Cases reported "Soft Tissue Injuries"

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1/60. Non-free osteoplasty of the mandible in maxillofacial gunshot wounds: mandibular reconstruction by compression-osteodistraction.

    We have treated 33 young men with medium to large (3-8 cm) bony and soft tissue defects of the lower third of the face caused by gunshot wounds. After debridement, collapsing the proximal segments for primary approximation of soft and hard tissues and a closed osteotomy of a small fragment of mandible, we used an original compression-distraction device, designed in 1982 and tested during 1983 (analogous devices were absent at that time) to reposition the mandible and cause callus to form (during distraction) between the fragment and to use the remaining stumps of bone to fill in the defect. The soft tissues were repaired at the same time. Twenty-eight of the patients presented within a few hours of injury, and the remaining five had old injuries. The only complications were in the group with old injuries where four patients developed abscesses that required drainage, but these did not interfere with the process of osteogenesis. All 33 patients had good functional and aesthetic results within 3-4.5 months. The method allows a bloodless minimally traumatic procedure which can be carried out in one stage. The results compare very favourably with the classic methods of the treatment of mandibular gunshot injuries.
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2/60. Treatment and stabilization of complex wounds involving the pelvic bone, groin, and femur with the inferiorly based rectus abdominis musculocutaneous flap and the use of power color Doppler imaging in preoperative evaluation.

    The authors present case reports demonstrating the trilevel utility of the inferiorly based rectus abdominis musculocutaneous flap in the closure of complex wounds involving the pelvis, groin, and femur that had failed previously or were not amenable to traditional closure techniques. The use of the rectus abdominis flap was especially advantageous for achieving infection eradication and large dead space closure. Additionally they present the emerging technique of power color Doppler imaging as a valuable tool in preoperative flap planning. This technique is particularly useful in evaluating the candidacy for rectus abdominis musculocutaneous flap placement of patients with a prior history of abdominal surgeries, trauma, infection, irradiation, or other conditions that might compromise the patency of the deep inferior epigastric vessels.
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3/60. Latissimus dorsi pedicle flap for coverage of soft tissue defects about the elbow.

    Sixteen consecutive patients who were treated with a pedicled latissimus dorsi flap for complex soft tissue defects about the elbow were reviewed. The average defect size was 100 cm2. Thirteen of the 16 patients achieved stable wound healing with a single procedure. Three patients had partial necrosis of the latissimus and required additional coverage procedures. We recommend that the latissimus dorsi flap should not be routinely used to cover defects more than 8 cm distal to the olecranon. The flap should be closely monitored in the first 48 hours, drains should be routinely used at the recipient and donor sites, and the elbow should be maintained in an extended position for the first 5 days after the procedure. The latissimus dorsi flap may also have a prophylactic role in selected patients with compromised soft tissue coverage about the elbow. The pedicled latissimus flap can be performed under loupe magnification and requires no microsurgical skills or equipment.
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4/60. Treatment of soft tissue defects in pediatric patients using the V.A.C. system.

    Twenty-seven consecutive pediatric patients presenting to the orthopaedic surgery or plastic surgery services were reviewed after completion of wound care with the vacuum Assisted Closure (V.A.C.) system. Each patient presented with complex soft tissue wounds requiring coverage procedures. patients with acute wounds and wounds present after nonsuccessful attempts at surgical closure (dehisced incisions and failed flaps) were treated. All soft tissue defects healed without extensive coverage procedures using the V.A.C. system. In the majority of patients, use of the V.A.C. system produced a profuse bed of granulation tissue over all exposed bone, tendon, joint, and/or hardware, which could be covered with split thickness skin graft. Other patients were treated successfully with delayed primary closure, local flap advancement (one patient underwent a pedicled cross-leg flap), or by secondary intention. Use of the V.A.C. device is valuable in increasing the rate of granulation tissue formation and healing of extensive soft tissue injuries in pediatric patients. This vacuum system aids in the debridement of necrotic tissue and local soluble inflammatory mediators that may inhibit the proliferation of granulation tissue. These improvements in the local wound environment seem to accelerate wound healing compared with traditional methods. Before the development of the V.A.C. system, a minimum of nine patients within this group would have required free tissue transfer to obtain adequate coverage. The V.A.C. device seems to permit earlier coverage with local tissue or split-thickness skin grafting techniques, thereby decreasing the need for extensive microvascular tissue transfers in pediatric patients.
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5/60. Temporoparietal fascial flap in orbital reconstruction.

