Small Laceration Research Articles

Subcutaneous emphysema during surgical gingival depigmentation: a case report

BackgroundSubcutaneous emphysema related to dental procedures is well documented in literature. It usually occurs during or within minutes to hours after dental treatment and can be easily diagnosed by the presence of crepitus on palpation. Although it is self-limiting, it can develop to potentially life-threatening complications.Case presentationTo the authors knowledge, this is the first report documenting the development of subcutaneous emphysema in a 22-year-old Egyptian female during lower surgical gingival depigmentation using NSK high speed, air driven handpiece operated at 0.25 MPa. Sudden swelling developed involving the right side of the face and immediate diagnosis of subcutaneous emphysema was made on the basis of the presence of crepitus during palpation of the swollen area. Intraoral examination revealed small tissue laceration of the loosely attached alveolar mucosa through which the pressurized air might have passed into the fascial spaces. Complete resolution of the swelling occurred after 7 days without further complications.ConclusionStraightforward surgical procedures, such as gingival depigmentation, can be complicated by the development of subcutaneous emphysema. The crucial role of dentists is to be aware of its signs and to immediately diagnose and manage it to avoid further complication.

Get the lead out-unusual ballistic patterns can lead to diagnostic delay

Slingshot injuries have been rarely reported in the literature and while the value of three dimensional imaging, intravenous antibiotics and exploration under anaesthesia remain the mainstay of treatment, this case highlights the need for careful examination when the clinical presentation is seemingly innocuous. Our initial working assumption was that the palpable lump was likely to be an old injury, supported by the single small laceration which seemed an unlikely entry wound due to its size and distant anatomical location. However, blunt exploration of the would revealed a tract, favouring emergent rather than elective management. We therefore highlight to the maxillofacial community the possibility of explosive residue having migrated or being found distant to impact location.

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for Gender Affirmation [ID 2683658

INTRODUCTION: The process of transitioning from female to male in transgender persons usually includes medical treatment as well as surgical interventions, including removal of the uterus and ovaries. Nulliparity and prolonged exposure of the vaginal mucosa to testosterone, which are common among transgender men, may present challenges to perform a vaginal hysterectomy with salpingo-oophorectomy. The aim of this study is to describe outcomes of vaginal-assisted natural orifice transluminal endoscopic surgery (vNOTES) approach to perform hysterectomy among transgender men as part of their gender-affirming care. METHODS: This is a case series observational study conducted at single tertiary medical center including all patients undergoing hysterectomy with bilateral salpingo-oophorectomy by vNOTES approach for gender-affirming care between February 2022 and April 2023. Primary outcome was defined as compound complication rate including intraoperative and postoperative. Patients' demographic and clinical charectaristics were collected from the electronic medical files. Pain at postoperative follow-up was evaluated using visual analog scores, which ranges from 0 (no pain) to 10 (worst pain possible). RESULTS: The study population included eight transgender men, all of whom were nulliparous and had undergone testosterone treatment for more than a year. Median age at surgery was 24 years and median body mass index was 30 kg/m2. Mean operative time of the surgery was 111 minutes (range: 91–143 minutes) and none required converting from vNOTES to an alternative approach. No extensive bleeding or organ damage was reported. For one patient, there was one small vaginal laceration requiring suture. All but one patient was discharged the same day. The patient requiring next-day discharge was complicated by postoperative urinary retention. On postoperative follow-up, median pain score was 3 (range: 1–5). CONCLUSION: Outcomes from this case series suggest that a vNOTES approach to hysterectomy among transgender men can be performed without surgical complications and with low self-reported pain.

