Site Of Laceration Research Articles

Triggering after partial tendon laceration

Triggering and tendon flap formation were studied after a transverse laceration of 50% of the width of the flexor digitorum profundus tendons of the hind limb of 14 adult sheep at various intervals after injury. The tendon laceration was not repaired and there was no post-operative immobilization. Triggering was not caused by bulbous scar formation but by the bunching of the tendon fibres proximal or distal to the laceration site. This bunched part of the tendon appeared to become incorporated into the healing process, with gradual spontaneous resolution of triggering. Failure of incorporation of this bunched part resulted in the formation of a flap in two tendons.

Posttraumatic spindle cell nodule of the buccal mucosa: Report of a case

A benign posttraumatic spindle cell proliferation arising at a site of laceration in the buccal mucosa of a 19-year old man is described. This lesion, which histologically mimicked a leiomyosarcoma, appears to represent a reactive process similar to that described as postoperative spindle cell nodules of the genitourinary tract. Reexcision of the area 1 month after biopsy revealed only scar formation and mild chronic inflammation. Recognition of this type of benign spindle cell proliferation at traumatized sites in the oral cavity is important if misdiagnosis and subsequent aggressive therapy is to be avoided.

Detection of bile leakage into the thoracic cavity by hepatobiliary scintigraphy

We report early detection of bile leakage into the thoracic cavity by hepatobiliary scintigraphy in a rare case of spontaneous withdrawal of the catheter for percutaneous transhepatic cholangiographic drainage (PTCD). An 81-year-old man with inoperable carcinoma of the common bile duct was readmitted with a 38 degrees C fever and suspected bile leakage from the hepatic biliary tree following withdrawal of the catheter for PTCD. While plain X-ray immediately after readmission revealed no abnormality in the chest or abdomen, hepatobiliary scintigraphy revealed not only bile leakage into the right thoracic cavity but also the site of laceration. We conclude that hepatobiliary scintigraphy is a simple, non-invasive procedure useful in the early detection and localization of bile leakage following spontaneous withdrawal of the catheter for PTCD.

Cyclic stress analysis of flexor tendon repair

A method of evaluating flexor tendon repair techniques with the use of cyclic testing is presented. This type of evaluation complements the presently used load-to-failure tests by providing more detailed information about gap formation at the repair site. During load-to-failure testing in this study, core sutures alone demonstrated initial gap formation at 0.85 kg tensile force or more; yet on cyclic testing all techniques demonstrated gap formation of 1.9 mm or greater at 0.5 kg tensile force. Thus cyclic testing demonstrated gap formation not readily apparent on load-to-failure testing. An epitenon stitch placed circumferentially around the laceration site added strength in both load-to-failure and cyclic tests, and significantly reduced gap formation regardless of the core suture technique.

Intrinsic healing of the laceration site in human superficialis flexor tendons in vitro

The intrinsic capability of the human superficialis flexor tendon to heal a reapproximated laceration site in vitro was examined. Segments of lacerated and sutured human superficialis flexor tendons from zone II were cultured for two, four, or eight weeks in vitro and analyzed by use of light and electron microscopy. We noted a specific pattern of intrinsic healing at the repair site during the incubation period. After two weeks, the cells of the epitenon from both tendon stumps proliferated and appeared to migrate into the repair site. Elongated cells of the thickened epitenon bridged the laceration and synthesized new collagen fibers. By eight weeks, a smooth contiguous tendon surface was restored and the internal collagen bundles were brought into intimate contact. The fibroblasts bridging the laceration, both in the epitenon and centrally in the repair site, were oriented perpendicular to the cut surfaces. The cells in the repair site were active in protein synthesis, and new collagen fibers were present. No cellular necrosis was observed in the internal repair site. Our results indicate that human superficialis tendons possess an intrinsic capacity to heal with diffusion and without dependence on extratendinous cells or on adhesions.