    OBJECTIVE: To evaluate the success of the temporoparietal fascial flap (TPFF) in the primary or secondary reconstruction of difficult orbital defects and to review the surgical techniques. DESIGN: Retrospective analysis. SETTING: Tertiary medical center. patients: Nine patients with diverse orbital cavity or periorbital soft tissue and bony defects due to trauma, benign or malignant neoplasms, and radiation treatment. INTERVENTIONS: Temporoparietal fascial flap anatomy and techniques of harvest and inset are reviewed in detail. Four cases are presented to illustrate possible variables in orbital reconstruction. Variables examined include the location of defects, the success of flap survival in orbital cavities after primary or secondary reconstruction, the effects of prior irradiation on flap survival, and the possibility of concurrent osteointegrated implant placement with TPFF reconstruction. MAIN OUTCOME MEASURES: Functional and aesthetic outcomes were determined by physical examination and preoperative and postoperative photographs. RESULTS: All patients had successful transfer of TPFF grafts without flap compromise. Temporoparietal fascial flap was a viable option for subtle orbital and malar contour defects. In chronically inflamed wounds such as with osteoradionecrosis and orbitoantral fistula, TPFF successfully restored vascularity, obliterated the defects, and enabled the placement of osteointegrated implants. The TPFF also supported the concurrent placement of a free calvarial bone graft. Finally, split-thickness skin grafted onto a pedicled TPFF showed 100% survival. CONCLUSIONS: The TPFF is one of the most reliable and versatile regional flaps in the head and neck for orbital reconstruction. This study presents the use of TPFF in a variety of orbital defects, from lateral bony rim defects to total exenteration. Timing of repair in this study spans from immediate reconstruction to reconstruction delayed more than 50 years after the initial injury. In all cases, reconstruction with TPFF resulted in improved bony and soft tissue contours, and incurred minimal morbidity.
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6/60. Reconstruction of the achilles tendon and overlying soft tissue using antero-lateral thigh free flap.

    Reconstruction of combined loss of the achilles tendon and overlying soft tissue was performed using an antero-lateral thigh free flap in three patients. The cutaneous portion is used to cover the open wound, and a piece of fascia lata is utilised to replace the missing segment of the achilles tendon. The skin defect ranged from 5 x 2.5 to 7 x 5 cm, and the tendon loss measured from 3.5 to 5.5 cm in length. All of the patients showed satisfactory functional results with a follow-up period from 3 to 9 months. The advantages of the procedure are that: it is a single-staged operation; it promotes rapid healing of the tendo Achilles since the tendon substitute is well vascularised; it is adaptable to a wide range of defect sizes and shapes; it can be performed in the supine position without the need for postural change; and it can restore good contour and causes minimal morbidity at the donor site.
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7/60. limb salvage of lower-extremity wounds using free gracilis muscle reconstruction.

    An extensive series reviewing the benefits and drawbacks of use of the gracilis muscle in lower-extremity trauma has not previously been collected. In this series of 50 patients, the use of microvascular free transfer of the gracilis muscle for lower-extremity salvage in acute traumatic wounds and posttraumatic chronic wounds is reviewed. In addition, the wound size, injury patterns, problems, and results unique to the use of the gracilis as a donor muscle for lower-extremity reconstruction are identified. In a 7-year period from 1991 to 1998, 50 patients underwent lower-extremity reconstruction using microvascular free gracilis transfer at the University of maryland shock Trauma Center, Johns Hopkins Hospital, and Johns Hopkins Bayview Medical Center. There were 22 patients who underwent reconstruction for coverage of acute lower-extremity traumatic soft-tissue defects associated with open fractures. The majority of patients were victims of high-energy injuries with 91 percent involving motor vehicle or motorcycle accidents, gunshot wounds, or pedestrians struck by vehicles. Ninety-one percent of the injuries were Gustilo type IIIb tibial fractures and 9 percent were Gustilo type IIIc. The mean soft-tissue defect size was 92.2 cm2. Successful limb salvage was achieved in 95 percent of patients. Twenty-eight patients with previous Gustilo type IIIb tibia-fibula fractures presented with posttraumatic chronic wounds characterized by osteomyelitis or deep soft-tissue infection. Successful free-tissue transfer was accomplished in 26 of 28 patients (93 percent). All but one of the patients in this group who underwent successful limb salvage (26 of 27, or 96 percent) are now free of infection. Use of the gracilis muscle as a free-tissue transfer has been shown to be a reliable and predictable tool in lower-extremity reconstruction, with a flap success and limb salvage rate comparable to those in other large studies.
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8/60. Combined ingestion and subcutaneous injection of elemental mercury.

