A rare penetrating injury through the axilla caused by stilt pole in a Bajau Laut boy

An 8-year-old child of Bajau Laut descent (a stateless tribe in Eastern Borneo and the Sulu archipelago) presented following a fall, with penetrating injury through the axilla caused by a stilt pole, exiting at the supero-anterior aspect of the left shoulder. Due to the lack of comprehension of modern medical treatment and poor language skills, the parents refused to consent for detailed radioimaging studies, nor surgical removal and exploration in the operating theatre. The removal of retained stilt pole was done in casualty area in Hospital Tawau, followed by local exploration under sedation and local analgesia. Despite the horrific injury, there was no limb-threatening neurovascular injury sustained. Management of such injury in the nomadic Bajau Laut population provides valuable insight and about the challenges and decisions of management.

Management of External Hemorrhage in Tactical Combat Casualty Care: The Adjunctive Use of XStat™ Compressed Hemostatic Sponges: TCCC Guidelines Change 15-03

Exsanguination from wounds in the so-called junctional regions of the body (i.e., the neck, the axilla, and the groin) was responsible for 19% of the combat fatalities who died from potentially survivable wounds sustained in Afghanistan or Iraq during 2001 to 2011. The development of improved techniques and technology to manage junctional hemorrhage has been identified in the past as a high-priority item by the Committee on Tactical Combat Casualty Care (CoTCCC) and the Army Surgeon General's Dismounted Complex Blast Injury (DCBI) Task Force. Additionally, prehospital care providers have had limited options with which to manage hemorrhage resulting from deep, narrow-track, penetrating trauma. XStat™ is a new product recently approved by the US Food and Drug Administration as a hemostatic adjunct to aid in the control of bleeding from junctional wounds in the groin or axilla. XStat has now been recommended by the CoTCCC as another tool for the combat medical provider to use in the management of junctional hemorrhage. The evidence that supports adding XStat to the TCCC Guidelines for the treatment of external hemorrhage is summarized in this paper.

Ultrasound imaging of the axillary nerve and its role in the diagnosis of traumatic impairment

PURPOSE

The axillary nerve (AN) is frequently injured during shoulder trauma and imaging is required to define the site and extent of nerve injury. However, the AN has a rather complex course through several soft tissue compartments of the shoulder and axilla. Therefore, imaging of the nerve with MRI and sonography is troublesome. Thus detection and sonographic assessment bases on thorough knowledge of local topography.

MATERIALS AND METHODS

This investigation aimed at defining reliable anatomical landmarks for AN-sonography in 5 volunteers and later validating the proposed sonographic examination protocol in 10 unselected patients.

RESULTS

With strict adherence to the proposed examination algorithm, sonography of the AN was feasible in all volunteers and patients. Furthermore, sonographic findings correlated nicely with the golden standard "surgical exploration" concerning severity and topography of neural impairment.

CONCLUSION

Based on our study results we propose our algorithm for AN-sonography as the first-line imaging tool for the assessment of axillary nerve trauma.

Safety and Effectiveness Evidence of SAM(r) Junctional Tourniquet to Control Inguinal Hemorrhage in a Perfused Cadaver Model

BACKGROUND

Hemorrhage from the trunk?appendage junctions is a common, preventable cause of death on the battlefield. The recently U.S. Food and Drug Administration (FDA)-cleared SAM? Junctional Tourniquet (SJT) was designed to control out-of-hospital inguinal and axillary hemorrhage. The purpose of the present study was to provide safety and effectiveness data associated with use of the SJT. Such data provided support for regulatory clearance.

METHODS

The SJT was tested in a perfused cadaver experiment simulating inguinal or axillary wound hemorrhage.

RESULTS

No safety problems or tissue damage occurred, and flow normalized promptly after tourniquet removal. During SJT use, an average of 107 mmHg occluded the distal external iliac artery in an average of 7 seconds of inflation time; manual pressure as a control averaged 139 mmHg. In SJT use, an average of 739 mmHg occluded the axillary artery in an average of 5 seconds of inflation time; manual pressure as a control averaged 1237 mmHg. The control was a referent that achieved results that were similar in one body area but different in the other; both findings indicate the device is as safe as, if not safer than, manual compression.

CONCLUSION

The SJT was shown to be safe and effective in hemorrhage control in a cadaver model for both the axillary and inguinal areas. The SJT's Target Compression Devices required pressures approximately equal to or lower than manual pressure to achieve hemostasis in these junctional regions.

