Distal Dorsal Thumb Mass: Giant Cell Tumor of the Tendon Sheath in an Unusual Location.

Giant cell tumor of the tendon sheath (GCTTS) is a common mass in the digits, hands, and upper extremities. Diagnosis is made on clinical examination, adjunctive imaging, and distinct intraoperative findings. Surgical excision is the mainstay of treatment. GCTTS are typically found on flexor surfaces with the dorsal distal thumb being an unusual location. Any surgical approach to the digit should balance oncologic margins with preserving function. GCTTS have a tendency to recur and should be approached in a methodical manner with risk factors of recurrence in mind. This case report reviews the history of GCTTS, surgical approaches to the digit, and risk factors for recurrence to achieve success in the surgical management of these tumors.

Pedunculated Natal Tooth: A Case Report.

Natal teeth are teeth present at birth and are a rare finding. They most commonly occur in the mandibular incisor region and are thought to occur as an accelerated premature growth of normal primary teeth. They may present in the varying stages of tooth eruption and rarely on a pedunculated stalk of alveolar mucosa as described in this case. Natal teeth may be surgically extracted if difficulty feeding or ventral tongue ulceration develops. This report presents the case of an unusual pedunculated natal tooth in a newborn at a community hospital and describes its surgical management.

Minimally Invasive Magnetic Removal of Forehead Foreign Body.

Residual foreign bodies are common sequelae of penetrating injuries. These may be left in situ or extracted and can be difficult to localize, often requiring wide exposure, which can be difficult to achieve in cosmetically sensitive areas. Different technological adjuncts are used to facilitate foreign body removal including fluoroscopy, ultrasound, and more recently, surgical magnets. This case describes and illustrates the unusual technique of using a sterile surgical magnet to both localize and remove a foreign body in the head and neck region using a minimally invasively technique.

Traumatic Pulmonary Arteriovenous Malformation Presenting as Spontaneous Hemothorax.

Pulmonary arteriovenous malformations (PAVM), also known as pulmonary arteriovenous fistulas, are abnormal connections between the pulmonary arterial and venous systems. The majority occur secondary to the congenital syndrome hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease. Trauma is an extremely rare etiology of PAVM, comprising less than 1% of all reported cases. Trauma can be associated with both immediate and delayed development of PAVM, and present similarly to PAVM associated with HHT. We report a case of a traumatic PAVM that developed in a patient one year following blunt thoracic trauma with a rib fracture. The patient subsequently developed a rupture of the PAVM, resulting in spontaneous hemothorax. She required multi-unit blood transfusion and multiple thoracostomy tube placements. The patient subsequently underwent a failed attempt at angioembolization of the PAVM. She eventually required a thoracotomy for surgical excision of the PAVM. We discuss the traumatic etiologies, clinical presentation, diagnostic assessments, and therapeutic modalities for the management of PAVM.

Hiatal Hernia With Gastric Perforation.

A 63-year-old male with a history of hiatal hernia presented with one day of hematemesis and acute peritonitis. Computed tomographic imaging revealed perigastric pneumoperitoneum concerning perforated viscus. Exploratory laparotomy revealed a Type III hiatal hernia with a perforated posterior gastric ulcer, which was reduced and repaired. This report describes a case of acute abdomen secondary to hiatal hernia, a rare presentation of hiatal hernia, along with its surgical management and postoperative care.

Superficial Temporal Artery True Fusiform Aneurysm With Several Lateral Feeding Vessels.

A 49-year-old man flight attendant with a past medical history of Roux-en-Y bypass and massive weight loss 18 months prior was referred for surgical management of a superficial temporal artery aneurysm. Imaging confirmed the diagnosis. Intraoperatively a 1 cm fusiform aneurysm was identified with numerous feeding side branch vessels. The aneurysm was suture ligated and excised in toto with pathologic analysis showing involvement of all vessel layers. This case highlights a rare true aneurysm of the superficial temporal artery and aberrant anatomy of multiple side branches feeding the aneurysm and complicating dissection and excision.

Chimeric Free Fibula Flap: An Encounter With Aberrant Anatomy.

