Friday, February 29, 2008

Another QOV

I added a border to the Snail's Tail quilt top posted earlier this year (see here). It is now 60 in square. I will be sending it to the Quilts of Valor Foundation to be used for a wounded soldier. It is interesting how a border can change a quilt. I think it looks much better with the simple border than without. It is machine pieced and machine quilted.

A close-up view.



Thursday, February 28, 2008

University of Arkansas Physics Centennial

I am more excited than I should be to be attending the 100th Year of Physics at the University of Arkansas in early April. I finally got someone to trade unassigned ER call weeks with me so that I can go. That's right I am a physics nerd, as my kid sister (now 46 yo) would say. I graduated with a BA Physics degree from U of A in 1978. I am look forward to visiting with the professors and fellow graduates.

I will get to hear Dr. Wolfgang Ketterle give the Centennial Maurer Distinguished Lecture. The title of the lecture is "New Forms of Quantum Matter Near Absolute Zero temperature". I hope I won't feel too lost. I have not kept up with the changes in Physics. (We all know it's tough enough keeping up with the changes in medicine.)

I have made my hotel arrangements, made arrangements for Rusty (my chocolate Labrador), and am mentally packing.

Wednesday, February 27, 2008

"My Worst Nightmare"

Recently I have had to deal with a patient who refers to herself as my "worst nightmare". I knew she would be difficult before I ever did her surgery. She had warned me that she always had a lot of pain and it was difficult to control. I knew she would need more TLC than most patients.

I always call outpatients the night of surgery. It helps me sleep better and hopefully them/their families too. The night of her surgery (and I have learned to double check phone numbers where they will be), I called three separate times over a 2 hour period to two numbers. No one answered any of them. I left a message that "If there are any problems tonight, please, have me paged through the Medical Exchange at ****. I will check on you again in the morning." That night it was quiet.

I called her the next morning and this time she answered.

"I'm in so much pain."

After going through a list of questions to make sure there were no other issues (no undue swelling, no fever, etc), "Have you tried taking the Xanax with the Percocet?"

"No. I didn't know I could do that."

I had written the Xanax prescription after seeing how she dealt with the pain in the recovery room. Nothing we tried had seemed to make her comfortable until we tried it. I mean nothing including morphine. And physically she appeared okay.

I explained that she could. That the Xanax would help her nerves and help her rest. "So why don't you try that. I'll call you again tonight." She agreed.

I called back that night (Friday). Things seemed to be better. Saturday was quiet. Sunday, just past noon, the pager goes off. I called the number.

"Dr. Bates, it's your worst nightmare. The pain is horrible and I don't have any pain medicine left."

I go through the same list. No undue swelling, no fever, etc. So I offer to call in some Darvocet (and do so). I don't offer to meet her and write a new script for the Percocet. I don't suggest that she go to the ER. Two hours later, the pager goes off again. Same patient.

"Dr. Bates, I'm so sorry. It's your worst nightmare again. I don't know what to do. The pain is so bad."

This time I firmly tell her that she will have to tough it out until tomorrow (Monday) as I can't phone anything stronger in for her. She will have to make due with the Darvocet. (By my count, the Percocet should have lasted her until Monday or Tuesday).

Nothing more from her until first thing Monday morning when she calls the office. "Dr. Bates, it's your worst nightmare. I am in so much pain."

"You are no where near my worst nightmare, but we won't go there. Why don't you come into the office so I can see you. You will have to come into the office before I give you anything more for pain."

She comes in. Her exam is benign. She is healing as expected. I touch the operative area gently--she flinches. I leave it and keep talking to her. She visibly relaxes, as the time passes. I keep up a constant patter. I remove her stitches and tape the incision. I deliberately touch the area again with slightly more pressure. This time there is less flinching. I keep talking to her. Then one more time palpate the area. This time pointing out how she allows me to do so.

I give her one more script for Percocet and Xanax. I caution her to take them as prescribed, not more often. I bring up the young actor, Heath Ledger, who recently "overdosed" on prescription medications. She says she didn't realize you could take too many. She did fine from that visit on.

So for her I think that much of her pain was in her head. I think she "thought" she hurt more than she "actually physically" did. I don't mean to belittle her pain, but she had had a few bad experiences with pain, so she ANTICIPATED that each new event would be as bad or worst. I think that "fear" adds to her pain.

I try to get patients to realize that there will be pain, but that each day will get a little better. I don't try to make "light" of it, but to get them to distract themselves. Or to "reassure" themselves that it is not a permanent state. Postoperative pain (I know there are exceptions) is not a permanent state. It will go away.

As far as being my worst nightmare--not even close. Some of my "worst" nightmares would include an abdominoplasty patient dying of a pulmonary embolism (PE) 2-4 weeks after surgery, any patient getting toxic shock (was consulted after the fact on a patient once who needed a gastrocnemius flap to cover her knee joint after surviving TSS post-knee surgery), or this.

Or if we're talking non-patient related then this (snakes wrapped around you).

Tuesday, February 26, 2008

Medical Protocols -- Little Rock Marathon

The Little Rock Marathon is in it's 6th year. The event this year takes place on Sunday March 2nd. I participated the first three years, finishing each year in less than 6 hours (as I once told Dr Val, I'm a not fast, more of a plodder). I walked/jogged the first year and then just walked the next two. Since then I have switched over to being part of the medical volunteer crew. My first year, I asked Dr Kent Davidson if there were any articles that I could read that would better prepare me. We both felt I would be okay with the blistered feet, the sprains, etc. So he gave me some information on exercise-associated collapse (see reference below). I kept the article and review it each year.

In addition, he gave me the Medical Protocols for the LR Marathon. These are Dr Davidson's guidelines for us. He has managed to recruit physicians, nurses, physical therapists (who do the muscle stretching and massages), EMT's and lay volunteers (who do some of the clerical work). It is a nice summary for anyone like me who volunteers, but is not in the sports medicine specialty.


EXERCISE-ASSOCIATED COLLAPSE (EAC)

Most common reason for treatment of runners in the medical tent following an endurance event. It is caused by blood pooling in the lower extremities at cessation of exercise with resultant hypotension and syncope. Collapse during the race usually implies some other cause, eg. cardiorespiratory, heat illness, or dehydration. May be exacerbated by dehydration or heat but these are not the primary problems.

Clinical Features:

  • Mental status--lightheaded, dizzy, brief loss of consciousness
  • Rectal temp--below 102.5 degrees Farenheit
  • Blood pressure--Orthostatic hypotension, improving with recumbancy (within 30 minutes)
  • Pulse--Tachycardia, improving with leg elevation
  • Lab--Normal serum sodium and glucose

Treatment:

  • Head down position on stretcher or cot with foot elevated 6 in
  • Monitor BP and pulse (check every 15 minutes)
  • Oral hydration
  • Expect recovery in 15-30 minutes

Prevention:

  • Appropriate cool-down -- continue moving (walking) after race
  • Encourage those that feel faint to lie down with legs elevated

HEAT-ASSOCIATED ILLNESS:

Ranges from nausea/vomiting to heat stroke. Milder forms can be treated with use of water soaked towels to head and trunk, and oral hydration. Heatstroke represents a medical emergency. It is diagnosed via altered mental status (usually unconsciousness) and a rectal temperature higher than 106.7 degrees F. Requires immediate measures to decrease body temperature (immersion in ice water), IV fluids and transportation to emergency department.


