An incisional hernia containing a gangrenous gallbladder: a case report and review of the literature.

We present a 76-year-old male who presented to the emergency department with 24 hours of sudden onset, severe abdominal pain. Physical exam and laboratory analysis indicated acute cholecystitis, and a CT scan demonstrated a ventral hernia containing an inflamed gallbladder. This patient was managed operatively with an open cholecystectomy. The ventral hernia was not repaired at the index operation in the setting of frank gallbladder necrosis. The patient recovered well after a short post-operative stay. This report is intended to illustrate an unusual presentation of acute, gangrenous cholecystitis with herniation through the ventral abdominal wall.

Palatal fractures: classification, patterns, and treatment with rigid internal fixation.

A classification of palatal fracture types is developed from patterns observed on CT scans, and success with open reduction techniques is correlated with fracture pattern. The six palatal fracture types are as follows: I, anterior and posterolateral alveolar; II, sagittal; III, parasagittal; IV, para-alveolar; V, complex; and VI, transverse. Associated fractures were LeFort I (100 percent), LeFort II and III (55 percent), mandible (48 percent), and dental (55 percent). Large segment, sagittally oriented palatal fractures could be stabilized with rigid internal fixation. Complete rigid fixation of the palate consists of (1) roof of mouth, (2) pyriform or alveolar, and (3) four LeFort I buttress stabilization. Comminuted palatal fractures were managed by standard LeFort I and alveolar buttress fixation, palatal splinting, and intermaxillary, fixation. If complete rigid fixation was employed in the palate in type II, III, and IV fractures, a palatal splint was avoided in 60 percent of these cases. Rigid internal fixation is therefore concluded to facilitate the treatment of certain types of palatal fractures by reduced length of intermaxillary fixation and avoidance of palatal splinting.

The edentulous Le Fort fracture.

A retrospective review of 328 Le Fort fractures has identified 20 (6.1%) of these fractures as edentulous. A review of treatment of the patients was conducted. Conservative (nonsurgical treatment methods) and classic open reductions produce aesthetic and functional results that lead to posterior and oblique positioning of the maxillary occlusal segment in comminuted fractures. Attention to positioning the maxilla by relating it to the mandible through maxillomandibular fixation minimized these deformities. Establishing maxillary-mandibular relationships in edentulous fractures, therefore, seems to have the same importance as establishing occlusion in dentulous patients as an important initial step in the treatment of comminuted Le Fort fractures.

High-energy ballistic and avulsive facial injuries: classification, patterns, and an algorithm for primary reconstruction.

A 17-year experience from 1977 to 1993 with gunshot, shotgun, and high-energy avulsive facial injuries emphasizes the superiority and safety of "ballistic wound" surgical management: (1) immediate stabilization in anatomic position of existing bone, (2) primary closure of existing soft tissue, (3) periodic "second look" serial debridement procedures, and (4) definitive early reconstruction of soft-tissue and bony defects. The series contains 250 gunshot wounds, 53 close-range shotgun wounds, and 15 high-energy avulsive facial injuries. Four general patterns of involvement are noted for both gunshot and shotgun wounds and three for avulsive facial injuries. The treatment algorithm begins with identifying zones of injury and loss for both soft and hard tissue. Gunshot wounds are best classified by the location of the exit wound; shotgun and avulsive facial wounds are classified according to the zone of soft-tissue and bone loss. Treatment, prognosis, and complications vary according to four patterns of gunshot wounds and four patterns of shotgun wounds. Avulsive wounds have not been recommended previously for ballistic wound surgical management. The appropriate management of high-energy avulsive and ballistic facial injuries is best approached by an aggressive treatment program emphasizing initial primary repair of existing tissue, serial conservative debridement, and early definitive reconstruction.

Case management: improving outcomes of care for ischemic stroke patients.

