A rare penetrating injury through the axilla caused by stilt pole in a Bajau Laut boy.

An 8-year-old child of Bajau Laut descent (a stateless tribe in Eastern Borneo and the Sulu archipelago) presented following a fall, with penetrating injury through the axilla caused by a stilt pole, exiting at the supero-anterior aspect of the left shoulder. Due to the lack of comprehension of modern medical treatment and poor language skills, the parents refused to consent for detailed radioimaging studies, nor surgical removal and exploration in the operating theatre. The removal of retained stilt pole was done in casualty area in Hospital Tawau, followed by local exploration under sedation and local analgesia. Despite the horrific injury, there was no limb-threatening neurovascular injury sustained. Management of such injury in the nomadic Bajau Laut population provides valuable insight and about the challenges and decisions of management.

Radial to axillary nerve transfer.

Axillary nerve injury is common after brachial plexus injuries, particularly with shoulder luxation. Nerve grafting is the traditional procedure for postganglionic injuries. Nerve transfer is emerging as a viable option particularly in late referrals. At the proximal arm the radial and axillary nerves lie close by. Sacrificing one of the triceps muscle nerve branches induces little negative consequences. Transferring the long head of the triceps nerve branch is a good option to recover axillary nerve function. The surgical technique is presented in a video, stressing the steps to achieve a successful result. The video can be found here: https://youtu.be/WbVbpMuPxIE .

STARplasty for Reconstruction of the Burned Axilla.

BACKGROUND: Postburn axillary contractures are common and significantly impact quality of life. Simple release combined with split thickness skin grafting necessitates a donor site, requires immobilization, and may result in poor functional outcome. Common methods of adjacent tissue rearrangement are not well designed to treat broad linear contractures. Flaps from the back, flank, or arm can be used, but may come with significant donor site morbidity. We demonstrate the use of the STARplasty, a novel adjacent tissue rearrangement initially developed to treat neosyndactyly, as a useful reconstructive option for the release of Kurtzman type 1 posterior or anterior axillary contractures. METHODS: A retrospective review was performed to identify patients who underwent STARplasties for treatment of type 1 axillary burn contractures. All reconstructions were performed by a single surgeon at a single ABA burn center (April 2011 to December 2015). A version of the surgical STARplasty technique previously described for treatment of neosyndactyly was modified for use in the axilla. Patient and injury demographics, as well as complications and outcome, were collected. RESULTS: Twelve patients with upper extremity burns underwent 16 primary STARplasties for treatment of axillary contractures. Three patients underwent simultaneous bilateral procedures. The majority (15/16) of the primary procedures were used to address contractures of the anterior axillary fold. Mean patient age was 51 (R 38-63) and average burn size was 35% (R 18-80). Average time from initial injury to primary reconstruction was 11.1 months (R 3-54). One patient required revision for persistent contracture and another experienced wound dehiscence that ultimately required split-thickness skin grafting. No other significant complications were noted, and all remaining patients had closed wounds and full range of motion by 30 days postprocedure. CONCLUSIONS: Axillary contractures remain common despite improvements in physical/occupational therapy. While common techniques, such as z-plasty, continue to be helpful for the surgical release of narrow contractures with bilateral laxity, axillary contractures are typically broad based and often contain only unilateral unburned tissue. Based on our experience, the axillary STARplasty represents a safe and efficacious technique to be considered in the case of broad-based contractures involving either the anterior or posterior axillary fold.

Anterolateral Thigh Flap for Reconstruction in Postburn Axillary Contractures.