Treatment Protocol:

  • Assess rectal temperature on admission and every 15 minutes
  • If rectal temp is greater than 104 with alteration of mental status, then cover athlete with towels and water or immerse and begin IV with NS.
  • For heat stroke initiate the above measures and prepare to transport when rectal temp less than 104 and vital signs (VS) are stable.
  • Offer oral fluids when athlete is able.
  • Discontinue passive cooling when rectal temp less than 102.
  • May discharge when temp has normalized, taking oral fluids, neurologic exam and cognitive function is normal.
  • For residual symptoms, eg. CNS, vascular, renal -- transfer to emergency facility for evaluation.

EXERCISE-ASSOCIATED MUSCLE CRAMPING (EAMC):

EAMC is painful, spasmodic, involuntary contraction of skeletal muscles involved in exercise. Generalized cramping (including non-exercising muscle groups), especially if associated with confusion or unconsciousness is more likely due to a metabolic disturbance and is not EAMC. It should be managed as a medical emergency with transport to an emergency department. EAMC can be managed with oral or IV hydration and passive stretching. Dehydration and electrolyte disturbance may contribute to EAMC but IV fluid management is not necessarily required for resolution.

Treatment:

  • Passive stretching
  • Oral hydration
  • Indications for IV fluid therapy
  1. Athlete is unable to drink
  2. Persistent cramping despite stretching and oral hydration
  3. Signs of severe dehydration, eg. dry mucous membranes, sunken eyes, inability to spit, persistent hypotension and tachycardia

HYPONATREMIA:

More commonly seen in ultra-endurance races than in marathons. Primary cause in these events is overhydration with inadequate replacement of electrolytes lost through sweating. Consider this possibility in an endurance athlete with altered mental status and normal rectal temperature.

Clinical features:

  • Alteration of mental status--uncoordination, lightheadedness, seizures, coma
  • Edema of hand and fingers -- rings fitting tight, weight gain during race
  • Serum sodium less than 130 mmol/L

Treatment:

  • If alert and serum sodium is more than 130 mmol/L, moniter and await spontaneous diuresis. Do not give IV fluids.
  • If serum sodium is less than 125 mmol/L and /or semi-comatose or comatose, transfer to emergency department. Treatment includes use of low dose diuretics and hypertonic saline.

INFECTION CONTROL MEASURES

  • Towel used for cooling or wiping athletes must not be reused.
  • Use Universal Precautions -- wear gloves
  • Sharps containers and medical waste bags are to be used for contaminated materials
  • Hand washing between patients.

Not mentioned in his handout, are the cold-related issues. We saw some of this last year. Several athletes came into the finish-line medical tent shivering uncontrollable and were found to have oral temps of 93-95 degree F. They were all alert and carried on appropriate conversations. We managed to warm them with space blankets and warm oral liquids (coffee, hot tea, etc) but found ourselves wishing we some space heaters. Still watching the weather reports here to try to "guess" what issues we will see this year.

 

REFERENCES

Exercise-Associated Collapse: Postural Hypertension, or Something Deadlier?; Dale B Speedy MD, Timothy D Noakes MD, Lucy-May Holtzhausen MBChB; The Physician and Sportsmedicine, Vol 31, No 3, March 2003

Marathon Racing & Medical Tips (Hyponatremia and Blister Care); Sports Injury Prevention Newsletter, Issue #2 (click on the PDF file)

Marathon Medicine by Dan Tunstall Pedoe; Royal Society of Medicine Press; 1 edition (2000)

Monday, February 25, 2008

Melanoma Review

I wrote a post about Melanoma last year here. It is a good review of melanoma in general, so I won't re-write it. Just want to hit a few highlights here.

  • Melanoma is a malignancy with the highest yearly increase in incidence. Every year, about 4% or 5% more patients than in the prior year get diagnosed with melanoma.
  • The good news is that most patients are cured because of early detection. The key is early detection.
  • There is up to 50% chance of recurrence in patients whose primary melanoma in the skin is greater than 4 mm in depth, or if there are any positive lymph nodes.
  • At this point in time, recurrence is almost equal to mortality. This is due to the fact that melanoma is relatively resistant to currently available cytotoxic chemotherapies and radiation therapies.
  • A personal history of endometriosis or uterine fibroma is associated with higher risk for cutaneous melanoma in women.
  • A history of ovarian cysts, uterine polyps, breast adenoma/fibroadenoma, or breast fibrocystic disease is not significantly associated with melanoma risk.

EARLY DETECTION IS KEY! So if you have any moles that look like these, go see your family doctor or dermatologist. Have a full skin exam done.

CURRENT TREATMENT

StageTreatmentAdjuvant
Stage 0:
Melanoma-in-situ
Wide ExcisionSkin Exams
Stage 1A:
Low-risk Primary
Wide ExcisionSkin Exams
Stage 1B and II:
Intermediate and high-risk primary
Wide ExcisionSkin Exams,
Imaging for metastasis,
Enrollment in clinical trial
Stage III or IV, resectableWide ExcisionSkin Exams,
Imaging for metastases,
Enrollment in clinical trial
Stage III or IV, unresectable Fine-needle aspiration or biopsy,
Imaging for metastases,
Enrollment in clinical trial

The Dr Benabio over at The Derm Blog has some nice information about Melanoma that you may want to check out.

REFERENCES

Current Treatments and Guidelines for Metastatic Melanoma; Jedd D Wolchok MD; Medscape Article, December 19, 2007

Novel Therapies for Metastatic Melanoma; Steven J O'Day MD; Medscape Article, December 19, 2007

Endometriosis Linked to Increased Risk for Melanoma; Laurie Barclay MD; Medscape Article, October 30, 2007

Sunday, February 24, 2008

SurgeXperiences 116--Call for submissions

The 16th edition of SurgeXperiences will be hosted on March 2 by South African surgeon, Bongi, at his blog Other Things Amanzi. Deadline for submissions is February 29. Start writing and submitting!

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Saturday, February 23, 2008

University Mall Project

When I first moved into my office in 1990, the University Mall was very vibrant. The mall was full of good stores (JC Penney, MM Cohns, Montgomery Wards, Hallmark, jewelry stores, shoe stores, etc), a cafeteria (Frankie's), a book store, a drug store (Osco Drugs), and more. It was easy to go over at lunch to buy a birthday or Christmas gift or just do a little shopping. It has steadily gone down hill in the last few years. Now the owners are tearing it down with plans to put in a multi-use building (retail shops, residential, medical and office spaces). I begin taking weekly photos at the end of January to watch the progress. Here are a few:

January 31, 2008

February 14, 2008

February 22, 2008

Friday, February 22, 2008

Boston Commons Minature Quilt

I made this Boston Commons minature quilt, 24 inches X 27 inches about 10 years ago. A few months ago, I gave it to a friend. I lived in Boston (well Jamaca Plains) for two years when I was a plastic surgery resident at Boston University Hospital (trained at that hospital, the VA, Boston City Hosp, and Lahey Clinic). I enjoyed my time there.
The Sunshine and Shadow instructions given here can be used to make the Boston Commons quilt. They are similar. Some think the Boston Commons to be a variation of the Sunshine and Shadow quilt pattern based on how the Commons of Boston is laid out. Eleanor Burns published a nice instructional book on the Boston Commons quilt. You can find it here.
Here is a close up.
I used fall colors because New Englands falls are so lovely.
The back is show so you can see the quilting detail.
My friend's cat who has fallen in love with the quilt.
I love that!

Thursday, February 21, 2008

Steriod Use in Girls

What do anabolic steroids have in common with amphetamines, tobacco, diet pills, laxatives, and anorectics?

They all are drugs used by adolescent girls seeking to stay thin, says Dr. Linn Goldberg of Oregon Health Sciences University.

Call me naive, but I had not heard of non-athletic girls using steroids until I heard this (Cheerleader Drawn to Steroid Use) on Good Morning America (GMA) yesterday morning. I was surprised, though maybe I shouldn't have been. I felt the need to read more about this. Here is some of what I learned.