Revealing digital nerve lesions–A comprehensive analysis of 2084 cases of a specialized center

BackgroundFinger nerve injuries have a significant impact on hand function and can result in reduced sensation, pain and impaired coordination. The socioeconomic implications of these injuries include decreased workplace productivity, reduced earning potential, and financial burdens associated with long-term medical treatment and rehabilitation. However, there is a lack of comprehensive literature regarding the incidence, mechanisms, and associated injuries of finger nerve lesions. MethodsA retrospective analysis was conducted on patients treated at our institution from January 2012 to July 2020. Cases of peripheral finger nerve lesions were identified using the digital hospital information system and ICD-10 Classification. Exclusion criteria included injuries to the median nerve at the carpal tunnel level or superficial branch of the radial nerve. Data were collected using a pseudonymized approach, and statistical analyses were performed using SPSS Statistics (Version 27). ResultsA total of 2089 finger nerve lesions were analyzed, with a majority of cases occurring in men. Most injuries97.4 % were caused by trauma, predominantly cut/tear injuries. Isolated finger nerve injuries were more common than multiple nerve injuries, with the index finger being the most frequently affected. Concomitant tendon and vascular injuries were observed in a significant proportion51.7 % of cases. Surgical management included direct nerve coaptation, interposition grafting and neurolysis. DiscussionFinger nerve injuries are the most prevalent type of nerve injury, often resulting from small lacerations. These injuries have substantial societal costs and can lead to prolonged sick leave. Understanding the epidemiology and etiology of finger nerve injuries is crucial for implementing effective preventive measures. Accompanying tendon injuries and the anatomical location of the nerve lesions can impact sensory recovery and treatment outcomes. Proper management of peripheral finger nerve lesions is essential for optimizing functional outcomes and minimizing the impact on daily activities. Treatment options should be tailored to the severity and underlying cause of the nerve injury.

Bilomas in a dog secondary to a bite injury

AbstractAn entire, Pomeranian, female dog was presented to the emergency unit with anorexia, fever, abdominal pain, jaundice and an inguinal hernia. The patient had been bitten by a dog 2 weeks earlier and was on antibiotics and non‐steroidal anti‐inflammatory drug without improvement. Ultrasonographic exam showed peritoneal effusion and hepatic cystic lesions. Fluid analysis was compatible with bile. Bilomas and an inguinal hernia were diagnosed. Computed tomography scan did not reveal the origin of the bilomas. Ultrasound‐guided drainage of the bilomas resulted in a slight improvement. The patient worsened, and an exploratory laparotomy was recommended. The owner declined the surgery due to a guarded prognosis and the dog was humanely euthanased. On postmortem examination, a small laceration of the common bile duct was observed, which was probably the cause of the biliary peritonitis. To the authors’ knowledge, this report represents the first description of intrahepatic bilomas secondary to a bite injury.

A rare case of delayed CSF leakage from the sphenoid sinus due to a stabbing

A patient with a non-missile penetrating brain injury might present fully conscious without any neurological deficit with a small linear laceration on skull as the only sign of injury. We present a 27-year-old man who was referred to us with new onset CSF leakage as rhinorrhea and history of penetrating stab wound injury to his right temporal region, 3 months ago. The imaging showed the tract of removed sharp object which was piercing the calvaria and the temporal lobe from the right temporal bone, entering the lateral wall of the cavernous sinus, adjacent to the siphon of the carotid artery till the lateral wall of the right sphenoid sinus, ultimately its distal tip entered the sphenoid sinus. The patient was treated through an endoscopic endonasal approach to repair the defect of his skull base. As a result, we should be cautious in facing these patients even if they are asymptomatic. Also doing complementary imaging modalities and other evaluations are crucial to not ignore any possible complications based on their history and examinations.

SAT345 Disappearing Adrenal Masses: A Tale Of Two Lesions

Abstract Disclosure: A. arooj: None. A. Lansdown: None. Introduction: Adrenal lesions are being increasingly detected on CT scans performed for other reasons. Adrenal lesions that “disappear” on subsequent imaging are rare, most commonly due to adrenal hematomas, cysts or infection. Case: 1 73-year-old man was admitted with a collapse and fall. CT head & angiogram demonstrated cerebral sinus thrombosis, subarachnoid hemorrhage and right parietal hematoma. Furthermore, high density4cm left adrenal lesion on CT abdomen(Fig 1) Consideration was given to COVID vaccine induced thrombotic thrombocytopenia. ACTH, aldosterone, renin, aldosterone renin ratio normal. Slightly low cortisol (386) after short synacthen test. Later, CT showed the left adrenal lesion had disappeared in Fig 2. Case 2: 36-year-old man following a road traffic collision, fell from his electric scooter at a speed of 30mph, also noted to have high blood pressure on admission. He had small laceration of the liver which was managed conservatively. CT abdomen and pelvis, showed a low density 28mm right adrenal nodule, measuring 37 Hounsfield Units,(fig 3) that was completely resolved in subsequent imaging (Fig4). His biochemistry reports of dexamethasone suppression test, renin, aldosterone, 24hr metadrenaline urinary profile and urinary cortisol remained normal. Learning points: "Disappearing", adrenal mass lesions are rare, though reported, and most commonly due to adrenal hematomas, cysts or infection.

