Abstract: Objective: Sulfur mustard (SM) is a bifunctional alkylating substance being used as chemical warfare agent (vesicant). It is still regarded as a significant threat in chemical warfare and terrorism. Exposure to SM produces cutaneous blisters, respiratory and gastrointestinal tract injury, eye lesions, and bone marrow depression. Victims of World War I as well as those of the Iran-Iraq war have suffered from devastating chronic health impairment. Even decades after exposure, severe long-term effects like chronic obstructive lung disease, lung fibrosis, recurrent corneal ulcer disease, chronic conjunctivitis, abnormal pigmentation of the skin, and different forms of cancer have been diagnosed. Methods: This review briefly summarizes the scientific literature and own results concerning detection, organ toxicity of SM, its proposed toxicodynamic actions, and strategies for the development of improved medical therapy. Results: Despite extensive research efforts during the last century, efficient antidotes against SM have not yet been generated because its mechanism of action is not fully understood. However, deeper insights into these mechanisms gained in the last decade and promising developments of new drugs now offer new chances to minimize SM-induced organ damage and late effects. Conclusion: Polymerase inhibitors, anti-inflammatory drugs, antioxidants, matrix metalloproteinase inhibitors, and probably regulators of DNA damage repair are identified as promising approaches to improve treatment.

Abstract: Wound repair is a complex integration of dynamic interactive processes involving cell-cell and cell-matrix interactions mediated by humoral messengers.1 These messengers that control the various cellular processes include cytokines, growth factors, and matrix metalloproteinases (MMPs).2 They regulate many of the processes that are crucial for wound healing, including chemotactic migration of inflammatory cells; mitosis of fibroblasts, keratinocytes, and vascular endothelial cells; neovascularization; and synthesis and degradation of extracellular components.3 The literature is replete with examples of effects of exogenous application of cytokines in animal models of both acute and chronic wounds.4 In all of these animal models, it has been suggested that wound healing would be enhanced by topical application of cytokines. Clinical trials have been performed for many of the cytokines and/or growth factors in both acute and chronic wounds.4 Unfortunately, the results of these trials have been largely disappointing, with only a single growth factor, platelet-derived growth factor (PDGF)-BB, being approved by the US Food and Drug Administration, and that was for a single indication, diabetic foot ulcers. There are several reasons why topical cytokine/growth factor therapy has failed.5 These include application of a single growth factor, application in large pharmaceutical doses, degradation of the peptide by proteases, and improper preparation of the wound. The application of a single growth factor may seem ill conceived. Normal wound healing is accomplished by a combination of cytokines, and they occur in a “natural“ cascade.6 Only a few attempts of combination or sequential cytokine therapy have been reported. Knighton et al7 used an autologous platelet releasate labeled as platelet-derived wound healing factors (PDWHF). Steed et al8 reported similar success with PDWHF. An extract of milk that contained insulin-like growth factor-1, PDGF, basic fibroblast growth factor, and transforming growth factor β (TGF-β) has been reported to be effective in accelerating healing inanimal models.9 The first wound healing clinical trial using sequential topically applied cytokines to accelerate healing was reported in 2000.10 The possible combinations or sequences for cytokines are endless. Moreover, attempting to determine levels of the various factors to include is formidable. The concept behind PDWHF was that the platelet releasate contained its cytokines in physiologic levels. Unfortunately, these levels were never critically examined, nor determined to be physiologic. Stem cells and stem cell–like multipotent cells are known to produce cytokine growth factors that serve as mediators to the cellular processes of the wound healing scheme.11 In a recent article, Xing et al12 demonstrated that amnion-derived multipotent progenitor cells increased gain of incisional breaking strength and decreased the incidence and severity of acute wound failure.12 They postulated that 1 possible mechanism for their results could be the effect of the cocktail of secreted cytokines from the cells. Cells in culture secrete factors, which may provide support to or affect the growth, differentiation, and protein production of other cells. These factors include cytokines, growth factors, chemokines, hormones, proteins, extracellular matrix, vesicles, receptors, antibodies, inhibitors, and granules. The purpose of this study was to determine the presence and levels of cytokines/growth factors in amnion-derived cellular cytokine solution (ACCS) and review the literature to determine the natural or physiological levels of these peptides in normally healing wounds.

