Complications of high volume circumcision: glans amputation in adolescents; a case report.

BACKGROUND: The past four years has seen a rapid roll-out of male medical circumcision services in South Africa in response to clinical trials showing circumcision prevents HIV acquisition in heterosexual men. Clinics conduct substantial numbers of circumcisions per day. We report three cases of glans amputation in adolescents attending high volume clinics where modified Models of Optimising Volume and Efficiency (MOVE) are implemented. CASE PRESENTATIONS: Three cases of glans amputation in young healthy men that presented for voluntary medical male circumcision. The procedures were performed by highly experienced medical officers in two cases. All these cases shared characteristics: younger males with immature genitalia, forceps guided circumcision, and likely operator fatigue. Voluntary male medical circumcision programs should include regular monitoring and evaluation and training of operators to ensure high quality surgical techniques such as working in clean areas and taking frequent breaks. CONCLUSION: Circumcision is a relatively simple medical procedure, however regular training and quality control in high volume Male Medical Circumcision sites is essential to prevent rare catastrophic adverse events.

A Uniquely Abnormal Stool Specimen: A Case Report.

BACKGROUND: Autoamputation of the appendix is a condition associated with the Ladd's procedure, a pediatric surgical technique for correction of intestinal malrotation. A 4-year-old male patient with a history of a Ladd's procedure performed as a newborn was brought in by his mother for "passing intestine" just prior to arrival. She reported that for several weeks her son had intermittent, crampy abdominal pain that resolved after the unusual-appearing bowel movement. After reviewing an image of the bowel movement, and in consultation with pediatric surgery, it was concluded that the patient had passed a devascularized appendix in his stool immediately prior to arrival. CASE REPORT: A 4-year-old boy with a past medical history of heterotaxy syndrome (inversion of the thoraco-abdominal organs), a double outlet right ventricle, and Ladd's procedure presented to the Emergency Department (ED) after "passing intestine" in his stool. Close examination of the photo demonstrated a tubular structure with taenia, consistent with an appendix. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Autoamputation of the appendix is an uncommon presentation in the ED. Passing a devascularized appendix is a benign condition and can present with weeks of intermittent abdominal pain that resolves with passage of appendix in the stool. Remnants of the appendix can remain within the intestinal lumen years after the Ladd's procedure. Emergency physicians with a general awareness of this rare phenomenon can confidently make the diagnosis and reassure worried parents.

Traumatic penile amputation: a case report.

BACKGROUND: Traumatic amputation of the penis is a rare surgical emergency. Although repair techniques have been well described in literature, failure of replantation and its causes are poorly understood and reported. Herein, we report the case of a 9 year old boy who underwent replantation of his amputated penis with delayed failure of the surgery, along with a discussion of recent advances in the management of this condition. CASE  PRESENTATION: A 9-year-old boy was referred to our hospital for traumatic amputation of the penis. Papaverine aided microsurgical replantation of the severed part was performed, but by 48 h, the glans became discoloured and necrosis set in by 4 days. Unfortunately, by day 12 two thirds of the re-implanted penis was lost along with overlying skin. CONCLUSION: Replantation of an amputated penis in a pediatric patient is a daunting task even for experienced surgeons. The vasodilatory effect of papaverine for vascular anastomosis is well described, but the use of a paediatric cannula for identification and instillation of papaverine into penile vasculature, has not been described for the repair of penile amputation. Despite its apparent failure, we believe this technique may be valuable to surgeons who might encounter this rare event in their surgical practice, especially in resource limited settings like ours.

Lawnmowers Versus Children: The Devastation Continues.

