White phosphorous civilian hand burns - An aid to timely treatment of a rare entity.

First discovered in 1669, white phosphorus is well known for its use in military warfare (Davis, 2002). Its application has since been expanded to include industrial disinfectants, fertilisers and fireworks (Davis, 2002). Exposure to white phosphorus can lead to severe chemical burns with high morbidity and potentially fatal systemic effects. Fortunately, civilian casualties from this potent agent are remarkably rare with few reports in the literature to date (Frank et al., 2008; Aviv et al., 2017). We present the case of a 27-year-old fisherman who sustained a chemical burn to his right hand from a substance suspected to be white phosphorus. We propose an evidence-based algorithm to guide non-military physicians literature on the acute management of white phosphorus burns to optimise timely emergency management of this uncommonly encountered substance.

Indocyanine green fluorescence angiography: A critical intra-operative assessment tool to aid decision making in complex hand trauma.

Indocyanine green fluorescence angiography (ICG-FA) is a validated non-invasive imaging tool used to assess tissue perfusion and guide intra-operative decision making in many surgical disciplines. Clinical assessment of tissue perfusion following crush or degloving traumatic hand injuries presents a significant challenge. This case report supports the critical role of intra-operative ICG-FA as a decision aid in complex hand trauma. We propose ICG-FA will minimise unnecessary tissue debridement, negating complex soft tissue reconstructive surgery and ultimately expediting tissue healing and return to function for hand trauma patients. A 35-year-old right hand dominant manual labourer presented to the emergency department after sustaining a crush injury to his right hand. Examination under anaesthetic revealed a comminuted open fracture of middle finger P2 with compromised soft tissue coverage. A formal assessment of hand perfusion was performed using a triad of clinical assessment, critical judgement and ICG-FA. The ICG-FA revealed a small skin flap affecting the dorsoradial P2 skin which was not perfused. This prompted meticulous minimal debridement of this tissue and prevented unnecessary over-debridement that would have resulted in complex soft tissue reconstruction. Currently the gold standard assessment for tissue perfusion in hand injuries is clinical judgement and is limited by subjective interobserver error [1]. IGA-FA has been proven to offer a real time assessment of tissue perfusion. This case demonstrates the use of ICG-FA as an adjunct to clinical examination and judgement, to optimise the accuracy of soft tissue perfusion assessment in complex hand trauma.

Traumatic open brachial plexus injuries: The importance of interdisciplinary collaboration.

Open traumatic brachial plexus injuries are rare, yet can be life threatening and require rapid clinic assessment. Early interdisciplinary collaboration is critical to achieve superior patient outcomes. This case of a 24-year-old female of a traumatic neck injury with contralateral brachial plexus injury demonstrates the limitations of early clinical assessment due to the potential for haemodynamic instability and highlights the priority of patient stabilisation. Early and active interdisciplinary collaboration in this case demonstrates its importance in accurate diagnosis and timely intervention to achieve better patient outcomes. As published in recent guidelines, this report shows the importance of early interdisciplinary involvement following stabilisation and resuscitation of the patient.

Free Vascularized Rectus Abdominis Transfer With Pedicled Intercostal Innervation for Functional Reconstruction of the Elbow in Total Brachial Plexus Palsy.

PURPOSE: Reanimation of palsied upper limbs usually follows an escalating pattern of nerve repair, nerve transfers, and musculotendinous transfers and culminates in free functioning muscle transfers. When there are no other musculotendinous options, we explored the possibility of transferring the rectus abdominus to the biceps by maintaining the nerve pedicle but dividing the vascular pedicle and anastomosing it to the brachial artery. METHODS: We performed anatomical dissection of the nerve and blood supply of 6 rectus abdominis muscles in 3 cadavers. A retrospective analysis of 4 patients in whom a rectus abdominus muscle transfer with a pedicled nerve, but free vascular supply, was then performed. RESULTS: The anatomical feasibility study demonstrated that it was possible to elevate the rectus abdominis on its intercostal nerve supply to the midaxillary line, allowing the muscle to be pedicled on its nerve supply and be transferred to the arm to reconstruct biceps. The vascular supply could be reestablished by anastomosis of inferior epigastric vessels to the brachial artery and veins. In 4 patients, elbow flexion strength of M3 or greater was achieved. Average elbow range of dynamic flexion was 120° (range, 92° to 131°). Shoulder stability and external rotation improved in all patients with resolution of shoulder subluxation. Two patients developed donor site hernias requiring mesh reconstruction. Complications included a hypertrophic recipient site scar in one patient, and recipient site wound dehiscence in another. CONCLUSIONS: Rectus abdominus can be transferred to reconstruct elbow flexion when other musculotendinous transfers are unavailable and as an alternative to free functioning muscle transfer. However, rectus abdominus transfer still requires microsurgical skills for the vessel anastomoses. This is an effective procedure for functional reconstruction of the elbow and adds to the armamentarium in the management of brachial plexus pathology when other transfers are unavailable. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