Axillary arteriovenous fistula after axillary plexus block

This report presents the case of a 51-year-old man who had an axillary arteriovenous fistula (AVF) as a complication of an axillary plexus block that was performed for internal fixation for a right forefinger phalanx fracture 4 years previously. While performing the axillary plexus block, a 22-gauge needle was placed inside the axillary sheath by observing the pulsations of the axillary artery. A pulsatile mass was found in the right axilla 1 day after the block was performed. Apart from this soft mass, the patient had no symptoms of vascular nerve damage. As the mass gradually increased in size, it became painful. During the past 3 months, in particular, the patient experienced repeated attacks of intermittent sharp pain and requested surgery. Digital subtraction angiography, performed 4 years after the axillary block, showed a tumor-like dilation was developing in both the right axillary artery and vein, almost simultaneously. Thus, the diagnosis of AVF was confirmed. The false aneurysm sac was excised and lateral repair of the axillary artery and vein was carried out under general anesthesia. Postoperative recovery was uneventful. The possible occurrence of an AVF after axillary plexus block should be kept in mind, because early diagnosis and treatment are necessary to avoid development of AVF and false aneurysm.

A case of penetrating axillary trauma

INTRODUCTION

Deep penetrating traumas of the axilla extending to the neck are rare and potentially dangerous.

OBSERVATION

An 11-year-old child presented with an impressive penetrating axillary injury extending to the neck after falling on a tree branch. The wound was explored in the operating room (OR). A fragment of the branch was removed without injuring any vascular structure. The only lesion concerned the hypopharynx.

DISCUSSION

Cervical wounds may have an axillary origin. These wounds must be systematically explored in the OR, given the risk of upper airway obstruction and vascular lesion.

Surfinoma: a case report on a pseudotumor developing after a surfing sports injury

We describe an unusual pseudotumor of the upper thorax, axillary, and shoulder girdle region with presentation 4 years after a surfing sports injury. We offer the coined term "Surfinoma" to describe a pseudotumor arising from a penetrating piece of fiberglass surf board, which induced a foreign body reaction.

[Axillary wound with complete vasculo-nervous section. Functional outcomes]

Axillary wound with complete vasculonervous section are rare in adults, males between 20 and 30 years being more affected. In children these lesions are even more rarely encountered. Immediate surgical repair of vascular and nervous sections is recommended. Neurological impalement may be severe when all nervous trunks in the axilla are affected. Recovery of the motor and sensitive deficit is a long process and is often partial, good functional outcome being rare. Recovery in children is supposed to be better due to a more rapid regenerative capacity of the nerves. We present the case of a 9-year-old boy with axillary wound and complete section of axillary artery, median, ulnar, radial and musculocutaneous nerves and medial cutaneous nerve of arm. Vascular reconstruction with venous graft and epiperineural nerve reconstruction was done. Kinetotherapy and physiotherapy was part of recovery treatment. Follow up at 15 months confirmed very good functional outcomes with almost complete motor and sensitive function of the limb.

[Angular approach in the surgical treatment of the axillary neurovascular bundle pathologies]

Different surgical approaches have been developed in the surgical treatment of various isolated and combined lesions of the axillary neurovascular bundle. The angular approach favorably differs from others and has a number of advantages. The angular approach was used to operate on 16 patients with varying abnormalities at this site, including 6 patients with traumatic lesion of the secondary trunks of the brachial plexus and 6 with space-occupying lesion, and 1 patient with the superior thoracic aperture; the remaining 6 patients with significant neurovascular compression syndrome, who had been operated on for various causes. The authors have made certain that the angular approach lightens a surgical intervention and shortens its duration substantially, by reducing the risk of postoperative pyoinflammatory complications, keloid cicatrices, and contractures. The surgical approach applied by the authors is universal and may be used in the treatment of pathology of the secondary trunks of the brachial plexus and vascular lesions, tumors, and pyoinflammatory processes of the axillary space.

Axillary lump: an unusual presentation of fat necrosis in the breast

The clinical presentation of an axillary lump, in majority of cases, raises suspicion of an enlarged lymph node due to malignant causes. In this case report, we established a diagnosis of an axillary lump caused by fat necrosis. We present this case report with review of the literature to familiarize clinicians with this condition.

Insidious onset of shoulder girdle weakness

STUDY DESIGN

Resident's case problem.

