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Plastic surgeons have the unique perspective of working with all types of patients and care teams from almost all specialties in surgery and medicine, which creates unique challenges in times of distress. As the initial epicenter of coronavirus disease 2019 cases in the United States, the University of Washington program was required to rapidly develop strategies to deal with the escalating crisis. All aspects of the program were affected, including the need to triage the urgency of plastic surgery care, safe staffing of plastic surgery teams, and the role of plastic surgery in the greater hospital community. In addition, as a residency training program, limiting the impact of resident education and maintaining a sense of community and connection among members of the program developed into important considerations. The authors hope that the narrative of their experience will provide insight into the decisions made in the University of Washington health care system but also remind others that they are not alone in dealing with the challenges of this pandemic.

Background With increasing public awareness of and greater coverage for gender-confirming surgery by insurers, more transgender patients are likely to seek surgical transition. The degree to which plastic surgery and urology trainees are prepared to treat transgender patients is unknown. Objective We assessed the number of hours dedicated to transgender-oriented education in plastic surgery and urology residencies, and the impact of program director (PD) attitudes on provision of such training. Methods PDs of all Accreditation Council for Graduate Medical Education–accredited plastic surgery (91) and urology (128) programs were invited to participate. Surveys were completed between November 2015 and March 2016; responses were collected and analyzed. Results In total, 154 PDs (70%) responded, and 145 (66%) completed the survey, reporting a yearly median of 1 didactic hour and 2 clinical hours of transgender content. Eighteen percent (13 of 71) of plastic surgery and 42% (31 of 74) of urology programs offered no didactic education, and 34% (24 of 71) and 30% (22 of 74) provided no clinical exposure, respectively. PDs of programs located in the southern United States were more likely to rate transgender education as unimportant or neutral (23 of 37 [62%] versus 39 of 105 [37%]; P = .017). PDs who rated transgender education as important provided more hours of didactic content (median, 1 versus 0.75 hours; P = .001) and clinical content (median, 5 versus 0 hours; P Conclusions A substantial proportion of plastic surgery and urology residencies provide no education on transgender health topics, and those that do, provide variable content. PD attitudes toward transgender-specific education appear to influence provision of training.

Background The transition to the Next Accreditation System is well underway, and a shift toward competency-based assessment in the form of milestones is now the standard. A significant effort has been completed by the Plastic Surgery Milestones Working Group to develop specific milestones and assessment tools for plastic surgery training. Methods The history of the development toward competency-based assessment was reviewed. Data regarding the trends and regulations associated with board certification and the role of maintenance of certification were reviewed. Results The work of the Plastic Surgery Milestones Working Group has sparked interest in assessment and created an opportunity for further development. The efforts toward validating assessment tools by our colleagues working in other surgical specialties serve as a suitable roadmap for further progress. Board certification is an integral part of successful practice and should be regarded as an expectation. Despite the burdens associated with maintenance of certification, it serves a valuable function in ensuring optimal patient care and is often retrospectively seen as an important component of practice. Conclusions The competency-based milestones are the new standard, and work on this new methodology of assessing plastic surgery trainees is expected to continue. Accurate assessment is critical to the pathways for board certification and maintenance of certification, which serve important roles for all parties involved in the delivery of medical care.

Metacarpal fractures comprise between 18–44 % of all hand fractures. Non-thumb metacarpals account for around 88 % of all metacarpal fractures, with the fifth finger most commonly involved [ 19 ]. The majority of metacarpal fractures are isolated injuries, which are simple, closed, and stable. While many metacarpal fractures do well without surgery, there is a paucity of literature and persistent controversy to guide the treating physician on the best treatment algorithm. The purpose of this article is to review non-thumb metacarpal anatomy and treatment protocols for nonoperative management of stable fractures, and compare existing literature on surgical techniques for treatment of acute fractures and complications.

Principles of effective assessment have become increasingly popular topics in graduate medical education. Changes in the structure of plastic surgery training demand a thorough understanding of the state-of-the-art in assessing surgical trainees. Moreover, the authors' understanding of different domains and methods of assessment and the available tools continues to grow.The authors reviewed the available literature regarding assessment in graduate medical education, specifically as it pertains to plastic surgery. In addition, the authors present principles of effective assessment and report on the currently available assessment methods.Assessment is multifaceted and impacts everyone, not just the individual learner. For assessments to be useful, they need to possess validity and reliability. Moreover, there is a necessary pragmatism limiting different methods and tools for assessing learners. Some types of assessment are universally familiar and include examples such as written examinations and procedural logs. Other emerging areas that are actively being researched involve simulation, nontechnical skills, and procedure-specific technical assessments.Updating the thoroughness and multidimensionality with which plastic surgery trainees are assessed is an evolving area and one that is ripe for continued research.

