Is Routine Imaging Necessary for the Management of Pediatric Hand Fractures Postoperatively?

BACKGROUND: Pediatric hand fractures heal remarkedly well, and clinically significant displacement after operative fixation is rare. Radiation exposure in medical practice is regulated by the Ionizing Radiation Medical Exposure Regulations 2017, and unnecessary radiation should be avoided. In the literature, there is paucity of information regarding the number of radiographs required in the postoperative period and guidelines are lacking. METHODS: This study aims to examine whether routine imaging or the lack of it influences functional outcome and time to discharge from the clinic. A retrospective data of pediatric hand fractures requiring intervention between 2014 and 2018 at our institution were conducted before and after elimination of routine postoperative imaging. A total of 230 patients were included in the study. RESULTS: Two cohorts of patients were identified. The first had routine postoperative radiographs, whereas the second did not have routine radiographs. There was no change in management and difference in the range of motion at discharge between the 2 groups (P = 0.74). Patients without routine imaging were discharged earlier from clinic (74.4 vs 108.2 days, P = 0.012). CONCLUSIONS: This study shows that clinically significant fracture displacement is rare after operative reduction and fixation in pediatric age group. It demonstrates our experience in refraining from routine postoperative radiographs. The overall benefit is to avoid unnecessary radiation and subsequent costs implicated.

Dermatofibrosarcoma Protuberans in Children.

OPINION STATEMENT: Paediatric dermatofibrosarcoma protuberans (DFSP) is a rare soft tissue malignant tumour which displays aggressive local behaviour and has low metastatic potential. The diagnosis is often delayed as DFSP is usually mistaken for other skin conditions, particularly in the early stages of disease. DFSP tends to follow an indolent course after the initial presentation with what is often described as a "rubbery lump". As the disease progresses, the lump tends to enlarge, change colour, and exhibit a more nodular consistency. In rare cases, DFSP can present as an ulcerated exophytic lesion or a depressed area of skin, making diagnosis even more challenging. A high index of suspicion is warranted for early diagnosis, and referral to a specialist unit with expertise in both oncologic resection and reconstruction. DFSP tumours arise from the dermis and grow with finger-like projections. Therefore, in cosmetically sensitive or functionally important locations, an excision and analysis technique that assesses all excision margins is the gold standard of care. Slow Mohs technique performed with en bloc excision is a well-tolerated option for oncologic resection of the tumour. Mohs technique can also be considered but can be challenging in children for reasons explained below. As an alternative, depending on the anatomical location, tumours can be excised with a wide local excision. While an excision technique that incorporates the deep fascia with a 3-cm peripheral margin is acceptable in adults, planning of the excision margin in children should involve consideration of preoperative imaging with MRI, site of the tumour, age, and physical built of the child. Patients should be offered all treatment options considering the local outcomes, available expertise, and cost. A multidisciplinary approach and good communication between team members is crucial. Close collaboration with a pathologist who is familiar with sectioning technique that allows margin control is of paramount importance. Soft tissue reconstruction should be performed immediately after oncologic clearance, although a staged approach may be required. Adjuvant radiotherapy should be avoided in children due to the long-term risk of secondary malignancies and potential for growth disruption.

Balancing Training Opportunities and Patient Outcomes: A Single Surgeon's Experience.

ABSTRACT: Microvascular free tissue transfer is the criterion standard of reconstruction post-oncological resections of the head and neck region. We present a consultant's first 200 consecutive microvascular head and neck reconstructions in independent practice. A retrospective analysis of a prospectively collected database of all head and neck reconstructions performed in the first 3 years of practice was performed. These included 200 consecutive microvascular head and neck reconstructions performed by a single surgeon at a tertiary referral center. We review the results and complications in this series and discuss factors significant for successful outcomes in head and neck reconstruction. We also highlight that different parts of the surgery in the majority of cases were performed by a trainee under the supervision of the senior surgeon and thus discuss the need for training future plastic surgeons with an interest in head and neck reconstruction.

