Ultrapulse Fractional CO 2 Laser With Different Fluences and Densities in the Prevention of Periorbital Laceration Scars: A Split-Scar, Evaluator-Blinded Study.

BACKGROUND: Periorbital laceration can result in complex, permanent scars, and even lead to serious complications such as cicatricial ectropion. Early intervention with laser devices has been suggested as a novel modality to reduce scar formation. However, no consensus exists regarding the optimal treatment parameters for scar management. This study evaluated the efficacy and safety of ultrapulse fractional CO 2 laser (UFCL) with different fluences and densities in preventing periorbital surgical scars. OBJECTIVE: To assess the efficacy and safety of UFCL with different fluences and densities in the prevention of periorbital laceration scars. METHODS: A prospective, randomized, blinded study was conducted on 90 patients with periorbital laceration scars of 2 weeks old. Four treatment sessions of UFCL were administered to each half of the scar at 4-week intervals, with halves treated with high fluences with low density versus low fluences with low-density treatment. Vancouver Scar Scale was used to assess the 2 portions of each individual scar at baseline, final treatment, and 6 months. The patient's 4-point satisfaction scale was used to evaluate the patient's satisfaction at baseline and 6 months. Safety was evaluated by registration of adverse events. RESULTS: Eighty-two of 90 patients completed the clinical trial and follow-up. There was no significant difference in Vancouver Scar Scale and satisfaction score between different laser settings between the two groups ( P > 0.05). Adverse events were minor and no long-term side effects were noted. CONCLUSIONS: Early application of UFCL is a safe, strategy to significantly improve the final traumatic periorbital scar appearance. Objective evaluation of scars did not identify differences in scar appearance between high fluences with low density versus low fluences with low density of UFCL treatment. LEVEL OF EVIDENCE: Level III.

Massagem perineal pré-natal para prevenção do trauma: piloto de ensaio clínico randomizado / Masaje perineal prenatal para la prevención del trauma: piloto de ensayo clínico aleatorizado / Antenatal perineal massage for trauma prevention: a pilot randomized clinical trial

Resumo Objetivo Avaliar a adesão de gestantes e acompanhantes à realização da massagem perineal digital durante a gestação e seu efeito na prevenção do trauma perineal no parto e na redução de morbidade associada nos 45 e 90 dias pós-parto. Métodos Estudo piloto de ensaio clínico randomizado com 153 gestantes de risco habitual, 78 mulheres no grupo de intervenção realizaram a massagem perineal digital e 75 mulheres do grupo controle receberam os cuidados habituais. Para a análise do desfecho principal (trauma perineal) e dos desfechos secundários, permaneceram em cada grupo 44 mulheres que tiveram parto vaginal. A intervenção foi realizada pela gestante ou acompanhante de sua escolha, diariamente, a partir de 34 semanas de gestação, por 5 a 10 minutos. Resultados A massagem perineal foi fator de proteção para edema nos primeiros 10 dias pós-parto (RR 0,64 IC95%0,41-0,99) e perda involuntária de gases nos 45 dias pós-parto (RR0,57 IC95%0,38-0,86). O ajuste residual ≥ 2 observado na análise das condições do períneo pós-parto mostrou uma tendência das mulheres do grupo intervenção terem períneo íntegro. As mulheres e os acompanhantes que realizaram a massagem perineal aceitaram bem a prática, recomendariam e fariam novamente em futura gestação. Conclusão A massagem perineal digital realizada diariamente, a partir de 34 semanas de gestação, foi uma prática bem aceita pelas mulheres e acompanhantes deste estudo. Apesar de não proteger a mulher de trauma perineal, esta prática reduziu o risco de edema 10 dias pós-parto e incontinência de gases 45 dias pós-parto. Registro Brasileiro de ensaio clínico: RBR-4MSYDX

