The effects of edema and self-adherent wrap on the work of flexion in a cadaveric hand.

PURPOSE: Early motion protocols after flexor tendon repair often require hand therapy in edematous digits. Self-adherent wraps are used in the postoperative period to reduce edema. The purpose of this study was to determine whether the presence of a self-adherent wrap affected the work of flexion during early motion protocols. METHODS: In an unpreserved cadaveric hand, the flexor digitorum profundus and flexor pollicis longus tendons were identified and attached to a tensile testing machine to measure work of flexion (WoF). We simulated subcutaneous edema by injecting normal saline into the digits. Moderate and severe edema was simulated by 10% and 20% increases in circumference of the digits, respectively. We evaluated 2 commonly used products: 2.5-cm Coban self-adherent wrap (3M, St. Paul, MN) and 2.5-cm Co-Wrap cohesive bandage (Hartmann, Rock Hill, SC). Statistical analyses include analysis of variance, 95% confidence intervals for average responses, and graphical display of both data and model predictions. RESULTS: In digits without edema or wraps, WoF ranged from 0.0114 J (small finger) to 0.0710 J (thumb). Without wraps, simulated moderate and severe edema was predicted to increase WoF by an average of 23% and 71%, respectively. Application of self-adherent wrap increased WoF values significantly in all digits. In the majority of conditions tested, application of self-adherent wrap increased WoF more significantly than moderate edema did. The effects of edema and self-adherent wrap were additive, producing WoF values 4 times the baseline values. CONCLUSIONS: Edema and self-adherent wrap increased WoF in this model. Therapists and surgeons should be aware of increased stress placed on tendons when early motion protocols are initiated in the presence of edema and self-adherent wrap. CLINICAL RELEVANCE: We recommend removal of self-adherent wrap before starting a therapy session.

A retroperitoneal bleed induced by enoxaparin therapy.

Retroperitoneal bleeding is one of the most serious, potentially lethal complications of anticoagulation therapy. Although well documented in fully heparinized and coumadinized patients, there are only few reports of life-threatening hemorrhages in low-molecular-weight heparin (LMWH)-treated patients. We present a case of almost fatal spontaneous retroperitoneal bleeding in a 71-year-old woman with pneumonia and acute coronary syndrome. After receiving combination therapy with Lovenox (enoxaparin), aspirin, and Plavix for 5 days, she developed acute hemorrhagic shock and possible intra-abdominal compartment syndrome. Urgent computed tomography scan of the abdomen and pelvis was performed and showed a left retroperitoneal hematoma. The patient's condition continued to deteriorate, which prompted emergent exploration. After evacuating 3 L of free blood from the peritoneal cavity, we managed to stabilize the patient. Our case of spontaneous retroperitoneal bleeding adds to the growing number of cases in which enoxaparin has been associated with severe bleeding. A high index of suspicion is necessary if the patient displays any of the signs and symptoms that suggest major hemorrhage. It appears that those at highest risk receive doses approaching 1 mg/kg subcutaneously every 12 hours, have renal impairment, are of advanced age, and receive concomitant medications that can affect hemostasis. On average, a retroperitoneal hematoma occurs within 5 days of therapy with enoxaparin. In high-risk patients, enoxaparin activity (anti-factor Xa) should be carefully monitored.

Coronary artery bypass via resternotomy after pectus excavatum repair.

Pectus excavatum is a chest wall deformity that commonly warrants pediatric surgical correction for cosmesis or respiratory impairment via sternotomy. The repair typically consists of sternal wedge osteotomy and subsequent placement of a Steinman pin across the sternum with fixation to the ribs bilaterally. Coronary artery bypass grafting (CABG) after surgical repair of the sternum with a metal implant poses an intriguing surgical challenge. Literature review reveals only one such previously described case. We present a case of coronary revascularization in an adult who previously underwent pectus excavatum repair with ligation of the internal mammary arteries. Our coronary revascularization was accessed through a resternotomy after surgical removal of the metal implant previously placed during the pectus excavatum repair. Autologous greater saphenous vein was used as a conduit for bypass. The patient did well postoperatively and was discharged on postoperative day 4. The pectus repair remained intact even after the median sternotomy was performed. This was confirmed at the 1-year follow-up for the patient. Resternotomy after pectus excavatum repair with a prosthetic implant poses a challenge to cardiothoracic surgeons. Many such repairs have been described in the pediatric population. As our society ages and coronary artery disease becomes more prevalent, this unique situation may be more commonly encountered. We present an approach to coronary artery bypass grafting via median resternotomy after pectus excavatum repair.

Thyroglossal duct cysts: a consideration in adults.

Thyroglossal duct cysts (TDC) are one of the most common pediatric midline neck lesions. Although they are present from birth, they usually become symptomatic in early childhood as a mass or draining sinus. Infection and abscess formation are frequent complications due to a communication between the cyst and the mouth with subsequent contamination by oral flora. We present a case of a 37-year-old male who presented with a newly symptomatic thyroglossal duct cyst. The patient presented to the infirmary with pain in the anterior neck particularly with swallowing. A midline mass was visible and palpable on examination. Subsequent neck exploration revealed a thyroglossal duct cyst filled with purulent material. Although uncommon in adults, thyroglossal duct cysts should be a part of the surgeon's differential diagnosis when presented with a neck mass. One should remember that an infected neck mass is the common presentation of thyroglossal duct cysts in adults, and the appropriate diagnostic studies need to be performed in order to best determine the diagnosis. Once diagnosed, the TDC is best treated using the Sistrunk procedure to limit recurrence.

A reexamination of the small overlap frontal crash.

The objective of this study was to examine and rank the Small Overlap Frontal Crash as one of the eight-group taxonomy proposed by Ford. The Ford taxonomy classifies real-world frontal-impact crashes based on the National Automotive Sampling System (NASS). Frontally-impacted vehicles were identified for 1985 - 2008 model year passenger vehicles with Collision Deformation Classification (CDC) data from the 1995 - 2008 years of NASS. Small overlap frontal cases were identified where there was no engagement of the vehicle frame rails, and the direct damage was located entirely outside of the vehicle frame rails. The results are that full engagement and offset (offset category means the direct damage overlaps the vehicle frame rail, with the center of direct damage between the frame rails) were the most frequent crashes contributing 35% each. The frequency of the small overlap frontal was 6%. The risks of injury (AIS ≥ 2) for the full engagement, offset, and small overlap were 8%, 6%, and 3% respectively. For this study, the number of small overlap vehicles was 1,118 and the number of injured nearside occupants was 100. This study-following the Ford approach and reasonably identifying the location of the longitudinal rails based on CDC-suggests that the small overlap is at worst a moderately dangerous crash in the overall scheme of frontal crashes. The implications of this study are that the safety community should reexamine the significance of the small overlap frontal crash against an overall taxonomy of crashes.