BACKGROUND: Accidents with lawnmowers can cause mutilating injuries to children. Safety guidelines regarding the use of lawnmowers were promoted by professional organizations beginning in 2001. The Pennsylvania Trauma Systems Foundation maintains a database including all admissions to accredited Levels 1 to 4 trauma centers in the state. The annual rates of admission for children in our state and the severity of injuries subsequent to introduction of safety guidelines have not been reported, to our knowledge. Ride-on lawnmowers have been associated with more severe injuries in children. QUESTIONS/PURPOSES: We asked: (1) What was the incidence of hospital admissions for children with lawnmower-related injuries during 2002 to 2013 and did the incidence vary by age? (2) What was the severity of injuries and did the severity vary by age? (3) How often did these injuries result in amputation? (4) What types of lawnmowers were involved? METHODS: This was a retrospective study using a statewide trauma registry. We queried the Pennsylvania Trauma Outcome Study database for children 0 to 17 years old admitted to trauma centers in Pennsylvania between January 2002 and January 2014 with injuries resulting from lawnmower-related accidents. All accredited Levels 1 to 4 trauma centers in the state are required to submit their data to the Pennsylvania Trauma Systems Foundation which maintains the Pennsylvania Trauma Outcome Study database. Demographic information, Injury Severity Scores, International Classification of Diseases procedure codes, and injury location codes were recorded. Type of lawnmower was determined from the narratives and was identified in 60% (119/199) of patients. Traumatic and surgical amputations performed during the index hospitalization were included in the analysis. Information on later surgeries was not available. Subjects were stratified by age: 0 to 6, 7 to 12, and 13 to 17 years old. RESULTS: The incidence of lawnmower injuries in Pennsylvania was a median five of 100,000 children (range, 4-12/100,000) during the study period. The median age was 6 years (range, 1-17 years). The median Injury Severity Score was 4 (range, 1-75). Children 0 to 6 years old had higher median Injury Severity Scores (median, 8; range, 1-75) compared with those 13-17 years old (median, 4; range, 1-20; difference of the medians, 4; p < 0.001). A total of 53% of the patients (106/199) underwent at least one amputation. There were 83 amputations in or of the foot, 18 in the leg, 14 in the hand, and three in the arm. Ride-on lawnmowers accounted for 92% (110/119) of mowers identified by type. CONCLUSIONS: The incidence of serious injuries to children owing to lawnmower-related trauma did not change during the 12-year study period. If children younger than 6 years had not been near the lawnmower and those younger than 12 years had not been operating one, at least 69% of the accidents might have been prevented. We recommend annual publicity campaigns during spring to remind the public of the dangers of lawnmowers to children. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Long-term outcome following upper extremity replantation after major traumatic amputation.

BACKGROUND: Amputations in general and amputations of upper extremities, in particular, have a major impact on patients' lives. There are only a few long-term follow-up reports of patients after macro-replantation. We present our findings in contrast with the existing literature. METHODS: Sixteen patients with traumatic macro-amputation of an upper extremity were eligible for inclusion in this study. Altogether, the patients underwent replantation in 3 institutions between 1983 and 2011. RESULTS: Twelve male and four female patients with an average age at injury of 40.6 years (range, 14-61 years) were included in this study. The mean follow-up period was 13.5 years (range, 4.4-32.6 years; SD, 5.7 years). The mean disabilities of the arm, shoulder and hand (DASH) outcome measure was 41 (range, 5.2-94.8; SD, 18.2), functional independence measurement (FIM) was 125 (range, 120-126; SD, 1.8). Chen I representing very good function was accounted in six, Chen II representing good function in eight, Chen III (fair) in one and Chen IV (bad function) in one patient. CONCLUSIONS: We found that while the majority of the included patients exhibited good or very good function of the extremity, none of the replanted appendages regained normal levels of functionality. In addition, all participants were very satisfied with their outcomes. Positive long-term results with high rates of subjective satisfaction are possible after replantation of upper extremities.

Pain Phenotypes and Associated Clinical Risk Factors Following Traumatic Amputation: Results from Veterans Integrated Pain Evaluation Research (VIPER).

OBJECTIVE: To define clinical phenotypes of postamputation pain and identify markers of risk for the development of chronic pain. DESIGN: Cross-sectional study of military service members enrolled 3-18 months after traumatic amputation injury. SETTING: Military Medical Center. SUBJECTS: 124 recent active duty military service members. METHODS: Study subjects completed multiple pain and psychometric questionnaires to assess the qualities of phantom and residual limb pain. Medical records were reviewed to determine the presence/absence of a regional catheter near the time of injury. Subtypes of residual limb pain (somatic, neuroma, and complex regional pain syndrome) were additionally analyzed and associated with clinical risk factors. RESULTS: A majority of enrolled patients (64.5%) reported clinically significant pain (pain score ≥ 3 averaged over previous week). 61% experienced residual limb pain and 58% experienced phantom pain. When analysis of pain subtypes was performed in those with residual limb pain, we found evidence of a sensitized neuroma in 48.7%, somatic pain in 40.8%, and complex regional pain syndrome in 19.7% of individuals. The presence of clinically significant neuropathic residual limb pain was associated with symptoms of PTSD and depression. Neuropathic pain of any severity was associated with symptoms of all four assessed clinical risk factors: depression, PTSD, catastrophizing, and the absence of regional analgesia catheter. CONCLUSIONS: Most military service members in this cohort suffered both phantom and residual limb pain following amputation. Neuroma was a common cause of neuropathic pain in this group. Associated risk factors for significant neuropathic pain included PTSD and depression. PTSD, depression, catastrophizing, and the absence of a regional analgesia catheter were associated with neuropathic pain of any severity.

