My Friend Herbie

Today is Herbie's 50th birthday. She is a friend from junior high school and on. She is an amazing person. This is her way of celebrating this milestone. She is the director of a residential center for Alzheimer patients in Tennessee. Her adopted mother had the disease. Herbie is good at the job. She is very caring, very patient, and organized. I am proud to say she is my friend.

Felon

 Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Felons and paronychia make up one third of all hand infections. The thumb and index finger are most often involved. Wooden splinters or minor cuts are common predisposing causes, yet over half of patients will give no history of injury. 

Felons are closed-space infections of the fingertip pulp (padding beneath the finger print area). Fingertip pulp is divided into numerous small compartments by vertical septa that stabilize the pad. Infection occurring within these compartments can lead to abscess formation, edema, and rapid development of increased pressure in a closed space. This increased pressure may compromise blood flow and lead to necrosis of the skin and pulp. It is most often caused by staph aureus. Felons that are untreated, are incorrectly treated, or have a prolonged course may lead to osteomyelitis. X-rays evaluation of the bone should be done in severe cases.

Treatment is incision and drainage. This will remove any pus present, but will also reduce the pressure within the closed compartment and restore blood flow.

1. The finger can be numbed with local anesthesia (digital block).
2. Make short skin incision with a number 11 blade over the area of maximum tenderness. Incise only the skin with scalpel. Do not cross the DIP joint crease (can create a contraction)
3. Evacuate any pus (and culture) using a blunt instrument, like a small hemostat. This will decrease the chance of injury to the digital nerve or the tendon sheath (can lead to acute tenosynovitis). Do not divide vertical fascial strands (septa) as this makes the fingertip pulp unstable.
4. Pack gauze loosely into the wound to prevent skin closure. Apply a loose dressing, splint finger, and elevate hand above the heart.
5. Followup in 2-3 days.

Incision Tips:
A longitudinal incision in the midline is effective without serious iatrogenic complications (nerve injury, tendon sheath injury).
Lateral or transverse incisions frequently cause ischemia and anesthesia by injuring one or both neurovascular bundles. If a lateral incision is used, it is best to incise the non-contact aspect of the finger (ulnar side of fingers, radial side of the thumb).
Fish-mouth incision can lead to an unstable painful fingertip.

Empirical antibiotic coverage for S aureus and streptococcal organisms should be provided. Given the rapid emergence of community-acquired methicillin-resistant S aureus, treatment with a drug more likely to be effective against this agent should be considered. Coverage for E corrodens may be indicated for immunosuppressed patients. Dicloxacillin, erthromycin, Keflex, nafcillin, and Bactrim DS are good ones to start the patient on while waiting for the culture. The recommended length of treatment varies from five to 14 days and depends on the clinical response and severity of infection.

Complications:
Osteomyelitis involving the distal phalanx.
The most serious complication is acute tenosynovitis. It may result from natural, contiguous spread of infection. It most often iatrogenic from inadvertent nicking of flexor tendon sheath with scalpel.
Other complications include skin necrosis, deformity of the fingertip, septic arthritis, and instability of the finger pad.


References

Infections of the Hand: A Guide to the Surgical Treatment of Acute and Chronic Suppurative ... By Allen Buckner Kanavel (Google eBook)

Wheeless' Textbook of Orthopedics Online
Common Acute Hand Infections--AAFP
Felon by Glen Vaughn, MD--eMedicine article

Breastsummer--noun

 Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

I've been checking Wordsmith's "A-Word-A-Day" for a couple of weeks now. I thought I might improve my vocabulary. Well, today's word is surprising. It looked like an interesting word for a plastic surgeon on a hot summer day. It's meaning did not live up to the word for me. Still, here it is...

breastsummer (BRES-sum-uhr, BREST-, BRES-e-muhr) noun
A horizontal beam supporting a wall over a large opening, such as a shop window.
[From breast (in architecture, part of a wall between a window and the floor) + Old French somier (packhorse, beam), from Latin sagma (packsaddle).]
-Anu Garg (words at wordsmith.org)

Foot-n'-Mouth Diseases

 Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

I often suffer from "foot-in-mouth" disease, but that isn't what is plaguing the British cattle industry. It's foot and mouth disease (FMD). It is also not hand, foot, and mouth disease (HFMD).