  • Among high school students, the use of androgenic steroid hormones is prevalent, with 1% to 2% of adolescent girls and 4% to 6% of adolescent boys having used an anabolic steroid at least once.
  • It is being used in teens as young as 12-, 13-, 14-year-olds.
  • Androgenic steroid use has been associated with the use of other illicit drugs, cigarette smoking, and alcohol use.
  • When taken in supra-physiologic doses, these drugs are known to cause a wide range of acute adverse effects (well, I already knew this).

Side Effects of Anabolic-Androgenic Steroid Hormones

Since I wanted to write this for my dear nieces (whom I don't think are using these drugs) and others like them, I will skip over the life-threatening side-effects (serious liver problems, serious heart problems, etc) and concentrate on the body-shape alterations. To me, these side-effects aren't worth the perceived benefits (increased muscle mass, "leaner" body) that might be gained by the use of androgenic steroids. The increased muscle mass and leaner body can be gotten by eating healthy and going to the gym.

Being thin is not worth these side effects:

VIRILIZATION (girls/women)

If given to women in high enough doses for a long enough period, the anabolic-androgenic steroid hormones cause virilization. This includes

  • excess facial and body hair
  • male-pattern baldness
  • acne (including on the chest and / or back)
  • deepening of the voice
  • increased muscularity
  • an increased sex drive.

GYNECOMASTIA (boys/men)

  • Fibrocystic masses, usually immediately deep to the nipple, may develop in men and adolescent boys who take anabolic-androgenic steroid hormones. This gives an increased breast size. The lesions are painful and may not resolve with discontinuation of the drug, but may have to be removed surgically.

ALTERED GROWTH (shortened stature in teens)

  • This is only an issue in adolescents. There may be premature closure of the epiphyses (growth plates in the bones) with prolonged use of high-dose anabolic-androgenic steroid hormones. This results in a shorter stature than would have been attained if there had not been interference with natural growth.

PSYCHOLOGICAL EFFECTS

A small percentage of users of high-dose anabolic-androgenic steroid hormones appear to exhibit clinically significant psychological signs and symptoms, including

  • highly aggressive behavior ("roid rage")
  • psychoses
  • depression (sometimes to the point of suicidal)

For MORE INFORMATION

Steroid Prevention Program Scores with High School Athletes; Robert Mathias; NIDA Notes, Vol 12, No 4, July/Aug 1997

Anabolic Steroids; NIDA for Teens, 2000

Use of Steroid for Self-Enhancement: An Epidemiologic/Societal Perspective; Charles E Yesalis, MPH, ScD; Medscape Article (AIDS Read 11(3):157-160, 2001. © 2001 Cliggott Publishing, Division of SCP Communications ) -- very nice article

Steroids in Sports: Questions Answered: Get Answers to 16 Questions About Performance-Enhancing Drugs in Baseball and Other Sports; Miranda Hitti, Louise Chang MD (reviewed by);
WebMD Medical News, Dec. 13, 2007

Wednesday, February 20, 2008

TBTAM to be guest on Dr A's Show

Tomorrow evening, February 21 at 9pm EST make time to listen "live" to the Dr Anonymous Program on Blog Talk Radio featuring his special guest - TBTAM!


TBTAM promises a show of "We'll be making Sandra Lee's Kwanza Cake an eleven course dinner for eight while slamming Big Pharma, dissecting the medical literature, giving out free medical advice and discussing the insanity known as gyno-food blogging. Who knows, I may even resurrect the Vagina Blogging song for the occasion!"

Dr A's program is a great chance to hear the voices of the medical blogosphere in the flesh. Dr Sid Schwab made his appearance two weeks ago. It was great hearing others (Bongi, etc) calling in to talk and hanging out with them in the chat room.


To listen, go to Blog Talk Radio
To call in - (646) 716-9514
To chat, you'll need to register. It's worth doing as the chat room is rather fun.
If you can't listen live, don't dismay - the shows are archived!

Total Lunar Eclipse Tonight

There will be a total eclipse of the moon tonight, February 20. If we don't get rain here in central Arkansas, we should have a good view. Alas, they're calling for cloudy skies here.

"In the Americas, the Atlantic, Europe and Africa, people have a ringside seat to tonight’s total eclipse. But in Asia, Australia and New Zealand, the eclipse occurs during daylight hours, when the eclipsed moon will be beneath the horizon as seen from that part of the world.

The moon is totally submerged in Earth’s shadow from 3:01 to 3:51 Universal Time Thursday morning, February 21. For North America, that means the total lunar eclipse is Wednesday evening, from 9:01 to 9:51 p.m. Central Time.

The total lunar eclipse lasts for some 50 minutes, though the moon is partially eclipsed for over an hour before and after the central totality. The eclipse lasts almost 3 and 1/2 hours from start to finish. The moon can pass through Earth’s shadow only when it’s directly opposite the sun in Earth’s sky in the constellation Leo." -- Earth & Sky

Here is a great explanation and great photos of lunar eclipse at MrEclipse.com

Here's the time line of the eclipse for where I live (from NASA).

Tuesday, February 19, 2008

How Much?!

Recently I was trying to get a patient pre-approved for a bilateral reduction mammoplasty. I sent the usual letter which included her history, her complaints, my physical findings, and my estimate of the amount of breast tissue to be removed. A Polaroid of the the patient's breasts was sent, as required, with the letter. I referenced the Schnur sliding scale (a scale that uses the patient's height and weight to determine the minimum tissue needed for removal to give relief of their physical complaints). I was certain she would be approved as I felt she met all the requirements, but I like to be certain.

About six weeks after the letter was sent and several phone calls, I received (and the patient got the same copy) a letter denying the surgery as she failed to meet the minimal tissue removal guidelines. I need to remove how much tissue?!

I re-read the letter. They too referenced the Schnur sliding scale (SSS). I called the physician reviewer, feeling like they had just misunderstood. Their letter stated "tissue removed per breast". I understood the SSS to be "total tissue removed".

I actually had a very pleasant conversation / exchange with Dr Insurance. He listened and let my fax him my copy of the original article. He then called me back and informed me that I had misread the article. I was confused (granted it had been years since I had re-read it, but I "knew" what it said) but looked again as we talked. Damn, he was right. As he pointed out, the original article measured the amount of tissue removed from the RIGHT breast only and not both added together. So the scale is per breast not total tissue removed.

Well, I have been looking back over all the information I have and have finally figured out part of the source of my confusion (other than simply wanting it to be so, as it makes it easier to accommodate these women). I scanned in a copy of the BCBS Manuel page I printed out back in July 2001. Note the heading says "Total Breast Tissue to Be Removed". Today when I type in the web address at the bottom of the same page, this is what you will see "Tissue per Breast". Same web address, but they corrected it some time between 2001 and now.
Why does it matter? Well for a patient who weights 225 lb and is 5'8" tall (BSA 2.21), approximately 750 gms of tissue have to be removed from each breast, not 300 gm from one and 45o gm from the other for a total of 750 gm. That's approximately 1.5 lb of breast tissue per side, and for most women that size 3 bra cup sizes.

Another example, 5'1" tall and weights 155 lb. This woman would have a BSA of 1.74 and would have to have 400 gms of breast tissue per side removed. That's at least 2 cup bra sizes for her.

That seems fair. It's hard to promise them (the patients) that you can remove that amount sometimes. It can also be difficult to estimate the amount to be removed just by exam. There was a recent article (see reference #2) that has a formula for the estimation. I may try it and see if it is any better than my "eye". The formula is 35 X sternal notch to nipple distance in cm + 60 X nipple to inframammary crease distance in cm - 1240.