Surgical Technique Utilizing Suture-Button Device for Central Metacarpal Ray Resection.

Certain technical demands must be overcome in order to accomplish the goals of creating a functional hand when performing a central digital ray resection of the hand. One of the biggest challenges is maintaining metacarpal gap closure and in such a way that the metacarpals are balanced and not rotated. Inadequate closure of the defect created between the metacarpals by a central ray resection will produce a persistent gap between the remaining fingers as well as the potential for malalignment. Current techniques are fraught with difficulty and have frequently proven inadequate. We describe a technique for performing a central ray resection without the worry of nonunion, malunion, or increase in gap. With the development of newer fixation devices, we have been able to perform central ray resection while optimally closing the gap, controlling rotation, and providing good hand function.

Surgical revision for stump problems after traumatic above-ankle amputations of the lower extremity.

BACKGROUND: Stump problems (SPs) secondary to traumatic lower limb amputation had a crucial influence on amputees' ability to return to living and work. The purpose of this study was to investigate the surgical management strategies of the SPs after above-ankle amputation of the lower limb secondary to trauma. METHOD: A cohort of clinical cases, who were troubled by SPs after above-ankle amputation following trauma, had undergone revision surgery of the stump and was analyzed retrospectively. Various factors were noted like sex, unilateral or bilateral, amputation type, and causes of trauma. Different SPs like excess soft tissue (where a considerable amount of soft tissue interposed between the rigid elements which hindered the fitting of a prosthesis), scar, ulcers, neuromas, and bone spurs were taken as dependent variables. The relationship between factors and SPs was analyzed. RESULTS: A total of 80 stumps were treated surgically. The frequency of excess soft tissue in above-knee amputation cases was higher than that in below-knee amputation (p = 0.007). Bone spur occurred more frequently in the unilateral amputation than in bilateral ones (p = 0.018). There was a significant difference in the ADL scores between admission and discharge (p = 0.000). CONCLUSION: Stump problems secondary to traumatic lower limb amputation had crucial influence on amputees' ability to return to living and work, appropriate evaluation and timely surgical revision showed excellent results.

[Management of peripheral injuries of the finger]. / Management peripherer Verletzungen der Finger.

The treatment of acute peripheral finger injuries is part of the daily routine of surgeons in emergency departments. This article presents the most common forms of peripheral finger injuries and the specific diagnostic and therapeutic aspects. The injuries include incision and tear injuries, injuries to the nailbed, distal extensor tendon injuries, severed flexor tendons of the distal joint, bite injuries, high-pressure injection injuries and amputation injuries of the distal phalanx of fingers. For the latter, the form, level and height of the amputation are decisive for therapy. Soft tissue defects on the extensor and flexor side of the finger are also common for emergency surgeons. The basic principles of the initial management of peripheral soft tissue injuries of the hand involve the reconstruction of tendons and nerves and soft tissue coverage. Pathogenic organisms are detectable in more than 80 % of bite wounds so that prophylaxis and therapy of infections are of special importance. An adjuvant antibiotic therapy is necessary for infections as well as for high-pressure injection injuries. It is also important for the treating physician to recognize when a hand surgeon must be involved.

[Experience in treatment of combined osteovascular limb injuries in children].

The article is dedicated to one of the currently important problems of present-day traumatology and angiosurgery, i. e. possibility of performing primary reconstructive operations in children with complete and incomplete amputations, open and closed bone fractures in the conditions of circulatory impairment. The authors share their experience in treatment of 92 patients presenting with such injuries, describing the main indications for carrying out repair operations, and drawing appropriate conclusions. The main stages of reconstructions are demonstrated by a series of clinical examples.

Oblique triangular neurovascular osteocutaneous flap for hook nail deformity correction.

