Ebook Surgical tips and skills (1st edition): Part 1

(BQ) Part 1 book Surgical tips and skills presents the following contents: Exsanguination problems in hand surgery, darpal tunnel open technique, fenestrated full thickness graft, drain tube identification with site specificity, cutting diathermy technique, dorsum of hand surgical closure technique,...

‘The reward of a thing well done is to have done it.’ RALPH WALDO EMERSON ‘Today's heresy is tomorrow's orthodoxy.’ HELEN KELLER This image shows the 20 triangulate faces of this polyhedron which are a reflection of the versatility of this design concept, more variations of which are illustrated in this text, which is really a second volume of the KPIF principle surgical tips and Felix C Behan FRCS, FRACS Associate Professor of Surgery University of Melbourne Plastic and Reconstructive Surgeon Department of Surgical Oncology Peter MacCallum Cancer Centre Melbourne, & Western Health skills Sydney Edinburgh London New York Philadelphia St Louis Toronto Churchill Livingstone is an imprint of Elsevier Elsevier Australia ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067 This edition © 2014 Elsevier Australia This publication is copyright Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible The publisher apologises for any accidental infringement and would welcome any information to redress the situation This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication National Library of Australia Cataloguing-in-Publication entry _ Author: Behan, Felix C., author Title: Surgical tips and skills / Felix Behan ISBN: 9780729540995 (paperback) Notes: Includes index Subjects: Surgery–Textbooks Surgery–Technique Dewey Number: 617.9 _ Content Strategist: Larissa Norrie Senior Content Development Specialist: Neli Bryant Project Managers: Karthikeyan Murthy and Rochelle Deighton Edited by Linda Littlemore Proofread by Tim Learner Cover and internal design by Stan Lamond Index by Robert Swanson Typeset by Toppan Best-set Premedia Limited Printed in China by China Translation & Printing Services Limited Foreword The skills of a plastic surgeon are acquired in many ways Most surgeons learn their craft from an experienced surgeon and then modify their practice in the light of their own experiences It is not surprising that changes in operative technique usually occur slowly, only changing rapidly when a new technology is introduced This has been most obvious in plastic surgery in the emergence of microsurgery, which has provided a method for the reconstruction of many major defects Unfortunately, simpler, more traditional classical methods of tissue transfer involving less operating time and hospitalisation are sometimes forgotten Almost 100 years ago, a Melbourne plastic surgeon, Jerry Moore, wrote a seminal book entitled Plastic Surgery based purely on his own personal experience and innovation It is pleasing to be asked to write a foreword to an equally important book, Surgical Tips and Skills by Felix Behan, which may also change the face of plastic surgery Like Moore, Professor Behan is an original thinker, and some 40 years ago he realised it is possible to raise composite flaps using embryological dermatomes, as these include skin, neurovascular tissue, lymphatics and fascia He gradually developed his own ideas of local tissue rearrangement based on this principle, enabling him to close defects that were previously irreparable My late brother Robert Marshall, surgeon and anatomist, grasped this principle of the vertical orientation of the circulation of the skin and underlying tissue, and was sufficiently impressed to include it in his book, Living Anatomy, Structure as a Mirror of Function, in 2001 Mr Marshall observed to the author that the improved vascularity in these island flaps may be a local sympathectomy effect Professor Behan has continued his innovative approach for more than 40 years, and shares with us in his new book numerous examples of remarkable reconstructions using local fascio-cutaneous keystone flaps together with many relatively simple but neat surgical tips to improve surgical outcomes This book is divided into three sections, Basic, Intermediate and Advanced, and there is something in it for aspiring surgeons as well as for the most experienced The Basic and Intermediate sections contain many surgical tips, including suturing techniques, harvesting of skin grafts and their applications, simple means of immobilisation and innovative methods of establishing drainage to improve the results of many plastic surgery procedures The Advanced section has beautifully illustrated examples of keystone fascio-cutaneous flap reconstructions, which