The distally based radial forearm fascia-fat flap for treatment of recurrent de Quervain's tendonitis.

A radial fascial flap has been described as a valuable and versatile option to provide appropriate tissue coverage of tendons, nerves, and soft tissues in the forearm and hand. We report the use of this distally based radial forearm fascia-fat flap to create a fascial tube to treat recurrent de Quervain's tendonitis.

Prospective comparison of panoramic tomography (zonography) and helical computed tomography in the diagnosis and operative management of mandibular fractures.

This prospective study compared the sensitivity of panoramic tomography (zonography) and helical computed tomography (CT) in diagnosing 73 mandibular fractures in 42 consecutive patients and correlated the results with known surgical findings. The purpose of the study was to determine the optimal radiologic examination for the diagnosis and operative management of mandibular fractures. The attending surgeons' interpretations of panoramic tomograms and helical CT images in the axial plane were compared with the patients' known surgical findings. A series of questions assessed the relative contribution of these two radiologic examinations in formulating an optimal operative plan for each patient. In the 42 patients studied, the sensitivity of helical CT was 100 percent in diagnosing mandibular fractures; this compared with 86 percent (36 of 42) for panoramic tomography, in which significantly more fractures were missed (p = 0.0412). In the six patients with fractures not visualized, the operative management was altered because of the new fracture visualized on helical CT. Of the seven missed fractures, six were in the posterior portion of the mandible. Comparing fracture detection by region, seven fractures found on helical CT were not visualized on panoramic tomography. Helical CT improved the understanding of the nature of mandibular fractures by providing additional information regarding fracture displacement and comminution and by locating injuries missed using panoramic tomography. This study suggests that helical CT alone may be more diagnostic than panoramic tomography alone in evaluating mandibular fractures. Helical CT sufficiently demonstrated details of fractures in 41 of 42 patients; in one patient, the nature of a dental root fracture was better delineated by panoramic tomography.

Contribution of conventional axial computed tomography (nonhelical), in conjunction with panoramic tomography (zonography), in evaluating mandibular fractures.

Previous studies comparing the sensitivity between different radiological exams have concluded that conventional axial computed tomography (CT; nonhelical) is unsuitable in the assessment of mandibular fractures. Axial CT was shown to have a reduced sensitivity compared with plain radiographs and panoramic tomography because it missed nondisplaced fractures in the posterior portion of the mandible. Because the resolution of CT has improved from the time of these previous studies, the authors were interested in assessing whether axial CT (nonhelical) could now provide additional clinically useful information and enhance our understanding of mandibular fractures, beyond that obtained from panoramic tomography alone. In their study, 5 staff surgeons initially evaluated the panoramic tomograms and then the CT scans of 39 patients with 66 fractures. A series of four questions assessed the relative contribution of these two radiological exams in formulating an optimal operative plan for each patient. The authors found that axial CT provided supplementary information regarding missed fractures, comminution, and the exact size and degree of displacement of fracture fragments. This additional data could have changed the operative plan in a substantial proportion of patients (17 of 39). Axial CT demonstrated two missed parasymphyseal fractures (2 of 39 patients) that were not seen on these patients' panoramic tomograms. Axial CT also revealed undiscovered comminution or demonstrated fracture displacement more precisely in 39% of patients (15 of 39) and 24% of fractures (16 of 66). This study demonstrates that axial CT was clinically useful as an additional investigation to panoramic tomography. Axial CT helped elucidate further the nature of suspected mandibular fractures.

Incidence of neurapraxia in digital nerve injuries.

Hand surgeons presented with a hand or finger laceration and an abnormal static two-point discrimination (> or =10 mm) must determine which patients require surgical exploration. There appears to be a paucity of data in the literature defining the incidence and nature of neurapraxia in this setting. A study was conducted in a busy urban practice to better understand this problem. To determine the incidence of intact nerves (i.e., neurapraxia) in digital nerve injury patients, the authors reviewed experience with 152 patients who presented with isolated digital nerve injuries over a 33-month period. Preoperative return of sensation and negative exploration cases were combined and referred to as the trauma-induced neurapraxia (TIN) group. There were 18 non-repair cases among the 152 isolated digital nerve injuries, giving a 12 percent incidence of TIN. Sensory recovery among the TIN patients ranged from 12 days to 6 months. In this study, the authors defined a group of patients who did not require surgical repair for isolated digital nerve injury as TIN cases. The TIN group represented 12 percent of the digital nerve trauma patients and required long follow-up for sensory recovery. This information is an important part of patient education and informed consent.

Latissimus dorsi myocutaneous flap reconstruction of neck and axillary burn contractures.

Neck and axillary burn contractures are both a devastating functional and cosmetic deformity for patients and a challenging problem for reconstructive surgeons. Severe contractures are more commonly seen in the developing world, a result of both the widespread use of open fires and the inadequacy of primary and secondary burn care in these vicinities. When deep burns are allowed to heal spontaneously, patients develop hypertrophic scarring of the neck and axillary areas. The back is typically spared, however, remaining a suitable donor site. We have used nine latissimus dorsi myocutaneous flaps in a total of six patients, finding the flaps effective in resurfacing both the neck and the axillary regions after wide release of burn contractures. Before flap mobilization, surgical neck release is often necessary to ensure safe, effective control of the airway in patients with significant neck contractures. Flap bulkiness in the anterior neck region can eventually be reduced by dividing the thoracodorsal nerve. Anchoring the skin paddle to its recipient site through the placement of tacking sutures will also help achieve a more normal anterior neck contour.

Diagnostic peritoneal lavage: fourteen years and 2,586 patients later.

During a fourteen year period, diagnostic peritoneal lavage was 98.5 per cent accurate in determining the presence or absence of blunt intraabdominal injuries among 2,586 patients. Of these, 69.4 per cent had a negative lavage and 29.2 per cent a positive lavage. Six patients (0.2 per cent) had a false-positive lavage. Thirty-two patients (1.2 per cent) had a false-negative lavage; however, all but one of these patients underwent exploratory laparotomy on the basis of clinical acumen or other diagnostic tests.

Delayed rupture or delayed diagnosis of rupture of the spleen.

Delayed rupture of the spleen was seen in only six of 302 patients undergoing splenectomy for splenic injury following blunt abdominal trauma. Only one of these six patients was asymptomatic for two days following the accident. This is an incidence of 2 per cent delayed rupture as compared with the 15 per cent quoted in the literature. An aggressive approach to the diagnosis of intra-abdominal injury has helped to eliminate the delay in recognition of rupture of the spleen. Peritoneal lavage has accurately identified those patients with intra-abdominal injury. We conclude that delayed rupture of the spleen is, in reality, usually a delay in diagnosis of splenic rupture.

Diagnostic peritoneal lavage in blunt abdominal trauma.

Diagnostic peritoneal lavage is accurate and safe. It leads to fewer unnecessary laparotomies than if clinical examination alone is used and nearly eliminates deaths from undiagnosed abdominal injuries. Persons with clinical abdominal findings, shock, altered sensorium, and severe chest injuries after blunt trauma should undergo the procedure.

Experimental effects of heparin or magnesium sulfate on the patency of microvascular anastomoses.

Partial amputations of the hind legs were done in 44 rats. The femoral arteries and veins were repaired by microvascular techniques. The systemic use of heparin, the local use of magnesium sulfate, and the combined use of the two drugs, were evaluated as to their influence on preventing thrombosis in these microvascular anastomoses. No benefit could be demonstrated from the use of these drugs.