Abstract: Smoke inhalation injury, either by itself or in the presence of a burn, is now well-recognized to result in severe lung-induced morbidity and mortality. The most common cause of death in burn centers is now respiratory failure.1–3 Overall, burn tragedies in history have markedly improved our knowledge of this injury (Table ​(Table1).1). Although smoke inhalation injury has been present since ancient times, it was probably the use of chemical warfare agents in World War I that first initiated the interest. Table 1 Notable events leading to smoke inhalation knowledge In 1915, the German army released aerosolized chlorine into the air toward the Allied troops. The response, upon breathing, was severe airway irritation with coughing, and severe exposure led to pulmonary edema and death. Filtering the gases with an activated charcoal filter removed the chlorine from the air,4,5 a method of decreasing lung damage. Phosgene gas, a component of smoke, was purified and also used as a chemical warfare agent along with mustard gas, also leading to lung damage.4 Phosgene is a common component of smoke today in any fire. The Cleveland Clinic Fire, in 1929, was caused by burning x-ray film. The cause of the many respiratory deaths was considered to be the released toxin, nitrogen dioxide, again a component of smoke in fires today.6 Skin burns were frequently absent and management of the lung injury became a priority for burn teams. The pulmonary pathology after smoke exposure was considered to be slough of the large- and small-airway mucosa causing obstruction to breathing. It was not until after the Coconut Grove Night Club Fire in 1942 that a surge of research in the pathophysiology of smoke inhalation developed.7,8 In this tragedy, hundreds of people were involved, many dying rapidly from apparent respiratory failure in the absence of burns. Others initially survived only to die later of what appeared to be pneumonia.7,8 Of importance was the fact that victims, not dead on arrival, appeared to be stable until 12- to 24-hours later, at which point the respiratory distress developed.7–9 Bronchial obstructions which developed, now recognized to be the result of the delayed airways mucosal slough, were caused by toxins that carried carbonaceous particles. Carbon monoxide poisoning was then well understood, so the initial use of oxygen was already established.9 By the mid-1940s, World War II was underway, and the risks of lung damage from closed-space fires were well recognized. Dr Oliver Cope, at the Massachusetts General Hospital, was instrumental in describing the pathology, time course, and the treatment of the severe cases of smoke inhalation injury. Respiratory assistance was recognized as a key factor in survival.9 The late effect on the airways and alveoli of smoke exposure was not yet appreciated, as ventilator assistance was not yet a tool used for longer-term survival. It was not until the use of blood-gas analysis in the late 1960s, that a clearer pattern of basic pathophysiology was determined along with the establishment of critical care medicine.10 The adult respiratory distress syndrome (ARDS) was also becoming recognized in the 1960s, and alveolar edema and collapse were recognized.11 It was still to be determined that smoke inhalation was mainly a large- and small-airway injury, although ARDS remained an alveolar damage process. Also, the role of bacteria in the lungs after inhalation injury became better recognized.12,13 A burst of research activity from the late 1970s and early 1980s better defined the chemical toxins found in smoke, including cyanide. Advances in the field of toxicology and the composition of aerosols provided the tools for research in the area. Identification of gas and particle phases of smoke and its components allowed for fairly accurate cause-and-effect hypotheses.11–16 The advances were followed by more active research on particle size and distribution in the lung. It was not appreciated until later that the particles carried gas phase toxins, which then deposited on the tracheal bronchial tree leading to the airways injury. The potentiating effect of a smoke injury on burn morbidity and mortality was well described in the 1980s. The mechanism of this potentiating effect still remains poorly understood.17–20 Overall, uncovering the physiologic changes in the lung evolved stepwise through fairly recent history (Table ​(Table22).21–23 Table 2 Historic progression of known physiologic changes in smoke injury Through the 1990s to the present, the research focus in this area has been to better define the biochemical and cell biologic changes, occurrence of which would explain the recognized physiologic changes. The products of airway inflammation, characteristics of smoke injury, have been of particular interest.24–29 Proinflammatory cytokines and free oxygen radicals have been demonstrated to play a significant role in both the lung and systemic response to smoke. More recently, apoptosis or programmed cell death has been found in the injured airways epithelium.28 The Station Nightclub Fire in Rhode Island in 2005 and the 9/11 World Trade Center tragedy in 2001 have led to a number of observations, stimulating further research.29,30 However, it is fair to state that the recently identified cell biologic and cell genetic changes have not yet altered the clinical management. The identified physiologic changes have, however, played a major role in improving management, thereby leading to a decrease in mortality and morbidity.

Abstract: Objective: Low-intensity currents (LIC) have gained popularity during the last years, and nowadays the majority of electrotherapy units may produce LIC. On wounding, the body produces a current, the current of injury, which promotes healing. Still, this current may gradually decrease resulting occasionally to delayed or limited wound healing. Thus, by applying the same LIC externally, healing may be accelerated by sustaining the LIC throughout the healing phases. The first review of research studies on the effect of LIC on wound healing is attempted, which can be considered useful for the practicing clinician, to provide an overview of current evidence on the effectiveness of LIC and provide protocols of treatment. Methods: Comprehensive review of randomized-controlled trials investigating the effect of LIC on wound healing. Results: The review revealed that LIC promote wound healing and appear to be effective in the range of 200–800 μA. The direct current may be continuous or pulsed and polarity may or may not be reversed. Conclusion: Research available indicates that LIC accelerate wound healing. Further research is required to clarify the healing effects of LIC on wounds.

Abstract: Objective: Magnets are purported to aid wound healing despite a paucity of scientific evidence. The purpose of this study was to evaluate the effect of static magnetic fields on cutaneous wound healing in an animal model. The literature was reviewed to explore the historical and scientific basis of magnet therapy and to define its current role in the evidence-based practice of plastic surgery. Methods: Standardized wounds were created on the backs of 33 Sprague-Dawley rats, which were divided into 3 groups with either a 23 gauss magnet (group 1), a sham magnet (group 2), or nothing (group 3) positioned over the wound. The rate of wound closure by secondary intention was compared between the groups. Literature review was conducted through searches of PubMed and Ovid databases for articles pertinent to magnets and wound healing. Results: Wounds in the magnet group healed in an average of 15.3 days, significantly faster than those in either the sham group (20.9 days, P = .006) or control group (20.3 days, P < .0001). There was no statistically significant difference between the sham and control groups (P = .45). Conclusions: An externally applied, low-power, static magnetic field increases the rate of secondary healing. Review of the literature reveals conflicting evidence regarding the use of magnetic energy to aid the healing of bone, tendon, and skin. Level I studies are lacking and difficult to execute but are needed to define conclusively the role of magnets in clinical practice.