Foot-in-Mouth Disease (FIMD) is an unintentional act of tactlessness or an uttered faux pas. To minimize these gaffes, it is often good to follow a "24-hour rule"--if you suspect you are about to utter a faux pas, tell the person "I'll have a better answer tomorrow." or just bite your tongue. Don't get caught thinking "as long as I'm telling the truth, I can say whatever I want". It is best to build in some kind of delay that allows emotional discipline which will help stifle tactless remarks. If you don't you may find yourself, the recipient of the "Foot-in-Mouth Award".

Foot-and-mouth disease is a severe, highly communicable viral disease of cattle and swine. It also affects sheep, goats, deer, and other cloven-hooved ruminants. FMD is not recognized as a zoonotic disease. The United States has been free of FMD since 1929, when the last of nine U.S. outbreaks was eradicated. The disease is characterized by fever and blister-like lesions followed by erosions on the tongue and lips, in the mouth, on the teats, and between the hooves. Many affected animals recover, but the disease leaves them debilitated. It causes severe losses in the production of meat and milk. Because it spreads widely and rapidly and because it has grave economic as well as clinical consequences, FMD is one of the animal diseases that livestock owners dread most.

Hand, foot, and mouth disease (HFMD) is a common illness of infants and children. It is characterized by fever, sores in the mouth, and a rash with blisters. HFMD begins with a mild fever, poor appetite, malaise ("feeling sick"), and frequently a sore throat. One or 2 days after the fever begins, painful sores develop in the mouth. They begin as small red spots that blister and then often become ulcers. They are usually located on the tongue, gums, and inside of the cheeks. The skin rash develops over 1 to 2 days with flat or raised red spots, some with blisters. The rash does not itch, and it is usually located on the palms of the hands and soles of the feet. It may also appear on the buttocks. A person with HFMD may have only the rash or the mouth ulcers.

Viruses from the group called enteroviruses (most commonly coxsackievirus A16) cause HFMD. HFMD caused by coxsackievirus A16 infection is a mild disease and nearly all patients recover without medical treatment in 7 to 10 days. Complications are uncommon. HFMD is moderately contagious. Infection is spread from person to person by direct contact with nose and throat discharges, saliva, fluid from blisters, or the stool of infected persons. A person is most contagious during the first week of the illness. HFMD is not transmitted to or from pets or other animals. No specific treatment is available for this or other enterovirus infections. Symptomatic treatment is given to provide relief from fever, aches, or pain from the mouth ulcers.

Preventive measures include frequent handwashing, especially after diaper changes, cleaning of contaminated surfaces and soiled items first with soap and water, and then disinfecting them by diluted solution of chlorine-containing bleach (made by mixing approximately ¼ cup of bleach with 1 gallon of water. Avoidance of close contact (kissing, hugging, sharing utensils, etc.) with children with HFMD may also help to reduce of the risk of infection to caregivers.

Scalp Avulsion Injuries

 Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Recently a post by Scalpel about a successful scalp replantation, after a 11 year old girl somehow gets her hair caught in a ferris wheel.  So I thought I'd share more about this injury.

The nature and mechanism of scalping injury have been reported by Koss et al. They emphasized "that it requires an oblique force to produce scalping, thus giving rise to the theory that the scalp tears at either of the bony ridges. The actual extent depends on the site, amount of hair caught, and the direction of the force." This was reemphasized by Bhattacharya et al. In all these descriptions, the extent of avulsion was from the supraorbital ridge to the nuchal line posteriorly. A case of avulsion of the face in continuity with the scalp reported by Dr. Abraham Thomas (1998) broke this pattern and showed that the actual extent depended on the speed and force of injury from the mechanical device and also the attitude and protective movements of the patient (successfully replanted--face and scalp). It was 1976 when the first successful replantation of a totally avulsed scalp was reported by Miller & others with return of normal hair growth and frontalis muscle function.

