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The development of a fistula between the tracheobronchial tree and oesophagus due to nonmalignant causes is uncommon. Division of the fistula with muscle flap interposition eliminates contact between the tracheobronchial segment and the oesophagus, theoretically decreasing the chance of recurrence as well as providing a robust blood supply to aid in healing. The split latissimus dorsi muscle flap is a well-suited flap for such repairs because of the ability to simultaneously cover two separate apertures (tracheobronchial and oesophageal). The authors describe the split latissimus dorsi muscle flap with step-by-step technique for repair of intrathoracic aerodigestive fistulas.

Background: The authors' goal was to determine whether the bacteria cultured from the mediastinal deep soft tissues matched those identified by the sternal bone cultures in cases of mediastinitis with clinically suspected sternal osteomyelitis, in hopes of eliminating the need for sternal bone biopsy. Methods: The authors retrospectively reviewed the charts of 27 Detroit Medical Center patients who underwent median sternotomy and developed mediastinitis with clinical suspicion of osteomyelitis between 1996 and 2004. Results: Although only 18 of 27 of the authors' patients had positive bone cultures, they demonstrate that in 94 percent (17 of 18) of these patients, the organisms cultured from the mediastinal deep soft-tissue cultures matched those cultured from the positive sternal bone cultures. Conclusions: With the results obtained from this study, the authors hope to promote a less-invasive means of investigating osteomyelitis in sternal wounds, to prevent the complications associated with obtaining a bone biopsy specimen in a contaminated soft-tissue setting. Instead, the authors suggest thoracic computed tomographic scanning as a noninvasive means of clinically demonstrating osteomyelitis of the sternum, and culture of the deep soft tissues of the mediastinum at the time of mediastinal debridement to determine the offending organism, if osteomyelitis is suggested by computed tomographic scan.

A case of a left small finger tumour that was diagnosed on histopathological review as Nora's lesion (bizarre parosteal osteochondromatous proliferation) is reported. There have been fewer than 150 cases reported in the literature to date and its pathophysiology is yet to be defined. Due to its rare presentation, Nora's lesion can easily go unrecognized and therefore inappropriately managed.

BACKGROUND The authors' goal was to demonstrate a technique of gaining added width from the right pectoralis major muscle flap through muscle fascia release, with the hope of attaining sturdier, tension-free dead space closure of the debrided mediastinum in cases of mediastinitis. METHODS The authors measured the preincisional and postincisional widths of the right pectoralis major flap following release of the fascia in nine patients who underwent mediastinal reconstruction using pectoralis major muscle flaps from 2002 to 2004 at the Detroit Medical Center. RESULTS The average width of the nine muscles was 16.3 +/- 1.7 cm before fascia release and 22.1 +/- 1.3 cm after release. The average increase in width was 5.8 +/- 1.3 cm, with a 95 percent confidence interval of 4.8 to 6.8 cm. A value of p < 0.0001 indicated that this increase in width was statistically significant. After fascial release, the width of the muscles increased by an average of 26.1 percent, with a 95 percent confidence interval of 21.6 to 30.6 percent. CONCLUSIONS The authors present a new technique that can be used to gain additional width from the right pectoralis major muscle in cases of mediastinal reconstruction using the pectoralis major muscle flap. With the added 26 percent of width obtained from the right pectoralis major muscle with fascia release, the authors contend that a sturdier and tension-free closure of the mediastinal dead space can be obtained, further expanding the indications for use of the pectoralis major muscle flap as the sole closure modality in even the most complicated cases of mediastinitis.

A case of fulminant dissecting cellulitis of the scalp in a fifteen-year-old African American male is reported. The presentation was refractory to standard medical treatment such that treatment required radical subgaleal excision of the entire hair-bearing scalp. Reconstruction was in the form of split-thickness skin grafting at the level of the pericranium following several days of vacuum-assisted closure dressing to promote an acceptable wound bed for skin grafting and to ensure appropriate clearance of infection. Numerous nonsurgical modalities have been described for the treatment of dissecting cellulitis of the scalp, with surgical intervention reserved for patients refractory to medical treatment. The present paper reports a fulminant form of the disease in an atypical age of presentation, adolescence. The pathophysiology, etiology, natural history, complications and treatment options for dissecting cellulitis of the scalp are reviewed, and the authors suggest this method of treatment to be efficacious for severe presentations refractory to medical therapy.

Isolated injury to the radial or ulnar artery results in no significant complications in patients who undergo repair or ligation of the injured artery. However, ligation of both infrabrachial vessels of the upper extremity is associated with limb loss from ischemia due to lack of collateral circulation. A rare case of acute ligation of both the radial and ulnar arteries in a drug abuser where collateral vessels preserved the circulation to the hand is reported.