many experienced surgeons would be pleased to claim as their own Plastic surgery has changed over the past 50 years, becoming dominated by cosmetic surgery and microsurgery with a decline in the art of local tissue repair, which is the fundamental basis of plastic surgery It is to be hoped this book may stimulate a resurgence of the more classical aspects of the specialty With the passage of time and tightening of resources, there will inevitably be more scrutiny by health administrators of the cost of plastic surgery procedures It will become increasingly difficult to justify operations that require expensive resources, multiple surgeons and prolonged operating times, when there are simple, less expensive alternatives readily available that produce results often superior in terms of function and appearance Professor Behan has shown the way – plastic surgeons need to sit up, take notice and embrace local fascio-cutaneous island reconstruction as an alternative to microsurgery or risk losing a large part of our specialty Donald R Marshall AM MB MS FRACS FACS v Foreword vi All surgeons enjoy discussing and evaluating surgical techniques Innovative means of practising their craft are a constant stimulus They also value the visual and even graphical demonstration of surgical procedures, as comprehensively illustrated in this text This surgical interest ranges from the simple to the complex A simple procedure done well that produces a functional outcome is as important as a major reconstruction after resection of a cancer Felix Behan has vast experience in both simple and complex reconstructive techniques, honed by many years of practice at the Peter MacCallum Cancer Institute and the Western Hospital in Footscray, Melbourne His work has encompassed both community trauma, including orthopaedics, and melanoma and other malignancies He worked as a senior plastic and reconstructive surgeon at both these places for almost 40 years, but his contribution has been much more than the conventional His techniques were noted to be original, and were carried out expeditiously with wonderful outcomes, as comprehensively illustrated throughout the text in the Basic, Intermediate and Advanced sections His work was initially regarded as idiosyncratic and was attributed to his innate skill in dealing with and repairing tissue with the keystone techniques However, it is an accepted truism that a surgical technique that cannot be taught will have minimal impact on surgical science without publication in the international literature I take some pride in having encouraged Felix to document his work scientifically, to classify it in a way that allows independent evaluation and, thus, to publish it for wider scrutiny of the keystone reconstructive principle The rest, as they say, is history, and now surgeons all over the world have learnt the simple but precise principles of reconstruction as developed by Felix Behan The photographic details in each section of this book will make the learning process even simpler His work has been published in the surgical literature and in previous textbooks, and he has presented his work around the world at multiple clinical meetings I am pleased to write the Foreword to this new volume, entitled Surgical Tips and Skills, which adds extra detail to these surgical techniques that have now been accepted internationally Understanding the principles behind the effective reconstruction of a skin defect is critical for a good outcome This textbook is filled with handy hints and clever surgical techniques to enable both the surgical tyro and the experienced surgeon to develop and amplify their reconstructive skills Few surgeons can claim a real advance in surgical technique This volume indicates that here is one surgeon who has made a real contribution Through his photographs, drawings and notes, this conclusion is made clear I commend Felix Behan for his innovative work The many patients who have benefited from his innate skill and techniques will be forever grateful for his ability, intelligence and endeavours, as will those in the future as other surgeons embrace these principles Surgical Tips and Skills is really a summary of his work as a reconstructive surgeon in this second volume focusing on the keystone perforator island flap concept Robert J S Thomas Distinguished Fellow in Surgical Oncology Peter MacCallum Cancer Centre Melbourne Preface Surgical Tips and Skills is a compilation covering aspects of surgical development with ongoing refinements in surgical technique based on experience The fact that one keeps seeking higher standards of surgical outcome leads one to question