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PubMed2003

The integral role of the plastic surgeon at a level I trauma center.

The role of plastic surgery in urban level I trauma centers in the United States has been largely undefined, despite the undeniable historical involvement of plastic surgery in reconstruction of posttraumatic defects. To explore and define this role, case data were prospectively collected during a 29-month period following initiation of a full-time plastic surgery position at an established urban level I trauma center. Referring and/or interacting surgical service, anatomical area of interest, and procedure data were tabulated. A total of 1009 operative reports comprising 1104 procedures were recorded. The most common interacting surgical services were orthopedics and general/trauma surgery; however, interaction occurred with a total of 10 surgical specialties. The upper extremity was the most common anatomical area operated on followed by head and neck, lower extremity, trunk, urogenital, and breast. A wide variety of procedures were performed in each anatomical area, demonstrating the broad scope of reconstructive surgery practiced in a trauma setting. Three hundred and twenty-four procedures involved expertise in microsurgery, flaps, and burn or frostbite care. Additional procedures commonly performed demonstrated considerable overlap with other fields of surgical specialization. This overlap in skills proved advantageous in distribution of facial trauma call and hand surgery coverage. Data presented in this study reinforce the idea that plastic surgery is a specialty defined by concept rather than anatomical area, and also demonstrate a significant role for plastic surgeons in a level I trauma center.

Colorado↗
PubMed1986

Thermogenesis with relation to exercise and exercise-training.

Exercise-training at environmental temperatures outside the thermal neutral zone, causes thermoregulatory adaptive reactions. In the heat, sweat efficiency is enhanced thus reducing the incidence of hyperthermia while in the cold discomfort and danger of frostbite are minimized by an improved cutaneous circulation specially in the extremities. Over long periods of time exercise does not affect thermogenesis except when refeeding. It is suggested that the reduced postprandial heat production reported in exercise-trained subjects is related to changes in nutrient metabolism which in turn could be related to insulin and norepinephrine modified actions.

Body Temperature Regulation↗
PubMed2006

Acquired port-wine stain related to acoustic neuroma.

Port-wine stains are frequently seen congenital vascular malformations consisting of ectatic dermal capillaries. Acquired port-wine stain that develops later in life is an uncommon vascular lesion that is morphologically identical to a congenital port-wine stain. In the majority of acquired port-wine stains, the aetiology is unknown, but trauma is an important causative factor. Other proposed aetiologies include chronic sun exposure, hormonal changes, frostbite injury, obstruction of the peritoneovenous shunt, herpes zoster infection, and cerebral arteriovenous malformation. Here we report the first case of a patient who had an acquired port-wine stain related to a solid brain tumour.

Adult↗
PubMed1985

Differential conduction of cold through barriers.

Despite the widespread use of ice packs in conjunction with ace bandages, padded ace bandages and compression dressings in the management of acute soft tissue trauma and sprains, the role of these barriers in the conduction of cold has not been adequately evaluated. Thermal probes were secured to both ankles of 62 healthy volunteers. The selected barrier was applied bilaterally and 500 g of chipped ice in a plastic bag was placed over the barrier on the right ankle for 30-45 minutes. A significant reduction in temperature of the right ankle was noted in all groups except in the padded ace group. The most rapid decrease in temperature was noted during the first 2 minutes of treatment. During the first minute, the surface temperature decreased an average of 22 degrees C (ace), 3.8 degrees C (dry washcloth), 5.2 degrees C (no barrier) and 5.4 degrees C (damp washcloth). After 10 minutes, the mean rate of cooling was 0.1-0.2 degree C and was approximately the same in all four groups. The Scheffe procedure indicated three homogeneous subgroups at 30 minutes: no barrier, damp washcloth; ace, dry washcloth; and padded ace. These findings question the clinical usefulness of the application of cold over padded aces and compression dressings and the use of a damp washcloth to 'protect' the skin from frostbite.

Bandages↗
PubMed1982

Endemic leg ulcers caused by Corynebacterium pyogenes in Thailand.

Corynebacterium pyogenes was isolated from leg ulcers found in 495 school children during an epidemic in Thailand in 1979 and 1980. Although C. pyogenes is frequently isolated from cattle, sheep, pigs, and goats, and less frequently from rabbits and guinea pigs, it rarely infects humans, where respiratory infections far outweigh skin infections. Cutaneous infections usually begin with a superficial abscess, then a frostbite-like lesion, followed by ulceration and even gangrene.

Adolescent↗
PubMed1984

The falklands: rate of British psychiatric combat casualties compared to recent American wars.

