Vascular Pedicle Injury Research Articles

Flexor Tendon Continuity and Negative X-ray: The "Combo" Negative Features in Finger Subamputation.

Background: The subamputation of fingers with vascular compromise presents a surgical challenge. Although tissue continuity may be considered a favourable prognostic element, in our experience, we noticed that there is not always a direct correlation between soft tissue involvement, radiographic appearance and final outcome. Methods: We included, in our study, all cases of vascular pedicle injury in which finger salvage was attempted with microsurgical revascularisation. Exclusion criteria were: integrity of both vascular pedicles, pedicle lesion without global circulatory compromise and patients treated immediately with amputation. Results: Between May 2018 and July 2023, 27 male patients with finger subamputation injuries were treated at our institution. In 11 cases of injured fingers, the only intact tissue was the flexor digitorum profundus (FDP) or flexor pollicis longus (FPL). Our global failure rate was 49%; whereas, in the subgroup of the 11 cases with continuity of the FDP or FPL, the failure rate rose to 73% and when the fingers showed flexor tendon integrity and radiographs demonstrated minimal bone damage, revascularisation failure was observed in all cases (100%). Conclusions: The results of the study show that subamputations with devascularisation, clinically presented with the combination of flexor tendon as the only element of tissue continuity and dislocation or minimal bone/articular injury, have a worse prognosis because of their trauma mechanism. We propose to add them to the Kay-Adani Classification as a subset of the poorest prognostic injuries group (III), to help surgeons to make decisions about the management of subamputation finger injuries.

Case Report on Penetrating Right Renal Trauma caused by a Wooden Stick

Blunt trauma by motor vehicle accidents and falls, followed by penetrating injuries comprise the common mechanisms of renal injury. Unilateral Penetrating Renal Trauma (UPRT) is extremely rare. Here, we reported a unique case of Right Penetrating Renal Trauma (RPRT). A nine-year-old male child, with a 124 cm height and 30 kg weight without any medical history, had a history of falling down from tree with right side penetrating abdominal injury. On admission, patient was vitally stable. Patient had macroscopic haematuria with haemoglobin count of 10 gm/dL, creatinine 1.2 mg/dL. The Computed Tomography (CT) demonstrated right-sided penetrating renal injuries by some foreign material perinephric haematoma with surrounding air foci with renal vascular pedicle injury. An emergency exploratory laparotomy was executed immediately. According to the American Association for the Surgery of Trauma (AAST) organ injury scale grading system, it was considered grade IV renal injury. Nephrectomy was done. Piperacillin and tazobactam was injected to prevent bacterial infection. The postoperative course was uneventful. Patient was discharged after seven days without any complications.

Case Report on Penetrating Right Renal Trauma caused by a Wooden Stick

Blunt trauma by motor vehicle accidents and falls, followed by penetrating injuries comprise the common mechanisms of renal injury. Unilateral Penetrating Renal Trauma (UPRT) is extremely rare. Here, we reported a unique case of Right Penetrating Renal Trauma (RPRT). A nine-year-old male child, with a 124 cm height and 30 kg weight without any medical history, had a history of falling down from tree with right side penetrating abdominal injury. On admission, patient was vitally stable. Patient had macroscopic haematuria with haemoglobin count of 10 gm/dL, creatinine 1.2 mg/dL. The Computed Tomography (CT) demonstrated right-sided penetrating renal injuries by some foreign material perinephric haematoma with surrounding air foci with renal vascular pedicle injury. An emergency exploratory laparotomy was executed immediately. According to the American Association for the Surgery of Trauma (AAST) organ injury scale grading system, it was considered grade IV renal injury. Nephrectomy was done. Piperacillin and tazobactam was injected to prevent bacterial infection. The postoperative course was uneventful. Patient was discharged after seven days without any complications.

A dual padding method for ischial pressure sore reconstruction with an inferior gluteal artery perforator fasciocutaneous flap and a split inferior gluteus maximus muscle flap.