Scalp Anatomy:
The layers of the scalp are easily remembered by the mnemonic SCALP:
S (skin) is the thickest in the body, measuring between 3-8 mm,
C (subcutaneous tissue)- The vessels, lymphatics, and nerves course through the subcutaneous layer just superficial to the galea.
A (aponeurotic layer) --The galeal aponeurosis, the strength layer of the scalp, is contiguous with the paired frontalis muscles anteriorly, the paired occipitalis muscles posteriorly, and the temporoparietal fascia laterally,
L (loose areolar tissue) is also known as the subgaleal fascia, the innominate fascia, and the subaponeurotic plane. The loose areolar tissue of this plane allow for scalp mobility. Scalp avulsions routinely occur through this layer, leaviing pericranium intact.
P (pericranium) is tightly adherent to the skull and should be left intact in scalp reconstruction to allow for "back-grafting" of the donor site or for a means of alternative recontruction in the event of a failed local tissue transfer.

The scalp is supplied by arterial branches and vena comitantes of the internal and external carotid systems into four distinct vascular territories. Extensive collateralization (connections between the four territories) of these vascular territories allows total scalp replantation based on a single vascular anastomosis. The scalp is innervated by branches of the three divisions of the trigeminal nerve, cervical spinal nerves, and branches from the cervical plexus.

Replantation is the treatment of choice in scalping injuries and should always be considered, even in case of a badly damaged scalp. Specific procedures regarding pre-, intra- and postoperative care are crucial to success in replantation. These include: hemodynamic stabilization of the patient without causing damage to possible donor vessels; cooling, cleaning and further proper care of the avulsed specimen; use of antibiotics and hemodilution to optimize the intra- and post-operative situation.

When replantation is not possible then as in the past the goals are to obtain calvarial (bone) coverage to prevent calvarial desiccation, sequestration, and sepsis. However, today, the reconstructive surgeon should also strive for a cosmetically appealing result in addition to merely achieving coverage. The best replacement for scalp tissue is scalp tissue. There is no other donor site in the body that will approximate the same hair-bearing qualities of scalp tissue. A wide variety of techniques has been used to close scalp defects. They include:

• Primary Closure--For small defects this is often the best option. Defects less than 3 cm in diameter can be closed primarily, but this varies depending on location. If primary closure is selected, any defect in the galea should be closed first with buried resorbable sutures, and skin edges should be reapproximated using suture or staples.


• Skin Grafting and Tissue Expansion--Placing split-thickness skin grafts can provide a quick and effective means of defect closure. Skin grafts require an adequately vascularized wound bed and are not successful if applied directly to exposed bone. Intact pericranium is typically sufficient to support a skin graft. Tissue expansion usually provides ample tissue with preservation of scalp sensation, color, thickness, and hair; however, it ultimately requires a minimum of 2 operative procedures. Patients should understand beforehand that this requires a commitment of at least 1-2 months


• Local Flaps--Local flaps are the workhorses of small to midsized scalp reconstructions. These flaps consist of skin, subcutaneous tissue, and galea, although occasionally small superficial defects may be adequately reconstructed using a flap elevated in the subcutaneous plane. Any local flap is best raised over named arterial systems. Raising a large flap and then covering the donor site with a skin graft is probably safest. One should avoid suture lines in areas where prosthetic material might be exposed.


• Free-tissue transfers--Before the advent of free-tissue transfers, closure of scalp defects covering more than 15-20% of the scalp was essentially impossible with a single procedure. Free flaps provide for single-procedure closure of large defects or complicated wounds involving scalp and bone. They can also provide improved wound healing in the setting of radiation or infection. However, they are time-consuming and expensive, and they all involve at least some donor site morbidity. Therefore, they should be reserved for appropriate situations when local flaps, skin grafting, or healing by secondary intent is not an option.


• Vacuum assisted Closure Device (VAC)--A vacuum assisted closure device has been used for large defects over the dura to promote the growth of granulation tissue. This tissue is then covered with a skin graft. The device works by applying uniform subatmospheric pressure to the wound, allowing it to develop a better blood supply, decreased bacterial counts, and robust granulation tissue.

