Darren L. Chester

Functional splinting of upper limb injuries with gauze-based topical negative pressure wound therapy.

Complex hand injuries can be difficult to dress effectively and achieve adequate splintage of the hand in a functional position. During the past 7 years, we have had a great deal of success with topical negative-pressure dressings in the management of complex blast-related extremity war injuries. We have more recently changed to using a gauze-based system and have found this particularly useful in dressing complex hand injuries. We have been able to use this vacuum dressing system to splint the hand in a position of function. This provides an easily applied dressing that, through topical negative pressure, promotes wound healing and ensures a resting functional position, thus minimizing postoperative stiffness. We have not been able to achieve this as efficiently with standard dressings and plaster-of-Paris casts. This article details the technique of functional splinting of complex hand injuries using a gauze-based, topical negative-pressure dressing system.

Bilateral breast reduction surgery in elderly women--a retrospective review of outcomes.

BACKGROUND Breast reduction surgery is successful in improving symptoms associated with breast hypertrophy. We sought to substantiate this in the elderly patient and ascertain how they regarded the outcome. METHODS The WHO defines elderly as 60 and over. All elderly patients undergoing BBR for breast hypertrophy over a ten-year period at a single institution were identified. Retrospective review of medical records was conducted and patients asked to complete a postal questionnaire. RESULTS 25/29 (86%) patients responded. 88% felt surgery improved appearance and symptoms. A statistically significant improvement in symptoms, appearance and confidence was demonstrated. 54% of patients voiced negative concerns regarding their surgery. One third were unhappy with final appearance. 2/24 regretted surgery. CONCLUSIONS Although studies showing positive outcomes for breast reduction in breast hypertrophy are many, none have specifically looked at elderly patients. Most patients seek relief of functional symptoms. Cosmesis seems to be less an issue. That they achieve improvement in symptoms is reassuring, despite longevity of symptoms and possible concomitant musculoskeletal degeneration. However despite satisfaction with relief of symptoms, much dissatisfaction can be felt over less than perfect cosmesis. We feel attention to detail is key, even in the elderly undergoing functional procedures.

The evolution of a hand day-surgery unit.

INTRODUCTION Following the merger of two major units to form a regional centre for plastic surgery in the West Midlands, acute hand surgery referrals reached overwhelming proportions. This study describes audits performed at three time points. The first highlighted the extent of in-patient delay and was instrumental in the subsequent development of a dedicated hand trauma day-case unit. PATIENTS AND METHODS Data were collected on 77 patients in June 2002, 109 patients in November 2003 and 90 patients in November 2004. The day-case unit opened on 1 November 2003. RESULTS The number of bed-days per patient fell from 2.63 to 1.34 (P < 0.001) over the study period. In November 2004, 51% of patients received a day-case procedure. Importantly, if admission was required at initial presentation, the delay to theatre reduced from 1.5 bed-days per patient in June 2002 to 0.6 in November 2004. Overall, the in-patient delay was significantly reduced (P < 0.001) but time from presentation to theatre was not significantly affected (P = 0.119). CONCLUSIONS This series of audits confirmed that a significant number of acute hand injuries are suitable for day-case procedures and that simple audit can lead to a significant change in service provision. Improvements were demonstrated in reduced in-patient delay and total stay. We hope that other units find our experience useful given that it may be possible to apply this approach to other forms of ambulatory trauma.

Results of upper limb digital and hand replant and revascularisation at a UK Hand Centre

BackgroundThere is an increasing awareness of replantation amongst the general public, with an expectation for reattachment of digits. Currently, there is a paucity of evidence on the outcomes of replantation or revascularisations in the UK with most surgical experience literature from the USA or East Asian countries.MethodsWe report a case series of 28 patients over a 7-year period with replantation or revascularisation performed at a tertiary National Health Service hand centre in the UK. Data was collected retrospectively from hospital clinical notes and electronic imaging.ResultsOut of the 28 patients identified, 16 had single digit replantation or revascularisation, of which 11 digits ultimately survived. Nine patients underwent multiple digit replantation or revascularisation with a combined total of 25 digits, only five of these digits survived.ConclusionsFactors found to adversely affect survival were increased number of attempted replants, power-saw mechanism of injury and prolonged ischaemic time. Reduced ischaemic times and single digit amputations were associated with improved survival.Level of Evidence: level IV, risk/prognostic study.

A sticky situation: methaemaglobinaemia in a hand trauma patient.

We describe a case of methaemoglobinaemia (MtHb) in a previously healthy 39-year-old gentleman who presented with a traumatic glass laceration to his right wrist that required emergency surgery to control bleeding and repair his ulnar artery. The MtHb was noted on blood gas analysis by the anaesthetist after the patient had a drop in arterial oxygen saturation under general anaesthetic. We initially suspected the lidocaine local anaesthetic injected proximal to his wound for pain control in the emergency department an hour preoperatively, but then discovered that the patient was a recreational user of ‘poppers’ and had in fact been using these drugs just before his injury and hospitalisation. The patients condition stabilised overnight with conservative management. Given how commonly hand surgeons and other clinical staff use local anaesthetics, we reviewed the literature on this uncommon, but potentially fatal, complication, its causes and evidence-based management.