Resumen Objetivo Evaluar la participación de mujeres embarazadas y acompañantes en la realización del masaje digital perineal durante el embarazo y su efecto en la prevención del trauma perineal durante el parto y en la reducción de la morbilidad asociada con los 45 y 90 días post parto. Métodos Estudio piloto de ensayo clínico aleatorizado con 153 mujeres embarazadas con riesgo normal, 78 mujeres en el grupo de intervención realizaron el masaje digital perineal y 75 mujeres del grupo control recibieron los cuidados habituales. Para el análisis del desenlace principal (trauma perineal) y de los desenlaces secundarios, permanecieron en cada grupo 44 mujeres que tuvieron parto vaginal. La intervención la realizó la mujer embarazada o el acompañante por ella elegido, diariamente, a partir de las 34 semanas de embarazo, por 5 a 10 minutos. Resultados El masaje perineal fue factor de protección para el edema en los primeros 10 días postparto (RR 0,64 IC95%0,41-0,99) y la pérdida involuntaria de gases en los 45 días post parto (RR0,57 IC95%0,38-0,86). El ajuste residual ≥ 2 observado en el análisis de las condiciones del perineo postparto mostró una tendencia en las mujeres del grupo intervención a que tengan el perineo íntegro. Las mujeres y los acompañantes que realizaron el masaje perineal recibieron bien la práctica, la recomendarían y la harían nuevamente en un futuro embarazo. Conclusión El masaje digital perineal realizado diariamente, a partir de las 34 semanas de embarazo, fue una práctica bien recibida por las mujeres y acompañantes de este estudio. Pese a que no protege a la mujer de un trauma perineal, esta práctica redujo el riesgo de edema a los 10 días post parto y la incontinencia de gases 45 días post parto.

Abstract Objective To evaluate the adherence of pregnant women and companions to the performance of digital perineal massage during pregnancy and its effect on the prevention of perineal trauma during childbirth and on the reduction of associated morbidity at 45 and 90 days postpartum. Methods A pilot study of a randomized clinical trial with 153 normal risk pregnant women; 78 women in the intervention group underwent digital perineal massage and 75 women in the control group received usual care. For the analysis of the main outcome (perineal trauma) and secondary outcomes, 44 women who had vaginal delivery remained in each group. The intervention was performed daily by the pregnant woman or the companion of her choice from 34 weeks of gestation during 5-10 minutes. Results Perineal massage was a protective factor for edema in the first 10 days postpartum (RR 0.64 95%CI 0.41-0.99) and involuntary gas loss at 45 days postpartum (RR0.57 95%CI 0.38-0.86). The residual adjustment ≥ 2 observed in the analysis of perineal conditions postpartum showed a trend of women in the intervention group having an intact perineum. The women and companions who performed perineal massage accepted the practice well, recommended it and would do it again in a future pregnancy. Conclusion The digital perineal massage performed daily from 34 weeks of gestation was a practice well accepted by women of this study and their companions. Although not protecting women from perineal trauma, this practice reduced the risk of edema at 10 days postpartum and gas incontinence at 45 days postpartum. Brazilian Clinical Trial Registry: RBR-4MSYDX

A Clinical Risk Model to Predict Obstetric Anal Sphincter Injuries in Laboring Patients.

OBJECTIVE: Our objective was to develop a risk stratification tool for predicting obstetric anal sphincter injury risk in women during labor. METHODS: In this retrospective cohort study of singleton deliveries within Kaiser Permanente Northern California, a predictive model for anal sphincter injury was developed within the 2013 birth cohort and validated in the 2014 birth cohort of 22,741 births. Predictors of obstetric anal sphincter injury were identified using multiple regression analysis and used to create a risk calculator tool based on effect size and clinical judgment. RESULTS: Duration of second stage of labor, vacuum delivery, history of anal sphincter injury, maternal and gestational ages, and maternal race and ethnicity were associated with elevated risk of anal sphincter injury. Using these risk factors, we developed a validated parity-stratified scoring system. Among nulliparous women, 116 (1.3%) had a score of zero, corresponding to a 0.9% risk, and 1024 (11.7%) had a score higher than 6, corresponding to a 27.5% risk of anal sphincter injury. Among the multiparous women, 1181 (8.4%) had a score of zero, corresponding to a 0.1% risk, and the 260 (1.9%) with a score higher than 10 had a 7.7% risk. The predictive ability of the score derived based on the 2013 data was applied to the 2014 data, and results showed that the predictive abilities were statistically similar, except for one subgroup: multiparous women with a total score of ≥10. CONCLUSIONS: Our anal sphincter injury risk stratification tool effectively predicts individual risk and can inform clinician and patient decision making to minimize maternal birth trauma.