Hook nail deformity results in aesthetic and functional problems after fingertip amputations. Previously described techniques do not correct the osseous defect, which may be the principle cause of the problem. We present a surgical technique based on a compound homodigital advancement flap combining bone of the distal phalanx, finger pulp, and skin. We describe this technique, report a case, and discuss the advantages over former techniques.

Severe limb pain suppresses chest pain in a patient with anterior myocardial infarction.

Cardiac complications of chest trauma range from arrhythmias and valvular avulsions to myocardial contusion, rupture, and--rarely--myocardial infarction. Herein, we described a 44-year-old male patient who presented to the hospital after receiving a blow from a fist directly to the chest and fingertip amputation during a fight; anterior myocardial infarction without any chest pain was coincidentally detected. Our case illustrates the importance of electrocardiography in the initial evaluation of patients with chest trauma and suspected injury to the coronary arteries.

Persistent median artery in a pediatric trauma patient: case report.

A persistent median artery is a well-described variation in the vascular anatomy of the upper extremity and hand, with an incidence of 1% to 30% in the general population. We present a case of a persistent median artery in a pediatric trauma patient. The median artery helped maintain blood flow to the nearly amputated hand after complete transection of radial and ulnar arteries.

Replantation of finger avulsion injuries: a systematic review of survival and functional outcomes.

PURPOSE: Recent studies presenting functional outcomes after replantation of finger avulsion injuries have challenged the historical practice of performing revision amputation for all complete finger avulsion injuries. The aim of this study is to conduct a systematic review of the English literature of replantation of finger avulsion injuries to provide best evidence of survival rates and functional outcomes. METHODS: A Medline literature search yielded 1,398 studies, using key words "traumatic amputation" or "replantation", with limitation to humans and finger injuries. Inclusion criteria required that studies meet the following requirements: (1) primary data are presented; (2) the study includes at least 5 cases with either complete or incomplete finger avulsion injuries at or distal to the metacarpophalangeal joint; (3) the study presents survival rates, total active arc of motion (TAM), or static 2-point discrimination (2PD) data; (4) data for incomplete and complete avulsions are reported separately; (5) patients are treated with microvascular revascularization or replantation. Survival rates, TAM, and 2PD data were recorded and a weighted mean of each was calculated. RESULTS: Thirty-two studies met the inclusion criteria. Of these 32 studies, all reported survival outcomes, 13 studies reported TAM (metacarpophalangeal, proximal interphalangeal, and distal interphalangeal), and 9 studies reported sensibility. The mean survival rate for complete finger and thumb avulsions having replantation was 66% (n = 442). The mean TAM of complete finger avulsions after successful replantation was 174° (n = 75), with a large number of patients in the included studies having arthrodesis of the distal interphalangeal joint. The mean 2PD in patients after replantation was 10 mm (n = 32). CONCLUSIONS: We found that functional outcomes of sensibility and range of motion after replantation of finger avulsion injuries are better than what is historically cited in the literature. The results of this systematic review challenge the practice of performing routine revision amputation of all complete finger avulsion injuries.

Lengthening of a thumb distal phalanx replanted to its metacarpus because of loss of the proximal phalanx: case report.

We report a successful thumb replantation by resecting the remnants of the crushed proximal phalanx and uniting the distal phalanx with the thumb metacarpal. The procedure resulted in extreme shortening, which we managed by distraction lengthening and deepening of the first webspace.

Trauma, gender reassignment, and penile augmentation.

INTRODUCTION: Penile trauma is common with standard management options. Gender reassignment techniques are rapidly changing and penile augmentation remains a controversial topic. Consequently, there is need for a state-of-the-art information in this area. AIM: This study aims to develop an evidence-based state-of-the-art consensus report on the management of penile trauma, gender, reassignment and penile augmentation. METHODS: The study provides state-of-the-art knowledge regarding the prevalence, etiology, medical and surgical management of penile trauma, gender reassignment and penile augmentation, representing the opinion of leading experts developed in a consensus process over a 2-year period. MAIN OUTCOME MEASURES: Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. CONCLUSIONS: Penile fracture should be managed surgically. Information should be readily available to patients to help them decide the surgical technique desired for gender reassignment and to justify any form of penile augmentation.

Replantation of above-knee amputation: a surviving but dysfunctional case needing secondary amputation.

Above-knee amputations are rare injuries that need emergent replantation or primary amputation. Although survival could be achieved in selective cases, postoperative function of the affected limb is usually unsatisfactory and a late amputation has to be performed for poor prognosis or severe complications. Experience of the surgical team may play an important role in primary decision making, which leads us to report one case of above-knee replantation with poor postoperative function and needing a late amputation. Scoring systems, expected results based on our case, and a brief review of literature concerning above-knee replantations are discussed.