Stroke is a leading cause of death and disability in the United States. Health care reform and escalating health care costs have caused both consumers and health care providers to become more concerned regarding health care provision for stroke patients. A case management practice model used in a 540-bed teaching hospital resulted in improved outcomes for ischemic stroke patients in the areas of: (a) functional ability, (b) appointment compliance, (c) length of stay, and (d) cost.

Comprehensive management of pan-facial fractures.

In the last 20 years, the management of pan-facial injuries has progressed to the point where immediate treatment using open reduction with rigid fixation is now the standard of care. After discussing the historical progression of treatments, the authors present a plan for treatment of craniofacial injuries based on the use of incisions that expose the four areas of the face: the frontal area, upper midface, lower midface and occlusion, and the basal mandibular area. According to the authors, five incisions permit access to the entire anterior craniofacial skeleton: the coronal, lower eyelid, upper and lower gingival-buccal-sulcus, and the preauricular-retromandibular. Through these incisions, the facial buttresses can be accessed to allow reduction and rigid fixation of facial fractures.

Case management: more population-based data.

A pilot project conducted in a 540-bed teaching hospital reveals more population-based data related to nursing case management, a system of patient care that promotes cost containment while ensuring quality outcomes. Positive outcomes were demonstrated in quality of care, patient satisfaction, staff satisfaction, length of stay, and cost.

Inferior alveolar nerve grafting: an approach without intermaxillary fixation.

Although most commonly seen with dental extractions, inferior alveolar nerve injury is occasionally seen with orthognathic surgery and facial trauma. Nerve grafting can be performed by lateral corticotomy without the use of maxillomandibular fixation. A case is reported with this technique and recovery of sensibility documented with quantitative sensory testing.

Case management: managing the nurse case manager.

Nurse executives and nurse managers have become proactive in response to the health care crisis by creating and implementing innovative health care delivery models such as nursing case management. Nursing case management utilizes a nurse as case manager and the unit-based system of managed care to achieve financial and clinical outcomes for target patient groups. Nurse managers can support the nursing case management model best by practicing good managerial skills, developing a participative style of leadership, and empowering the nurse case manager.

Flap reconstruction of the stenotic vagina.

Reconstruction of the congenital or acquired stenotic vagina has traditionally been accomplished by skin grafting or reverse perineorrhaphy in addition to other less successful methods. The advent of musculocutaneous flaps has provided an excellent means of reconstructing the vagina after exenterative surgical treatment; however, the bulk associated with these flaps has precluded their use in reconstruction of the stenotic vagina. Thin, supple, axial pattern fasciocutaneous flaps based on the terminal branches of the internal pudendal artery provide a reliable and durable vaginal lining after surgical enlargement. Seven flaps have been used in four patients without complications. A follow-up period of greater than three years has yielded excellent results.

Use of unlicensed assistive staff.

Recent reports indicate that nurses spend less time with their patients today than in the past (Hendrickson, Doddato, & Kovner, 1990; Misener, Frelin, & Twist, 1987 & Quist, 1992). This may lead to high frustration levels, low morale, and compromised patient care. Unlicensed assistive staff (patient care assistants and unit assistants), when used appropriately, can provide essential support and make a significant contribution to the delivery of efficient and effective patient care. Key issues, when using these staff members, are role clarity and appropriate delegation. Increased health care technology, the proliferation of nursing and medical knowledge, and new health care delivery models have impacted upon the way nurses and unlicensed assistive personnel work together. The way in which these staff members are organized and work together not only will affect the quality of nursing care that is delivered but outcomes of care as well.

Autogenous reconstruction of the temporomandibular joint.