Compartment syndrome caused by false aneurysm

A case is reported in which the measurement of compartment pressures using a blood pressure transducer (Matsen, Winquist and Krugmire 1980) provided the diagnosis of arterial false aneurysm as the cause of a compartment syndrome. Case report. An 18-year-old man gave a history of striking the ulnar border of his left forearm against a wardrobe. He sustained a small cut which was sutured, but one week later he noticed increasing pain in the forearm, inability to move the fingers effectively and parasthesiae in a!! the fingers. On examination, there was tenderness over the forearm flexor muscles, the fingers could not be extended actively or passively beyond the mid-position, and there was decreased sensation to light touch in the fingertips. A diagnosis of compartment syndrome was made and soft tissue swelling seemed to be the cause. Under genera! anaesthesia, the pressure within the three forearm muscle compartments was measured using a standard blood pressure transducer (Matsen et a! 1980). The pressure in the common extensor compartment was 29 mmHg and in the lateral compartment (brachioradia!is and wrist extensors) it was 18 mmHg, but in the flexor muscle mass, the pressure was 60/50 mmHg, in an oscillating wave-form resembling an arterial pulse. The tip ofthe cannula was moved within the compartment so that it was away from the vessels, but the pulsati!e recording continued. A false aneurysm was suspected and on re-examination it was possible to detect faint pulsation of the swollen forearm. On exploration, a large haematoma was evacuated from within the flexor muscles and a false aneurysm was observed near the site of the skin laceration (Fig. 1). The opening in the artery was repaired and a flexor compartment fasciotomy performed ; the other compartments were not decompressed because the pressure had fallen to below 10 mmHg. After 10 days the skin wound was closed and five weeks later he had regained full movement, power and sensation in the forearm ; clinically, both the radial and the u!nar artery at the wrist were patent.

Which renal lacerations will heal satisfactorily with nonsurgical management?

If there was a correlation between the type of renal laceration and its healing, and if radiologic evaluation on admission could accurately diagnose the type of renal laceration present, then surgical intervention could be reserved for those renal lacerations that will not heal satisfactorily by themselves. We reviewed the outcome of initially conservative or immediate operative treatment of renal laceration in 122 patients. Thirty-six patients were managed initially without operation. All fifteen cortical lacerations and all five deep lacerations that created only a small parenchymal defect healed themselves, with 4 of the 16 patients available for follow-up having hypertension. In contrast, six deep lacerations that caused large parenchymal defects, six disrupted poles or segments, and four split kidneys did not have satisfactory healing with conservative management, necessitating delayed renal surgery, or causing hypertension or both. Because computed tomography on admission can accurately diagnose the site and extent of a renal laceration, it should be possible to decide early which patients truly will benefit from conservative management.

Regional Differences in Matrix Formation in the Healing Flexor Tendon

In 20 white leghorn chickens, the effect of proximity (proximal vs. distal) to the repair site and the effect of sheath excision versus sheath repair on biochemical matrix formation in the healing zone 2 flexor tendon were studied. In 14 animals, the profundus tendon of the long toe on both feet was lacerated and repaired in zone 2. In the right foot, the sheath was repaired, and on the left foot, the sheath was excised. Segments proximal and distal to the laceration site were studied at six weeks postrepair compared to control segments. Sheath excision versus sheath repair had no effect on the net matrix formation of the healing flexor tendon. A higher DNA content and lower hydroxyproline and hexosamine contents were present in the healing tendons, indicating the healing process was not complete at six weeks. Sheath excision versus sheath repair had no effect on net matrix formation in the healing tendon. There is no difference in DNA content or glycosaminoglycan content in the proximal versus distal segments. There was a significantly greater net hydroxyproline content in the proximal segment versus the distal segment of the healing tendon, which was not present in similar control segments. These results support the concept that the zone 2 flexor tendon does not respond to injury as a homogeneous structure.

Intrinsic restoration of the flexor tendon surface in the nonhuman primate

A pattern of restoration of the smooth gliding surface was noted in lacerated monkey flexor tendon segments maintained in a cell free tissue culture environment over a 9-week period. The epitenon fibroblasts proliferated and migrated into the laceration site, forming collagen fibers that bridged the defect. After the smooth tendon surface was restored, the epitenon cellular response diminished.

Application of 2-dimensional contrast studies during pericardiocentesis

Two-dimensional echocardiographic contrast studies were performed in 16 patients with pericardial effusion. A 4-chamber view was obtained by positioning the transducer at the apex. The exploratory needle was visualized in 9 patients. Five milliliters of saline solution were injected through the exploring needle and a cloud of echoes indicated its position. Microbubbles were seen in all 16 patients. This technique enabled the operator to identify that the needle was inadvertently in the left ventricle in 2 patients and in the right ventricle in 1. Furthermore, in 2 patients, when fluid could not be aspirated, the contrast study confirmed that the needle was in the pericardial sac; in both cases, pericardial fluid could be aspirated with slight manipulation of the needle. In a patient with a stab wound a negative contrast effect indicated the probable site of laceration. Thus, 2-dimensional contrast echocardiography was useful in locating needle position, which facilitated pericardiocentesis.