Incidence of traumatic peripheral nerve injuries and amputations in Sweden between 1998 and 2006.

BACKGROUND: To define the epidemiological pattern of nerve injuries and traumatic amputations in Sweden, 1998-2006, and investigate possible targets for emerging neural engineering and neuroprosthetic technologies. METHODS: The Swedish Hospital Discharge Register was used as the information base, including data from all public inpatient care, excluding outpatient data. ICD-10 codes were used to classify nerve injuries and traumatic amputations of high incidence levels or inpatient care time. Selected codes, causative factors, age and gender distribution were discussed in detail, and potential targets for tailored solutions were identified. RESULTS: Incidence rate was determined as 13.9 for nerve injuries and 5.21 for amputations per 100,000 person-years. The majority of injuries occurred at the wrist and hand levels, although it could be concluded that these are often minor injuries requiring less than a week of hospitalization. The single most care-consuming nerve injury was brachial plexus injury, constituting on average 68 injuries and 960 hospital days annually. When minor amputations of fingers and toes were disregarded, the most frequent site of amputation was between the knee and ankle (24 patients/year). CONCLUSIONS: Based on an analysis of incidence and care time, we find that brachial plexus injuries and lower leg amputations should be the primary targets of new technologies.

Repair of thumb defect by using the toenail flap: biomechanical analysis of donor foot-a retrospective cohort study.

BACKGROUND: The thumb accounts for 50% of the total hand function. This study reports the functional outcomes and complications of people with traumatic thumb amputations who underwent toe-to-thumb reconstruction. METHODS: From January 2013 to January 2018, 29 patients with second-degree thumb defect underwent thumb reconstruction with distal phalangeal braided toenail flap. The footscan foot pressure gait analysis system was used to measure the index changes of the same foot before and after 1, 3 and 6 months. The contact area, peak pressure, impulse value, contact time of each gait phase, centre of gravity coordinate and foot balance were analysed statistically. RESULTS: Twenty-nine cases of thumb reconstruction recovered well. After following up for 6-15 months, the appearance of the reconstructed thumb was close to normal, and the sensation was restored to S3+. The two-point discrimination was 6-8 mm, and the function of the thumb was good. The function of the donor foot was well restored, and no skin ulceration, pain and claudication were noted during walking. Compared with that before the operation, the biomechanical indices of the donor foot were basically restored to normal 6 months after the operation. Only the stress and impulse values of the third metatarsal head were significantly increased, forming a stress concentration area centred on the third metatarsal head. CONCLUSIONS: This study confirmed that the toenail flap with distal phalangeal bone restored the second-degree thumb defect without destroying the main functional structure of the sole. The biomechanical indices of the donor foot were basically restored to normal 6 months after the operation. Only the stress concentration area centred on the third metatarsal head, and the pain on the forefoot was induced after the operation. Discomfort, callus formation, metatarsal fasciitis, etc., can lead to fatigue fracture of the third metatarsal bone in severe cases, which requires further follow-up and observation. TRIAL REGISTRATION: Clinicaltrials.gov , NCT03879941; registered on 10 March 2019, retrospectively.

Traumatized index finger pollicization for thumb reconstruction-A case report.

When the index finger is injured or severed with a traumatic thumb amputation, transfer of the injured index finger can restore the function of the thumb. The purpose of this study was to evaluate the result of the transfer of an injured index finger for the traumatic loss of the thumb. A patient had a traumatic amputation at the first metacarpal level with the bone defect of the second metacarpal and proximal part of index finger. She was treated with a pedicled transfer of the injured index finger to the ipsilateral thumb. Postoperative evaluations included thumb range of motion, opposition and pinch function, grasp and pinch strength, sensation, and a patient-rated appearance of the thumb and hand. In result, the blood supply of the transferred traumatic index fingers was normal, and the transferred index fingers survived without complications. The range of motion of the first metacarpophalangeal joint and interphalangeal joint was almost the same as that of a normal thumb. The opposition and pinch function of the thumb was also normal. The patient is able to complete activities of daily living with the new thumb. Nevertheless, the sensation has not yet been completely restored. In conclusion, it is feasible to treat traumatic thumb amputation with the transfer of injured index finger.