labeled panfacial. See the image below.
  

Extraoral Defects

Restoration of facial defects can be accomplished either surgically, prosthetically, or by using a combination of both methods. The choice of method depends on many factors like size and location of the defect as well as the age of the patient. Surgical reconstruction is indicated when the defect is small, involves mobile structures like eyelids or lips, or it occupies the are of the cranial vault.  

The prosthetic approach is superior to the surgical approach if the defect is larger in size or if the blood supply to the area is compromised for example a nasal septal defect. "Color match" and "patient acceptance", especially in nasal or auricular prostheses, make prosthetic rehabilitation more advantageous to the surgical approach, especially if the defect is large like mentioned before. 

It is important to use prosthetic materials with certain properties in order to achieve the best clinical success and patient acceptance. These properties include color stability, ease of fabrication, dimensional stability, and edge strength. Flexibility, low thermal conductivity, biocompatibility, and surface texture are also important. Silicones are the most widely used of materials for facial restorations here in the United States. The type most commonly used, RTV Silicone, has surface texture and hardness within the range of human skin. 

Methods for attaching and holding facial prostheses must be as invisible and discrete as possible to make them more aesthetically pleasing. Using tissue undercuts or attaching the prosthesis to the patient's eyeglasses or dentures can help mechanically retain the device. Medical-grade adhesives or tapes are also under study for this purpose (like shown below); the downside to this is that they collect dirt and are unhygienic.

(An artificial nose is attached with medical-grade adhesive.)

Mandibular Defects

• Class I - Radical alveolectomy with preservation of mandibular continuity
• Class II - Lateral resection of the mandible distal to the cuspid area
• Class III - Lateral resection of the mandible to the midline
• Class IV - Lateral bone graft and surgical reconstruction
• Class V - Anterior bone graft and surgical reconstruction
• Class VI - Anterior mandibular resection without surgical reconstruction

Surgical reconstruction using a bone graft is the best approach that a surgeon can take to correct defects of the mandible. The bone graft restores continuity to the mandible and provides a prosthesis-bearing area. However, surgical reconstruction may be contraindicated in patients receiving radiation therapy or in individuals with residual tumors.

If mandibular resection involves the lower border of the mandible, the remaining segments deviate toward the defect side, backward, and upward. Using intermaxillary fixation for 5-7 weeks following the resection can reduce the deviation. The placement of a resection guidance appliance can also help minimize the deviation. These appliances are temporary and are removed once acceptable occlusal relationship and proper proprioception are attained.

Tongue Defects

Tongue (glossal) defects can be partial or total. Factors influencing prosthetic prognosis of restoring the tongue include the presence or absence of teeth and the type of procedure that is combined with the glossectomy (eg, mandibulectomy, palatectomy, radiation therapy). Patients with partial glossectomy (ie, < 50% of tongue removed) suffer minimal functional impairment and require no prosthetic intervention. Removal of more than 50% of the tongue requires construction of a palatal or lingual augmentation prosthesis.

Maxillofacial Prosthodontist

Today the class period was dedicated to research on Maxollofacial Prosthethics below are my findings. 

Maxillofacial Prosthetics is a subspecialty of Prosthodontics that involves rehabilitation of patients with defects or disabilities that were present when born or developed due to disease or trauma. Prostheses are often needed to replace missing areas of bone or tissue and restore oral functions such as swallowing, speech, and chewing.Prosthetic devices may also be created to position or shield facial structures during radiation therapy.

The Typed of Prostheses are as follows:

Extraoral Prostheses:

Ocular Prosthesis
Replaces Eye


Orbital Prosthesis
Replaces Eye and surrounding tissues


Auricular Prosthesis
Replace Ear


Nasal Prosthesis
Replaces Nose


Midfacial Prosthesis
Replaces part of the face which may involve more thanone structure


Somatic Prosthesis
Replaces a body part like fingers, hands, etc


Radiation Shield
Worn during radiation therapy for protection of normal tissues

Intraoral Prostheses:


Surgical Obturator Prosthesis
Covers palate after partial or total loss of the maxilla (upper jaw). This is used after surgery to provide closure


Interim and Definitive Obturator
Covers palate after partial or total loss of maxilla or due to cleft palate. It restores teeth and gums and has an extension which closes the defect or hole for swallowing, eating, chewing, and speaking. 


Palatal Lift Prosthesis
Helps soft palate assume correct position for speech


Palatal Augmentation (Drop) Prosthesis
Alters palate prosthetically for speech


Mandibular Resection Prosthesis
Replaces portion of the jaw that has been lost and restores gums and teeth

Fluoride Carrier
Tray filled with Fluoride gel for patients with dry mouth from medications, radiation therapy, or certain medical conditions. Helps to strengthen, protect and preserve compromised teeth

March 3 2015

This class period was dedicated to obtaining my judges for my presentation which is coming up. I was able to send out emails to the following doctors: Dr. Shai Rozen, Dr. Samuel Barnett, Aya Hamao-Sakamoto (D.D.S., Ph.D.) and Dr. Joseph Leach. I hopefully hear back from at least two so I can secure my judges in time. These doctors are all part of the UT Southwestern Staff and I was able to view their profiles at the UT Southwestern website and get in contact with them. They all specialize in either facial reconstruction, maxillofacial injuries, and trauma. With their specialized education and skills their participation as judges will be a great enhancement to my overall presentation. I did not have much time to research since I spent the majority of my time just filling out the judge request forms and crafting emails as well as a short amount of my time speaking to my high school counselor in regards to some financial aid issues I was having. What I did read however I found very interesting; will provide the link at the bottom of this post as well as a summary of the key highlights: 

The topic I looked at today was Orbital Floor Fractures: 

Blowout fractures of the orbital floor require consultation with an ophthalmologist and maxillofacial trauma specialist (oral and maxillofacial surgeon, otolaryngologist or plastic surgeon).

Blowout fractures of the orbital floor require consultation with an ophthalmologist and maxillofacial trauma specialist (eg, oral and maxillofacial surgeon, otolaryngologist, plastic surgeon). Several approaches are available including subciliary, subtarsal, transconjunctival, and transconjunctival with lateral canthotomy. The subciliary approach has the most complications (eg, ectropion) and the transconjunctival approach the least complications.

However, when major surgical exposure is necessary, a transconjunctival approach with or without a lateral canthotomy incision is recommended.