The role of laparoscopy in closed abdominal injury

ObjectiveTo investigate the effect of laparoscopy on the diagnosis and treatment of closed abdominal injury. MethodsA total of 26 patients with closed abdominal injury admitted to our hospital from January 2016 to January 2019 were searched. All patients were treated by laparoscopy. All patient reports were made with the informed consent of the patients. ResultsAll patients were diagnosed clearly during operation. Among them, there were 3 cases of gastric perforation, 2 cases of liver rupture, 13 cases of spleen rupture, 3 cases of small intestine rupture, 1 case of liver round ligament laceration, 2 cases of small mesenteric vascular laceration, 1 case of colon liver mesenteric laceration, and 1 case of retroperitoneal hematoma. Of the 26 patients in this group, 23 (88.5%) completed laparoscopically or laparoscopically assisted; 5 cases (19.3%) only performed laparoscopic exploration without special treatment, and 3 cases (11.5%) switched to laparotomy. The blood loss was 50–2000 ml (mean 500 ml), and the operative time was 60–180min (mean 128min). The length of hospital stay was 3–21 d (mean 9 d). There were no complications or deaths related to laparoscopy in the whole group. Conclusion Laparoscopic technique has the advantages of less trauma, high diagnosis rate and fast recovery. It can also be used for surgical treatment in the diagnosis and treatment of closed abdominal injury, so as to achieve the purpose of comprehensive diagnosis and treatment. The limitations of laparoscopy should also be noted.

The Need To Address Skin Pathologies Amidst Flooding Crisis In Pakistan.

Madam, As the monsoon approached, Pakistan was ravaged by extreme rainfalls and deadly flooding which affected 33 million people, including 16 million children. (1) With this disaster came a horde of water- borne diseases. The officials recorded over 600,000 people reporting to the relief camps with illnesses, including gastroenteritis, skin infections, acute respiratory infection, cases of malaria, and bites ranging from insects to dogs. (2) Among these diseases, skin pathologies are the second most common complaint reported by the flood- affected population and even though they might be the second most common cause of morbidity; small wounds, lacerations, punctures and skin infections resulting from them are the first to appear in the impact phase after any hydrologic disaster, including floods, rendering it crucial to address skin related pathologies as a priority. (3) Skin diseases may not seem important, with malnutrition, gastroenteritis, malaria and dengue looming in the relief camps, Still the lack of attention can lead to disastrous effects ranging from atypical bacteria like vibrio vulnificus and mycobacterium marinum causing skin infections, infestations with scabies to necrotising soft tissue infection (NSTI) complicating traumatic soft tissue injuries (3.4). This significantly increases the burden of diseases and puts great stress on the already crippled healthcare system in the affected areas and also leads to increase suffering which could easily be avoided by timely precautions and preventative measures taken to decrease the burden. Unfortunately, this isn’t the first time Pakistan has been dealing with the aftermath of a hydrologic disaster. In 2010, Pakistan faced a flood crisis resulting in 1600 deaths and 143,780 skin infections as the third most common cause of illness. (5) The numbers of infections aren’t different from the ones being reported in the recent monsoon floods. This warrants an imminent need to develop a flood response system to reduce the risk of dermatological diseases, tailored to the risk and population of the area. Health awareness programs to educate the masses about practicing good hygiene, making use of sunshine to deal with diseases like scabies which are rampant in the camps, and active involvement of community workers with basic first aid kit to treat minor cuts, lacerations could significantly reduce the morbidity and mortality associated with these conditions. ---Continue

Sagittal Synostectomy With Tension Band Sutures for Correction of Sagittal Craniosynostosis.

