Salvage of shoulder joint through simplification of wound management.

Infection is a common sequela of open dislocation of the shoulder joint. This typically leads to joint surface and humeral head necrosis, resulting in severe limitation of motion. Few cases of open and infected glenohumeral joints have been reported, and none had a good functional outcome with pain-free, near-full range of motion. Here we report the case of a 24-year-old man, who sustained a severe degloving injury of his left shoulder with an open glenohumeral joint, in a road traffic accident. We describe a treatment plan that salvaged near-full range of shoulder motion and resulted in pain-free active and passive movements.

Refugee camps, fire disasters and burn injuries.

In the past five years, no fewer than 15 conflicts have brought unspeakable tragedy and misery to millions across the world. At present, nearly 20 people are forcibly displaced every minute as a result of conflict or persecution, representing a crisis of historic proportions. Many displaced persons end up in camps generally developing in an impromptu fashion, and are totally dependent on humanitarian aid. The precarious condition of temporary installations puts the nearly 700 refugee camps worldwide at high risk of disease, child soldier and terrorist recruitment, and physical and sexual violence. Poorly planned, densely packed refugee settlements are also one of the most pathogenic environments possible, representing high risk for fires with potential for uncontrolled fire spread and development over sometimes quite large areas. Moreover, providing healthcare to refugees comes with its own unique challenges. Internationally recognized guidelines for minimum standards in shelters and settlements have been set, however they remain largely inapplicable. As for fire risk reduction, and despite the high number of fire incidents, it is not evident that fire safety can justify a higher priority. In that regard, a number of often conflicting influences will need to be considered. The greatest challenge remains in balancing the various risks, such as the need/cost of shelter against the fire risk/cost of fire protection.

Dans les 5 années écoulées, ce ne sont pas moins de 15 conflits armés qui ont propulsé des millions de personnes à travers le monde dans une tragédie et une misère indescriptibles. Actuellement, 20 personnes sont déplacés de force chaque minute en raison d'un tel conflit ou de persécutions, ce qui est une crise historique. Nombre d'entre elles se retrouvent dans des camps de réfugiés de fortune, totalement dépendants de l'aide humanitaire. Les conditions précaires de survie dans ces quelque 700 camps placent ces réfugiés dans une situation de risque non seulement de santé mais aussi de violence physique, sexuelle et mentale (enfants soldats, « recrutement ¼ terroriste). La densité d'habitations installées sans plan est un facteur pathogénique majeur, dans lesquelles les incendies peuvent toucher une superficie très importante. En outre, la dispensation de soins aux réfugiés pose des problèmes spécifiques. Des standard minimums de déploiement ont été édictés au niveau international, mais ils restent largement inapplicables. La prévention des incendies reste une préoccupation secondaire, malgré leur fréquence car il s'agit de trouver une priorité entre la réalisations d'abris sûrs pour dispenser les soins et la prévention des incendies, à coût peu extensible.

Microsurgery in the burn population - a review of the literature.

The management of patients suffering from burn injury poses unique challenges for the reconstructive surgeon, both in the acute and delayed settings. Once resuscitative measures are optimized and hemodynamic stability is achieved, early burn debridement and coverage is performed. Traditionally, this consists of excision of devitalized tissue and subsequent coverage using split thickness skin grafts. However, in certain instances, and depending on the extent and nature of the burn injury, skin grafting (or even local tissue rearrangement) may not be a reasonable option. in these cases, free tissue transfer may provide a viable reconstructive alternative. While free flap reconstruction is rare in burn surgery, particularly in the acute setting, burn injuries that expose vital structures, such as tendon, nerve, bone, or deep vessels, require robust flap coverage. in the delayed setting, unsightly scar formation and contracture often occurs secondary to skin graft coverage. These significant patient morbidities are often amenable to free tissue transfer as well. This review article discusses the indications, applications, and problems with free flap surgery for burn injuries in both the acute and delayed setting, and summarizes the available literature on microsurgical free tissue transfer for burn management.

