Understanding diabetic cheiroarthropathy: a focus on clinical presentation.

Diabetic cheiroarthropathy (DCA) is a relatively uncommon and underdiagnosed complication of poorly controlled diabetes. It is caused by non-enzymatic glycation of collagen that ultimately leads to microvascular damage and polyarticular stiffness. If diagnosed early, optimal management of serum glucose levels may lessen joint stiffness and prevent microvascular and macrovascular complications associated with diabetes mellitus. We review the case of a 55-year-old male with type 2 diabetes mellitus who was diagnosed with DCA after complaints of chronic joint stiffness and immobility.

The Impact of Venous Reconstruction on Finger Replantation Success Rates Based on Level of Injury.

PURPOSE: The requirement for anatomic venous reconstruction in digit replantation is an ongoing area of research. In this study, we evaluated our institutional experience to study whether replantation success is affected by the presence or absence of vein repair, stratified by the level of injury. METHODS: A retrospective review was performed at an urban, level-1 trauma center of all single-digit replantations performed in adults from 2012 to 2021. Patient demographics, injury mechanism, level of injury, whether a vein was repaired, and replant survival were recorded. RESULTS: Sixty-seven single replanted digits were included. Patients were, on average, 38 years old, and 94% were men. The most common mechanism of injury was a sharp laceration (81%). The overall survival rates for all replantations were 68.7% (46/67) and 60% (12/20) for distal finger replantation. Patients with digital replantations at Tamai zone III or more proximal exhibited a 1.8 times increase in survival rates when one vein was repaired versus zero veins (84.4% vs 46.7%). Patients with digital replantations at Tamai zones I and II exhibited similar survival rates. CONCLUSIONS: Replantations at or proximal to the middle phalanx should be repaired with at least one artery and vein to maximize the chance for success. However, for distal finger replantations, artery-only replantation is a viable option when vein anastomosis is not achievable. TYPO OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Evaluation of microMend wound closure device in repairing skin lacerations.

BACKGROUND: microMend, a novel microstaple skin closure device, may be able to close simple lacerations. This study aimed to evaluate the feasibility and acceptability of using microMend to close these wounds in the ED. METHODS: This was an open-label, single-arm clinical study conducted at two EDs within a large urban academic medical centre. Wounds closed with microMend underwent assessments performed at days 0, 7, 30 and 90. Photographs of treated wounds were rated by two plastic surgeons using a 100 mm visual analogue scale (VAS) and a wound evaluation scale (WES), which has a best possible score of 6. Participants rated pain during application and both participants and providers rated their satisfaction with the device. RESULTS: Thirty-one participants were enrolled in the study: 48% were female and the mean age of participants was 45.6 (95% CI 39.1 to 52.1). The mean wound length was 2.35 cm (95% CI 1.77 to 2.92), with a range of 1-10 cm. Mean VAS and WES scores at day 90 as evaluated by two plastic surgeons were 84.1 mm (95% CI 80.2 to 87.9) and 4.91 (95% CI 4.54 to 5.29), respectively. The mean pain score with application of the devices was 7.28 mm (95% CI 2.88 to 11.68) on a scale of 0-100 mm using VAS. Local anaesthesia was used in 9 patients (29%, 95% CI 20.7 to 37.3) of participants (of whom 5 required deep sutures). Ninety per cent (90%) of participants rated their overall assessment of the device as excellent (74%) or good (16%) at day 90. There were no serious adverse events in any participants in the study. CONCLUSION: microMend appears to be an acceptable alternative for closing skin lacerations in the ED, providing good cosmetic results, with high levels of satisfaction by patients and providers. Randomised trials are needed to compare microMend with other wound closure products. TRIAL REGISTRATION NUMBER: NCT03830515.

Limited Flexor Sheath Incision and Drainage in the Emergency Department in the Management of Early Pyogenic Flexor Tenosynovitis.