Premature fusion of the sagittal suture is the most common form of craniosynostosis and can be treated using a variety of open or endoscopic approaches. Existing approaches have varying degrees of effectiveness. Open approaches, whether performed early or late, can be associated with significant blood loss and the need for transfusion. Endoscope-assisted approaches are minimally invasive but require months of postoperative helmet therapy to help remodel the skull. Implantation of springs or distractors requires a second operation for removal of the devices. Here, we present an alternative technique for early correction of sagittal craniosynostosis combining sagittal synostectomy with tension band sutures to remodel the skull without need for transfusion or helmet therapy. We retrospectively reviewed the medical records of all patients treated for sagittal craniosynostosis using a synostectomy with tension band sutures at a single tertiary care institution. Data on patient demographics, operative factors, and postoperative course were collected. Thirty-four patients underwent the novel procedure. The median preoperative cephalic index was 68 and improved to 76 immediately postoperatively. The median blood loss was 10 mL while the operative duration was 112 minutes. No blood transfusions were needed. One small dural laceration was encountered that was promptly repaired. There were no postoperative complications. Patients presenting for follow-up visits showed continued improvement in head shape and cephalic index. A modified sagittal craniectomy with tension band sutures to remodel the skull is effective in achieving immediate correction of sagittal craniosynostosis. The correction remains durable over long-term follow-up. Importantly, the technique can be performed with minimal blood loss and reduces transfusion risk, operative time, and overall morbidity compared with traditional open approaches while avoiding the need for helmet therapy necessitated by endoscopic approaches.

Trans-fissure and trans-lobar coil insertion technique for small lesions positioned inside the fissure.

The objective of this study is to present a technique of localization of difficult-to-locate lesions inside the fissure by deploying a coil with one of its ends left inside the fissure, and also, to evaluate the safety and the efficiency of this localization technique. Ten (10) patients with lesions in the fissure were identified during discussion at the multidisciplinary team meeting (MDT) and were recruited in the study. Attending surgeons verified that the lesions were unable to be located with minimally invasive approaches. These patients underwent localization of their lesion/s inside the fissure with a coil which was inserted through an adjacent lobe, through the fissure and inside the lesion with the other end protruding inside the fissure. All patients were next subjected to resection of their lesions with minimally invasive approaches. All patients had their lesions resected (with wedge resection or segmentectomies) with adequate margins (R0 resection). No conversion to thoracotomy was necessitated to attempt to palpate the lesion. Small, localized pneumothorax was noted in 7 patients; whereas, all patients had small laceration of their lung parenchyma along the course of the needle without, however, any action needed for these sequalae. The presented technique offers precise localization which leads to successful and safe resection of difficult-to-locate lesions inside the fissure via minimally invasive approaches. The clinical implications of this technique are numerous and its utilization can augment the successful performance of minimally invasive techniques for lesions situated inside the fissure.

PA13 Unilateral facial flushing in a 3-year-old girl

Abstract A 3-year-old girl presented with an 18-month history of left-sided facial erythema involving her left cheek. This occurred within seconds to minutes after eating food and lasted between 5 and 20 min before complete spontaneous resolution without any associated symptoms. The flushing was not confined to a particular food type. She was born at 37 weeks via forceps-assisted delivery, which had resulted in a small laceration to her left upper cheek. She had no significant past medical history and was not on any medications. Her twin sister did not suffer from the same phenomenon. Examination revealed no abnormalities to her facial skin. Ingestion of a chocolate bar provoked immediate subtle erythema extending from her left preauricular skin to her left mid-cheek. Overlying skin texture and temperature was unchanged, and there was no associated hyperhidrosis. Examination of the cranial nerves was unremarkable at baseline and after provocation. The erythema completely resolved after 5 min. This little girl had Frey syndrome (FS) secondary to traumatic forceps-assisted delivery at birth. Frey syndrome typically consists of gustatory hyperhidrosis and flushing in response to chewing or the smell, taste or thought of food in the auriculotemporal distribution. It is due to aberrant regeneration of parasympathetic fibres instead of sympathetic fibres along the auricolotemporal branch of the mandibular nerve following trauma or infection to the parotid gland (O’Neill JP. Lucja Frey—historical relevance and syndrome review. Surgeon 2008; 6:178–81). Instead of causing the production of saliva in response to food, the aberrant fibres cause flushing and hyperhidrosis. In adults, FS is associated with previous surgery to the parotid gland. There are case reports of it arising as a consequence of forceps-assisted delivery in infants. One study reported eight cases of FS in infants in response to a food stimulus. Six of the cases had a history of forceps-assisted delivery. None of the infants experienced any associated hyperhidrosis. It was concluded that FS arose from trauma to the parotid gland following forceps-assisted delivery at birth. All cases resolved spontaneously without treatment (Dizon MV. Localized facial flushing in infancy. Auriculotemporal nerve (Frey) syndrome. Arch Dermatol 1997; 133:1143–5). The FS is often erroneously attributed to a food allergy. A thorough history for previous trauma to the parotid region or forceps-assisted delivery is recommended in infants with unilateral facial flushing. As FS runs a benign, self-limiting course in children, our patient was reassured and discharged without treatment.