Acute compression of the median nerve in the forearm usually occurs from compartment syndrome. A case of acute compression neuropathy of the median nerve from a foreign body, where there was no evidence of compartment syndrome, is reported. The diagnosis was made from the patient's symptoms and radiographs. Early recognition and decompression of the forearm with removal of the foreign body led to full recovery.

Children with dermatomyositis may have extensive subcutaneous and intermuscular calcium-laden fluid collections referred to as "milk of calcium." The distinctive MR appearance of such collections in an upper extremity of a 16-year-old girl is presented. MR can differentiate these collections from abscesses and guide appropriate therapy.

The case for discussion today is t ha t of a male pa t ien t wi th ful l th ickness burns involving the face and neck. Glor ia Kuhn, DO, res ident in emergency medicine, will present the case. E t i Gursel, MD, ass i s t an t professor of surgery at Wayne Sta te Univers i ty and director of the Burn Uni t a t Detroi t Genera l Hospital , is the guest speaker . G l o r i a Kuhn, DO: The Detroi t Police Medivac Uni t was called by a commun i ty hospi tal to t r anspor t a pa t ien t to the burn center. On a r r iva l at the t r ans fe r r ing hospital , the medical team es t ima ted tha t the pa t i en t had experienced about 20% body surface a rea (BSA) par t i a l and ful lthickness burns involving the face, an ter ior chest, upper arms, and neck. The pat ient ' s blood pressure was 130/80, t empera tu re was 98.4, and pulse ra te was 45 beats /minute . There were no oral burns, and the nasa l hai rs were not singed. Respi ra t ions were regu la r and quiet, and the chest was clear. The e lec t rocardiogram (EKG) was in te rpre ted as sinus b radycard ia wi th a ra te of 50 beats per minute . The complete blood cell count (CBC), glucose, blood urea n i t rogen (BUN) and se rum electrolytes were normal. The pa t i en t had a l ready received 500 cc of lac ta ted Ringer ' s solution wi thout glucose over two hours th rough a scalp vein needle. The scalp vein needle was removed, and two large bore angioca the te rs were inser ted in pe r iphera l veins, and securely fastened. A nasogast r ic tube was inserted, and the gastr ic asp i ra te was clear. One hundred cc of red ur ine was obta ined when the u re the ra l ca the te r was inserted. The ur ine was posit ive for hemoglobin but there were no red cells in the spun sediment. The pa t i en t was covered with s ter i le sheets and t ranspor ted to the burn center. En route, he received nasa l oxygen and was placed on cardiac monitor. The hea r t ra te rema ined 46 to 50 bea ts /minute but there were no symptoms of hypoperfusion. At the recei~ving hospital , mann i to l was infused because of possible hemoglob inur ia or myog~b inu r i a . The pa t ien t has progressed uneventful ly except for a br ief episode of supraven t r i cu la r t achycard ia which responded to digi ta l izat ion. Eti Gursel, MD: The burned pa t ien t should be approached jus t as any other t r a u m a pa t ien t . The t eam approach should be used, so t ha t the p a t i e n t is eva lua ted in a logical, comprehensive fashion. Rapid eva lua t ion is necessary, for the aggress iveness of in i t ia l resusci ta t ion depends on the ex ten t of the burn and the presence of associated injuries. There is no such th ing as a minor burn. I have seen e lde r ly p a t i e n t s die from sepsis c o m p l i c a t i n g a " mino r " 10% BSA burn. The following series of steps should be performed dur ing in i t ia l burn resusci tat ion. 1) Clear the a i rway. Oxygen adminis t ra t ion , in tuba t ion and ven t i l a to ry ass is tance is necessary if there is r esp i ra to ry distress or evidence of l a ryngea l

A case of momentary exposure of the right hand to irradiation from a microwave oven is described. Transient paresthesias and a cold, pale hand resulted but resolved spontaneously in 60 minutes without treatment. Even momentary exposure can result in severe coagulation necrosis, with eventual loss of the exposed extremity.

A unique case of high-pressure injury to the hand is described with extension of the injectate to the elbow. Diagnosis includes the need for high levels of suspicion and evaluation by radiography. Meticulous debridement and copious saline lavage, and decompression of the carpal tunnel space, followed by split-thickness grafting, were successful in this case.

In the past four years, four cases of gasoline contact burns have been treated at the Detroit General Hospital Emergency Department. Signs are erythema and blister formation within 24 hours. Treatment is removal of contaminated clothing and washing the surface with soap and water plus open exposure of the wounds. Renal failure is not caused by skin absorption but may develop following inhalation.