La prise en charge des patients atteints de brûlures pose des défis uniques pour le chirurgien de reconstruction, à la fois dans les cadres aigus et retardés. Une fois les mesures de réanimation sont optimisés et la stabilité hémodynamique est obtenue, il faut faire le débridement précoce et la couverture de la brûlure. Traditionnellement, il s'agit de l'excision des tissus dévitalisés et la couverture par division ultérieure en utilisant des greffes de peau partielle épaisse. Cependant, dans certains cas, et en fonction des dimensions et la nature de la brûlure, une greffe de peau n'est pas toujours une option raisonnable. Dans ces cas, le transfert de tissu libre peut fournir une alternative viable. Alors que la reconstruction de lambeau libre est rare dans la chirurgie des brûlures, en particulier dans le cadre aiguë, les brûlures qui exposent les structures vitales, telles que les tendons, nerfs, os, ou les vaisseaux profonds, nécessitent une couverture robuste. Dans le cadre retardé, la formation de cicatrices inesthétiques et de contractures se produit fréquemment secondaire à une couverture de greffe de peau. Souvent ces morbidités importantes sont aussi prêtent au transfert de tissu libre. Cet article de revue discute les indications, les applications, et des problèmes avec la chirurgie de lambeau libre pour des brûlures dans les cadres aigus et retardés. Cet article résume aussi la littérature disponible sur la microchirurgie du transfert de tissu libre pour la prise en charge des brûlures.

Preliminary arteriovenous fistula for free-flap reconstruction in the diabetic foot.

We present our experience at the American University of Beirut Medical Center with two diabetic patients suffering from large necrotic and infected foot ulcers. Both patients were ambulatory at the time of presentation despite their extensive wounds and were believed to have a useful limb with adequate protective sensation worth saving. Below-knee amputation was prevented in both cases by successful soft-tissue coverage of the ulcers using microvascular composite-tissue transfer a few days after performing a preliminary arteriovenous fistula with a long vein graft loop. The flap vessels were anastomosed end-to-end to the arterial and venous limbs of the divided arteriovenous loop. This reconstructive technique of difficult diabetic wounds of the lower extremity, though in two stages, may be safer than one long procedure in a high-risk patient. It is technically easier than long interpositional vein grafts at the same time as free-flap transfer or microvascular anastomoses with small and diseased vessels. It definitely provides more chance of success as larger vessels are used to supply the flap. It permits distension of the vein graft at normotensive physiologic pressures and allows testing the arterial anastomosis as well as the venous flow before final flap transfer. Above all, it allows extreme freedom in performing tension-free anastomoses away from the infected wound.

Ulnar collateral ligament rupture of the first metacarpophalangeal joint: a frequently missed injury in the emergency department.

Between July 1991 and December 1995, 28 patients elected to consult one of the senior authors for a second opinion or were referred to him by their family physician after being reassured and discharged from our emergency department with the simple diagnosis of "soft tissue contusion" to the thumb. Physical examination and stress radiographs of these patients revealed a missed injury to the ulnar collateral ligament (UCL) of the first metacarpophalangeal joint in 18 patients (64.3%), 12 of whom required surgical repair. Apparently, UCL injuries are frequently underestimated in our emergency department, although the real number is unknown because some patients may have decided to seek further treatment elsewhere. In addition to the numerous trivial injuries that are frequently seen in any emergency department, emergency physicians have the added responsibility of detecting those injuries that require referral to a specialist.

Microsurgical free tissue transfer: a valuable reconstructive procedure--review of 75 cases.

