Targeted high concentration botulinum toxin A injections in patients with Raynaud's phenomenon: a retrospective single-centre experience.

Raynaud's phenomenon is a vasospastic condition affecting hands and feet which may lead to rest pain, ischemic ulcers and gangrene. Botulinum toxin A has been shown to improve peripheral circulation and relieve vasospastic symptoms. Our aim was to assess our treatment outcomes following Botulinum toxin A injections in patients with Raynaud's phenomenon and to explore the importance of toxin concentration and injection sites. Retrospective chart review of patients with primary and secondary Raynaud's syndrome treated with Botulinum toxin A injections and a literature review was conducted. The toxin dose, injection sites, symptom relief, healing of ulcers and complications were assessed. A total of 30 treatment episodes over a 7½ year period were included. All patients had failed medical management. Botulinum toxin A injection was injected primarily in the vicinity of the palmar digital neurovascular bundle. The average total Botulinum toxin A dose injected was 156 U and the concentration was 50 U/ml. All patients reported an improvement in symptoms and healing of digital ulcers. One patient reported a temporary muscle weakness. Six patients had a single treatment episode with long term benefit. Systemic sclerosis patients had an average of 6-month interval between treatment episodes. Higher doses of Botulinum toxin A has been well tolerated with no long term adverse effects. Our study shows that targeted low volume higher concentration Botulinum toxin A injections are effective in treating Raynaud's phenomenon.

The Mersey Burns App: evolving a model of validation.

INTRODUCTION: 'Mersey Burns App' is a smartphone/tablet application that aids in the assessment of total burn surface area (TBSA) and calculation of fluid resuscitation protocols in burns. This paper presents two studies assessing the speed and accuracy of calculations using Mersey Burns (App) in comparison with a Lund and Browder chart (paper) when a burn is assessed by medical students and clinicians. METHODS: The first study compared the speed and accuracy of TBSA and resuscitation calculation for a photograph of a burn with App and paper using burns and plastics and emergency medicine trainees and consultants. Developing on some of the feedback and results of that study, a second study was then carried out using burns-naive medical students assessing a fully simulated burn with both modalities. Preference and ease of use of each modality were assessed anonymously. RESULTS: The clinician study showed a lower variance in TBSA and fluid calculations using the App (p<0.05). The student study showed no difference in mean TBSA estimations (p=0.7). Mean time to completion of calculations was faster and calculations were more likely to be correct with the App (p<0.001). Students favoured the App in the following categories: preference in emergency setting, confidence in output, accuracy, speed, ease of calculation, overall use and shading (p<0.0001). CONCLUSIONS: Mersey Burns App can facilitate quicker and more accurate calculations than Lund and Browder charts. Students also preferred the App. This suggests a useful role for the App in the care of patients with burns by inexperienced staff.

Use of Botulinum Toxin Injections in the Treatment of Cold Intolerance.

There is currently no consensus on the treatment of cold intolerance in extremities in post-trauma patients. We aim to present two cases where botulinum toxin type A injections were used to improve symptoms of cold intolerance. Botulinum toxin type A (Allergan) was injected into the area around the palmar digital neurovascular bundle on both sides of the affected finger. We performed this in two patients, and both had good improvement of symptoms. One patient was discharged, and the other remained under routine follow-up with potential yearly botulinum injections to aid symptoms during the winter months. Both patients are pleased with their outcomes and report significant improvement from the low-risk treatment. In both described cases, injections of botulinum toxin had a significant effect on their symptoms. We conclude that botulinum toxin type A may be used as a treatment modality to improve symptoms of cold intolerance after trauma.

Visualizing the vascular history of nonmelanoma skin tumors: an in vivo human study.