BACKGROUND

An 18-year-old man presented to physical therapy 3 days after insidious onset of painless left shoulder girdle weakness.

DIAGNOSIS

Decreased light touch sensation was noted on the lateral left shoulder. In addition, weakness was present with shoulder abduction, flexion, external rotation, and internal rotation. Results of magnetic resonance imaging and radiography of the cervical spine, brachial plexus, and left shoulder were normal, Electromyography and nerve conduction velocity study findings were consistent with axillary nerve palsy. The results of the physical examination and diagnostic studies were most consistent with axillary nerve mononeuropathy, probably caused by traction or pressure due to wearing a pack while hiking or firing a weapon.

DISCUSSION

With sling protection, limitation of physical activity, and gradual return to progressive resistance exercises, the patient had full return of strength and function 2 1/2 months after onset of symptoms. The differential diagnosis for shoulder girdle weakness should be well understood by physical therapists. This knowledge will help the therapist promptly identify the cause of shoulder girdle weakness and initiate appropriate treatment. If the condition requires further evaluation or treatment by another healthcare provider, prompt identification of pathology will allow appropriate timely referral.

Successful closure of feline axillary wounds by reconstruction of the elbow skin fold

This report describes the successful closure of five chronic feline axillary wounds. The aetiology was known to be forelimb entrapment in a neck collar in three cases and was suspected in the others. Each cat underwent a single surgical procedure during which the wound was debrided, the normal structure of the elbow skin fold was restored and the remaining skin defect was closed primarily. None of the cats had undergone any previous reconstruction attempts. No postoperative complications were observed and the wounds healed uneventfully. Cats have well-developed elbow skin folds, allowing a wide range of limb motion to occur. Having a forelimb trapped in a neck collar not only creates a wound in the axilla but also disrupts the normal anatomy of the skin fold. This report demonstrates that restoring the elbow skin fold before closing the wound may improve the chances of a successful reconstruction at the first surgical intervention.

Rehabilitation following repair of a torn latissimus dorsi tendon

BACKGROUND AND PURPOSE

This report describes the rehabilitation of a patient following surgical repair of a torn latissimus dorsi tendon. The scientific rationale for the treatment progression is discussed.

CASE DESCRIPTION

A 35-year-old man with a ruptured latissimus dorsi tendon 6 weeks following surgical repair was referred for physical therapy to recover range of motion and strength sufficient for return to work as a police officer on the SWAT team. A review of tendon healing in animal studies is presented and related to the development of the plan of care for this patient.

OUTCOMES

Latissimus dorsi muscle isometric force generation on the injured side was 92% of that of the uninjured side. The patient returned to work as a SWAT team member.

DISCUSSION

No detailed reports of postoperative latissimus dorsi tendon rehabilitation are available. The program for this patient was based on research demonstrating the timeline for recovery of tensile strength in healing tendons. This approach can direct rehabilitation following repair of other tendons, especially in uncommon injuries where specific guidelines have not been developed.

Chronic axillary wound repair in a cat with omentalisation and omocervical skin flap

A mature, neutered male domestic cat was presented with a chronic axillary wound of unknown origin and at least three years' duration. The diagnostic investigation included screening tests for feline leukaemia virus and feline immunodeficiency virus, tissue culture and histological examination. No underlying aetiology or perpetuating cause could be identified. An omental flap was created, passed via a subcutaneous tunnel, and packed into the wound site after excision of all chronic granulation tissue. The skin defect was closed using an omocervical axial pattern skin flap. A small area of the distal edge of the flap became necrotic but the defect healed by second intention. To the author's knowledge, this is the first clinical report of the use of an omocervical skin flap for repair of a chronic axillary wound in a cat. This flap offers a useful alternative where the use of a thoracodorsal axial pattern flap is not possible due to the extent of the lesion.

Axillary Burns: Extended Grafting and Early Splinting Prevents Contractures

The development of contractures is a common complication after burn injuries. Axillary burns often result in limited abduction of the arm and present a major hindrance in rehabilitation. To prevent axillary contractures after burn injury, we perform a special grafting technique. In this study we treated 17 patients with 23 axillary burns using this technique. Patients were splinted early, and an intensive physiotherapy program was started 5 days after splinting. After 12 months, the mean abduction of the successfully treated axillary burns was 152 degrees. A secondary reconstruction was needed in only 5 of the 23 treated axillary burns. For the treatment of axillary burns, we recommend the described grafting technique in combination with early splinting and intensive physiotherapy.