The Adipofascial Deltopectoral Flap to Cover the Brachial Plexus in Thoracic Outlet Syndrome and Radiation Plexitis.

Revascularisation of the brachial plexus is controversial. Traditional techniques use free tissue transfer of omentum, groin fat or muscle, on the principle of supplying rich quantities of vascularised tissue to wrap around the nerves permitting neural gliding and revascularising the scarred nerves. However, the complexity of an additional microsurgical procedure coupled with uncertainty of their effectiveness have curtailed their clinical application. We describe a local pedicled transposition flap that is a novel modification of the deltopectoral (DP) flap using only the subcutaneous adipofascial tissue vascularised by the medial pectoral perforators. This flap is harvested through the supraclavicular brachial plexus access incision. This avoids free tissue transfer and additional donor scarring, yet provides adequate volumes of well-vascularised tissue for mechanical protection and revascularisation of the plexus. We reviewed sixteen consecutive patients who underwent a pedicled adipofascial DP flap to protect the brachial plexus over the 20-year study period. Inclusion criteria were patients with recurrent thoracic outlet compression and patients with radiation plexitis. At latest follow-up (average 3.6 years), 75% of patients reported the improvement or resolution of symptoms. The majority of patients reported improved pain scores (82%) with an average pain visual analogue scale (VAS) score of 5.1. Patients were very satisfied with scar outcomes, reporting low Vancouver Scar Scale Scores and low scar VAS scores. Post-operative MR imaging, available in 31% of the cohort, demonstrates the maintenance of flap position and vascularity at an average of 2.1 years. This novel and simple technique is recommended in aiding revascularisation and cover of the brachial plexus in recurrent and recalcitrant plexopathy.

Current Strategies for Reconstruction of Soft Tissue Defects of the Spine.

Spinal surgery has been revolutionized by advances in instrumentation, bone graft substitutes, and perioperative care. Extensive dissection, creation of large areas of dead space, and the use of instrumentation in compromised patients, however, predisposes to high rates of wound complications. Postoperative wound complications in patients undergoing complex spinal surgery can have devastating sequelae, including hardware exposure, meningitis, and unplanned reoperation. Recognition of high-risk patients and prediction of wound closure difficulties, combined with preemptive reconstructive surgical strategies may prevent complications. The purpose of this review is to discuss the principles of spine wound management and provide a synopsis of the soft tissue reconstructive strategies utilized in spinal surgery. We review the senior author's preferred reconstructive algorithm for the management of these complex wounds, in addition to outcomes data relating to the timing of reconstructive surgery.

Radial nerve palsies associated with paediatric supracondylar humeral fractures: a caution in the interpretation of neurophysiological studies.

Traumatic and iatrogenic neurological complications associated with paediatric supracondylar humeral fractures are well recognised. The severity of the nerve injury associated with supracondylar humeral fractures can be difficult to assess clinically and relies upon clinical progression or absence of recovery and neurophysiology. It is accepted that complete nerve palsy with neurophysiological complete block and absence of clinical recovery after three months requires surgical exploration and reconstruction. However, we argue that even a partial nerve palsy that is failing to recover as expected by 3 months should be explored even when the neurophysiology suggests the nerve is in continuity. We report two cases of closed Gartland type III paediatric extension-type supracondylar humeral fractures treated with closed reduction and percutaneous pinning and open reduction and internal fixation, respectively. Both children developed persistent postoperative radial nerve motor palsy. Neurophysiological studies sought prior to exploration indicated a degree of sensory nerve function in both cases, indicating a nerve in continuity. Subsequent surgical exploration revealed interfragmentary radial nerve compression at the fracture site at two levels in one case and at one level in the second case. The site of compression was excised and the nerve grafted. Excellent near-normal radial nerve recovery was achieved except for the persistent loss of extensor carpi radialis function in the first child. We publish these findings to highlight the possibility of misinterpreting the incomplete nerve lesion and the neurophysiology of a nerve in continuity, as a nerve that would spontaneously recover. At exploration, in these two cases, it was clear by the level of interfragmentary compression that the nerve would not have recovered without surgical intervention. We recommend exploration and repair of the radial nerve, when function to the nerve is compromised, even in the face of neurophysiological evidence of an intact nerve.

