儿童上肢晚期神经损伤的治疗

报告并评价儿童上肢晚期神经损伤的治疗效果。方法：报道１３岁以下儿童平均７岁上肢晚期神经损伤１５例２１条（正中神经８条，尺神经７条，桡神经５条，肌皮神经１条）。完全断裂９条，粘连、压迫１２条。损伤神经的处理时间为伤后１年至１４年（平均４年４个月）。采用神经外膜对端缝合术７条，神经松解术１２条，自体神经移植术１条，神经瘤对端缝合术１条。结果：１３例１８条神经随访１年至２３年６个月（平均４年９个月），优良率为６６．７％，尚有２７．８％病人恢复了保护性感觉。结论：本研究证实晚期神经损伤有修复价值，儿童病人能取得更满意疗效。     

Peripheral Nerve Injuries of the Upper Extremity: Sensory Return of 137 Neurorrhaphies

The results of sensory recovery of 137 neurorrhaphies of the upper extremity in 96 patients are reviewed. There were 85 primary and 52 secondary repairs. Various factors influencing the results and an evaluation based on the 2-point discrimination test are presented. Secondary repair within 3 months in the hand area gives better results than primary repair.     

Risk Factors for a False-Negative Examination in Complete Upper Extremity Nerve Lacerations

Background: Many patients with complete nerve lacerations after upper extremity trauma have a documented normal peripheral nerve examination at the time of initial evaluation. The purpose of this study was to determine whether physician-, patient-, and injury-related factors increase the risk of false-negative nerve examinations. Methods: A statewide health information exchange was used to identify complete upper extremity nerve lacerations subsequently confirmed by surgical exploration at 1 pediatric and 2 adult level I trauma centers in a single city from January 2013 to January 2017. Charts were manually reviewed to build a database that included Glasgow Coma Scale score, urine drug screen results, blood alcohol level, presence of concomitant trauma, type of injury, level of injury, laterality, initial provider examination, and initial specialist examination. Bivariate and multivariable analyses were performed to evaluate risk factors for a false-negative examination. Results: Two hundred eighty-eight patients met inclusion criteria. The overall false-negative examination rate was 32.5% at initial encounter, which was higher among emergency medicine physicians compared with extremity subspecialists (P < .001) and among trauma surgeons compared with surgical subspecialists (P = .002). The false-negative rate decreased to 8% at subsequent encounter (P < .001). Risk factors for a false-negative nerve examination included physician specialty, a gunshot wound mechanism of injury, injury at the elbow, and age greater than 71 years. Conclusion: There is a high false-negative rate among upper extremity neurotmesis injuries. Patients with an injury pattern that may lead to nerve injury warrant prompt referral to an upper extremity specialist in an effort to optimize outcomes.     

Vascularized Nerve Grafts and Vascularized Fascia for Upper Extremity Nerve Reconstruction

Since 1976, experimental and clinical studies have suggested the superiority of vascularized nerve grafts. In this study, a 27-year experience of the senior author is presented regarding vascularized nerve grafts and fascia for complex upper extremity nerve reconstruction. The factors influencing outcomes as well as a comparison with conventional nerve grafts is presented. Since 1981, 21 vascularized nerve grafts, other than vascularized ulnar nerve, were used for reconstruction of nerve injuries in the upper extremity. Indications were prolonged denervation time, failure of the previously used conventional nerve grafts, and excessive scar in the recipient site. Injury was in the hand/wrist area (n = 5), in the forearm (n = 4), in the elbow (n = 2), in the arm (n = 4), or in the plexus (n = 6). Vascularized sural (n = 9), saphenous (n = 8), superficial radial (n = 3), and peroneal (superficial and deep) nerves were used. The mean follow-up was 31.4 months. Vascularized nerve grafts for upper extremity injuries provided good to excellent sensory return in severely scarred upper extremities in patients in whom conventional nerve grafts had failed. They have also provided relief of causalgia after painful neuroma resection and motor function recovery in selective cases even for above the elbow injuries. Small diameter vascularized nerve grafts should be considered for bridging long nerve gaps in regions of excessive scar or for reconstructions where conventional nerve grafts have failed.     

Medical Malpractice in Nerve Injury of the Upper Extremity

Background: Medical malpractice accounts for more than $55 billion of annual health care costs. Updated malpractice risk to surgeons and physicians related to upper extremity peripheral nerve injury has not been published. Methods: A comprehensive database analysis of upper extremity nerve injury claims between 1995 and 2014 in the United States was conducted using the Medical Professional Liability Association Data Sharing Project, representing 24 major insurance companies. Results: Nerve injury in the upper extremity accounted for 614 (0.3%) malpractice claims (total of 188 323). Common presenting diagnoses included carpal tunnel syndrome (41%), upper extremity fractures (19%), and traumatic nerve injuries to the shoulder or upper limb (8%). Improper performance (49% of total claims) and claims without evidence of medical error (19%) were the most common malpractice suits. Orthopedic surgeons were the most frequently targeted specialists (42%). In all, 65% of nerve injury claims originated from operative procedures in a hospital, 59% of claims were dismissed or withdrawn prior to trial, and 30% resulted in settlements. Thirty-three percent of claims resulted in an indemnity payment to an injured party, with an average payout of $203 592 per successful suit. Only 8% of claims resulted in a completed trial and verdict, and verdicts were overwhelmingly in favor of the defendant (83%). Conclusions: Most malpractice claims from peripheral nerve injuries in the United States arise from the management of common diagnoses, occur in the operating room, and allege improper performance. Strategies to reduce malpractice risk should emphasize the management of common conditions and patient-physician communication.     

