Amputación vs. salvataje: Enfoque Ortoplástico. Acerca de un caso / Amputation vs. salvage: Orthoplastic Approach. Case report

Introducción. Los cirujanos ortopédicos y plásticos trabajaban por separado cuando se enfrentaban a casos reconstructivos desafiantes que involucraban la reconstrucción del tejido blando y esquelético. Cirugía Ortoplástica es el nombre dado a la asociación de Cirugía plástica y ortopédica. Objetivos. Describir el Enfoque Ortoplástico en traumatismos masivos de miembros y su importancia en el abordaje multidisciplinario de pacientes. Material y método. El presente es un estudio descriptivo retrospectivo, en el cual se describe un caso con una lesión masiva de miembro inferior, en el Parque de la Salud, Posadas, Misiones, Argentina, entre febrero y mayo del 2022. Reporte de caso: Se presenta un caso de una paciente femenina de 24 años de edad con lesión masiva por desguantamiento de extremidad inferior derecha producto de accidente en vía pública al ser arrastrada debajo de una unidad de transporte público. Discusión. El salvamento de la extremidad y la amputación temprana con soporte protésico son las dos modalidades empleadas para las formas extremas de traumatismo de la extremidad inferior, con poca claridad en cuanto a lo que el paciente debe esperar en términos de resultados de calidad de vida. Conclusión. La decisión de amputar o salvar una extremidad es compleja. Los cirujanos ortopédicos y plásticos involucrados en esta atención deben tener una comprensión clara del papel del otro y la importancia de cada uno para una buena resolución. Esto es lo que llamamos el Enfoque Ortoplástico de la cirugía reconstructiva de las extremidades.

Introduction. Orthopedic and plastic surgeons worked separately when faced with challenging reconstructive cases involving skeletal and soft tissue reconstruction. "Orthoplastic Surgery" is a name given to the Association of Orthopedic and Plastic Surgery. Objectives. Describe the Orthoplastic Approach in massive limb trauma and its importance in the multidisciplinary patient approach. Material and Method. This is a retrospective descriptive study, in which a case with a massive lower limb injury is described, in the Parque de la Salud, Posadas, Misiones, Argentina, between February 2022 and May 2022. Case Report. A case of a 24-year-old female patient with massive injury due to dismantling of the right lower extremity as a result of an accident on public roads when she was dragged under a public transport unit is presented. Discussion. Limb salvage and prosthetic supported early amputation are the two modalities employed for extreme forms of lower extremity trauma with little clarity as to what the patient should expect in terms of quality of life outcomes. Conclusion. The decision to amputate or save a limb is complex. The orthopedic and plastic surgeons involved in this care must have a clear understanding of each other's role and the importance of each for a good resolution. This is what we call the "Orthoplastic Approach" to reconstructive surgery of the extremities

Semi-occlusive management of fingertip injuries with finger caps: A randomized controlled trial in children and adults.

BACKGROUND: Human fingertips can regenerate functionally and cosmetically excellent skin and soft tissues. Physiological conditions suppress scar formation and are thus a prerequisite for regenerative healing. Self-adhesive film dressings can provide such favorable conditions. The semi-occlusive treatment is superior to surgery. However, standard dressings leak malodorous wound fluid eventually until the wound is dry. Therefore, we developed and tested a silicone finger cap that forms a mechanically protected, wet chamber around the injury. Its puncturable reservoir allows access to the wound fluid for diagnostic and research purposes and the delivery of pro-regenerative drugs in the future. METHODS: Patients >2 years with full-thickness fingertip injuries unsuitable for simple primary closure were randomized to start treatment with either the film dressing or the silicone finger cap. After 2 weeks, we changed to the other treatment. Patients' choice on the preferred treatment after 4 weeks was the primary outcome parameter. Additionally, we monitored adverse events, unplanned visits, tissue gain, functionality, cosmetic outcome, and quality of life. RESULTS: We randomized 11 patients 2 to 72 years to each group. Eighteen to 20 (90%, intention-to-treat) patients preferred the finger cap. All patients were satisfied with the cosmetic outcome, 88.9% had no disturbing sensibility changes, and 73.7% could report no distortion in the finger's daily use. Epithelialization took between 5 weeks for Allen II and up to 9 weeks in Allen IV injuries. There were 19 device-related adverse events under film dressing and 13 under the finger cap. There were neither severe adverse device effects nor unexpected severe adverse device effects. CONCLUSION: Employing the summative or synthetic primary endpoint "patient decision for one or the other procedure," our pseudocross-over-designed RCT succeeded in statistically significantly demonstrating the superiority of the silicone finger cap over conventional film therapy. The finger cap was safe and effective, reaching excellent results on all treated injuries without any need for disinfection, antibiotics, shortening of protruding bones, or treatment of hypergranulations. Distal to the tendon insertions, we did not see any limitations regarding injury mechanism, amputation plane, or patients' age.

