Influence of restraining devices on patterns of pediatric facial trauma in motor vehicle collisions.

In the Commonwealth of Pennsylvania, it is required that all children under the age of 4 years be restrained by an infant seat or car seat appropriate for their age and weight. Furthermore, all individuals riding in the front seat must be restrained by a seatbelt. This study examined the relationship between patterns of facial injuries and the use of restraining devices in the pediatric population. A retrospective analysis was performed on motor vehicle collision data submitted to the Pennsylvania Trauma Outcome Study database from 1990 through 1995. Criteria for submission included trauma patients who were admitted to the Intensive Care Unit, those who died during hospitalization, those who were hospitalized for more than 72 hours, or those who were transferred in or out of the receiving hospital. A subset of 412 pediatric patients, 15 years of age or younger, was analyzed for patterns of facial injury and the presence or absence of restraining devices. Restraining devices were categorized as a car seat or a seatbelt. Statistical analysis was performed using chi-square and Fisher's exact tests. Of the 412 pediatric patients, only 17 children were restrained with a car seat and 121 were wearing a seatbelt. A total of 30 children sustained facial fractures, and 50 children suffered facial lacerations. There was a statistically significant increase in the incidence of facial fractures with increasing age of the child (p < 0.001). Of children with facial fractures, 70 percent of those 5 to 12 years old and 90 percent of those 13 to 15 years old were unrestrained (p = 0.166). In conclusion, despite legislation mandating the use of restraints, a large proportion of children involved in motor vehicle collisions were unrestrained. Furthermore, there seems to be a direct relationship between the age of a child and the incidence of facial fractures sustained in motor vehicle collisions.

The influence of air bags and restraining devices on extremity injuries in motor vehicle collisions.

The influence of air bags and other restraining devices on injury after motor vehicle collisions is not well defined. This study examined the relationship between the use of restraining devices and the incidence of extremity injuries in motor vehicle collisions. A retrospective analysis was performed on motor vehicle collision data submitted to the Pennsylvania Trauma Outcome Study database from 1990 through 1995. Criteria for submission included trauma patients who were admitted to the intensive care unit, who died during hospitalization, who were hospitalized for more than 72 hours, or who were transferred in or out of the receiving hospital. A total of 21,875 patients met these criteria. These patients were analyzed for the presence or absence of upper and lower extremity injuries and were compared based on their use of restraining devices. Restraining devices were categorized into four groups: air bag alone, air bag and seat belt, seat belt or carseat without air bag, and no restraining device. Statistical analysis was performed using the chi-squared test of association. For contingency tables with small expected frequencies, Fisher's exact test was used. Study participants included 11,688 men and 10,185 women with a mean age of 38 +/- 20 years. There were 16,033 drivers and 5,842 passengers. Air bags were deployed in 472 instances. In 297 of these cases, additional restraint was provided with a seat belt. In 6,632 cases, air bags were not deployed; however, patients were restrained with either a seat belt or a carseat. In 14,771 cases, patients were not restrained. When comparing restraining devices as a group vs. no restraint, there was a significant decrease in the incidence of upper (p = 0.018) and lower (p < 0.001) extremity injuries. Air bags, however, were associated with an increased incidence of both upper (p = 0.033) and lower (p = 0.002) extremity injuries when compared with no restraint or when compared among patients who were restrained. As a group, restraining devices decrease the incidence of upper and lower extremity trauma sustained by patients injured in motor vehicle collisions. Air bags, however, are associated with an increased incidence of upper and lower extremity injuries when compared with seat belts alone or when no restraining devices are used.

Bilateral radial artery pseudoaneurysms associated with bilateral ulnar artery atresia: a case report.

Pseudoaneurysms of the radial artery are uncommon and most often localized in an area of penetrating vascular trauma or iatrogenic injury. Hypoplasia of the ulnar artery is even more rare. We report a case of bilateral radial artery pseudoaneurysms associated with complete absence of any ulnar contribution to the vascularity of the hand. A patient presented with bilateral tender masses adjacent to the anatomic snuff boxes that interfered with hand function. After confirming that these masses were bilateral radial artery pseudoaneurysms, resection of the pseudoaneurysms and microscopic reconstruction of the arterial segments preserved vascular integrity of the hands and provided relief of the patient's pain.

The influence of airbag and restraining devices on the patterns of facial trauma in motor vehicle collisions.