INTRODUCTION: The formation of cutaneous carcinoma has been shown to rely on neovascularization, with angiogenesis being implicated in the invasive process of skin malignancy and metastasis. To date, studies of angiogenesis have generally been limited to in vitro, animal (often murine), or postexcision histopathologic models. METHODS: To demonstrate the angiogenic progression of human tumors in vivo, this study has used the Spectrophotometric Intracutaneous Analyser (SIAscope; Biocompatibles, Surrey, United Kingdom) to produce parametric images of 250 nonmelanoma skin cancers and 13 actinic keratoses. This provides a history, in images, of the vascular basis of skin cancer formation. RESULTS AND CONCLUSIONS: While displaying that the in vitro findings of angiogenesis are indeed occurring in vivo in humans, this technique also suggests a practical means to allow accurate application and monitoring of antiangiogenic therapy. In addition, it raises the possibility of differentiating superficial from nonsuperficial nonmelanoma skin cancers in an office-based setting, thus allowing accurate usage of surgical or nonsurgical treatment methods.

Use of volar distal radius plate dorsally for wrist arthrodesis in patients with upper limb spasticity: A retrospective review.

Standard wrist arthrodesis implants are generally designed for adult joints with arthritis. They are often too big for patients with limb spasticity who generally tend to have osteopenic and smaller bones for their age, resulting in high complication rates. We previously described the novel use of volar distal radius variable-angle locking plate (APTUS® Wrist distal radius system 2.5, Medartis AG, Basel, Switzerland) on the dorsum for wrist arthrodesis in patients with limb spasticity. This study aimed to further establish the use of the implant by reporting the outcomes in cohort A (nondistal radius plate) and cohort B (distal radius plate cohort). Patient-reported outcome measures were used to assess the primary outcome, whereas secondary outcomes included implant-related complications and improvement in wrist position and fusion rates. A total of 17 wrist arthrodesis procedures were performed over a period of 4 years in 15 patients for wrist deformity secondary to limb spasticity. There were no complaints of implant prominence, implant or tendon irritation, metacarpal prominence, or extension requiring further treatment in cohort B. Cohort A had a high implant removal rate that is comparable to the published literature. Both groups reported significant improvement in hygiene and wrist position but neither group had any appreciable gain in function. Volar distal radius variable-angle locking plates appear to be safe and have superior patient acceptability and low complication rates when used dorsally for wrist arthrodesis in patients with upper limb spasticity. Comparable overall satisfaction rates in cohort B were reported in relation to the literature and the cohort A in this study.

Salvaging Digital Replantation and Revascularisation: Efficiency of Heparin Solution Subcutaneous Injection.

BACKGROUND: Distal digital replantation and revascularisation remains one of the demanding microsurgical procedures due to the difficulty of vascular anastomosis. Venous congestion is the most commonly encountered problem after replantation due to the difficulty of venous anastomosis in traumatic injuries. Heparin, among other drugs, is commonly used to facilitate venous drainage and prevent thrombosis. However, systemic heparin can be contraindicated in some patients. The senior author has experience of subcutaneous heparin injection for venous congestion in thirteen patients. METHODS: An amount of 1 ml of calcium heparin (25,000 U) was mixed in 2.4 ml of normal saline making a solution that has 1000 U per 0.1 ml. 1000 U (0.1 ml) of the solution was injected directly into the congested replanted digits. This was repeated twice daily until venous congestion improved. RESULTS: All the congested replanted digits survived without systemic side effects. There were no local side effects of the treatment. The PT and APTT have shown slight increase but they remained within the normal range. Haemoglobin levels have dropped slightly but no patients were at any risk of developing anaemia or needed blood transfusion. CONCLUSIONS: Subcutaneous heparin injections can salvage the replanted digits when venous congestion is a warning flag for replantation failure. It is safe and very efficient in patients where systemic heparin cannot be administered. However, this article shows the results in only thirteen patients which is a small number to show the efficacy, safety, and side effects.

Apert syndrome: A consensus on the management of Apert hands.