Aesthetic surgery training in a changing healthcare environment.

Aesthetic surgery is a rapidly evolving sub-speciality, both technologically and conceptually. It is therefore critical that plastic surgery training coincides with this rapid evolution. Recent fiscal limitations in public health provision and trainee working-time legislation may impact the delivery of high quality aesthetic surgery training. There is an urgent need to address the delivery of aesthetic training in current training paradigms in Ireland and we propose a number of strategies to obliterate the learning curve.

The Aesthetic Surgery Literature: Do Plastic Surgeons Remain at the Cutting Edge?

BACKGROUND: The aesthetic surgery arena has become a competitive marketplace. Recognition as an authority in aesthetic surgery remains a powerful marketing tool for plastic surgeons, but have significant inroads been made by other specialties? The aims of this study were to analyze publication trends relating to the top five most commonly performed aesthetic surgical procedures, and to assess the origins (i.e., source specialty, authorship, institutions, and countries) of published aesthetic surgical research. METHODS: Based on the seventeenth annual multispecialty data set provided by the American Society for Aesthetic Plastic Surgery, the top five most commonly performed aesthetic surgical procedures were selected. A temporal analysis of publication and citation rates, source institution and country, publishing journal, funding agency trends, and level of evidence was undertaken from 1970 to 2013. RESULTS: Using the search criteria, 7762 articles were identified. There was an 8.8-fold increase in publication volume when the first decade (n = 375) was compared with the last decade (n = 3326). Over the past four decades, 52.2 percent of publications (n = 4053 of 7762) originated from plastic surgery research institutions, with varying contributions from other specialties. Competition was greatest in relation to authorship of blepharoplasty- and rhinoplasty-related publications. CONCLUSIONS: Although plastic surgeons continue to maintain a center-stage presence in terms of authorship of aesthetic surgical literature, significant contributions are now made by other specialties. Plastic surgeons must continue to foster high-quality, peer-reviewed research and innovations to maintain their visibility as leaders in the aesthetic surgery literature and sustain a competitive advantage in aesthetic surgery practice.

Mechanical and cellular processes driving cervical myelopathy.

Cervical myelopathy is a well-described clinical syndrome that may evolve from a combination of etiological mechanisms. It is traditionally classified by cervical spinal cord and/or nerve root compression which varies in severity and number of levels involved. The vast array of clinical manifestations of cervical myelopathy cannot fully be explained by the simple concept that a narrowed spinal canal causes compression of the cord, local tissue ischemia, injury and neurological impairment. Despite advances in surgical technology and treatment innovations, there are limited neuro-protective treatments for cervical myelopathy, which reflects an incomplete understanding of the pathophysiological processes involved in this disease. The aim of this review is to provide a comprehensive overview of the key pathophysiological processes at play in the development of cervical myelopathy.

Quality of Life and Surgical Outcomes After Soft-Tissue Reconstruction of Complex Oncologic Defects of the Spine and Sacrum.

BACKGROUND: Tumor-related spinal surgery has been revolutionized by recent advances in spinal stabilization, modern neuroimaging, and perioperative intensive medicine. This study examines clinical outcomes and factors associated with complications following reconstruction of complex oncologic defects of the spine and sacrum, in an attempt to increase preoperative recognition of high-risk patients with diminished wound-healing capacity and to optimize clinical outcomes in this cohort. METHODS: We performed a retrospective analysis of fifty-five consecutive patients who underwent soft-tissue reconstruction with or without osseous stabilization of defects following spinal or sacral tumor resection at a quaternary referral center over a twelve-year period. Surgical outcomes included the prevalence of postoperative complications and success of wound closure at the latest follow-up. Health-related quality-of-life outcomes were assessed using the EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer 30-Item Core Quality of Life Questionnaire) and SF-36 (Short Form-36) questionnaires. RESULTS: The mean age of the cohort was 46.7 years (range, eighteen to seventy-one years), with a male preponderance (3:1). Soft-tissue reconstructions (n = 70 flaps) were performed in the fifty-five patients. Overall, 36.3% of patients had wound complications. There was a twofold higher wound complication rate after delayed (60%) compared with immediate (29%) reconstruction (p = 0.03). Patients undergoing delayed reconstruction reported significantly lower SF-36 and EORTC QLQ-C30 scores. CONCLUSIONS: Orthoplastic management of spinal tumors should involve a strategy for preoperative recognition of patients at risk of compromised wound-healing. Prophylactic soft-tissue reconstruction can achieve stable definitive wound closure and potentially avoid the need for secondary procedures in appropriately selected patients. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Audiovisual preconditioning enhances the efficacy of an anatomical dissection course: A randomised study.