References:

Reconstruction of Acquired Scalp Defects: An Algorithmic Approach; Plastic & Reconstr Surg, Vol 116(4):54e-72e, September 15, 2005. Leedy, Jason E. M.D.; Janis, Jeffrey E. M.D.; Rohrich, Rod J. M.D.
Psychological Sequelae of Failed Scalp Replantation; Plastic & Reconstr Surg.; Vol 113(6):1573-1579, May 2004. Mowlavi, Arian M.D.; Bass, Michael J. B.S.; Khurshid, Khurshid A. M.D.; Milner, Stephen M.D.; Zook, Elvin G. M.D.
Total Face and Scalp Replantation [Case Report]; Plastic and Reconstructive Surgery, Vol 102 (6) November 1998, pp 2085-2087; Thomas, Abraham M.S., M.A.M.S., M.Ch., F.A.I.S., F.I.C.S.; Obed, Vijay M.S., M.Ch.; Murarka, Anil M.S., M.Ch.; Malhotra, Gopal M.S., M.Ch.
Scalping Injury; Plast. Reconstr. Surg., Vol 55: 439, 1975; Koss, N, Robson, M, and Krizek, TJ
Successful Replantation of an Avulsed scalp by Microvascular Anastomoses; Plast. Reconstr. Surg. Vol 58: 133, 1976.; Miller, G D H, Anstee, E J, and Snell, J A

Messanger Bag Purse

I finished the messenger bag, 11" by 12''. There are two zippered compartments and another with a magnetic closure. The strap is a heavy nylon. There is a Swivel Snap Hook for keys. I did the quilting with gold metallic thread.

I enjoyed making this bag and can see making several of these for my nieces for Christmas. I know at least a couple of them would really like the bag. One niece (a nurses aide--trying to get her to go to nursing school) is really into purses of all kinds, probably more than shoes.

Necrotizing Soft Tissue Infections

 Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I thought I would write about necrotizing soft tissue infections after receiving a comment on an earlier posting by Buckeye Surgeon. Necrotizing soft tissue infections are not new. They were first described in the US Civil War. The term "necrotizing fascitis" was coined in 1952 by Wilson. There are multiple pathogens (bacteria) that can cause necrotizing infections. These include beta-hemolytic streptococci, coagulase-positive staphylococci (often MRSA), gram-negative enteric pathogens (clostridia perfringens), and peptostreptococci (an anaerobic bacteria). There is a progressive association of this disease with intravenous drug use, and this is a challenging population to work with and to diagnose. There is a progressive problem in our country with morbid obesity, and these patients are at increased risk as well. 
Necrotizing soft tissue infection is any infection of the soft tissue that is associated with necrosis requiring operative intervention. This usually occurs in the context of a critically ill patient. Necrotizing soft tissue infection is really a spectrum of disease, depending upon the level of the skin and subcutaneous tissue that is involved. There are various terms used including necrotizing cellulitis, which is generally a more superficial infection but still can cause significant necrosis. The traditional term, necrotizing fascitis, really refers to tracking in either the superficial or the deep fascial planes and often involves the subcutaneous fat, which is a relatively avascular area and therefor at high risk, particularly in the very obese patient. Even deeper infections can cause myonecrosis with significant destruction of the muscle.

The diagnosis is based on a constellation of symptoms, physical signs, and laboratory assessment. Pain out of proportion to the physical findings is the major symptom. This can sometimes be difficult to interpret,especially if the patient is already far down the course of their illness and does not have a clear mental status. Other signs include: an x-ray with a huge amount of gas in the soft tissue, tense edema, purple discoloration, and cutaneous gangrene. There may be blistering of the skin. Late signs include a patient in shock or with sever organ dysfunction. The laboratory signs to look at include: admission WBC (white blood count) greater than 15.4 or Na (sodium) level less than 135.

If you (the surgeon) are doubt, take the patient to the operating room for exploration down to the fascia level. Look for the ominous signs, such as some thrombosis of the microvasculature, dishwater fluid; or being able to push your finger along the deep fascial planes with no resistance. It has been shown that if you diagnose and treat the patient early (getting the patient to the operating room within 24 hours), the mortality is about 30-36%. If diagnosis and treatment is delayed, the mortality rate nearly doubles (70%). Sometimes amputation of the infected arm or leg will be necessary.

The major principle in the management of these diseases, in any necrotizing process, is surgical management. The goal here is early intervention. The principle is wide debridement of all necrotic tissue. That often involves decompression of fascial planes and may require an amputation, which is a difficult decision to make at the first operation, but in many circumstances can be lifesaving. It is recommended that you should schedule a return to the operating room within 12 to 24 hours for repeat debridement, careful inspection of the wound, and evaluation for progression of necrosis. If the patient is clinically deteriorating, then take them back sooner than that. It is important to remember that you're going to create large wounds in these patients in order to get an adequate debridement. The subcutaneous necrosis often extends well beyond the skin changes, and really it cannot be appreciated until you are in the operating room. These wounds may require reconstruction later.