Do we know How to avoid OASIs in non-Supine Birth Positions? a retrospective cohort analysis / Sabemos como evitar as LOEAs em posições de parto não supinas? Uma análise de coorte retrospectiva

Abstract Objective To evaluate the association between the upright and supine maternal positions for birth and the incidence of obstetric anal sphincter injuries (OASIs). Methods Retrospective cohort study analyzed the data of 1,728 pregnant women who vaginally delivered live single cephalic newborns with a birth weight of 2,500 g. Multiple regression analyses were used to investigate the effect of the supine and upright positions on the incidence of OASIs after adjusting for risk factors and obstetric interventions. Results In total, 239 (13.8%) births occurred in upright positions, and 1,489 (86.2%) in supine positions. Grade-III lacerations occurred in 43 (2.5%) patients, and grade-IV lacerations occurred in 3 (0.2%) women. Supine positions had a significant protective effect against severe lacerations, odds ratio [95% confidence interval]: 0,47 [0.22- 0.99], adjusted for the use of forceps 4.80 [2.15-10.70], nulliparity 2.86 [1.44-5.69], and birth weight 3.30 [1.56-7.00]. Anesthesia (p<0.070), oxytocin augmentation (p<0.228), shoulder dystocia (p<0.670), and episiotomy (p<0.559) were not associated with the incidence of severe lacerations. Conclusion Upright birth positions were not associated with a lower rate of perineal tears. The interpretation of the findings regarding these positions raised doubts about perineal protection that are still unanswered.

Resumo Objetivo Avaliar a associação entre as posições maternas verticais e supinas ao nascimento e a taxa de incidência de lesões obstétricas do esfíncter anal (LOEAs). Métodos Estudo coorte retrospectivo que analisou os dados de 1.728 gestantes que tiveram parto vaginal cefálico simples com peso ao nascer de 2.500 g. Análises de regressão múltipla foram usadas para investigar o efeito de posições supinas ou verticais sobre a taxa de incidência de LOEAs após o ajuste para fatores de risco e intervenções obstétricas. Resultados No total, 239 (13,8%) nascimentos ocorreram nas posições verticais, e 1,489 (86,2%), nas posições supinas. Lacerações graves de grau III ocorreram em 43 (2,5%) pacientes, e de grau IV, em 3 (0,2%) mulheres. As posições supinas tiveram um efeito protetor significativo contra lacerações graves, razão de probabilidades [Intervalo de Confiança de 95%]: 0,47 [0.22-0.99], ajustado para o uso de Fórceps 4.80 [2.15-10.70], nuliparidade 2.86 [1.44-5.69], e peso ao nascer 3.30 [1.56-7.00]. Anestesia (p<0.070), aumento de ocitocina (p<0.228), distocia de ombro (p<0.670), e episiotomia (p<0.559) não estiveram associados à incidência de laceração grave. Conclusão As posições de parto verticais não estiveram associadas a uma menor taxa de ruptura perineal. A interpretação dos achados referentes a essas posições levantou dúvidas sobre a proteção perineal que ainda aguardam respostas.

FIGO Statement: Restrictive use rather than routine use of episiotomy.

International standards for clinical staffing of delivery care in maternity units are currently lacking, with resulting gaps in provision leading to adverse outcomes and very poor experiences of care for women and families. While evidence­informed modelling approaches have been proposed based on population characteristics and estimated rates of complications, their application and outcomes in low­resource settings have not been reported. Here, FIGO's Safe Motherhood and Newborn Health Committee proposes indicative standards for labor wards as a starting point for policy and program development. These standards consider the volume of deliveries, the case mix, and the need to match clinical care requirements with an appropriate mix of professional skills among midwifery and obstetric staff. The role of Shift Leader in busy labor wards is emphasized. Application of the standards can help to assure women and their families of a safe but also positive birthing experience. FIGO calls for investment by partners to test these clinically­informed recommendations for delivery unit staffing at hospital and district level in low­ and middle­income country settings.

Incidence of Obstetric Anal Sphincter Injuries After Training to Protect the Perineum.