Recurrent primary abscesses in the hand: consider panton-valentine leukocidin-positive Staphylococcus aureus

A 24-year-old right-hand dominant student presented with a 3 day history of increasing pain, swelling, and redness in the left palm. There was no recent history of trauma. She gave a history of a similar episode affecting the contra-lateral palm 6 weeks previously and had undergone incision and drainage of a palm abscess elsewhere. She had completed a 1 week course of oral co-amoxiclav and the wound had healed. Her past medical history was unremarkable; in particular, she was not diabetic or immunocompromised. She did not take any regular medications, had no allergies, and was a non-smoker. On examination there was a tender, fluctuant swelling with overlying cellulitis in the distal part of the left palm. There were no clinical signs suggestive of flexor sheath infection and there was no palpable lymphadenopathy. She had a mild pyrexia of 37.6°C, but all other observations were in the normal range. Radiographs of the left hand and chest were unremarkable. Admission bloods tests showed a serum white blood cell count of 10.7 x 109/L, neutrophilia of 8.8 x 109/L, and C-reactive protein of 3 mg/L. Serum haemoglobin, electrolytes, and fasting glucose (5.7 mmol/L) were in the normal range and a urine dipstick was negative. A left palmar abscess was suspected; she was admitted and intravenous flucloxacillin and benzylpenicillin were given. At operation a subcutaneous collection of pus was incised and drained from the left palm and sent for microbiological analysis. She remained afebrile post-operatively and made a good recovery. Pus and tissue samples grew methicillinresistant Staphylococcus aureus (MRSA) positive for Panton-Valentine leukocidin (PVL) toxin. The microbiology team advised treatment with oral clindamycin. She underwent MRSA decolonization treatment at home, supervised by the infection, prevention, and control team. There have been no further abscesses at 6 months follow-up. PVL is a cytotoxin produced by certain strains of S. aureus (SA) that causes targeted leukocyte destruction and tissue necrosis (Shallcross et al., 2010). Recently there has been growing international concern about the emergence of PVL-toxin secreting strains of staphylococcus (PVL-SA) that appear to be highly pathogenic, causing severe disease in young healthy individuals with no risk factors for hospital transmission. Although the exact role of PVL toxin in the pathogenesis of these strains is unclear, there are strong epidemiological links between PVL-SA and severe and recurrent skin and soft-tissue infections (SSTIs) (Lina et al., 1999). There are also reported cases of invasive infections due to PVL-SA including necrotizing fasciitis, purpura fulminans, and a form of severe communityacquired necrotizing pneumonia in previously healthy individuals that has a high mortality of up to 75% (Lina et al., 1999). The association between PVL-SA and primary skin abscess formation is well documented, with a recent study showing that 92.7% of staphylococcal primary skin abscesses were due to PVL strains (del Giudice et al., 2009). Cases can be recognized on clinical features such as their recurrent and spontaneous nature; the presence of necrosis, furuncles, carbuncles or folliculitis; and pain and erythema out of proportion to the cutaneous findings. The current prevalence of PVL-SA in the UK appears to be low, with 9.7% of staphylococcal clinical isolates referred to the Staphylococcal Reference Unit being positive for PVL genes (Shallcross et al., 2010). However, recent data from the UK Health Protection Agency (HPA) shows that the number of PVL-SA cases being identified is increasing year on year, although this may reflect increased awareness and case recognition (Health Protection Agency, 2011). Moreover, PVLpositive MRSA, which has strong epidemiological links to community-associated MRSA (CA-MRSA), is also on the rise with 1049 cases identified in 2010 and making up almost half the PVL cases (www.hpa.org.uk). To our knowledge no cases of recurrent primary abscess in the hand due to PVL have been published and this case, although unusual, highlights the need for all hand surgeons to be aware of this potentially severe infection. The prevalence of PVL-SA is increasing, and so hand surgeons should consider the diagnosis in patients presenting with primary hand abscesses, Letters to the Editor Short Report Letters 480316 JHS0010.1177/1753193413480316The Journal of Hand SurgeryShort report letters 2013

Modified Fogli temporal lift

Figure 1 Spinal needle introduced above the eyebrow and delivered into the incision site. Elevation of the ptotic brow is an integral part of rejuvenation of the upper third of the face. Many methods have been described from the direct excision of a skin ellipse from the forehead to the mobilisation of the forehead in a cephalic direction accessed though a coronal, endoscopic, transblepharoplasty or combination of some or all of these incisions. Fogli described an efficient and simple temporal lift technique that uses galeapexy to address the ptotic tail of the brow and crow’s feet. His approach consists of a temporal incision 3 cm behind the hairline, followed by subgaleal dissection and then a subcutaneous dissection that allows the freed, lifted cephalic galea, previously incised, to be anchored directly to the temporal aponeurosis. This cutaneous redraping raises the brow tail and a detachment of the orbicularis fibres. Suturing of the scalp is hence achieved without tension, without eliminating hair and prevents backward displacement of the hairline. The senior author has modified Fogli’s lifting and fixation technique to achieve a more accurate lift of the mid-lateral eyebrow.