BACKGROUND: Pyogenic flexor tenosynovitis (PFT) has been considered a surgical emergency. Varying operative approaches have been described, but there are limited data on the method, safety, and efficacy of nonoperative or bedside management. We present a case series where patients with early flexor tenosynovitis are managed using a limited flexor sheath incision and drainage (I&D) in the emergency department (ED) to both confirm purulence within the flexor sheath and as definitive treatment. METHODS: A retrospective study of all patients clinically diagnosed in the ED with flexor tenosynovitis at our institution from 2012 to 2019 was performed. Patients with frank purulence on examination were taken emergently to the operating room (OR). Patients with equivocal findings underwent limited flexor sheath I&D in the ED. Safety and efficacy were studied for patients with early flexor tenosynovitis managed with this treatment approach. RESULTS: Thirty-four patients met the inclusion criteria. Ten patients underwent direct OR I&D, and 24 patients underwent ED I&D. In the ED I&D group, 96% (24 of 25) of patients did not have frank purulence in the flexor sheath and were managed with bedside drainage alone. There were no procedural complications and no need for repeat operative intervention. Time to intervention (3.1 hours vs 8.4 hours) was significantly shorter for the ED I&D group compared with the OR I&D group. Within the ED I&D group, 86% of patients exhibited good/excellent functional scores. CONCLUSIONS: Limited flexor sheath I&D in the ED provides a potential safe and effective way to manage patients with early flexor tenosynovitis.

Practical Management of Lumps and Bumps of the Fingers, Hand, and Wrist.

BACKGROUND: Primary care physicians encounter many patients who present with lumps and bumps on their fingers, hands, and wrists. Some benign lesions including ganglion cysts, epidermal inclusion cysts, and giant cell tumors of the tendon sheath that are benign and can be managed by primary care clinicians most of the time in an outpatient setting. METHODS: We conducted a narrative of review of literature on the clinical presentation, diagnosis, prognosis, and management of common types of lumps and bumps found on the fingers, hand, and wrist. CONCLUSIONS: Based on the literature review and our clinical practice, we provide indications for referral to plastic surgeons or other specialists for these lesions.

Practical Management of Lumps and Bumps of the Fingers, Hand, and Wrist.

BACKGROUND: Primary care physicians encounter many patients who present with lumps and bumps on their fingers, hands, and wrists. Some benign lesions including ganglion cysts, epidermal inclusion cysts, and giant cell tumors of the tendon sheath that are benign and can be managed by primary care clinicians most of the time in an outpatient setting. METHODS: We conducted a narrative of review of literature on the clinical presentation, diagnosis, prognosis, and management of common types of lumps and bumps found on the fingers, hand, and wrist. CONCLUSIONS: Based on the literature review and our clinical practice, we provide indications for referral to plastic surgeons or other specialists for these lesions.

Rethinking the Need for Nail Plate Removal: A Comparison of the Risks Between Standard Nail Bed Repair and Nonoperative Management.

PURPOSE: Nail bed injuries are commonly treated with nail plate removal and repair due to concern for future nail deformity. There is controversy whether this is necessary. We compared the outcomes for adult patients with simple nail bed lacerations who underwent either formal nail bed repair or nonoperative management. METHODS: A retrospective cohort study was performed of adult patients with nail bed lacerations from 2012 to 2019. Nail bed lacerations were diagnosed in patients with fingertip injuries resulting in subungual hematoma greater than 50% or in any subungual hematoma in the setting of a distal phalanx fracture. All patients included had an intact nail plate. Patients were treated with nail bed laceration repair or nonoperatively without nail plate removal. The primary outcome was the development of a nail deformity. Secondary outcomes included infection, fracture nonunion, and patient-reported functional outcomes using the quick Disabilities of the Arm, Shoulder and Hand score. RESULTS: Thirty-eight patients with nail bed lacerations were treated nonoperatively, and 40 patients were treated with nail bed repair. The average follow-up time was 4.5 weeks in the office. In addition, 1-year evaluation of patients was performed through telephone interview. The patients in the nonoperative group exhibited no statistically significant difference in the calculated risk for nail deformities compared with the nail bed repair group (13% vs 23%, relative risk = 0.58, P = 0.40, 95% confidence interval = 0.42-1.25). There were no significant differences in secondary outcomes or quick Disabilities of the Arm, Shoulder and Hand scores between groups. CONCLUSIONS: The authors observed no meaningful difference in the rate of nail deformities in adult patients who underwent nail bed repair compared with those managed nonoperatively.

3D Printed N-95 Masks During the COVID-19 Pandemic: Lessons Learned.