Abstract: Objective: The treatment of hyperhidrosis, generalized or focal is a challenge for both physicians and surgeons. Focal hyperhidrosis—axillary, palmar, plantar, craniofacial—is the most common. Generalized hyperhidrosis is usually secondary to a systemic disorder or may be simply drug induced. Focal hyperhidrosis has its onset in childhood or adolescence and has a dramatic effect on one's quality of life. Medical, surgical, and electrical therapies can be employed to relieve hyperhidrosis in most patients. Methods: A review of the medical and surgical literature was performed to identify the usual causes and remedies for hyperhidrosis. Results: Specific treatments, medical and surgical are recommended for all affected individuals. Conclusion: Patients with hyperhidrosis need not suffer in silence. Etiologies can be identified for most. Safe and effective therapeutic options are available.

Abstract: Objective: The lack of adequate means to objectively characterize cranial shape contributes to ongoing controversies in the surgical management of craniosynostosis. Cranial shape analysis must address relevant clinical questions objectively and thoroughly and must be broadly applicable across the spectrum of normal and abnormal. Herein, we demonstrate and statistically validate an automated computed tomography (CT)-based application for 3-dimensional characterization of skull morphology. The technology is intended for application to diagnostic imaging, surgical planning, and outcomes assessment. Methods: Three-dimensional vector analysis (3DVA) was applied to craniofacial CT data, generating three-dimensional cranial surface point clouds. Validation: To assess accuracy, measurements derived from the 3DVA analysis of a CT scan of a skull phantom were compared to those made directly from the Digital Imaging and Communications in Medicine data on a Vitrea workstation. To assess reproducibility, 3 readers independently analyzed human head CT scans using 3DVA. Application: A normative database of 86 age-incremental pediatric patients was created. Preoperative craniosynostosis case datasets were analyzed using 3DVA and were compared with age-matched normative datasets. Results: Accuracy and reproducibility of less than 1% mean error and less than 0.5 mm standard error in all cases validated 3DVA-derived distances. Three-dimensional vector analysis point clouds provide qualitative and quantitative representations of morphology. Regional dysmorphology in craniosynostosis cases is demonstrated graphically. Conclusions: Three-dimensional vector analysis generated accurate, reproducible, and comprehensive craniofacial morphometric data. 3DVA may be used for paired data analysis (eg, a single subject undergoing surgical correction), comparative group data analysis, and craniofacial data archiving. The technique can provide objective characterization of craniofacial morphology previously not possible.

Abstract: Objective: Growth factors demonstrate mixed results improving wound healing. Amnion-derived multipotent cells release physiologic levels of growth factors and tissue inhibitors of metalloproteinases. This solution was tested in models of acute and chronic wound healing. Methods: Acute model: Sprague-Dawley rats underwent laparotomy incisions. The midline fascia was primed with phosphate-buffered saline, unconditioned media, or amnion-derived cellular cytokine suspension prior to incision. Breaking strength of laparotomy wounds was tested with an Instron tensiometer. Incisional hernia formation was measured after 28 days. Chronic model: Chronic, infected granulating wounds were produced in rats by excising full thickness burn eschars inoculated with Escherica coli. Granulating wounds were treated with unconditioned media or amnion-derived cellular cytokine suspension. Treatments were applied either on day 0 and day 7 or day 0 and then every other day. Wounds were traced every 72 hours and biopsied for quantitative bacteriology. Results: Acute model: Priming with amnion-derived cellular cytokine suspension increased the breaking strength of laparotomy incisions in comparison with phosphate-buffered saline or unconditioned media (P < .05). Acute wound failure and incisional hernia formation was 100% in the phosphate-buffered saline and unconditioned media groups and 18% in the amnion-derived cellular cytokine suspension–treated group (P <.05). Chronic model: The rate of wound closure was accelerated in amnion-derived cellular cytokine suspension–treated chronic wounds (P < .05). Multidosing improved the effect. Conclusions: A physiologic solution of cytokines and tissue inhibitors of metalloproteinases improves healing in models of acute and chronic wounds. Such a cocktail can be produced from amnion-derived multipotent progenitor cells.