OBJECTIVES: Obstetric anal sphincter injuries (OASISs) are a devastating postpartum complication; reducing rates is paramount to improving quality of care. In Norway, implementation of a perineal protection program decreased the incidence of OASIS by 48%. We sought to assess impact on OASIS rates following a similar program. METHODS: This institutional review board-approved, retrospective cohort study was performed in an academic hospital system. The periods of analysis were November 2014 through October 2015 for the preintervention arm and November 2015 through October 2016 for the postintervention arm. From November 2 to 6, 2015, 2 Norwegian experts conducted a didactic and hands-on, on-site workshop focusing on perineal protection. The experts were then present on labor and delivery wards to reinforce perineal protection in live deliveries. Teachings were emphasized at departmental meetings for the remainder of the year. Data were extracted from electronic medical records and manually audited. RESULTS: The rate of vaginal delivery was similar among both periods (6504 and 6650; P = 0.059). Obstetric anal sphincter injury rates decreased from 211 (3.2%) preintervention to 189 (2.8%) after the workshop. Although this represented 32 fewer injuries, it was not statistically significant (P = 0.179). Obstetric anal sphincter injuries following forceps-assisted deliveries did decline significantly from 103 (28%) to 81 (21%) (P = 0.014). In addition, incidence of fourth-degree lacerations during resident deliveries decreased significantly from 10 (0.6%) to 3 (0.2%) (P = 0.047). CONCLUSIONS: An educational workshop focusing on perineal support was not associated with a significant reduction in overall OASIS rates. Nevertheless, decreased forceps-related OASIS and fourth-degree lacerations rates support positive influence of the intervention.

Assessment, prevention and management of skin tears.

Skin tears are common in older people. They are acute wounds that are at high risk of becoming complex, chronic wounds due to the interplay between the physiological changes in the skin and trauma from the external environment. Skin tears have been reported to have prevalence rates equal to, or greater than, those for pressure ulcers. A comprehensive risk assessment should include assessment of the individual's general health (chronic/critical disease, polypharmacy and cognitive, sensory and nutritional status); mobility (history of falls, impaired mobility, dependent activities of daily living, and mechanical trauma); and skin (extremes of age, fragile skin and previous skin tears). A recognised classification system should be used to identify and document skin tears and guide treatment decisions in line with local wound management protocols. Nurses and carers are in a prime position to prevent, assess and manage skin tears.

A new method for the prevention of skin laceration during vacuum-assisted breast biopsy.

OBJECTIVE: To describe a new technique to prevent skin laceration during ultrasound-guided vacuum-assisted breast biopsy with the insertion of a spinal needle between the mass and the skin. METHODS: The study includes 118 patients with 118 breast imaging-reporting and data system Category 3 masses located very close to the skin or areola, which were excised using the mammotome system with a spinal needle inserted just above the site of insertion of the probe. RESULTS: The mean distance between the most superficial portion of the mass to the under surface of the overlying skin was 1.3 ± 0.4 mm. The average procedure time was 13.5 ± 4.2 min. A complete excision was achieved in 100% of the cases, and the procedure was well tolerated by all the patients. No patient experienced serious adverse events such as a skin laceration. CONCLUSION: This is the first study to prevent skin laceration during vacuum assisted breast biopsy. Advances in knowledge: The method described in this study is simple, safe and well tolerated by patients.

To cut or not to cut, that is the question: A review of the anatomy, the technique, risks, and benefits of an episiotomy.

Childbirth can be a traumatic experience on the female body. Some techniques may be implemented to make the process smoother and decrease the potential lacerations that can occur. Episiotomies have been used by obstetricians and midwives to help make the fetal decent down the vaginal canal less turbulent. A physician must use his best judgment on when it is necessary to make this incision and what form of incision to make. Before making an incision one must understand the female external and internal anatomy and thoroughly comprehend the stages of birth to understand how and what complications can occur. Even though an episiotomy is a minor incision, it is still a surgical incision nonetheless and as with any form of surgery there are both risks and benefits that are to be considered. Nevertheless, episiotomies have proven to help ease births that are complicated by shoulder dystocia, prevent severe lacerations, and decrease the second stage of labor. The following comprehensive review provides a description of the female anatomy, as well as an extensive description of why, when, and how an episiotomy is done. Clin. Anat. 30:362-372, 2017. © 2017 Wiley Periodicals, Inc.

