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A rare foot injury consisting of an irreducible, closed combined distal and proximal articulation dislocation of two adjacent metatarsals (second and third), called a "double floating metatarsal," was encountered in a 29-year-old man. The anatomy, mechanism of injury, and sequence of the surgical procedure are presented and discussed.
Some of the radiologic features of chain-saw injuries are described. These occurred in an industrial logging community, where the use of such machines is common. The increasing availability of chain saws for domestic use makes it likely that accident and emergency departments will be seeing a wide variety of injuries following accidents with chain saws. The radiologic appearances include the chipping of bone, the breaching of joint cavities, and partial severing of tubular bones.
The deltoid fasciocutaneous flap is a thin, reliable flap that is easily dissected from the posterolateral arm. It has large-caliber vessels and is capable of sensory reinnervation to portions of the flap above the deltoid/triceps groove through the lateral brachial cutaneous nerve. There is little sensory return to the large vascular territory, which can be extended inferiorly below the deltoid triceps groove. The donor site can be closed primarily or skin grafted and when large may be objectionable to some patients. The flap is an excellent choice for extremity soft-tissue reconstruction on the plantar or palmar surfaces. Protective sensibility has returned to all reinnervated flaps. We present our experience in 10 patients with extremity problems.
One rectus abdominis muscle flap, when based on superior and inferior pedicles, can be transferred simultaneously as two free-muscle flaps in two different configurations during the same operation. The two free flaps based on either pedicle are safe, reliable, and extremely well vascularized. Excellent functional and cosmetic results have been achieved in five patients with minimal donor-site morbidity. It has been our flap of choice for reconstructing the moderate- to large-sized defects at two separate sites of the upper and lower extremities.
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BACKGROUND: A thin skin flap is often required for optimal resurfacing of particular areas of the body. An anterolateral thigh perforator flap can be thinned to an extent to which it is vascularized by the subdermal plexus only. This study presents a novel flap thinning technique and its application for resurfacing the dorsum of the foot. METHODS: From July of 2002 to October of 2003, 18 patients underwent resurfacing of the dorsum of the foot with thin anterolateral thigh flaps. The main perforators were strategically located in the flap center to keep the peripheral area within the vascular territory. The flaps were larger than needed, initially elevated subfascially, and then thinned to the suitable thickness while the pedicle was still attached. The dissection of perforators in the adipose layer close to the dermis entry was carried out microscopically. Flap sizes ranged from 3 x 3 to 16 x 8 cm. RESULTS: Seventeen flaps survived completely and one had distal superficial necrosis of 1 x 2 cm. No debulking procedures were necessary. Average follow-up was 12 months. CONCLUSIONS: A thin flap vascularized through subdermal plexus is reliable. Microsurgical dissection of the perforator is a recommended technique. The thin anterolateral thigh perforator flap provides ideal reconstruction in resurfacing the dorsum of the foot.
BACKGROUND: The thoracodorsal artery perforator flap was first introduced in 1995. Many authors focused on using anatomical landmarks to identify skin perforators and on thinning procedures for a skin paddle. In this study, we used the superthin free thoracodorsal artery perforator flap for resurfacing shallow defects of the extremities in 10 patients. METHODS: Two anatomical landmarks previously presented by other authors were used for the guidance of flap elevation. The first landmark represented the site of the proximal skin perforator originating from the descending branch of the thoracodorsal artery, and the second landmark marked the site of the thoracodorsal neurovascular hilum. Ten flaps were performed, and all skin perforators originated from the descending branch of the thoracodorsal artery. The skin paddle carried only skin and the superficial adipose layer, and the largest skin paddle was 23 x 9 cm. RESULTS: All defects were resurfaced with smooth contour, except for one flap in which the authors encountered flap tip superficial necrosis. The operative findings did not coincide with the first anatomical landmark in five patients. Likewise, these findings were not consistent with the second landmark in eight patients. In four patients, the thoracodorsal neurovascular hilum was located at the same level of the scapular tip or even above it. These unwanted anatomical variations increased the difficulty of exploration for skin perforators. CONCLUSIONS: The thoracodorsal artery perforator flap is a feasible choice for shallow defects in superthin form. Using a color Doppler device to identify the skin perforators preoperatively is highly suggested to prevent unexpected anatomical variations.