Reconstruction of axillary contractures with thoracodorsal perforator island flap

The axilla is one of the most frequently sites affected by contractures after severe burns. These contractures often cause cosmetic problems and functional deficiency. A variety of therapeutic methods such as skin grafting, Z-plasties, local flaps, island flaps, and free flaps, have been reported for treatment of the contractures. Each has its own advantages and drawbacks. In this clinical study we report 15 cases of post burn axillary contractures treated with thoracodorsal perforator-based cutaneous flaps. The flaps were harvested in range of sizes up to as large as 27 cmx15 cm. All flaps survived completely without even marginal necrosis. The donor sites were closed primarily except in one case who needed a small skin graft. Satisfactory improvement in shoulder abduction was obtained. The range of abduction was on average 46.6+/-19.3 degrees before the operations and 159+/-12.4 degrees after the operations. Cosmetic results were satisfactory from the patient's point of view. The thoracodorsal perforator flap can be safely raised to meet any size required even in the most severe contractures. The donor site scar may be considered as acceptable considering the advantages of the flap. We strongly recommend this flap as the treatment of choice in releasing challenging axillary contractures.

[Study on the application of arm medial fascio-cutaneous flap pedicled with cutaneous nerve and nutrient vessel]

OBJECTIVE

To investigate the application of arm medial fascio-cutaneous flap pedicled with cutaneous nerve and nutrient vessel.

METHODS

From February 1999 to December 2004, 18 cases of skin and soft tissue defect in axillary region, elbow and forearm were treated with arm medial fascio-cutaneous flap pedicled with cutaneous nerve and nutrient vessel. Arm medial fascio-cutaneous flap was directly transferred in 3 cases, adversely transferred in 15 cases. The flap area was 4.5 cm x 8.5 cm.

RESULTS

Vein circulation crisis was observed in 3 cases. Of the 3 cases, 1 was necrosis and the other 2 by decompressing small vein were saved. The rest 15 cases survived. The period of follow-up was 3 to 30 months. Flap was satisfactory in appearance and function.

CONCLUSION

Arm medial fasciocutaneous flap pedicled with cutaneous nerve and nutrient vessels can be directly or adversely transferred to repair adjacent soft tissue defect.

Re-emphasising the efficacy of the multi-purpose, self-adjustable, aeroplane splint for the splinting of axillary burns

This article re-emphasises the efficacy of the previously described multi-purpose, self-adjustable, aeroplane splint for the splinting of axillary burns. This superior to the commonly used contoured splint for various reasons namely (i) its usability during the acute burn care rehabilitation, (ii) its cost effectiveness, (iii) its durability, and (iv) its strength. Above all due to its easy maneuverability this splint provides easy accessibility around environmental barriers. Though we acknowledge that there is a possibility of 'chord of circle' development due to the use of this splint, we have been successful in preventing such a complication simply by prescribing pressure garment concomitantly with this splint. Thus this article highlights the efficacy of earlier described multi-purpose, self-adjustable, aeroplane splint for the splinting of axillary burns.

Adjustable aesthetic aeroplane splint for axillary burn contractures

Managing axillary burns with an Aeroplane Splint has been known for its effectiveness for years. However, poor compliance in using the various models of currently available aeroplane splints leads to an inadequate outcome, because of the discomfort produced not only in wearing but also while ambulating within the community. In developing countries like India the biggest barrier to environmental accessibility is the presence of multiple permanent structures like narrow thoroughfares, entry/exit sites of public transport, and narrow aisles. These pose a challenge to rehabilitation professionals while prescribing large splints. An attempt to target these problems was made by Manigandan et al, but aeroplane splints, even the one described by them does not deal with the major problem of aesthetic appeal as identified by many of our patients. Accordingly this article presents a new model of the aeroplane splint with innovative changes, focussing on aesthetic appeal while maintaining all the benefits of the splint described by Manigandan et al.