Proper preservation of amputated parts: A multi-level shortcoming.

BACKGROUND: Successful replantation relies on proper preservation of traumatically amputated parts. The established protocol for preservation, however, is inconsistently adhered to. The objective of this study is to examine the rate of proper preservation in multiple patient populations. METHODS: A retrospective review of patients from 2015 to 2019 at a single academic institution was conducted. Patients were included if they suffered a traumatic amputation, the amputated part was present for evaluation by the hand surgery team, and modality of preservation was documented. Additional data including method of patient transport, replantation attempt, and operative outcome were assessed. Patients were stratified based on whether proper preservation was employed and compared using chi-square tests. RESULTS: Ninety-one patients were included, thirty-one (34.1%) of whom had amputated parts which were properly preserved. Patients from referring facilities were more likely to present with properly preserved parts (45.0%) than those presenting from home (25.5%), though this did not meet significance (P = .051). In total, 74 patients arrived via EMS with 35.1% adherence to preservation protocol. Of the 31 patients who had properly preserved parts, 58.1% underwent attempted replant; of the 60 patients who had improperly preserved parts, 23.3% underwent attempted replantation (P = .001). CONCLUSIONS: The majority of patients who suffer traumatic amputations do not present with properly preserved amputated parts, limiting potential replantation. With a direct correlation to attempted replantation, proper preservation is a crucial aspect of care and should not be overlooked when seeking to optimize efforts and results. LEVEL OF EVIDENCE: Level IV.

Negative-Pressure Wound Therapy Application in Fingertip Replantations and a Systematic Review.

BACKGROUND: Fingertip replantation is technically challenging. Venous congestion is one of the most common causes of replantation failure. Therefore, various venous drainage procedures and salvage techniques have been used in venous congestion. Negative-pressure wound therapy has proven beneficial in limb injuries, yet limited studies of fingertip replantation exist. This study aims to analyze risk factors in fingertip replantation and to evaluate the feasibility and clinical benefits of negative-pressure wound therapy compared with other salvage techniques. METHODS: From January of 2015 to December of 2019, 27 patients (27 digits) who experienced fingertip amputation over Tamai zone I or II underwent replantation. Salvage negative-pressure wound therapy was applied for venous congestion postoperatively. Replantation data were collected for further analysis. RESULTS: The overall survival rate of digit replantation with salvage negative-pressure wound therapy was 92.6 percent (25 of 27). The blood transfusion rate was 11.1 percent (three of 27). The average hospitalization time was 8.04 ± 1.43 days and the median duration of negative-pressure wound therapy was 6 days (range, 4 to 8 days; interquartile range, 2 days). There is no significant difference between the survival and failure groups for all risk factors evaluated. CONCLUSION: Negative-pressure wound therapy is a simple and effective salvage option to relieve venous congestion in fingertip replantation with a satisfactory survival rate, low blood transfusion rate, and short inpatient stay. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Fingertip Amputation Injury of Allen Type III Managed Conservatively with Moist Wound Dressings.