Abstract: Debridement is one of the essential tools of wound management.1 It is defined as the removal of nonviable material, foreign bodies, and poorly healing tissue from a wound, and it facilitates the processes of granulation, contraction, epithelialization, and healing. The most direct form of debridement is surgical excision, although other reasonable options exist for patients who are poor surgical candidates or who have wounds in need of less aggressive debridement. These alternative debridement options include the following: mechanical debridement, which is exemplified by wet to dry dressings or pressure irrigation; autolytic debridement, in which occlusive dressings allow wound proteases to liquefy necrotic tissue; biologic debridement, which utilizes maggot therapy; and enzymatic debridement, which utilizes agents such as collagenase or papain-urea. Collagenase has been shown to be useful for degredation of collagen and elastin but not fibrin. Papain-urea's main action is to solubilize fibrin. Numerous enzyme preparations have been investigated and used clinically since the 1940s.2 It has been reported that proteolytic enzyme treatment of wounds with substantial bacteria bioburden is unsafe unless treated in conjunction with topical antimicrobials. These enzymatic agents demonstrated rapid eschar degradation but allowed for significant bacterial proliferation and invasion.5–5 These reports were based on studies indicating that enzyme-treated wounds were associated with increased bacterial counts as well as studies indicating that topical enzyme treatment of burn wounds was associated with the development of burn wound sepsis. The potential for systemic sepsis could be reduced by concomitant use of topical antimicrobial agents along with the topical enzyme treatment regimen.2,3 Collagenase and papain-urea are frequently utilized, when indicated, for chronic wound care, yet the effects of enzymatic debriding agents on the microbiology of chronic-infected wounds has not been extensively characterized. Wound preparation methods are necessary to manage wound healing in an effort to accelerate healing and allow for complete closure secondarily, or to prepare for surgical closure.6 Frequent sharp debridement has been shown to accelerate wound healing and it has been postulated that enzymatic wound debridement may therapeutically benefit wound healing in a similar way.1,6 This study evaluates the microbiological effects of the actions of collagenase or papain-urea in a chronically infected wound model.

Abstract: Objective: Human skin is a complex bilayered organ that serves as a protective barrier against the environment. The loss of integrity of skin by traumatic experiences such as burns and ulcers may result in considerable disability or ultimately death. Therefore, in skin injuries, adequate dermal substitutes are among primary care targets, aimed at replacing the structural and functional properties of native skin. To date, there are very few single application tissue-engineered dermal constructs fulfilling this criterion. Silk produced by the domestic silkworm, Bombyx mori, has a long history of use in medicine. It has recently been increasingly investigated as a promising biomaterial for dermal constructs. Silk contains 2 fibrous proteins, sericin and fibroin. Each one exhibits unique mechanical and biological properties. Methods: Comprehensive review of randomized-controlled trials investigating current dermal constructs and the structures and properties of silk-based constructs on wound healing. Results: This review revealed that silk-fibroin is regarded as the most promising biomaterial, providing options for the construction of tissue-engineered skin. Conclusion: The research available indicates that silk fibroin is a suitable biomaterial scaffold for the provision of adequate dermal constructs.

Abstract: Objective: Millions of patients are treated annually in the United States, United Kingdom, and Germany with either acute or chronic wounds. The purpose of this study is to compare how the medical education systems in the United States, Germany, and United Kingdom have prepared their physician trainees to deal with clinical issues of wounds. Methods: A retrospective study was performed in the United States by obtaining medical school curriculum data from the American Association of Medical Colleges, 2005. In the United Kingdom, data were obtained from the individual medical schools listed in the Royal Society of Medicine. In Germany, data were collected from a questionnaire sent to all the medical schools. Results: The total hours of required wound education received in the United States was 9.2 hours in the 4 years of medical school. In the United Kingdom, the total time devoted to wound-related issues equaled 4.9 hours over 5 years. In Germany, a total of 9 hours of wound education was provided over 6 years. Conclusions: Chronic wounds represent a serious problem for patients in terms of quality of life, lost employment time, and loss of income. Our comparison of the required wound education among the medical schools of United States, United Kingdom, and Germany demonstrated that all 3 systems are deficient in preparing future physicians to treat wound problems. We recommend that medical schools throughout the world devote a portion of their core curriculum to educating student physicians in the understanding of wound pathophysiology and treatment.

Abstract: The Short Form McGill Pain Questionnaire (SF-MPQ) is an abbreviated version of McGill Pain Questionnaire (MPQ) developed for pragmatic reasons to improve the clinical utility of the MPQ. Although the SF-MPQ has been used in more than 250 published studies, few studies have examined the core constructs it measures. The objective of this study was to evaluate in a sample with burn injuries whether the factor structure of the SF-MPQ is consistent with the theoretic pain constructs it purports to measure. Participants (n = 338) met American Burn Association's criteria for major burn injury and had a mean total body surface area burned of 14%. They were mostly male (70.1%) and Caucasian (63.4%) with an average age of 41.25 years. There were 2 primary findings. First, confirmatory factor analysis yielded fit index values demonstrating viability of a 2-factor, oblique, solution composed of sensory and affective latent constructs. These findings were consistent with previous work and the theoretic constructs. Second, results from a relatively new model consisting of 8 SF-MPQ items demonstrated potential viability for measuring similar constructs.

Abstract: Background: The nail gun is a commonly utilized tool in carpentry and construction. When used properly with appropriate safety precautions, it can facilitate production and boost efficiency; however, this powerful tool also has the potential to cause serious injury. The most common site of nail-gun injuries in both industrial and nonoccupational settings is the hand. Materials and Methods: We report on two patients with nail-gun injuries to the hand. A review of the literature and discussion of clinical evaluation and treatment of nail-gun injuries to the hand are presented. Results: Two patients present with soft tissue injuries to the hand with the nail embedded and intact at the injury site. Operative removal of the nail and wound care resulted in successful treatment in both cases. Nail-gun injuries to the hand vary in severity on the basis of the extent of structural damage. Treatment is based on the severity of injury and the presence and location of barbs on the penetrating nail. Conclusion: Healthcare providers must understand and educate patients on the prevention mechanics of nail-gun injuries. Nail-gun injuries to the hand necessitate appropriate evaluation techniques, understanding of surgical management versus nonsurgical management, and awareness of potential pitfalls in treatment.