Management of Complex Upper Extremity Trauma with Associated Vascular Injury

Introduction  Combined soft tissue and vascular injuries of the upper extremity pose several challenges at once to the plastic surgeon. Many decisions have to be taken urgently that will influence the salvage or amputation of the affected extremity. The aim of this article was to provide an evidence-based outline for the management of such injuries. Learning objectives of this article are as follows: (1) approach to a patient with upper extremity composite tissue and vascular injury presenting to the emergency, (2) decision-making as to when to salvage and when to go for amputation of the traumatized upper extremity, (3) role of imaging in emergency situation, (4) role of fasciotomy, (5) intraoperative sequencing of steps, and (6) options for vascular reconstruction and the flaps used for coverage. After reading this article, the reader should have a clear understanding of the management of vascular injury in a patient with composite defects of upper extremity.     

Self-inflicted penetrating injuries at a Level I Trauma Center

Introduction

Although gunshot and stab wounds are a common cause of self-inflicted injury, very little is understood about this mechanism of injury. The aim of this study was to characterise the epidemiology and outcomes of patients who injured themselves with a gun or sharp object.

Methods

After IRB approval, the LAC + USC Trauma Registry was utilised to identify all patients who sustained a self-inflicted injury caused by firearm (GSW) or stabbing (SW) from 1997 to 2007. Demographic data, injury characteristics, surgical interventions, and outcomes were abstracted and analysed.

Results

During the 11-year study period, a total of 753 patients (1.6%) were admitted for a self-inflicted injury. Of these, 369 (49.0%) had a self-inflicted penetrating injury, with 72 (19.5%) having sustained a GSW and 297 (80.5%) having a SW. Overall, the mean age was 36.4 ± 15.8 years, 83.5% were male, with a mean ISS of 7.4 ± 11.0. The most commonly injured body region in GSW patients was the head (76.4%), followed by the chest (15.3%) and in SW patients the upper extremity (37.0%), followed by the abdomen (36.4%). When compared to SW, GSW were significantly more frequent in males (21.4% vs. 9.8%, p = 0.04), and were most commonly to the head (21.4% vs. 8.2%, p = 0.02). Patients sustaining a GSW were more likely to be older than 55 years (22.2% vs. 8.4%, p < 0.001). Intoxication was noted at presentation in 38.3% of screened GSW patients and 39.9% of SW patients. SW patients required operative intervention more frequently (40.9% vs. 22.2%, p < 0.01), with 12.8% of them requiring exploratory laparotomy. However, patients who shot themselves were much more likely to die (66.7%) than those presenting with SW (1.7%). For those presenting with a GSW to the head, the mortality rate was even higher, at 80%. Mortality did not differ between males and females in either group.

Conclusion

Although a self-inflicted SW is far more common than a self-inflicted GSW, patients sustaining a GSW are more severely injured, and have a nearly 110-fold increased risk of death. Though less lethal, stab wounds still consume significant amounts of healthcare resources and incur large in-hospital costs. The average hospital charge incurred for treating these self-inflicted injuries was five times the amount spent per annum on American citizens. Self-inflicted penetrating injuries represent a golden opportunity for secondary prevention through psychiatric intervention. These interventions may not only preserve life but also improve resource utilisation.     

选择性上肢神经阻滞和静脉局部麻醉的进展

临床实践中，尽管臂丛神经阻滞可采用多种人路以满足上肢区域麻醉的需要，但有时仍需应用一些不常见的技术，如选择性上肢神经阻滞和静脉局部麻醉（IVRA），来阻滞非源自臂丛的神经或弥补臂丛神经阻滞不全。     

The plastic surgeon intervention at a Level I Trauma Center

The historical origins of plastic surgery prove how important this speciality is in trauma care. Nowadays, the need of a plastic surgeon in a Level I Trauma Center is unquestionable. This report analyzes the number of critically injured patients operated on by plastic surgeons over a period of 5 years at a Level I Trauma Center. The cases were categorized by the anatomical regions requiring surgery. A total of 1,741 patients were operated on resulting in 2,496 procedures over a period of 5 years. The year of 2001 registered the highest number of recorded procedures, with 391. In several cases, two or more major procedures were performed on the same patient, such as nerve, tendon, and artery repair. Except in the year 2003, the hand was the most common anatomical area operated on. The head and neck were the second most frequent anatomical region operated on, with 662 procedures recorded. The average age of the patients submitted to surgery was 32. 8 years. A total of 176 cases involved the participation of other specialities namely, orthopedics and vascular surgery. The specialized procedures categories performed by plastic surgery teams at a trauma center were facial and hand fracture treatment, burn treatment, amputations, flaps, skin grafts, replants, tendon, and nerve and artery repair. This study shows, in a clear way, how important the role of a plastic surgeon is in a Level I Trauma Center and how wide, flexible, and important this speciality can be. Meetings where the paper was presented: the 35th Meeting of Portuguese Society of Plastic Reconstructive and Aesthetic Surgery, in Cascais, Portugal, on November 11, 2005; the 15th Meeting of Spanish Society of Plastic Reconstructive and Aesthetic Surgery, in Coruna, Spain, on June 3, 2005; and the 25th Meeting of Portuguese Society of Surgery, in Lisboa, Portugal, on March 9, 2005