Why tibial plateau fractures are overlooked.

BACKGROUND: Tibial plateau fractures (TPFs) are sometimes overlooked in the emergency room (ER). Using a national register covering 18 years we aimed to find out why and to evaluate if use of a specific radiographic decision rule, Pittsburgh Knee Rules (PKRs), could have reduced the number of overlooked TPFs. METHODS: Medical records for 137 patients, prospectively registered during 18 years by the Danish Patient Compensation Association (DPCA) (a national register), were studied. The inclusion criterion was a delayed diagnosis of a fracture in the knee following a trauma. Case records, legal assessments, and evaluations by specialist doctors were reviewed, and the consequences of the delayed diagnosis for outcome and treatment were registered. RESULTS: Only 58 patients (42%) had been evaluated according to PKRs. In 53 patient cases, the fracture was not diagnosed on radiographs obtained at the first medical contact. However, in 84% of these cases, the fracture was visible or was suspected by retrospective evaluation. 50 out of 79 patients, for whom X-rays were not obtained, were candidates for radiographs according to PKRs, 17 cases lacked information to evaluate by PKRs and 12 cases were not candidates. In 53% of all cases, it was evaluated that the fracture position had worsened at the time of diagnosis. A significant disability compensation was granted in 36% of cases due to the delayed identification of fractures, totaling 841,000 EUR. CONCLUSIONS: The major reasons for overlooking TPFs were 1) difficulty in recognizing the fractures on X-rays and 2) that X-ray decision rules were not employed. Two thirds of the patients, for whom a radiograph had not been prescribed, would have had an X-ray, if the PKRs had been used. Overlooking TPFs significantly increased patient disability in one third of cases. We recommend that healthcare professionals in the ER use X-ray decision rules in addition to clinical examination to avoid overlooking TPFs. When standard radiographs are evaluated as normal in patients that are clinically suspect of a TPF, oblique X-rays, magnetic resonance imaging (MRI) or Computed Tomography (CT)-scan should be considered.

Indocyanine green angiography in oncoplastic breast surgery, a prospective study.

INTRODUCTION: The use of Indocyanine green angiography (ICG-A) in oncoplastic breast-conserving surgery (OBCS) has not yet been investigated. This prospective trial applied ICG-A in volume displacement and replacement OBCS to localize perforators and determine tissue supplied by the perforator. Furthermore, to investigate and correlate the intraoperative ICG-A to postoperative surgical site infection, skin necrosis, epidermolysis, and timely onset of adjuvant therapy. METHODS: ICG-A was performed at three pre-set timepoints during surgery; after lumpectomy, upon dissection of possible perforators, and after wound closure. All patients were followed with clinical evaluations before surgery, 4 weeks, 4-6 months, and 12 months postoperatively. RESULTS: Eleven patients were included: seven volume displacement and four volume replacement OBCS. ICG-A located the tissue supplied by the perforator and demonstrated sufficient perfusion in all cases. The ICG-A corresponded to the surgeons' clinical assessment. One patient developed a postoperative infection and seroma and was treated conservatively. No patients had postoperative necrosis, loss of reconstruction, or lymphedema of the arm. Edema of the breast occurred in four patients (36.4%). Scar assessments were significantly worse at 4-weeks and 4-6 months. The quality of life improved significantly during follow-up. Adjuvant treatment was administered timely in all cases. CONCLUSION: ICG-A was feasible for OBCS in assessing intraoperative perfusion. Perfusion was sufficient in all patients and corresponded to the surgeon's clinical evaluation. No patients developed postoperative necrosis. Though edema of the breast occurred in 36.4%, a larger sample size is needed to investigate a possible correlation with ICG-A. Further studies, which includes patients requiring extensive tissue replacement challenging the borders of perfusion, are needed.

Corrigendum: Giant, Bleeding, and Ulcerating Proliferating Trichilemmal Cyst, With Delayed Treatment Due to Coronavirus Outbreak: A Case Report and Review of the Literature.

[This corrects the article DOI: 10.3389/fsurg.2021.680160.].

[Conservative treatment of iatrogenic milk fistula].

