Wine, Honey, and Boiling Oil: A Modern Understanding of Ancient Wound Care Practices.

The origins of wound care date back to ancient civilizations. From boiling oil to honey to wine, healers and caregivers have adopted a fascinating array of items to cleanse, dress, and bandage wounds over the ages. While wound care practices have developed over time, the physicians and surgeons of ancient times and the Middle Ages helped build the foundation for present-day wound care. A modern scientific understanding of these treatments illustrates why practitioners abandoned some practices while others remain in use today.

Meta-analysis of imaging techniques for the diagnosis of complex regional pain syndrome type I.

PURPOSE: To compare the effectiveness of imaging techniques in aiding and confirming the diagnosis of complex regional pain syndrome (CRPS) type I. METHODS: We conducted a meta-analysis of randomized controlled studies that evaluated the effectiveness of 3 different imaging techniques in aiding the diagnosis of CRPS type I. A systematic search in bibliographical databases resulted in 24 studies with 1,916 participants. RESULTS: To determine the effectiveness of each imaging technique, we determined the average specificity, sensitivity, negative predictive value, and positive predictive value and then statistically compared them using the analysis of variance statistical test, which indicated that compared with magnetic resonance imaging and plain film radiography, triple-phase bone scan had a significantly better sensitivity and negative predictive values. However, there appeared to be no statistical significance between imaging techniques when we evaluated specificity and positive predictive value using the analysis of variance test. CONCLUSIONS: The findings of this meta-analysis support the use of triple-phase bone scan in ruling out CRPS type I, owing to its greater sensitivity and higher negative predictive value than both magnetic resonance imaging and plain film radiography. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic I.

Posterior Interosseous Nerve Graft: Utilizing External Landmarks and Anthropometric Ratios to Predict Available Length for Digital Nerve Reconstruction in a Cadaveric Study.

Objective: In digital nerve defects that require grafting, autografts remain the efficacious option. The sensory posterior interosseous nerve (PIN) is an ideal choice as it is of similar caliber to digital nerves and leaves no donor morbidity upon resection. However, a finite length of harvestable PIN exists, and considerable variations of this length have been reported in the literature. There exists no predictive model to estimate this length. We sought to determine a method to accurately predict the available length of PIN based on individual patient anthropometry. Methods: A cadaveric dissection study was performed in a fresh tissue laboratory. The length of the sensory branch of the PIN and various anthropometric measurements were made in respect to surface anatomy of the ulna to develop a predictable ratio for available PIN donor graft. Results: A total of 16 specimens were obtained. On average the length of the PIN was 5.7 cm (range: 3.3-9. cm) and the length of the ulna was 25.7 cm (range: 23.5-30.6 cm). The ratio of PIN to ulnar length was 0.222 (r = 0.4651). Using one-fifth the length of the ulna, the mean predicted length of the PIN was 5.14 cm (range: 4.7-6.1 cm). On univariate analysis, there was no significant difference between the measured and predicted PIN length (P = .249). Conclusion: An anthropometric ratio predicated on reproducible surface anatomy of the ulna is a useful tool in predicting the sensory PIN length. Such a prediction may be a useful in guiding patient discussions concerning surgical options for digital nerve reconstruction.

Objectif: Dans les cas d'anomalies des nerfs digitaux qui exigent une greffe, les autogreffes sont les plus efficaces. Le nerf interosseux postérieur (NIP) sensitif est le choix idéal, car son calibre est semblable à celui des nerfs digitaux et qu'il ne provoque aucun problème de santé au site de résection. Cependant, la longueur du NIP pouvant être récolté est limitée, et d'énormes variations sont présentées dans les publications. Aucun modèle prédictif ne permet d'évaluer cette longueur. Les chercheurs ont entrepris d'établir une méthode pour prédire avec fiabilité la longueur disponible du NIP d'après les caractéristiques anthropométriques de chaque patient. Méthodologie: Les chercheurs ont procédé à une étude de dissection cadavérique dans un laboratoire de tissus frais. Ils ont mesuré le rameau sensitif du NIP et diverses dimensions anthropométriques d'après l'anatomie de surface de l'ulna pour établir un ratio prévisible de greffe du NIP disponible chez le donneur. Résultats: Les chercheurs ont obtenu 16 prélèvements et calculé une longueur moyenne du NIP de 5,7 cm (plage de 3,3 cm à 9,6 cm) et une longueur moyenne de l'ulna de 25,7 cm (plage de 23,5 cm à 30,6 cm). Ils ont calculé un ratio de 0,222 (r = 0,4651) entre la longueur du NIP et de l'ulna. D'après le cinquième de la longueur de l'ulna, ils ont prédit une longueur moyenne du NIP de 5,14 cm (plage de 4,7 cm à 6,1 cm). À l'analyse univariée, ils n'ont constaté aucune différence significative entre la longueur mesurée et prédite du NIP (P = 0,249). Conclusion: Le ratio anthropométrique établi d'après l'anatomie de la surface reproductive de l'ulna est un outil utile pour prédire la longueur du NIP sensitif. Une telle prédiction peut être utile pour orienter les échanges avec le patient au sujet des possibilités chirurgicales de la reconstruction du nerf digital.