A total of 75 cases of microsurgical composite tissue transfer to reconstruct defects of the head and neck, trunk, upper and lower extremities performed at the American University of Beirut Medical Center between January 1992 and December 1997 were evaluated in a retrospective study. There was a failure rate of 6.6% and a complication rate of 13.3%. Our results show that free tissue transfer can be considered as a safe and viable treatment option in a wide variety of clinical situations including early soft tissue coverage of complex extremity wounds, limb sparing procedures for malignant neoplasms, reconstruction of the head and neck area, treatment of chronic osteomyelitis, and finally reconstruction of the foot in patients with severe diabetic neuropathy and peripheral vascular disease. A brief discussion of the history of microvascular free tissue transfers as well as their value in modern reconstructive surgery is also presented.

Lingual thyroid: tongue-splitting incision for transoral excision.

Two patients presenting to the Central Military Hospital of Beirut with symptomatic lingual thyroid are reported. I131 thyroid scanning revealed the lingual thyroid to be the only functional thyroid tissue present in each patient. Subsequent CT scanning demonstrated the large size of these ectopic thyroids causing significant mechanical obstruction. These were excised transorally using a posterior midline tongue-splitting incision and reimplanted in the rectus abdominis muscles. Details of this modified tongue-splitting surgical approach are described. A brief review of the literature concerning lingual thyroid and its surgical treatment is also presented as well as three patients operated on for lingual thyroid at the American University of Beirut Medical Centre between 1975 and 1994 using an external neck incision.

Fibrohistiocytic sarcoma of the thumb treated by wide resection and immediate free flap reconstruction. Case report.

A 29 year old surgical resident presented with a fibrohistiocytic sarcoma over the thumb of his dominant right hand. The tumour was widely excised including the ulnar neurovascular bundle. The resultant defect was immediately reconstructed with a sensory forearm free flap from the opposite upper extremity. The patient was then given a curative dose of cobalt-60 radiotherapy starting in the fourth postoperative week. With a comprehensive regimen of physiotherapy and splinting, the patient regained an almost full range of movement in his right thumb and was able to resume his regular duties in the operating theatre two months after his operation. Soft tissue sarcomas of the hand are a real therapeutic challenge. Adequate control of the tumour in most instances requires amputation because limb sparing procedures require soft tissue coverage not available locally or achieved easily. In addition, preservation of a hand, or parts of it, with poor functional capacity, is not helpful.

Balloon compression of the intramaxillary sinus for intractable post-traumatic bleeding from the maxillary artery. Case report.

We present a case of severe intractable epistaxis after midfacial trauma in which the bleeding was identified as coming from the descending palatine artery, a branch of the maxillary artery. It could not be controlled by simple packing, and was stopped by inserting a balloon into the maxillary sinus, tamponading the injured vessel in the sphenopalatine fossa (pterigopalatine fossa). We describe an easy and practical emergency manoeuvre to control bleeding from inaccessible branches of the maxillary artery and to prevent rebleeding after embolisation.

Early microvascular reconstruction of Gustilo type III-C lower extremity wound. Case report.

Current algorithms for lower limb injuries recommend amputation for most Gustilo type III-C injuries with a limb salvage index score of 6-8 or more. Recent improvements in the timing and technique of microvascular flaps with the reduction in bone healing time as a result of better fixation devices and early bone grafting make the option of limb salvage after such severe injuries a valid and acceptable therapeutic approach. We present a case of severe shot gun injury to the leg with a limb salvage index score of 9 that was successfully salvaged by vascular reconstruction followed three days later with a microvascular osteocutaneous scapular flap anastomosed to the divided limbs of a preliminary arteriovenous fistula that had been constructed at the time of the initial vascular repair. The patient was able to walk unaided one year after the injury.

Necrotising infection of the orofacial tissues in neonates (noma neonatorum). Case report.

Noma neonatorum should be differentiated from noma, in that it is typically a disease of seriously ill premature infants whose birth weight was low, and is caused by Pseudomonas aerugenosa septicaemia. We know of only two case reports of noma neonatorum involving newborn infants born at full term, so we report here another case of noma neonatorum in a neonate born at full term. In addition we describe the differences between noma neonatorum and noma (cancrum oris), a clinically related entity.