A 59-year-old male presented with recurrent mucoepidermoid carcinoma of the mandible. A resection with immediate free fibula flap reconstruction was done. The osteocutaneous free fibula flap relies on the peroneal artery and its distal perforators. Variant patterns necessitate consideration of the challenging to dissect proximal myocutaneous perforator raised on a single or double anastomosis, depending on origin. Even in cases of flap salvage, the fibula flap remains a reliable flap. This case describes a fibula flap with a sole proximal myocutaneous perforator identified during dissection despite a normal preoperative Doppler.

Miniplate Fixation to an Edentulous Mandibular Fracture in Panfacial Trauma.

A 70-year-old edentulous male presented with bilateral mandible and left midface fractures following an assault. Imaging confirmed fractures and showed mandible thickness greater than 20 millimeters. The patient was treated by open reduction internal fixation with miniplates via an intra-oral approach and recovered without deficit. While miniplate fixation and an intra-oral approach is typically reserved for the dentulous patient, this case illustrates that in select edentulous patients with sufficient bone thickness and amenable midface fractures this technique may be successfully utilized.

A Rare Case of Extramedullary Plasmacytoma Presenting as Large Abdominal Mass.

A 79-year-old female with a past medical history of multiple myeloma, diabetes mellitus and chronic kidney disease presented to the hospital with generalized weakness. The patient was found to have a firm abdominal wall mass with no underlying skin changes or drainage on physical examination. Computerized tomography of the abdomen and pelvis without contrast revealed a large mass-like structure in the anterior abdominal wall in the subcutaneous region extending into the abdomen through the mesentery with juxtaposition and partial involvement of the left hepatic lobe and distal stomach. Solitary extramedullary plasmacytomas are extremely rare tumors that occur outside of the bone marrow in the absence of systemic involvement. This case reports details the finding of an extramedullary plasmacytomas, which accounts for less than 5% of plasma cell neoplasms.

Complicated Surgical Removal of an Adherent Port-a-Cath After 11 Years of Implantation.

A 65-year-old woman with a medical history significant for anal cancer was referred by her primary care physician for a port-a-cath removal. The port was placed prior to treatment of squamous cell carcinoma of the anus, 11 years prior to this scheduled removal. She received chemotherapy and radiation in accordance with the Nigro protocol, treating the anal cancer to complete resolution. During port removal, a fibrous capsule was dissected and the port was removed from the left upper breast border along with proximal portion of the catheter. Significant difficulty was found in removing the remaining catheter despite sustained traction and guidewire insertion. Fluoroscopy revealed an intravascular adhesion of the catheter tip in the superior vena cava, which could not be freed. In order to prevent vascular injury, the adhesed portion of the distal catheter was left in place with three large surgical clips placed distally. This case highlights the very rare complication of complete vascular adherence of the terminal catheter tip and extended port intracorporeal time as a risk factor for adhesion. This case also highlights the importance of timely permanent central venous catheter removal following completion of its intended regimen.

Using lectures to identify student misconceptions: a study on the paradoxical effects of hyperkalemia on vascular smooth muscle.

Medical students have difficulty understanding the mechanisms underlying hyperkalemia-mediated local control of blood flow. Such control mechanisms are crucial in the brain, kidney, and skeletal muscle vasculature. We aimed to identify medical students' misconceptions via assessment of students' in-class knowledge and, subsequently, improve future teaching of this concept. In-class polling was performed with the TurningPoint clicker response system (n = 860) to gauge students' understanding of three physiological concepts related to hyperkalemia: membrane potential (Vm), conductance, and smooth muscle response. Vm includes the concepts of equilibrium potential (Veq) for specific ions, as well as driving force (DF = Vm - Veq). Students understood the concept of DF (~70% answered correctly), suggesting their understanding of Vm. However, students misunderstood that hyperkalemia results in depolarization (~52% answered correctly) and leads to an increase in potassium conductance (~31% answered correctly). Clarification of the type of smooth muscle as vascular increased the percentage of correct responses (~51 to 73%). The data indicate that students lacked knowledge of specific potassium conductance in various muscle types, resulting in divergent responses, such as the canonical depolarization in skeletal muscle versus hyperpolarization in smooth muscle cells during hyperkalemia. Misunderstanding of this crucial concept of conductance is directly related to the students' performance. Furthermore, we connected the paradoxical effect of hyperkalemia to pathological acute and chronic hyperkalemia clinical scenarios.