Complete Penile Amputation: An Anatomical Reference and Surgical Pearls to Ensure a Successful Replantation.

How common are penile amputations, and how are they treated?What key anatomic structures are involved?What are some technical pearls for a successful replantation?What are common complications, and how can they be prevented/treated?

Repair of a large primary subtemporal encephalocele in a 3-year-old child: case report.

Primary encephaloceles (PEs) present only rarely in the temporal region; in the rare instance that they project through the floor of the middle fossa they are secondary. In this case report the authors report on the management of a giant PE extending through the floor of the middle fossa.An 8-month-old boy presented to the authors' service with a large PE projecting into his neck through a missing left middle fossa floor; the lesion was causing significant meta-, dys-, and hypoplasia of the structures of the anterolateral neck on that side. Surgical goals for this patient included the following: 1) removal of potentially epileptogenic and dysfunctional tissue; 2) preservation of cranial nerves; 3) prevention of cognitive decline or iatrogenic deficit; 4) prevention of CSF leak; 5) reconstruction of skull base; 6) prevention of airway and swallowing compromise; and 7) cosmesis. After a multidisciplinary evaluation with ENT, plastic surgery, and neurology, an operation was performed using a preauricular infratemporal approach when the patient was 3 years old. Gliotic tissue was resected and amygdala, hippocampus, and middle cerebral artery were preserved.The immediate results of the operation showed good immediate outcome. Seizure freedom and neurodevelopment outcomes remain to be seen at follow-up.

Anatomic landmarks for Basal joint injections.

OBJECTIVE: Basal joint arthritis is a common cause of pain and disability, particularly in elderly women. Corticosteroid injection with splinting provides a reliable long-term relief for patients with mild arthritis. Proper location of the basal joint with anatomic landmarks can facilitate diagnosis and treatment of basal joint arthritis while avoiding inadvertent injury to local structures. The purpose of this study is to identify bony anatomic landmarks for basal joint injections and aid clinicians in avoiding inadvertent injury to surrounding structures on the radial side of the wrist. METHODS: Twenty fresh cadaveric wrists were dissected with the aid of loupe magnification. The distal edge of the radial styloid and the palpable dorsal aspect of the thumb metacarpophalangeal joint were used as bony anatomic landmarks for the identification of the basal joint along a longitudinal vector. Measurements of the distance from our anatomic landmarks to the basal joint space were recorded. The locations of the radial artery and the superficial branch of the radial nerve were noted in relation to the borders of the anatomic snuffbox at the basal joint level. RESULTS: The basal joint of the thumb is located 2.44 ± 0.34 cm distal to the distal edge of the radial styloid, and 4.47 ± 0.29 cm proximal to the metacarpophalangeal joint. At the level of the basal joint, the radial artery is found 0.76 ± 0.12 cm dorsal to the extensor pollicis brevis tendon. The first branch of the superficial branch of the radial nerve is volar to the abductor pollicis longus tendon in 84% of the specimens and courses over the abductor pollicis longus tendon in 16%. CONCLUSION: The basal joint of the thumb is approximately 2.4 cm distal to the radial styloid and 4.5 cm proximal to the metacarpophalangeal joint. Placement of a needle in the basal joint space immediately dorsal to extensor pollicis brevis tendon while applying longitudinal traction on the thumb is more likely to avoid damage to the radial artery and the superficial branch of the radial nerve.

Anatomic landmarks for the first dorsal compartment.

OBJECTIVE: Knowledge of anatomic landmarks for the first dorsal compartment can assist clinicians with management of de Quervain's disease. The radial styloid, the scaphoid tubercle, and Lister's tubercle can be used as superficial landmarks for the first dorsal compartment. METHODS: Thirty-two cadaveric wrists were dissected, and measurements were taken from the predetermined landmarks to the extensor retinaculum. The compartments were also inspected for variability of the abductor pollicis longus tendon and intracompartmental septations. RESULTS: The average length of the extensor retinaculum from its proximal to distal extent measured approximately 2.2 cm. The distal aspect of the radial styloid was 0.3 cm distal to the distal aspect of the extensor retinaculum, and the distance between the distal aspect of the extensor retinaculum and the APL-Lister's-Scaphoid juncture was approximately 0.5 cm. A separate compartment for the extensor pollicis brevis was noted in 35% of the specimens. The abductor pollicis longus tendon demonstrated great variability with 1, 2, 3, or 4 slips in 9%, 30%, 43%, or 26% of the specimens, respectively. CONCLUSION: The superficial bony prominences of the radial wrist can be used reliably as anatomic landmarks for the first dorsal compartment.

Variations in the anatomy of the third common digital nerve and landmarks to avoid injury to the third common digital nerve with carpal tunnel release.