Abstract: Background: Burn injuries are among the most devastating injuries seen in the emergency units. The epidemiology of this injury varies from one part of the world to another. This is a 3-year report in an attempt to provide information on the current epidemiology of burns in this center. Method: Patients admitted into the University of Calabar Teaching Hospital, with burn injuries were prospectively studied between February 2005 and January 2008. Results: The 59 patients (33 males and 26 females) accounted for 3.7% of trauma patients and their ages ranged from 15 to 70 years (mean 29.4 years). Flame burn was the commonest injury seen in 48 (81.3%) patients because of petrol and kerosene, whereas chemical burn that involved 7 (11.9%) patients ranked second. Morbidity included burns wound infection in 13 (22%) patients and contractures in 6 (10.2%) patients. The outcome was fatal in 15 (25.4%) patients. Conclusion: The establishment of burn support groups dedicated to publicity on prevention based on areas of risk highlighted in this study and provision of financial aid as well as provision of modern burn care facilities would improve outcome.

Abstract: De Quervain's disease is a common cause of wrist pain and disability. Tendon entrapment of the first dorsal compartment can be managed with conservative or surgical modalities.1 Treatment strategies include immobilization, corticosteroid injections, and operative release. Successful nonoperative management with corticosteroid injections has been demonstrated repeatedly in 50% to 80% of patients,2–4 particularly in acute cases.5 Maintaining a high level of success with corticosteroid injections may depend on our knowledge of the first dorsal compartment for precise needle placement. In this study, we propose the use of identifiable bony landmarks in the radial aspect of the wrist for proper location of the first dorsal compartment. Numerous anatomic and surgical studies have shown great variability in tendon structure and organization of the first dorsal compartment.6–10 Septations within the osteofibrous tunnel and slip multiplicity of the abductor pollicis longus (APL) have all been raised as possible causes of de Quervain's tenosynovitis,11 or causes for failed steroid injections.6 Despite the multitude of anatomic studies, none have addressed the need for clear anatomic landmarks required for successful injection. We report our measurements of bony landmarks for the first dorsal compartment and their application to the nonoperative management of de Quervain's disease.

Abstract: Objective: Capsular contracture is a common complication associated with reconstructive breast surgery. The optimal time interval between the completion of tissue expansion and placement of the permanent implant is arbitrary and incompletely studied in the literature. The aim of the study was to determine whether the time interval between completion of expansion and placement of the permanent implant would affect the incidence of capsular contracture. Methods: We conducted a retrospective study of 112 patients with breast cancer, including 140 breasts, who underwent postmastectomy tissue expander placement between 1997 and 2004. All patients underwent replacement of tissue expander with a permanent prosthesis. Data were collected retrospectively, including whether the patient smoked, underwent radiation therapy, had saline or silicone implant reconstruction, required reoperation after tissue expander placement or after permanent implant placement, Baker classification, and the interval between completion of expansion and placement of permanent implant. Results: We used a logistic regression model to incorporate the predictors of capsular contracture. Keeping all other predictors constant, we found that the time interval between implant exchange had no effect on capsular contracture. The only significant predictor of capsular contracture was whether the patient required a reoperation after the permanent implant was placed (P = .0001). Conclusions: Allowing the capsule around a tissue expander to mature does not significantly affect development of capsular contracture. However, a complication that necessitates disrupting the periprosthetic capsule of the permanent implant with an operation significantly increases odds of developing contracture.

Abstract: Background: The posterior interosseous nerve (PIN) can be difficult to locate within the radial tunnel. The deep branch of the radial nerve (DBRN) enters the supinator muscle after passing under the arcade of Frohse. It courses through the superficial portion of the supinator muscle to exit distally as the PIN. Anatomic landmarks could facilitate diagnosis and treatment of radial tunnel syndrome and aid in the injection and decom- pression of the radial nerve. Methods: Eighteen cadaveric arms were used to identify anatomic landmarks to facilitate location of the PIN. The landmarks used include the palpable proximal radial edge of the radial head, proximally, and the mid-width of the wrist, distally. The skin was incised along this longitudinal line through the fascia. Deep within this plane the PIN was identified exiting the distal edge of the superficial portion of the supinator muscle. The proximal and distal edges of the supinator muscle were measured from the proximal radial aspect of the radial head. In addition, the course of the DBRN was appreciated proximal and distal to the superficial part of the supinator muscle. Results: The PIN was identified to exit the superficial part of the supinator muscle at an average distance of 7.4 ± 0.4 cm distal to the proximal radial aspect of the radial head. Distal to the distal edge of the supinator muscle, the PIN passed along a longitudinal vector from the radial head to the mid-width point of the wrist. From within the supinator muscle the DBRN courses retrograde in an oblique direction toward the lateral edge of the distal most part of the biceps tendon. Conclusion: The anatomic landmarks of the radial head and the mid-width of the dorsal wrist can be used to predict the course and location of the PIN. The DBRN can be predicted to enter the superficial part of the supinator muscle approximately 3.5 cm distal to the radial head, and the PIN is predicted to exit the supinator at 7.5 cm distal to the radial head.