A milk fistula is a rare condition, and only 27 cases have been reported in the latest systematic review from 2020. A fistula can be iatrogenic or spontaneous. The content of tissue factors in breast milk promotes granulation in wounds, which can lead to hypergranulation and lack of epithelialization. In this case report, a 29-year-old breastfeeding woman developed a milk fistula after surgical removal of a naevus on suspicion of being a melanoma. Hypergranulation of the wound was successfully treated with corticosteroid, which inhibits growth factor in breastmilk, and breastfeeding was continued during treatment.

Giant, Bleeding, and Ulcerating Proliferating Trichilemmal Cyst, With Delayed Treatment Due to Coronavirus Outbreak: A Case Report and Review of the Literature.

We report a case of a large, ulcerating proliferating trichilemmal cyst in a 76-year-old woman, with clinical, radiological, macroscopic, and microscopic correlation. The outbreak of the Coronavirus pandemic delayed her treatment. We review the literature on proliferating trichilemmal cysts, which are relatively rare tumors, which, generally, are considered benign. However, we found a high rate of malign cases, which stresses the importance of rapid surgical excision and histological diagnosis. Even though our proband had delayed treatment, the tumor did not transform into a malignant form.

Optimal Insertion Depth for Nasal Mid-Turbinate and Nasopharyngeal Swabs.

Millions of people are tested for COVID-19 daily during the pandemic, and a lack of evidence to guide optimal nasal swab testing can increase the risk of false-negative test results. This study aimed to determine the optimal insertion depth for nasal mid-turbinate and nasopharyngeal swabs. The measurements were made with a flexible endoscope during the collection of clinical specimens with a nasopharyngeal swab at a public COVID-19 test center in Copenhagen, Denmark. Participants were volunteer adults undergoing a nasopharyngeal SARS-CoV-2 rapid antigen test. All 109 participants (100%) completed the endoscopic measurements; 52 (48%) women; 103 (94%) white; mean age 34.39 (SD, 13.2) years; and mean height 176.7 (SD, 9.29) cm. The mean swab length to the posterior nasopharyngeal wall was 9.40 (SD, 0.64) cm. The mean endoscopic distance to the anterior and posterior end of the inferior turbinate was 1.95 (SD, 0.61) cm and 6.39 (SD, 0.62) cm, respectively. The mean depth to nasal mid-turbinate was calculated as 4.17 (SD, 0.48) cm. The optimal depths of insertion for nasal mid-turbinate swabs are underestimated in current guidelines compared with our findings. This study provides clinical evidence to guide the performance of anatomically correct nasal and nasopharyngeal swab specimen collection for virus testing.

Study protocol for a 10-year prospective observational study, examining lymphoedema and patient-reported outcome after breast reconstruction.

INTRODUCTION: Over the last decades, treatment of breast cancer has become increasingly more effective. Consequently, an increasing number of women are living with late effects of breast cancer treatment, including disfiguring scars, deformity or asymmetry of the breast, secondary lymphoedema and other physical and psychosocial late effects. Data from this study will provide knowledge on how to guide breast reconstruction in the future towards outcomes with fewer complications, higher long-term quality of life (QoL) and satisfaction with the aesthetic outcome. The development of secondary lymphoedema, for which the effect of breast reconstruction has yet to be established, will be thoroughly examined. METHODS AND ANALYSIS: Women receiving breast reconstruction (autologous and implant based) at the Department of Plastic Surgery and Burns Treatment, Rigshospitalet, will be invited to participate. The patients will be followed for 10 years postoperatively. Demographic, health-related, oncological characteristics and treatment data will be registered. Validated assessment tools, such as the BREAST-Q and Beck Depression Inventory, will be used to measure an extensive range of clinical outcomes, including QoL, life and aesthetic satisfaction and depression. Arm range of motion will be measured with a goniometer and lymphoedema by bioimpedance spectroscopy, compared with circular arm measurements. ETHICS AND DISSEMINATION: This study will be conducted according to the 5th version of the Helsinki Declaration. The regional ethical committee for Capital Region Denmark did not find the study notifiable, according to the law of the committee § 1, part 4. All data will be anonymised before its publication. This study will be conducted according to the Danish data protection regulation and is catalogued and approved by the Capital Region Head of Knowledge Centre. According to the Danish health law § 46, part 2, this study does not need the Danish Patient Safety Authority's approval. The findings of this study will be submitted to international peer-reviewed journals.