This paper examines factors leading to the low rate of combat psychiatric casualties in the British recapture of the Falklands compared to the American experience in North Africa, Italy, Europe and South Pacific theatres during World War II, the Korean Conflict and Vietnam. The factors compared are those thought to affect rates seen in these past wars. The factors highlighted are psychiatric screening of evacuees, presence of psychiatric personnel in line units, intensity of combat and use of elite units. Factors also mentioned are presence of possible occult psychiatric casualties such as frostbite and malaria, amount of indirect fire and the offensive or defensive nature of the combat. A unique aspect of the Falklands War examined is the exclusive use of hospital ships to treat psychiatric casualties and the impact of Geneva Convention rules regarding hospital ships on the classic treatment principles of proximity and expectancy. The types and numbers of various diagnoses are also presented. The British Campaign in the Falklands produced a remarkably low rate of psychiatric casualties. When viewed in light of American experience in recent wars, this low rate represents a concentration of optimal factors leading to healthy function in combat. The results of this war should not be used to predict a similar outcome in future combat as this particular constellation of factors may not recur.

Combat Disorders↗
PubMed2003

The iceman: discovery and imaging.

The anatomic features of a 5,300-year-old mummy, the iceman, were documented with conventional radiographic, portable computed radiographic, and conventional and spiral computed tomographic images obtained between September 1991 and June 2001. A team of scientists and radiologists from Austria, Italy, and the United States supervised the examinations and interpreted the images. The images demonstrated excellent preservation of the mineralized skeleton with profound dehydration of the soft tissues. The skeleton exhibited several types of trauma, including (a) healed rib fractures, (b) hairline skull fractures and a compression deformity of the thorax, probably acquired while encased in the glacier, and (c) damage acquired during the effort to recover the corpse. Skeletal variants were present, as was evidence of degenerative arthritis, frostbite, vascular calcification, and adaptation to cultural and geographic influences. In terms of anatomy and apparent health-related conditions, the iceman was very similar to modern humans. An arrowhead lodged between the rib cage and the left scapula was the probable cause of the iceman's death. Study of the images also provided insight regarding postmortem processes that led to the iceman's mummification.

Animals↗
PubMed2004

Reproducibility of the cold-induced vasodilation response in the human finger.

Cold-induced vasodilation (CIVD) is a cyclic oscillation in blood flow that occurs in the extremities on cold exposure and that is likely associated with reduced risk of cold injury (e.g., frostbite) as well as improved manual dexterity and less pain while working in the cold. The CIVD response varies between individuals, but the within-subject reproducibility has not been adequately described. The purpose of this study was to quantify the within-subject variability in the CIVD response under standardized conditions. Twenty-one volunteers resting in a controlled environment (27 degrees C) immersed the middle finger in warm water (42 degrees C) for 15 min to standardize initial finger temperature and then in cold water (4 degrees C; CWI) for 30 min, on five separate occasions. Skin temperature (Tf) and blood flow (laser-Doppler; expressed as percent change from warm-water peak) responses that describe CIVD were identified, including initial nadir reached during CWI, onset time of CIVD, initial apex during CIVD, time of that apex, and overall mean during CWI. Within-subject coefficient of variation for Tf across the five tests for the nail bed and pad, respectively, were as follows: nadir, 9 and 21%; onset, 18 and 19%; apex, 12 and 17%; apex time, 23 and 24%; mean 10 and 15%. For blood flow, these values were as follows: nadir 52 and 64%; onset, 6 and 5%; apex, 33 and 31%; apex time 9 and 8%; and mean 43 and 34%. Greater variability was found in the temperature response of the finger pad than the nail bed, but for blood flow the variability was similar between locations. Variability in onset and apex time between sites was similar for both temperature and blood flow responses. The reproducibility of the time course of CIVD suggests this methodology may be of value for further studies examining the mechanism of the response.

Blood Flow Velocity↗
PubMedDate not supplied

Cryotherapy and nerve palsy.

Ice application is one of the most extensively used treatments for athletic injuries. Frostbite is a recognized danger. Five cases of nerve palsy resulting from ice application are reported here. These palsies were temporary. They usually resolve spontaneously without any significant sequelae. This complication can be avoided by not using ice for more than 30 minutes and by guarding superficial nerves in the area.

Adolescent↗
PubMed2005

The impact of threatening information about pain on coping and pain tolerance.