Early in 2020, the pandemic resulted in an enormous demand for personal protective equipment (PPE), which consists of face masks, face shields, respirators, and gowns. At our institution, at the request of hospital administration, the Lifespan 3D Printing Laboratory spearheaded an initiative to produce reusable N95 masks for use in the hospital setting. Through this article, we seek to detail our experience designing and 3D printing an N95 mask, highlighting the most important lessons learned throughout the process. Foremost among these, we were successful in producing a non-commercial N95 alternative mask which could be used in an era when N95 materials were extremely limited in supply. We identified five key lessons related to design software, 3D printed material airtightness, breathability and humidity dispersal, and ability for communication. By sharing our experience and the most valuable lessons we learned through this process, we hope to provide a helpful foundation for future 3D-printed N95 endeavors.

Transabdominal Breast Augmentation: A Review of 114 Cases Performed over 14 Years.

BACKGROUND: Abdominoplasty patients are frequently candidates for breast rejuvenation as well. Transabdominal breast augmentation permits insertion of breast implants through the abdominoplasty incision. This combined procedure is preferentially performed in an outpatient setting under monitored anesthesia care and nerve blocks. METHODS: This study was a 14-year retrospective review of a single surgeon's technique and outcomes using transabdominal breast augmentation through a low transverse abdominoplasty incision in select patients requesting simultaneous abdominoplasty and bilateral breast augmentation. Patients had minimal ptosis, smoking cessation a minimum of 4 weeks before surgery and indefinitely thereafter, and a lack of superior abdominal or significant breast surgery. RESULTS: The study's 114 patients had a mean follow-up of 19.2 months. The procedure was performed under monitored anesthesia care with intercostal nerve blocks for most patients [n = 107 (93.9 percent)] and general anesthesia [n = 7 (6.1 percent)] for a few. Seventy-nine patients [n = 74 (64.9 percent)] underwent additional procedures, with most (n = 48) undergoing suction-assisted lipectomy. Many patients underwent multiple procedures. Most complications occurred predictably along the central distal abdominoplasty flap and were minor (small wound breakdown, seroma, and mild skin infection). Major complications [n = 8 (7.0 percent)] included two patients with implant malposition requiring revision and one patient with a Baker grade III capsule; notably, this patient was a half-pack-per-day smoker with a body mass index of 27 kg/m. CONCLUSIONS: Transabdominal breast augmentation is a safe, reliable procedure in the appropriately selected, healthy patient and may be used in minimally to moderately ptotic patients who request concurrent breast augmentation and abdominoplasty. Morbidity compares favorably to reported abdominoplasty series in the appropriately selected patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Methods and pitfalls in treatment of fractures in the digits.

This article describes the indications for and methods of managing phalangeal fractures. The fractures around the finger joints are particularly difficult to treat. The technical details and pitfalls for these cases are discussed in detail. The problems associated with the phalangeal fractures such as articular destruction, nonunion, and postoperative care are also discussed. The authors present their preferred surgical treatment, with review of recent advancement regarding the treatment of phalangeal fractures.

The pedicled reverse-flow lateral arm flap for coverage of complex traumatic elbow injuries.

PURPOSE: The pedicled reverse-flow lateral arm flap has been described primarily for the reconstruction of nontraumatic elbow wounds. We describe our experience using this flap in staged operations for soft tissue coverage after elbow trauma, including acute coverage of open fractures and salvage of infected hardware. METHODS: Review of patients who underwent staged pedicled reverse-flow lateral arm flap transfer for coverage of traumatic elbow defects. RESULTS: Three patients were identified; all underwent 2-stage repair with flap delay for coverage of traumatic elbow injuries. Each patient had stable wound coverage with this flap. The only complication was 5% distal flap necrosis in 1 patient. CONCLUSIONS: The pedicled reverse-flow lateral arm flap provides reliable soft tissue coverage of traumatic elbow defects with minimal donor-site morbidity.

Bone graft substitutes.

Replacement of missing bone stock is a reconstructive challenge to upper extremity surgeons and decision-making with regards to available choices remains difficult. Preference is often given to autograft in the form of cancellous, cortical, or corticocancellous grafts from donor sites. However, the available volume from such donor sites is limited and fraught with potential complications. Advances in surgical management and medical research have produced a wide array of potential substances that can be used for bone graft substitute. Considerations in selecting bone grafts and substitutes include characteristic capabilities, availability, patient morbidity, immunogenicity, potential disease transmission, and cost variability.