Abstract: Objective: Sulfur mustard (SM) causes blisters on the human skin. These blisters delay healing of the skin and make the victims more susceptible to infection. In vitro models have been used for protection studies against SM injury, but study on wound healing after SM exposure has not been explored. The purpose of this study was to test whether the addition of exogenous growth factors could improve the rate of SM wound healing. Methods: The model consisted of normal human epidermal keratinocytes seeded into 6-well plates, exposed to SM, and wounded (disruption of the cell monolayer) with a sterile wounding instrument. Cells were then stained and images were captured to measure percentage wound fill. Epidermal growth factor (EGF) and keratinocyte growth factor (KGF) were tested in this model. Results: EGF (1 ng/mL) significantly increased wound fill on all of the days tested (days 6, 9, and 12). KGF did not significantly improve wound healing. Conclusions: EGF showed promise as a potential therapy for SM-induced wounds. This in vitro model was a valuable tool for screening therapeutics before animal testing. These results will be used to develop a dressing that can slowly release EGF on to a debrided wound bed to help speed the healing process.

Abstract: Nodular fasciitis is defined by the World Health Organization as a benign and reactive fibroblastic growth extending from the superficial fascia into the subcutaneous tissue or muscle.1 It is a tumor-like spindle-cell lesion that is often mistaken for a sarcoma as a result of its rapid growth, rich cellularity, and mitotic activity.2 The proliferating tissue is fundamentally composed of myofibroblasts, which are commonly found in granulation tissue, arterial intima, the stroma of desmoids, fibromatoses, angiofibromas, and soft-tissue sarcomas.3 Nodular fasciitis presents as a rapidly growing mass, occasionally with pain or tenderness. The treatment is complete excision and recurrence is rare. They are generally small, solitary, equally distributed between genders, and more common in the third to fifth decades of life.4 Lesions are commonly located on the extremities, occasionally on the trunk, and infrequently on the head and neck. Lesions in the orofacial region are rare but, when they do occur, are most commonly located in the skin of the face, parotid gland, buccal mucosa, labial mucosa, and tongue.5 We present an unusual presentation of a facial nodular fasciitis on an infant.

Abstract: Open intra-articular fractures of the distal humerus are frequently the result of a high-energy trauma. These injuries can be associated with severe bone and articular cartilage fragmentation, extensive soft tissue damage, and concomitant injuries, which may jeopardize limb integrity and patient survival. Because of the complexity of injury, treatment is generally difficult, and subsequent clinical outcome is often poor.1,2 A case of complete medial column bone loss of the distal humerus after an open elbow fracture and the final outcome after reconstruction via a free vascularized osteocutaneous fibular graft are presented.

Abstract: The chemical warfare (CW) agents lewisite (dichloro [2-chlorovinyl] arsine) and sulfur mustard (bis[(2-chloroethyl]sulfide) have been weaponized and stockpiled in a number of countries around the world.1 Although the military use of both compounds is primarily as incapacitants because of their potent vesicant activities, they can also induce a range of toxic pathologies that result in death if exposure is high enough. In historical reports that recount experimental work with these CW agents, it is unusual for the synthetic process by which the munitions-grade products were produced (resulting in varying compositions of the test agents) to be identified. In addition, these records seldom state whether the material used was distilled to produce a higher-purity test article. Therefore, for the purposes of this overview, when it is not possible to identify what the makeup of the actual test agents is, we will refer to them as either sulfur mustard or lewisite, and the distilled products as “HD” and “L,” respectively. Since its first use in 1917 by the Germans at Ypres, Belgium, sulfur mustard has been utilized in a number of military conflicts. It has well-documented cytotoxic,2 mutagenic,3,4 and vesicant properties.5,6 At very high exposures, sulfur mustard also induces profound systemic effects,7–9 which include the classic signs of a strong alkylating poison as well as a shock-like syndrome that does not respond to treatment.10,11 Other than its well-understood antimitotic effects, the mechanism of toxic action of this CW agent is unknown, and antidotes do not exist against its action.1,2,12,13 Lewisite was the result of American efforts to develop an arsenical vesicant to counter German gas use during World War I. After an extensive research program, it was identified as the lead candidate and weaponized in 1918.14 The toxicity and vesicant activity of this compound in comparison with that of HD is unclear from the historical literature, with a variety of reports describing it as having less-to-more vesicant activity.14 What is clear, however, is that lewisite is a rapid acting and powerful vesicant and its arsenical makeup renders it a potent cytotoxin and blood poison.15 In contrast to sulfur mustard, antidotes against this potent vesicant have been developed. British anti-lewisite16 as well as other less toxic, more water-soluble chelators17–21 have been shown to be effective in preventing lewisite toxicity. Lewisite has not been convincingly documented as being used in the battlefield1 and its utility as a CW agent has been debated.14 Nevertheless, it has been extensively weaponized as a mixture with sulfur mustard, ostensibly to lower the freezing temperature of the latter compound. Undoubtedly, use of this CW mixture would result in painful and difficult-to-treat tissue injury, which heals slowly. The modulatory effects of temperature on the toxicity of xenobiotics have long been a topic of investigation. During the early part of the last century, the toxicity of colchicine was shown to be dramatically temperature dependent, with its lethality in frogs increasing several hundred folds with only a 12°C increase in temperature.22 Subsequent work showed that a large variety of drug actions were temperature dependent and by 1961, a review article identified more than 300 citations in this area.23 Indeed, there is a wealth of information available on how temperature modulates the metabolism, distribution, and excretion of a wide range of currently used pharmaceuticals as well as the toxicity of selected xenobiotics.23–25 Although this research area does not seem to have been as broadly active in recent years, the effects of both hypothermia and hyperthermia have been the topics of interest with respect to improving the efficacy of some cancer chemotherapies.26–28 Tissue culture studies have shown the increased toxicity of a number of compounds (notably alkylating agents such as Melphalan) with increased temperature. These studies have led to successful clinical trials, using chemotherapy and hyperthermia. Although the success of some of these trials has shown the utility of this approach, the mechanism(s) by which hyperthermia enhances the toxicity of these drugs is unclear, although a number of hypotheses have been advanced, including enhanced membrane permeability, increased metabolic activation to toxic species, increased rate of hydrolysis, increased blood flow, and increased rate of reaction of the drug with critical macromolecules.29–31 In this report, we briefly compare the toxicities of lewisite and sulfur mustard both in vitro and in vivo and also provide an overview of historical and recent work on the effect of temperature on the toxicity of these vesicating CW agents.

