37.4 Specialty III: Plastic and Reconstructive Surgery (Skin Grafts and Flaps, Cleft Lip and Palate, Facial Fractures, Hand Injuries), Orthopedics (Fractures, Dislocations, Bone and Joint Infections, Bone Tumors) and Pediatric Surgery (Hernias, CDH, Esophageal Atresia, Obstruction, Hirschsprung Disease, Neonatal Jaundice, Tumors)

Why this area matters

Road crashes and falls make fractures and facial injuries common in Filipino emergency rooms. Cleft lip and palate are among the most common birth defects. Biliary atresia and Hirschsprung disease must be recognized early because the timing of surgery decides the outcome. The TOS tests recognition, first aid and the operation of choice.

Plastic and reconstructive surgery

• The reconstructive ladder:
  • healing by secondary intention;
  • primary closure;
  • skin grafts;
  • local flaps;
  • distant flaps;
  • free tissue transfer (microvascular flaps).
• Skin grafts:
  • split-thickness grafts (epidermis and part of the dermis): cover large areas and take more easily, but contract more and look worse;
  • full-thickness grafts: better color and less contraction, used for the face and hands, but from limited donor sites;
  • graft take needs a vascular bed (grafts fail on bare bone, tendon without paratenon or cartilage), immobilization and no infection, hematoma or seroma.
• Flaps carry their own blood supply and are used over exposed bone, tendon, implants or vessels.
• Cleft lip and palate:
  • multifactorial, with links to maternal smoking, anticonvulsants and folate deficiency;
  • early problems are feeding (special bottles) and ear disease;
  • lip repair at about 3 months (the "rule of 10s": 10 weeks, 10 pounds, hemoglobin 10 g/dL) and palate repair at about 9 to 18 months, before speech develops;
  • managed by a team (speech, dental, ENT, orthodontics).
• Facial trauma:
  • secure the airway (risk from bleeding and mandible fractures) and check the cervical spine;
  • Le Fort fractures: I (horizontal, maxilla above the teeth), II (pyramidal, through the nasal bridge), III (craniofacial dissociation);
  • orbital floor (blow-out) fracture: diplopia on upward gaze from inferior rectus entrapment, infraorbital numbness and enophthalmos;
  • zygomatic fractures: flattened cheek and trismus;
  • mandible fractures: malocclusion, often bilateral;
  • septal hematoma must be drained to prevent septal necrosis (saddle nose).
• Hand injuries:
  • test tendon and nerve function before anesthesia;
  • flexor tendon injuries need early surgical repair;
  • "fight bite" wounds over the knuckles need exploration, washout and antibiotics (amoxicillin-clavulanate);
  • flexor tenosynovitis (Kanavel signs) needs urgent drainage.
• Aesthetic surgery: safety comes first. Watch for unlicensed injectable fillers (for example liquid silicone), which cause granulomas and embolism.
• Burn reconstruction: scar contractures are released and grafted, and hypertrophic scars and keloids are treated with pressure garments, silicone and steroid injection.

Fractures and dislocations

• Fracture principles:
  • reduce (closed or open);
  • hold (cast, internal or external fixation);
  • rehabilitate;
  • always check neurovascular status before and after manipulation, and X-ray the joint above and below.
• Common fractures and dislocations:
  • Colles fracture: distal radius with dorsal displacement ("dinner fork"), from a fall on an outstretched hand in osteoporotic women;
  • scaphoid fracture: anatomical snuffbox tenderness. Immobilize even when the first X-ray is normal, because of avascular necrosis and nonunion risk;
  • supracondylar humerus fracture in children: risk to the brachial artery and median (anterior interosseous) nerve, with Volkmann ischemic contracture;
  • anterior shoulder dislocation: the most common, with axillary nerve injury (numb "regimental badge" area);
  • posterior hip dislocation (dashboard injury): the leg is short, flexed, adducted and internally rotated, with sciatic nerve risk; reduce urgently to prevent avascular necrosis;
  • hip fractures in the elderly: displaced intracapsular fractures disrupt the femoral head blood supply and are treated by hemiarthroplasty or total hip replacement; extracapsular fractures by internal fixation. Early surgery (within 48 hours) reduces complications;
  • tibial shaft fractures: frequently open, with a high risk of compartment syndrome.
• Fracture complications: fat embolism (hypoxia, confusion and petechial rash 24 to 72 hours after long-bone fractures), DVT, malunion and nonunion, avascular necrosis and complex regional pain syndrome.
• Pediatric fractures involve the growth plate. Child abuse is suspected from posterior rib fractures, metaphyseal corner fractures, multiple fractures of different ages and injuries that do not match the story.