one’s own ability Eventually, the accumulation of this experience bears fruit One has only to compare the techniques and achievements of one’s earlier years to see the advantage of this maturation process This text is essentially a summary of 40 years of experience practising surgery in both the public and the private domains The advent of digital photography supersedes reams of text, which are sometimes hard to comprehend The alphabetical sequence, common to modern surgical textbooks for ready reference, is an attempt to cover the gamut of reconstructive cases that present in any surgical domain, based on one central tenet: the simplest way is usually the best With the advantage of external reviewers, the levels of expertise were factored in to create three sections of the book covering Basic, Intermediate and Advanced stages of this technical development The text also includes a comprehensive index As a consequence, the principles of evidence-based medicine – initiatives to improve health management and health outcomes while reducing health costs – are reflected in all these cases, with Level (expert evidence and opinions) and Level (retrospective case series) All the singular cases illustrated are just examples of the many that have been compiled and have either been presented internationally at meetings or are in the process of separate publication, or both This compilation, drawn from approximately 3000 keystone flap reconstructions over the past 20 years in all regions of the body, has created a ‘How To Do’ guide on some reconstructive facets that others find difficult It is interesting that the Annals of the Royal College of Surgeons of England is now in the 10th year of ‘Technical Tips’ – meaning people like to read pearls of wisdom The science of the keystone has many elements, with recent publications looking at the evidence – the flaps are closed under tension and the vascular dynamics characteristically displayed contradict established principles of plastic surgery, requiring further elucidation The anatomical construction of skin, fat and fascia, a prerequisite to any successful keystone flap, is indispensable and the mark-outs within the dermatomes echo the embryological development of the human Speaking in Paris recently, a senior plastic surgeon, Dr Arnoldo Fournier, said to me: ‘Felix, you have captured the art of reconstruction by these principles’ He was referring to the fact that every keystone aligned along the dermatomes has both somatic and autonomic support to supplement the arterial and venous connections while not negating any lymphatic and humeral input Microsurgery is based on an artery, a vein and possibly a nerve and thus has a different structural arrangement Historically I must publicly recognise the contribution of Professor Gordon Clunie in relation to the publication of scientific material as editor of the ANZ Journal of Surgery He told me that with any new scientific principle “launch it locally, and you will get full recognition” His other famous recommendation was “if you have anything to say in print, find the time to publish” Professor Bob Thomas also gave me sound advice in 2003, when the first article on the keystone was submitted to the ANZ Journal of Surgery with multiple authors He said, “This is a good idea It’s yours and have it as a single author.” xi This ‘technical tips’-style of publication is a means of illustrating how to employ these techniques I hope this straightforward, comprehensively illustrated presentation will encourage many more of my colleagues, at whatever stage of their careers, to xii re-explore loco-regional reconstruction in conjunction with microsurgical expertise This Surgical tips and skills is a companion volume to the first publication: Keystone perforator island flap concept Acknowledgments Surgical Tips & Skills is really a companion textbook to our first publication, The Keystone Perforator Island Flap Concept Some have even called it ‘Volume II’ in view of its extensive range of cases featuring this KPIF principle I must acknowledge first and foremost all the patients and the referrals from my oncologist and surgical colleagues, Professor Andrew Sizeland, Associate Professor Steve Kleid and Dr Sorway Chan at Peter MacCallum, together with Professor Steve Chan and Associate Professor Trevor Jones, and the members of the orthopaedic team, including Associate Professor Ray Crowe and Associate Professor Chris Harris at the Western Hospital The patients have repeatedly said they are grateful for the work we have all achieved, and without reservation they gave me permission to compile and use a photographic record of these cases