BACKGROUND: Reconstruction of postburn axillary contractures is difficult and particularly challenging without healthy adjacent soft tissue for axillary scar resurfacing. In this case, a free soft-tissue transfer is among the best treatment options. Here, we describe our experience with free anterolateral thigh (ALT) flap for reconstruction in postburn axillary contractures. METHODS: We enrolled 10 patients with postburn axillary contractures from August 2003 to July 2015. They all underwent wide scar contracture release through a transverse incision from the anterior axillary fold to the posterior axillary fold. The ALT flap was subfascially raised. The huge soft tissue defect after scar release was resurfaced with the ALT flap. RESULTS: Eight male patients and 2 female patients (age, 16-64 years; mean, 46 years) were included. The mean total burn surface area, follow-up time, duration between injury onset and free-flap transfer surgery, and flap size were 48%, 27 months, 7.7 months, and 12 × 23 cm, respectively. The most common recipient vessels were the thoracodorsal artery and vein (77%). The mean improvement in the range of motion of shoulder abduction was 86 degrees (range, 60-130 degrees). The mean operative time was 7 hours. All flaps survived without reexploration or failure. All but 1 donor site was managed by split-thickness skin grafting. No infection, hematoma, or deaths were noted postoperatively. Transient brachial palsy was noted in a 16-year-old male patient postoperatively, with full recovery 3 months after. CONCLUSIONS: For postburn axillary contractures without healthy adjacent soft tissue for scar resurfacing, ALT flap reconstruction represents a suitable treatment option. It allows simultaneous surgery on both the donor and recipient sites, without the need to change the patient's position. Furthermore, the ALT flap provides sufficient soft tissue and blood flow for reconstruction, leading to satisfactory functional outcomes.

Defining the minimum anatomical coverage required to protect the axilla and arm against penetrating ballistic projectiles.

INTRODUCTION: Defining the minimum anatomical structural coverage required to protect from ballistic threats is necessary to enable objective comparisons between body armour designs. Current protection for the axilla and arm is in the form of brassards, but no evidence exists to justify the coverage that should be provided by them. METHOD: A systematic review was undertaken to ascertain which anatomical components within the arm or axilla would be highly likely to lead to either death within 60 min or would cause significant long-term morbidity. RESULTS: Haemorrhage from vascular damage to the axillary or brachial vessels was demonstrated to be the principal cause of mortality from arm trauma on combat operations. Peripheral nerve injuries are the primary cause of long-term morbidity and functional disability following upper extremity arterial trauma. DISCUSSION: Haemorrhage is managed through direct pressure and the application of a tourniquet. It is therefore recommended that the minimum coverage should be the most proximal extent to which a tourniquet can be applied. Superimposition of OSPREY brassards over these identified anatomical structures demonstrates that current coverage provided by the brassards could potentially be reduced.

Spontaneous rupture of a posttraumatic aneurysm of the axillary artery-a rare cause of hemorrhagic shock in children.

Posttraumatic aneurysms of the axillary artery are extremely scarce. In pediatrics, no similar case has been described. Injuries of axillary artery are often associated with ischemic complications, whereas the bleeding risks are not well documented. We report the case of a 5-year-old boy who was admitted with a scapular pulsatile lump 2 weeks after a domestic accident. During his stay, he suddenly presented a hemorrhagic shock. The patient was immediately admitted to the operating room to undergo surgical hemostasis and was then transferred to intensive care unit to stabilize his vital functions. This case shows the possibility of spontaneous and life-threatening acute bleeding of posttraumatic aneurysms of the axillary artery.

Humeral avulsions of the inferior glenohumeral ligament complex involving the axillary pouch in professional baseball players.

INTRODUCTION: Humeral avulsion of the inferior glenohumeral ligament is a rare injury in athletes and can involve different parts of the complex. Axillary pouch avulsion, in particular, has only recently been recognized in the literature, but has never been described in professional baseball pitchers. MATERIALS AND METHODS: A retrospective review of professional baseball players presenting to our institution over 5 years was performed. Patients with Bankart lesions or fractures were excluded. Preoperative MRI was retrospectively correlated with the clinical and arthroscopic findings, as available. RESULTS: Four professional baseball pitchers were identified, all who had axillary pouch humeral avulsions of the inferior glenohumeral ligament. There was a concomitant avulsion of the anterior band in one patient. Associated findings included labral tears (n = 2) and partial thickness tear of the rotator cuff (n = 2). Three patients ultimately had their axillary pouch avulsions repaired at most recent follow-up. CONCLUSIONS: APHAGL lesions can be seen in overhead athletes such as baseball pitchers and should be carefully considered as a potential cause of disability. Appropriate diagnosis is important to ultimately elucidate the optimal management of these lesions.

Ultrasound imaging of the axillary nerve and its role in the diagnosis of traumatic impairment.