Complications in Laparoscopic Cholecystectomy: Experiences from A Study of 1425 Cases

Objective: To evaluate the complications of laparoscopic cholecystectomy in the symptomatic cholelithiasis and other benign gall bladder diseases. Methods: This descriptive observational study was carried out at CMH Dhaka and CMH Jashore from March 2016 to Jun 2022, to evaluate the frequency and outcome of management of all the complications in laparoscopic cholecystectomy. A total of 1425 patients of laparoscopic cholecystectomy were included in this study. Patients were followed up for a period of three months after operation. The complications in laparoscopic cholecystectomy observed in this study were divided into (i) Access related (ii) Intraoperative (biliary and extrabiliary) and (iii) Postoperative. Results: The incidence of access-related, intraoperative or procedure-related biliary, extrabiliary and postoperative complications were 3.64%, 2.95%, 4.98% and 1.96% respectively. Access related complications were extraperitoneal insufflations 1.40%, port site bleeding 1.19%, small bowel laceration 0.21% and transverse colon injury 0.07%.Procedural biliary complications included common bile duct (CBD) injury 0.14%, common hepatic duct (CHD) injury 0.07% and iatrogenic gall bladder perforation with bile leakage 2.74%. Procedural extrabiliary complications were Liver injury 0.56%, duodenal perforation 0.07%, colon perforation 0.07%, bleeding through cystic artery 0.49% and bleeding from gall bladder fossa 1.12%. Two colonic perforations and one duodenal perforation were the major complications encountered in this series. Two colonic perforations required conversion to open procedure but duodenal perforation was managed laparoscopically by intracorporeal suturing. Total nine (0.63%) patients required conversion to open procedure. Postoperative complications included port site infection (PSI) 1.05%, port site hernia 0.56%, major sepsis 0.14% and ischemic stroke 0.07%. There was no retained stone, biliary stricture and mortality reported in this series. Conclusion: Complications in laparoscopic cholecystectomy are mainly due to access related and intraoperative and have their own characteristics.. CBD transaction, CHD injury, Colonic perforations and duodenal perforations were the major complications requiring conversion to open procedure except duodenal perforation which was dealt laparoscopically. Conversion to open procedure should not be considered as a complication. J Bangladesh Coll Phys Surg 2023; 41: 75-81

