Closed Traumatic Avulsion of Both Flexor Digitorum Tendons: An Addition to the Leddy and Packer Classification and Review of the Literature.

Objective: We encountered the case of a patient who presented with an avulsion of both flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons from their respective insertion in the ring finger. We aim to discuss the novel treatment of this injury pattern in the context of all previously encountered cases in the literature. Materials and Methods: We examined the case of our patient with avulsion of both flexor tendons in the same finger and discuss the novel method of treatment in our case. Additionally, we performed a literature review of all previous reported cases and discuss the treatment modalities and outcomes associated with each. Results: We have shown a novel and successful treatment technique for avulsion of both the FDP and FDS tendons. We identified twelve other cases of this injury pattern and have compared all outcomes documented. Conclusion: Closed tendon avulsion of both flexor tendons in the same finger is rare. We described a case and additionally propose a modification to the flexor tendon avulsion classification to incorporate this injury pattern and aid its management.

Low risk squamous cell carcinoma and appropriate follow up.

A recent article in the BJD postulated that it may be "Time to reconsider skin cancer-related follow-up visits". In our unit, we too have been seeing too many patient's unnecessarily and we put in place measures to reduce the numbers of outpatient appointments thereby diverting the resources saved into professional development.

Toxin for Treating Raynaud Conditions in Hands (The TORCH Study): A Systematic Review and Meta-analysis.

Background: Raynaud disease of the hands is a complex disorder resulting in inappropriate constriction and/or insufficient dilation in microcirculation. There is an emerging role for botulinum toxin type A (BTX-A) in the treatment armamentarium for refractory Raynaud disease. The aim of this systematic review was to critically evaluate the management of primary and secondary Raynaud disease treated with BTX-A intervention. Methods: We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of clinical studies assessing treatment of primary or secondary Raynaud disease with BTX-A by searching Ovid MEDLINE and Embase databases from inception to first August 2023. The review protocol was prospectively registered on the PROSPERO database (CRD42022312253). Results: Our search strategy identified 288 research articles, of which 18 studies [four randomized controlled trials (RCTs), two non-RCTs, five case series, and seven retrospective cohort studies] were eligible for analysis. Meta-analysis demonstrated that the probability of pain visual analog scale score improvement with BTX-A intervention was 81.95% [95% confidence interval (74.12-87.81) P = 0.19, heterogeneity I 2 = 26%] and probability of digital ulcer healing was 79.37% [95% confidence interval (62.45-89.9) P = 0.02, heterogeneity I 2 = 56%]. Conclusions: Delivery of BTX-A to digital vessels in the hand may be an effective management strategy for primary and secondary Raynaud disease. A definitive, appropriately-powered RCT with objective functional and patient-reported outcome measures is required to accurately assess and quantify the efficacy of BTX-A in Raynaud disease of the hands.

Exploring the burden of actinic keratoses through development of a patient decision aid: a mixed methods study.

BACKGROUND: Actinic keratoses (AKs) present on sun-exposed sites and are considered precursors of cutaneous squamous cell carcinoma (cSCC). A better understanding of the experiences of patients with this condition may improve patient-provider relationships and guide the introduction of shared-decision making (SDM) to treatment decisions. OBJECTIVES: To develop a patient decision aid (PDA) for field treatment of multiple actinic keratoses in line with the International Patient Decision Aid Standards (IPDAS), by (i) characterising the burden and lived experiences of patients with multiple AKs, (ii) understanding the decisional needs of patients requiring field treatment and (iii) exploring clinician preferences regarding field treatment for multiple AKs. MATERIALS AND METHODS: This mixed methods study followed the most up-to-date guidelines set out by the IPDAS Collaboration; a voluntary body which aims to enhance the quality of PDAs by developing an evidence-based systematic process for the development of unbiased and effective PDAs. RESULTS: Multiple actinic keratoses have a psychosocial impact on patients. Patients feel supported through the integration of evidence-based information to guide SDM. CONCLUSIONS: We propose that the use of a PDA for multiple AKs provides a key role in supporting informed shared patient-provider decision making and empowers patient involvement in their prospective treatment strategy.

Retrospective analysis of radiological investigation of surgically excised head and neck lipomas.