Anatomic surface landmarks to guide injection for posterior interosseous nerve block.

Proper injection of the posterior interosseous nerve (PIN) is important for both the therapeutic and diagnostic management of wrist pain. However, no anatomical study exists describing the site of injection based on individual wrist width. We sought to develop a reproducible anthropometric ratio utilizing external wrist surface anatomy to predict a safe and accurate injection site for the PIN. Fresh frozen cadaver forearms were dissected at the University of Louisville tissue lab. Several anthropometric measurements were obtained in order to develop a reproducible ratio to calculate location of injection. A total of 16 cadaver forearms of equal male to female ratio were obtained. On average, the male forearm had a greater mean wrist circumference obtained at the level of Lister's tubercle compared to female forearms, 17.1 cm vs. 13.5 cm. An injection given ulnar to proximal edge of Lister's tubercle at a length of one-fourth the distance between Lister's tubercle and radial aspect of ulnar styloid resulted in 100% accurate perineural injection without intraneural injection. An anthropometric ratio of one-fourth the distance from Lister's tubercle to the ulnar styloid was able to predict accurate injection sites for the distal PIN in cadaveric specimens of varying anatomical proportions.

Surface Landmarks to Provide a Safe Ulnar Nerve Block in the Wrist: Anatomical Study and Literature Review.

Introduction: Use of local anesthesia in awake patients undergoing hand surgery has become increasingly popular. A thorough understanding of local anatomy, such as the distal wrist for ulnar nerve block, is required to provide safe blockade. We sought to conduct an anatomic study of the distal wrist and review cadaveric studies describing various techniques for ulnar nerve block. Methods: Dissection of fresh-frozen cadaver forearms at the University of Louisville Robert Acland Fresh Tissue Lab assessing relationships between the flexor carpi ulnaris tendon and the ulnar nerve and the ulnar artery was performed. Three cadaveric studies on ulnar nerve blockade using the ulnar, volar, and/or transtendinous technique were identified and reviewed. Results: A total of 16 cadaver forearms of equal male to female ratio were obtained. The ulnar nerve was noted to be directly posterior to the flexor carpi ulnaris tendon in 15 (93.8%) forearms, with 1 (6.3%) specimen having the nerve extend along the ulnar border of the flexor carpi ulnaris. The ulnar artery was radial to the ulnar nerve 1 cm proximal to the pisiform in all specimens. In all 3 cadaveric studies, only the ulnar technique was associated with no ulnar artery and/or ulnar nerve injury. Conclusion: Knowledge of distal wrist anatomy can help minimize risk of iatrogenic injury during local blockade. On review, the ulnar approach provides the safest method for ulnar nerve block.

Students teaching students: A survey of a medical student led surgical skills workshop - A prospective cohort study.

BACKGROUND: Surgical skills training is a recognized vital component of medical education, yet a standardized curriculum does not exist. Early opportunities for skills development and mentorship may increase student interest in pursuing surgery. We evaluated the effects of a student-led, faculty-supervised suture clinic on student comfort level with basic surgical skills and interest in surgery. METHODS: A cohort survey study of 103 second-year medical students participating in a surgical skills course was performed between the years 2016-2018. Upon completion of the course, we assessed their comfort level with performing six basic skills as well as their interest in pursuing surgery based on pre- and post-course surveys. RESULTS: Mean age was 25 years and 50.5% were female. Most students (61.2%) had no prior suturing experience. Upon completion of the course, there was a significant improvement (p = < 0.0001) in comfort level for each of the six skills. Most students (81%) reported an increased interest in surgery. CONCLUSIONS: Early implementation of a basic skills workshop can augment student comfort level and promote an interest in surgery. Peer student mentors can effectively lead the workshop and minimize the time commitment needed by surgical faculty. This can serve as a new direction in medical education and an avenue for further studies to analyze the longitudinal effects of the curriculum on career choice and success in surgical residency.