The woman that prompted all this, I estimated about 200-300 gm less per side than required. I'm not willing to make her a "B" cup just to meet the requirements (see my reasons here). And over-estimating the amount and then not meeting it can get a "not covered" and no payment after the fact. Thankfully, Dr Insurance approved her for me. He felt that I was doing her for the "correct" reasons. I appreciate the discussion we had.

REFERENCES
Reduction Mammaplasty: Cosmetic or reconstructive Procedure?; Annals of Plastic Surgery, Vol 27, No 3, Sept 1991, pp232-237

A Formula Determining Resection Weights for Reduction Mammaplasty; Plastic & Reconstructive Surgery. 121(2):397-400, February 2008; Descamps, Marjanne J. L. M.R.C.S.; Landau, Alex G. M.B.; Lazarus, Dirk F.C.S.; Hudson, Don A. F.R.C.S., F.C.S., M.Med.

Monday, February 18, 2008

Threatened

Recently I was "threatened" by a patient. So the news of therapist Kathryn Faughey being slashed to death in her Manhattan office Tuesday evening has really stayed with me. And it wasn't even her patient. Was my patient's threat serious? Here's the story.

A few weeks ago I saw two women, good friends, together in consultation. Both wanted procedures done (non-facial), similar goals but different procedures needed. Patient one (Uno) had lost a family member to an unexpected (car accident) death within the past year, but assured me that she was through with most of her grieving. We spent time discussing this. I wanted to be sure she was ready to proceed. The second patient (Dos) was Uno's best friend and had taken care of her while her friend grieved. She wasn't so sure her friend was through grieving. I finished the consultation and sent them home to think things over with instructions to both to be sure. They called back a week later and scheduled a day when both could have their procedures done on the same day. Their husbands would come and sit together in the waiting room. I once again, voiced my concern about the timing of surgery for Uno. Still I could not find anything "solid" to hang a refusal on.

Two days prior to surgery, Uno called and admitted she was not ready. She canceled, but her friend, Dos, had her surgery. All went well. Both came back for Dos' followup visit. Uno was so impressed with Dos' outcome, she wanted to reschedule. But as I finished removing stitches, Uno told me that her husband was afraid of her dying if she had surgery. She then told me "If anything had happened to Dos and she had died, I would have killed you." We discussed her husband's fear of her dying. I ask her if she could understand his fear better in light of her fear of her friend dying. I told Uno, in front of Dos, that I really thought she needed to wait for six months or more to grieve more (both she and her husband) before we considered re-scheduling her. I encouraged her to talk to her minister or a counselor without directly acknowledging the threat.

Did I handle it correctly? I'm not a psychiatrist, but I hope I did.

My condolences to Kathryn Faughey' family and friends.

Sunday, February 17, 2008

SurgeXperiences 115 is up!

Chris over at Made a Difference is the host of  SurgeXperiences 115.  It is now up and is worth your time.  Please, go take a look.
 
Here is the catalog of past surgXperiences editions.   If you wish to host a future edition, please contact Jeffrey who runs the show here.

Friday, February 15, 2008

Flannel Flag Quilt

When I first found this quilt top, I was told it was made of "cigar felts". It is made of 128 "flags", 8 across and 16 down. I have several other "flags" that aren't sewn together. I am thinking about disassembling the quilt top, removing some of the duplicates, and adding in some that aren't there. Maybe doing two so they are wall size. Then I could display them better once they are quilted.

I have learned that they are not felts. They were not associated with cigars. They are cotton flannels. They were associated with cigarettes as premiums. That doesn't make me any less enamored of them. There is so much history there. The history of advertising, quilting, society, and more.
 
Check out some of these of these flags -- the countries -- Austria-Germany, Siam (with the elephant), Ireland (with the harp), the United States (only 48 stars). Korea is spelled with a "C" (not pictured).
And China (with the lion), Denmark (red with the white cross), Poland (eagle on red field with blue X), Liberia (similar to the US flag (one white star in blue field with red/white strips).

Here are some others I have not sewn together. The Germany one is interesting--remember this flag was pre-World Wars. The purple and red is Morocco.
Here is Norway, Burma, Egypt, and Switzerland.


SOME HISTORY

The practice of inserting advertising in tobacco products and packaging began about 1870 and continued throughout the late 19th Century into the first decades of the 20th Century. The inserts or premiums that I find interesting are the ones that became parts of quilts. Tobacciana includes tin tobacco tags, cigarette cards, cigar ribbons, silks, and flannels. The ribbons, silks, and flannels were often collected and sewn into quilts.
 
Silk Cigar Ribbons
These ribbons were used to tie the bundles of cigars.    Often the ribbon had the tobacco company’s name imprinted on it.  The ribbons came in bright colors;  most commonly gold or yellow, but also blue, green, orange, purple and red. Cigar ribbons are narrow in width, usually about 3/4 inches wide. They are usually 12-15 inches long. (an example can be seen here)
 
Pillows, tablecloths, and quilts were made to show off the ribbon collections.  Log cabins and fans were two popular patterns.
 
Tobacco Silks
Tobacco or cigarette “silks” were often made of  silk or silk satin, a silk-cotton cloth blend, a cotton sateen or even a plain woven cotton.  These “silks” were beautiful and printed with pictures of various themes:  floral, flags, American Indian motifs, bathing beauties, animals, and more.  Several came in series.  One such group was the city seals which contained over 75 individual items.  (examples can be seen here)
 
Here is a website related to a A Floral Silkies Quilt with pictures and the family history of the quilt.
 
 
Flannels
Tobacco “flannels” were actually made of a cotton flannel fabric.  These too were printed with designs such as the “silks.”   (examples can be seen here)
 
 
 
 
I wish some company would do something like the above today. It would be great! Godiva does with ribbons, but how much chocolate would I have to eat to get enough ribbon to make a quilt? I have a couple of these ribbons. Anyone want to send me their ribbons? Any company (for healthy products) want to start doing something like the above premiums?
 
 
 
REFERENCES
Textile Tobacco Inserts and Premiums used in American Quilts, and Related Household Articles; By Laurette Carroll, Quilt Maker,
Quilt Collector and Quilt Historian
 
"Better Choose Me: Addictions to Tobacco, Collecting, and Quilting, 1880-1920"; Ethel Ewart Abrahams and Racheal K. Pannabecker from Uncoverings 2000
 
America's Quilting History; Tobacco Premium Quilt History: Silks, Ribbons & Flannels -- womenfolk.com
 
A Flag Quilt Launches a Search into the Past; Merikay Waldvogel; Quilting Today, Issue 68, pp 26-28
 
Museums & Quilts; Attic Treasures for Everybody at the Bowers
 
Museum of Cultural Art; Carter Houck; Quilter's Newsletter Magazine, Jan/Feb 1995, No 269, pp 40-41

Wednesday, February 13, 2008

Amputations, Prosthetics, and War

Chris' request for "your impressions of the effect of war on surgery, of surgery on war, ...." for the next SurgeXperience is the source of inspiration for this post.

I have never been in the military so I have no direct experience. My father (see picture at right, died in 1966) was in the army. He was an orthotist, a specialist in designing and fitting orthopedic braces. I think my father would be absolutely amazed by the advances in the field. I know I am.

Prosthetists, on the other hand, specialize in designing and making artificial limbs. Wars through the ages have greatly influenced the need for and design of artificial limbs. This has been true for both the upper and lower extremities.