Seattle, Wash. The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented. (Plast. Reconstr. Surg. 126: 2205, 2010.)

The hand, by virtue of its position in space, complex anatomical composition, and characteristic biomechanical properties, is subject to a host of disease processes and traumatic injuries. This article reviews the presentation, evaluation, treatment, and outcomes of treatment in hand infections, high-pressure injection injuries, Dupuytren disease, and arthritis.

The thumb has a significant impact on the overall function of the hand, and its absence can result in major impairment and disability. Functional impairment following the loss of the thumb will reliably degrade the overall function of the hand with a loss of 50 % of grasp, 30 % of pinch, and 20 % of hook strengths. Given these factors, the thumb has been assigned a relative value of impairment of 40 %, further emphasizing the dictum that the thumb should be replanted in all situations possible. The mechanism of injury is a significant predictor of ultimate function, both in regard to strength and range of motion. It should be noted that severe avulsion and crush injuries affect the functional outcome, as well as the possibility of performing the replantation. Replantation should proceed in a stepwise manner, following a thorough debridement and irrigation of the injury site and amputated part. Midlateral incisions on the amputated part and proximal stump allow for exploration of the volar structures, including the flexor sheath and neurovascular bundles. Ultimately, functional success is based upon the ability of the surgeon to reconstruct the bony and soft tissues, as well as the patient’s motivation and compliance with perioperative management and rehabilitative hand therapy.

BACKGROUND The goals of thumb reconstruction include the restoration of thumb length, strength, position, stability, mobility, sensibility, and aesthetics. It is a rare event when all of these objectives can be achieved, and prioritization should be based on the goals and functional demands of the patient. METHODS In this article, the authors review the most common reconstructive strategies for all types of traumatic thumb defects. RESULTS Replantation is approached first as the primary option for most amputations. Nonreplantable injuries are organized using a simple classification adapted from Lister, dividing thumb amputations into four functional categories: soft-tissue deficit with acceptable length, subtotal amputation with borderline length, total amputation with preservation of the carpometacarpal joint, and total amputation with destruction of the carpometacarpal joint. Within each category, relevant microsurgical and nonmicrosurgical reconstructive techniques are discussed, with a focus on appropriate technique selection for a given patient. Evidence and outcomes data are reviewed where available, and case examples from our own experience are provided. CONCLUSIONS Given that available options now range from simple gauze dressings to complex microsurgical reconstruction, preservation of reconstructive flexibility is essential and should be facilitated by judicious preservation of intact structures. The divergence of available reconstructive pathways underscores the importance of knowing one's patients, understanding their motivation, and assessing their goals. Only in properly matching the right reconstruction with the right patient will a mutually satisfactory result be achieved.

Purpose To compare the efficacy, tolerance, and safety of manual manipulation at day 7 to day 1 following collagenase Clostridium histolyticum (CCH) injection for Dupuytren contracture. Methods Eligible patients were randomized to manipulation at day 1 versus day 7 following CCH injection. Preinjection, premanipulation, postmanipulation, and 30-day follow-up metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint contractures were measured. Pain scores were recorded at each time point. Data were stratified per cohort based on primary joint treated (MCP vs PIP). Means were compared using paired and unpaired t -tests. Results Forty-three patients with 46 digits were eligible and were randomized to 1-day (22 digits) and 7-day (24 digits) manipulation. For MCP joints, there were no significant differences in flexion contractures between 1- and 7-day cohorts for initial (47° vs 46°), postmanipulation (0° vs 2°), or 30-day follow-up (1° vs 2°) measurements. Premanipulation, the residual contracture was significantly lower in the 7-day group (23° vs 40°). For PIP joints, there were no significant differences between 1- and 7-day cohorts for initial (63° vs 62°), premanipulation (56° vs 52°), postmanipulation (13° vs 15°), or 30-day (14° vs 16°) measurements. There were no significant differences in pain or skin tears between the 2 groups. No flexor tendon ruptures were observed. Conclusions The effectiveness of CCH in achieving correction of Dupuytren contractures was preserved when manipulation was performed on day 7, with no differences in correction, pain, or skin tears. These data suggest that manipulation can be scheduled at the convenience of the patient and surgeon within the first 7 days after injection. Type of study/level of evidence Therapeutic I.