According to the National Highway Traffic Safety Administration (1990), there were more than 3 million motor vehicle collisions severe enough to lead to significant injury or fatality. Airbags may prevent brain and facial injury caused by these accidents. To date, however, no study has focused primarily on the correlation between facial injuries and the use of airbags and restraining devices. A retrospective analysis was performed on motor vehicle collision data submitted to the Pennsylvania Trauma Outcome Study database from 1990 through 1995. Criteria for submission to the database included admission to the intensive care unit, death during hospitalization, hospitalization for >72 hours, or transfer to or from the receiving hospital. There were 15,450 patients who sustained facial trauma (identified by ICD-9 codes) and were analyzed for patterns of injury and the presence or absence of protective devices. Protective devices were categorized into four groups: airbag alone, airbag with seatbelt, seatbelt or car seat without airbag, and no restraining devices. Statistical analysis was performed using chi-squared test of association. For contingency tables with small expected frequencies, Fisher's exact test was used. There were 9408 male and 6042 female subjects, with a mean age of 38 years (range, 3 to 98 years). There were 11,672 drivers and 3778 passengers. Airbags were deployed in 429 instances. In 276 of these cases, additional restraint was provided with a seatbelt. Airbags were not deployed in 4866 cases when a seatbelt or a car seat was used. In 10,155 cases, no restraining device was employed. There was significantly more facial trauma in patients without protective devices (p < 0.001). Drivers sustained significantly fewer facial fractures when airbags were used, either alone or in combination with a seatbelt (p < 0.001); however, there was no difference in the number of facial lacerations. Among passengers, airbags provided protection from lacerations (p < 0.001) but had no impact on the incidence of facial fractures. In collisions in which airbags were deployed, the use of a seatbelt provided no additional protection from facial fractures or lacerations. In summary, the use of any protective device decreased the incidence of facial fractures and lacerations sustained in motor vehicle collisions (p < 0.001). Airbags provided the best protection of all currently available devices.

Tear of an anomalous lumbrical muscle as a source of pain in the hand.

Symptoms from adhesions between lumbrical and interosseous muscles at the metacarpophalangeal joint have been described. We report a case in which symptoms were secondary to a tear in an anomalous lumbrical muscle of the ring finger.

The axillary tree as a source of musculocutaneous and fasciocutaneous flaps in a fixed-skin porcine model.

Our understanding of muscle, fascia, and skin flap physiology is based largely on data obtained from rodent, rabbit, or canine models. The presence of a well-developed panniculus carnosus confounds the extrapolation of data from these animals to humans. This study attempted to define microsurgically applicable musculocutaneous and fasciocutaneous flaps in the pig that would be comparable to flaps commonly used in humans. Lead oxide was injected into each axillary artery of three standard white domestic swine. Gross dissection and radiographic studies were used to define the specific anatomic fasciocutaneous territory served by the branches of the circumflex scapular artery. Eight musculocutaneous flaps based on the thoracodorsal artery and eight fasciocutaneous flaps based on the circumflex scapular artery were elevated. Although all flaps survived in their entirety, the fasciocutaneous flaps did not, as in man, have an easily dissectable axial blood supply. This finding suggests that the porcine scapular fasciocutaneous flap, although reliable as a pedicled flap, is difficult to employ as a free tissue transfer.

Midpalmar approach to the carpal tunnel: an alternative to endoscopic release.

The midpalmar approach involves making a 2.5-cm incision in the palm, sparing the skin directly overlying the carpal tunnel. Through this incision, a small fiber-optically illuminated retractor is introduced, which allows direct inspection of the transverse carpal ligament and any anatomic variations of the median nerve. The transverse carpal ligament can then be safely and completely divided under direct visualization. This approach also allows inspection of the carpal tunnel for any space-occupying masses or neurolysis, if deemed necessary. By avoiding a skin incision directly over the carpal tunnel, the postoperative course is very gentle and very similar to that of an endoscopic release. Unlike the endoscopic release, this approach is versatile, easy to learn, allows complete visualization of the anatomy, and does not require expensive instrumentation.

Staged reconstruction of abdominal wall defects after intra-abdominal catastrophes.

Advances in surgical intensive care have improved survival in patients with major traumatic or infectious intra-abdominal insults. Patients who recover are often left with massive abdominal wall defects. Sufficient autogenous tissue may not be available for reconstruction and synthetic mesh followed by skin grafting can lead to unaesthetic results or complications. We report on four patients with abdominal wall defects and their reconstruction after intra-abdominal injury. Treatment involved local wound care to stimulate granulation tissue, which is eventually skin grafted to close the wound. Patients are then allowed to make a full recovery. Soft-tissue expanding prostheses are placed during a second operation and inflated over subsequent weeks. Finally, the skin graft is excised, a polytetrafluoroethylene patch is placed into the fascial defect, and the expanded skin is used to achieve wound closure.

Idiosyncratic allergic reaction to textured saline implants.

In the literature, multiple conditions, including hematomas, self-limited cutaneous eruptions, and generalized systemic complaints, have been attributed to breast implants. We report the first case of idiosyncratic allergic reaction to the textured surface of a mammary prosthesis. The reaction was documented by patch testing of the textured surface compared with smooth-surface silicone controls. Symptoms resolved with removal of the implants and have not recurred after insertion of smooth-walled implants. Whereas the physiology of this condition remains unclear at this time, it is important to recognize the possibility of a delayed hypersensitivity reaction when considering reconstruction with a textured breast implant.

