Plastics in Practice (Resident Review)

A mangled upper extremity can look unsalvageable before resuscitation, perfusion, and debridement reveal what function remains.In this episode of Plastics in Practice, we build a practical limb-salvage sequence—from life-threatening priorities and early antibiotics to revascularization, compartment assessment, reconstruction, and rehabilitation.Key takeaways:• Put life before limb. Complete trauma resuscitation, control hemorrhage, and document perfusion, motor function, and sensation before committing to salvage or amputation.• A MESS of seven is a risk signal, not an upper-extremity amputation verdict. A 2024 meta-analysis suggested that at least one in five patients above the included studies’ MESS amputation thresholds underwent limb salvage.[1]• For an open long-bone fracture within BOAST's scope, give intravenous prophylactic antibiotics as soon as possible, ideally within one hour of injury. Hand, wrist, and digit injuries are outside this BOAST’s scope and may be managed locally using similar principles.[2]• If the limb is ischemic, restore flow as soon as possible. When timely definitive vascular repair is not feasible because of patient physiology or skeletal instability, a temporary vascular shunt can rapidly restore perfusion while stabilization proceeds.[6]• In adults with traumatic extremity injury, on repeated or continuous monitoring, delta pressure equals diastolic blood pressure minus intracompartmental pressure. A value above thirty millimeters of mercury may assist in ruling out acute compartment syndrome; thirty or less is concerning but not diagnostic and must be integrated with serial examination.[3]• Functional salvage requires meticulous debridement, stable bone, vascular repair, coordinated tendon and nerve reconstruction, durable soft-tissue coverage, and rehabilitation planned from the beginning.[4,5]This content is for educational purposes only and is not medical advice.🎧 Full episodes available now:Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ#MangledUpperExtremity #LimbSalvage #OpenFracture #Revascularization #CompartmentSyndrome #HandTrauma #HandSurgery #PlasticSurgeryEducation #PlasticsInPracticeReferences:1. Yoneda H, Takeda S, Saeki M, et al. Utility of severity scoring systems for mangled upper limb salvage: a systematic review and meta-analysis. Injury. 2024;55(4):111447. doi:10.1016/j.injury.2024.1114472. British Orthopaedic Association. BOAST - Open Fractures. Published December 2017. https://www.boa.ac.uk/resource/boast-4-pdf.html3. American Academy of Orthopaedic Surgeons. Management of Acute Compartment Syndrome Evidence-Based Clinical Practice Guideline. 2025. https://www.aaos.org/acscpg20254. Macrì M, Pugliese P, Accardo G, et al. Current principles in the management of a mangled hand. J Hand Surg Glob Online. Published online August 21, 2024. doi:10.1016/j.jhsg.2024.07.0095. Nayar SK, Alcock HMF, Edwards DS. Primary amputation versus limb salvage in upper limb major trauma: a systematic review. Eur J Orthop Surg Traumatol. 2022;32(3):395-403. doi:10.1007/s00590-021-03008-x6. Wahlgren CM, Aylwin C, Davenport RA, et al. European Society for Vascular Surgery 2025 Clinical Practice Guidelines on the Management of Vascular Trauma. Eur J Vasc Endovasc Surg. 2025;69(2):179-237. doi:10.1016/j.ejvs.2024.12.018