Orthopedic Traumatology: Open Fractures, Compartment Syndrome & Physeal Injuries

Gustilo-Anderson Classification of Open Fractures

Open fractures carry substantial risks of osteomyelitis, non-union, and amputation:

• Type I: Clean open wound $< 1.0\text{ cm}$ in length; minimal soft tissue injury; simple fracture pattern with minimal comminution. SSI risk: $0-2\%$.
• Type II: Laceration $1.0\text{ to }10.0\text{ cm}$ in length; moderate soft tissue damage; moderate comminution; no extensive soft tissue flaps or avulsions. SSI risk: $2-7\%$.
• Type III: Open wound $> 10.0\text{ cm}$ in length with extensive soft tissue damage, periosteal stripping, or high-energy mechanism (high-velocity gunshot, farm machinery, severe crush):
  • Type IIIA: Extensive soft tissue laceration but adequate periosteal coverage of bone remains.
  • Type IIIB: Extensive soft tissue injury with periosteal stripping and exposed bone requiring free tissue transfer or rotational flap coverage.
  • Type IIIC: Open fracture associated with major arterial injury requiring vascular repair for limb salvage, regardless of wound size.
• Emergency Treatment: Immediate tetanus prophylaxis, early intravenous antibiotic therapy (First-generation cephalosporin [Cefazolin] for Types I/II; add an aminoglycoside [Gentamicin] for Type III; add crystalline Penicillin for barnyard/soil contamination covering Clostridium), antibiotics given as early as possible (ideally within 1 hour of injury), operative irrigation and debridement (immediately for gross contamination or vascular injury, within about 12 hours for high-energy injuries and within 24 hours for others), and fracture stabilization.

Acute Compartment Syndrome

Increased pressure within a non-yielding osteofascial compartment compromising microvascular capillary perfusion. Most common following tibial shaft fractures, forearm fractures, crush injuries, and reperfusion after prolonged ischemia.

• Clinical Features (The "5 Ps"):
  1. Pain out of proportion to the injury (the earliest and most sensitive symptom).
  2. Pain elicited on passive stretching of the muscles in the involved compartment (the most reliable physical diagnostic sign).
  3. Paresthesias and sensory deficits in the distribution of traversing peripheral nerves (indicates early nerve ischemia, typically occurring within 30 minutes).
  4. Pallor and Poikilothermia (coolness).
  5. Pulselessness (a late, ominous sign indicating irreversible myonecrosis).
• Diagnostic Measurement: Intracompartmental pressure $> 30\text{ mmHg}$ or a Delta Pressure (Diastolic Blood Pressure minus Intracompartmental Pressure) $\le 30\text{ mmHg}$ confirms the diagnosis.
• Definitive Treatment: Emergent Decompressive Fasciotomy of all affected compartments (e.g., complete four-compartment fasciotomy of the leg: anterior, lateral, superficial posterior, deep posterior). Delays beyond 6 to 8 hours cause irreversible myonecrosis, Volkmann's ischemic contracture, or amputation.

Pediatric Physeal Fractures: The Salter-Harris Classification

Pediatric long bones possess an active cartilaginous growth plate (physis). Physeal injuries are classified from Type I to Type V using the mnemonic SALTR:

Bone and joint infections

• Septic arthritis:
  • an emergency, because cartilage is destroyed within days;
  • hot swollen joint, fever and refusal to move or bear weight;
  • in children, Kocher criteria help separate it from transient synovitis (fever over 38.5 °C, inability to bear weight, ESR over 40, WBC over 12,000);
  • organisms are S. aureus (most common), gonococcus in sexually active adults, and Salmonella in sickle cell disease;
  • joint aspiration (cell count, Gram stain, culture) before antibiotics, then surgical washout and IV antibiotics.
• Acute osteomyelitis:
  • in children it is hematogenous, affecting the metaphysis of long bones;
  • in adults it follows open fractures, surgery or diabetic foot ulcers;
  • MRI is the most sensitive test; X-ray changes appear after 10 to 14 days;
  • treated with prolonged antibiotics and surgical drainage of abscesses or debridement of dead bone (sequestrum; new bone is the involucrum).
• Tuberculosis of bones and joints: Pott disease of the spine (gibbus, cold abscess, paraplegia) and TB of the hip and knee are treated with anti-TB drugs, with surgery for deformity and neurologic deficit.