Locally Advanced Scalp Tumors: Clinical and Survival Outcomes of a Tertiary Unit.

INTRODUCTION: Locally advanced nonmelanoma skin cancers of the head and neck are well described in the current literature. However, data about clinical and survival outcomes are lacking. We present survival data from a tertiary head and neck cancer unit in London. METHODS: A retrospective analysis of data collected from a single institution was conducted. All patients with locally advanced cutaneous scalp carcinomas invading the skull between 2011 and 2019 were included. Data included patient demographics, tumor, comorbidities, interventions, flap survival, and metal work exposure. Survival outcomes were examined using Kaplan-Meier analysis. RESULTS: Twenty-three patients were identified. The mean age was 72 years. Eighteen patients were male, and 5 were female. Five patients were immunosuppressed. Nineteen patients underwent outer cortex drill-down/full-thickness calvarial resection, followed by reconstruction with free tissue transfer. Six patients had titanium mesh reconstruction after segmental skull resections. Three patients underwent further surgery because of exposed metalwork. Disease-free survival at 3 years after surgery was 60%. CONCLUSIONS: Locally advanced nonmelanoma skin cancers invading the bone are sporadic. There are little published data on clinical and survival outcomes in this group. Despite the nature of these skin lesions, a high degree of local control can be obtained by extensive surgical resection, outer table drill-down, and calvarial resection. We conclude that aggressive management of the bony invasion improves disease-free survival and improves local control.

The Oxford Finger Nail Appearance Score - a new scoring system for fingernail deformity following paediatric finger tip trauma.

Fingernail deformity is common, yet current methods used to define cosmetic appearance following trauma are mainly descriptive. In order to quantify the cosmetic appearance of the fingernail, we developed the Oxford Fingernail Appearance Score using a three stage iterative process. The score has five cosmetic components marked as binary outcomes composed of nail shape, nail adherence, eponychial appearance, nail surface appearance and presence of a split. In the first stage, two assessors independently assessed 25 photographs of fingernails taken at a minimum of four months following paediatric nail bed repair and compared them to the corresponding contralateral uninjured finger. Following refinement in the score, ten different assessors scored a further 62 photographs of fingernails taken after paediatric nail bed repair. Assessors completed each of the five components, and the overall component score was calculated by statisticians post-hoc, taking the ideal appearance of each component as 1 ("identical to opposite" for nail shape, eponychium and surface, "complete" for adherence, "absent" for split) and all the non-ideal appearances as 0. Assessors effectively scored the photographs' integer values between 0 (least optimal appearance) and 5 (most optimal appearance). Refinements in the scoring system resulted in an improvement in a weighted kappa statistic of 0.36 (95% CI:0.09,0.68) in the initial score to 0.52 (95% CI: 0.42, 0.61). The Oxford Fingernail Appearance Score is a user-friendly and reliable scoring system which has application in a clinical trial setting.

Dermatofibrosarcoma protuberans (DFSP) in children: A combined multidisciplinary approach.

Dermatofibrosarcoma protuberans (DFSP) is rare, comprising (1%-6%) of all sarcomas. The incidence is less than one per million before the age of 20. It is a locally aggressive tumor with a low risk of metastasis. We share our experience in the management of three pediatric patients with complex cases of DFSP in a combined surgical approach involving plastic and dermatologic surgery, using the slow Mohs micrographic surgery technique.

Perioral pressure ulcers in patients with COVID-19 requiring invasive mechanical ventilation.