Recently, the temporomandibular joint has been reconstructed with a variety of alloplastic materials; however, functional results are often limited, and long-term stability of the reconstruction is questionable. In contrast, costochondral rib grafting with rigid internal fixation and a temporoparietal fascia flap allows complete functional reconstruction of the temporomandibular joint with autogenous tissue. Thirteen joint reconstructions in 11 patients were followed for up to 7 years and stability of the reconstruction was confirmed. The anterior incisal opening improved from a mean of 14 to 31 mm. Normal occlusal relationships were either reestablished or preserved. Joint pain was ameliorated. The preferred reconstruction of the temporomandibular joint is by autogenous tissue for disc and joint replacement. The treatment provides primary therapy in total joint reconstruction where tumor, trauma, or failed prosthetic joint replacement necessitate complete reconstruction.

Inferior alveolar nerve reconstruction with a polyglycolic acid bioabsorbable nerve conduit.

A custom-designed polyglycolic acid (PGA) bioabsorbable nerve conduit was used to reconstruct a 25-mm defect in the right inferior alveolar nerve. The initial nerve injury, following a dental extraction, resulted in loss of lower lip sensation and severe facial pain. Sixteen months after tooth extraction, with no improvement in symptomatology, the alveolar canal was enlarged in diameter by means of mandibular osteotomy to accommodate a 2-mm-diameter polyglycolic acid tube. The proximal end of the inferior alveolar nerve was sutured into the polyglycolic acid tube. The mental nerve was sutured into the distal end of the tube. Pain of neural origin was relieved in the early postoperative period. Two years following nerve reconstruction, pain relief remains excellent and perception of pressure and vibration is similar to the thresholds for these perceptions on the contralateral lip.

Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment.

The medial canthal tendon and the fragment of bone on which it inserts ("central" fragment) are the critical factors in the diagnosis and treatment of nasoethmoid orbital fractures. The status of the tendon, the tendon-bearing bone segment, and the fracture pattern define a clinically useful classification system. Three patterns of fracture are appreciated: type I--single-segment central fragment; type II--comminuted central fragment with fractures remaining external to the medial canthal tendon insertion; and type III--comminuted central fragment with fractures extending into bone bearing the canthal insertion. Injuries are further classified as unilateral and bilateral and by their extension into other anatomic areas. The fracture pattern determines exposure and fixation. Inferior approaches alone are advised for unilateral single-segment injuries that are nondisplaced superiorly. Superior and inferior approaches are required for displaced unilateral single-segment injuries, for bilateral single-segment injuries, and for all comminuted fractures. Complete interfragment wiring of all segments is stabilized by junctional rigid fixation. All comminuted fractures require transnasal wiring of the bones of the medial orbital rim (medial canthal tendon-bearing or "central" bone fragment). If the fracture does not extend through the canthal insertion, the canthus should not be detached to accomplish the reduction.

Sequencing LeFort fracture treatment (Organization of treatment for a panfacial fracture).

The types of midfacial fractures and their complexity were evaluated in admissions to the Maryland Institute of Emergency Medical Service Systems (MIEMSS) during the years of 1984 to 1988. Two hundred and sixty-eight LeFort fractures were treated and followed (3.2 percent of admissions). One half (50 percent) had skull fractures and 40 patients (15 percent) had LeFort, skull and mandibular fractures. Isolated nasoethmoidal fractures were observed in 176 patients and in 107 patients (39 percent) of patients with LeFort fractures. Isolated mandibular fractures were observed in 321 patients and in 104 patients with LeFort fractures (39 percent). Eleven percent of patients had midfacial, nasoethmoidal and frontal sinus fractures. Six percent of patients had midfacial, frontal bone, frontal sinus and nasoethmoidal fractures (Cranial Base Crush Syndrome). Twenty two percent of patients had LeFort and frontal sinus fractures. Reconstruction of multiple area injuries is simplified by a highly organized treatment sequence that conceptualizes the face in two groups of two units. Each unit is divided into sections, and each section is assembled in three dimensions. Sections are integrated into units and units into a single reconstruction. Conceptually, in each unit, facial width must first be controlled by orientation from cranial base landmarks. Projection is then (and often reciprocally with width) established. Finally, facial length is set both in individual units and in the upper and lower face. Soft tissue is considered the "fourth dimension" of facial reconstruction. Bone reconstruction should be completed as early as possible to minimize soft tissue shrinkage, stiffness and scarring of soft tissues in nonantomic positions.(ABSTRACT TRUNCATED AT 250 WORDS)

Rigid stabilization of sagittal fractures of the maxilla and palate.