BACKGROUND Fingertip amputation injury is treated surgically or conservatively. Management strategies for these injuries vary depending on not only the site and the degree of tissue loss in the wound but also the country and region. Conservative management or revision amputation is common in the United States. On the other hand, operative management such as replantation or reconstruction is preferred in Japan; accordingly, a surgery is performed even in cases eligible for conservative management. Here, we report a case of fingertip amputation injury for which reconstructive surgery was recommended by a plastic surgeon, but the patient opted for conservative treatment, which was performed using moist wound dressings. CASE REPORT A 36-year-old woman suffered an Allen type III fingertip amputation injury with her right middle finger crushed in a thick iron door. The amputated fingertip was not retrieved. The plastic surgeon in charge initially recommended reconstructive surgery to the patient. However, the patient opted for conservative management; therefore, she visited the Wound Care Department in our hospital. Conservative treatment using moist wound dressings (Plus moist™) was performed, and the wound healed after 12 weeks, with outstanding aesthetic and functional results. CONCLUSIONS Conservative management with moist wound dressings can be a successful treatment modality for Allen type III fingertip amputation injury. In cases where the fingertip amputation injury can be treated using either surgery or conservative treatment, it is better to prioritize the patient's wishes when selecting the treatment option.

St Andrew's COVID-19 surgery safety study: hand trauma.

INTRODUCTION: Adaptation is vital to ensure successful healthcare recovery during the COVID-19 pandemic. Hand trauma represents the most common acute emergency department presentation internationally. This study prospectively evaluates the COVID-19 related patient risk, when undergoing management within one of the largest specialist tertiary referral centres in Europe, which rapidly implemented national COVID-19 safety guidelines. MATERIALS AND METHODS: A prospective cohort study was undertaken in all patients referred to the integrated hand trauma service, during the UK COVID-19 pandemic peak (April-May 2020); all were evaluated for 30-day COVID-19 related death. Random selection was undertaken for patients with hand trauma who either underwent non-operative (control group) or operative (surgery group) management; these groups were prospectively followed-up within a controlled cohort study design and telephoned at 30 days following first intervention (control group) or postoperatively (surgery group). RESULTS: Of 731 referred patients (566 operations), there were no COVID-19 related deaths. Both groups were matched for sex, age, ethnicity, body mass index, comorbidities, smoking, preoperative/first assessment COVID-19 symptoms, pre- and postoperative/first assessment isolation and positive COVID-19 contact (p > 0.050). There were no differences in high service satisfaction (10/10 compared with 10/10; p = 0.067) and treatment outcome (10/10 compared with 10/10; p = 0.961) scores, postoperative/first assessment symptoms (1%, 1/100 compared with 0.8%, 2/250; p = 1.000) or proportion of positive tests (7.1%, 1/14 compared with 2.2%, 2/92; p = 0.349), between the control (n = 100) and surgery (n = 250) groups. CONCLUSION: These data support continued and safe service provision and no increased risk to patients who require surgical management. Such findings are vital for healthcare providers when considering service adaptations to reinstate patient treatment.

Experience with the Use of Splint Caps for the Management of Fingertip Amputation Injuries.

Background: Fingertip amputation injuries are common hand injuries amongst all ages. If occurring as a result of workplace accidents, these injuries has the potential to lead to significant socioeconomic costs. Non-surgical techniques can treat these injuries with the potential to alleviate the burden of these socioeconomic costs. The aim of our study is to describe an alternative, cost-effective device to manage fingertip amputation injuries, and to present our short-term outcomes with this treatment modality. Methods: A retrospective study of patients with isolated fingertip amputation injuries who received treatment with semi-occlusive dressing and splint cap from 1 February 2018-21 December 2018 was conducted. The semi-occlusive dressing used was UrgoTul. The splint cap is a 3-dimensional thermoplastic splint to cover the semi-occlusive dressing of the injured finger. Results: There were 28 patients and 31 digits. The average age was 39.9 ± 12.7 years. 89.3% were male, 75% were foreign workers, 96.4% were blue-collared workers, 40% had dominant hand injuries and 25.8% had nailbed involvement. The average duration of follow-up was 66 ± 37.4 days and the average duration of hospital leave was 6.5 ± 4 weeks. The splint cap was applied for an average of 18.1 ± 6.2 days. The total time for tissue regrowth was 27.5 ± 8.8 days. 14.8% had residual nail deformities and return of sensation took 31.5 ± 11 days. Grip strength was 82.5% of unaffected hand. The mean range of motion at the distal interphalangeal, proximal interphalangeal and metacarpophalangeal joint was 58.8 ± 21.3°, 86.9 ± 15.5°, 81.4 ± 6.0° respectively, and 63.9 ± 23.6° and 66.3 ± 17.3° at the interphalangeal and metacarpophalangeal joint of the thumb respectively. Cost analysis will be further elaborated in the paper. Conclusions: Fingertip amputation injuries have a potential for regeneration through healing by secondary intention under semi-occlusive dressing conditions. The splint cap provides an easy to fashion, cost-efficient and comfortable addition to semi-occlusive dressings for fingertip injuries.