UNLABELLED: The benefits of incorporating audiovisual materials into learning are well recognised. The outcome of integrating such a modality in to anatomical education has not been reported previously. The aim of this randomised study was to determine whether audiovisual preconditioning is a useful adjunct to learning at an upper limb dissection course. Prior to instruction participants completed a standardised pre course multiple-choice questionnaire (MCQ). The intervention group was subsequently shown a video with a pre-recorded commentary. Following initial dissection, both groups completed a second MCQ. The final MCQ was completed at the conclusion of the course. Statistical analysis confirmed a significant improvement in the performance in both groups over the duration of the three MCQs. The intervention group significantly outperformed their control group counterparts immediately following audiovisual preconditioning and in the post course MCQ. Audiovisual preconditioning is a practical and effective tool that should be incorporated in to future course curricula to optimise learning. Level of evidence This study appraises an intervention in medical education. LEVEL OF EVIDENCE: Kirkpatrick Level 2b (modification of knowledge).

Systematic antibody generation and validation via tissue microarray technology leading to identification of a novel protein prognostic panel in breast cancer.

BACKGROUND: Although omic-based discovery approaches can provide powerful tools for biomarker identification, several reservations have been raised regarding the clinical applicability of gene expression studies, such as their prohibitive cost. However, the limited availability of antibodies is a key barrier to the development of a lower cost alternative, namely a discrete collection of immunohistochemistry (IHC)-based biomarkers. The aim of this study was to use a systematic approach to generate and screen affinity-purified, mono-specific antibodies targeting progression-related biomarkers, with a view towards developing a clinically applicable IHC-based prognostic biomarker panel for breast cancer. METHODS: We examined both in-house and publicly available breast cancer DNA microarray datasets relating to invasion and metastasis, thus identifying a cohort of candidate progression-associated biomarkers. Of these, 18 antibodies were released for extended analysis. Validated antibodies were screened against a tissue microarray (TMA) constructed from a cohort of consecutive breast cancer cases (n = 512) to test the immunohistochemical surrogate signature. RESULTS: Antibody screening revealed 3 candidate prognostic markers: the cell cycle regulator, Anillin (ANLN); the mitogen-activated protein kinase, PDZ-Binding Kinase (PBK); and the estrogen response gene, PDZ-Domain Containing 1 (PDZK1). Increased expression of ANLN and PBK was associated with poor prognosis, whilst increased expression of PDZK1 was associated with good prognosis. A 3-marker signature comprised of high PBK, high ANLN and low PDZK1 expression was associated with decreased recurrence-free survival (p < 0.001) and breast cancer-specific survival (BCSS) (p < 0.001). This novel signature was associated with high tumour grade (p < 0.001), positive nodal status (p = 0.029), ER-negativity (p = 0.006), Her2-positivity (p = 0.036) and high Ki67 status (p < 0.001). However, multivariate Cox regression demonstrated that the signature was not a significant predictor of BCSS (HR = 6.38; 95% CI = 0.79-51.26, p = 0.082). CONCLUSIONS: We have developed a comprehensive biomarker pathway that extends from discovery through to validation on a TMA platform. This proof-of-concept study has resulted in the identification of a novel 3-protein prognostic panel. Additional biochemical markers, interrogated using this high-throughput platform, may further augment the prognostic accuracy of this panel to a point that may allow implementation into routine clinical practice.

The upper hand on compartment syndrome.

