Classification of soft-tissue degloving in limb trauma.

Compressive, tortional and abrasive deforming forces are translated to the limbs during high energy trauma. The long bones may be fractured in many patterns with a varying extent of fragmentation and comminution but the soft-tissues appear to absorb the forces in a predictable way. We retrospectively reviewed a series of 79 complex limb injuries treated in a dedicated centre where the clinical notes and photo-documentation were meticulously kept and where the outcomes were known. The soft-tissue injuries were then described and revealed four patterns of injury: abrasion/avulsion, non-circumferential degloving, circumferential single plane and circumferential multi-plane degloving. These patterns occurred either in isolation or occasionally in combination. Resuturing of degloved skin was only successful in non-circumferential (pattern 2) cases. Radical excision of devitalised tissue followed by soft-tissue reconstruction in a single procedure was successful in all patterns apart from pattern 4 (circumferential multi-plane degloving). In pattern 4 we recommend serial wound excision prior to reconstruction.

Quantification of circulating cell-free plasma DNA and endothelial gene RNA in patients with burns and relation to acute thermal injury.

BACKGROUND: Major burn represents a multi-system insult to the human body. Despite improvements in mortality and morbidity, reliable predictors of outcome are lacking. Raised levels of cell-free nucleic acids have been detected in various pathological processes including burns. We quantified circulating nucleic acids as potential objective measures of burn severity with predictive and prognostic value. METHODS: Expression of endothelial specific cell-free mRNA and cell-free DNA were measured in plasma of 19 burn patients at days 1-3 and week 10 following acute thermal injury and in 19 healthy controls by real-time quantitative PCR. RESULTS: Expression of endothelial specific mRNA was higher in burn patients compared to controls (p<0.001). DNA levels were significantly higher in the burn population in the first 48 h following injury. Plasma RNA and DNA levels related to %TBSA burn in the first 24h and to the levels of circulating endothelial progenitor cells. CONCLUSIONS: We show that plasma levels of endothelial specific mRNA and DNA are elevated acutely following burns, and relate to severity in terms of %TBSA burnt.

Mobilization of endothelial progenitor cells into the circulation in burned patients.

BACKGROUND: Bone marrow-derived endothelial progenitor cells (EPCs) have been detected in the peripheral blood of patients following thermal injury. EPCs migrate to sites of active neovascularization in response to mediators released after trauma, contributing to wound healing. The aim was to characterize levels and kinetics of EPCs in burned patients, then relate these to key mobilizing factors, vascular endothelial growth factor (VEGF) and the chemokine (C-X-C motif) ligand 12 (CXCL 12), and compare them with those in healthy subjects. METHODS: The study included 19 adult patients with superficial or full-thickness burns and 50 blood donor volunteer controls. EPCs, identified by cell surface markers CD45(dim/-), CD133+, CD144+ and VEGF receptor 2, were quantified by four-colour flow cytometry. Plasma VEGF and CXCL12 were measured using enzyme-linked immunosorbent assay. RESULTS: Burned patients showed a rapid rise in EPC levels within 24 h, a ninefold increase compared with controls, returning to basal levels by 72 h. Body surface area burned correlated strongly with the degree of mobilization. EPC levels correlated significantly with rises in plasma VEGF and CXCL12. CONCLUSION: Thermal injury induced a rapid rise in EPCs that was proportional to the extent of the burn and significantly correlated with levels of angiogenic cytokines. Such cytokines may be used to stimulate EPCs as a future therapeutic target in burned patients.

The factors considered by editors of plastic surgery journals in evaluating submitted manuscripts.