Rigid stabilization of sagittal fractures of the palate is described that utilizes plate and screw fixation in the palatal vault. Accurate reduction of facial width is obtained, and stability is significantly enhanced. An existing laceration or a longitudinal incision in the palatal mucoperiosteum provides exposure for maxillary adaption plate application. The transpalatal reduction should be supplemented by fixation at the piriform aperture, the zygomaticomaxillary and nasomaxillary buttresses, and by the use of an arch bar. Since slower bone healing may be observed following palatoalveolar fractures, the occlusion must be observed for deviation throughout a full 16-week period even though early motion and soft diet are permitted. Removal of the plate and screws in the roof of the mouth is sometimes required and utilizes local anesthesia.

Le Fort fractures without mobility.

The Le Fort fracture without maxillary mobility constitutes 9 percent of maxillary fractures observed over a 3-year period. A high Le Fort (level II or III) injury exists as a one- or two-piece incomplete fracture. The degree of fracture is insufficient to permit mobility of the maxillary alveolus. Frequently, an obvious unilateral zygomatic fracture is present. Physical findings consist of bilateral eyelid ecchymosis and malocclusion. The occlusal disturbance may consist of either crossbite, open bite, maxillary rotation, or lack of proper dental intercuspation. On CT scan, fractures are best demonstrated in the posterior and medial maxillary walls at the Le Fort I level; they are most obvious unilaterally with contralateral fractures that may be subtle. Bilateral maxillary sinus fluid is consistently present on CT. Treatment usually consists of observation and traction elastics but may require mobilization of the fragments followed by open reduction and rigid fixation.

Frontal cranioplasty: risk factors and choice of cranial vault reconstructive material.

A study of patients with large cranial defects involving the frontal bone, frontal sinus, nose, and orbit does not support the contention that there is a clear superiority of reconstructive material despite a history of previous bone infection. No patient with an isolated cranial reconstruction experienced an infection despite location in the area of the frontal sinus or the use of acrylic material. All patients experiencing infection underwent simultaneous reconstruction of the frontal cranium and nose and three- or four-wall reconstruction of the orbit, where the frontal sinus had previously been eliminated and where a previous bone infection had been present. Risk factors associated with cranioplasty were timing (p = 0.001) and cranial vault reconstruction in communication with previously infected ethmoid sinuses and the nose (p = 0.03). A history of previous bone infection suggests increased risk (p = 0.15). The choice of reconstructive material was not significant, although acrylic cranioplasties did not experience the complications expected from a review of the literature.

Midface fractures: advantages of immediate extended open reduction and bone grafting.

Experience with 240 midface (Le Fort and zygoma) fractures in multiple trauma patients has emphasized that superior aesthetic results are obtained by immediate extended open reduction with primary bone grafting. Internal fixation of 110 zygomatic and 130 Le Fort fractures was performed in the lower midface (zygomaticomaxillary and nasomaxillary buttresses). Open reduction of the condyle was employed in five concomitant Le Fort and subcondylar fractures with a loss of ramus height to prevent superior and posterior displacement of the middle and lower face. Bone grafts were utilized in 74 patients. They were most frequently employed in the orbit and less frequently in the lower midface. Bone graft survival paralleled that observed under elective conditions, and a slightly higher infection rate was observed. Extended open reduction and immediate bone grafting adds a new dimension to the aesthetic results obtained from facial fracture treatment. Structural bony integrity and pre-injury facial architecture may be restored in the absence of soft-tissue contracture. Restoration of the pre-injury facial architecture (the essence of facial fracture treatment) is more accurately accomplished when these techniques are utilized.