Letters to the Editor / Injury, Int. J. Care Injured 45 (2014) 2110–2119 b
Key Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, PR China
*Corresponding
author at: Department of Orthopedic Center, Third Hospital of Hebei Medical University, No. 139 Zi Qiang Road, Shijiazhuang, Hebei 050051, PR China. Tel.: +86 0311 8860 3682; fax: +86 0311 8702 3626 E-mail addresses: [email protected] (Y. Liu), [email protected] (Y. Zhang). http://dx.doi.org/10.1016/j.injury.2014.07.024
Letter to the Editor Disability after nondisplaced and minimally displaced radial head fractures: Misleading conclusions Smits and colleagues [1] assume that upper extremity symptoms and disability (DASH scores) an average of 3.8 years following nonoperative treatment of nondisplaced and minimally displaced radial head fractures relate directly to impairment resulting from that injury. In doing so, they ignore extensive evidence that symptoms and disability have limited correlation with pathophysiology and impairment and are most highly correlated with mood, coping strategies, and circumstances [2–4]. We know that nondisplaced and occult fractures of the radial head without associated ligament injury or other fractures result in minimal impairment, mostly a very slight loss of extension. We would not expect this to create substantial symptoms or disability. This paper represents both a missed opportunity to clarify this for orthopaedic surgeons as well as an unfortunate reinforcement of the myth that there is a direct correspondence between disease (pathophysiology) and illness (symptoms and disability). Conflict of interest None declared. References [1] Smits AJ, Giannakopoulos GF, Zuidema WP. Long-term results and treatment modalities of conservatively treated Broberg–Morrey type 1 radial head fractures. Injury 2014. http://dx.doi.org/10.1016/j.injury.2014.05.034. [2] Bot AG, Doornberg JN, Lindenhovius AL, Ring D, Goslings JC, van Dijk CN. Longterm outcomes of fractures of both bones of the forearm. J Bone Joint Surg Am 2011;93:527–32. [3] Lindenhovius AL, Doornberg JN, Ring D, Jupiter JB. Health status after open elbow contracture release. J Bone Joint Surg Am 2010;92:2187–95. [4] Menendez ME, Bot AG, Hageman MG, Neuhaus V, Mudgal CS, Ring D. Computerized adaptive testing of psychological factors: relation to upper-extremity disability. J Bone Joint Surg Am 2013;95:e149.
Mariano E. Menendez David Ring* Orthopaedic Hand and Upper Extremity Service, Yawkey Center, Suite 2100, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA *Corresponding author. Tel.: +1 617 643 7527; fax: +1 617 726 0460 E-mail addresses: [email protected] (M.E. Menendez), [email protected] (D. Ring). http://dx.doi.org/10.1016/j.injury.2014.07.023
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Letter to the Editor Iatrogenic lung injury on radiological evidence: Is it always wise to blindly follow the image? Dear Editor, I read with interest the article by Kong and Clarke [1]. The authors have done a great service in publishing the mistakes made by medical professionals in attempting to address chest injuries and pleural pathologies. I wanted to, if I may, make a more general point regarding the incidence and management of iatrogenic injuries in the chest. Those of us in the cardiothoracic surgical community regularly encounter referrals of unfortunate patients with chest drains in the wrong place. However, we have also encountered instances where an iatrogenic injury has been reported on Computer Tomography (CT) scanning as a result of chest drain malposition but which have in fact turned out to be false. In the last year for instance we have had a radiologically reported case whereby a large-bore chest drain had been inserted into a large bulla inadvertently and another whereby a large-bore chest drain had been inserted into lung parenchyma. Both indications for drainage were pneumothoraces. Both reports turned out to be inaccurate upon surgical confirmation. This is highly unfortunate as patients would have unnecessary procedures based upon the CT report of an iatrogenic injury. The cases illustrate that iatrogenic injuries may actually be over-reported as artefacts may be present on the CT which inadvertently give the impression of something more sinister [2]. These ‘pseudo iatrogenic injuries’ have been reported elsewhere. A rather incisive German paper reported numerous instances whereby large bore chest drains appear to enter the lung parenchyma but in actual fact do not [3]. Their explanations for the discrepancy include the fact that firstly the chest drain is in a fissure and this may not be obvious on the