Laceration of the inferior vena cava of angiographic demonstration

Laceration of the inferior vena cava (IVC) often presents as an acute surgical emergency requiring immediate operative intervention. We show that when the patient's clinical condition permits, angiography may delineate the site of caval laceration and active hemorrhage, and identify associated arterial injuries. Contrast extravasation from the IVC also is reported for the first time.

Giant Cell Tumor of Tendon Sheath Developing at the Site of Tendon Laceration

A 32-year-old man suffered sharp trauma to the volar aspect of the wrist. A lacerated tendon found on exploration had been left unrepaired and the skin closed primarily. A few months later the patient presented with a nodule at the same site. Reoperation demonstrated a 2 X 1 cm nodule bridging the gap between the stumps of the previously severed palmaris longus tendon. Pathologic examination of the nodule revealed the typical microscopic appearance of giant cell tumor of tendon sheath (GCTTS) in continuity with the lacerated tendon. The literature regarding the relationship of trauma to the development of GCTTS presents interesting controversy about whether this lesion is reparative or neoplastic.

Transplantation of Lacerated Corneas

We performed penetrating keratoplasties in eight eyes with opaque corneas from healed corneal lacerations that extended into the corneoscleral limbus. We found dense fibrovascular membranes that extended from the laceration site over the surface of the iris into the angle in several cases and posteriorly to involve the ciliary body in all cases. In seven eyes moderate to severe increases of intraocular pressure occurred postoperatively. Additionally, five eyes had retinal detachments which were either present at the time of surgery or which developed postoperatively. The corneal grafts remained transparent in all eight eyes and visual acuity improved in four.

Ruptured human renal allograft Pathogenesis and management

From January, 1963, to January, 1977, 4 cases of acute allograft rupture occurred in 474 renal transplants performed at the Cleveland Clinic, an incidence of 0.8 per cent. Rupture developed between the fifth and sixteenth day after transplantation during a period when the patients required dialysis because of poor allograft function. All patients had surgical exploration and successful repair of the laceration. Biopsies in each case at the site of laceration revealed findings consistent with acute allograft rejection. The rejections were mild in 2 cases, moderate in one, and severe in another. Two kidneys failed to sustain function, and the patients were returned to chronic hemodialysis two to five months later. None required a nephrectomy. The other two kidneys are functioning well, with serum creatinine values of 1.3 and 1.5 mg./100 ml. one year after allograft rupture. Since rupture of a renal allograft does not appear to increase the intensity of rejection nor does it represent a severe type of rejection, transplant nephrectomy can be avoided unless hemorrhage is uncontrollable from the site of laceration.

Control of experimental traumatic renal hemorrhage by embolization with autogenous blood clot.

Hemorrhage from artificially produced renal lacerations was controlled by selective arterial embolization with either plain or Amicar-mixed autogenous blood clot in ten dogs. The laceration sites healed as renal scars. Despite the presence of scattered, small renal infarcts caused by the embolization, hypertension did not develop in any dog during the two-month follow-up. No long-term differences could be detected between kidneys embolized with plain or modified clot. Although it is recognized that dogs have a more active fibrinolytic system than humans, the results of this study suggest that selective arterial embolization is a feasible method for controlling renal hemorrhage.

Superficial temporal artery aneurysms.

