The impact of living with severe lower extremity lymphedema: a utility outcomes score assessment.

BACKGROUND: Debilitating lower extremity lymphedema can be either congenital or acquired. Utility scores are an objective measure used in medicine to quantify degrees of impact on an individual's life. Using standardized utility outcome measures, we aimed to quantify the health state of living with severe unilateral lower extremity lymphedema. METHODS: A utility outcomes assessment using visual analog scale, time trade-off, and standard gamble was used for lower extremity lymphedema, monocular blindness, and binocular blindness from a sample of the general population and medical students. Average utility scores were compared using a paired t test. Linear regression was performed using age, race, and education as independent predictors. RESULTS: A total of 144 prospective participants were included. All measures [visual analog scale, time trade-off, and standard gamble; expressed as mean (SD)] for unilateral lower extremity lymphedema (0.50 ± 0.18, 0.76 ± 0.22, and 0.76 ± 0.21, respectively) were significantly different (P < 0.001) from the corresponding scores for monocular blindness (0.64 ± 0.18, 0.84 ± 0.16, and 0.83 ± 0.17, respectively) and binocular blindness (0.35 ± 0.17, 0.61 ± 0.28, and 0.62 ± 0.26, respectively). CONCLUSIONS: We found that a sample of the general population and medical students, if faced with severe lymphedema, is willing to theoretically trade 8.64 life-years and undergo a procedure with a 24% risk of mortality to restore limb appearance and function to normal. These findings provide a frame of reference regarding the meaning of a diagnosis of severe lower extremity lymphedema to a patient and will allow objective comparison with other health states.

Iatrogenic arteriovenous fistula in the hand: a case report.

Peripheral intravenous cannulation is widely used in medicine. Arteriovenous fistulas are rare complications but their occurrence has never been reported in the hands. We report on a young patient who developed a high flow arteriovenous fistula on the dorsum of her hand two weeks after a failed peripheral intravenous cannulation attempt.

Rapid intraoperative zygoma fracture imaging.

BACKGROUND: A fractured zygoma frequently results in an aesthetically displeasing facial asymmetry. Open reduction and internal fixation may accurately realign the facial skeleton but often with undesirable sequelae. The authors' objective was to develop a precise technique of intraoperative zygoma fracture imaging using a C-arm to permit anatomical fracture realignment while reducing the extent of skeletal exposure required. The simplicity and accessibility of this method should allow its widespread clinical application. METHODS: First, using a model skull, the relative positions of the C-arm required to adequately depict zygoma projection, width, arch contour, and zygoma rotation were defined. Second, diverse zygoma fracture types were created in six cadaver heads with a Mini Bionix machine and were repaired using C-arm guidance; accuracy was confirmed with postoperative computed tomography. Third, after defining optimal operating room setup, the accuracy in a clinical case was assessed. RESULTS: Two C-arm views were defined. The zygoma projection view (C-arm at 70 to 90 degrees to the skull's coronal plane) allows visualization of projection, width, and contour. The rotation view (C-arm at 70 to 90 degrees to the skull's sagittal plane) allows visualization of zygoma rotation. Postoperative computed tomographic imaging confirmed anatomical repair in all cases. Average operating room duration was less than 30 minutes, with operating room times decreasing progressively. CONCLUSIONS: The authors have developed an accurate technique of intraoperative zygoma fracture imaging and reduction guidance. This technique may decrease the risks of open access by potentially limiting direct skeletal exposure to buttresses where skeletal stabilization is required. In addition, this method is simple, can be learned and used rapidly, and is readily accessible.

Zygomatic arch deformation: an anatomic and clinical study.