BackgroundVarious surgical management methods have been proposed for ischial sore reconstruction, yet it has the highest recurrence rate of all pressure ulcer types. A novel approach combining the advantages of a perforator-based fasciocutaneous flap and a muscle flap is expected to resolve the disadvantages of previously introduced surgical methods.MethodsFifteen patients with ischial pressure ulcers with chronic osteomyelitis or bursitis, who underwent reconstructive procedures with an inferior gluteal artery perforator (IGAP) fasciocutaneous flap and a split inferior gluteus maximus muscle flap from January 2011 to June 2016, were analyzed retrospectively. The split muscle flap was rotated to obliterate the deep ischial defect, managing the osteomyelitis or bursitis, and the IGAP fasciocutaneous flap was rotated or advanced to cover the superficial layer. The patients’ age, sex, presence of bursitis or osteomyelitis, surgical details, complications, follow-up period, and ischial sore recurrence were reviewed.ResultsAll ischial pressure ulcers were successfully reconstructed without any flap loss. The mean duration of follow-up was 12.9 months (range, 3–35 months). Of 15 patients, one had a recurrent ulcer 10 months postoperatively, which was repaired by re-advancing the previously elevated fasciocutaneous flap.ConclusionsThe dual-flap procedure with an IGAP fasciocutaneous flap and split inferior gluteus maximus muscle flap for ischial pressure ulcer reconstruction is a useful method that combines the useful characteristics of perforator and muscle flaps, providing thick dual padding with sufficient vascularization while minimizing donor morbidity and vascular pedicle injury.

Imaging of Renovascular Disease

A variety of different imaging techniques have been used for the diagnosis of renal vascular diseases. The wide range of renal vascular diseases include congenital renal artery and vein variations, aneurysms, arteriovenous malformations (AVMs), renal artery stenosis, renal vein thrombosis, vasculitis, and traumatic injuries, such as dissection and vascular pedicle injury. In this article, we discuss the role of invasive and noninvasive imaging in each of these abnormalities and their typical features. Because renal artery stenosis is an important vascular abnormality encountered in clinical practice, imaging of this entity will be emphasized.

Splenic nonenhancement at computed tomography: A sign of the hypoperfusion complex

When splenic nonenhancement is seen at computed tomography, one should look for signs of vascular pedicle injury; if injury to the vascular pedicle is not present, nonenhancement of the spleen could be secondary to severe vasoconstriction and may be considered an additional sign of the hypoperfusion complex. The presence of splenic nonenhancement may also help differentiate the hypoperfusion complex from other types of bowel injury.

Indicators of genitourinary tract injury or anomaly in cases of pediatric blunt trauma

Purpose: Microscopic hematuria (≥20) RBCs per high-power field [HPF]) has been used frequently as an indicator for genitourinary (GU) tract injury in pediatric cases of blunt trauma. The aim of this study was (1) to determine whether a certain threshold of microscopic hematuria was associated with GU tract injury in our patient population, and (2) to identify additional factors warranting evaluation of the GU tract. Methods: The records of 100 patients under 18 years of age whose discharge diagnosis in the trauma registry included hematuria or GU tract injury were reviewed retrospectively (1989 through 1993). The following data were collected: age, sex, mechanism of injury, physical findings, associated injuries, urinalysis results, radiographic study results, disposition, and outcome. Data were anayzed using the SPSS program. Results: The majority of children were victims of motor vehicle accidents. All but one study patient had an intravenous pyelogram and/or computed tomography sca. Twenty-seven patients had GU tract injuries or previously unrecognized congenital anomalies (9 contusions, 5 lacerations, 1 vascular pedicle injury, 4 bladder injuries, 3 urethral/vaginal tears, 5 anomalies). Twenty-seven percent (3 of 11) of children with minor injuries and 25% (2 of 8) of those with major injuries had microscopic hematuria of less than 20 RBCs HPF . Mechanism of injury and hypotension were not associated with GU tract injury. One third of the patients with isolated chest or abdominal injuries, and 50% of those with combined chest/addominal injuries had GU tract injuries or anomalies identified. Pelvic fracture was associated with GU tract injury or anomaly in 50% of cases ( P < .02). Conclusion: The authors found that (1) a threshold of ≥20 RBCs HPF as an indication for radiograph evaluation would have missed 28% of cases with GU tract injuries or occult anomalies, and (2) pelvic fractures and abdominal/chest injuries help to identify patients who require evaluation of the GU tract. The need for GU tract evaluation in pediatric trauma patients is based as much on clinical judgment as on the presence of hematuria.