Background A critical element of a thriving academic plastic surgery program is the quality of faculty. A decline in recruitment and retention of faculty has been attributed to the many challenges of academic medicine. Given the substantial resources required to develop faculty, academic plastic surgery has a vested interest in improving the process of faculty recruitment and retention. Methods The American Council of Academic Plastic Surgeons Issues Committee and the American Society of Plastic Surgeons/Plastic Surgery Foundation Academic Affairs Council surveyed the 83 existing programs in academic plastic surgery in February of 2012. The survey addressed the faculty-related issues in academic plastic surgery programs over the past decade. Recruitment and retention strategies were evaluated. This study was designed to elucidate trends, and define best strategies, on a national level. Results Academic plastic surgery programs have added substantially more full-time faculty over the past decade. Recruitment efforts are multifaceted and can include guaranteed salary support, moving expenses, nurse practitioner/physician's assistant hires, protected time for research, seed funds to start research programs, and more. Retention efforts can include increased compensation, designation of a leadership appointment, protected academic time, and call dilution. Conclusions Significant change and growth of academic plastic surgery has occurred in the past decade. Effective faculty recruitment and retention are critical to a successful academic center. Funding sources in addition to physician professional fees (institutional program support, grants, contracts, endowment, and so on) are crucial to sustain the academic missions.

Calculating impairment in burn patients is crucial to understanding outcome. However, it is rarely reported after burns, presumably because the process of calculating impairment ratings is complicated and tedious. Computerized systems have been developed that facilitate the process, but it has not been established in burn patients that these systems reduce the time required to calculate impairment. We evaluated the Dexter Evaluation and Therapy System by Cedaron Medical Inc (Davis, CA). A sample of 10 manually recorded ratings was compared with 10 performed on the Dexter®. Mean time for the manual technique was 65 ± 35 minutes versus 37 ± 13 minutes for the Dexter® (P

It has been shown that preconditioning either by proximal pedicle clamping or by pedicle intravascular drug administration, for example with adenosine, can improve flap survival. These methods, however, are not well suited to random-pattern flap transfer in the clinical setting. The aim of this study was to evaluate clinically applicable preconditioning methods for random-pattern flaps. Eighteen male Sprague-Dawley rats were used. Bipedicled dorsal skin flaps (2 x 8cm) containing panniculus carnosus were elevated. In the ischaemic preconditioning group the cranial pedicle was clamped for 20min, followed by 40min reperfusion before the cranial pedicle was cut, producing a caudally based random-pattern flap. In the pharmacologic preconditioning group adenosine was locally injected in the cranial half of the flap before the cranial pedicle was cut. In the control group saline was locally injected instead of adenosine and the pedicle was cut in the same manner. Flap survival area was evaluated at day 7. Flap survival area in both preconditioning groups was significantly higher than in the control group (P0.05). Both preconditioning methods can improve random-pattern flap survival in rats. These methods may prove useful in the clinical setting.

Deep hand burns with exposed tendons and joints are rare but devastating injuries. They cannot be grafted and require flaps. Abdominal or groin flaps are commonly used, but they are bulky and require separation of the digits. We tried the Millard "crane" flap for these burns and compared our patients' results with those of patients who had received standard abdominal skin flaps. Eleven deep hand burns that had been treated with flaps were evaluated. Six patients had been treated with the crane flap and 5 had been treated with conventional abdominal skin flaps. All crane procedures provided graftable wound beds. The total active ranges of motion of all 11 patients 6 months after the surgical procedures showed no statistical difference. The crane method also provides good cosmetic results. None of the hands treated with crane flaps required procedures to separate the digits or debulk the flaps, but all of the hands treated with conventional abdominal skin flaps required these types of procedures.

Ischemia and reperfusion causes tissue injury that can be partially prevented by mild hypothermia. In this study we postulated that hypothermic protection could occur if imposed only during reperfusion. Rabbit ears were partially amputated, the central artery occluded for 6 h followed by reperfusion at an ambient temperature of either 20 or 24 degrees C resulting in ischemic ear temperatures of 22.5 vs. 24.7 degrees C. Ear temperature of rabbits remaining in the 24 degrees C room increased with reperfusion to 32.4 degrees C whereas those moved to the 20 degrees C room increased to 30.0 degrees C by 2 h of reperfusion. Ear volume was used as a measure of tissue edema and was measured for 7 days after the ears were allowed to reperfuse. Normalized myeloperoxidase content (polymorphonuclear cell accumulation) was significantly greater in the 24 degrees C ischemia-24 degrees C reperfusion group compared with the other groups. Ear edema was significantly less in the two groups exposed to 20 degrees C reperfusion compared with the 24 degrees C ischemia-24 degrees C reperfusion group. Peak ear volume was 5.0 times baseline for the 24 degrees C ischemia-24 degrees C reperfusion, 4.0 times baseline for the 20 degrees C ischemia-24 degrees C reperfusion, 3.4 times baseline for the 24 degrees C ischemia-20 degrees C reperfusion, and 3.3 times baseline for the 20 degrees C ischemia-20 degrees C group. We conclude that mild hypothermia reduces PMN accumulation and is more effective in preventing tissue injury when imposed during reperfusion compared with during ischemia.