Basic suture technique: Instructional videos explaining suturing for medical students in a qualitative study.

BACKGROUND: Understanding basic surgical skills is important for medical students prior to entering residency regardless of future specialty. In these videos we provide instruction for suturing as it relates to skin closure. MATERIAL AND METHODS: Instructional videos were created by the senior faculty (R.A. and M.K.) to teach medical students at the University of Louisville suturing techniques. RESULTS: Entering and exiting the needle at an angle of 90° or greater allows for tissue eversion. Inadequate eversion of tissue or inadequate angling of the needle will lead to tissue inversion. When suturing uneven edges, a deep bite on the low side and a shallow bite on the high side will allow for appropriate tissue leveling. For buried sutures, skin eversion with substantial dermal bites and proper knot location is essential. CONCLUSION: Understanding the basics of skin apposition will provide students with knowledge about primary wound healing and prepare them for residency.

Anatomic Landmarks to Locate the Median Nerve for Safe Wrist Block or Carpal Tunnel Steroid Injection.

Introduction: Carpal tunnel syndrome is the most common entrapment neuropathy involving the upper extremity. As such, various nonoperative techniques have been developed to aid in management of mild to moderate disease, including local steroid injection. However, definitive guidelines for needle/injection location have not been defined, especially in relation to diminishment of iatrogenic injury to the median nerve. Methods: A cadaveric study was designed to determine the average width of the median nerve, as well as its location specifically in relation to the palmaris longus (if present), the flexor carpi radialis, and the midpoint of the wrist. All measurements were obtained at the radial tip of the interstyloid line. Results: Data demonstrated that the average width of the median nerve was 7.85 mm and that it lies ulnar in location to the palmaris longus (3 mm), as well as the midpoint of the wrist at the radial tip of the interstyloid line (0.43 mm). Furthermore, the distance between the median nerve and the flexor carpi radialis was measured to be 9.57 mm. Outcomes: Therefore, injection location should be radial with respect to the palmaris longus and the midline of the wrist. It can be just ulnar to the flexor carpi radialis tendon or between 8 and 10 mm radial to the midpoint of the wrist in order to prevent median nerve injection and direct trauma to the nerve.

The Unexpected Hand Patient.

Objective: Physicians should be aware of patients trying to obtain a diagnosis for secondary gain. Malingering is a diagnosis that should be suspected when objective findings do not support the subjective symptoms and there is secondary gain. Methods: A series of 21 cases are presented that support this position. The charts of 21 patients with a diagnosis of reflex sympathetic dystrophy (chronic regional pain syndrome) and nonanatomic findings were evaluated. Results: The patients in this series were found to be malingering based on discrepancies between subjective symptoms and objective findings. Conclusions: The diagnosis of malingering should be based on thorough history, physical examination, electrodiagnostic studies, imaging studies, and evaluation of all medical records.

Iatrogenic Injury to the Median Nerve During Palmaris Longus Harvest: An Overview of Safe Harvesting Techniques.

Background: A rare and disastrous complication of harvesting a tendon graft is the misidentification of the median nerve for the palmaris longus. Methods: The authors report a referred case in which the median nerve was harvested as a free tendon graft. Results: Few reports of this complication are found in the literature despite the frequency of palmaris longus tendon grafting and the proximity of the palmaris tendon to the median nerve. Given the obvious medicolegal implications, the true incidence of this complication is difficult to assess. Discussion: Safe harvesting of the palmaris longus mandates a thorough understanding of the relevant anatomy, in particular the proper differentiation between nerve and tendon and recognition of when the palmaris longus tendon is absent. Techniques to facilitate proper identification of the palmaris longus are outlined.

Preservation of the Sterile Matrix, Hyponychium, and Fingertip Pad in Fingertip Reconstruction With Composite Fingertip and Nail Bed Graft and Volar V-Y Advancement Flap.