Injury of the axillary nerve subsequent to recurrence of shoulder dislocation. Clinical and electromyographic study

Injuries of the axillary nerve subsequent to recurrence of glenohumeral dislocation have received only minimal attention. It is the purpose of this study to define the prevalence and the progression in time of injury of the axillary nerve in patients with recurrence of anterior shoulder dislocation. For two years we observed a total of 185 patients who had had primary shoulder dislocation. Excluded from the study were patients who had fractures associated with metabolic disorders that favored neurologic deficit. During the period of study, 98 patients contacted us again after recurrence of the dislocation: there were 89 patients aged over 60 years and 9 aged below 60 years. All of the patients were evaluated clinically and submitted to EMG in order to verify the condition of the axillary nerve. Four patients (4%) had neuroapraxia of the axillary nerve. One of these also had neuroapraxia of the radial nerve. Of the four patients, one was a male aged 34 years; the others were all aged over 60 years. In all of the cases, function of the axillary nerve completely recovered after a mean period of 4 months (3-5.3 months) after recurrence. Injury of the axillary nerve can occur at the time of the first recurrence of the injury. However, prevalence is significantly lower than that observed after primary dislocation. The occurrence of this injury should be taken into consideration, particularly in elderly patients, in order to avoid erroneous clinical diagnosis and massive rupture of the cuff subsequent to recurrence of the dislocation.

Thermal capsulorrhaphy

The initial wave of enthusiasm for thermal capsulorrhaphy has subsided. Long-term clinical data were lacking until D'Alessandro et al's prospective study indicated the results were not as promising as the previously reported short-term studies. Complications including obliteration or attenuation of capsular tissue, axillary nerve injury, and chondrolysis have all been reported in recent years further raising concern about the widespread use of this procedure. The inexact nature of how much "shrinkage" is being performed has led surgeons to further develop surgical technique in capsular plication, shift, or advancement. Although it remains to be seen if these techniques will lead to good clinical outcomes, it appears that they more closely resemble the original operative procedure-anterior capsular shift.

Nerve injury about the shoulder in athletes, part 1: suprascapular nerve and axillary nerve

Nerve injuries about the shoulder in athletes are being recognized with increasing frequency. Prompt and correct diagnosis of these injuries is important to treat the patient and to understand the potential complications and natural history so as to appropriately counsel athletes. This 2-part article is a review and an overview of the current state of knowledge regarding some of the more common nerve injuries seen about the shoulder in athletes.

A multi-purpose, self-adjustable aeroplane splint for the splinting of axillary burns

External splinting has been acknowledged for many years as a useful approach for preventing and correcting burn contractures. Though this practice could be traced back many centuries, there is still a dearth of knowledge regarding a good splint to serve these purposes for axillary burns. The newly designed multi-purpose, self-adjustable aeroplane splint presented in this report helps in various ways, such as improving compliance, and positioning during preoperative, postoperative and rehabilitative phases of axillary burn management. It acts as a splint that provides circumferential pressure for scar management, provides prolonged stretch to contracted tissue and acts as a serial cast in increasing the shoulder range. Most of all, it is very much user-friendly, thus enhancing compliance and giving a good outcome in axillary burns.

Alterations in functional movement after axillary burn scar contracture: a motion analysis study

Children with axillary burns often develop scar contractures that restrict shoulder movement. Objective data on functional movement patterns after contracture formation is sparse. The purpose of this study was to determine how axillary contractures affect shoulder movement during activities of daily living (ADLs). This was a prospective study of children with axillary contractures scheduled for surgical release. Three-dimensional upper extremity kinematic analysis was used to assess shoulder, elbow, and trunk motion during two ADLs: high reach and hand to back pocket. Results were compared with a pool of 49 normal age-matched controls. Eleven children with axillary contractures were compared with controls. During high reach, significant decreases in shoulder flexion, shoulder internal rotation, arm pronation, and trunk extension occurred. Elbow flexion increased significantly. In the hand to back pocket task, shoulder extension and elbow flexion decreased and shoulder abduction increased. Axillary contractures result in quantifiable movement changes during ADLs. Aggressive rehabilitation is required to prevent contracture formation. Three-dimensional motion analysis is a unique tool for the quantification of functional limitations and provides an objective method to evaluate treatment efficacy in patients with axillary contractures.

Anterior shoulder dislocation with axillary artery and nerve injury

We report a rare case of left axillary artery injury associated with anterior dislocation of the left shoulder in a 25 yrs old male as a result of a road traffic accident. The shoulder dislocation was reduced. A left upper limb angiogram showed an obstructed left axillary artery. The obstructed segment was surgically reconstructed with a Dacron graft. Six months post operation in follow up, he was found to have good left shoulder function and no neurovascular deficit. This is an injury that could have been easily missed without a simple clinical examination.