Selective Episiotomy: Indications, Techinique, and Association with Severe Perineal Lacerations / Episiotomia seletiva nos dias atuais: indicações, técnica e associação com lacerações perineais graves

Abstract Introduction Episiotomy is a controversial procedure, especially because the discussion that surrounds it has gone beyond the field of scientific debate, being adopted as an indicator of the "humanization of childbirth". The scientific literature indicates that episiotomy should not be performed routinely, but selectively. Objectives To review the literature in order to assess whether the implementation of selective episiotomy protects against severe perineal lacerations, the indications for the procedure, and the best technique to perform it. Methods A literature search was performed in PubMed using the terms episiotomy or perineal lacerations, and the filter clinical trial. The articles concerning the risk of severe perineal lacerations with or without episiotomy, perineal protection, or episiotomy techniques were selected. Results A total of 141 articles were identified, and 24 of them were included in the review. Out of the 13 studies that evaluated the risk of severe lacerations with and without episiotomy, 5 demonstrated a protective role of selective episiotomy, and 4 showed no significant differences between the groups. Three small studies confirmed the finding that episiotomy should be performed selectively and not routinely, and one study showed that midline episiotomy increased the risk of severe lacerations. The most cited indications were primiparity, fetal weight greater than 4 kg, prolonged second stage, operative delivery, and shoulder dystocia. As for the surgical technique, episiotomies performed with wider angles (> 40°) and earlier in the second stage (before "crowning ") appeared to be more protective. Conclusions Selective episiotomy decreases the risk of severe lacerations when compared with the non-performance or the performance of routine episiotomy. The use of a proper surgical technique is fundamental to obtain better results, especially in relation to the angle of incision, the distance from the vaginal introitus, and the correct timing for performing the procedure. Not performing the episiotomy when indicated or not applying the correct technique may increase the risk of severe perineal lacerations.

Resumo Introdução A episiotomia é um procedimento controverso, devido, em parte, à discussão sobre sua realização ter ultrapassado o campo do debate cientifico, sendo adotada como indicador associado com a "humanização do parto." A literatura mostra que a episiotomia não deve ser realizada rotineiramente, mas de forma seletiva. Questões relativas à sua indicação, técnica de realização e associação com lacerações perineais graves são objeto de amplo debate e pesquisa. Objetivos Revisar a literatura para avaliar se a realização da episiotomia seletiva protege contra lacerações perineais graves, quais são suas indicações, e qual a melhor técnica para realizar este procedimento. Método Foi realizada busca no PubMed com os termos episiotomy ou perineal lacerations utilizando o filtro clinical trial. Foram selecionados os artigos que tratavam do risco de lacerações perineais graves com e sem episiotomia, ou de técnicas de proteção perineal ou de episiotomia. Resultados Foram identificados 141 artigos, dos quais 24 foram incluídos na revisão. Dos 13 estudos que avaliaram o risco de lacerações graves com e sem episiotomia, 5 demonstraram o papel protetor da episiotomia seletiva, e 4 não mostraram diferenças significativas entre os grupos. Três pequenos estudos confirmaram o achado de que a episiotomia deve ser realizada seletiva e não rotineiramente, e um estudo mostrou que a episiotomia mediana aumenta o risco de lacerações graves. Quanto às indicações, as mais citadas foram a primiparidade, peso fetal maior do que 4kg, período expulsivo prolongado, parto operatório e distocia de ombro. Quanto à técnica, episiotomias realizadas com ângulos mais abertos (> 40°) e mais precocemente no período expulsivo (antes do "coroamento") parecem ser mais protetoras. Conclusões Episiotomias seletivas reduzem o risco de lacerações graves comparativamente à não realização de episiotomia ou à realização de episiotomia rotineira. Para esse resultado, é fundamental a utilização de técnica operatória correta, principalmente em relação ao ângulo de inclinação e distância da fúrcula vaginal, além do momento de sua realização. Deixar de realizar a episiotomia, com a técnica correta e quando bem indicada, pode aumentar o risco de lacerações perineais graves.