Microsurgical composite tissue transfer: an expanding horizon in reconstructive surgery.

Seven cases of microsurgical composite tissue transfer to reconstruct defects of the upper and lower extremities performed at the American University of Beirut Medical Center between January 1992 and July 1993 are evaluated in a retrospective study. These cases illustrate the various clinical situations where free flaps can be used to an advantage. A brief discussion of the history of microvascular free flap transfers as well as their value in modern plastic and reconstructive surgery is also presented.

Pressure garment therapy (PGT) of burn scars: evidence-based efficacy.

Hypertrophic burn scars pose a challenge for burn survivors and providers. In many cases, they can severely limit a burn survivor's level of function, including work and recreational activities. A widespread modality of prevention and treatment of hypertrophic scarring is the utilization of pressure garment therapy (PGT). Despite the magnitude of the problem of hypertrophic scarring and the ubiquitous use of pressure garments as therapy, strong clinical evidence of the efficacy of PGT in the literature is lacking. Some of the challenges facing measurement of efficacy of PGT on hypertrophic scarring are lack of clear definitions for degree of hypertrophic scarring, inability to quantify pressure applied to scars, patient noncompliance to strict PGT time schedules, and inability to conduct randomized controlled trials comparing PGT to no therapy for ethical reasons since PGT is considered a standard of care. In this review, we attempt to summarize and analyze evidence-based literature on PGT and its efficacy in burn hypertrophic scars published in English language in the past 15 years.

Les cicatrices de brûlures hypertrophiques représentent un défi pour les survivants de brûlures et les fournisseurs. Dans de nombreux cas, ils peuvent gravement limiter le niveau de fonction d'un survivant de brûlure, y compris au travail et pendant les loisirs. Une modalité généralisée de la prévention et le traitement des cicatrices hypertrophiques est l'utilisation de la thérapie de vêtement de compression (TVC). Malgré l'ampleur du problème des cicatrices hypertrophiques et l'utilisation omniprésente de vêtements compressifs en tant que thérapie, dans la littérature il n'y a pas de preuves cliniques solides de l'efficacité de la TVC. Quelques-uns des défis auxquels fait face la mesure de l'efficacité de ce traitement sur les cicatrices hypertrophiques sont: le manque de définitions claires pour degré de cicatrisation hypertrophique, l'incapacité de quantifier la pression appliquée sur les cicatrices, la non-conformité des patients en ce qui concerne les horaires strictes du traitement, et l'incapacité de mener des essais comparatifs randomisés comparant cette thérapie à aucun traitement pour des raisons éthiques car la TVC est considérée comme une norme de soins. Dans cette revue, nous tentons de résumer et d'analyser la littérature fondée sur des preuves de la TVC et son efficacité dans les cicatrices hypertrophiques des brûlures publiés en langue anglaise au cours des 15 dernières années.

Acute burn resuscitation and fluid creep: it is time for colloid rehabilitation.

Fluid overloading has become a global phenomenon in acute burn care. The consensus Parkland formula that has excluded colloid use, the impact of goal-directed resuscitation, and the overzealous on the scene crystalloid resuscitation combined with subsequent inefficient titration of fluid administration and lack of timely reduction of infusion rates, have all contributed to this phenomenon of fluid overloading, known as fluid creep and recognized only recently, constituting a landmine in modern burn care. Solid evidence is supportive to the fact that excessive administration of crystalloid and the abandonment of colloid replenishment at some point of resuscitation are the major contributors to fluid creep. With available evidence from the literature, the present is a comprehensive review of literature about fluid creep, trying to determine the etiology behind it as well as to propose strategies to control its magnitude and complications, namely through colloid administration amongst other options.

Reverse tissue expansion by liposuction deflation adopted for harvest of large sheet of full-thickness skin graft.