PURPOSE: Trauma to the zygomatic arch classically leads to 1 of 3 injury patterns: fracture with medial displacement, fracture with posterior telescoping, or explosive burst with lateral displacement. We identified an additional injury pattern whereby the arch undergoes significant bending in the axial plane without fracture. PATIENTS AND METHODS: In the anatomical part of the study, computed tomography (CT) scans of patients with arch deformation without fracture were analyzed for location, degree, and type of arch bending. In the clinical part, patients were divided into "arch deformation without fracture" and "arch fracture" groups and their demographic characteristics compared. Three patients from each group, all treated with the Gillies' technique, underwent postoperative CT scanning to compare accuracy of zygoma repair. RESULTS: Bending occurred most commonly in the middle and posterior thirds of the zygomatic arch, with average deformation of 11 degrees . Post-Gillies' repair, average residual arch deformation was 2 degrees . Patients with arch deformation without fracture were significantly younger than those with arch fracture (24 yrs vs 42 yrs, P < .05). Unlike patients with arch fractures, all those with arch bending treated with the Gillies' maneuver had near anatomic zygoma realignment. CONCLUSION: Zygomatic arch deformation without fracture occurs in 19% of zygoma injuries in our group and is likely elastic in nature. We believe this injury pattern is important clinically as it may decrease the need for coronal exposure, facilitate anatomic repair, and provide stability without hardware fixation.

Algorithm for head computed tomography imaging in patients with mandible fractures.

PURPOSE: Trauma to the mandible can potentially increase our predictive accuracy for intracranial injuries (ICIs) because of the mandible's strength, anatomic proximity, and direct connection to the skull base. Our goals were to: 1) investigate the association of mandible fractures with traumatic brain injury (TBI) and intracranial lesions (ICLs); and 2) determine predictors of ICIs in a level 1 Canadian trauma center with distinct patient demographics and fracture etiologies. PATIENTS AND METHODS: A retrospective chart review was performed of medical records of mandible-fracture patients treated at our institution from 1997 to 2003. Patients who had undergone postinjury computed tomography (CT) of the head with a minimum of 4 weeks' follow-up were considered eligible. Data collected included patient and fracture characteristics, neurologic evaluation, and the presence of concomitant injuries. RESULTS: One hundred eighty-one patients were reviewed, of whom 86 were found eligible, with demographics representative of an urban-trauma population. The incidence of TBI was 68.6%, and of ICLs, 27%. Logistic regression identified alcohol (odds ratio [OR], 3.97), concomitant facial fracture (OR, 2.77), and other systemic injury (OR, 2.59) as independent predictors of an ICI in mandibular fracture patients. Importantly, ICIs were observed in 19% of mandible-fracture patients, satisfying the criteria for mild TBI, and in 17% of patients without any evidence of TBI. CONCLUSIONS: Some authors have advocated treating mandible fractures on an outpatient basis, with a focused workup. Our results of significant concomitant ICI in mandible-fracture patients, conversely, suggest that such management may inadvertently result in the oversight of potentially life-threatening injuries. Thus, we recommend mandatory intracranial CT imaging if the patient's neurologic status at time of injury is unknown or meets the criteria of TBI, or if positive predictors for ICL are present.

Effect of treatment delay on mandibular fracture infection rate.

BACKGROUND: The incidence of infection secondary to mandibular fractures ranges from 0 to 30 percent, resulting in significant sequelae. Unlike other variables that may influence infection, delayed repair is often unavoidable. The objective of this study was to accurately identify the effect of treatment delay on mandibular fracture infection rate by adjusting for confounders, thus providing strong evidence for preoperative management of these patients. METHODS: A retrospective review of mandibular fracture patients treated at the Montreal General Hospital was performed. Length of time delay between injury and operative intervention (< or = 72 hours and > 72 hours) and presence of infection were noted. Logistic regression was used to analyze the effect of treatment delay on infection, after adjustment for covariates. RESULTS: One hundred seventy-seven patients fulfilled the selection criteria and had complete records. The overall incidence of infection was 14 percent (95 percent confidence interval, 8.8 to 18.8 percent). Multiple logistic regression showed no evidence (odds ratio, 2.96; 95 percent confidence interval, 0.87 to 10.1) (p = 0.08) that treatment delay of more than 72 hours is a significant predictor of infection. The incidence of nonunion was 36 percent in the infection group (95 percent confidence interval, 17.2 to 54.8 percent) and 0 percent in the no-infection group. CONCLUSIONS: Infections following mandibular fractures frequently require extended treatment and significantly increase costs. These results show that delay of mandibular fracture treatment greater than 72 hours does not significantly increase infection risk. Repair should occur promptly after the injury. If that is not possible, the standard patient management should not be altered, as the benefits of doing so are unproven.