Implementação de práticas assistenciais para prevenção e reparo do trauma perineal no parto / Implementación de prácticas asistenciales para la prevención y reparación de trauma perineal en el parto / Implementation of care practices to prevent and repair perineal trauma in childbirth

RESUMO Objetivos Implementar práticas assistenciais para prevenção e reparo do trauma perineal no parto normal. Métodos Estudo quase-experimental, realizado no Hospital da Mulher Mãe-Luzia, Macapá, AP. Realizaram-se 74 entrevistas com enfermeiros e médicos e 70 com puérperas, e analisaram-se dados de prontuários (n=555). O desenvolvimento da pesquisa se deu em três fases: pré-auditoria e auditoria de base (fase 1); intervenção educativa e implementação de boas práticas assistenciais (fase 2); auditoria pós-implementação (fase 3); a análise foi pela comparação das fases 1 e 3. Resultados Após a intervenção educativa, menos profissionais incentivavam puxos dirigidos, realizavam episiotomia e suturavam lacerações de primeiro grau; mais mulheres informaram que o parto foi em posição litotômica; mais registros nos prontuários indicaram o uso de Vicryl® na sutura da mucosa e pele. Conclusões A intervenção educativa melhorou os cuidados e os desfechos perineais, porém há lacunas na implementação das evidências e inadequações no manejo do cuidado perineal.

RESUMEN Objetivo Implementar prácticas asistenciales para la prevención y reparación del trauma perineal en el parto. Método Estudio casi experimental, conducido en el Hospital da Mulher Mãe-Luzia, Macapá, AP. Se realizaron 74 entrevistas con médicos y enfermeras y 70 con puérperas y se analizaron los datos de registros médicos (n=555). La investigación se desarrolló en tres fases: preauditoría y auditoría de base (fase 1); intervención educativa e implementación de buenas prácticas asistenciales (fase 2); auditoría posimplementación (fase 3); el análisis fue comparando las fases 1 y 3. Resultados Después de la intervención educativa, menos profesionales incentivaban pujo dirigido, realizaban episiotomía y suturaban desgarros de primer grado; más mujeres tuvieron el parto en posición litotomía; más registros indicaban uso de Vicryl® para suturar la mucosa y piel. Conclusión La intervención educativa ha mejorado el cuidado y los resultados perineales, pero hay lagunas en la implementación de evidencias y deficiencias en el cuidado perineal.

ABSTRACT Objective To implement care practices for perineal trauma prevention and repairing in normal birth. Method Quasi-experimental study conducted at Hospital da Mulher Mãe-Luzia, in Macapá, AP, Brazil. Seventy-four (74) nurses and obstetricians and 70 post-partum women were interviewed and the records of 555 patients were analyzed. The study was conducted in three stages: pre-audit and baseline audit (phase 1); educational intervention and implementation of best practices (phase 2); post-implementation audit (phase 3). Data was analyzed by comparison of the results of phases 1 and 3. Results Following the educational intervention, a lower number of health professionals encouraged directed pushing, performed episiotomies and repaired first-degree lacerations; more women reported lithotomy position; more patient records indicated the use of Vicryl™ to suture the perineal mucosa and skin. Conclusion The educational intervention improved birth care and perineal outcomes. Nevertheless, gaps were identified in the implementation of evidence, as well as inappropriate perineal care management

Proximal femoral fractures and vascular injuries in adults: Incidence, aetiology and outcomes.