Amputation surgery is one of the oldest known surgically performed procedures. The surgical principles originally described by Hippocrates remain true today. There have been refinements of surgical technique such as hemostasis, anesthesia, and improved perioperative conditions have occurred. You can find a nice review of the history of amputation surgery here. Here are some of the highlights:

  • 385 BCE - Plato's Symposium, Hippocrates' De Articularis
  • 1st century CE - Use of cautery for large vessels (Celsus), first mention of ligatures, removal of gangrenous extremity through viable tissue edge with bone cut shorter than the soft tissues
  • 1528 - Advent of gunpowder and increase in extremity injuries
  • 1529 - Ambroise Pare, ligature introduced, also thick ligature used as a tourniquet
  • 1588 - William Cloves, first successful above-knee amputation
  • 1679 - Younge and Lowdham, introduction of local flaps for wound closure (animal bladders used previously)
  • 1781 - John Warren, first successful shoulder amputation
  • 1806 - Walter Brashear, first successful hip joint amputation
  • 1837 - Liston, routine use of flap closure
  • 1825 - Nathan Smith, through-knee amputation described
  • 1870 - Stokes, Grittis procedure modified (ie, Gritti-Stokes amputation)
  • 1873 - Eschmarch -- rubber bandage used rendering amputation bloodless, reproducible, and safer; limitation of use described per procedure, as well as avoidance of use on infected limbs
  • 1943 - Major General Norman T. Kirk, indicated guillotine amputations in war setting should be completed as distal as possible and completed later under calmer conditions
  • 1960-1980 - Recommendation to salvage knee in vascular amputations

Even without war, there are amputations that occur due to trauma and disease (mostly peripheral vascular disease, but also cancer and infection). This graft is from the National Limb Loss Information Center Fact Sheet, revised 2006.

During amputation surgery, several actions can be taken to maximize the function of the residual limb. These include the following:

  • Shortening and beveling the bone end to allow adequate soft tissue coverage
  • Sharply transecting the nerve under tension to allow retraction and to decrease the likelihood of neuroma formation
  • Securing the muscles with a myodesis or myoplasty to create a structurally stable and functional limb
  • Positioning the wound edges to avoid bony prominences at the far distal end of the residual limb
  • Keeping the bony lever arm as long as possible but covering it with adequate muscle and soft tissue to avoid fitting problems later (sometimes length will have to be given up to obtain the coverage)

Post-amputation, assuming wound healing is going well, then it becomes important to train the patient to perform ADL and ROM exercises and to improve strength and mobility. Prevention of contractures is important. During this time, a program to prepare the residual limb for the prosthesis should be initiated. A skin desensitization program (both upper and lower extremities)consists of the following:

  • Gentle tapping and massage (with a washcloth) on the distal portion of the residual limb
  • Scar mobilization and massage to prevent excessive scar formation from causing the soft tissues and skin to adhere to underlying bone
  • Edema control, initially with ace wraps and, when the drainage subsides, with a residual limb (stump) shrinker
  • The application of pressure to the distal aspect of the residual limb to prepare the limb for weight acceptance

A rigid, removable dressing may be used over the residual limb during this phase. The rigid dressing serves the following functions:

  • Aids in edema control and leads to rapid residual limb shrinkage
  • Promotes healing by providing protection and preventing edema
  • Desensitizes the limb
  • Prevents residual limb trauma
  • Reduces wound pain

Prosthetics

Ideally, a prosthesis must be comfortable to wear, easy to put on and remove, light weight, durable, and cosmetically pleasing. A prosthesis must function well mechanically and require only reasonable maintenance. Prosthetic use largely depends on the motivation of the individual, as none of the above characteristics matter if the patient will not wear the prosthesis. The second and third reference articles are good discussions on the various types of prosthetics.

Some history of prosthetics I found in various articles:

Between 3500 and 1800 B.C.

  • the first recorded allusion to a war injury that required a prosthesis can be found in the Rig-Veda. This is a sacred poem of India, written in Sanskrit which tells the tale of the warrior queen Vishpla, who—having lost her leg in battle—was fitted with a prosthetic leg made of iron so that she could return to the battlefield.

300 B.C.

  • The oldest known prosthesis, which was discovered in a tomb in Capua, Italy, was an artificial leg made out of copper and wood dating back to 300 BC. It was destroyed by bombing during World War II.

During the Middle Ages and the Renaissance

  • In the 15th and 16th centuries many prostheses were made from iron. They were created for soldiers by the same craftsmen who made their suits of armor. Ambroise Pare, a French army surgeon, contributed both to the practice of surgical amputation and to the design of limb prostheses. (see picture of an iron hand designed by Pare, 16th century)

U.S. Civil War

  • Created a great need for artificial limbs. The picture below is of Corporal David Cole and his leg prostheses, ca 1865. He has an amputation at the knee joint.
  • The federal government committed to providing prosthetics to injured soldiers, representing the first ever large-scale program to provide prostheses.
  • The Great Civil War Benefaction provided a model for government support that aided prosthetic technology development through two world wars and continues today in the Defense Advanced Research Projects Agency (DARPA) programs and in the military’s commitment of the latest in prosthetic devices and rehabilitation services to today’s service members.

In 1917, the Artificial Limb Manufacturers and Brace Association was formed. It has evolved into the American Orthotic and Prosthetic Association (AOPA -- a trade association of companies in O&P).

Antipersonnel mines (landmines) were first used on a wide scale in World War II. Since then they have been used in many conflicts, including in the Vietnam War, the Korean War, the first Gulf War. Precursors of the weapon are said to have first been used in the American Civil War in the 1800s.

In 1945, the National Academy of Sciences established the Artificial Limb Program in response to the plight of WWII amputee. Much emphasis was placed on investigating the movement of normal human limbs so that prostheses could be designed to appear as life-like as possible.

1946 - Suction socket and patellar tendon-bearing prosthesis

In 1952, the National Research Council Committee on Prosthetics Research and Development led officials at the VA to conclude that a totally new service delivery system for artificial limbs was required to assure the highest quality of functional gain for limb-wounded veterans. To implement this, special training programs were set up at NYU and UCLA to bring in limb-fitting personnel for an intensive 12-week training course that led to certification for applications of the new technologies to VA standards. On completion of the course a "limb fitter" became a Certified Prosthetist, a status subsequently required by the VA for reimbursement of services to veterans. The program continued for more than two years until the national need was met. The information was later transferred to various medical school prosthetics and orthotics training centers throughout the world. [It is my understanding that UCLA was teaching upper extremity prosthetics, and NYU lower extremity prosthetics.  The American Board for Certification in Orthotics and Prosthetics was founded in 1948.  "Certified Prosthetist" is registered to ABC. --personal correspondence with Al Pike, CP)

 

1950's -- RGP initiated the use of fiberglass materials

**"The period from 1945-1965 is now viewed as a time of unparalleled scientific and technical advances in O&P.  Key findings from this era still provide the conceptual basis for virtually all contemporary techniques.  Although many factors have contributed to the long-term successes of this era, two key aspects were the coordination of research and evaluation efforts and the long-term commitment of significant governmental funding.

Although the field is currently in a relatively high state of clinical development, most advances in recent decades have been technical.  Little or no advances in fundamental principles have occurred since the termination of significant governmental funding for O&P research and development in the 1960's"--from Prosthetics/Orthotics Research for the Twenty-first Century:  Summary 1992 Conference Proceedings--John W. Michael, MEd, CPO, John H Bowker, MD." (personal correspondence with Al Pike, CP) 

In the 1980's-- Companies began to turn away from fiberglass and begin to the use of flexible, thermoplastic materials which reduce the weight of the prosthesis and maximize comfort. The two piece socket design has given amputees a more freedom of movement and energy than before. The custom, total-contact, suction design has practically eliminated pistoning in the socket, increased stability and the ability to maximize energy storing potential. 