Quantitative analysis of the orbital floor defect after zygoma fracture repair.

PURPOSE: Moderate-energy zygoma fractures result frequently in a posteromedially displaced bone fragment. Closed reduction using a force vector directed in an anterolateral direction frequently produces stable repair of these injuries. Exploration of the orbital floor (OF) is not routinely undertaken. However, as the zygoma forms a significant portion of the OF, realignment may create an unrecognized OF defect. Routine OF exploration may be unnecessary and carries the risks of eyelid malposition, scarring, and extraocular muscle injury. Our goal was to quantitatively describe the effect of zygoma reduction on OF defect size and identify predictors for floor exploration. PATIENTS AND METHODS: Retrospectively, patients with moderate energy zygoma fractures were identified. Fractures inadequately reduced on the postoperative computed tomography (CT) scan or those which underwent OF exploration were excluded. The sizes of preoperative and postoperative floor defects from CT scans were measured. Globe projection was measured. Statistical analysis was carried out using Student's t test. RESULTS: Of 102 identified patients, 15 satisfied the inclusion criteria. The average pre- and postoperative OF defects measured 0.3 and 0.6 cm(2), respectively. This difference approached statistical significance, but was clinically insignificant except in 1 patient. Similarly, globe projection was clinically similar between the repaired and unaffected sides, except in the same patient. CONCLUSION: In majority, repair of moderate energy zygoma fractures does not clinically significantly increase OF defect or produce enophthalmos. In patients with significant displacement of the zygoma at the level of OF with comminution of floor fragments, the reduction maneuver may create a critical size defect and we believe should be followed by floor exploration.

Surgical correction of congenital constriction band syndrome in children: Replacing Z-plasty with direct closure.

Congenital constriction band syndrome is a sporadic condition that may also be present in association with other congenital anomalies. It has an incidence varying from one in 1200 to one in 15,000 live births. There is a significant predilection for the upper extremities and distal limbs. The two main objectives for the treatment of congenital constriction band syndrome are improvement of function and improvement of cosmetic appearance. Different surgical techniques, such as Z-plasty, have been described and used for decades; however, direct closure after the excision of the constricting band seems to be the simplest and most appropriate, allowing the fatty tissue to naturally reposition itself under the skin. This technique is used in a two-stage approach to avoid affecting distal circulation to the limb.

Silver-coated nylon dressings for pediatric burn victims.

BACKGROUND: Silver dressings are a proven method for burn treatment. Current challenges associated with burn treatment include pain management and limited hospital resources. A new silver-coated nylon dressing was used at the Montreal Children's Hospital (Montreal, Quebec) to help reduce traumatic dressing changes and cost. METHODS: Burn victims in a pediatric patient population were followed over two years. Patients were excluded if they were evaluated more than 48 h postburn or if the burn affected less than 5% of the total body surface area. The same burn team admitted and treated all case subjects, and one dressing nurse recorded and monitored all progress throughout the study to ensure standardization. RESULTS: Fifteen patients were included in the study. The average number of dressing changes needed was 4.13, with a median of three changes. The average total body surface area burned was 8%, with a mean of 13.9 days before superficial wounds were re-epithelialized. The average length of in-hospital stay was four days. The cost was $388 less for silver-coated nylon dressings than for silver sulfadiazine cream for seven days of treatment. Silver-coated nylon dressings did not leave any residue or pseudoeschar on the wounds and were easily maintained at home. CONCLUSION: The silver-coated nylon dressings are as effective as other silver dressings used for pediatric burn victims. The dressings are less traumatic, require fewer resources and do not leave wound residue compared with other dressings.