The second principle, after wide and frequent surgical debridement, is antimicrobial therapy. Empiric broad spectrum coverage is certainly warranted for these critically ill patients. You want to cover streptococci and clostridia, which are the most rapidly progressive of these organisms that are associated with necrotizing infections. It should be remembered that this is often a mixed infection, so it's important to cover the gram-negatives as well. Penicillin in high doses provides excellent coverage for streptococci and clostridia. Clindamycin is suggested for clostridia coverage. As a protein-synthesis inhibitor, clindamycin may both reduce toxin production and may also bind the toxin produced by clostridia which is thought to be responsible for the rapid decline of many of these patients. Gentamicin is usually added as the gram-negative coverage unless there is significant renal dysfunction, in which case a fluoroquinolone is used. Because of the emergent resistance pattern to MRSA, particularly in intravenous drug users, vancomycin may be warrented in these patients until culture results return.

These patients end up in the intensive care unit (ICU). There has to be good glycemic control and nutritional support. These patients are very hypermetabolic and have large wounds and high-protein needs (similar to burn patients). All these issues must be addressed.

Once the infection is controlled and the patient begins to stabilize and heal, then the issue of wound closure can be addressed. The clean wound really needs to 5-10 days old with appearance of clean granulation tissue. Then a skin graft, a flap, or wound suture can be done. If the patient continues to be unstable, alternative wound treatment such as continued wound dressings or the use of the a wound vac may be the best option.

How do you prevent this illness? The best way is to keep your skin intact. The next best thing is to have good hygiene. Wash your hands. Clean any cuts, scraps, etc. Control any underlying chronic illnesses like diabetes.

References:
Treating Severe Soft Tissue Infections: How and What I Do by Eileen M. Bulger, MD, FACS (Medscape article well worth reading)

Necrotizing Fascitis by Robert A Schwartz, MD--an eMedicine article

NECROTIZING FASCIITIS [Commonly Known as The "Flesh Eating" Bacteria];

Necrotizing Fascitis--Wikipedia Article

Radial (Thumb) Polydactyly

 Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Radial (thumb) polydactyly occurs in 0.08 per 1000 live births among both black and white populationgroups. It is not as common as ulnar polydactyly. When thumb duplication occurs alone, it is usually unilateral and sporadic. Those involving a triphalangeal thumb may be inherited as an autosomal dominant trait. As with triphalangeal thumb, delta phalanx has often been found to have a strong family history of inheritance. The basic classification system was defined by Wassel in 1969. His classification was based on the level of duplication and the number of bones in the thumb, and has seven groups (types I to VII) according to the level of the bifurcation. The thumb is often hypoplastic (smaller than normal), so the reconstructed thumb is nearly always smaller than the opposite side.  

Classification--Types I to VII based on level of duplications:

I : bifid distal phalanx (DP)(bone under the finger nail)

II: duplicated DP
III: bifid proximal phalanx (PP) (digit bone nearest the palm)
IV: most common type with duplication of proximal phalanx which rest on broad metacarpal
V: bifid metacarpal (MC) (bone in palm)
VI: duplicated MC
VII: triphalangism

Treatment:

The strategy of surgery is to used the "accessory digit" to augment the thumb that is kept. The duplicated thumb is skeletonized and removed at the MCP joint, retaining all of its soft tissue structures (which help augment size of the remaining thumb). When sharing equal halves, for the reconstruction of a thumb, it is best to preserve a single nail to prevent a nail ridge. Often an “80 percent rule” is followed -- generally keeping a given thumb segment if it is 80 percent of normal thumb size, otherwise a Bilhaut-Cloquet type of thumb-sharing procedure is more likely to be indicated. It is mostly indicated for types I and II deformities.