Abstract: The use of autologous grafts in aesthetic and reconstructive surgery has become increasingly common, especially with the growing popularity of fat and cartilage autografts in facial and nasal surgery. However, as with any technique innovation, the benefits come with some potential risks. Since contaminated grafts have the potential to grow bacteria, patients who receive them are theoretically placed at increased risk for infection. This study was designed to survey plastic surgeons on their practices following inadvertent contamination of autografts. A literature review also was conducted to learn what others recommend for handling such incidents. The survey results and published literature provide a basis for developing algorithms intended to guide surgeons in managing the contamination of a variety of autograft types used in plastic surgery.

Abstract: Chronic pressure ulcers are a significant health problem, especially in elderly individuals and individuals with spinal cord injury or other debilitating illness that render them immobile. Chronic open wounds often require many months of treatment and reduce the quality of life of already ill patients. Traditional treatment modalities of pressure ulcers include the use of support surfaces, position changes, nutrition balancing, frequent dressing changes, hydrotherapy, surgical debridement, and surgical reconstruction. Progress generally is slow and often incomplete. All too often amputation becomes the only alternative. Pressure ulcers present an enormous financial burden for the healthcare system as well as for patients. Pelham et al1 noted that although specific costs associated with pressure ulcers are difficult to determine because of comorbidities in chronically ill individuals, in-hospital care of patients with pressure ulcers costs 50% more than care for patients without ulcers. Hirshberg et al2 reported an average hospital charge of $48,934 per patient for treatment of ulcers, which did not include the treatment before hospitalization or the cost of pharmaceuticals. Other studies estimate treatment costs in the billions of dollars per year in the United States.3,4 A need exists for an effective treatment that decreases the healing time and severity of ulcers, is easy to use, and is cost-efficient. We report a case of a quadriplegic patient with 3 large, long-standing (years) stage~III and IV pressure ulcers that were treated with pulsed radio frequency energy (PRFE).5 Previous in vitro studies have suggested that this system may be beneficial in the reparative process of chronic wounds.5,6

Abstract: Background: The third common digital nerve (TCDN) has been described as the most commonly injured digital nerve during carpal tunnel release (CTR). Anatomic variations of the origin and course of the TCDN from the median nerve may place this structure at risk. Anatomic landmarks may be useful to predict the location of the TCDN to minimize the risk for injury to this structure during CTR. Methods: Twenty cadaveric hands were used to determine the origin and course of the TCDN. The origin of the TCDN from the median nerve was identified in relation to the transverse carpal ligament (TCL), cardinal line, and superficial palmar arch. The course of the TCDN was inspected in relation to the scaphoid tubercle and ring finger. Results: Three specific anatomic variations for the origin of the TCDN were identified: type 1 originating proximal to the distal edge of the TCL (3 of 20 patients), type 2 originating distal to the TCL but proximal to the superficial palmar arch (14 of 20 patients), and type 3 originating distal to the TCL and at or distal to the superficial palmar arch (3 of 20 patients). The origin of the TCDN was measured as an average of 5.0 ± 1.2 mm distal to the cardinal line. The TCDN coursed along an oblique vector from the scaphoid tubercle to the midpoint of the palmar digital crease of the ring finger for type 2 or type 3 variations. Near the cardinal line, the oblique course of the TCDN traverses the vector of thelongitudinal incision used for CTR. Conclusion: The TCDN is one of the most frequently damaged neurological structures during CTR. Iatrogenic injury to this structure can be disabling and even devastating to patients. A detailed knowledge of the carpal tunnel and its underlying structures can prevent inadvertent injury to the TCDN. Anatomic landmarks to predict the origin and the course of the TCDN allow the surgeon to preoperatively predict the possible locations and paths of this important structure. This information can prove to be useful in avoiding injury to the TCDN by clinicians performing CTR in their practice, whether via the open or via endoscopic technique.