to detail these reconstructive manoeuvres and ‘help anyone else like us’ Next I must publicly acknowledge the staff at both these institutions, from the wards, from theatre and the clinics, at both the surgical and the nursing levels Without their input, of course, the clinical success could not have been assured I am grateful for the invaluable help offered by the library staff at the Western Hospital for researching almost every aspect of every reference used in the text It was my French colleague, Dr T Boukris, who originally suggested the term ‘omega variant’ for the horseshoe-shaped design used throughout I am also grateful for the technical expertise and assistance of the following: • Kevin Tan, for his IT expertise, who compiled the initial submission of the text, constructing the alphabetical sequence of cases • Ashwini Supperamohan as an Editorial Assistant who in the intermediate phase composed the initial quartet arrangement of the clinical images from my extensive photographic records to make the text as clear as has been achieved in this format • Andrew Sanderson, also as an Editorial Assistant, who contributed to the penultimate stages of preparation including drawings • Margaret Clancy, who refined the final text with me to produce the end result as a readable, logical and easily accessible format I am also indebted to all the confidential reviewers for their constructive suggestions, which resulted in the progression of cases spread over three tiers of competency This may help explain the format Lastly I must acknowledge the tolerance of my wife, Mariette, for my hours and days of absence during this compilation period xiii Reviewers Peter F Burke MBBS (Melb) FRCS (Eng) FRACS FACEM DHMSA Senior Consultant Surgeon, Latrobe Regional Hospital, Traralgon, VIC, Australia Steven Chan MBBS PhD (Lond) FRACS Professor of Surgery, The University of Melbourne, NorthWest Academic Centre, VIC, Australia Tim Francis BSc MBBS FRACGP General Practitioner, Nambucca Heads, NSW, Australia Sarah-Jane McEwan BMed DCH FRACGP FARGP AdvDRANCOG FACRRM CertClinEd District Medical Officer, Hedland Health Campus, Port Hedland, WA, Australia Julian Peters BMedSci (Hons) MBBS, FRACS (Plast) Senior Consultant Plastic Surgeon, The Royal Melbourne Hospital, Parkville, VIC, Australia xiv ADVANCED Aesthetic closure of a neck defect – case series no Notes _ _ _ INTRAOPERATIVE Figure 7: At days post-op, when the loops were cut as shown They are left in situ because removal causes pain, but they self-deliver once the exaggerated eversion has subsided (2–3 days) The strategic mattress sutures at appropriate tensional points are left in for 2–3 weeks The LMS style is used on all these cases, avoiding any buriedknot problems 4/4 _ _ _ _ _ _ Outcome Figure 8: Here the suture marks have subsided with dermal apposition being the keynote for accurate healing This soundly healed wound was the appearance before commencing XRT He has a strong quality-of-life response and thanked us for our expertise, ‘I look normal, Doc’ Notes _ _ _ Fully healed without complications in preparation for radiotherapy SURGICAL TIPS AND SKILLS _ 127 ADVANCED 1/3 Aesthetic closure (melanoma) – case series no INTRAOPERATIVE Closure of melanoma defect over the tendo Achilles (4 × cm) using the KPIF saphenous vein with ad hoc perforators, all of which are contained in the KPIF Introduction Problem Following excision of a large melanoma a defect of × cm was created overlying the tendo Achilles Grafting in such a site is standard, although the underlying tendo Achilles creates problems with graft healing and stabilisation The KPIF is based along the sural nerve adjacent to the short The alternative use of skin grafts over this site poses intrinsic problems in relation to graft stability, adhesions to the underlying tendo Achilles, wound breakdown with local trauma/irritation and pressure effects when resting Figure 1: The Clark L IV melanoma Notes _ _ _ _ _ _ _ _ _ Solution The KPIF SURGICAL TIPS AND SKILLS 128 Figures and 3: Excision down to and including the encircling fascia, which has the advantage that any subcutaneous fat does not separate nor disintegrate in assessment the correct pathological level The sural and short saphenous nerve complexes are spared Notes ADVANCED Aesthetic closure (melanoma) – case series no 2/3 _ INTRAOPERATIVE Figure 4: Creation of the keystone with division of the fascia along the convex margin without undermining of the flap or the margins of the defect, which facilitates apposition of the margins prior to closure under physiological tension Notes _ _ _ _ Figure 5: Paradoxical hyperaemia (PH) is part of the appearance on