BACKGROUND: Facial pressure ulcers are a rare yet significant complication. National Institute for Health and Care Excellence (NICE) guidelines recommend that patients should be risk-assessed for pressure ulcers and measures instated to prevent such complication. In this study, we report case series of perioral pressure ulcers developed following the use of two devices to secure endotracheal tubes in COVID-19 positive patients managed in the intensive care setting. METHODS: A retrospective analysis was conducted on sixteen patients identified to have perioral pressure ulcers by using the institutional risk management system. Data parameters included patient demographics (age, gender, comorbidities, smoking history and body mass index (BMI)). Data collection included the indication of admission to ITU, duration of intubation, types of medical devices utilised to secure the endotracheal tube, requirement of vasopressor agents and renal replacement therapy, presence of other associated ulcers, duration of proning and mortality. RESULTS: Sixteen patients developed different patterns of perioral pressure ulcers related to the use of two medical devices (Insight, AnchorFast). The mean age was 58.6 years. The average length of intubation was 18.8 days. Fourteen patients required proning, with an average duration of 5.2 days. CONCLUSIONS: The two devices utilised to secure endotracheal tubes are associated with unique patterns of facial pressure ulcers. Measures should be taken to assess the skin regularly and avoid utilising devices that are associated with a high risk of facial pressure ulcers. Awareness and training should be provided to prevent such significant complication.Level of evidence: Level IV, risk/prognostic study.

Lightning injuries in Northern Ireland.

INTRODUCTION: Lightning injuries are uncommon in Northern Ireland (NI) with scarce reports detailing incidence and local experience. We present a case study of 3 patients involved in a single lightning strike with a review of the incidence of similar injuries in the province. METHODS: Data from TORRO's National Lightning Incidents Database between 1987 and 2016 (30 years) were searched to identify victims of lightning injuries in NI. Information on 3 patients with lightning injuries that were managed in our regional burns and plastic surgery service was collected and examined. A supplementary search in hospital records was conducted over the last 20 years to identify additional data. RESULTS: Prior to our study, 6 victims of lightning injuries were identified of whom 5 survived and 1 died. Our 3 patients comprised of 2 children and 1 accompanying adult. All survived but the adult suffered cardiac arrest and required a prolonged period of cardiopulmonary resuscitation. CONCLUSION: While lightning injuries are rare in NI, this is the first report of more than one person affected by a single lightning incident in the province. In our limited experience, immediate public response and prolonged cardiopulmonary resuscitation efforts facilitated by automated defibrillators result in a favourable outcome.

Delayed diagnosis of dermal leiomyosarcoma mimicking keloid scar.

A 43-year-old man developed an abnormal scar 6 months following excision of a leiomyoma from his left shoulder. The scar was elevated, irregular in shape, pink-red in colour, hard in consistency and it was extending beyond the margins of the original wound. A diagnosis of a keloid scar was considered and the patient was managed as such. He underwent a planned procedure for intralesional excision of the keloid scar. The histopathological examination showed a diagnosis of leiomyosarcoma. This case report presents a delayed diagnosis of dermal leiomyosarcoma mimicking a keloid scar. The patient subsequently underwent wider excision of the tumour with curative intention.

Euglycaemic ketoacidosis: a potential new hazard to plastic surgery day case and inpatient procedures.

A woman aged 44 underwent elective standard abdominoplasty and bilateral mastopexy (superiorly based pedicle with vertical scar) following weight loss of 8.5 stone (53.9 kg) over a 5-year period. She had type 2 diabetes and her antidiabetic medications included metformin, liraglutide and empagliflozin. Towards the end of the first postoperative day, she reported gradual onset of nausea, vomiting and abdominal pain. Her condition continued to deteriorate overnight, becoming tachycardic and tachypnoeic. Urgent investigations showed severe diabetic ketoacidosis with euglycaemia. She was managed with fluid resuscitation, insulin infusion and intravenous sodium bicarbonate in the high dependency unit. She made a complete clinical and biochemical recovery and was discharged on day 9 postoperatively. This case illustrates a diagnostic challenge of a serious life-threatening complication of diabetes in the postoperative period associated with a novel class of antidiabetic medications, sodium-glucose cotransporter 2 inhibitors.