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]
case 1Wrist 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
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
boyd and Peters
Plast Surg Vol 23 No 3 Autumn 2015204
case 2delayed 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 recon-struction. 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/implantAlloplastic (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 expectationsCancer factors• Previous surgery and adjuvant therapies (including timing,
complications)• Ongoing treatments• Surveillance• Family history