Successful ROTEM-guided transfusion therapy in a case of rural paediatric trauma.

Massive transfusion therapy in severe paediatric trauma is a challenge. When this occurs in a rural setting, the potential delays in accessing medical services can lead to worse coagulopathy on presentation. We report successful treatment of a child post-traumatic lower limb amputation where treatment was only initiated 3 hours postinjury due to difficulties in access/retrieval. Rotational thromboelastometry (ROTEM)-guided, goal-directed haemostatic therapy perioperatively utilising a blood product ratio of 2:2:1 units of red blood cell:free frozen plasma:platelet reverted his coagulopathy. This report aims to raise awareness of the utility of ROTEM in paediatric trauma.

Failure of Indomethacin and Radiation to Prevent Blast-induced Heterotopic Ossification in a Sprague-Dawley Rat Model.

BACKGROUND: Although use of nonsteroidal antiinflammatory drugs and low-dose irradiation has demonstrated efficacy in preventing heterotopic ossification (HO) after THA and surgical treatment of acetabular fractures, these modalities have not been assessed after traumatic blast amputations where HO is a common complication that can arise in the residual limb. QUESTIONS/PURPOSES: The purpose of this study was to investigate the effectiveness of indomethacin and irradiation in preventing HO induced by high-energy blast trauma in a rat model. METHODS: Thirty-six Sprague-Dawley rats underwent hind limb blast amputation with a submerged explosive under water followed by irrigation and primary wound closure. One group (n = 12) received oral indomethacin for 10 days starting on postoperative Day 1. Another group (n = 12) received a single dose of 8 Gy irradiation to the residual limb on postoperative Day 3. A control group (n = 12) did not receive either. Wound healing and clinical course were monitored in all animals until euthanasia at 24 weeks. Serial radiographs were taken immediately postoperatively, at 10 days, and every 4 weeks thereafter to monitor the time course of ectopic bone formation until euthanasia. Five independent graders evaluated the 24-week radiographs to quantitatively assess severity and qualitatively assess the pattern of HO using a modified Potter scale from 0 to 3. Assessment of grading reproducibility yielded a Fleiss statistic of 0.41 and 0.37 for severity and type, respectively. By extrapolation from human clinical trials, a minimum clinically important difference in HO severity was empirically determined to be two full grades or progression of absolute grade to the most severe. RESULTS: We found no differences in mean HO severity scores among the three study groups (indomethacin 0.90 ± 0.46 [95% confidence interval {CI}, 0.60-1.19]; radiation 1.34 ± 0.59 [95% CI, 0.95-1.74]; control 0.95 ± 0.55 [95% CI, 0.60-1.30]; p = 0.100). For qualitative HO type scores, the radiation group had a higher HO type than both indomethacin and controls, but indomethacin was no different than controls (indomethacin 1.08 ± 0.66 [95% CI, 0.67-1.50]; radiation 1.89 ± 0.76 [95% CI, 1.38-2.40]; control 1.10 ± 0.62 [95% CI, 0.70-1.50]; p = 0.013). The lower bound of the 95% CI on mean severity in the indomethacin group and the upper bound of the radiation group barely spanned a full grade and involved only numeric grades < 2, suggesting that even if a small difference in severity could be detected, it would be less than our a priori-defined minimum clinically important difference and any differences that might be present are unlikely to be clinically meaningful. CONCLUSIONS: This work unexpectedly demonstrated that, compared with controls, indomethacin and irradiation provide no effective prophylaxis against HO in the residual limb after high-energy blast amputation in a rat model. Such an observation is contrary to the civilian experience and may be potentially explained by either a different pathogenesis for blast-induced HO or a stimulus that overwhelms conventional regimens used to prevent HO in the civilian population. CLINICAL RELEVANCE: HO in the residual limb after high-energy traumatic blast amputation will likely require novel approaches for prevention and management.