This study examined the impact of threatening information on coping and pain tolerance in a healthy adult sample. Prior to engaging in a Cold Pressor Test (CPT), 121 college students were randomly assigned to one of three conditions: a threat condition in which they read an orienting passage warning them about symptoms and consequences of frostbite (pain as a signal for nociception), a reassurance condition in which they read an orienting passage about the safety of the CPT (pain independent of nociception), or a control condition in which no orienting passage was read before the experimental task. Only 15.6% of participants in the threat group completed the CPT to its 4-minute duration, compared with 55.6% in the reassurance group and 45.2% of those in the control group. Even though groups did not differ on level of reported pain, threatened participants catastrophized more about the pain and reported less use of cognitive coping strategies (reinterpreting pain sensations, ignoring pain, diverting attention away from pain to other experiences, and using coping self-statements) than other respondents. A path analysis indicated that the relation between threat and pain tolerance was fully mediated by catastrophizing and cognitive coping. Together, findings suggest that pain appraised as threatening contributes to a specific pattern of coping responses associated with a reduced capacity to bear pain.

Adaptation, Psychological↗
PubMed2005

Pernio in pediatrics.

Pernio, or chilblains, is a localized inflammatory lesion of the skin resulting from an abnormal response to cold. Five cases were seen among adolescent female patients who presented to our rheumatology service in a pediatric tertiary care center in the winter of 2003 to 2004. All 5 patients were thin (BMI of <25th percentile) and had either toes or fingers that were affected. For each, laboratory evaluation results were unremarkable, including negative antinuclear antibody profile results. Symptomatic treatment, with or without medication, was recommended. Pernio most commonly occurs among young women but may occur among older individuals or among children. Because pernio develops among susceptible individuals who are exposed to nonfreezing cold, the lesions usually begin in the fall or winter and disappear in the spring or early summer. Acute pernio may develop 12 to 24 hours after exposure to the cold. Single or multiple erythematous, purplish, edematous lesions appear, accompanied by intense pain, itching, or burning. Chronic pernio occurs with repeated exposure to the cold and the persistence of lesions. In an acute exacerbation, the major differential diagnosis alternative would be Raynaud's phenomenon, which consists of sharply demarcated cutaneous pallor and cyanosis, followed by erythema, of far shorter duration (hours rather than days). Frostbite is freezing of tissue, with resultant tissue necrosis. Several conditions have been described as predisposing subjects to pernio, including the presence of cryoproteins, excessive cold exposure, and anorexia nervosa among children and systemic lupus erythematosus and antiphospholipid antibodies among adults. It is important, therefore, when evaluating a patient with pernio, both to exclude an underlying diagnosis and to determine whether additional testing is necessary. The lesions of acute pernio are usually self-limited but may lead to recurrent disease. The involved limb should be cleaned and dried, and rewarming should occur. Prevention is the best form of therapy, and cold exposure should be minimized after an initial insult. The prognosis for properly treated pernio is excellent. Nifedipine, which produces vasodilation, has been demonstrated to be effective in reducing pain, facilitating healing, and preventing new lesions of pernio. We think that the 5 cases seen in our rheumatology clinic represent an increase, compared with prior years; the dermatology clinic at the University of Colorado reported a series of 8 children treated during a 10-year period. The reasons for the possible increase are likely multifactorial, with cold climate, a vulnerable population with thin body habitus, and cold exposure all being contributing causes. Of note, the quality of cold in Colorado is quite dry; however, the winter of 2003 to 2004 was not particularly colder or drier than prior years. All patients were very thin, and thin body habitus may be associated with increased cutaneous vasoreactivity. It is also unclear how these cases of pernio may reflect that winter's fashion trends (2 patients reported wearing sandals in winter). General pediatricians, particularly those who practice in colder climates, should be aware of the presentation and treatment of pernio in childhood.

Acute Disease↗
PubMed2006

Trench foot: the medical response in the first World War 1914-18.

The approaching 90-year anniversary of United States entry into the Great War is an apt time to examine the response to trench foot (now called nonfreezing cold injury [NFCI]) in this conflict. Trench foot appeared in the winter of 1914, characterized by pedal swelling, numbness, and pain. It was quickly recognized by military-medical authorities. There was little debate over whether it was frostbite or new condition, and it was quickly accepted as a specific disease. The major etiologies proposed were exposure, diet, and infection. The opinion emerged that it was caused by circulatory changes in the foot caused by cold, wet, and pressure. Predisposing factors included dietary inadequacy and fatigue. A number of labels were first given to the disease. However, the name "trench foot" was eventually officially sanctioned. Trench foot became a serious problem for the Allies, leading to 75 000 casualties in the British and 2000 in the American forces. Therapy for trench foot involved a number of conventional, tried-and-tested, and conservative methods. Some more innovative techniques were used. Amputation was only used as a last resort. Prevention involved general measures to improve the trench environment; modification of the footwear worn by the men; and the provision of greases to protect them from moisture. The medical reaction to this condition seems to have been relatively effective. The causation was identified, and prophylactic measures were introduced to fit this model; these seem to have been successful in reducing the prevalence of the condition by 1917-18.