To determine if small avulsion fractures of the thumb ulnar collateral ligament (UCL) with minimal (or = 2.0 mm) displacement can successfully be treated by cast immobilization, the authors reviewed 9 patients with minimally displaced fractures initially treated by casting. Despite immobilization within an average of 2 days of the initial injury (range, 0-6 days), a minimum of 6 weeks of immobilization in a cast, and adequate rehabilitation, all 9 patients had persistent thumb pain, especially with activities requiring strong pinch. After undergoing open reduction and internal fixation, the patients had relief of thumb pain and pinch strength improved from 36% of the contralateral side to 89% (p.01). Grip strength increased from 77% to 93% (p.05), but the ranges of motion of the thumb metacarpophalangeal and interphalangeal joints were not significantly altered. Minimally displaced UCL avulsion fractures frequently have significant rotation that prevents successful fracture healing even with prompt cast immobilization.

The functional outcome after surgery was determined in 21 patients an average of 29 months (range, 24-52 months) after surgery to evaluate the efficacy of arthroscopic repair of triangular fibrocartilage complex (TFCC) tears and ulnar shortening. All of the patients had reparable lesions of the TFCC treated after a delay of more than 6 months from the time of injury. The patients' average age was 32 years and all patients had wrist pain limiting them from work and/or sports prior to surgery. After surgery, there was a significant relief of pain (p.01). Grip strength and range of motion averaged 83% +/- 18% and 81% +/- 16%, respectively, of that of the uninjured side. At follow-up evaluation, 14 patients with repairs underwent follow-up studies; the TFCC was noted to be intact in 12 patients.

To evaluate the efficacy of arthroscopic repair of the triangular fibrocartilage complex (TFCC), functional outcome was determined after arthroscopic repair of 22 wrists in 21 patients. Average follow-up was 36 months (range, 26 to 48 months) and the patients' average age was 30 years (range, 22 to 38 years). All patients had wrist pain limiting them from work or any sports. Twelve of the 14 patients with positive arthrograms had an avulsion of the TFCC from the sigmoid notch (Palmer type 1D tears). Of the 6 patients with negative arthrograms, 5 had peripheral tears (Palmer type 1B). Five patients had associated lunotriquetral ligament repairs and 7 had ulna shortening osteotomies. There was a significant relief of pain and increase in work and sports activities (P < .01). Postoperative range of motion averaged 86% +/- 9% of the contralateral side and grip strength averaged 82% +/- 20% of the contralateral side. There was a significant correlation between the delay from injury to surgical repair and the final total range of motion and grip strength. Follow-up studies in 15 patients found that the repairs were intact in 12. Arthroscopic repair results in significant relief of pain and an increase in the ability to perform at work or sports.

Treatment of Dupuytren disease with collagenase clostridium histolyticum is increasingly used among hand surgeons. Although it is generally safe and efficacious, complications related to enzymatic fasciotomy occur. Postapproval surveillance and communication among hand surgeons continues to refine the indications, contraindications, and complications recognized in the treatment of Dupuytren disease with enzymatic therapy. Major treatment-related adverse events previously reported include flexor tendon rupture and complex regional pain syndrome. We report a patient who experienced total loss of a well-established volar ring finger skin graft following collagenase injection and propose a potential mechanism of vulnerability. This case may illustrate the susceptibility of type I collagen, which is uniformly present in a healed skin graft bed, to degradation with collagenase. We propose a cautious approach when considering treatment of a Dupuytren cord with collagenase in the presence of an overlying skin graft, regardless of the age of the graft.

Neutrophil adherence and/or aggregation has been implicated in ischemia reperfusion injuries. We examined the role of P-selectin in PMN-mediated injury after reperfusion of the rabbit ear. The ear was partially amputated, and then reattached leaving the central artery and vein intact. To induce ischemia the central artery was then occluded. Treatment was at reperfusion with either saline or one of two murine P-selectin mAbs, designated PB1.3 and PNB1.6 mAb PB1.3 cross-reacts with rabbit P-selectin and prevents histamine-induced leukocyte rolling, whereas PNB1.6 does not. Using a peroxidase-antiperoxidase system P-selectin was detected in the ischemic ear, but not in the nonischemic ear. Ear volume increased to 5.3 times baseline in the saline-treated animals (n = 8), 6.6 times baseline in the nonblocking mAb PNB1.6-treated animals (n = 2), and 3.7 times baseline in the blocking mAb PB1.3-treated animals (n = 8). Estimated tissue necrosis of the combined saline- and PNB1.6-treated animals was 46 vs. 2.7% for the mAb PB1.3-treated animals. We conclude that: (a) P-selectin is expressed in ischemia reperfusion; (b) P-selectin participates in PMN-endothelial cell interactions in ischemia reperfusion; and (c) inhibiting P-selectin adhesion significantly reduces reperfusion injury.

