The skin and subcutaneous tissue of the hand are thin, and bones, tendons and neurovascular bundles are present beneath the skin. Skin coverage is necessary for reconstruction when treating soft tissue defects of the hand, but scar formation leads to functional impairment. To minimize scar formation, it is important to use well-vascularized and thin skin flaps for hand reconstruction. The anterolateral thigh flap (ALT flap), one of the perforator flaps, has been promoted for use in certain surgeries due to favorable features, such as its large and thin skin paddle, long pedicle length and minimal donor site morbidity, and despite its disadvantageous anatomical vascular variation. We would like to present our results of soft tissue reconstruction of the hand using the ALT flap. Flap thickness can be adjusted to match defect site requirements by using the thinning technique. Because the surgical fields are the hand and thigh, surgeries can be performed simultaneously using a two team-approach, without repositioning the patient, which reduces the total time required. Thus, the ALT flap is a particularly useful source for the reconstruction of soft tissue defects in the hand.
We encountered a case of iatrogenic injury in the right pericardiophrenic artery, which is a branch of the internal thoracic artery, due to central venous catheter (CVC) insertion. CVC insertion was performed in a 64-year-old woman at another hospital ; her systolic blood pressure decreased. Chest-XP revealed right mediastinal expansion, and enhanced computed tomography revealed a mediastinal hematoma, which was diagnosed as a complication of CVC. The patient was then brought to Tokai University Hospital for treatment. We performed angiography and identified extravasation from the right pericardiophrenic artery ; hence, transcatheter arterial embolization (TAE) was performed using a gelatin sponge and micro-coils. The patient's condition improved after TAE, so she was transferred to the previous hospital. To our knowledge, injured right pericardiophrenic artery as a complication of CVC has not been reported thus far. In this paper, we report a case of iatrogenic injury in the right pericardiophrenic artery that was successfully treated using TAE.
Delayed post-traumatic pseudoaneurysm of mesenteric artery is an uncommon complication after blunt abdominal injury. The rupture of pseudoaneurysms may result in a critical situation. Thus, it is crucial to know the clinical course, detecting this complication earlier.
The case presented herein features an unruptured traumatic pseudoaneurysm of the ileocolic artery. A 60-year-old man was involved in a car crash and found lying on the road. On arrival, we diagnosed the patient by computed tomography (CT) scan as having traumatic aortic dissection and mesenteric hematoma adjacent to the ileocecal area, both of which were treated conservatively. Eight days after admission, the patient complained of abdominal pain. The next day, a follow-up CT scan showed a freshly formed unruptured pseudoaneurysm of the ileocolic artery. The pseudoaneurysm was treated successfully by transarterial embolization without bowel ischemia. Trauma physicians should take care to recall this complication when treating blunt abdominal trauma patients with mesenteric vascular injury.
We report a case of esophageal perforation caused by fracture dislocation of the thoracic spine. A 70-year-old man was injured in a bicycle accident and diagnosed with multiple fractures of the spine (C2, T2, T10-11), facial bones, and the left ribs. After halo-vest immobilization, esophageal perforation became apparent adjacent to the fracture fragment of T2, concomitant with upper mediastinal abscess. Conservative management was employed by continuing application of the halo device and prevention of contamination of the field for subsequent orthopedic surgery. As a result of irrigating the abscess with an endoscopically inserted nasoesophageal catheter and percutaneous CT-guided drainage, the infection was soon relieved and internal fixation of T2 was successfully performed. Afterwards, the esophageal perforation closed spontaneously and the patient made a good recovery without symptoms.
The revised guidelines of JATEC (Japan Advanced Trauma Evaluation and Care) include a focus on CT imaging and introduce the novel concept of three-step evaluation of whole-body CT scan. The first step, called FACT (Focused Assessment with CT for Trauma), focuses on assessment of pre-selected areas and injuries to develop a rapid treatment strategy in a few minutes, in which massive intracranial hematoma, aortic injury, pulmonary contusion, pneumothorax, hemothorax, pericardial hematoma, hemoperitoneum, pelvic and spinal fractures, and abdominal organ injuries are evaluated. The second step should be performed right after FACT and it includes evaluation of active bleeding, which needs to be treated immediately, as well as injuries that are not recognized in FACT. The third step is detailed evaluation of any trivial findings to reduce misses. It is recommended to evaluate CT findings with important clinical factors to start adequate treatment without delay. The important clinical factors include age of the patient, number of bleeding sites and their tightness, coagulation status, medication and past history related to coagulation, time passed since the event, the form of organ injury, mechanism of injury and vital signs.