the release of the tourniquet Note the arrow again shows the RDS The figure-of-8 tension suture (FETS) points × are shown at the midpoint of the convex and concave margins These remain in place for at least weeks to avoid ruptural separation Notes _ _ Figure 6: The combination of FETS and HEMMING sutures is shown Notes _ _ _ _ _ _ _ SURGICAL TIPS AND SKILLS _ _ _ 129 ADVANCED 3/3 Aesthetic closure (melanoma) – case series no INTRAOPERATIVE Figure 7: The appearance at approximately weeks before the continuous sutures are cut with delayed removal of the remaining strategic mattress sutures The exaggerated eversion will subside further once the loops are cut Notes _ _ _ _ _ Outcome Figure 8: Healed appearances at months Note the staged removal of sutures creates a good aesthetic result Notes _ _ _ _ _ _ _ _ _ SURGICAL TIPS AND SKILLS 130 30 minutes for the procedure, a short hospital stay, totally pain free Females are not committed to wearing trousers No complications recorded ADVANCED Ankle joint double KPIF – case series no Introduction Double KPIFs in the yin yang manner is an alternative solution to microvascular anastomosis of the exposed anterior (talocrural) ankle joint and surrounding tendons with a defect measuring 13 × cm Problem Defects over the anterior ankle joint are a difficult problem, and one usually has to resort to microvascular anastomosis Comorbidities create more problems Figure 1: The presenting defect INTRAOPERATIVE Double KPIF using the yin-yang principle for closure over mid-line anterior ankle defect 1/4 Notes _ _ _ _ _ _ _ _ _ Solution Double KPIF closure of a ~13 × 6-cm defect with VAC dressings in an elderly patient’s (L) lower limb following infected/ trauma loss of soft tissue and exposure of underlying vital structures Notes _ _ SURGICAL TIPS AND SKILLS Figure 2: KPIF mark-out along the medial side over the medial malleolus, L4 and L5 embryological dermatomes The proximal part with saphenous neurovascular support is left in situ The distal one-third, undermined with fascial support, facilitates transposition to cover part of the defect _ _ 131 ADVANCED 2/4 Ankle joint double KPIF – case series no INTRAOPERATIVE Figure 3: Interlocking of the paired KPIFs in the yin yang manner is facilitated by undermining to allow transposition The medial KPIF is undermined distally and the lateral KPIF undermined proximally Notes _ _ _ _ _ Figure 4: Appearance on release of the tourniquet Notes _ _ _ _ _ _ _ _ _ Figure 5: The appearance prior to mesh grafting of the secondary defect above the lateral malleolus SURGICAL TIPS AND SKILLS Notes _ _ _ _ _ _ _ _ 132 _ ADVANCED Ankle joint double KPIF – case series no 3/4 _ _ _ _ _ INTRAOPERATIVE Figure 6: The secondary defect over the medial malleolus is mesh grafted Notes _ _ _ _ Figure 7: Appearance days post-op Notes _ _ _ _ _ _ _ _ _ SURGICAL TIPS AND SKILLS _ 133 ADVANCED 4/4 Ankle joint double KPIF – case series no INTRAOPERATIVE Outcome Figure 8: Postoperative appearance at weeks with full functional recovery The patient has almost no pain relating to this procedure, particularly relevant in the elderly population and features strongly on quality-of-life criteria Notes _ _ _ _ _ _ This simple procedure with minimal morbidity has relevance in the ageing population No recorded complications SURGICAL TIPS AND SKILLS 134 ADVANCED Bony defects around the knee joint (KPIF) – case series no Introduction Reconstructions of defects involving exposed bone and/or metal around the knee joint are complicated Traditionally, the gastrocnemius myocutaneous flap is standard procedure for such locations However, the KPIF, based on random perigeniculate perforators, laterally designed, is a viable alternative for closure of defects where the bone, joint space or metal hardware is exposed Microvascular reconstruction is more surgically complex and, in the elderly, vascular integrity may be compromised Problem INTRAOPERATIVE Duet procedure done in association with Associate Professor Ray Crowe Closure using a lateral genicular KPIF 1/4 Figure 1: An open reduction internal fixation (ORIF) for a fractured tibial plateau Notes _ _ _ _ _ _ _ _ _ _ SURGICAL TIPS AND SKILLS Figure 2: Clinical history: following a skiing accident in America the patient underwent ORIF for stabilisation of the tibial plateau This was complicated by infection and wound breakdown at weeks following a haematoma that became contaminated on return to Australia VAC dressings were organised in preparation for definitive closure of the × 10-cm defect over the exposed tibia and peroneal compartment Notes _ 135 ADVANCED 2/4 Bony defects around the knee joint (KPIF) – case series no INTRAOPERATIVE