[Proximal interlocking of humeral intramedullary nails and risk of axillary nerve injury]

QUESTION

Possible injuries to the axillary nerve are criticised in antegrade and retrograde endomedullary nailing of the humeral shaft during proximal interlocking. Clinical experience seems not to support the theory of a high risk of nerve injury. The real risk although remains unknown under anatomical-morphological aspects.

MATERIAL AND METHODS

Eight complete human cadaveric shoulder-arm regions with original soft-tissue coverage had been used. Four times the unreamed humeral nail (UHN) had been inserted retrograde, and four times antegrade, distributed in each pair. Antegrade interlocking was performed after skin incision and spreading of soft tissues through the aiming devices. This involved one oblique bolt from lateral to medial. Retrograde proximal interlocking was performed under image intensifier. This involved triple interlocking, once dorso-ventrally and twice latero-medially. The incision paths have been marked. After preparation of the nerve stem in the lateral axillary portal the different branches have been searched and exposed. The spatial relations of bolts and nerve branches have been measured and the insertion path of the bolts has been revised, finally lesions of nerve structures have been documented.

RESULTS

We found the latero-medially inserted bolt heads of the retrograde approach and the oblique bolt head of the antegrade approach being placed in a safe distance from the medio-dorsally positioned stem of the axillary nerve. On the other hand the dorsoventrally inserted bolt head (retrograde approach) showed in most cases a very tight relation to the nerve stem. Exploring the axillary nerve and its branches showed in no case a direct nerve lesion.

CONCLUSIONS

We suggest to perform only a sharp cutaneous incision and then to prepare the muscle only by careful spreading until touching bone, with tissue retraction during drilling. In retrograde nailing the dorso-ventral bolt should only be used in extreme proximal fractures.

The treatment of subcapital humerus fracture with dynamic helix wire and the risk of concommitant lesion of the axillary nerve

Displaced subcapital fractures of the humerus represent a therapeutic challenge for the surgeon, all the more so because of their high incidence among osteoporotic patients. Open surgical repair involves increased risk of avascular necrosis of the humeral head, while percutaneous reduction and fixation often fails as a result of loosening pins. As a possible solution, a minimally invasive technique was developed in which a dynamic titanium wire helix is inserted into the medullary space of the diaphysis of the humerus and then rotated proximally into the head fragment. This new approach for osteosynthesis was performed in 84 patients, most of whom had suffered two- or three-part fractures. Results were evaluated by the Constant Functional Score, indicating an average 87% rehabilitation. An associated anatomical study of 53 human cadavers investigated the position of the main branches of the axillary nerve relative to the surgical placement of the wire helix. In all cases, the distance between the most vulnerable anterior branch of the axillary nerve (ABAN) and the operative site was sufficient, as long as insertion occurs in the distal third of the distance between the head of the humerus and the deltoid tuberosity. Utilization of the titanium helix results in prompt healing of subcapital fractures while offering minimal risk for the elderly osteoporotic patient and does not endanger branches of the axillary nerve.

Rupture of the axillary (circumflex) nerve and artery in a champion jockey

Rupture of the circumflex artery and nerve, without fracture or dislocation, is a rare traumatic event. Such a case is reported in a champion flat jockey who sustained blunt trauma to the shoulder after a fall during a race; the literature is also reviewed. At urgent surgical exploration, the axillary artery and nerve were repaired. The patient subsequently successfully returned to professional riding. This case highlights the difficulties in diagnosis and management.

Latissimus dorsi myocutaneous flap reconstruction of neck and axillary burn contractures

Neck and axillary burn contractures are both a devastating functional and cosmetic deformity for patients and a challenging problem for reconstructive surgeons. Severe contractures are more commonly seen in the developing world, a result of both the widespread use of open fires and the inadequacy of primary and secondary burn care in these vicinities. When deep burns are allowed to heal spontaneously, patients develop hypertrophic scarring of the neck and axillary areas. The back is typically spared, however, remaining a suitable donor site. We have used nine latissimus dorsi myocutaneous flaps in a total of six patients, finding the flaps effective in resurfacing both the neck and the axillary regions after wide release of burn contractures. Before flap mobilization, surgical neck release is often necessary to ensure safe, effective control of the airway in patients with significant neck contractures. Flap bulkiness in the anterior neck region can eventually be reduced by dividing the thoracodorsal nerve. Anchoring the skin paddle to its recipient site through the placement of tacking sutures will also help achieve a more normal anterior neck contour.