Europe↗
PubMed2000

In-area and backcountry snowboarding: medical and safety aspects.

Snowboarding is now a well-established winter sport and a popular mode of mountaineering. In-area and backcountry snowboarding are defined, as well as a new term, glisse, that refers to all types of skis and snowboards. New developments in equipment focus on boot and binding systems. Backcountry travel is highlighted, including ascent with snowshoes, skis, a splitboard, and crampons. Injuries are about 4-6 per 1000 snowboarding days. Upper extremity injuries are most often wrist sprains or fractures. Lower extremity injuries are primarily ankle sprains and are generally less severe than knee injuries in skiers. Fracture to the lateral process of the talus has been called snowboarder's fracture. Backcountry injuries include avalanche suffocation and trauma, deep snow immersion asphyxiation, hypothermia, frostbite, dehydration, fatigue, acute mountain sickness, and sunburn. Specific recommendations for prevention and safety are discussed.

Ankle Injuries↗
PubMed2003

Peripheral responses to cold: case studies from an Arctic expedition.

OBJECTIVE: An Arctic expedition provided an opportunity to examine the interaction between cold injury and peripheral acclimatization. The conditions were similar to those during which acclimatization has been demonstrated, yet they were also conducive to development of peripheral cold injury. METHODS: Extremity digit temperatures were measured during 30-minute peripheral cold-water (4 degrees C) immersion (CWI) in 2 explorers (R.G. and T.L.) before and after a 109-day Arctic ski trek (average T(air) = -21 degrees C). This self-supported trek involved carrying heavy backpacks (up to 45 kg) and hauling sleds (approximately 100 kg). RESULTS: During the expedition, the explorers' hands did not sustain frostbite, but their feet developed moderate trench foot. Unexpectedly, both men exhibited lower mean finger temperatures during CWI after the expedition in right and left hands (R.G. by 0.9 degrees C and 0.2 degrees C; T.L. by 1.8 degrees C and 1.1 degrees C), suggesting peripheral acclimatization was impaired. In contrast, mean toe temperatures during CWI were warmer in both right and left feet for T.L. (by 3.6 degrees C and 2.3 degrees C) and in the left foot for R.G. (by 1.3 degrees C) postexpedition. There was no change in R.G.'s right toe mean temperature. CONCLUSIONS: We speculate that prolonged heavy load carriage may have impaired blood flow or nerve conduction in the hands and inhibited acclimatization. Our data also suggest that despite incidence of moderate trench foot, acclimatization can still occur after resolving this injury.

Acclimatization↗
PubMed2005

Spectrum of injuries from glacial sports.

OBJECTIVE: Glacial sports continue to be a popular form of wilderness activity, but no published studies have commented on this type of sport or focused on the injury patterns of glacial accidents. The objectives of this study were to investigate the types and frequency of injuries associated with a glacial-crevasse or ice-field fall. METHODS: The trauma registry data and radiology record system of a pediatric and adult level 1 trauma center were evaluated from January 1997 through August 2003. All admissions with injuries caused by a glacial-crevasse or ice-field fall were reviewed. RESULTS: During the 5 1/2-year period we identified 12 patients, of whom 9 (75%) were male. The average age was 30.2 years with an age range of 9 to 57 years. Six patients fell into glacial crevasses, and the other 6 slid down an ice field of a glacier. Leading diagnoses were head injury (44.6%), thorax injury (20.1%), and lower extremity injury (18.4%). Serious injuries were observed in 66.6% of the patients with a Glasgow Coma Scale of 3 to 8. CONCLUSIONS: A wide spectrum of injuries is associated with glacial accidents. They range from common extremity injuries with fracture or joint instability and peripheral frostbite to potentially life-threatening nonorthopedic trauma, which requires intensive clinical and radiological work-up. Injury prevention strategies should focus on wearing helmets to reduce head injuries and adequate clothing to forestall or prevent hypothermia, for these are the most severe and life-threatening injuries.

Adolescent↗
PubMed1996

Injuries in cross-country skiing: a critical appraisal of the literature.