PURPOSE: The axillary nerve (AN) is frequently injured during shoulder trauma and imaging is required to define the site and extent of nerve injury. However, the AN has a rather complex course through several soft tissue compartments of the shoulder and axilla. Therefore, imaging of the nerve with MRI and sonography is troublesome. Thus detection and sonographic assessment bases on thorough knowledge of local topography. MATERIALS AND METHODS: This investigation aimed at defining reliable anatomical landmarks for AN-sonography in 5 volunteers and later validating the proposed sonographic examination protocol in 10 unselected patients. RESULTS: With strict adherence to the proposed examination algorithm, sonography of the AN was feasible in all volunteers and patients. Furthermore, sonographic findings correlated nicely with the golden standard "surgical exploration" concerning severity and topography of neural impairment. CONCLUSION: Based on our study results we propose our algorithm for AN-sonography as the first-line imaging tool for the assessment of axillary nerve trauma.

Axillary arteriovenous fistula after axillary plexus block.

This report presents the case of a 51-year-old man who had an axillary arteriovenous fistula (AVF) as a complication of an axillary plexus block that was performed for internal fixation for a right forefinger phalanx fracture 4 years previously. While performing the axillary plexus block, a 22-gauge needle was placed inside the axillary sheath by observing the pulsations of the axillary artery. A pulsatile mass was found in the right axilla 1 day after the block was performed. Apart from this soft mass, the patient had no symptoms of vascular nerve damage. As the mass gradually increased in size, it became painful. During the past 3 months, in particular, the patient experienced repeated attacks of intermittent sharp pain and requested surgery. Digital subtraction angiography, performed 4 years after the axillary block, showed a tumor-like dilation was developing in both the right axillary artery and vein, almost simultaneously. Thus, the diagnosis of AVF was confirmed. The false aneurysm sac was excised and lateral repair of the axillary artery and vein was carried out under general anesthesia. Postoperative recovery was uneventful. The possible occurrence of an AVF after axillary plexus block should be kept in mind, because early diagnosis and treatment are necessary to avoid development of AVF and false aneurysm.

[Treatment of proximal humerus fractures: relative position of different locking plates to the axillary nerve]. / Versorgung von Humeruskopffrakturen: Lagebeziehung proximaler Verriegelungsplatten zum N. axillaris.

OBJECTIVES: Placement of a proximal humerus locking plate through a percutaneous transdeltoid approach bears the advantages of a minimally invasive approach but may compromise the anterior branches of the axillary nerve. This anatomic study aimed to develop a risk profile for 6 types of modern proximal humerus locking plates as to their interference with the axillary nerve. MATERIALS AND METHODS: In this study six different implants (Arthrex®, DePuy®, Königsee®, Smith & Nephew®, Stryker® and Synthes®) were placed on the intact proximal humerus of 33 embalmed cadaveric upper extremities and the relative positioning between the axillary nerve and the screw holes was determined. RESULTS: All locking plates displayed an area of risk which concerned 3 out of 7 (Arthrex®), 4 out of 10 (DePuy®), 2 out of 9 (Königsee®), 3 out of 11 (Smith & Nephew®), 3 out of 11 (Stryker®) and 6 out of 12 (Synthes®) screw holes of the plate. CONCLUSIONS: Using the anterolateral percutaneous deltoid splitting approach the relative position of the axillary nerve to the holes of a specific implant is of relevance for avoidance of iatrogenic lesions to the nerve.

Chronic axillary wounds in cats: what do we know and how should we manage them?

PRACTICAL RELEVANCE: Axillary wounds most often occur in outdoor cats that wear a collar, typically after having been missing. These wounds are commonly chronic and indolent in nature, and although there is so far no consensus on an explanation for this, it is likely that there are several factors involved. CLINICAL CHALLENGES: Axillary wounds are often difficult to manage due to the frequent presence of infection, their histopathological characteristics and their location, where there is excessive tension and movement of the axillary tissues. Initial surgical treatment has a high reported incidence of failure and complications in the literature, with wound breakdown reported most commonly. Giving due consideration to the difficulties of managing these wounds, however, will help practitioners to decrease the occurrence of complications and the need for multiple procedures, and therefore improve the outcome. EQUIPMENT: Initial approach and surgical management can be achieved using standard medical equipment and surgical kit available to general practitioners. EVIDENCE BASE: This review discusses the surgical techniques reported in the literature to have successfully treated chronic axillary wounds and recommendations are also provided based on the authors' clinical experience.