Quantifying outcomes for leech therapy in digit revascularization and replantation.

We retrospectively reviewed 201 digit replantations or revascularizations that were performed between August 2007 and June 2015. Leeching therapy was used in 48 digits and was more commonly required in replanted digits. In revascularized digits, leeching was used significantly more frequently in avulsion injuries and injuries associated with fractures. Digits that were leeched for more than 4.5 days had significantly higher rates of survival of digits after replantation or revascularization. Leeching was associated with higher incidence of transfusion, higher mean number of transfusions, and longer length of stay. We conclude from this study that leeching is used more frequently after digital replantation than revascularizaion, and in revascularized digits, leeching is used more often in avulsion injury and in patients with fractures. In patients requiring leeching therapy, leaching for more than 4.5 days leads to higher rate of digital survival. Level of evidence: IV.

Pediatric hand injuries: Practical approach for primary care physicians.

OBJECTIVE: To present a practical and evidence-based approach for primary care physicians to the diagnosis and initial management of common pediatric hand injuries, and to identify injuries requiring prompt referral. SOURCES OF INFORMATION: Clinical evidence and expert recommendations were identified by using MEDLINE and EMBASE for each topic presented. MAIN MESSAGE: Pediatric hand injuries are a common reason for physician consultation. The most common and potentially problematic pediatric hand injuries include fingertip injuries, phalangeal fractures, tendon injuries, and hand burns. Management is limited by difficulties in proper assessment of the hand and the paucity of evidence to guide treatment. Nevertheless, outcomes in children are typically excellent. CONCLUSION: Appropriate assessment, initial management, and, if necessary, timely referral of pediatric patients with hand injuries are paramount given the importance of the hand in function and child development. While some principles from managing adult hand injuries might apply, children often require special considerations.

Fingertip injuries in children: a review of the literature.

Fingertip injuries in children are a common presentation in emergency settings. These injuries result from a variety of mechanisms with most occurring at home by crushing fingers in a door and are distressing for the child and parent or carer. It is essential that emergency clinicians respond competently and confidently. This article reviews the literature on the management of fingertip crush injuries to establish, where possible, best evidence. The article also describes the anatomy and assessment of the finger in relation to fractures of the distal phalanx, nail bed injury and subungual haematoma, and considers the use of antibiotics in the treatment of a subungual haematoma with a distal phalanx fracture.

Old Tricks for New Dogs? John Caddy and the Victorian Origins of TCCC.

The success of Tactical Combat Casualty Care (TCCC) in reducing potentially preventable combat deaths may rely on both specific interventions (such as tourniquets) and the systematized application of immediate care. Essential elements of a combat care system include clear specification of immediate care priorities, standardized methodology, and inclusion and training of all nonmedical personnel in early response. Although TCCC is fairly recent, the construct is similar to that first suggested during the mid-nineteenth century by John Turner Caddy (1822-1902), a British Royal Navy staff surgeon. Although naval warfare engagements at the time were relatively infrequent, casualties could be numerous and severe and often overwhelmed the small medical staff on board. Caddy recognized that nonmedical personnel properly trained in the fundamentals of combat injury management would result in lives saved and greatly improved morale. The novelty was in his attempt to make procedures simple enough to be performed by nonmedical personnel under stress. However, Caddy's guidelines were completely overlooked for nearly two centuries. The principles of best practice for managing combat trauma injuries learned in previous wars have often been lost between conflicts. Understanding the historical roots of combat first responder care may enable us to better understand and overcome barriers to recognition and retention of essential knowledge.

Civilian Prehospital Tourniquet Use Is Associated with Improved Survival in Patients with Peripheral Vascular Injury.