BACKGROUND: Trauma of the midfoot and ankle joint are among the most commonly treated injuries in the emergency unit. The "Ottawa ankle rules" were introduced in 1992 to lower the amount of radiographs based on a standardized clinical examination. The weakness of the "rules" is the low specificity reported in several clinical studies. METHOD: We introduced a new indirect stress technique to examine the ankle and the midfoot after low-energy, supination-type trauma, avoiding direct palpation of the injured region. RESULTS: In 354 prospectively documented patients, the Bernese ankle test produced a sensitivity of 100% and a specificity of 91%. CONCLUSION: Compared with the original Ottawa ankle rules, the number of false-positive findings could be significantly reduced, resulting in a reduction of 84% in radiographs after low-energy, supination-type trauma ankle and midfoot trauma. Further investigations have to be performed to prove whether these findings are reproducible within other clinical settings, which could result in major cost savings for the health care system.
BACKGROUND: In nail apparatus melanomas (NAM), the role of standard melanoma prognostic factors is under discussion. The prognostic influence of traumas to the clinically apparent tumour has not been sufficiently examined. OBJECTIVES: To estimate the influence of traumas against the background of standard prognostic factors on the course of NAM. METHODS: In 33 patients (20 women, 13 men, median age 65.0 years) with NAM (median tumour thickness 3.5 mm), we retrospectively examined a detailed history of trauma to the affected extremity at first presentation. Histological or other standard prognostic factors and follow-up were studied prospectively using a standardized protocol. RESULTS: Of 33 patients, 21 had suffered injury to the clinically apparent melanoma primary between 4 and 72 months prior to definitive surgical treatment (diagnostic biopsy up to 3 months ahead of excision of the melanoma was not considered). Eight of these patients had undergone inadequate therapy procedures. In Kaplan-Meier analysis, trauma to the clinically apparent tumour and tumour thickness were found to be significant prognostic factors for recurrence-free survival, and trauma to the clinically apparent tumour, Clark level and tumour thickness were significant prognosis predictors for overall survival. In Cox's proportional hazards model, trauma to the clinically apparent tumour was found to be a significant and independent risk factor with regard to overall survival (hazard ratio 5.39; P = 0.029). An influence of trauma on the primary pathogenesis of NAM could not be confirmed. Only three patients reported trauma prior to the onset of tumour. CONCLUSIONS: From our data, trauma to the clinically apparent tumour might be a considerable risk factor in NAM. The diagnosis of NAM should be considered in lesions of the nail apparatus and further deterioration of the prognosis due to inadequate therapeutic attempts or injury to the NAM should be avoided.
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An effective method of providing pain relief in hydrofluoric acid burns is reported, using a Bier's block type technique and regional intravenous calcium gluconate. This method allows satisfactory analgesia and prevents further tissue destruction, without the risk and added discomfort of increased tissue tensions associated with local infiltration of calcium.
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The financial outcome and epidemiology of ballet dancers' injuries were studied by examining workers' compensation insurance records covering 3 seasons (3 years) of activity for a large professional ballet company. One hundred four dancers sustained 309 injuries that resulted in insurance payouts for medical costs of $398,396. The average cost per injury was $1289. Although only 4.2% of the injuries resulted in medical costs exceeding $5000, these represented 60.0% of the total medical costs. Nine injuries resulted in medical costs in excess of $10,000 each. Overall, there were 2.97 injuries per injured dancer. Twenty-four dancers (23.0% of the injured) sustained 5 or more injuries each and thus were responsible for 51.9% (161) of all injuries. The foot (74 injuries, 23.9%), lumbar spine (71, 23.0%), and ankle (41, 13.3%) were the most frequently injured anatomic regions. The experience of this ballet company is similar to that of a college athletic department or a professional sports team. All could employ similar strategies to reduce injuries and associated costs.
Injuries of peroneal tendons are rare. Diagnosis of traumatic rupture is often late and presents as chronic ankle instability. A case of a complete traumatic rupture of both peroneal longus and brevis tendons with acute clinical and radiological diagnosis is presented. Surgical repair was performed by direct end-to-end suture on the 4th day after trauma, with excellent functional outcome at 1-year follow-up.
Although the treatments and results of subtalar dislocations are usually considered as nonproblematical, review of 10 cases seen over a 6-year period proved otherwise. Difficulties were encountered with four of these cases consisting of associated foot injuries, failure to recognize the dislocation, incarceration of the dislocation, vascular complications, and iatrogenic infection. The management of these cases is discussed.
The purpose of this study was to clarify the role of the ankle ligaments in controlling the tibial rotation for different foot positions. A 6 degrees of freedom device was constructed for in vitro simulation of this movement transfer during the support phase of gait. Tibia rotation angle was measured for different foot positions and vertical loads, while the ligament integrity was modified. Data were collected from eight legs of four different cadavers. The results showed that vertical loading is unimportant to influence tibial rotation, while the lateral ankle ligaments have significant influence, especially during eversion. It was concluded that chronic partial or total lateral ankle instability may contribute to knee and foot injuries through abnormal tibial rotation.