An algorithmic approach to the management of limb ischemia in infants and young children.

BACKGROUND: Vascular injuries in newborns are rare and most commonly occur in the process of obtaining vascular access for monitoring organ system functions or interventions in critical care. Care of vascular injuries in neonates poses several challenges, with the most significant arguably being the lack of clinical experience with such injuries. An algorithm for the management of arterial injuries in pediatric patients is investigated and reported. METHODS: A retrospective chart analysis was performed on all patients consulted for the management of vascular injury by the plastic surgery service at Texas Children's Hospital between 1997 and 2005. The outcomes and procedures were reviewed. RESULTS: Thirty vascular insults in 28 patients were evaluated and treated by the senior author (J.D.F.) using this protocol. Thirty-seven percent (11 of 30) were approached surgically, including two cases treated with thrombolysis alone. The remaining 63 percent (19 of 30) were managed with more conservative interventions, including anticoagulation and clinical optimization. When color Doppler imaging was used preoperatively to locate and describe the characteristics of vascular injuries, visualized lesions coincided with the surgical findings in 100 percent (11 of 11 cases). Twenty-three limbs (77 percent) were salvaged completely using this algorithm, one was initially salvaged but later developed limb-length discrepancy requiring amputation, and one experienced complete limb loss. The remaining patients (five of 30) died as a result of complications of their primary medical conditions before limb salvage could be assessed. CONCLUSION: This evaluation demonstrates the efficacy of the proposed algorithm used to determine direction of care in the event of arterial injury in small children.

Compartment syndrome in all four extremities: a rare case associated with systemic capillary leak syndrome.

While isolated limb injuries often lead to suspicion for and treatment of compartment syndrome, multi-limb compartment syndrome induced by a systemic disease is a rare entity, in which lack of immediate diagnosis can have catastrophic consequences to the patient. We present a patient with idiopathic systemic capillary leak syndrome (SCLS) resulting in compartment syndrome in all four extremities. Treatment required bilateral hand, forearm, calf, and thigh fasciotomies. Presenting symptoms included pain in all four extremities, malaise, and confusion. Laboratory data included polycythemia, hypoalbuminemia, leukocytosis, and elevated creatinine, but not a monoclonal spike on serum electrophoresis as is common in SCLS. Thus, when faced with clinical evidence of multiple extremity compartment syndrome, the surgeon should consider systemic disorders, such as SCLS, and aggressively treat the compartment syndrome as well as the underlying disease.

Evaluation and reduction of nasal trauma.

Nasal trauma plays a large and important role in the field of craniofacial trauma. The resulting aesthetic, structural, and functional sequelae associated with these injuries necessitate a thorough understanding of the topic. This includes an appreciation for the unique anatomic features of the region, the important aspects of the initial history and examination, nasal injury classification, and subsequent treatment timing and options. While a large body of literature has accumulated on the topic, the purpose of this article is to focus on both clinically relevant information and pearls of management. Additionally, age-specific concerns, secondary procedures, and nasal fracture grafting, will be addressed as well.

Crystal deposition disease masquerading as proliferative tenosynovitis and its associated sequelae.

Extra-articular crystalline deposition secondary to gout, and less commonly, pseudogout is a well known phenomenon. Despite this well-documented entity of extra-articular deposition, there have been few reports of infiltration of the flexor tendon sheath of the hand. Here, we present a case series of this unique occurrence, including surgical techniques, pathology, and the clinical outcomes of 5 patients. We encountered 2 cases of calcium pyrophosphate and 3 cases of uric acid deposition into the flexor tendon sheath masquerading as common tendonopathies. These include cases of carpal tunnel syndrome, nonsuppurative flexor tenosynovitis, trigger finger, and attrition rupture of the flexor tendons. Although, medical therapy is the cornerstone of treatment for diseases that result in crystal deposition, these cases emphasize the potential need for surgical therapy in the armamentarium of their management. This case series demonstrates the importance of inclusion of crystal deposition into the flexor tendon sheath in the differential diagnosis in patients that present with uncharacteristic symptomatology of common flexor tendonopathies.

Negative pressure therapy is effective to manage a variety of wounds in infants and children.

Negative pressure therapy (NPT) has been accepted as a valuable adjunct for wound closure in adults; however, reports on its effectiveness in young children and infants, including neonates, are limited. A retrospective chart review was conducted on children treated with NPT at a single institution between January 2003 and December 2005. Wound volumetric measurements were calculated at the start and end of therapy. Sixty-eight patients with 82 wounds were identified. The mean age was 8.5 years (range 7 days-18 years). Twenty patients (29%) were 2 years of age or younger, including eight neonates. Wound types included: pressure ulcers (n=13), extremity wounds (n=18), dehisced surgical wounds (n=19), open sternal wounds (n=10), wounds with fistulas (n=3), and complex abdominal wall defects (n=6). Low suction pressures (<100 mmHg) were generally used in children younger than 4 years of age. Following NPT, 93% of wounds decreased in volume. The average wound volume decrease was 80% (p<0.01, n=56). NPT can be effectively used to manage a variety of wounds in children and neonates. No major complications were identified in our retrospective review. Prospective studies are required to better refine the use of this technology in children.

Deformational plagiocephaly associated with ocular torticollis: a clinical study and literature review.

The etiology of craniofacial asymmetry secondary to positional plagiocephaly with or without concomitant congenital muscular torticollis has been well established. It has been proposed that the craniofacial asymmetry secondary to congenital superior oblique palsy involves a similar etiology. The causal relationship has been thought to be a result of the adoption of certain head and neck positioning, which predisposes the infant to develop preferential resting positions during supine sleep. We present a single subject with ocular torticollis and resulting plagiocephaly, and we distinguish the resultant craniofacial findings from those seen in patients with congenital muscular torticollis-associated deformational plagiocephaly. The distinctions that exist between the resultant asymmetries observed in ocular torticollis with superior oblique palsy and those found with congenital muscular torticollis suggest that the facial hemihypoplasia observed in conjunction with ocular torticollis may be the result of gravitational forces rather than compressive forces.