INTRODUCTION: Vascular injuries (VI) presenting during internal fixation (IF) of proximal femoral fractures (PFF) are potentially limb- and life-threatening. The purpose of this systematic review of the literature is to report on their incidence, associated complications and to give special emphasis in their prevention. MATERIALS AND METHODS: A comprehensive review of the literature was undertaken using the PRISMA guidelines with no language restriction. Case reports of VIPFF-IF and series of PFF-IF with cases of VI published between inception of journals to March 2015 were eligible for inclusion. Relevant information was divided in two parts. Part I included the analysis of cases of VIPFF-IF, with the objective of establishing the frequency of injury of each vessel, the types and mechanisms of injury, the diagnostic and therapeutic modalities, and the outcomes. Part II analysed series of PFF-IF, which included case(s) of VI for assessing the incidence of VIPFF-IF. RESULTS: Overall 160 articles with 182 cases of VIPFF-IF met the inclusion criteria. The injuries to extrapelvic vessels prevailed over those of intrapelvic vessels. There was a higher frequency of injury to the deep femoral artery and its branches in extrapelvic vessels and of external iliac artery and vein in intrapelvic vessels. The types of injury were: compression, intimal flap tear, disruption of the intimal layer with thrombosis, laceration with haemorrhage, and puncture or progressive erosion leading to a pseudoaneurysm (PSA) or arteriovenous fistula (AVF), with high prevalence for PSA, followed by lacerations. PSAs were more frequent in extrapelvic lesions and lacerations in the intrapelvic vessels. There were 7 non-iatrogenic injuries, produced by a displaced lesser trochanter fragment or other bone fragments, and 175 iatrogenic injuries (96.15%). The intrapelvic intraoperative protrusion of instruments or implants, or the post-operative migration of implants produced the injuries of intrapelvic vessels. For iatrogenic injuries of extrapelvic vessels the prevalent mechanism was a displaced lesser trochanter fragment, either intra- or postoperatively, followed by injuries by an overshot drill bit or a protruding screw; several other mechanisms completed the list. The clinical and radiological investigations were similar to those of VI elsewhere. VI occurred either at the time of fracture, during surgery or after it, early or late, weeks, months or even years after IF. The diagnostic and therapeutic modalities were most diverse, and the incidence of morbidity and mortality was 18.06%. The overall incidence of VIPFF-IF was 0.49%. CONCLUSION: The incidence of VIPFF-IF is low, though it will probably rise because of the increasing frequency of PFF. With few exceptions, these injuries, which are potentially limb and life-threatening, are iatrogenic, resulting of errors in IF, with different types of lesions to intra- and extrapelvic vessels running in close proximity to the bone. Although the surgeon should bear in mind this possibility and achieve early diagnosis and prompt accurate treatment, there is no consensus as to what is the best diagnostic or therapeutic modality. A precise diagnosis of the preoperative vascular status of the limb, monitoring of the displacement of the lesser trochanter fragment, careful and gentle reduction of the fracture, and precise handling of instruments and implant selection and placement during IF, are factors to consider in order to prevent this complication, which should never be underestimated.

Parturient perineal distensibility tolerance assessed by EPI-NO: an observational study / Tolerância da parturiente à extensibilidade perineal avaliada pelo EPI-NO: estudo observacional / Tolerância da parturiente à extensibilidade perineal avaliada pelo EPI-NO: estudo observacional

Objective : To determine how parturient women tolerate the use of a perineal distensibility assessment technique using the EPI-NO device. Methods : An observational study with a total of 227 full-term parturient women was performed. During the evaluation with EPI-NO, parturient patients were asked about their sensation of discomfort. The degree of discomfort was measured using the Visual Analogue Scale, with a score from zero to 10. The Mann-Whitney test was applied to assess perineal distensibility measured by EPI-NO and the degree of discomfort caused by the test according to parity. The relation between perineal distensibility and discomfort was analyzed by using the Spearman correlation test (r). Results : The test with EPI-NO caused only slight discomfort (mean Visual Analogue Scale of 3.8), and primiparous women reported significantly greater discomfort (mean Visual Analogue Scale of 4.5) than did multiparous (mean Visual Analogue Scale=3.1), with p<0.001 women. A negative correlation was observed, in other words, the greater the perineal distensibility on the EPI-NO, the lower the pain reported by the patients (r=-0.424; p<0.001). Conclusion : The assessment of perineal distensibility with EPI-NO was well tolerated by the parturient women. .

Objetivo : Determinar como a mulher parturiente tolera o uso de uma nova técnica de extensibilidade perineal, por meio do aparelho EPI-NO. Métodos : Estudo observacional com um total de 227 gestantes a termo. Durante a avaliação pelo EPI-NO, as parturientes foram perguntadas sobre a sensação de desconforto. O grau de desconforto foi medido usando a Escala Visual Analógica, com escore entre zero a 10. O teste de Mann-Whitney foi usado para avaliar a extensibilidade perineal avaliada pelo EPI-NO e o grau de desconforto causado pelo teste de acordo com a paridade. A relação entre extensibilidade perineal e desconforto foi avaliada pelo teste de correlação de Spearman (r). Resultados : O teste com EPI-NO causou apenas leve desconforto (média da Escala Visual Analógica de 3,8), sendo que as primíparas reportaram mais desconforto de modo significativo (média da Escala Visual Analógica de 4,5) que as multíparas (média da Escala Visual Analógica de 3,1), com p<0,001. Observou-se correlação negativa, ou seja, a maior extensibilidade no EPI-NO foi acompanhada de menor dor referida pelas pacientes (r=-0,424; p<0,001). Conclusão : A avaliação da extensibilidade perineal com EPI-NO foi bem tolerada pelas parturientes. .