BACKGROUND: The third common digital nerve (TCDN) has been described as the most commonly injured digital nerve during carpal tunnel release (CTR). Anatomic variations of the origin and course of the TCDN from the median nerve may place this structure at risk. Anatomic landmarks may be useful to predict the location of the TCDN to minimize the risk for injury to this structure during CTR. METHODS: Twenty cadaveric hands were used to determine the origin and course of the TCDN. The origin of the TCDN from the median nerve was identified in relation to the transverse carpal ligament (TCL), cardinal line, and superficial palmar arch. The course of the TCDN was inspected in relation to the scaphoid tubercle and ring finger. RESULTS: Three specific anatomic variations for the origin of the TCDN were identified: type 1 originating proximal to the distal edge of the TCL (3 of 20 patients), type 2 originating distal to the TCL but proximal to the superficial palmar arch (14 of 20 patients), and type 3 originating distal to the TCL and at or distal to the superficial palmar arch (3 of 20 patients). The origin of the TCDN was measured as an average of 5.0 +/- 1.2 mm distal to the cardinal line. The TCDN coursed along an oblique vector from the scaphoid tubercle to the midpoint of the palmar digital crease of the ring finger for type 2 or type 3 variations. Near the cardinal line, the oblique course of the TCDN traverses the vector of the longitudinal incision used for CTR. CONCLUSION: The TCDN is one of the most frequently damaged neurological structures during CTR. Iatrogenic injury to this structure can be disabling and even devastating to patients. A detailed knowledge of the carpal tunnel and its underlying structures can prevent inadvertent injury to the TCDN. Anatomic landmarks to predict the origin and the course of the TCDN allow the surgeon to preoperatively predict the possible locations and paths of this important structure. This information can prove to be useful in avoiding injury to the TCDN by clinicians performing CTR in their practice, whether via the open or via endoscopic technique.

Surreptitious injection of mineral oil: a case report of sclerosing lipogranulomatosis.

The use of injectable liquids for cosmetic purposes has been described by numerous clinicians informing the public of its destructive consequences. Several reports of layperson injections have come out recently indicating that the practice is still prevalent worldwide. Reports of self-administration of various liquid agents appear to have a unifying clinical presentation termed sclerosing lipogranulomatosis (SL). Although the clinical manifestations of SL were published at the turn of the century, the pathologic findings were not described until 1950. Immediate and delayed complications of this entity relate to the offending agent used and the site of injection. Some of the more commonly used liquids, paraffin (mineral oil), and polydimethyl siloxane (injectable silicone), have been administered to the scrotum, lower extremities, breast, and face. We report a case in which a patient injected mineral oil into his hips and describe the pathologic findings, complications, and subsequent course of treatment. We have also summarized the world's literature relating to the surreptitious injection of exogenous agents.

Assessment of the distal extent of the A1 pulley release: a new technique.

OBJECTIVE: Sharp division of the A1 pulley is a time-honored technique for the treatment of flexor tendon entrapment; however, this procedure is not without complications. The anatomy of the A1 pulley system has been carefully investigated. Knowledge of superficial anatomic landmarks can assist with demarcating the distal edge of the A1 pulley and prevent damage to the critical A2 pulley. METHODS: Nine fresh cadaveric hands were dissected with the aid of loupe magnification. On the basis of known anatomic landmarks of the proximal portion of the cruciate (C0) pulley, percutaneous placement of a 25-gauge needle 5 mm proximal to the palmar digital crease marked the distal extent of the trigger finger release. Sharp division of the A1 pulley was performed with a scalpel until the needle was encountered, thus completing the release. RESULTS: A complete release of the pulley was achieved in all specimens with preservation of the A2 pulley. No digital nerve or artery injuries were noted with open inspection of the flexor sheath. CONCLUSION: Percutaneous marking of the distal extent of the A1 pulley is a safe and reliable method that not only ensures complete release of the A1 pulley but also preserves the A2 pulley. The placement of a small gauge needle adds no morbidity to this minimally invasive technique.

Anatomic landmarks for the radial tunnel.

BACKGROUND: The posterior interosseous nerve (PIN) can be difficult to locate within the radial tunnel. The deep branch of the radial nerve (DBRN) enters the supinator muscle after passing under the arcade of Fröhse. It courses through the superficial portion of the supinator muscle to exit distally as the PIN. Anatomic landmarks could facilitate diagnosis and treatment of radial tunnel syndrome and aid in the injection and decompression of the radial nerve. METHODS: Eighteen cadaveric arms were used to identify anatomic landmarks to facilitate location of the PIN. The landmarks used include the palpable proximal radial edge of the radial head, proximally, and the mid-width of the wrist, distally. The skin was incised along this longitudinal line through the fascia. Deep within this plane the PIN was identified exiting the distal edge of the superficial portion of the supinator muscle. The proximal and distal edges of the supinator muscle were measured from the proximal radial aspect of the radial head. In addition, the course of the DBRN was appreciated proximal and distal to the superficial part of the supinator muscle. RESULTS: The PIN was identified to exit the superficial part of the supinator muscle at an average distance of 7.4 +/- 0.4 cm distal to the proximal radial aspect of the radial head. Distal to the distal edge of the supinator muscle, the PIN passed along a longitudinal vector from the radial head to the mid-width point of the wrist. From within the supinator muscle the DBRN courses retrograde in an oblique direction toward the lateral edge of the distal most part of the biceps tendon. CONCLUSION: The anatomic landmarks of the radial head and the mid-width of the dorsal wrist can be used to predict the course and location of the PIN. The DBRN can be predicted to enter the superficial part of the supinator muscle approximately 3.5 cm distal to the radial head, and the PIN is predicted to exit the supinator at 7.5 cm distal to the radial head.

Extremity reconstruction using nonreplantable tissue ("spare parts").

After a severe digital or extremity injury, the replantation surgeon should always seek to make the best use out of what tissue is available for reconstruction. Exercising sound surgical judgment and being creative allow the surgeon to restore function to critical areas of the hand or extremity by the judicious use of available tissues that would otherwise be discarded. The use of "spare parts" should, therefore, always be considered to facilitate digital or extremity reconstruction when routine replantation is not possible or is likely to produce a poor functional result. The surgeon should always try to use available nonreplantable tissue to preserve length, obtain soft tissue coverage, or most importantly improve the function of remaining less injured digits. This article presents several case studies that illustrate the principals of spare parts reconstruction performed at the time of the initial debridement using nonreplantable tissue to provide coverage or improve function.