In this study we tested the hypothesis that neutrophil products are present in ischemic skin flaps and that they are abolished with preconditioning of the skin. Random back flaps were created on rats, and the sequential appearance of neutrophil products and tissue oxidants was measured in the skin flaps. These flaps had predictable skin necrosis (4.7 +/- 0.8 cm) in the distal ends, while preconditioned flaps had no skin necrosis. Neutrophil products were assayed by both histomorphometrics and myeloperoxidase assays. Lipid peroxidation products were measured to assess tissue oxidant production. These data demonstrate that there is an increase in myeloperoxidase activity in skin flaps that is statistically significantly greater in the distal ends of the flaps at 24 hours (p < 0.05). The lipid peroxidation products were statistically significantly elevated at 48 hours in the distal ends (p < 0.05). Preconditioning the skin as a bipedicled skin flap for 7 days and then dividing the distal attachment abolished neutrophil products and tissue oxidant activity in the skin flaps (p < 0.05). These data suggest that neutrophil products and oxidant production are increased in ischemic skin and that preconditioning of the flap markedly attenuates this response.

From 1985 to 1990, six patients were treated for ipsilateral fractures of the scaphoid and radius. All these injuries resulted from falls from a substantial height, with multiple injuries occurring in all patients. Two of the patients had minimally displaced fractures (1.0 mm), whereas the other four patients had moderately displaced scaphoid fractures (2.0 mm). The treatment for fracture of the distal radius was dependent on the fracture type, but all the scaphoid fractures were treated with internal fixation. All the fractures united, with the radial fractures healing in 6 weeks and the scaphoid fractures healing in an average of 13 weeks. The follow-up time averaged 2.9 years (range, 1.0 to 4.6 years). Internal fixation of the scaphoid in these combined injuries allowed for earlier and more aggressive therapy to maximize wrist and forearm motion.

Background: In order to improve digit motion after zone-II flexor tendon repair, rehabilitation programs have promoted either passive motion or active motion therapy. To our knowledge, no prospective randomized trial has compared the two techniques. Our objective was to compare the results of patients treated with an active therapy program and those treated with a passive motion protocol following zone-II flexor tendon repair. Methods: Between January 1996 and December 2002, 103 patients (119 digits) with zone-II flexor tendon repairs were randomized to either early active motion with place and hold or a passive motion protocol. Range of motion was measured at six, twelve, twenty-six, and fifty-two weeks following repair. Dexterity tests were performed, and the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome questionnaire and a satisfaction score were completed at fifty-two weeks by ninety-three patients (106 injured digits). Results: At all time points, patients treated with the active motion program had greater interphalangeal joint motion. At the time of the final follow-up, the interphalangeal joint motion in the active place-and-hold group was a mean (and standard deviation) of 156° ± 25° compared with 128° ± 22° (p < 0.05) in the passive motion group. The active motion group had both significantly smaller flexion contractures and greater satisfaction scores (p < 0.05). We could identify no difference between the groups in terms of the DASH scores or dexterity tests. When the groups were stratified, those who were smokers or had a concomitant nerve injury or multiple digit injuries had less range of motion, larger flexion contractures, and decreased satisfaction scores compared with patients without these comorbidities. Treatment by a certified hand therapist resulted in better range of motion with smaller flexion contractures. Two digits in each group had tendon ruptures following repair. Conclusions: Active motion therapy provides greater active finger motion than passive motion therapy after zone-II flexor tendon repair without increasing the risk of tendon rupture. Concomitant nerve injuries, multiple digit injuries, and a history of smoking negatively impact the final outcome of tendon repairs. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

From 1986 to 1990, twelve patients were treated for avulsions of the flexor digitorum profundus in either the ring or the long finger. Six patients had misleading x-ray films because the tendon had retracted farther than the fracture pattern had suggested. All of these patients had avulsion fractures from the palmar aspect of the distal phalanx. Although the classification of Leddy and Packer is very helpful in determining the prognosis for these injuries, the fracture patterns are not reliable in predicting the location of the retracted tendon end preoperatively. Therefore all flexor digitorum profundus tendon avulsions should be surgically repaired as soon as possible.