Solution Figure 3: The KPIF is designed laterally, extending proximally and laterally above the knee joint from the level of the tibial tuberosity The distal two-thirds of the flap is undermined with fascial lining and the proximal one-third left attached prior to rotational manoeuvring based on peri-geniculate (ad hoc) random perforator support Doppler localisation was not employed in this instance The flap was aligned to the vicinity of the L3–L5 embryological dermatome mark-outs Notes _ Figure 4: The digit used to raise the plane of blunt dissection, ensuring the fascial base to the KPIF Note the shiny fascial lining Debridement of the wound was completed once the flap was raised Notes _ _ SURGICAL TIPS AND SKILLS 136 _ _ _ _ ADVANCED Bony defects around the knee joint (KPIF) – case series no Notes _ _ _ INTRAOPERATIVE Figure 5: The omega (Ω) variant/horseshoe-shaped flap is rotated 90° to cover the fracture and metal The margins are trimmed and the secondary defect closed with mesh grafting 3/4 _ _ _ Figure 6: The completed procedure with grafting to the secondary defect The time frame (120 minutes) is shown Notes _ _ _ _ _ _ _ _ SURGICAL TIPS AND SKILLS _ 137 ADVANCED 4/4 Bony defects around the knee joint (KPIF) – case series no INTRAOPERATIVE Outcome Figure 7: The aesthetic appearance months following surgery Notes _ _ _ _ _ _ _ _ _ Figure 8: Another case (from another surgeon) showing typical appearances of gastrocnemius flap reconstruction, the standard alternative Notes _ _ _ _ _ _ _ SURGICAL TIPS AND SKILLS _ 90-minute procedure Satisfactory resolution of the split skin grafting; the flap healed without any vascular or wound complications Bibliography 138 Podlewski, J., 1989 Medial gastrocnemius myocutaneous flap Plast Reconstr Surg 83 (3), 578–579 ADVANCED Cheek melanoma – reconstruction in an irradiated field – case series no Introduction This 65-year-old male had a carcinoma of the larynx that needed postoperative radiotherapy at a tertiary referral centre The area of depilation of the (R) cheek extended from the angle of the jaw to the angle of the mouth Biopsy confirmed malignant melanoma (MM), necessitating wide local excision in this already irradiated field Problem INTRAOPERATIVE See also case series no 36 (same patient) Duet procedure done in association with Associate Professor Steve Kleid (surgical oncologist) The KPIF is used to close an x 5-cm cheek defect in an irradiated field 1/3 Figure 1: Melanoma (XRT) following treatment for a carcinoma of the larynx Radionecrotic breakdown of the neck tissues was repaired with a pectoralis major myocutaneous flap before the development of the MM of the cheek Notes _ _ _ Solution Notes _ _ _ SURGICAL TIPS AND SKILLS Figure 2: KPIF aligned along the body of the mandible from the direction of the submandibular region upwards towards the surgical defect, which measures × cm, showing the buccal fat pad, with excision just above the plane of the buccal and mandibular branches of the facial nerve 139 ADVANCED 2/3 Cheek melanoma – reconstruction in an irradiated field – case series no INTRAOPERATIVE Figure 3: Insertion of the KPIF flap The white arrow shows the red dot sign (RDS) PH here is variable, reflecting the vascular changes consequent on previous irradiation Notes _ _ _ _ _ Figure 4: Note the increase in vascularity in the irradiated field does show a cyanotic variant of the RDS; the RDS is a biological marker of improved vascularity, a characteristic of the KPIF Notes _ _ _ _ _ Note the slower vascular dynamics as a result of the irradiated field SURGICAL TIPS AND SKILLS Figure 5: The closed wound – the preauricular area (upper one-third) shows the typical vascular flare of the KPIF while the slightly hypovascular remainder is an indication of the XRT changes Notes _ _ _ _ _ 140 _ ADVANCED Cheek melanoma – reconstruction in an irradiated field – case series no Figure 6: The aesthetic outcome Notes _ _ _ _ _ _ INTRAOPERATIVE Outcome 3/3 _ _ _ _ _ _ _ _ 75-minute procedure Good quality of life, no complications recorded SURGICAL TIPS AND SKILLS 141 ... Khan, W., 2 011 Tourniquet use in upper limb surgery Hand 6, 16 5 17 3 SURGICAL TIPS AND SKILLS _ BASIC 1/ 1 Wound preparation – pre-wash technique PREOPERATIVE Introduction Every surgical. .. with microsurgical expertise This Surgical tips and skills is a companion volume to the first publication: Keystone perforator island flap concept Acknowledgments Surgical Tips & Skills is really... hand therapy department completes the management SURGICAL TIPS AND SKILLS 20 BASIC Hand splintage – technique – single roll plaster splintage Plaster splintage following hand surgery is a standard