If there are two equal digits, one should remove the radial one and reconstruct the radial collateral ligament rather than the ulnar collateral ligament (more important for the stability of the thumb). When duplication is at level of joint, types II and IV, the collateral ligament of the digit to be discarded needs to be preserved and sewn to the remaining digit across the retained joint. If the MCP joint remains unstable, fusion of MP joint is considered when the child reaches the age of ten or 12. The tendons of the thumb(s) have to be addressed. EPL (extensor pollicus longus) and FPL (flexor pollicus longus) may be split and insert on both digits, each with its own eccentric insertion. Duplicated EPL and FPL tendons should be transferred over to the remaining digit. The abductor brevis tendon may attach to the radial duplicated thumb and the adductor pollicis usually attaches to the ulnar thumb. The abductor brevis is transferred into an anatomic insertion site on the ulnar thumb (the one being kept). The web space (space between the thumb and index finger) may be contracted. In this case, the dorsal skin of the discarded thumb should be used to assist with making the web space deeper.

Treatment of Type IV should be done very early, because if one waits too long, the supernumerary component displaces the normal component into markedly radial or ulnar deviation. If left, it will continue to grow this way.

References:
Monozygotic Twins Disordant for Thumb Polydactyly; Plastic & Reconstructive Surgery. Vol 113(1):449-451, January 2004; Peterson, Steven L. D.V.M., M.D.; Rayan, Ghazi M. M.D.

Triplicated Thumb; Plastic & Reconstructive Surgery. Vol 100(2):418-421, August 1997; Atabay, Kenan M.D.; Latifoglu, Osman M.D.; Demirkan, Ferit M.D.; Yavuzer, Reha M.D.

Treatment of Congenital Upper Extremity Problems; Plastic & Reconstructive Surgery. Vol 119(5):101e-129e, April 15, 2007; Netscher, David T. M.D.; Baumholtz, Michael A. M.D.

Thumb Polydactyly: Clinical Outcome after Reconstruction; CH Yen, WL Chan, HB Leung, KH Mak; Journal of Orthopaedic Surgery 2006;14(3):295-302

Ulnar Polydactyly

 Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

First, let me thank Dr. Rob for giving me the idea for this posting. Check out his post on "Hand of the Beholder".  

Ulnar polydactyly (extra finger on the small finger side of the hand) may be isolated or part of a syndrome. It is much more common than radial polydactyly (extra fingers/thumb on the thumb side of the hand). A family history is often present. Both autosomal dominant and recessive patterns have been observed. When unilateral (one hand only), it is more common on the left side (76%) rather than the right (24%). There is a predominance towards males and African American when unilateral. Syndromic associations with ulnar polydactyly are more common among Caucasians than African Americans. Pedunculated (like a skin tag or nubbin) ulnar polydactyly (Type I) in an African American child is rarely syndromic or associated with other anomalies. More than 40 different syndromes were reported with ulnar polydactyly. They include Trisomy 18, Ellis-van Creveld Syndrome, and Apert Syndrome.

There are five types of ulnar polydactyly
Type I: small cutaneous appendage in the form of a wartlike skin nubbin that is raised above the skin surface without nail or bone

Type II: extraneous digit with a small nail and ossicle (bone) with or without a poorly developed joint of which the digit lacks tendons, does not articulate (no joint) with the fifth metacarpal (5th is small finger, metacarpal in the bone in the palm) , and does not have any function

Type III: more developed than type II, but the proximal (nearest the palm) phalanx (small bone in the finger) is infrequently fully develped and often hypoplastic (under developed) or absent. Despite this the middle phalanx or remaining proximal phalanx articulates with a bifid fifth metacarpal head. The proximal phalanx may be fused to the fifth metacarpal at a 90-degree angle

Type IV: is a fully developed sixth digit with its own metacarpal shaft.

Type V: is associated with syndactyly (ie polysyndactyly). Other polydactyly case that include bony anomalies such as bifurcation of the distal phalanx, angular deformities, or cross bones are grouped into this type.

The goals of treatment in ulnar polydactyly are for improving function and appearance and social acceptance. Treatment of congenital hand differences at an early age allows maximal cerebral (brain-to-hand) functioning of hand parts and should be completed before school age.

• Type I requires no treatment (unless there is an objection to the small "wart-like" skin tag).


• Type II will often require surgical excision. Only if the pedicle is very narrow can ligation be done. The practice of ligation in the newborn is sometimes condemned, especially without evaluating the patient. Ligation can be done using a 4-0 silk suture for pedunculated polydactyly, but the patient’s family should be warned about possible complications. Ligation can leave a small nubbin, sometimes with retained bone or cartilage. This can be symptomatic and require surgical excision. Gangrene of the digit that has not sloughed or infection may complicate ligation.