There are a number of insults that can compromise the soft tissue envelope of the hand. Soft tissue reconstruction seeks to restore both the aesthetic appearance and the function of the hand. The purpose of this review is to describe recent advances in hand soft tissue reconstruction. Skin grafts and skin substitutes both are useful reconstructive options for certain defects. Digital coverage continues to be subject to refinements that lead to better reconstructions. Flaps based on donor sites from the dorsal metacarpal artery system are finding continually expanding uses in hand reconstruction. Traditional notions of forearm-based donor tissue are being challenged, leading to better hand reconstructions with less donor morbidity. Finally, improvements in free tissue transfer enable the expansion of reconstructive possibilities available for hand coverage.

Learning objectives After reading this article, the participant should be able to: 1. Identify the fracture patterns and types of metacarpal fractures. 2. Recognize when surgery is indicated for a given fracture. 3. Discuss the pathophysiology of Bennett's fractures and treatment. 4. List surgical treatment options and their relative advantages and disadvantages. 5. Be familiar with pediatric metacarpal injuries and when surgery is indicated. Background Metacarpal fractures are among the most common injuries seen in the emergency room and a staple for the hand surgeon. Knowledge of the types of fractures that occur and the appropriate treatment options is critical core knowledge for the hand surgeon. With the advent of superior implants and intraoperative fluoroscopy, powerful treatment options exist for metacarpal fractures and are at the disposal of the informed hand surgeon. Methods Closed reduction and cast immobilization, Kirschner wires, lag screws, plate fixation, and other techniques are all available to the hand surgeon. Bone grafting in highly comminuted fractures also deserves consideration. Results The majority of metacarpal fractures can be treated closed and do well with compliant hand therapy. Those fractures requiring operative intervention likewise do well, provided that the appropriate technique is used for the situation. For example, long oblique shaft fractures are optimally treated with lag screws, whereas short oblique fractures do better with Kirschner wires or plate fixation. When the correct therapy is tailored to the injury, most metacarpal fractures can be treated with predictably good outcomes. Conclusions Metacarpal fractures are common occurrences in the office of the hand surgeon. The different types of injury patterns must be recognized by the surgeon and appropriate treatment then executed to serve both the patient and hand surgeon optimally.

Tissue ischaemia and/or reperfusion cause some of the injury seen in several clinical disorders and are responsible for considerable mortality and morbidity in humans. Part of the injury occurring after reperfusion of ischaemic tissue is the result of interactions between leukocytes adhering to vascular endothelium. Blocking the function of the leukocyte adhesion beta 2 integrin complex (CD11/CD18) leads to improved outcome following ischaemia and reperfusion. Functional blockade of either P-selectin or L-selectin prevents leukocyte rolling. Blocking leukocyte adherence at one of several levels may provide improved outcome in a variety of diseases associated with ischaemia and reperfusion.

Ischemia-reperfusion (I/R) leads to organ injury and organ dysfunction in a variety of clinical disorders. Preclinical investigations examining leukocyte adhesion molecules in I/R provided overwhelming evidence that blocking the function of leukocyte adhesion molecules would be highly effective in improving outcome in clinically relevant diseases. Unfortunately, all 9 of the recently completed phase 2 and 3 clinical trials examining antiadhesion therapy have failed. In this report, we show that a modest increase in ischemic time results in conversion from a CD18-dependent to a CD18-independent injury. This fundamental change in the mechanism of injury can be reduced by inhibition of caspases leading to blockade of apoptosis. Muscle injury resulting from aortic clamping was measured by release of creatine kinase. I/R injury following ischemia of 60 minutes or less and 3 hours of reperfusion was significantly reduced by pretreatment with anti-CD18 monoclonal antibody. However, 90 minutes of ischemia resulted in a marked increase in injury that was not reduced by CD18 blockade. Importantly, the injury resulting from 90 or 120 minutes of ischemia was reduced by the pancaspase inhibitor z-VAD. We propose that the length of ischemia can result in a fundamental change in the mechanism of injury and that all preclinical investigations of I/R must be evaluated with increasing ischemia if they are to model the clinical disease. The result showing CD18-independent I/R injury is not unique; likewise, protection by caspase inhibitors is not unique. However, we show for the first time that caspase inhibitors are effective when CD18 blockade is not.