Isolated axillary artery injury due to blunt trauma in ice hockey.

We report the first case of a purely isolated axillary artery dissection because of focal blunt trauma to the axilla. A 42-year-old man presented to our outpatient orthopedic clinic 7 days after a fall during a hockey game whereby another player's skate blade struck the patient directly in the axilla without disrupting the skin. The patient denied having any symptoms of shoulder dislocation but experienced some pain and numbness, which subsided rapidly. Then he developed a cool hand with exertional claudication. Physical examination revealed absent radial and brachial pulses. Computed tomographic angiography demonstrated dissection of the distal axillary artery extending to the middle two-thirds of the brachial artery. Following urgent consultation with vascular surgery, the patient was treated operatively with reverse saphenous interpositional grafting and embolectomy. This case illustrates the need to have a heightened index of suspicion to all injuries to the axilla and the importance of performing careful soft tissue and neurovascular examinations in hockey players presenting with shoulder complaints, even when bony injury is not present.

Pre-expanded pedicled thoracodorsal artery perforator flap for postburn axillary contracture reconstruction.

INTRODUCTION: The axillary region is one of the sites most frequently affected by postburn contractures. In this clinical study, we used pre-expanded pedicled thoracodorsal artery (TDA) perforator flaps for release of postburn contracture of the axillary region. PATIENT AND METHODS: Five patients with severe axillary burn contractures were reconstructed with six pre-expanded pedicled TDA perforator flaps between 2008 and 2010. All were men ranging in age from 20 to 26 years (mean, 22 years). Mean time of follow-up was 12 months. Flap and donor site complications, preoperative, and postoperative range of motion of axillary joint were evaluated. RESULTS: All flaps survived without significant complications. Partial flap necrosis was seen in only one flap. Minimal transient venous congestion occurred in one flap during the early postoperative period. A complete range of motion at the axillary joint was achieved in all patients by the end of the reconstruction period. The donor sites were closed primarily with linear scars in all cases. CONCLUSION: The pre-expanded pedicled TDA perforator flap is a suitable alternative for coverage of the axillary defects after the release of the burn contractures. A pliable texture and large size flap can be obtained to transfer to the axillary area and the donor site scar is considered as cosmetically acceptable.

A case of penetrating axillary trauma.

INTRODUCTION: Deep penetrating traumas of the axilla extending to the neck are rare and potentially dangerous. OBSERVATION: An 11-year-old child presented with an impressive penetrating axillary injury extending to the neck after falling on a tree branch. The wound was explored in the operating room (OR). A fragment of the branch was removed without injuring any vascular structure. The only lesion concerned the hypopharynx. DISCUSSION: Cervical wounds may have an axillary origin. These wounds must be systematically explored in the OR, given the risk of upper airway obstruction and vascular lesion.

Propeller flaps: classification and clinical applications.

Propeller flaps feature a highly reliable reconstructive method, based on a perforator vessel. Since their introduction in 1991, a great variety of propeller flaps have been described, according to their shape and their potential of coverage. Indeed, these flaps have progressively been refined and modified, concerning their vascularity and space design. The authors present a classification of propeller flaps. This anatomical classification is necessary to understand the dissection procedure and the differences between the numerous types of propeller flaps nowadays described. It is the international classification, which should be used for the description and conception of these flaps.

Determining the optimum anatomical coverage of side plates for the VIRTUS body armour and load carriage system.