This study comprehensively reviews and critically appraises recent literature on cross-country skiing injuries. Particular attention was paid to the study design when reviewing the literature, thereby producing a measure of internal and external validity. From these data, the factors associated with the aetiology, frequency, site distribution and types of cross-country skiing injuries are examined. The incidence of injury in cross-country skiing is estimated to be between 0.49 and 5.63 per 1000 skier days. The most common injuries are medial collateral ligament sprains of the knee, and ulnar collateral ligament sprains of the thumb. Overuse and cold injuries (e.g. hypothermia and frostbite) appear to be common as well, although the data do not provide an estimate of incidence. Comments in the literature on prevention of these injuries are mainly empirical: they recommend safer equipment, wise choice of terrain and a general increase in skier awareness of ways to prevent injury. However, rigorous studies that adequately evaluate preventive intervention strategies have yet to be conducted. Cross-country skiing is relatively safe and a suitable activity for physical fitness and rehabilitation. In the future, studies employing an analytical design will be required to evaluate the effectiveness of injury prevention intervention strategies.

Arm Injuries↗
PubMed2001

Potential applications of heat and cold stress indices to sporting events.

Many recreational and elite athletes participate in sporting events every year. However, when these events are conducted under hostile environmental conditions, whether in cold or hot climates, the risk for environmental illnesses increases. The higher the stress, the greater is the potential for performance decrements, injuries and illnesses. The most common expected heat illnesses are heat exhaustion and heatstroke, whereas hypothermia and frostbite are the most common cold injuries. However, heat and cold stress indices can minimise the risk for environmental illnesses and dehydration by following the recommendations and guidelines which accompany these indices. Stress indices should be used by athletes, coaches and officials to prevent injury and improve safety conditions for competitors and participants in recreational activities. All participants should be made aware of warning signs, susceptibility and predisposing conditions. Coaches should be aware of their responsibility with regard to the safety of their trainees, and officials should organise and plan events at times that are likely to be of low environmental stress. However, they must also be prepared and equipped with the means necessary to reduce injuries and treat cases of collapse and environmental illnesses. The lack of a friendly, small and simple device for environmental stress assessment is probably the main reason why stress indices are not commonly used. We believe that developing a new portable heat and cold stress monitor in wristwatch format for use by those exposed to environmental stress could help in the decision making process of expected hazards caused by exercising and working in hostile environments, and might help prevent heat and cold illnesses.

Cold Temperature↗
PubMed2002

Dermatologic disorders of the athlete.

The most common injuries afflicting the athlete affect the skin. The list of sports-related dermatoses is vast and includes infections, inflammatory conditions, traumatic entities, environmental encounters, and neoplasms. It is critical that the sports physician recognises common and uncommon skin disorders of the athlete. Knowledge of the treatment and prevention of various sports-related dermatoses results in prompt and appropriate care of the athlete. Infections probably cause the most disruption to individual and team activities. Herpes gladiatorum, tinea corporis gladiatorum, impetigo, and furunculosis are sometimes found in epidemic proportions in athletes. Vigilant surveillance and early treatment help teams avoid these epidemics. Fortunately, several recent studies suggest that pharmacotherapeutic prevention may be effective for some of these sports-related infections. Inflammatory cutaneous conditions may be banal or potentially life threatening as in the case of exercise-induced anaphylaxis. Athletes who develop exercise-induced anaphylaxis may prevent outbreaks by avoiding food before exercise and extreme temperatures while they exercise. Almost all sports enthusiasts are at risk of developing traumatic entities such as nail dystrophies, calluses and blisters. Other more unusual traumatic skin conditions, such as talon noire, jogger's nipples and mogul's palm, occur in specific sports. Several techniques and special clothing exist to help prevent traumatic skin conditions in athletes. Almost all athletes, to some degree, interact with the environment. Winter sport athletes may develop frostbite and swimmers in both fresh and saltwater may develop swimmer's itch or seabather's eruption, respectively. Swimmers with fair skin and light hair may also present with unusual green hair that results from the deposition of copper within the hair. Finally, athletes are at risk of developing both benign and malignant neoplasms. Hockey players, surfers, boxers and football players can develop athlete's nodules. Outdoor sports enthusiasts are at greater risk of developing melanoma and non-melanoma skin cancer. Athletes spend a great deal of time outdoors, typically during peak hours of ultraviolet exposure. The frequent use of sunscreens and protective clothing will decrease the athlete's sun exposure. It is critical that the sports physician recognises common and uncommon skin disorders of the athlete. Knowledge of the treatment and prevention of various sports-related dermatoses results in prompt and appropriate care of the athlete.

Anaphylaxis↗