S2666 Three Simultaneous Sources of Upper GI Bleeding

Introduction: Acute upper GI bleeding is one of the most common causes of gastrointestinal related hospitalizations. Presentation of these patients commonly includes melena, hematemesis, or unstable hematochezia. One of the most common etiologies for this presentation is peptic ulcer disease. However less common causes include Dieulafoy lesions and iatrogenic gastric fistulas. The following case discusses three simultaneously diagnosed causes of upper GI bleeding. Case Description/Methods: An 82-year-old male with a history of splenectomy presented with melena and syncope. The day of arrival patient had syncopized after having multiple large bouts of black stool. On presentation, he was hypotensive, and tachycardic. His hemoglobin was 6.3 g/dL with a BUN of 62 mg/dL. An EGD was planned following patient stabilization. Initial EGD revealed a single 8mm ulcer in the duodenal bulb with no stigmata of bleeding. Just distally to the ulcer in the duodenal sweep was an actively bleeding Dieulafoy lesion. Hemostasis was achieved with bipolar cautery and the active bleed was stopped. Retroflexion during the initial procedure showed retained clot and old blood in the fundus that was presumed from the Dieulafoy lesion. Despite intervention, patient continued to have large bouts of melena the evening after the procedure. A 2nd EGD was performed and showed a stable ulcer and no signs of recurrent Dieulafoy. The fundus was now more visible and revealed ischemic damage. Careful inspection revealed a fistula with suture material free floating. Review of the operative note from the splenectomy revealed patient suffered a small laceration to the gastric fundus during the procedure which was repaired with an inner row of sutures. Given the size of the fistula, decision made for a CT scan to better define the anatomy. Unfortunately, the patient continued to decompensate, and family ultimately elected for comfort care. (Figure) Discussion: Dieulafoy lesions and gastric fistulas are both relatively rare, but potentially life-threatening, conditions. A Dieulafoy is a narrow artery that bleeds through a small mucosal defect. Therapeutic endoscopy can control the bleeding in 90% of patients while angiography is being accepted as an alternative to endoscopy for inaccessible lesions. The most common site for a Dieulafoy lesion to appear is in the lesser curvature. Gastric fistulas status post splenectomy occur in less than 1% of cases with the usual site along the greater curvature near the fundus.Figure 1.: Top left: Index EGD showing a single cratered 8mm ulcer in the duodenal cap. Top right: Index EGD with active Dieulafoy bleed in the duodenal sweep, just distal to ulcer. Bottom left: 2nd EGD showing free floating suture material and ischemia in the fundus Bottom right: 2nd EGD showing obvious fistula with ischemic changes, obscured by clot and old blood during index endoscopy.

Pediatric Cranial Dog Bite Injuries: More than Meets the Eye.

Case PresentationA six-month-old female presented to a community hospital with small lacerations to the scalp, face, and left eyelid from a dog bite injury. Computed tomography imaging revealed an impacted right frontal bone fracture and left superior orbital fracture, prompting transfer, neurosurgical repair, and infectious disease management of the injury.DiscussionThis report highlights the importance of having a high level of suspicion for deeper injury in pediatric and especially infant craniofacial dog bites, obtaining radiographic imaging, and initiating appropriate multidisciplinary triage to prevent life-threatening infection and complications.

English

Iatrogenic bladder injuries with Intra-peritoneal extravasations are standardly managed surgically. However, we are presenting a case of iatrogenic intra-peritoneal bladder injury which developed after an emergency caesarean section that was managed successfully by conservative therapy. The trial of conservative approach may prove beneficial to minimize the chances of any invasive interventions in such cases. Bladder injuries are of two types namely intra-peritoneal and extra-peritoneal. Of which, extra-peritoneal is most common type.1 Bladder laceration happens during separation of bladder from uterine cervix during caesarean sections and abdominal hysterectomies.2 Usually bladder injuries are identified intra-operatively and managed on table. If diagnosis is made post-operatively, then management becomes challenging due to non-specific clinical features, exposure to radiation, sepsis due to urinary extravasation and prolonged hospital stay, psychological stress to both patient and surgeon. The clinical features suspicious of bladder injury are abdomen distension, urinary ascites, blood-stained urine, abdominal pain, paralytic ileus, fever and deranged renal parameters.3 Extra-peritoneal and intra-peritoneal bladder ruptures are treated differently. According to American Urological Association (AUA) guidelines, Intraperitoneal bladder injury needs surgical repair. There are limited case reports in literature about conservative management of small intra-peritoneal bladder lacerations. This is a case report of one such intra-peritoneal bladder injury treated with non-operative approach.

Interventional Radiology in Renal Trauma.