**Fiberglass along with carbon fiber are still used today to make light, one piece sockets for prostheses. (personal correspondence with Al Pike, CP)

Currently--the Iraq War

  • Attitudes are changing to keep service members in the service. They get sent to Walter Reed and Brooke to completely rehab so they can stay in the service. That is the goal, and they are getting really good rehab to accomplish it. The military is giving it all the latest technology. The VA is going to have to change when they start dealing with these service members when they are vets. They will be used to having the latest, most technological advanced prosthetics.
  • **The VA has established four Polytrauma Centers for OEF/OIF and works closely with the DOD to provide the same new prosthetic technology to veterans of all conflicts.  Current planing is to establish Amputee Care Centers following the new CARF Amputee Care Standards. (personal correspondence with Al Pike, CP)

  • DARPA’s program, Revolutionizing Prosthetics, seeks to develop a “single prosthetic arm system that is suitable for trans-humeral and shoulder disarticulation amputees". This would revolutionize the entire field of prosthetics through the use of neurally controlled devices that will “restore full motor and sensory capability to upper extremity amputee patients. This revolutionary prosthesis will be controlled, feel, look and perform like the native limb,”

Currently, Landmines World-Wide

  • It is estimated that there are between 15,000 and 20,000 new casualties caused by landmines and unexploded ordnance each year. That means there are some 1,500 new casualties each month, more than 40 new casualties a day, at least two new casualties per hour. Most of the casualties are civilians and most live in countries that are now at peace.
  • In Cambodia, for example there are over 45,000 landmine survivors recorded between 1979 and 2005. These survivors often (almost always) have limb-loss. Most of these people are civilians. (Source: Landmine Monitor Report 2005)

Currently, January 2008--Sports

I am amazed by this story. It shows just how far prosthetics have come. Maybe we are getting to the "Six Million Dollar Man".

South African double amputee Oscar Pistorius, who runs with carbon fibre blades attached to his legs, will not be allowed to compete in Beijing.

A report commissioned by the International Association of Athletics Federations says the prosthetics used by Pistorius gave him an advantage over other runners.

"Pistorius was able to run with his prosthetic blades at the same speed as the able-bodied sprinters with about 25 percent less energy expenditure," the report concluded.

There are three main military centers in the United States that deal with amputees, prosthetics and rehabilitation. *** They are :

SOME PROSTETIC COMPANIES

Liberating Technologies of Holliston, MA

  • The company designs and manufactures prosthetic devices such as the Boston Digital™ Arm System and the VariGrip™ prosthetic controller for below-elbow amputees. These are new state-of-the-art microprocessor-based prosthetic controllers that can be customized to accommodate the individual user's needs rather than requiring the user to adapt to the controller.

  • Also distributes products for three of the leading international suppliers of powered prostheses; RSLSteeper of England, VASI of Canada and Centri of Sweden.
  • The company also supplies powered prosthetic accessories such as: batteries, chargers, hands, wrists, elbows and shoulder joints, electrodes and other input devices as well as silicone and PVC cosmetic gloves and custom high-definition cosmetic covers.

Motion Control, Inc.

  • Was originally established in 1974 by a group of faculty members and researchers at the University of Utah, led by Dr. Stephen Jacobsen.
  • First made available in 1981, the Utah Artificial Arm is the premier myoelectric prosthesis for elbow, hand, and wrist. It represents the advanced combination of technology, superior performance, and cosmetic appearance, for above elbow and higher level amputees.
  • In 1997, the second generation Utah Arm, called the Utah Arm 2, or "U2," replaced the original version, with major improvements in the electronics, motor and transmission. The U2 brought a new level of rugged dependability and user friendliness to the Utah Arm.
  • In 2004, microprocessor technology was incorporated into the Utah Arm 3. Two microcontrollers are programmed for the elbow and hand, thus allowing separate inputs and therefore simultaneous control of both. This allows the wearer to operate the elbow and hand at the same time for more natural function than was possible before. In addition, the U3 uses a computer interface which greatly simplifies fine tuning the elbow and hand controls. Many veterans of the Iraqi war have been fitted with the Utah Arm 3 at Walter Reed Army Medical Center and Brooke Army Medical Center.
  • Motion Control was acquired by the Fillauer Companies in January 1997, and became part of one of the most comprehensive orthotic and prosthetic development and manufacturing companies in the world. Fillauer is headquartered in Chattanooga, Tennessee, and Motion Control continues to operate in Salt Lake City, Utah.

 

Otto Bock of Duderstadt, Germany**

  • The company was started in the year 1919 by the prosthetist Otto Bock to supply thousands of war veterans with prostheses and orthopedic products.   He found the demand could not be met with traditional artisan methods.  He developed the idea of manufacturing prosthetic components in series production and to deliver these directly to the orthopedic mechanics on site. This was the cornerstone for the orthopedic industry.
  • From the very beginning, he continually tested new materials for their applicability in manufacturing processes. This made him a forerunner in the use of aluminum parts, which he was applying to prosthetics as early as the 1930s. His steadily growing business would later employ a staff of 600.
  • C-Leg Series  is  has a fully microprocessor-controlled knee joint.  It allows give a natural gait pattern.  It is allows safe, smooth walking at different speeds and on all surfaces.

RGP Prosthetic Research Center in San Diego

  • Have been innovators since the beginning when prosthetics were still made with wood.
  • They were one of the first 100 facilities in the country to receive a certificate of approval from the American Board of Certification (ABC).
  • Guth co-developed the CAT-CAM Ischial Containment suction socket (John Sabolich and Kevin Carroll--patent 636421)***
    in 1985 which revolutionized the quality of life for above knee amputees. By containing the Ischiam bone, Guth aligned the pelvis with the femur enabling amputees to walk and run leg over leg instead of kicking and dragging the leg forward. "By containing the Ischiam and providing a lightweight suction fit, we are able to put the prosthesis in a position that is aligned with the body allowing amputees to walk with a natural gait pattern," said Guth.
  • One of the first facilities in the United States to obtain the BioSculptor computer aided design system, they continue to search for the most accurate fitting techniques that ensure a total-contact suction fit. "Our goal is to design a custom prosthesis that fits the lifestyle of amputees, not one that the amputee has to adjust their life to."

OSSUR

  • Has more than thirty years’ experience in the design and production of high-tech orthopaedic devices.
  • Their newest platform is Bionic Technology - a precise fusion of artificial intelligence and human physiology that is transforming the technological landscape.
  • Power Knee -- replaces the concentric muscle activity of the quadriceps and can lift the user from a seated position, support the user when ascending inclines, and power them up stairs. It has an active pendulum motion that propels the user forward and enhances the pelvic rotation for a more natural gait.
  • PROPRIO FOOT -- Angling itself appropriately, it also helps amputees to sit and stand up easily and more naturally. It, also, has a calibrated alignment control feature. Overall, the effect is a feeling of improved proprioception with a more balanced, symmetric and confident gait with reduced wear and tear on the back, hips and knees.


College Park Industries, Inc.

  • Incorporated in 1988 upon completion of the first TruStep Foot prototype, designed and built by David L. Robinson.
  • Provides the most anatomically correct prosthetic feet available today.
  • End-users of College Park products are lower limb amputees of all ages who maintain low to high activity levels.


Seattle Limb Systems

  • Has a corporate history with products dating back to WWII.
  • Some of Seattle Systems' products have been previously introduced under these company names: USMC, SOGI, Lenox Hill, Ralph Storrs, Inc., Pope Brace Co., M+IND, Orthomedics, Johnson's Orthopedic Designs, Zinco, Joint Solutions, Seattle Limb Systems, OrthoMold and DOBI-Symplex.
  • SNK 100 Knee Series -- feature pneumatic cylinders that automatically optimize the swing back speed to ensure a smooth and natural transition during changes in walking speed. They are constructed of high strength titanium that is both light and durable. The compact design can be easily used for women and children. The load brake locks flexion during stance phase and releases during swing phase for a smooth motion and stable stance.