CT. Secondly, large bore drains may cause a ‘sinking’ effect of the surrounding parenchyma to deceive one into thinking that the drain is going through the lung. It is worth noting that large-bore drains should be inserted using an open technique. If this is the case and one bluntly dissects down to the intercostal space, opens the parietal pleura, removes any adhesions with their finger and only then introduces the chest drain, the chances of that drain going into the lung are almost impossible. The exception would be the blind introduction of a large chest drain via a trocar which the authors correctly highlight. The 19th century Danish philosopher, Søren Kierkegaard, once said ‘‘There are two ways to be fooled. One is to believe what isn’t true; the other is to refuse to believe what is true’’ [4]. The intelligence and ability to critically differentiate what is presented in front of them and not be fooled is the unnerving skill of the surgeon. Hence, whilst I acknowledge the importance of identifying and treating iatrogenic injuries following chest drains, we must be equally cautious in blindly following CT reports which suggest iatrogenic injury without assessing the patient clinically and making a more prudent diagnosis which can otherwise result in unnecessary distress for the patient. Conflict of interest The author declares no conflict of interest. References [1] Kong VY, Clarke DL. The spectrum of visceral injuries secondary to misplaced intercostal chest drains: experience from a high volume trauma service in South
Letters to the Editor / Injury, Int. J. Care Injured 45 (2014) 2110–2119
2118
Africa. Injury 2014. http://dx.doi.org/10.1016/j.injury.2014.05.013. pii:S00201383(14)00252-6, [Epub ahead of print]. [2] Filograna L, Tartaglione T, Filograna E, Cittadini F, Oliva A, Pascali VL. Computed tomography (CT) virtual autopsy and classical autopsy discrepancies: radiologist’s error or a demonstration of post-mortem multi-detector computed tomography (MDCT) limitation? Forensic Sci Int 2010;195(1–3):e13–7. [3] Flu¨ckiger F, Kullnig P, Ju¨ttner-Smolle F, Melzer G. The intrapulmonary pseudomalposition of chest tubes in the computed tomogram (CT). Rofo 1991;155(6):494–8. [4] Kierkegaard S. The essential Kierkegaard. Princeton University Press; 2000.
Priyadharshanan Ariyaratnam* Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham HU165JQ, United Kingdom *Tel.: +44 01482461625 E-mail address: [email protected] (P. Ariyaratnam).
http://dx.doi.org/10.1016/j.injury.2014.07.022
Fig. 1. Open right middle third tibia fracture which was first treated with open reduction and external fixation. The postoperative period was complicated by wound infection and bone exposure.
Letter to the Editor
with derotation of the flap to its original position, local heparinization, small punctures or using leeches. Strategies to improve venous flow should then be considered by reconstructive surgeons. We present a case of a 50-year-old male with an open right middle third tibia fracture after being ran over be a tractor. Open reduction and external fixation was initially performed. The postoperative period was complicated by wound infection and bone exposure (Fig. 1). The wound was debrided and reconstructed with a fasciocutaneous perforator-based propeller (908 rotation) flap. The flap was dissected in the suprafascial plane until the vicinity of the marked perforators was reached, and then subfascial to facilitate the localization and incorporation of two posterior tibial artery perforators. Venous supercharging was performed using a tributary branch from the great saphenous vein, which was found at the same axial plane of the perforators, and so, without additional restrictions in flap transposition, mobility and rotation capacity (Fig. 2). The donor site was grafted with split-skin graft. Healing was uneventful (Fig. 3). We adopted the concept of free-style perforator-flap surgery to reconstruct a lower limb defect. Flap design and harvest were accomplished according to previous Doppler mapping, adjacent to the soft-tissue defect. Venous supercharging was performed by incorporating an axial tributary vein, without compromising the