• Types III, IV,and V require surgical removal to improve function and appearance and to prevent complications. Type V requires sometimes more involved surgical reconstruction of the hand in addition to that of polydactyly. Surgical treatment may require skin release, balancing of tendons, alignment of joint surfaces, rearrangement of intrinsic musculature, or osteotomy to correct angular deformities. Incisions should be made in the mid-axial line and retain adequate skin for closure; otherwise with growth, a scar may migrate volarly and create a contracture. If necessary, the wound can be closed with a Z-plasty to prevent longitudinalscarring for incisions longer than 1 cm in children around 1 year old.

References:

Ulnar Polydactyly by Ghazi M. Rayan, M.D., and Bret Frey, M.D.; Plastic & Reconstructive Surgery. 107(6):1449-1454, May 2001.

Congenital Malformations of the Hand and Forearem edited by D. Buck-Gramcko; chapter on Ulnar polydactyly; London: Churchill-Livingstone, 1998.

eMedicine article on Supranumerary Digit by Carter G Abel, MD

Development of the Human Hand: A Short, Up-to-Date Overview by Helga Fritsch

Hand--Wikipedi article--good pictures of normal anatomy

Polydactyly--Wikipedi article

Seventeen!

 Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

I (guess) congratulations are in order for this Arkansas family. Michelle and Jim Bob Duggar who live in Springdale, Arkansas with their 16 children just welcomed their 17th child into the world. She was born yesterday, August 2nd. The baby, Jennifer Danielle, was born at 10:01 AM (CT), weighing in at 8 pounds, 8 ounces and measuring 21 inches in length. Their other children range in age from 21 months to 19 years of age. There are two sets of twins. There are now 10 boys and 7 girls. And they want more. I am amazed, absolutely amazed. Michelle even home schools the children. She must be one organized woman!

My father had one son and one daughter with his first wife. My mother had three sons and four daughters with my father. She then had another son with my step-father. My step-father had three daughters and two sons with his first wife. So when you add them all up, I had 14 brothers and sisters of one kind or another. However, the only ones who ever lived under the same roof with me were the ones my mother had--eight of us. Remember the show "Eight is Enough". Our house was full, very full. We didn't have nine bathrooms like the Duggars have. Maybe it wouldn't have seemed so full if we had.

My roommate in college was an environmental science major. She used to give me grief about wanting more than two children. She argued that we needed to only replace ourselves. The world was overpopulated. I've lost track of her, but know she had three children (at least). I was never blessed with any, so I guess she had one for me.

The Duggars seem to be good parents, seem to be able to provide for the children they have, seem to be thrilled with each birth. I sure hope all is as it seems, because I know how difficult it was on my Mom just with her eight.

God bless you Michelle Duggar with all the love and patience and strength you need.

Heat Related Illnesses

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Here in Arkansas, we are just now getting to the hottest part of our year. The first few weeks of August are typically the hottest for us. This is when we have to worry the most about heat related health issues. I don't typically see heat related injuries in my practice, but do in my relatives (heat cramps and heat exhaustion) who don't always follow common sense regarding the summer heat. My husband likes to mow the yard during the hottest part of the day. I will occasionally see it affect postoperative patients who “think” they are back to normal and find they are more sensitive to the heat than they expected.

The very young and the elderly are especially vulnerable to the heat. People with chronic health issues are also at greater risk and need to take special care to stay healthy in the heat.

Key Precautions for Prevention of Heat-Related Illness

• If possible try to acclimate to the weather. Those who work in the heat are usually more "used" to it. Humidity can make it "seem" warmer than the actual temperature (heat index).
• Dress for the heat. Wear lightweight, light-colored clothing and use a hat or umbrella. If your post-surgery garments (girdles for tummy tucks or liposuction) or casts are unavoidable, then consider staying indoors or carrying a hand-held battery operated fan with mist
• Don't just carry water or juice with you. Drink it, even if you don't feel thirsty. Avoid alcohol and caffeine, which can dehydrate the body. If you are recently post-surgery, you may need even more fluids than normal. Drink enough that your urine is light in color.
  