Endolite

  • leading supplier of innovative prosthetic products and services, offering lower limb component manufacture and distribution to North America.
  • They are a member of the Blatchford Group of companies. They are at the forefront of developing digital, electronic, and intelligent interface systems to enhance the lives of people with limited mobility.

Ohio Willow Wood

  • Founded in 1907 by a double amputee, William E Arbogast who was injured in a railroad accident at age 21years. One leg was amputated above the knee, the other below the knee.
  • The Earthwalk 2 Flexible Keel Foot and Ankle System provides freedom of mobility that is more natural. The “late stop” ankle feature allows for easy roll over so the foot can maintain foot flat longer. This action is important for less-active amputees who require more stability and less dynamic response.
  • Magnum Heavy-Duty (HD) System was created to stand up to the pressure of higher weight (up to 350 lb) patients, ensuring that they can continue to lead the active, self-sufficient lives.

  • The GeoFlex Knee is a friction-controlled polycentric knee, created for amputees who need stability but do not want a manual locking knee. Those who are less active, or just learning to walk (U.S. Activity Levels 1 & 2), are well suited for this knee. Amputees experience stability for up to 20 degrees of flexion under load, and feel secure and confident with each step. This unique knee accommodates a hip flexion contracture without giving up knee stability and allows for easier cosmetic finishing.

**Some corrections and additions made February 14, 2008 after corresponding with Al Pike, CP.   I'd like to thank him for his contributions.

  ***Further corrections/additions made February 15, 2008 after further correspondence with Al Pike, CP.  I want to thank him for helping me get it right.

REFERENCES

Amputations of the Lower Extremity; Janos Ertl MD and others; eMedicine Article, May 11, 2007

Lower Limb Prosthetics; Brian Kelly DO and others; eMedicine Article, Nov 2, 2007

Upper Limb Prosthetics; Brian Kelly DO and others; eMedicine Article, Oct 10, 2007

American Academy of Orthotists and Prosthetists (AAOP)

American Orthotists and Prosthetists Association (AOPA)

Revolutionizing Prosthetics; Muphen R Whitney; Military Medical Technology Online Archives, Sep 29, 2005 in Volume: 9 Issue: 6

Faculty Pioneer Development Of Advanced Artificial Limbs --UCLA History

History of Prostheses; University of Iowa Medical Museum

International Campaign to Ban Landmines (ICBL) -- I strongly believe in this.

***Prosthetic Reconstructions:  Making the Industry, Re-Making the Body, Modeling the Nation; Lisa Herschback; History Workshop Journal 44 (1997): 23-57 (shared with me via a PDF file by Al Pike, CP)

 

SOME BLOG POSTS ON AMPUTATION

SurgeonsBlog -- Confessional; Aug 3, 2007

GruntDoc -- I cut off a finger the other day; Nov 19, 2007

Notes of an Aneshesioboist -- Amputation; Jan 23, 2008

other things amanzi -- callous; Feb 5, 2008

War Amputees--Iraq and Afghanistan (the entire blog)

Tuesday, February 12, 2008

Happy Valentine's Day!

I know it's a few days early, but I wanted to share these three links with you. All have to do with "hearts".

The first one -- thanks to Street Anatomy for the heads up on this one! The cupcakes actually "bleed" jam. If you are inclined to make these are your Valentine, the recipe can be found at YumSugar.

The second one --don't forget to listen in to Dr. Anonymous's BlogTalkRadio Show on Valentine's Day night - Thursday, February 14th at 9pm eastern time. His guests will be medical bloggers Dr. Val, Jenni from Chronic Babe, Crzegrl, and EE. Join us for The Doctor Anonymous Show: Valentine's Day Estrofest. You won't want to miss it!

And third, but not least, is a link to Penny Sanford's blog where she shares her pattern for this "heart yo-yo".

Monday, February 11, 2008

Late Reconstruction of the Nail Bed

Recently I received the following e-mail:

"I came across your blog about fingertip injuries. When I was 4 years old I slammed a door on my pinky finger. The tip came off leaving me with what they call a hook nail. I have been trying to research any procedures that may improve the appearance of my finger. Do you have any suggestions or info on any procedures."

Secondary reconstruction is always less effective than "doing it right" at the time acute care is given to a nail bed injury. The appearance and shape of the nail improves during the first year after the injury so no attempts at reconstruction of the nail bed should be made until after the first year. You may want to refer back to my post on fingernail anatomy and fingertip injuries.

Typical nail deformities that require reconstruction include:

  • Non-adherent nails -- is the most common deformity of the nail plate after injury. It occurs due to scar tissue in the sterile matrix which prevents attachment of the nail plate to the nail bed. The non-adherent nail "sits" upwardly deviated from the nail bed. The lack of nail plate adherence becomes more of a functional than a cosmetic problem when more than one third of the distal nail is non-adherent. This allows it to catch on clothing and other articles putting the nail bed at risk for further injury. Dirt and other debris gather underneath the non-adherent nail and cause further irritation. Nail adherence on more than two thirds of the nail bed rarely results in a functional impairment.
  • Split nail deformities -- A longitudinal split in the nail is often the result of an underlying axial scar beginning in the germinal matrix of the nail bed. The scar divides the nail plate during formation. The nail plate grows out as 2 distinct plates.
  • Irregular contours -- The linear ridging deformity of the nail following a trauma is most often associated with an underlying bone or soft tissue abnormality. The ridging usually is more of a cosmetic problem more than a functional one.
  • Hook nail -- is usually the result of a fingertip amputation, with partial or complete loss of the supporting tuft of the distal phalanx (bone) and a loss of the distal nail bed and fingertip soft tissue. The regenerating nail plate follows the contour of the repaired fingertip amputation, angling in a dorsal (top) to volar (palm) direction. The hook-nail deformity is more than a cosmetic disfigurement to the patient's finger. The tip of the finger is often tender and chronically irritated, and sensibility may be impaired. The patient may also have difficulty grasping fine objects. Occasionally, the nail may catch on clothing or other utensils and become a constant source of trauma.

  • Pincer nail deformity -- represents a loss of the normal convex shape of the nail plate. The lateral edges of the nail plate have a marked convexity, turning acutely volarly (towards the palm) and taking on the characteristic shape of an omega sign when viewed head on at the distal phalanx. The exact etiology of this deformity is somewhat obscure, but a loss of the lateral integrity of the distal phalanx may occur, allowing this greater curvature of the nail plate. Paronychial infections may be more frequent with this type of nail irregularity.

  • Loss of the eponychium with synechiae -- Burns are the most common cause of loss of the eponychium. Other causes include friction avulsions, crush injuries, and complex lacerations. The eponychium contributes to the epidermoid keratinization of the nail, providing the characteristic sheen on a dorsal nail plate. So loss of the eponychium can result in an unsightly nail or notched deformity which can be a source of tenderness for the patient.

TREATMENT

Non-adherent Nail

  • Treatment involves trimming the nail back to normal sterile matrix. The scar in the nail bed is then excised and the defect is closed primarily or with split matrix grafts. Primary closure may be obtained with minimal nail bed undermining if the defect is less than 1-2 mm. The nail plate should adhere to the graft.
  • If the cause of non-adherence is due to hyperkeratosis of the nail bed, then the nail is removed. Then the hyperkeratosis is removed by scraping the sterile matrix with the edge of the scalpel blade down to the level of the normal nail bed. The nail either grows out completely or partially adheres to the nail bed. The procedure may be repeated if complete adherence is not achieved.