Abstract: Objective: To audit the referral patterns of burns in an emergency department compared with national referral guidelines. Methods: A retrospective case note audit of patients attending an emergency department with a diagnosis of “burn” in a 1-year period. Results: Only one quarter of the patients were managed according to the suggested national referral criteria for burns. Large and full thickness burns were managed appropriately but those at important anatomical sites and in patients at the extremes of age were managed less well. Conclusion: Increased awareness of the national referral guidelines, along with further education of staff within this department, may improve management of burn injuries. It is likely that referral patterns are similar in other emergency departments and may be improved by training staff in the assessment and management of burns. Increased adherence to the guidelines is likely to improve patient outcome at the expense of increased patient numbers and workloads in regional burns units that have implications for funding and service provision.

Abstract: Objective: Sharp division of the A1 pulley is a time-honored technique for the treatment of flexor tendon entrapment; however, this procedure is not without complications The anatomy of the A1 pulley system has been carefully investigated Knowledge of superficial anatomic landmarks can assist with demarcating the distal edge of the A1 pulley and prevent damage to the critical A2 pulley Methods: Nine fresh cadaveric hands were dissected with the aid of loupe magnification On the basis of known anatomic landmarks of the proximal portion of the cruciate (C0) pulley, percutaneous placement of a 25-gauge needle 5 mm proximal to the palmar digital crease marked the distal extent of the trigger finger release Sharp division of the A1 pulley was performed with a scalpel until the needle was encountered, thus completing the release Results: A complete release of the pulley was achieved in all specimens with preservation of the A2 pulley No digital nerve or artery injuries were noted with open inspection of the flexor sheath Conclusion: Percutaneous marking of the distal extent of the A1 pulley is a safe and reliable method that not only ensures complete release of the A1 pulley but also preserves the A2 pulley The placement of a small gauge needle adds no morbidity to this minimally invasive technique

Abstract: Objective: This study aims to contextualize an unintended intraoperative electrocautery burn that occurred on our service within the spectrum of all intraoperative electrocautery burns. Methods: A case report of the incident was drafted, and the relevant literature present in PubMed and industry publications was reviewed. Results: Intraoperative electrocautery burns can be divided into 4 categories: (1) direct contact burns resulting from inappropriate operator use of the active electrode, (2) burns at the grounding electrode site due to improper attachment or placement, (3) burns resulting from electrode heating of pooled solutions, and (4) burns occurring outside the operative field as a result of circuits generated between the active electrode and an alternate grounding source. We herein report an unintended intraoperative electrocautery burn of the fourth category. An aberrant intraoperative circuit utilized previously placed in-dwelling titanium plating in the patient's right brow as the grounding electrode, resulting in 3 × 3-cm full-thickness skin necrosis overlying the site of hardware implantation. Conclusions: Literature recommendations to reduce this type of electrocautery burn suggest avoiding grounding pad placement on the forearm and lateral thigh, although further investigation is needed to determine optimal grounding electrode placement with respect to known indwelling hardware.

Abstract: Objectives: The objective of this study is to introduce modifications in paraspinous muscle flap surgery and compare this new variation's ability to salvage infected hardware with the classic technique. Infected posterior spine wounds are a difficult problem for reconstructive surgeons. As per experience, hardware retention in infected wounds maintains spinal stability, decreases length of stay, and decreases the wound healing complication rate. Methods: An 11-year retrospective office and hospital chart review was conducted between July 1996 and August 2007. All patients who underwent paraspinous muscle flap reconstruction for postspine surgery wound infections during this time period were included. There were 51 patients in the study representing the largest reported series, to date, for this procedure. Twenty-two patients underwent treatment using the modified technique and 29 patients were treated using the classic technique. Results: There was no statistical difference between the 2 groups in demographics, medical history, or reason for initial spine surgery. The hardware salvage rate associated with the modified technique was greater than the rate associated with the classic technique (95.4% vs 75.8%; P = .03). There were fewer postreconstruction wound healing complications requiring hospital readmission in the modified technique group than the classic group (13.6% vs 44.8%; P = .04). Patients in the modified technique group demonstrated a shorter mean length of stay than the patients in the classic group (23.7 days vs 29.7; P = .25). Conclusions: The modified paraspinous muscle flap technique is an excellent option for spinal wound reconstruction, preservation of spinal hardware, and local infection control.

Abstract: Background: Keloids are characterized by excess collagen deposition within the dermis. Although the exact cause of the potentially overactive fibroblasts has yet to be elucidated, many etiological possibilities have been suggested. As fibroblasts originating from keloids appear to have an increased migration and proliferation rate, cell-signaling studies examining these factors may offer an opportunity to further our understanding of the pathogenesis of this disease. One of such cell-signaling messengers is the enzyme Ras-related C3 botulinum toxin substrate (RAC), which has never been investigated in keloid scars. Objective: This study explores the role of RAC activity in keloid disease. Method: Primary fibroblast cell lines were established from the margin of keloid (KF) scars as well as from the surrounding normal tissue (NF) from one anatomical site of the same patient. Migration and proliferation assays were performed, comparing matching NFs and KFs, and after cell lysis, RAC activity was assessed. Results: Comparing fibroblasts from 3 different patients, KFs migrated (P < .05) and proliferated (P < .05) faster than NFs. The activity levels of RAC were increased in KFs compared with NFs. Conclusion: KFs migrate and proliferate faster than NFs. RAC activity increases in KFs when compared with NFs. Inhibition of RAC could lead to a new therapeutic approach.