Proximal humerus nailing: a randomized clinical trial between curvilinear and straight nails.

BACKGROUND: Intramedullary nailing of displaced proximal humerus fractures is an attractive option in the elderly patient. However, in recent reports, some existing intramedullary nails have shown high rate of complications, so new designs are being developed. The objective of the present study is to report on outcomes and complications when comparing a straight to a curvilinear nail design. METHODS: We prospectively include 54 patients with Neer's 2- or 3-part proximal humerus fractures. Two were lost to follow-up, 26 were surgically treated with a new straight humeral nail (MultiLoc, Synthes) mean age 69 (range, 47-87 years), and 26 with a curvilinear nail (Polarus, Acumed) mean age 71 (range, 38-89 years). At final follow-up (average 14 months), patients underwent a clinical and radiographic evaluation. Clinical outcome was assessed with the adjusted Constant score. RESULTS: All but 1 fracture went on to radiographic union. Mean Constant score in the Polarus nail was 72.7 ± 16.0 and 83.3 ± 16.7 in the MultiLoc (P = .246). Symptoms related with rotator cuff disease were present in 19/26 patients (73%) and in 9/26 (34.6%), respectively (P = .001). The mean neck-shaft angle at final follow-up was 135° in the MultiLoc group and 130° in the Polarus group (P > .05). Reoperation rate was 42% for Polarus and 11.5% for MultiLoc. CONCLUSION: Straight intramedullary nails had a comparable union rate to an accepted curvilinear design, with a much lower incidence of complications. Rotator cuff pain and dysfunction can be minimized with the use of newer generation straight nails.

Table saw injuries: epidemiology and a proposal for preventive measures.

BACKGROUND: Table saws are ubiquitous devices in professional, home, and school woodshops that have the potential to cause severe injuries. Many of these injuries results in finger and thumb tendon, nerve, and vascular damage or amputation. Long-term outcomes of these injuries can include functional and sensory deficits. Table saw manufacturers are required to equip saws with blade guards to prevent blade contact; nevertheless, treatment of table saw injuries is a common occurrence in U.S. emergency departments. METHODS: The authors performed a literature search using PubMed and the Cumulative Index to Nursing and Allied Health Literature to compile epidemiology data relevant to table saw injuries. The authors also reviewed the U.S. Consumer Product Safety Commission's briefing package on table saw blade contact injuries. RESULTS: Over 30,000 table saw injuries occur annually. Fingers and hands are the most frequently injured body parts, and lacerations are the most common injuries. Individuals suffering from occupational injuries tend to be younger than those injured during amateur woodworking. A small but important minority of injuries are to students participating in school shop classes. Medical costs for the treatment of table saw injuries are estimated at more than $2 billion every year. CONCLUSIONS: SawStop technology stops the saw blade when contact with skin is made, resulting in a small cut rather than a more complicated laceration or amputation. The application of this novel technology in saw designs can prevent serious injuries that deleteriously affect lives at the personal and societal levels.

The tertiary management of pretibial lacerations.

Pretibial lacerations remain one of the commonest yet most neglected conditions facing emergency departments and plastic surgeons alike. Furthermore, these injuries afflict the most vulnerable groups of adults - the elderly and the infirm. It is essential therefore to have an approach to pretibial lacerations based on best available evidence, in order to optimize wound outcomes, but perhaps more importantly, to safeguard the general health of the vulnerable individual. We present an evidence-based approach to the tertiary management of these injuries and propose a treatment algorithm that we have utilized in our unit to successfully manage 40% of tertiary referrals of pretibial lacerations in a conservative manner.