During the past year there have been important advances in both plastic surgery research and clinical care that continue to exemplify the diversity and innovation characteristic of the specialty. The nature of plastic surgery is indeed diverse, often leading the plastic surgeon to every area of the body in the quest to restore form and function. By incorporating his or her creative insight into the application of basic surgical principles for this purpose, the plastic surgeon is able to make a tremendous contribution to the challenges and problems impacting all areas of surgery. As in past years, basic research has focused on wound healing, flap physiology, reperfusion injury, nerve injury and regeneration, craniofacial and bone biology, and the exciting new areas of tissue engineering and gene therapy. Throughout all of these areas the multidisciplinary nature of plastic surgery and plastic surgery research contribute to its dynamic future as a core surgical subspecialty. This review will focus on a number of these areas but will only present a brief sampling of the huge scope of plastic surgery research and developments over the past year.

Background: It is essential to identify patients at high risk of death and complications for future studies of interventions to decrease reperfusion injury. Methods: We conducted an inception cohort study at a Level I trauma center to determine the rates and predictors of death, organ failure, and infection in trauma patients with systolic blood pressure ≤ 90 mm Hg in the field or in the emergency department. Results: Among the 208 patients with hemorrhagic shock (blood pressure ≤ 90 mm Hg), 31% died within 2 hours of emergency department arrival, 12% died between 2 and 24 hours, 11% died after 24 hours, and 46% survived. Among those who survived ≥ 24 hours, 39% developed infection and 24% developed organ failure. Increasing volume of crystalloid in the first 24 hours was strongly associated with increased mortality (p = 0.00001). Conclusion: Hemorrhage-induced hypotension in trauma patients is predictive of high mortality (54%) and morbidity. The requirement for large volumes of crystalloid was associated with increased mortality.

Seventy-three patients were treated with either intrafocal pinning (Kapandji technique) alone or in combination with external fixation between 1988 and 1993 for extra-articular fractures of the distal radius (with or without a nondisplaced extension into the radiocarpal articular surface) with inadequate alignment after initial closed reduction. Sixty-one patients were available for follow-up examination at an average of 34 months (range, 24-71 months). The average age was 52 years (range, 16-84 years). Thirty-three of the patients were female. The patients all had dorsally displaced extra-articular fractures, although 56% had a nondisplaced extension of the fracture into the radiocarpal joint and 46% had a nondisplaced fracture extending into the distal radioulnar joint. The patients were separated into groups based on age, degree of comminution, and whether external fixation was also used. In the older patients, range of motion, grip strength, and pain relief were significantly better when external fixation was used, even when only 1 cortex of the radius demonstrated comminution. In the younger patients, good results in terms of range of motion, grip strength, and pain relief were obtained when percutaneous intrafocal pins were used alone in patients with comminution of only 1 surface of the radius (50% of the metaphyseal diameter). Whenor = 2 sides of the radial metaphysis were comminuted, the patients with external fixation had better results than those without external fixation. Although the correction of palmar tilt and radial tilt did result in better functional results, the restoration of radial length had the most significant effect on range of motion and grip strength.

To evaluate the efficacy of arthroscopic repair of the triangular fibrocartilage complex (TFCC) tears treated within 4 months after injury, functional outcome after repair was determined following arthroscopic repair in 24 patients. The patients' average age was 31 years (range, 22-38 years); the average follow-up period was 34 months (range, 26-48 months). All patients had wrist pain limiting their participation in work prior to surgery. Patients with central attrition tears identified by arthroscopy were excluded from the study. Twenty-three patients had a preoperative arthrogram. Twelve of the patients with positive arthrogram findings had an avulsion of the TFCC from the sigmoid notch (Palmer type 1D tears). Of the eleven patients with negative arthrograms, 10 had ulnar tears in capsular attachments of the TFCC. The ulna variance averaged 0.2 mm +/- 0.6 mm. Separate arthroscopic techniques were developed for reattaching the TFCC to the radius (nine patients) versus to the peripheral capsule on the volar or ulnar side of the wrist (eight patients). Postoperatively, there was a significant relief of pain (p.01). Postoperative range of motion averaged 89% +/- 9% SD of the contralateral side, and grip strength averaged 85% +/- 20% SD of the contralateral side. Thirteen of the 19 patients returning to work did so in their original jobs.

Fourth-degree hand burns are rare but devastating injuries. They cannot be grafted readily but often require flaps and amputation, and impairment is significant. We report our 10-year experience (1981 to 1990) with deep hand burns to characterize our treatment and outcome. A total of 25 patients (35 hands) were treated. Eight local flaps, nine distant flaps, and two free-tissue transfers were performed. Eleven hands were treated with K-wire immobilization and grafting. Thirty-three amputations were done. Postburn function was evaluated in 25 salvaged hands. Eleven hands had good outcomes, whereas seven had moderate sequelae and seven were severely affected. Patients who were treated with flap coverage of exposed tendons and joints had better functional outcomes than those treated with delayed closure with immobilization and grafting. The excellent outcomes in the flap coverage group justifies the added commitment of technical and therapeutic resources that this treatment requires.