A normal-looking radiograph can hide a ligament injury that becomes stiffness, deformity, or arthritis if it is missed.In this episode of Plastics in Practice, we connect reduction, stability testing, imaging, early motion, and operative decision points across finger, thumb, carpal, and distal radioulnar joint injuries.Key takeaways:• Treat the PIP joint as a motion emergency: permanent stiffness can develop within about two weeks. After reduction, confirm congruity and stability, then begin early protected motion when the joint is stable.[1]• Use the thirty-fifty rule as a guide for dorsal PIP fracture-dislocations: less than thirty percent articular involvement is usually stable, thirty to fifty percent is tenuous, and more than fifty percent is usually unstable. Clinical stability still overrides fragment size.[1]• Avoid axial traction during reduction of a dorsal finger MCP dislocation. Traction can pull the volar plate into the joint and convert a simple injury into an irreducible complex dislocation.• For a thumb UCL injury, no firm endpoint is the strongest red flag for a complete tear; angle thresholds vary. A Stener lesion places the adductor aponeurosis between the ligament and bone, blocking anatomic healing.[2,3]• A scapholunate gap around three millimeters or more, an angle above seventy degrees, or dorsal lunate tilt above fifteen degrees supports instability, but normal static films do not exclude a dynamic injury.[4]• On the lateral wrist radiograph, trace the radius, lunate, and capitate. Loss of collinearity plus median nerve symptoms is the perilunate warning pattern; outcomes are better when treatment begins within seven days than after delay.[5]This content is for educational purposes only and is not medical advice.🎧 Full episodes available now:Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ#HandLigamentInjury #WristInstability #PIPJoint #SkierThumb #Scapholunate #Perilunate #HandSurgery #PlasticSurgeryEducation #PlasticsInPracticeReferences:1. Elfar J, Mann T. Fracture-dislocations of the proximal interphalangeal joint. J Am Acad Orthop Surg. 2013;21(2):88-98. doi:10.5435/JAAOS-21-02-882. Dean B, Rodrigues J, Riley N, et al. Guideline on managing thumb ulnar collateral ligament injuries: the British Society for Surgery of the Hand Evidence for Surgical Treatment findings and recommendations. J Hand Surg Eur Vol. 2024;49(10):1195-1201. doi:10.1177/175319342412746123. Qamhawi Z, Shah K, Kiernan G, et al. Diagnostic accuracy of ultrasound and magnetic resonance imaging in detecting Stener lesions of the thumb: systematic review and meta-analysis. J Hand Surg Eur Vol. 2021;46(9):946-953. doi:10.1177/17531934219930154. Dietrich TJ, Toms AP, Cerezal L, et al. Interdisciplinary consensus statements on imaging of scapholunate joint instability. Eur Radiol. 2021;31(12):9446-9458. doi:10.1007/s00330-021-08073-85. van der Oest MJW, Duraku LS, Artan M, et al. Perilunate injury timing and treatment options: a systematic review. J Wrist Surg. 2022;11(2):164-176. doi:10.1055/s-0041-1735841

A tendon transfer can be perfectly woven and still fail if the joint is stiff, the tissue bed is scarred, or the donor cannot match the lost motion.In this episode of Plastics in Practice, we build a practical framework for tendon transfers—from donor selection and tensioning to radial, median, and ulnar nerve palsy reconstruction and postoperative retraining.Key takeaways:• Make the hand ready first: joints must be supple, and the transfer must glide through a quiet soft-tissue bed. A contracture release and tendon transfer require incompatible rehabilitation and should not be combined.• Match excursion and power: finger flexors provide about seventy millimeters of excursion, finger extensors fifty, and wrist motors thirty; a donor can lose up to one motor grade after transfer.[1,4]• Favor an expendable donor, a direct line of pull, synergistic motion, one donor for one function, and tension near the donor's working length.[1,4]• For high radial palsy, the classic FCR set restores wrist extension with PT to ECRB, finger MCP extension with FCR to EDC, and thumb extension with PL to a rerouted EPL. A fused wrist favors an FDS donor because tenodesis cannot supplement FCR excursion.[1,2]• Median palsy opponensplasty commonly uses FDS or EIP; the donor and pulley must recreate palmar abduction, flexion, and pronation rather than abduction alone.[3]• In ulnar palsy, a positive Bouvier test identifies simple clawing that may accept a static MCP block; a negative test signals complex clawing that needs dynamic intrinsic replacement.• Protect the transfer for four weeks, add passive stretching around week six, begin strengthening around week eight, and progress toward unrestricted activity at three months.[1]This content is for educational purposes only and is not medical advice.🎧 Full episodes available now:Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ#TendonTransfer #RadialNervePalsy #MedianNervePalsy #UlnarNervePalsy #HandSurgery #PlasticSurgeryEducation #PlasticsInPracticeReferences:1. Gardenier J, Garg R, Mudgal C. Upper extremity tendon transfers: a brief review of history, common applications, and technical tips. Indian J Plast Surg. 2020;53(2):177-190. doi:10.1055/s-0040-17164562. Jain NS, Barr ML, Kim D, Jones NF. Tendon transfers, nerve grafts, and nerve transfers for isolated radial nerve palsy: a systematic review and analysis. Hand (N Y). 2024;19(3):343-351. doi:10.1177/155894472211505163. Coulshed N, Xu J, Graham D, Sivakumar B. Opponensplasty for nerve palsy: a systematic review. Hand (N Y). 2024;19(7):1037-1043. doi:10.1177/155894472311744814. Coulet B. Principles of tendon transfers. Hand Surg Rehabil. 2016;35(2):68-80. doi:10.1016/j.hansur.2015.12.011