BACKGROUND: Tourniquet use has been proven to reduce mortality on the battlefield. Although empirically transitioned to the civilian environment, data substantiating survival benefit attributable to civilian tourniquet use is lacking. We hypothesized that civilian prehospital tourniquet use is associated with reduced mortality in patients with peripheral vascular injuries. STUDY DESIGN: We conducted a multicenter retrospective review of all patients sustaining peripheral vascular injuries admitted to 11 Level I trauma centers (January 2011 through December 2016). The study population was divided into 2 groups based on prehospital tourniquet use. Baseline characteristics were compared and factors associated with mortality identified. Logistic regression, adjusting for demographic, physiologic and injury-related parameters, was used to evaluate the association between prehospital tourniquet use and mortality. Delayed amputation was the secondary end point. RESULTS: During 6 years, 1,026 patients with peripheral vascular injuries were admitted. Prehospital tourniquets were used in 181 (17.6%) patients. Tourniquet time averaged 77.3 ± 63.3 minutes (interquartile range 39.0 to 92.3 minutes). Traumatic amputations occurred in 98 patients (35.7% had a tourniquet). Mortality was 5.2% in the non-tourniquet group compared with 3.9% in the tourniquet group (odds ratio 1.36; 95% CI 0.60 to 1.65; p = 0.452). After multivariable analysis, the use of tourniquets was found to be independently associated with survival (adjusted odds ratio 5.86; 95% CI 1.41 to 24.47; adjusted p = 0.015). Delayed amputation rates were not significantly different between the 2 groups (1.1% vs 1.1%; adjusted odds ratio 1.82; 95% CI 0.36 to 9.99; adjusted p = 0.473). CONCLUSIONS: Although still underused, civilian prehospital tourniquet application was independently associated with a 6-fold mortality reduction in patients with peripheral vascular injuries. More aggressive prehospital application of extremity tourniquets in civilian trauma patients with extremity hemorrhage and traumatic amputation is warranted.

Liposuction Aspirate Fluid Adipose-Derived Stem Cell Injection and Secondary Healing in Fingertip Injury: A Pilot Study.

BACKGROUND: Although fingertip injuries account for a high proportion of trauma patients, the correct surgical approach is still debated. The authors compared the traditional conservative approach and a new treatment based on the injection of liposuction aspirate fluid. METHODS: Forty consecutive patients with a fingertip injury were dichotomized into group A (control group; conservative approach) and group B (treatment group). Group B underwent liposuction, followed by filtration of the lipoaspirate in a closed device (MyStem EVO kit), allowing the nonenzymatic separation of liposuction aspirate fluid, which was then injected at the site of injury. Objective outcomes were time for healing, strength, mobility of joint, and touch and sensory function. Subjective outcomes were cold intolerance, pain, hand disability, and aesthetic result. An aliquot of liposuction aspirate fluid was sent to the laboratory for cellular isolation and analysis by flow cytometry and in vitro differentiation assays. RESULTS: The average healing time was 22.3 days in group B and 24.9 days in group A (p < 0.05). Eighty-five percent of group B patients and 67 percent of group A patients scored normal to diminished superficial sensibility (p < 0.05). Group A had higher pain and cold intolerance scores (p < 0.05). Group B scored greater aesthetic and disabilities outcome results (p < 0.05). The cell isolation yield was 8.3 × 10(5)/ml, with a percentage of viable cells of 74.3 percent. Flow cytometry identified a mesenchymal immunophenotype, and in vitro osteogenic and adipogenic induction confirmed the bilinear potential of the isolated cells. CONCLUSION: This clinical study demonstrates for the first time the regenerative potential of liposuction aspirate fluid adipose-derived stem cells in a clinical application. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Immediate and 24-h blood pressure-lowering effects of arm crank exercise in patients with traumatic lower-limb amputation: a randomized cross-over study.