Perforator-based propeller flap with venous axial supercharging for reconstruction of a leg defect Reconstruction of lower limb defects has always been a challenge because of the limited availability of local flaps [1]. Local muscle flaps can be used to treat difficult wounds of the lower limb but these can be associated with impaired function due to local muscle sacrifice [2]. With the development of perforator flaps, more predictable flaps have become accessible for lower limb reconstruction, without the morbidity at the donor site seen with conventional musculocutaneous flaps, and providing an excellent colour and texture match [1,3]. A perforator-based propeller flap is an island-shaped flap that incorporates the perforators and can be rotated around an axis. The inconvenience of this flap is its limited size [4]. Thus, when the defect size and vascular status of the nearby tissues grant a reconstruction with local perforator flaps, the surgery and the morbidity can be limited to one body area. One perforator-based flap offer the widest arc of rotation, serving as propeller flaps, but if more than one perforator vessel was preserved flap mobility may be limited, however, the flap still can be used as a rotation or advancement flap. If the flap is based on a single perforator, the perfusion in this perforator will increase and contribute to the recruitment of adjacent perforasome territories, which are interconnected by direct and indirect (choke vessels) linking vessels. Besides their advantages, there are also some possible drawbacks in using these flaps. It is necessary to establish the realistic dimensions of such a flap, and the safe vascular limits of a perforator pedicle. The identification of perforators by Doppler examination can lead to possible false positive and negative results, due to the superficial location of the main axial source vessels in the lower limb, and it seems more reasonable to find the perforators during surgery by careful microsurgical dissection. The most important complication is complete or partial flap loss in consequence of venous problems. Venous congestion of the tip or of the entire flap is usually related to the insufficient flow in the perforator pedicle, because of inadequate selection of the perforator, insufficient dissection and mobilization around the vein. If venous congestion is observed intra-operatively, venous supercharging of the flap can be done by performing a microvascular venous anastomosis, and other flaps may be saved
Fig. 2. A propeller perforator flap was used for reconstruction. The flap was based on two posterior tibial artery perforators. A venous branch of the great saphenous vein was found at the same rotational plane and included in the flap (identified with a blue Medi-Loop1).
Key Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, PR China
*Corresponding
author at: Department of Orthopedic Center, Third Hospital of Hebei Medical University, No. 139 Zi Qiang Road, Shijiazhuang, Hebei 050051, PR China. Tel.: +86 0311 8860 3682; fax: +86 0311 8702 3626 E-mail addresses: [email protected] (Y. Liu), [email protected] (Y. Zhang). http://dx.doi.org/10.1016/j.injury.2014.07.024
Letter to the Editor Disability after nondisplaced and minimally displaced radial head fractures: Misleading conclusions Smits and colleagues [1] assume that upper extremity symptoms and disability (DASH scores) an average of 3.8 years following nonoperative treatment of nondisplaced and minimally displaced radial head fractures relate directly to impairment resulting from that injury. In doing so, they ignore extensive evidence that symptoms and disability have limited correlation with pathophysiology and impairment and are most highly correlated with mood, coping strategies, and circumstances [2–4]. We know that nondisplaced and occult fractures of the radial head without associated ligament injury or other fractures result in minimal impairment, mostly a very slight loss of extension. We would not expect this to create substantial symptoms or disability. This paper represents both a missed opportunity to clarify this for orthopaedic surgeons as well as an unfortunate reinforcement of the myth that there is a direct correspondence between disease (pathophysiology) and illness (symptoms and disability). Conflict of interest None declared. References [1] Smits AJ, Giannakopoulos GF, Zuidema WP. Long-term results and treatment modalities of conservatively treated Broberg–Morrey type 1 radial head fractures. Injury 2014. http://dx.doi.org/10.1016/j.injury.2014.05.034. [2] Bot AG, Doornberg JN, Lindenhovius AL, Ring D, Goslings JC, van Dijk CN. Longterm outcomes of fractures of both bones of the forearm. J Bone Joint Surg Am 2011;93:527–32. [3] Lindenhovius AL, Doornberg JN, Ring D, Jupiter JB. Health status after open elbow contracture release. J Bone Joint Surg Am 2010;92:2187–95. [4] Menendez ME, Bot AG, Hageman MG, Neuhaus V, Mudgal CS, Ring D. Computerized adaptive testing of psychological factors: relation to upper-extremity disability. J Bone Joint Surg Am 2013;95:e149.