PURPOSE: Differentiating benign lipomas from malignant causes is challenging and preoperative investigative guidelines are not well-defined. The purpose of this study was to retrospectively identify cases of head and neck lipomas that were surgically resected over a 5-year period and to identify the radiological modality chosen and features discussed in the final report. Multidisciplinary outcomes and pathology reports were examined with a view to identifying high risk features of a lipoma to aid in future risk stratification. METHODS: Retrospective chart review of pathology characteristics, radiological features (modality, size, calcifications, septations, globular/nodular foci), multidisciplinary discussion and history of presenting complaint was performed. RESULTS: Two liposarcomas and 138 lipomas were identified. Twenty-two percent of all lipomas received radiological investigation. Twenty-two percent of imaging referrals were possibly inappropriate. Furthermore, radiological features suggestive of malignancy were not present in the final radiology report, X2 = 28.8, p < 0.0001. CONCLUSION: As expected, the incidence of liposarcoma is low. There is limited awareness of radiology referral guidelines superimposed with a tendency to over-investigate lipomas. Furthermore, radiological features suggestive of malignancy were inconsistently reported on and not documented in multidisciplinary discussions. Therefore, we propose a multidisciplinary checklist for referring physicians and radiologists to aid in diagnostic work-up.

White phosphorous civilian hand burns - An aid to timely treatment of a rare entity.

First discovered in 1669, white phosphorus is well known for its use in military warfare (Davis, 2002). Its application has since been expanded to include industrial disinfectants, fertilisers and fireworks (Davis, 2002). Exposure to white phosphorus can lead to severe chemical burns with high morbidity and potentially fatal systemic effects. Fortunately, civilian casualties from this potent agent are remarkably rare with few reports in the literature to date (Frank et al., 2008; Aviv et al., 2017). We present the case of a 27-year-old fisherman who sustained a chemical burn to his right hand from a substance suspected to be white phosphorus. We propose an evidence-based algorithm to guide non-military physicians literature on the acute management of white phosphorus burns to optimise timely emergency management of this uncommonly encountered substance.

Investigating the effectiveness of oral ketamine on pain, mood and quality of life in treatment resistant chronic pain.

Introduction: Chronic pain is defined as pain lasting longer than 3 months. This often causes persistent emotional distress and functional disability that is refractory to conventional treatments. Emerging evidence suggests that oral Ketamine therapy may have a specific role in managing treatment-resistant chronic pain. This study aimed to assess the effectiveness of oral ketamine within a tertiary chronic pain management clinic. Methods: This study was a clinic-based retrospective descriptive study of 79 patients with a broad range of chronic pain diagnoses and treated with oral ketamine over a period up to 12 years. Changes in pain, mood and quality of life (QoL) were assessed using a numerical pain severity score, the Brief Pain Inventory (BPI), the Public Health Questionnaire (PHQ-9) and American Chronic Pain Association Quality of Life (QoL) scale. Results: 73 patients were accessible for follow-up (mean daily dose and treatment duration were 193.84 mg and 22.6 months respectively). Pain scores decreased (p < 0.0001) on both numerical scores (41.6% decrease) and BPI scoring (mean decrease 2.61). Mood improved (p < 0.0001) across both PHQ-9 and BPI measurements. Patients also reported less difficulty with daily activities and improved QoL. The most common adverse reaction was drowsiness (21.9%), with 30.1% reporting no adverse reactions from Ketamine. Discussion: This work adds to the growing body of evidence that under the supervision of a pain specialist, oral ketamine therapy may be a safe, tolerable and effective treatment for chronic pain conditions which have not responded to other management options. Further research is required to produce a more accurate understanding of its chronic use. Key message: This real-world study shows that patients being treated with oral ketamine for chronic pain report decreased severity of pain, improved mood and increased quality of life across all conditions.

Indocyanine green fluorescence angiography: A critical intra-operative assessment tool to aid decision making in complex hand trauma.

Indocyanine green fluorescence angiography (ICG-FA) is a validated non-invasive imaging tool used to assess tissue perfusion and guide intra-operative decision making in many surgical disciplines. Clinical assessment of tissue perfusion following crush or degloving traumatic hand injuries presents a significant challenge. This case report supports the critical role of intra-operative ICG-FA as a decision aid in complex hand trauma. We propose ICG-FA will minimise unnecessary tissue debridement, negating complex soft tissue reconstructive surgery and ultimately expediting tissue healing and return to function for hand trauma patients. A 35-year-old right hand dominant manual labourer presented to the emergency department after sustaining a crush injury to his right hand. Examination under anaesthetic revealed a comminuted open fracture of middle finger P2 with compromised soft tissue coverage. A formal assessment of hand perfusion was performed using a triad of clinical assessment, critical judgement and ICG-FA. The ICG-FA revealed a small skin flap affecting the dorsoradial P2 skin which was not perfused. This prompted meticulous minimal debridement of this tissue and prevented unnecessary over-debridement that would have resulted in complex soft tissue reconstruction. Currently the gold standard assessment for tissue perfusion in hand injuries is clinical judgement and is limited by subjective interobserver error [1]. IGA-FA has been proven to offer a real time assessment of tissue perfusion. This case demonstrates the use of ICG-FA as an adjunct to clinical examination and judgement, to optimise the accuracy of soft tissue perfusion assessment in complex hand trauma.