Traumatic aneurysms of the extracranial segment of the external carotid artery are rare. With the exception of four cases involving the facial artery (1–4) and one involving the retroparotid segment of the external carotid artery (6), the site of aneurysm is always the superficial temporal artery. Winslow and Edwards (5) in 1935 reviewed the world literature and were able to find fewer than 100 cases of post-traumatic aneurysms of the superficial temporal artery. Occasional case reports have appeared in the literature since that time. Because of the rarity of these aneurysms, we are reporting two cases demonstrated by selective external carotid angiography. Case Reports Case I: C. M., a 62-year-old white woman with a past history of a cerebrovascular accident, fell at home, striking her head. She was examined in the Emergency Department of the Boston City Hospital. Small contusions over the right orbit and in the right temporal area were noted. The patient was discharged and remained asymptomatic for three days until she was found semistuporous in bed. On examination she was drowsy but responded to verbal stimuli. Under the resolving contusion in the right temporal area were two 5 mm pulsatile masses, the pulses synchronous with the radial pulse. Compression of the superficial temporal artery obliterated the pulses. Skull roentgenograms showed no evidence of fracture. A right internal carotid angiogram was normal. Right external carotid angiography, performed to permit study of the pulsatile mass over the scalp, disclosed 2 saccular aneurysms of the superficial temporal artery (Figs. 1 and 2). After the coma cleared, both aneurysms were excised. They proved to be false aneurysms of the superficial temporal artery, that is, the lining of the aneurysms was fibrous connective tissue rather than intima. Case II: C. H., a 28-year-old Negro male, was struck in the left temple with a bottle and a 2 cm laceration was produced. The patient controlled the bleeding by compression; he was not seen by a physician, and the laceration was not sutured. Approximately one week later the patient noted a pulsatile mass at the laceration site, but because it was painless, he did not seek medical attention. Bifrontal headaches developed shortly thereafter, and by three months they had become persistent and incapacitating. Examination showed a 1 em pulsatile mass in the left temporal area. The mass could be reduced and the pulse obliterated by compressing the ipsilateral superficial temporal artery. Skull radiographs were normal. Left external carotid angiography showed a saccular aneurysm (Figs, 3 and 4) with a well delineated neck. Because of the regression of the headache and lack of further expansion, it was elected to follow the patient clinically rather than to excise the lesion. Discussion A false aneurysm is an organized hematoma which retains its communication with the arterial lumen.

A study of fourth degree perineal lacerations and their sequelae

One hundred thirty-four cases of fourth degree perineal lacerations, with follow-up on 126, have been studied. These occurred in 9,757 vaginal deliveries at the Moses H. Cone Memorial Hospital, an incidence of 1.73. Of these, 88 per cent occurred in primigravidas; 96 per cent of the patients had forceps deliveries and 100 per cent had median episiotomies. Prophylactic antibiotics, special diets, and laxatives were used sparingly and seemed to follow the whim of the obstetrician rather than any pattern of indication. Seven complications are encountered, 4 of which were related to the laceration. There were 2 rectovaginal fistulas, one occurring early the other late. The late fistula healed spontaneously in 4 months but there was no follow-up on the early fistula. There were 2 rectal hemorrhages from the site of laceration. Both were controlled by suture through the rectum.

Urgent surgery for finger flexor tendon and nerve lacerations; with emphasis on advancement of the divided profundus tendon distal to the level of laceration.

Injuries to the flexor surfaces of the fingers and thumb may divide the tendons of the superficial and deep flexor muscles, damage the corresponding tendon sheaths, or interrupt digital sensory nerves. The effects on functions are devastating, especially if both the profundus and the sublimis tendons have been cut, unless surgical repair is successful. Infection, rough handling, probing, and too much dissection make for poor results. In very clean wounds an expert can restore fair or good function. When the surgeon encounters a contused or contaminated wound, or is in doubt how to proceed, he will best serve the patient by cleansing the wound and closing it without tendon repair. After the wound is well healed, a tendon graft can be performed. The techniques here described emphasize the possibility of locating the tendon sutures at levels other than the site of laceration, so as to minimize adhesion and scarring. In some situations it is necessary to excise the sublimis tendon and rely on suturing the profundus. If the profundus tendon has been divided by a laceration less than 2 cm. from its insertion, the proximal end of the lacerated tendon can be advanced for attachment to the distal phalanx. It is essential that the wrist and finger joints be kept in a properly flexed position by external immobilization during the period of healing.

HYPERTENSION IN A PATIENT WITH A SOLITARY ISCHEMIC KIDNEY

Goldblatt1and others have shown that hypertension develops in dogs and in monkeys when one kidney is made ischemic by partially clamping its artery. The hypertension is more readily produced when one kidney is first removed. This case is reported because of its bearing on previous work and because no analogous case has been found in the literature. REPORT OF CASE History.— A man aged 57, who first came to the University of Chicago Clinics July 27, 1937, had pneumonia at the age of 30 but was otherwise well until December 1935, when he fell down a flight of stairs. The same day the right kidney was removed because of laceration. Histologic preparations of the removed kidney showed no pathologic changes except massive hemorrhage at the site of laceration (fig. 1). After the operation thrombophlebitis developed in the legs, but otherwise the patient recovered without difficulty. He was well