Mariano E. Menendez David Ring* Orthopaedic Hand and Upper Extremity Service, Yawkey Center, Suite 2100, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA *Corresponding author. Tel.: +1 617 643 7527; fax: +1 617 726 0460 E-mail addresses: [email protected] (M.E. Menendez), [email protected] (D. Ring). http://dx.doi.org/10.1016/j.injury.2014.07.023
2117
Letter to the Editor Iatrogenic lung injury on radiological evidence: Is it always wise to blindly follow the image? Dear Editor, I read with interest the article by Kong and Clarke [1]. The authors have done a great service in publishing the mistakes made by medical professionals in attempting to address chest injuries and pleural pathologies. I wanted to, if I may, make a more general point regarding the incidence and management of iatrogenic injuries in the chest. Those of us in the cardiothoracic surgical community regularly encounter referrals of unfortunate patients with chest drains in the wrong place. However, we have also encountered instances where an iatrogenic injury has been reported on Computer Tomography (CT) scanning as a result of chest drain malposition but which have in fact turned out to be false. In the last year for instance we have had a radiologically reported case whereby a large-bore chest drain had been inserted into a large bulla inadvertently and another whereby a large-bore chest drain had been inserted into lung parenchyma. Both indications for drainage were pneumothoraces. Both reports turned out to be inaccurate upon surgical confirmation. This is highly unfortunate as patients would have unnecessary procedures based upon the CT report of an iatrogenic injury. The cases illustrate that iatrogenic injuries may actually be over-reported as artefacts may be present on the CT which inadvertently give the impression of something more sinister [2]. These ‘pseudo iatrogenic injuries’ have been reported elsewhere. A rather incisive German paper reported numerous instances whereby large bore chest drains appear to enter the lung parenchyma but in actual fact do not [3]. Their explanations for the discrepancy include the fact that firstly the chest drain is in a fissure and this may not be obvious on the CT. Secondly, large bore drains may cause a ‘sinking’ effect of the surrounding parenchyma to deceive one into thinking that the drain is going through the lung. It is worth noting that large-bore drains should be inserted using an open technique. If this is the case and one bluntly dissects down to the intercostal space, opens the parietal pleura, removes any adhesions with their finger and only then introduces the chest drain, the chances of that drain going into the lung are almost impossible. The exception would be the blind introduction of a large chest drain via a trocar which the authors correctly highlight. The 19th century Danish philosopher, Søren Kierkegaard, once said ‘‘There are two ways to be fooled. One is to believe what isn’t true; the other is to refuse to believe what is true’’ [4]. The intelligence and ability to critically differentiate what is presented in front of them and not be fooled is the unnerving skill of the surgeon. Hence, whilst I acknowledge the importance of identifying and treating iatrogenic injuries following chest drains, we must be equally cautious in blindly following CT reports which suggest iatrogenic injury without assessing the patient clinically and making a more prudent diagnosis which can otherwise result in unnecessary distress for the patient. Conflict of interest The author declares no conflict of interest. References [1] Kong VY, Clarke DL. The spectrum of visceral injuries secondary to misplaced intercostal chest drains: experience from a high volume trauma service in South
Letters to the Editor / Injury, Int. J. Care Injured 45 (2014) 2110–2119
2118
Africa. Injury 2014. http://dx.doi.org/10.1016/j.injury.2014.05.013. pii:S00201383(14)00252-6, [Epub ahead of print]. [2] Filograna L, Tartaglione T, Filograna E, Cittadini F, Oliva A, Pascali VL. Computed tomography (CT) virtual autopsy and classical autopsy discrepancies: radiologist’s error or a demonstration of post-mortem multi-detector computed tomography (MDCT) limitation? Forensic Sci Int 2010;195(1–3):e13–7. [3] Flu¨ckiger F, Kullnig P, Ju¨ttner-Smolle F, Melzer G. The intrapulmonary pseudomalposition of chest tubes in the computed tomogram (CT). Rofo 1991;155(6):494–8. [4] Kierkegaard S. The essential Kierkegaard. Princeton University Press; 2000.