Split Nail Deformities

  • Treatment is determined by the underlying problem.
  • Longitudinal scars on the sterile matrix of the nail bed can usually be treated by excision and primary closure. Small Z-plasties (2 mm in length) can be used to alter the direction of the scar. Larger scars will require a split-thickness nail bed graft following excision. Loss of the central portion of the germinal matrix requires grafting with a full-thickness germinal matrix graft from the toe.
  • Adhesions within the eponychial fold are treated by removing the nail plate and dividing the synechia transversely. Upward traction on the open portion of the nail fold should allow visualization to perform the transverse incision. Any scar tissue of the germinal matrix and dorsal roof of the eponychium must be excised. A germinal matrix graft is then applied. Simple excision of the germinal matrix scar with primary approximation is less effective.
  • Reconstruction of the dorsal roof of the eponychium help restores the normal sheen to the regenerating nail. A silicone sheet (acts as a splint for the graft) should be placed in the nail fold to maintain the integrity of the eponychial fold until the grafts have "taken".

Linear Ridging Deformity

  • As with the other deformities, the nail plate must be removed and the sterile matrix visualized. An incision is made over the ridge in a longitudinal fashion. The sterile nail bed is elevated from side to side (radially and ulnarly) to expose the underlying tissue. Scar tissue, foreign bodies, or bony exostosis must be removed. The nail bed is redraped and sutured with 7-0 chromic sutures. Any excessive scarring of the sterile matrix should be excised and replaced with a split-thickness nail bed graft. The nail plate or silicone sheeting is then placed over the repair and under the eponychial fold.

Hook Nail Deformity

  • Can be somewhat difficult because of the loss of bony and soft tissue support. Secondary reconstruction is centered on recreating the initial defect, then restoring the bony and/or soft tissue support.
  • Soft tissue support on the volar (palm-side) aspect of the finger can be accomplished with V-Y Atasoy/Kleinert flaps, lateral Kutler flaps, a cross-finger flap, or a thenar crease flap.
  • Split nail bed grafts (distal edge) are applied directly to the volar flaps, and the proximal edge is sutured to the native nail bed.
  • Restoring the bony support is less predictable. Distraction osteogenesis, bone grafting, and step cutting in the distal phalanx are likely to lead to a high rate of resorption.
  • Microvascular composite flaps of nail bed, bone, and soft tissue from the toe have been described with excellent results. A high level of microsurgical expertise is essential and the patient must be willing to sacrifice a toe for this procedure. This may be hard to justify as the local flaps mentioned above are easily and more reliably performed.
  • Revision amputation is an alternative to reconstructing a problematic hook-nail deformity.

Pincer Nail Deformity

  • Is corrected by using dermal grafts to "build up" the sides of the nail bed. This is done by first removing the nail plate. Then an incision is made in an oblique fashion in the pulp of the distal fingertip just distal to the end of the lateral nail folds. The nail bed is elevated off the distal phalanx by passing a Freer periosteal elevator into the wound gently pushing proximally. This will create a tunnel that is 2-3 mm wide and extends the full distance of the nail bed, including the germinal matrix. Care must be taken not to damage or buttonhole the overlying nail bed.
  • Nylon sutures (5-0) are then placed through the dorsal skin into the tunnel created between the distal phalanx and the lateral bed. The suture is carried out of the wound to capture the proximal end of a dermal graft. The suture is passed back through the tunnel and out the dorsal skin, exiting near the entrance of the previous suture. The dermal graft is advanced through the tunnel by pulling on the sutures. The suture is tied, securing the dermal graft in the tunnel. The excess length of the dermal graft is excised, and the wound is closed with a single nylon suture. Both sides (medial and lateral) of the nail plate are done in the same way.
  • A silastic sheet (the old nail won't work here--wrong shape) is introduced into the eponychial fold. The sheeting is removed in approximately 10 days. The procedure has had excellent results in restoring the nature contours of the nail plate.

Loss of the eponychium with synechiae

  • Entirely removing the nail plate is often necessary to see the remaining edges of the proximal nail fold. As with the other deformities, any scar tissue of the nail bed, matrix, etc must be removed.
  • Composite grafts can be obtained from the large or second toe. These composite grafts include the dorsal roof of the eponychial fold as well as the dorsal skin.
  • The composite graft is sutured in place with a 7-0 chromic and 6-0 nylon sutures, and the nail plate is replaced. The surgical site is then covered with sterile gauze and dressed as described previously.
  • The survival of the grafts can be precarious. The postoperative immobilization must be meticulous.
  • Occasionally enough skin is available on the dorsum (top) of the finger to rotate or transpose as local flaps to the eponychium. A split sterile matrix graft can then be sutured to the undersurface of the flap to restore the dorsal roof bed. The donor site of the flap is closed primarily or covered with a split-thickness skin graft.

COMPLICATIONS / OUTCOMES

The results of the initial repair are far better than reconstructive attempts.

Infections to the nail bed following repair are uncommon.

Split-thickness sterile matrix grafts are required for areas of nail bed loss. The excellent results obtained from split grafting the nail bed defects have made this procedure common practice for most hand surgeons. The donor site heals without difficulty with most authors reporting no residual deformities secondary to graft harvesting. Orientation of the split graft on the recipient bed does not affect adherence or nail plate morphology. Though most will have good results, some patients may have some nail plate irregularity with linear ridging or distal nonadherence (usually at the site of the initial avulsion and not at the site of donor harvesting).

Germinal matrix defects must be treated with a full-thickness germinal matrix graft. The type of material (silicone sheet, nail plate, sterile petroleum jelly-impregnated gauze) placed in the eponychial fold does not appear to influence the final outcome and appearance of the regenerating nail plate.

It can not be said enough:

Careful initial repair has a better outcome than secondary reconstructive surgery.

REFERENCES

Nail Pathology; Michael Neumeister MD and Dimitrios Danikas MD; eMedicine Article, October 27, 2004

The Perionychium; Zook EG, Brown RE; In: Green DP, ed. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone; 1999.

Nailfold Reconstruction for Correction of Burn Fingernail Deformity; Plastic & Reconstructive Surgery, 117(7):2303-2308, June 2006; Donelan, Matthias B. M.D.; Garcia, Jesus A. M.D., Ph.D.

Nail Transfer: Evolution of the Reconstructive Procedure; Plastic & Reconstructive Surgery. 100(4) Supplement 1:907-913, September 1997; Endo, Takashi M.D.; Nakayama, Yoshio M.D.; Soeda, Shougo M.D.

Nail Lengthening and Fingertip Amputations; Plastic & Reconstructive Surgery. 112(5):1287-1294, October 2003; Adani, Roberto M.D.; Marcoccio, Ignazio M.D.; Tarallo, Luigi M.D.

Nail Regeneration by Elongation of the Partially Destroyed Nail Bed; Plastic & Reconstructive Surgery. 111(1):167-172, January 2003; Lemperle, Gottfried M.D., Ph.D.; Schwarz, Martin M.D.; Lemperle, Stefan M. M.D.

Nail Surgery; Neh Onumah MD and Richard Scher MD; eMedicine Article, September 18, 2006

Sunday, February 10, 2008

Call for Submissions--SurgeXperiences 115

Chris over at Made a Difference will be hosting SurgeXperiences 115 on February 17. Submissions should be made by February 15th. He has asked:
 
"Please send me your impressions of the effect of war on surgery, of surgery on war, and any observations, musings, or comparisons from inside or outside the theater of war. Please submit your entries here, or if it is easier, you can email them to me here."
 
The current SurgeXperiences is up here at Notes of an Anesthesioboist.
 
Here is the catalog of past surgXperiences editions.   If you wish to host a future edition, please contact Jeffrey who runs the show here.