Traumatic open brachial plexus injuries: The importance of interdisciplinary collaboration.

Open traumatic brachial plexus injuries are rare, yet can be life threatening and require rapid clinic assessment. Early interdisciplinary collaboration is critical to achieve superior patient outcomes. This case of a 24-year-old female of a traumatic neck injury with contralateral brachial plexus injury demonstrates the limitations of early clinical assessment due to the potential for haemodynamic instability and highlights the priority of patient stabilisation. Early and active interdisciplinary collaboration in this case demonstrates its importance in accurate diagnosis and timely intervention to achieve better patient outcomes. As published in recent guidelines, this report shows the importance of early interdisciplinary involvement following stabilisation and resuscitation of the patient.

Posterior interosseous neuropathy: distinguishing from a proximal radial neuropathy.

The posterior interosseous nerve is the terminal motor branch of the radial nerve that innervates the extensor carpi ulnaris and the extensors of the thumb and fingers. We describe a case of a posterior interosseous neuropathy presenting with the typical 'finger drop' and partial 'wrist drop'. We focus on the clinical signs that distinguish it from a more proximal radial neuropathy, clarified by nerve conduction studies and needle electromyography. Multimodal imaging of the forearm did not identify a compressive lesion. Persistent symptoms prompted surgical exploration 5 years after initial onset. It identified compression of the posterior interosseous nerve in the region of the arcade of Frohse and leash of Henry. The sites were decompressed and concurrent salvage secondary reconstructive tendon transfers were required in view of the severe axonal loss with minimal chance of functional reinnervation.

Free Vascularized Rectus Abdominis Transfer With Pedicled Intercostal Innervation for Functional Reconstruction of the Elbow in Total Brachial Plexus Palsy.

PURPOSE: Reanimation of palsied upper limbs usually follows an escalating pattern of nerve repair, nerve transfers, and musculotendinous transfers and culminates in free functioning muscle transfers. When there are no other musculotendinous options, we explored the possibility of transferring the rectus abdominus to the biceps by maintaining the nerve pedicle but dividing the vascular pedicle and anastomosing it to the brachial artery. METHODS: We performed anatomical dissection of the nerve and blood supply of 6 rectus abdominis muscles in 3 cadavers. A retrospective analysis of 4 patients in whom a rectus abdominus muscle transfer with a pedicled nerve, but free vascular supply, was then performed. RESULTS: The anatomical feasibility study demonstrated that it was possible to elevate the rectus abdominis on its intercostal nerve supply to the midaxillary line, allowing the muscle to be pedicled on its nerve supply and be transferred to the arm to reconstruct biceps. The vascular supply could be reestablished by anastomosis of inferior epigastric vessels to the brachial artery and veins. In 4 patients, elbow flexion strength of M3 or greater was achieved. Average elbow range of dynamic flexion was 120° (range, 92° to 131°). Shoulder stability and external rotation improved in all patients with resolution of shoulder subluxation. Two patients developed donor site hernias requiring mesh reconstruction. Complications included a hypertrophic recipient site scar in one patient, and recipient site wound dehiscence in another. CONCLUSIONS: Rectus abdominus can be transferred to reconstruct elbow flexion when other musculotendinous transfers are unavailable and as an alternative to free functioning muscle transfer. However, rectus abdominus transfer still requires microsurgical skills for the vessel anastomoses. This is an effective procedure for functional reconstruction of the elbow and adds to the armamentarium in the management of brachial plexus pathology when other transfers are unavailable. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

The Adipofascial Deltopectoral Flap to Cover the Brachial Plexus in Thoracic Outlet Syndrome and Radiation Plexitis.