The publication of clinical- or laboratory-based research in peer-reviewed journals is seen as the final end point rewarding many months of detailed work. For both trainees and established consultants alike, having a submitted manuscript rejected is both frustrating and disheartening. All journals publish details regarding manuscript structure and preparation. However these "in-house" guidelines tell little about what editors are looking for in their journals, and indeed what can be done to ensure acceptance of any work that researchers submit. The authors surveyed the editors of 40 peer-reviewed plastic surgery and related subspeciality journals regarding factors that influence their decision to accept or reject a manuscript. The aim was to establish factors that influence editors' decisions regarding submitted papers, which then would enable aspects to be highlighted that authors could address to expedite publication and produce relevant guidelines to facilitate this process. The results demonstrate that editors value an original, rigorously designed manuscript with valid methodology and appropriate conclusions. Adherence to the philosophy and aims of the journal and the journal's target audience will further improve the likelihood of successful publication for the submitting authors.

Prospective survey of factors affecting risk discussion during consent in a surgical specialty.

BACKGROUND: The Department of Health in the UK has developed new consent guidance but without clear recommendations on how the incidence and severity of a given risk should influence its discussion during the process of obtaining informed consent. Plastic surgery is a litigation-prone specialty that offers a paradigm for assessing attitudes to consent. METHODS: A questionnaire was sent to all surgeons at six plastic and reconstructive surgery units within the UK. It enquired what incidence of a relatively frequent minor severity risk such as wound infection, or an extremely rare but major risk such as stroke, would merit its discussion when obtaining informed consent for elective surgery. RESULTS: Sixty of 85 questionnaires were returned. For a minor risk, there was a consensus that an incidence threshold of 5 per cent or greater would necessitate its discussion. For a major risk, the modal threshold was 0.1 per cent, but there was a greater variability of response. CONCLUSION: There was a wide variation of opinion as to how frequently a major risk must occur before it is likely to be conveyed to a patient during the process of consent. The findings suggest that recent change in case law has yet to disseminate fully in one surgical specialty, with the potential for the challenge that consent is not 'informed'.

Dermal cellular inflammation in burns. an insight into the function of dermal microvascular anatomy.

The damage caused by thermal trauma is augmented by the subsequent inflammatory response in a similar fashion to reperfusion injury. Animal studies have demonstrated a significant role for neutrophils in this delayed damage, but little is known about the numbers of neutrophils or other leucocytes that enter human skin following burns. We have longitudinally examined profiles of leucocyte migration into five cases of human partial thickness burns in relation to continued dermal microvascular destruction during the acute post-burn period. All burn wounds had a rapid influx of neutrophils that was followed by a delayed influx of macrophages. Compared to the controls, the two superficial burns also had rapid and sustained influx of CD4 and CD8 lymphocytes via patent post capillary venules in the dermal superficial vascular plexus, whilst in the three deeper burns, in which this superficial vascular plexus was occluded, the number of lymphocytes decreased. These results suggest that the patterns of leucocyte extravasation were dependent on the initial level of vascular occlusion, indicating that the dermal microvascular anatomy plays a pivotal role in determining the composition of the extravascular inflammatory cell infiltrates. The potential importance of this finding is highlighted by the differences in wound behaviour associated with the different leucocyte profiles.

Burn depth and its histological measurement.

This paper describes a new technique for burn depth measurement, based on the histological assessment of dermal microvascular occlusion in burn biopsies. The technique was validated in a preliminary study of acute progressive microvascular damage in five adults with partial thickness burns. Burn depth was calculated at three time points post burn from the mean histological measurement of the most superficial patent and the deepest blocked vessels in five separate sections from each biopsy. The results were expressed as a percentage of the total dermal thickness and correlated well with the laser Doppler measurement of dermal blood flow and clinical estimation of burn depth. The reproducibility of the technique was tested by the repeated blind analysis of five randomly chosen biopsies on a separate occasion. Altman-Bland plot analysis demonstrated a median variation of 0.1% (95% confidence interval -1 to 2%). A second independent observer (MPHT), who carried out a blind analysis of the same randomly chosen biopsies, tested the precision of the technique. The median variation was 2% (95% confidence interval -5 to 8.5%).

Describing severe limb trauma.