Background: The goals of fingertip reconstruction are to achieve adequate soft-tissue coverage and a functional nail plate and to maintain sensation, proprioception, and cosmesis. Objective: We present a composite tissue graft and volar V-Y advancement flap for reconstruction of a traumatic amputation of a fingertip, which provided optimal preservation of the hyponychium and the volar pad for prevention of a hook nail. Historically, composite fingertip grafts have not been recommended for adults with large defects. Methods: The amputated nail bed, hyponychium, and a 10 × 20-mm segment of the fingertip were utilized as a composite graft for reconstruction of the nail bed in an adult. The addition of a volar V-Y advancement flap to reconstruct the fingertip was necessary for complete soft-tissue reconstruction. Results: The reconstruction resulted in nail plate adhesion without significant nail deformity and a functional and sensate fingertip. Conclusion: Components of amputated fingertips including the sterile matrix, hyponychium, and part of the fingertip can be utilized in a composite graft to yield satisfactory functional and cosmetic results in adults.

Patient selection.

Patient selection is the process by which an evaluating surgeon decides whether to accept responsibility for the care and treatment of a potential patient. It is assumed the physician has the requisite knowledge to assess the anatomic disorder and the technical ability to render appropriate care if needed. The aim of this article is to help the less experienced health care professional sort out which patients, either by true psychological disorder or personality and behavioral traits, pose the highest risk of a poor outcome. An unsatisfactory outcome can be measured not only by failure to resolve the disorder but also by expenditure of a disproportionate amount of practice resources in achieving resolution of the problem.

High pressure injection injuries of the hand.

High-pressure injection injuries of the hand represent one of the most serious surgical emergencies of the upper extremity. It is imperative to understand the mechanism of injury and the parts that take place for this injury to occur (material, pressure, site of injury). Prompt recognition and treatment may alter the final outcome.

Forty-Year Follow-up of Full-Thickness Skin Graft After Thermal Burn Injury to the Volar Hand.

BACKGROUND: The hands are commonly affected in severe thermal burn injuries. Resulting contractures lead to significant loss of function. Burn contracture release and skin grafting are necessary to restore hand function. We report a case in which surgical reconstruction of a volar hand burn was performed with full-thickness skin grafting. The patient had a 40-year follow-up to assess the function and cosmesis of the repaired hand. METHODS: We report a case in which a 15-month-old boy presented after receiving third-degree burns to the left volar hand, including the flexural aspects of the index, long, and ring fingers by placing it on a hot kitchen stove burner. The patient subsequently underwent scar contracture release and full-thickness skin grafting. RESULTS: Eleven years after reconstruction, further contractures developed associated with the patient's growth, which were reconstructed with repeat full-thickness skin graft from the inguinal region. No recurrence was witnessed afterward and 40 years after initial injury, the patient maintains full activities of daily living and use of his hand in his occupation. CONCLUSIONS: There is debate regarding the superiority of split-thickness versus full-thickness grafts during reconstruction. Our case strengthens the argument for durability of a full-thickness skin graft following thermal burn injury.

An Inexpensive Suture Practice Board.

OBJECTIVE: We provide a design for an effective suture practice board for surgical instruction that is both easily assembled and repaired. METHODS: This model's design is achieved through inexpensive materials that do not compromise adequate simulation through repetitive use. We used a wooden board, synthetic microfiber cloth, and metal plates and screws to create the suture board. Two pieces of synthetic microfiber cloth, folded along the long axis, were attached to the outer edges of the wooden board using an electric screwdriver, with the metal plates and screws to secure the attachment. RESULTS: Upon completion of construction, we have a board sufficient for instructing various suturing techniques. CONCLUSIONS: Our suture board design provides an effective practice material that is an improvement in cost, as well as reusability compared with other models. Our board has the advantage over animal tissues, such as chicken's or pigs' feet, because it is not perishable and maintains its durability over extended periods of time. This model is advantageous compared with other commercially available synthetic models because the materials are cheaper and more easily replaced. Our suture board model provides sufficient simulation to enhance the user's skills across various suturing techniques in a manner that is cost-effective in production and maintenance.

Malingering by proxy: a form of pediatric condition falsification.

The deliberate production or feigning of signs or symptoms in a child by a caretaker is well recognized as factitious disorder by proxy, a psychiatric condition commonly reported in the pediatric literature. However, it is not as well recognized that the false illness portrayal may also be the result of a parent instructing the child to malinger. A case report of a 13-year-old patient who feigned an immobile upper extremity for the purpose of obtaining a legal settlement is presented. Physicians are encouraged to make protecting the child from parental or iatrogenic harm a priority. Recommendations for careful confrontation and expedient resolution are made.