Priyadharshanan Ariyaratnam* Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham HU165JQ, United Kingdom *Tel.: +44 01482461625 E-mail address: [email protected] (P. Ariyaratnam).
http://dx.doi.org/10.1016/j.injury.2014.07.022
Fig. 1. Open right middle third tibia fracture which was first treated with open reduction and external fixation. The postoperative period was complicated by wound infection and bone exposure.
Letter to the Editor
with derotation of the flap to its original position, local heparinization, small punctures or using leeches. Strategies to improve venous flow should then be considered by reconstructive surgeons. We present a case of a 50-year-old male with an open right middle third tibia fracture after being ran over be a tractor. Open reduction and external fixation was initially performed. The postoperative period was complicated by wound infection and bone exposure (Fig. 1). The wound was debrided and reconstructed with a fasciocutaneous perforator-based propeller (908 rotation) flap. The flap was dissected in the suprafascial plane until the vicinity of the marked perforators was reached, and then subfascial to facilitate the localization and incorporation of two posterior tibial artery perforators. Venous supercharging was performed using a tributary branch from the great saphenous vein, which was found at the same axial plane of the perforators, and so, without additional restrictions in flap transposition, mobility and rotation capacity (Fig. 2). The donor site was grafted with split-skin graft. Healing was uneventful (Fig. 3). We adopted the concept of free-style perforator-flap surgery to reconstruct a lower limb defect. Flap design and harvest were accomplished according to previous Doppler mapping, adjacent to the soft-tissue defect. Venous supercharging was performed by incorporating an axial tributary vein, without compromising the
Perforator-based propeller flap with venous axial supercharging for reconstruction of a leg defect Reconstruction of lower limb defects has always been a challenge because of the limited availability of local flaps [1]. Local muscle flaps can be used to treat difficult wounds of the lower limb but these can be associated with impaired function due to local muscle sacrifice [2]. With the development of perforator flaps, more predictable flaps have become accessible for lower limb reconstruction, without the morbidity at the donor site seen with conventional musculocutaneous flaps, and providing an excellent colour and texture match [1,3]. A perforator-based propeller flap is an island-shaped flap that incorporates the perforators and can be rotated around an axis. The inconvenience of this flap is its limited size [4]. Thus, when the defect size and vascular status of the nearby tissues grant a reconstruction with local perforator flaps, the surgery and the morbidity can be limited to one body area. One perforator-based flap offer the widest arc of rotation, serving as propeller flaps, but if more than one perforator vessel was preserved flap mobility may be limited, however, the flap still can be used as a rotation or advancement flap. If the flap is based on a single perforator, the perfusion in this perforator will increase and contribute to the recruitment of adjacent perforasome territories, which are interconnected by direct and indirect (choke vessels) linking vessels. Besides their advantages, there are also some possible drawbacks in using these flaps. It is necessary to establish the realistic dimensions of such a flap, and the safe vascular limits of a perforator pedicle. The identification of perforators by Doppler examination can lead to possible false positive and negative results, due to the superficial location of the main axial source vessels in the lower limb, and it seems more reasonable to find the perforators during surgery by careful microsurgical dissection. The most important complication is complete or partial flap loss in consequence of venous problems. Venous congestion of the tip or of the entire flap is usually related to the insufficient flow in the perforator pedicle, because of inadequate selection of the perforator, insufficient dissection and mobilization around the vein. If venous congestion is observed intra-operatively, venous supercharging of the flap can be done by performing a microvascular venous anastomosis, and other flaps may be saved
Fig. 2. A propeller perforator flap was used for reconstruction. The flap was based on two posterior tibial artery perforators. A venous branch of the great saphenous vein was found at the same rotational plane and included in the flap (identified with a blue Medi-Loop1).