INTRODUCTION: Apert Syndrome is a congenital condition characterised by primary craniosynostosis, midfacial malformations and complex symmetrical malformations of the hands and feet. The hands demonstrate one of the most complex collections of congenital upper limb deformities, posing a significant challenge for the paediatric hand surgeon. This study examines the extant literature and current practice of the four UK specialist craniofacial units regarding the management of Apert hands in order to provide a basis for guideline development. METHODS: The current literature was reviewed. Survey-type questionnaires were distributed to the four UK specialist craniofacial units and responses analysed. RESULTS: Management of the Apert hand is largely dictated by the degree of malformation present. Although all units aim to achieve a five digit hand, variation in the timing of surgery, operative protocols and mobilisation policies exist. CONCLUSION: The results of this study provide an interesting snapshot of the current management of Apert hands across four UK craniofacial surgery units. The four UK units remain congruent on most areas surrounding the management of Apert hands although some minor inter-unit variation exists. A multidisciplinary approach to management remains fundamental in optimising the regain of function and aesthetically acceptable hands.

Amniotic constriction bands: a case series and proposed new classification system.

INTRODUCTION: Amniotic constriction bands occur in approximately one in every 15,000 live births and is graded using the Patterson Classification system. METHODS: A case series of all patients with amniotic constriction band that presented to Alder Hey Children's Hospital was compiled between the years 1993 and 2012, data was described and a classification system developed. RESULTS: Thirty seven patients were identified. Of these 17 had amniotic constriction confined to the upper limbs and three of the lower limbs only. Seventeen had both upper and lower limb deformity. Twenty eight children underwent surgical intervention whilst nine to date have not. CONCLUSION: Constriction band of the upper limb was the most common with lower limb bands the least. There is no agreement on the nomenclature of this condition making amalgamation of the literature problematic. A more specific classification of upper limb bands has been suggested which includes anatomical location and depth of band.

An isolated digital lipoblastoma.

This report presents a girl with a lipoblastoma of a finger presenting as a macrodactyly. Documented inflammation of the digit at birth raises suspicion of neo-adipogenesis, which is recognised in lipomas. This case highlights a rare site for lipoblastomas and explores a potential aetiopathogenesis.

The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy.

An interdisciplinary European group of clinical experts in the field of movement disorders and experienced Botulinum toxin users has updated the consensus for the use of Botulinum toxin in the treatment of children with cerebral palsy (CP). A problem-orientated approach was used focussing on both published and practice-based evidence. In part I of the consensus the authors have tabulated the supporting evidence to produce a concise but comprehensive information base, pooling data and experience from 36 institutions in 9 European countries which involves more than 10,000 patients and over 45,000 treatment sessions during a period of more than 280 treatment years. In part II of the consensus the Gross Motor Function Measure (GMFM) and Gross Motor Function Classification System (GMFCS) based Motor Development Curves have been expanded to provide a graphical framework on how to treat the motor disorders in children with CP. This graph is named "CP(Graph) Treatment Modalities - Gross Motor Function" and is intended to facilitate communication between parents, therapists and medical doctors concerning (1) achievable motor function, (2) realistic goal-setting and (3) treatment perspectives for children with CP. The updated European consensus 2009 summarises the current understanding regarding an integrated, multidisciplinary treatment approach using Botulinum toxin for the treatment of children with CP.

A supernumerary extensor tendon to the thumb with an accessory tendon to extensor indicis.

We present a report of an anatomical variation, the function of which is unclear. An anomalous, independent tendon to the thumb was accompanied by an accessory supernumerary tendon to the extensor indicis. This particular variation has not previously been described and was discovered during routine dissection of a male cadaveric upper limb. It is important to revisit these variations of anatomy as they may be relevant to explain clinical signs or during surgical procedures as detailed in this report.

Customised silicone prostheses for the reconstruction of chest wall defects: technique of manufacture and final outcome.

Chest wall reconstruction with a customised silicone prosthesis in 13 patients (five patients with pectus excavatum, six Poland's syndrome and two with post-surgical chest wall deformity) is presented. An alginate impression or CT scan with three-dimensional reconstruction was used to produce the final mould from which the silicone prosthesis was fabricated. The surface of the silicone implant was roughened to reduce capsular contracture and holes were incorporated to allow for tissue integration. Twelve patients had aesthetically acceptable results after a mean of 5 years follow up. This series indicates that accurate assessment of the defect, modifications on manufacture and proper placement of the implant result in a more satisfactory final outcome.