Bone tumors

• Metastases are the most common bone tumors in adults (breast, prostate, lung, kidney, thyroid). Multiple myeloma causes punched-out lytic lesions.
• Benign tumors:
  • osteochondroma: the most common benign bone tumor, an exostosis near the knee;
  • osteoid osteoma: night pain relieved by NSAIDs;
  • giant cell tumor: epiphyseal, in young adults, with a "soap bubble" appearance;
  • enchondroma in the hands;
  • simple bone cyst: pathologic fractures in children.
• Malignant tumors:
  • osteosarcoma: adolescents, metaphysis around the knee, sunburst and Codman triangle;
  • Ewing sarcoma: diaphysis, onion-skin reaction;
  • chondrosarcoma: adults, pelvis;
  • treated with biopsy planned by the treating surgeon, chemotherapy and limb-sparing surgery.
• Impending pathologic fracture of a long bone is fixed prophylactically.

Pediatric surgery

• Congenital diaphragmatic hernia:
  • usually left posterolateral (Bochdalek);
  • respiratory distress at birth, a scaphoid abdomen and bowel sounds in the chest, with pulmonary hypoplasia and pulmonary hypertension;
  • intubate immediately and decompress the stomach with a nasogastric tube; avoid bag-mask ventilation, which distends the bowel in the chest;
  • repair after stabilization, not as an emergency.
• Esophageal atresia with tracheoesophageal fistula:
  • the most common type has a proximal blind pouch with a distal fistula;
  • polyhydramnios, drooling, choking and cyanosis at the first feed, and a nasogastric tube that coils in the pouch on X-ray, with gas in the stomach from the fistula;
  • linked to the VACTERL association;
  • keep the baby nil by mouth with suction of the upper pouch, then surgical repair.
• Intestinal obstruction:
  • bilious vomiting in a newborn is malrotation with volvulus until proven otherwise, needing an urgent upper GI contrast study and the Ladd procedure;
  • duodenal atresia shows a double-bubble sign and is associated with Down syndrome;
  • jejunoileal atresia, meconium ileus (cystic fibrosis) and intussusception (air or contrast enema reduction, with surgery for failure or perforation) are other causes;
  • pyloric stenosis is treated by pyloromyotomy after correction of the metabolic alkalosis.
• Hirschsprung disease:
  • absent ganglion cells in the distal bowel (rectum and sigmoid), from failed neural crest migration;
  • failure to pass meconium within 48 hours, constipation, distention and a "squirt sign" with explosive stool on rectal examination;
  • risk of Hirschsprung enterocolitis;
  • diagnosed by rectal suction biopsy (no ganglion cells); a contrast enema shows a transition zone;
  • treated by a pull-through operation.
• Surgical jaundice in infants:
  • biliary atresia: conjugated jaundice beyond 2 weeks with pale (acholic) stools and dark urine;
  • ultrasound and hepatobiliary scintigraphy, and intraoperative cholangiogram to confirm;
  • the Kasai portoenterostomy works best before about 60 days of life, and liver transplantation is needed later in many;
  • choledochal cyst causes jaundice, pain and a mass and is excised to prevent cancer.
• Inguinal hernia and hydrocele:
  • pediatric inguinal hernias are indirect (patent processus vaginalis) and are repaired soon after diagnosis by herniotomy, urgently in infants because of incarceration risk;
  • most communicating hydroceles resolve by 1 to 2 years.
• Abdominal wall defects:
  • omphalocele: covered by a sac, at the umbilicus, with associated anomalies (chromosomal, cardiac, Beckwith-Wiedemann);
  • gastroschisis: no sac, to the right of the umbilicus, with fewer associated anomalies; cover the bowel and prevent heat and fluid loss.
• Pediatric tumors:
  • Wilms tumor: a smooth flank mass that does not cross the midline, in a well child;
  • neuroblastoma: an irregular mass that crosses the midline, in a sick child, with high urine catecholamines;
  • both are treated with surgery and chemotherapy; details are in the pediatric oncology section.