To examine the role of neutrophil adhesiveness in the tissue injury involving the ischemic "at risk" area of random flaps, we used the monoclonal antibody 60.3, which binds selectively to the primary neutrophil adherence-mediating glycoprotein CD18 in a random cutaneous flap model. Control animals that had flaps elevated and replaced (n = 12) had a mean distal necrosis of 31.9 +/- 9.3 percent of the total flap surface area. Treatment with monoclonal antibody 60.3 (n = 12) reduced distal necrosis to 10.6 +/- 7.5 percent (p < 0.005). Inhibiting inosculation by interposing a thin silicone sheet decreased distal flap survival; however, the protective effect of monoclonal antibody 60.3 on improving flap survival was unchanged. Control isolated flaps (n = 13) had a mean distal necrosis of 49.0 +/- 15.5 percent compared with 22.2 +/- 5.6 percent for the antibody-treated (n = 8) isolated flaps (p < 0.05). We conclude that increased neutrophil adhesiveness plays an important role in the tissue injury involving the ischemic "at risk" area of random flaps and the transient, specific inhibition of leukocyte adherence by monoclonal antibody 60.3 improves the distal survival of random flaps in this model. Moreover, we conclude that "graft inosculation" contributes to "flap" survival in this model; however, conclusions regarding the effect of treatment are not altered by blocking inosculation.

Open reduction and internal fixation is often required in comminuted, displaced intra-articular fractures of the distal radius when closed manipulation has failed to restore articular congruity. Results of surgical stabilization and articular reconstruction of these injuries are reviewed in this retrospective study of 49 patients with 52 displaced, intra-articular distal radius fractures. Forty-three patients with a mean age of 37 years (range, 17-79 years) were available for evaluation. The mean follow-up time was 38 months (range, 22-69 months). When rated by the system proposed by the Association for the Study of Internal Fixation (ASIF), 19 were ASIF type C2 and 21 were ASIF type C3. An injury score system based on the initial injury x-ray films was used to classify severely comminuted intra-articular fractures and to identify those associated with carpal injury. Postoperative fracture alignment, articular congruity, and radial length were significantly improved following surgery. Grip strength averaged 69 +/- 22% of the contralateral side, and range of motion averaged 75 +/- 18% of the contralateral side after surgery. A combined outcome rating system that included grip strength, range of motion, and pain relief averaged 76 +/- 19% of the contralateral side. Using regression analysis, a significant decrease was found in the combined rating with more severe fracture patterns as defined by the ASIF system, Malone classification, and the injury score system. The injury score system presented here and, in particular, the number of fracture fragments correlated most closely with the outcome of all classification systems examined. Operative treatment of complex distal radius fractures with reconstruction of articular congruity with internal fixation and/or external fixation can significantly improve functional outcome. The degree to which articular step-off, gap between fragments, and radial shortening are improved by surgery is strongly correlated with improved outcome, even when the results are corrected for severity of initial injury, whereas correction of radial tilt or dorsal tilt did not correlate with improved outcome.

The adhesive interaction between circulating leukocytes and the vessel wall is a critical event in host defense against microbial invasion and in the repair of tissue damage. Altered leukocyte-endothelial interactions, however, may sometimes contribute to the pathogenesis of vascular and tissue injury in inflammatory and immune disorders. This chapter will briefly summarize our current understanding of the molecular basis of leukocyte adherence to endothelium in inflammatory and immune reactions and discuss anti-adhesion therapy as a novel approach to the treatment of a wide spectrum of clinical disorders.

Between 1986 and 1990, five patients have been treated for full-thickness skin loss proximal to the level of the anterior joint line of the ankle following open reduction and internal fixation of closed C3 (ASIF) pilon fractures. The average delay from injury to the initial open reduction and internal fixation was 4.6 days. Anteromedial and posterolateral incisions were used to expose the fractures, resulting in a bipedicle flap over the anterior aspect of the ankle joint at the time of the initial surgery. The minimum distance between these two incisions for these five patients was 6.0 to 9.0 cm (average of 7.4 cm). Free tissue transfers using the radial forearm flap were effective in providing durable but thin coverage for this difficult problem of soft-tissue coverage in an area requiring a thin flap with a long vascular pedicle. The risk for skin necrosis at the time of surgery may be minimized by spacing the incisions up to 12.0 cm apart in addition to avoiding the period of maximal tissue ischemia occurring 3 to 6 days after the injury.