Radial wrist pain, a locking digit, and lateral elbow pain can all be called overuse—but a few centimeters can change the diagnosis, treatment, and surgical target.In this episode of Plastics in Practice, we map de Quervain tenosynovitis, intersection syndrome, trigger finger, and lateral elbow tendinopathy from focused examination through splinting, injection, rehabilitation, and surgical release.Key takeaways:• Map radial-sided symptoms by location: de Quervain disease localizes at the radial styloid, while intersection syndrome produces dorsoradial pain and often crepitus four to six centimeters proximal to Lister tubercle.• De Quervain disease involves the APL and EPB in the first dorsal compartment; a separate EPB subcompartment can explain incomplete response after injection or release.• Current evidence supports considering corticosteroid injection plus three to four weeks of thumb-spica immobilization as first-line management for de Quervain disease; ultrasonography can help target anatomic subcompartments.[1,2]• Trigger finger localizes to the A1 pulley near the volar metacarpal head—even when the patient feels the click at the PIP joint.• Corticosteroid injection succeeds in roughly two thirds of trigger digits in pooled randomized trials; persistent locking, fixed contracture, or failed conservative care should prompt evaluation for A1 pulley release.[3]• Lateral epicondylitis is better framed as lateral elbow tendinopathy: confirm focal pain with grip or resisted wrist extension, consider radial tunnel symptoms, and avoid promising a rapid cure from any single intervention.[4]This content is for educational purposes only and is not medical advice.🎧 Full episodes available now:Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ#Tenosynovitis #TriggerFinger #DeQuervain #HandSurgery #PlasticSurgeryEducation #PlasticsInPracticeReferences:1. Challoumas D, Ramasubbu R, Rooney E, et al. Management of de Quervain tenosynovitis: a systematic review and network meta-analysis. JAMA Netw Open. 2023;6(10):e2337001. doi:10.1001/jamanetworkopen.2023.370012. He KS, He KS, Cheah A, et al. Unblinding de Quervain: a systematic review of ultrasound-guided injection of corticosteroids for treatment of stenosing tenosynovitis of the first extensor compartment. J Med Radiat Sci. 2023;70(3):319-326. doi:10.1002/jmrs.6813. Pathak SK, Salunke AA, Menon PH, et al. Corticosteroid injection for the treatment of trigger finger: a meta-analysis of randomised control trials. J Hand Surg Asian Pac Vol. 2022;27(1):89-97. doi:10.1142/S242483552250014X4. Lowdon H, Chong HH, Dhingra M, et al. Comparison of interventions for lateral elbow tendinopathy: a systematic review and network meta-analysis for Patient-Rated Tennis Elbow Evaluation pain outcome. J Hand Surg Am. 2024;49(7):639-648. doi:10.1016/j.jhsa.2024.03.007

Extensor tendon injuries are easy to underestimate: a small dorsal wound can conceal a complete laceration, a contaminated MCP joint, or a central slip injury that declares itself later.In this episode of Plastics in Practice, we review the examination, zone-based repair strategy, rehabilitation, complications, and reconstruction of extensor tendon injuries.Key takeaways:• Use the eight-zone map to localize injury and choose a repair and rehabilitation plan; odd-numbered zones lie over joints.• Test beyond simple active extension: juncturae can mask a complete zone-six EDC laceration, the Elson test assesses the central slip, and table-top thumb lift helps isolate EPL function.• Repair lacerations involving more than half of the tendon in zone two, the zone-three central slip, and zone four; avoid unnecessary bulk or shortening in the thin distal mechanism.• Treat a zone-five fight bite as a contaminated joint injury—explore the capsule, debride and irrigate, and defer tendon repair until the wound is clean.• Match rehabilitation to repair strength: zones one and two usually need continuous extension protection for six to eight weeks, while stronger repairs in zones four through eight can support protected early motion. Recent randomized trials support relative-motion extension protocols for selected zone-four to zone-six repairs.[1,2]• Anticipate extensor lag, loss of flexion, adhesions, and tendon rupture; consider tenolysis only after a sustained therapy plateau and use grafts or tendon transfers selectively.This content is for educational purposes only and is not medical advice.🎧 Full episodes available now:Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ#ExtensorTendonSurgery #HandSurgery #TendonRepair #PlasticSurgeryEducation #SurgicalPearls #PlasticsInPracticeReferences:1. Cela-López M, Méndez-Pérez C, Domínguez-Prado DM, et al. Relative motion extension orthosis versus classic immobilization in extensor tendon repairs (zones IV-VI of the hand): a randomized controlled trial. Hand (N Y). Published online February 27, 2026. doi:10.1177/155894472614224832. Hirth MJ, Hunt I, Briody K, et al. Comparison of two relative motion extension approaches (RME with versus without an additional overnight orthosis) following zones V-VI extensor tendon repairs: a randomized equivalence trial. J Hand Ther. 2023;36(2):347-362. doi:10.1016/j.jht.2021.06.006