Traumatic injuries to the kidney and collecting system can range widely from small lacerations to significant bleeding and its sequelae. Urinary obstruction can occur in the renal pelvis, ureters, or urethra. Interventional radiology plays a significant role in treatment and management, in many cases requiring emergent action. Endovascular embolization is frequently the first-line approach to treating hemorrhage. Percutaneous interventions for urinary obstruction include nephrostomy and suprapubic catheter placement. In this article, we outline the clinical approach and interventional methods used in the evaluation and treatment of renal trauma. Several case presentations demonstrate the role of interventional radiology in renal trauma.

The Use of a Suture Mediated Vascular Closure Device to Achieve Hemostasis following Arterial Access through Previously Implanted Synthetic Grafts

Percutaneous endovascular aneurysm repair (EVAR) and peripheral interventions using the Perclose Proglide suture mediated system has not been adequately studied in patients with synthetic grafts at access sites. We report the use of the Perclose Proglide in 10 patients in whom previously inserted synthetic grafts in the groin were punctured for arterial access (5 for peripheral interventions and 5 undergoing EVAR). In patients undergoing peripheral interventions a single device was used, while in patients undergoing EVAR 2 devices were employed per access site. The preclosing technique was used in every case. Hemostasis was achieved in all patients. No complications were observed except for a small laceration and a localized hemodynamically nonsignificant stenosis, without any clinical sequel. This small case series indicates the feasibility of percutaneous access with the Perclose Proglide system to perform EVAR and peripheral endovascular interventions in the presence of synthetic grafts in the groin, with promising outcomes.

Characteristics and the Emergency Department Cost of Tendon Injuries of the Hand

Objective: Hand injuries lead to high morbidity rate, and long-term labor loss due to their functional significance, and tendon injuries occur in more than 50% of patients even with small lacerations. We aimed to evaluate the characteristics and the emergency department cost of tendon lacerations of hand injuries.
 Methods: The study's data were obtained retrospectively by digital scanning of the files of patients admitted to the ED with an isolated hand injury from June 2014 to June 2016. The characteristics of patients and the emergency department costs from billing information were recorded and analyzed.
 Results: A total of 132 patients included. The mean age of the patients was 33.32±13.03 years, and 83.3% were male. The vast majority of injuries occurred at home (64.4%), more than half of the injuries were caused by puncture-cutting tools (54.5%), and the most injured location was the flexor area (56.8%). The mean of the number of injured tendons were 2.50±2.26 tendons. The average cost of tendon injuries was 1.065,34±828,90 TL, and the flexor tendon injuries had the highest cost average.
 Conclusion: Tendon injuries affect especially the young adult male population. The ED expenses of tendon injuries are high enough to mind and even more evident when further hospital beds and following physical therapy costs and the costs related to the labor loss were added.
 Keywords: Hand, tendon injuries, cost, emergency department

Case 3: A Rare Cause of Syncope in an Adolescent Boy.

1. Yalile Perez, MD* 2. Ruchi Gupta, MD† 3. Richard Mazzaccaro, MD* 1. *Department of Pediatrics, Lehigh Valley Health Network, Allentown, PA 2. †Department of Pediatric Cardiology, Children’s Hospital of Philadelphia Cardiac Center Allentown, Allentown, PA A 17-year-old Hispanic boy is admitted to the PICU for evaluation after a syncopal episode. He was walking at the mall when he suddenly collapsed and was unresponsive for approximately 30 seconds. The boy has no history of syncope, chest pain, or palpitations but reports occasional dizziness during exertion. He quit smoking cigarettes about 5 months ago but admits to using cannabis. There is no family history of sudden cardiac death or early coronary artery disease. His pulse rate is 72 beats/min, respiratory rate is 12 breaths/min, right arm blood pressure is 137/56 mm Hg, pulse oximetry reading is 99% on room air, and body mass index is 24.8. Physical examination reveals an alert adolescent in no acute distress. He has a small laceration on his lower lip and chin, and both upper central incisors are fractured. His cardiovascular examination yields a grade 2/6 systolic ejection murmur heard best at the left lower sternal border. On palpation, the point of maximal impulse is displaced laterally. The remainder of his examination findings are normal. His comprehensive metabolic panel is notable for a creatinine level of 1.08 mg/dL (95.47 μ mol/L) and normal electrolyte levels. A complete blood cell count is normal. Urine toxicology screen is positive for cannabinoids. His initial troponin is elevated …