AIM: This study aimed to investigate the clinic and 24-h postexercise hypotension (PEH) after a moderate-intensity arm crank exercise session in individuals with traumatic lower-limb amputation. PARTICIPANTS AND METHODS: Nine men (46±17 years) with unilateral traumatic lower-limb amputation participated in two experimental sessions conducted randomly: an aerobic exercise (EXE: arm crank ergometer, 30 min) or a control session (CON: participants remained seated on the cycle ergometer, 30 min). Clinic and 24-h systolic, diastolic, and mean blood pressure (BP) response were measured after both sessions. The clinical measurements of blood flow and forearm vascular resistance (FVR) were also performed. RESULTS: Compared with the preintervention period, the BP levels did not change in the CON session. However, EXE resulted in a significant hypotensive effect in systolic (-10±0.9 mmHg, P≤0.05), diastolic (-11±1.5 mmHg, P≤0.05), and mean BP (-11±1.2 mmHg, P≤0.05) during the entire postexercise period. The PEH was accompanied by a decreased FVR over the entire postintervention period (P≤0.05). Significant reductions were found for 24-h average systolic, diastolic, and mean BP levels (P=0.03, 0.01, and 0.02, respectively) following EXE compared with the CON session. CONCLUSION: These results showed, for the first time, that individuals with traumatic lower-limb amputation presented immediate and 24-h PEH after a single bout of arm crank exercise testing. The PEH at the clinic condition was justified, at least in part, by the reduction in peripheral FVR.

Traumatic Hemipelvectomy with a Contralateral Unstable Pelvis and Acetabular Fracture: A Case Report and Review of the Literature.

CASE: A traumatic hemipelvectomy (THP) is a rare life-threatening injury, with limited reports in the civilian population. We present the case of a patient who sustained a massive pelvic injury with an incomplete unilateral THP, a contralateral unstable pelvis, and a fracture of the acetabulum. CONCLUSION: With advancements in resuscitative techniques, carefully timed and planned surgical interventions, and a coordinated multidisciplinary approach, a greater number of patients may be able to survive a massive pelvic injury.

Experiences with Regional Anesthesia for Analgesia During Prolonged Aeromedical Evacuation.

INTRODUCTION: There is much debate regarding the appropriate analgesic management of patients undergoing medical evacuation following combat trauma. Our primary objective was to review the utility of regional anesthetic techniques in patients undergoing aeromedical evacuation following surgical limb amputation as treatment for combat trauma. METHODS: This study was conducted as an observational retrospective cohort whereby acutely injured amputee patients were identified via the U.S. Transportation Command's patient movement database. The Theater Medical Data Store was cross-referenced for additional patient care data including opioid consumption, duration of regional technique, pain scores, and rates of intubation. RESULTS: Eighty-four records were retrieved from the Theater Medical Data Store. All 84 patients were victims of improvised explosive device detonation requiring limb amputation and subsequent transport from Kandahar Airfield or Camp Bastion, Afghanistan, to the United States. The majority of interventions remained in place throughout the evacuation process. A significant decrease in opioid consumption in patients receiving regional anesthesia was identified at each leg of the medical evacuation process. Pain scores were sporadically reported and not statistically different. Higher rates of intubation were identified in the nonregional anesthetic group. DISCUSSION: Our analysis demonstrates the feasibility and effectiveness of applying regional anesthetic techniques for pain management to our combat wounded trauma patients throughout multiple stages of aeromedical evacuation. Benefits include the potential for less sedation and less opioid consumption while potentially foregoing the requirement for intubation during transport.Carness JM, Wilson MA, Lenart MJ, Smith DE, Dukes SF. Experiences with regional anesthesia for analgesia during prolonged aeromedical evacuation. Aerosp Med Hum Perform. 2017; 88(8):768-772.

Injury to the male external genitalia: a comprehensive review.

While rare, trauma and injury to the male external genitalia can result in significant consequences regarding function, appearance, psychological effects, and overall quality of life. Due to the relative paucity of literature regarding male external genitalia injuries, few standardized protocols exist. This review aims to outline common clinical causes of male external genitalia injuries by both anatomic location and etiology. Initial stabilization, long-term reconstruction, and coverage options are discussed in detail. Outcomes of complex grafts have favorable success rates of 90-100% in the hands of experienced surgeons. Outcomes of penile, testicular trauma also have favorable outcomes when managed appropriately. Attempts at reconstruction after initial injury stabilization should be undertaken at high-volume centers where a multidisciplinary approach can be employed. This manuscript will be an excellent reference and source that can provide direction for evaluation and management of these complex presentations.