Full-thickness skingraft is a valid option to release burn scar contractures with the main purpose of correcting the induced limitation in function and improve the disfiguring appearance of the scar. The main pitfall remains the limited availability of these grafts, especially when large sheets are needed. We present an application of a previously described technique known as reverse tissue expansion, which permits the harvesting of a large sheet of full thickness skin graft when needed. This method was adopted to release a burn scar contracture in a 32-yr-old man who sustained a 65% TBSA burn secondary to a gasoline tank explosion at the age of 7 yr followed by multiple reconstructive procedures. The patient presented with a disfiguring anterior neck contracture coupled to limited range of motion. Improvement of neck extension was contemplated using full-thickness skin graft harvested following reverse tissue expansion achieved by deflation liposuction of the donor site.

Numeric expression of aesthetics and beauty.

Debate over what constitutes beauty, particularly beauty of the human body, has raged since philosophy began. Interested scholars have debated the meaning of beauty for centuries. However, it seems that numbers and the resulting numeric relationships play a fundamental role in the classification of the human body, and that a harmonic profile or body shape is produced only at certain definite numeric relationships. The beauty of individual features depends on "ideal" proportions, and it is suggested that expressing beauty in terms of geometry is possible. As the demand for aesthetic surgery has increased tremendously over the past few decades, it is becoming essential to be able to assess the possible satisfaction that can be expected after an aesthetic surgery procedure and to determine the beauty of the final result as precisely as possible.

Nutritional and pharmacological modulation of the metabolic response of severely burned patients: review of the literature (part 1).

Severe burn patients are some of the most challenging critically ill patients, with an extreme state of physiological stress and an overwhelming systemic metabolic response. Increased energy expenditure to cope with this insult necessitates mobilization of large amounts of substrate from fat stores and active muscle for repair and fuel, leading to catabolism. The hypermetabolic response can last for as long as nine months to one year after injury and is associated with impaired wound healing, increased infection risks, erosion of lean body mass, hampered rehabilitation, and delayed reintegration of burn survivors into society. Reversal of the hypermetabolic response by manipulating the patient's physiological and biochemical environment through the administration of specific nutrients, growth factors, or other agents, often in pharmacological doses, is emerging as an essential component of the state of the art in severe burn management. Early enteral nutritional support, control of hyperglycaemia, blockade of catecholamine response, and use of anabolic steroids have all been proposed to attenuate hypermetabolism or to blunt catabolism associated with severe burn injury. The present study is a literature review of the proposed nutritional and metabolic therapeutic measures in order to determine evidence-based best practice. Unfortunately, the present state of our knowledge does not allow the formulation of clear-cut guidelines. Only general trends can be outlined which will certainly have some practical applications but above all will dictate future research in the field.

Nutritional and Pharmacological Modulation of the Metabolic Response of Severely Burned Patients: Review of the Literature (Part II)*.

Severe burn patients are some of the most challenging critically ill patients, with an extreme state of physiological stress and an overwhelming systemic metabolic response. Increased energy expenditure to cope with this insult necessitates mobilization of large amounts of substrate from fat stores and active muscle for repair and fuel, leading to catabolism. The hypermetabolic response can last for as long as nine months to one year after injury and is associated with impaired wound healing, increased infection risks, erosion of lean body mass, hampered rehabilitation, and delayed reintegration of burn survivors into society. Reversal of the hypermetabolic response by manipulating the patient's physiological and biochemical environment through the administration of specific nutrients, growth factors, or other agents, often in pharmacological doses, is emerging as an essential component of the state of the art in severe burn management. Early enteral nutritional support, control of hyperglycaemia, blockade of catecholamine response, and use of anabolic steroids have all been proposed to attenuate hypermetabolism or to blunt catabolism associated with severe burn injury. The present study is a literature review of the proposed nutritional and metabolic therapeutic measures in order to determine evidence-based best practice. Unfortunately, the present state of our knowledge does not allow the formulation of clear-cut guidelines. Only general trends can be outlined which will certainly have some practical applications but above all will dictate future research in the field.