Microvascular steal phenomenon in lower extremity reconstruction.

Macrovascular bypass procedures and microvascular free tissue transfer have resulted in dramatic improvements in lower limb salvage. Although vascular steal is a well-documented phenomenon in the surgical literature, there is a paucity of information on its potential impact in microvascular surgery, particularly in relation to lower extremity reconstruction in the elderly patient with peripheral vascular disease. We report three cases of lower extremity reconstruction using microvascular free tissue transfer in which the free flap survived but the distal extremity suffered progressive ischemic necrosis. A retrospective analysis of these cases defines the conditions in which microvascular steal phenomenon may adversely influence lower limb salvage.

Prosthetic vascular graft and autogenous vein graft with free-tissue transfer in attempted lower-limb salvage.

Chronic wounds of the lower extremity are frequent causes of osteomyelitis and amputation in patients with peripheral vascular disease. Advances in vascular surgical techniques, allowing distal arterial bypass via synthetic grafts or autogenous vein grafts, have significantly increased the frequency of limb salvage. In the last two decades, this increasing success has contributed to an even greater rate of extremity salvage. The authors report a case of attempted limb preservation, using a combination of macrovascular polytetrafluoroethylene (Goretex) grafting, reverse saphenous vein interposition, and vein-patch angioplasty, to facilitate microvascular free-tissue transfer.

Optimal management of inguinal vascular graft infections.

Vascular graft infections demand serious attention due to the potential for mortality or limb loss. Management modalities range from conservative wound debridement and drainage to graft resection and extra-anatomical revascularization. A retrospective chart review was conducted to evaluate wound complications in patients who underwent inguinal vascular bypass in an attempt to define the incidence of wound complications and guidelines for their management. Vascular operations involving femoral anastomoses were performed on 1,637 patients; 58 wound infections occurred in 57 patients (3.5%) over an 8-year period at our institution. There were 16 graft infections in 15 of these 57 patients (0.92%). Ten patients were treated with local muscle flaps, 1 with a fasciocutaneous thigh flap, and 5 with graft excision and either extra-anatomical bypass or amputation. Local flap coverage appears to be as effective as graft excision for the treatment of inguinal vascular graft infections. An algorithm for optimal management of these infections is presented.

Major neurovascular complications of endoscopic carpal tunnel release.

Endoscopic carpal tunnel release is becoming an increasingly popular method of surgically correcting median nerve compression. Several complications have been suggested as possibilities following the technique; however, to date, there have been only isolated reports of iatrogenic injury to major neurovascular structures in the hand. We report both a case of transection of the median nerve and a pseudoaneurysm of the superficial palmar arch following endoscopic carpal tunnel release.

Extradigital glomus tumor as a cause of knee pain.

Although there exists much debate in the dermatohistopathologic literature about the exact characterization of the glomus tumor, this case illustrates what should be considered the sine qua non indications of clinically significant glomus tumors, i.e., exquisite pain and complete relief of pain with surgical excision. One should not, therefore, limit the inclusion of glomus tumors to the differential diagnosis of severe localized pain only in the upper extremity.

A barrier technique for pulsed irrigation of cavitary wounds.

A technique for barrier protection during pulsed irrigation of cavitary wounds is presented. The method is discussed within the context of current concerns regarding intraoperative viral transmission.

Magnetic resonance imaging in the evaluation of persistent carpal tunnel syndrome.

Magnetic resonance imaging was used to assess nine median nerves in the wrists of seven patients who had signs and symptoms of persistent compressive median neuropathy despite previous carpal tunnel release. Intraoperative findings were then correlated in eight surgically treated cases with both MRI findings and postoperative results. Magnetic resonance imaging suggested a potential abnormality in each of eight operative cases. These findings correlated very well with both intraoperative observations and postoperative results, which indicated that some abnormality involving either the median nerve or the transverse carpal ligament had been present in all cases. Magnetic resonance imaging proved to be a sensitive and specific tool in the evaluation of persistent postoperative median nerve compression.

Delayed debulking of free muscle flaps for aesthetic contouring debulking of free muscle flaps.

Although denervated muscle and myocutaneous free flaps atrophy over a period of time, when used for surface coverage they may remain bulky, resulting in a less than optimal aesthetic result. With the availability of a number of donor sites, soft tissue defects can often be reconstructed with like tissue in a single stage. Even though the goal of all plastic surgeons is to achieve a good cosmetic result, special circumstances might dictate that need take precedence over form. We have had six cases where a bulky muscle was used to achieve well vascularised coverage. After wound closure had been successfully accomplished, a secondary debulking procedure was performed safely for a final acceptable aesthetic result.

Amputation stump salvage using a "banked" free-tissue transfer.

A free radical forearm flap was salvaged from a nonreplantable amputated extremity and banked on the ipsilateral chest wall. Later, the flap was simply rotated to provide coverage of the proximal humeral stump, eliminating the need for a second microvascular procedure.