Revascularisation of the brachial plexus is controversial. Traditional techniques use free tissue transfer of omentum, groin fat or muscle, on the principle of supplying rich quantities of vascularised tissue to wrap around the nerves permitting neural gliding and revascularising the scarred nerves. However, the complexity of an additional microsurgical procedure coupled with uncertainty of their effectiveness have curtailed their clinical application. We describe a local pedicled transposition flap that is a novel modification of the deltopectoral (DP) flap using only the subcutaneous adipofascial tissue vascularised by the medial pectoral perforators. This flap is harvested through the supraclavicular brachial plexus access incision. This avoids free tissue transfer and additional donor scarring, yet provides adequate volumes of well-vascularised tissue for mechanical protection and revascularisation of the plexus. We reviewed sixteen consecutive patients who underwent a pedicled adipofascial DP flap to protect the brachial plexus over the 20-year study period. Inclusion criteria were patients with recurrent thoracic outlet compression and patients with radiation plexitis. At latest follow-up (average 3.6 years), 75% of patients reported the improvement or resolution of symptoms. The majority of patients reported improved pain scores (82%) with an average pain visual analogue scale (VAS) score of 5.1. Patients were very satisfied with scar outcomes, reporting low Vancouver Scar Scale Scores and low scar VAS scores. Post-operative MR imaging, available in 31% of the cohort, demonstrates the maintenance of flap position and vascularity at an average of 2.1 years. This novel and simple technique is recommended in aiding revascularisation and cover of the brachial plexus in recurrent and recalcitrant plexopathy.

Current Strategies for Reconstruction of Soft Tissue Defects of the Spine.

Spinal surgery has been revolutionized by advances in instrumentation, bone graft substitutes, and perioperative care. Extensive dissection, creation of large areas of dead space, and the use of instrumentation in compromised patients, however, predisposes to high rates of wound complications. Postoperative wound complications in patients undergoing complex spinal surgery can have devastating sequelae, including hardware exposure, meningitis, and unplanned reoperation. Recognition of high-risk patients and prediction of wound closure difficulties, combined with preemptive reconstructive surgical strategies may prevent complications. The purpose of this review is to discuss the principles of spine wound management and provide a synopsis of the soft tissue reconstructive strategies utilized in spinal surgery. We review the senior author's preferred reconstructive algorithm for the management of these complex wounds, in addition to outcomes data relating to the timing of reconstructive surgery.

Radial nerve palsies associated with paediatric supracondylar humeral fractures: a caution in the interpretation of neurophysiological studies.

Traumatic and iatrogenic neurological complications associated with paediatric supracondylar humeral fractures are well recognised. The severity of the nerve injury associated with supracondylar humeral fractures can be difficult to assess clinically and relies upon clinical progression or absence of recovery and neurophysiology. It is accepted that complete nerve palsy with neurophysiological complete block and absence of clinical recovery after three months requires surgical exploration and reconstruction. However, we argue that even a partial nerve palsy that is failing to recover as expected by 3 months should be explored even when the neurophysiology suggests the nerve is in continuity. We report two cases of closed Gartland type III paediatric extension-type supracondylar humeral fractures treated with closed reduction and percutaneous pinning and open reduction and internal fixation, respectively. Both children developed persistent postoperative radial nerve motor palsy. Neurophysiological studies sought prior to exploration indicated a degree of sensory nerve function in both cases, indicating a nerve in continuity. Subsequent surgical exploration revealed interfragmentary radial nerve compression at the fracture site at two levels in one case and at one level in the second case. The site of compression was excised and the nerve grafted. Excellent near-normal radial nerve recovery was achieved except for the persistent loss of extensor carpi radialis function in the first child. We publish these findings to highlight the possibility of misinterpreting the incomplete nerve lesion and the neurophysiology of a nerve in continuity, as a nerve that would spontaneously recover. At exploration, in these two cases, it was clear by the level of interfragmentary compression that the nerve would not have recovered without surgical intervention. We recommend exploration and repair of the radial nerve, when function to the nerve is compromised, even in the face of neurophysiological evidence of an intact nerve.

Aesthetic surgery training in a changing healthcare environment.

Aesthetic surgery is a rapidly evolving sub-speciality, both technologically and conceptually. It is therefore critical that plastic surgery training coincides with this rapid evolution. Recent fiscal limitations in public health provision and trainee working-time legislation may impact the delivery of high quality aesthetic surgery training. There is an urgent need to address the delivery of aesthetic training in current training paradigms in Ireland and we propose a number of strategies to obliterate the learning curve.