Seventy-nine severe limb injuries were retrospectively reviewed to compare the AO/ASIF and the Gustillo classifications. Specifically, the suitability of these classifications with respect to prognosis and management of these cases was compared. A healed and stable wound was the ultimate outcome measure. Surrogate outcome measures used were: the time to healing; the number of anaesthetics until the wounds were healed; and the number of operations until the wounds were healed. Any change in lifestyle following the injury was also assessed. The primary healing rates of the AO/ASIF groups showed significant (P < 0.001) inter-group differences. However, when the injuries were classified using the Gustillo system, the primary healing rates did not show any differences between the groups. Also, differences in the other outcome measures were most pronounced when using the AO/ASIF system. Importantly, changes in lifestyle correlated with the injury score when using the AO/ASIF system (P < 0.05). Unlike the AO/ASIF system, the Gustillo system was not applicable in 100% of cases. A modified AO/ASIF scoring system is proposed which provides a good predictor of outcome.

Spontaneous rupture of extensor pollicis longus tendon in a kick boxer.

A 23 year old male kick boxer presented with a 24 hour history of pain and being unable to extend the interphalangeal joint of the left thumb. There was no history of trauma or any other risk factor for spontaneous rupture of the extensor pollicis longus tendon. On the previous day, he had been doing reverse press ups on the dorsum of his hands with his wrists hyperflexed as part of his training for kick boxing. At operation the extensor pollicis longus tendon was found to be divided at the level of the dorsal tubercle of the radius and was not directly repairable. The treatment was an extensor indicis proprius transfer. We suggest that the cause of the tendon rupture was direct pressure on the dorsal tubercle of the radius sustained while performing reverse press ups.

Grip and pinch strength variations in different types of workers.

We measured grip and pinch strengths in non-manual, light manual and heavy manual workers using a Jamar dynamometer and a pinch measuring device. Heavy manual workers had the strongest grips with the least difference between sides. Office workers had the weakest grips and the greatest difference between sides. Light manual workers were between these two groups. Consequently, the occupation of the patient must be taken into account when using grip and pinch strength measurements to assess the need for rehabilitation and in medicolegal reports.

Anatomy of the internal mammary veins and their use in free TRAM flap breast reconstruction.

The anatomy of 61 internal mammary veins (IMV) in the 3rd, 4th and 5th intercostal spaces was studied in 34 fresh human cadavers by injection and corrosion methods and surgical dissection. The IMV was present in all 34 cadavers. Four different patterns of venous anatomy were identified: Types 1 (69%) and 2 (26%) were common, Types 3 (3%) and 4(2%) were rare. The most common arrangement (Type 1) consists of the internal mammary vein running medial and parallel to the artery to the 4th intercostal space where it divides into the medial and the lateral IMV, the lateral crossing the internal mammary artery (IMA) anterior to it in direction from medial to lateral. Both veins are connected by interconnecting branches. The mean diameter of internal mammary veins is 2.7 mm (range 1.1-4.8 mm) for the medial and 1.8 mm (range 0.5-3.5 mm) for the lateral one. The mean distance from the lateral bordoffof the sternum of the medial vein is 9 mm (range 2-18 mm) and 14 mm (range 9-24 mm) for the lateral vepfpff. We present a review of 7 patients in whom internal mammary vessels were used as recipient vessels for breast reconstruction with free TRAM flaps with no complications, as well as the advantages and disadvantages of such a procedure.

Hyperamylasaemia in ruptured aortic aneurysm: incidence and prognostic implications.

A study was carried out to determine the incidence of increased serum amylase activity in patients with ruptured aortic aneurysm during the 48 h after presentation and to assess its clinical significance. In a prospective series of 25 patients, hyperamylasaemia occurred in ten and was significantly associated with poor outcome (P = 0.005). In patients who died or had a major complication, serum amylase activity was significantly higher than in those who had an uncomplicated postoperative recovery (P < 0.05). There was a correlation between preoperative serum amylase activity and length of stay in the intensive care unit after operation (rs = 0.78 (95 per cent confidence interval 0.54-0.90), P < 0.002). Serum amylase activity may be useful as a prognostic indicator in patients with ruptured aortic aneurysm.