Metacarpal fractures are common injuries, accounting for approximately 30% to 40% of all hand fractures and with a lifetime incidence of 2.5%. Traditionally regarded as an innocuous injury, metacarpal fractures tend to be associated with successful outcomes after closed reduction and immobilization. Hand compartment syndrome (HCS) is a rare clinical entity with potential devastating consequences in terms of loss of function and quality-of-life outcomes. We discuss the case of a 44-year-old woman presenting with multiple closed metacarpal fractures as a result of low-energy trauma, complicated by acute HCS. We review the presentation, clinical assessment, and optimal surgical management of acute HCS with reference to international literature.

Nonoperative modalities to treat symptomatic cervical spondylosis.

Cervical spondylosis is a common and disabling condition. It is generally felt that the initial management should be nonoperative, and these modalities include physiotherapy, analgesia and selective nerve root injections. Surgery should be reserved for moderate to severe myelopathy patients who have failed a period of conservative treatment and patients whose symptoms are not adequately controlled by nonoperative means. A review of the literature supporting various modalities of conservative management is presented, and it is concluded that although effective, nonoperative treatment is labour intensive, requiring regular review and careful selection of medications and physical therapy on a case by case basis.

Pheochromocytoma presenting as recurrent urinary tract infections : a case report.

INTRODUCTION: Pheochromocytomas are rare, potentially fatal, neuroendocrine tumors of the adrenal medulla or extra-adrenal paraganglia. Their clinical presentation varies greatly from the classic triad of episodic headache, diaphoresis and tachycardia to include a spectrum of non-specific symptomatology. CASE PRESENTATION: A 43-year-old Caucasian woman was referred to us from primary care services with a three-month history of recurrent urinary tract infections on a background of hypertension, latent autoimmune diabetes of adulthood and autoimmune hypothyroidism. At 38 years she required insulin therapy. Despite medication compliance and dietary control, she reported a recent history of increased insulin requirements and uncontrolled hypertension with concomitant recurrent urinary tract infections. A renal ultrasound examination, to rule out underlying renal pathology, revealed an incidental 8cm right adrenal mass of both solid and cystic components. A subsequent computed tomography of her abdomen and pelvis confirmed a solid heterogeneous mass consistent with a pheochromocytoma. There were no other features suggestive of multiple endocrine neoplasia. Urinary collection over 24 hours revealed grossly elevated levels of catecholamines and metabolites. Following an open right adrenalectomy, our patient's insulin requirements were significantly reduced and her symptoms resolved. Two weeks post-operatively, an iodine-131-metaiodobenzylguanidine scintigraphy was negative for residual tumor and metastatic disease. Urinary catecholamine and metabolite concentrations were within the normal range at a follow-up six months later. CONCLUSION: Pheochromocytoma is a rare catecholamine-producing tumor requiring a high index of suspicion for early diagnosis. Our case report serves to highlight the importance of considering pheochromocytoma as a differential diagnosis in the atypical setting of recurrent urinary tract infections and concomitant autoimmune disease.

Risk analysis of blood transfusion requirements in emergency and elective spinal surgery.

Spinal surgery has long been considered to have an elevated risk of perioperative blood loss with significant associated blood transfusion requirements. However, a great variability exists in the blood loss and transfusion requirements of differing patients and differing procedures in the area of spinal surgery. We performed a retrospective study of all patients undergoing spinal surgery who required a transfusion≥1 U of red blood cells (RBC) at the National Spinal Injuries Unit (NSIU) at the Mater Misericordiae University Hospital over a 10-year period. The purpose of this study was to identify risk factors associated with significant perioperative transfusion allowing the early recognition of patients at greatest risk, and to improve existing transfusion practices allowing safer, more appropriate blood product allocation. 1,596 surgical procedures were performed at the NSIU over a 10-year period. 25.9% (414/1,596) of these cases required a blood transfusion (n=414). Surgical groups with a significant risk of requiring a transfusion>2 U RBC included deformity surgery (RR=3.351, 95% CI 1.123-10.006, p=0.03), tumor surgery (RR=3.298, 95% CI 1.078-10.089, p=0.036), and trauma surgery (RR=2.444, 95% CI 1.183-5.050, p=0.036). Multivariable logistic regression analysis identified multilevel surgery (>3 levels) as a significant risk of requiring a transfusion>2 U RBC (RR=4.682, 95% CI 2.654-8.261, p<0.0001). Several risk factors in the spinal surgery patient were identified as corresponding to significant transfusion requirements. A greater awareness of the risk factors associated with transfusion is required in order to optimize patient management.