    A 40-year-old man with a history of schizophrenia and inflammatory soft tissue lesions after self-injection of elemental mercury presented to the Emergency Department. Multiple skin abscesses associated with fever required operative debridement. An incidental finding of oral mercury ingestion was followed clinically and did not result in complications. Exposure to elemental mercury through injection or ingestion is an uncommon event, but one the Emergency Physician may encounter. Subcutaneous mercury injection should be managed with local wound debridement, whereas ingestions are rarely of clinical significance.
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9/60. Severe, traumatic soft-tissue loss in the antecubital fossa and proximal forearm associated with radial and/or median nerve palsy: nerve recovery after coverage with a pedicled latissimus dorsi muscle flap.

    A total of 6 patients with complex, traumatic wounds of the antecubital fossa and proximal forearm were included in this study. All patients presented with radial and/or median nerve palsies in addition to their soft-tissue defect. Except for 1 patient with a 15-cm defect of the radial nerve, all other traumatized nerves appeared in-continuity at the time of surgery. However, the nerve injury was severe enough to induce wallerian degeneration (i.e., axonotmesis in traumatized nerves in-continuity). Three patients required brachial artery reconstruction with a reverse saphenous vein graft. Wound coverage was accomplished using a pedicled latissimus dorsi muscle flap, which was covered with a split-thickness skin graft. Successful reconstruction was obtained in all patients. Follow-up ranged from 2 to 6 years. The range of motion at the elbow and forearm was considered excellent in 5 patients and good in the remaining patient who had an intra-articular fracture. Motor recovery of traumatized nerves in-continuity was observed in all but 1 patient who had persistent partial anterior interosseous nerve palsy. The grip strength of the injured hand measured 70% to 85% of the contralateral uninjured hand. median nerve sensory recovery was excellent in all patients. The versatility of the pedicled latissimus dorsi muscle flap for coverage of these complex wounds with traumatized neurovascular bundles around the elbow is discussed.
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10/60. Peroneus brevis rotation flap: anatomic considerations and clinical experience.

    BACKGROUND: Large soft tissue defects of the distal third of the leg are common occurrences at trauma centers. Massive defects often require vascularized free tissue transfer for coverage; however, smaller defects may frequently be closed by rotation of local tissue. The peroneus brevis muscle is ideally located to provide coverage of the exposed distal fibula. methods: An anatomic dissection of the peroneus brevis muscle and its vascular pedicles was performed in 10 fresh cadaveric leg specimens. patients who underwent this procedure at our institution were retrospectively reviewed. RESULTS: Each dissected muscle had an average of 3.5 vascular pedicles (range, 2-6), which arose from the peroneal artery in all but two cases. The average distance of the distal pedicle from the tip of the lateral malleolus was 6.7 cm (range, 3.5-12.0 cm). The muscle belly ended an average of 6.0 mm proximal to the tip of the lateral malleolus. Half of the specimens had muscle bellies that extended to or past the tip of the lateral malleolus. This rotation flap has been successful in covering four wounds with exposed distal fibula in four patients. CONCLUSION: The anatomic characteristics of the peroneus brevis muscle are ideal for soft tissue coverage of the distal fibula. Ease of elevation and reliability have made this rotational flap the procedure of choice for small soft tissue defects over the distal fibula at our institution.
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