Blunt renal trauma in children: healing of renal injuries and recommendations for imaging follow-up.

Initial CT grading of renal injury was correlated with the frequency of complications and the time course of healing in 35 children. All renal contusions (grade 1, 8) and small parenchymal lacerations (grade 2, 8) healed without complications. All lacerations extending to the collecting system (grade 3, 9) resulted in mild to severe loss of renal function with progressive healing over 4 months. One of four segmental infarcts (grade 4A), and five of six vascular pedicle injuries (grade 4B) resulted in severe loss of renal function. Complications, including urinoma (2), sepsis (1), hydronephrosis (1), and persistent hypertension (2), were limited to grade 3 and 4 injuries. Our results suggest that mild renal injuries do not require follow-up imaging. Major renal lacerations and vascular pedicle injuries, however, often result in loss of renal function and should be followed up closely due to the risk of delayed complications. Follow-up examinations should continue for 3-4 months until healing is documented.

Major Blunt Renal Trauma in the Pediatric Population: Is a Nonoperative Approach Indicated?

We evaluated and treated at our institutions 22 consecutive patients with major blunt renal trauma: 20 had major renal lacerations (grades 3 to 5) as defined by initial computerized tomography, and 2 had vascular pedicle injuries without parenchymal injury and were excluded. An attempt was made to treat all children with a nonoperative approach. Two patients (10%) required renal exploration: 1 for persistent bleeding and 1 in whom a renal neoplasm could not be excluded. The remaining 18 patients (90%) were stabilized and observed. No child required delayed renal exploration. All traumatized renal units demonstrated function on followup studies. Hypertension did not occur in the 13 patients available for long-term followup. We conclude that nonoperative management is a suitable alternative to early exploration in children with major blunt renal lacerations.

CT of severe renal trauma in children: evaluation and course of healing with conservative therapy

Over a 2-year period, blunt renal injuries were classified on a four-point scale: grade 1, contusions; grade 2, tears limited to the cortex (renal lacerations); grade 3, tears extending to the collecting system (renal fractures); and grade 4, renal vascular pedicle injuries. We report our findings in nine children with grade 2 and grade 3 blunt renal injuries who were evaluated with CT. One patient had a nephrectomy; the other eight were managed nonsurgically. Six patients had follow-up CT scans 5-19 months later to assess healing. Scars were evident in each case, and the extent of deformity paralleled the magnitude of the initial injury. One patient with a grade 2 injury and two patients with grade 3 injuries healed with small focal scars; three patients with grade 3 injuries healed with large polar scars. In five patients, the CT findings were compared with the findings on 99mTc-DTPA renal imaging. The injured kidneys contributed 30-45% (mean, 38%) of total renal function. In six patients with renal trauma who were treated conservatively, the involved kidneys healed and significant kidney function was preserved, although early surgical intervention might have been beneficial for one of these patients. Prospective studies are needed to evaluate further the effectiveness of this conservative approach.

Operative indications in penetrating renal trauma.

In a review of 53 patients with penetrating renal injuries treated between 1978 and 1983 at San Francisco General Hospital, we correlated several factors with the extent of renal damage to determine whether major and minor injuries could be differentiated preoperatively, thereby avoiding unnecessary surgical exploration. Of 56 injured kidneys (three patients had bilateral injuries), 35 sustained major injuries, 17 minor, and four vascular pedicle injuries. The presence of shock, the degree of hematuria, the location of the entry site, and the type of injury did not permit reliable discrimination among these categories. Intravenous urography was most often nondiagnostic, and only the presence of extravasation or nonfunction was specific for major injury. Computed tomography provided accurate preoperative assessment in 11 cases, however, allowing nonoperative management in eight renal injuries.