• Avoid using salt tablets unless directed by a physician.
  
• Avoid strenuous activity. If you must do something physically demanding (work or football/band practice), try to do it during the coolest part of the day (between 4 am and 7 am). If you must do it later in the day, remember fluids. If you are sweating, you are losing fluids and salts. Consider drinking one 8-oz Gatorade for every 1-3 8-oz water.
  
• Stay indoors as much as possible. Use a fan or air conditioning. Really important if you are newly post-surgery, very young or elderly, have a heavy cast on.
  
• Take regular breaks when engaging in physical activity on warm/hot days. Take time out to find a cool place (shade tree, indoors, lake).

Common Heat-Related Disorders
Heat Cramps
Symptoms include painful spasms, usually in the legs and abdominal muscles.
Treatment–
• Stop the activity and rest in a cool place.
• Lightly stretch or gently massage the muscle to relieve the spasms. Sip or slowly drink cool water.
Heat Exhaustion
Symptoms include heavy sweating. Skin may be cool, pale, and clammy (even with the sweating). Pulse will be fast and may be weak. Breathing is often fast and shallow. The person may feel faint and/or dizzy. They may complain of headache, weakness, and thirst. The person may have nausea and vomiting. Core (rectal) temperature is elevated, usually around 100 F or more.
Treatment–
• Get to a cool place.
• Lie down and loosen up your (their) clothing.
• Apply cool, moist cloths. If water hose or mist available, use it to cool the skin.
• Give sips of cool water or ice chips. Gatorade or other sports drinks will help replace the salt that has been lost. Salty snacks are appropriate, as tolerated. If unable to keep this down, then needs to be seen in the emergency room for IV fluids.
Heat Stroke
Symptoms include a temperature of 103 F or more (105 F or more). No sweating, a rapid pulse, fast and shallow breathing. The skin will be flushed (red), hot, and dry. The person will have nausea, dizziness, a headache, and confusion or delirium. The person may be unconscious.
Treatment–
• This is a severe medical emergency. Summon emergency assistance or get the person to the hospital without delay. Delay can be fatal.
• Move the person to a cooler environment while waiting for the EMT’s.
• Use whatever method available (cool baths, water hose, misting) to begin reducing the body temperature while waiting.
Don't forget to Protect your Pets. Animals, like we humans, can easily overheat during the hot summer months. Many of us include our animals in our outdoor activities (walking, picnics, etc) so please protect them as well as yourselves.
• Limit exercise to the coolest part of the day, typically early morning. Watch for warning signs–glassy eyes, frantic panting.
• Make sure your dog has constant access to shade and an endless supply of cool, clean water.
• Never leave a dog in a car, even for a few minutes.
• Remember that older, obese, and short-nosed dogs are less tolerant of the heat.
Heat stroke in animals, as in humans, can be deadly and requires emergency medical attention. While seeking medical help, cool the animal down with wet towel, spray him/her with cool water, provide ice chips if conscious.
Symptoms of heat stroke in animals can include:
• Sluggish and non-responsive demeanor
• Bright red and/or dry tongue and gums• Vomiting or diarrhea
• Unusual breathing pattern, heavy panting, or high heart rate
References:
Heat Exhaustion and Heat Stroke--eMedicineHealth
When the Sun Goes Up, Don’t Let Your Guard Down
By Julie Irby , Special to Redcross.org
Tips for Preventing Heat-Related Illness--CDC
Heat exhaustion: First aid--MayoClinic.com

"Crazy" Quilt for a Baby

Here is a picture of part of a baby quilt I made for one of our CRNA's. I like to use up scraps this way. The quilt is made by sewing the strips of scrap fabric directly onto the back and batting. In this way, the "quilting" is done as you "piece" the quilt. It is never enough quilting for me though, so I always end up doing more when I am done with the pieced quilt. I, also, find that this is a quilt the mother of the baby will use. They will get on the floor with the baby and "find" things in the quilt. Where is the horse? Where is the sheep? Can you find the blue? What about red? Can you find a star? Where is the flower? Can you find the tree? or the dog? I hope that it helps with the mother-child bonding, but also with the education-by-play of the young baby-toddler. And if it doesn't, well, I enjoyed making the quilt.