INTRODUCTION: Side plates are worn by UK Armed Forces as part of the VIRTUS body armour and load carriage systems to protect the thorax and abdomen from high-velocity threats. The VIRTUS project has provided the impetus to objectively demonstrate the anatomical coverage provided by side plates. METHOD: CT scans of 120 male UK Armed Forces personnel were analysed to ascertain the vertical distance between the anterior axillary fold and iliac crest, and horizontal distance between anterior and posterior borders of the liver, delineating the boundaries of essential medical coverage from the side aspects. The percentage of shot-lines intersected by the existing Enhanced Combat Body Armour (ECBA) plates as well as an optimised plate based on the maximum potential dimensions of essential coverage was determined in the Coverage of Armour Tool. RESULTS: ECBA plates were 101 mm shorter and 4 mm narrower than a plate with dimensions providing essential medical coverage for the 50th percentile subject (157×315 mm). Coverage increased by 35% when using two ECBA plates as side coverage in addition to using the front and rear OSPREY plates in the VIRTUS vest. Two side plates with dimensions providing essential medical coverage for the 50th percentile increased anatomical coverage by a further 16%. CONCLUSIONS: This analysis has provided strong evidence that ECBA plates are already optimised for side protection, despite not being originally designed for this purpose. They are correctly positioned within the VIRTUS soft body armour vest and the width of the ECBA plate is only 3% less than what would be optimum size for the 50th percentile. Although the height of the plate could be increased to further enhance the anatomical coverage, it is unlikely that this would be acceptable in terms of the human factors, equipment integration or additional mass.

Surfinoma: a case report on a pseudotumor developing after a surfing sports injury.

We describe an unusual pseudotumor of the upper thorax, axillary, and shoulder girdle region with presentation 4 years after a surfing sports injury. We offer the coined term "Surfinoma" to describe a pseudotumor arising from a penetrating piece of fiberglass surf board, which induced a foreign body reaction.

Use of pectoralis major perforators for local "free-style" perforator flap in axillary reconstruction: a case report.

Axillary scar contracture in a previously poly-traumatized present a challenging task for a reconstructive surgeon from the functional and esthetic standpoint. While harvest of local myocutaneous flaps will obviously contribute to further limitation of arm movements in already functionally impaired shoulder, pedicled perforator flaps from the lateral and posterior thoracic region may not be available due to extensive scarring after high-energy trauma with soft-tissue loss. We present a new perforator pedicled flap, designed, and harvested exclusively on the basis of "free style perforator flap" concept, based on the perforators coming from the pectoral region. The operative technique and outcome are discussed in this report.

[Posterior circumflex humeral artery perforator flap (PCHAP-flap) in axillary scar release]. / Arteria circumflexa humeri posterior perforátor (PCHAP) lebeny alkalmazása axillaris hegkorrekcióban égési sérülés után.

Scar contracture after burn injury is frequent in the axillary region. If conservative treatment of scars limiting the range of motion of the shoulder joint fails, surgical correction is needed. The authors performed an early reconstruction in a case with unstable scar formation and limited range of motion after burn injury to the axillary region, using the posterior circumflex humeral artery perforator flap. In their opinion, the flap (beside its conventional use as a free flap) may be useful as an island flap in the reconstruction of the axillary region, e. g. for axillary scar release.

Outcomes of Early Use of an End of Range Axilla Orthotic in Children Following Burn Injury.

Scar contracture is a significant complication of burn injury. This study aimed to describe outcomes of early axilla orthotic use at end of range abduction in children, following a burn to the axilla region. A retrospective review of 76 children (mean age 3.9 years [SD 3.6]) treated at a tertiary children's hospital from 2006 to 2016 was conducted. No child developed axilla contracture for the duration of the 2-year study follow-up with no adverse events recorded. If orthotic use was ceased <60 days post-burn, it was considered not an essential intervention to maintain range of movement, leaving 49 children using the orthotic ≥60 days. Compared with the children who ceased orthotic use in <60 days, children who required the orthotic ≥60 days had a significantly higher frequency of deep-dermal burn (59 vs 25%, p = .01), flame mechanism (25 vs 5%, p = .03), and burn injury distribution involving the anterior trunk, flank, and arm (18 vs 3%, p = .03). Early signs of contracture, considered loss of full axilla range or significant banding, developed in nine children within 3 months post-burn. With intensive therapy, all returned to full axilla range by 9 months post-burn. Children with skin tension at end of range shoulder movement at the 1-month clinical assessment were 11 times more likely to develop early signs of contracture (95% confidence interval [CI]: 1.9-62.1, p = .007). Intensive orthotic use at end of range shoulder abduction in children with axilla burns is well tolerated. When undertaken with ongoing therapist review, full axilla range can be maintained.