Entrance, exit, and reentrance of one shot with a shotgun

The case being reported is one of a homicidal shotgun fatality with an unusual wound pattern. A 34-year-old man was shot at close range with a 12-gauge shotgun armed with No. 5 birdshot ammunition. The shot entered the left axillary region, exited through the left infraclavicular region, and thereafter penetrated the left side of the neck, causing tearing of the left common carotid artery and the right internal carotid artery. The entrance wound in the axilla was larger than the other wounds, and before autopsy it was believed that the shotgun had been fired twice, causing one wound in the neck and one wound perforating the infraclavicular region and exiting through the left axillary region. Thus, this case shows that unusual wound patterns in shotgun fatalities can easily lead to incorrect assumptions with regard to number and direction of shots fired unless thorough investigation is carried out postmortem.

Use of omental pedicle grafts in the management of non-healing axillary wounds in 10 cats

A retrospective analysis of the clinical case histories of 10 domestic shorthaired cats that underwent omentalisation, using a vascular pedicle of greater omentum, of chronic non-healing axillary wounds was carried out. Wounds were debrided and closed in a primary fashion following omentalisation. The cats had undergone a modal number of three previous repair attempts over a three- to 18-month period (mean 11 months) before referral. Further dehiscence occurred in eight cases, requiring a modal number of one further attempt at closure of the wound. Other complications included incisional herniation (two cats), serous exudate from the axillary wound (two cats) and paracostal abscessation (one cat). Long-term cure was achieved in seven of the 10 cases, with wounds finally having healed at a mean of 24 days post-omentalisation. Chronic axillary wounds are particularly difficult to treat and there are no reports of consistently successful techniques for their repair. This report suggests that omentalisation of these wounds may be a step towards such a repair procedure.

Distant entry pneumothorax in a competitive fencer

An elite level fencer sustained a penetrating wound to the upper arm after his opponent's blade broke. Standard care for a deep puncture wound was given but it was some time before the athlete presented symptoms of a pneumothorax, which was confirmed by radiograph. Although resolution of this case was unremarkable, the possibility of penetrating thoracic injury, even when the point of entry is well outside the thorax and the athlete is not immediately symptomatic, should be born in mind by medical personnel working with fencers.

Use of seven-flap plasty for the treatment of axillary and groin postburn contractures

Axillary and groin contracture with limitation of abduction of the arm and leg are one of the most common complications of burns. In this paper we report the technique of using seven-flap plasty for treating axillary and groin scar contractures. The advantages of using this technique are that it does not need prolonged splinting and intense and painful physical therapy.

Determination of firing distance and firing angle by neutron activation analysis in a case involving gunshot wounds

This paper reports the determination of the firing distance and a method for the evaluation of the firing angle in a fatal incident caused by two gunshots. Neutron Activation Analysis (NAA) was used to determine the Sb pattern around the bullet entrance holes on a garment of the victim, and around bullet holes produced by different shots on test targets from the gun and ammunition under investigation. The calibration curves obtained at various distances and firing angles enabled the determination of the firing distances and angles of the crime shots with a standard deviation of +/- 2 cm and +/- 5 degrees, respectively.

A systematic approach to flap selection for the axillary burn contracture

Any soft-tissue deficiency about the axilla unfortunately may readily be translated into a functional limitation of the upper extremity that should be addressed in a simple yet expeditious fashion. Commonly a sequela of burn injuries, significant skin destruction in kind must be restored. Whatever the etiology of major deformities, the vital axillary structures and preservation of shoulder range of motion may best be accomplished by resurfacing with the use of vascularized tissues taken from sources adjacent to the defect. If this is the case, the efficacious application of these local muscle or fascial flaps mandates a realization that such choices are finite in number. A schema for a reasonable flap selection process has been devised based on the relative severity and anatomic location of the axillary burn scar contracture.

Brachial plexus injury caused by impalement

Open injuries of the brachial plexus are rare. One such case, that of a 68-year-old impaled on a fence spike, is presented here. Certain principles to guide evaluation and treatment are discussed. Concomitant injury to the pleura or to vascular structures requires immediate attention; the extent and type of plexus damage may be determined from physical findings and the nature of injury. The results of plexus reconstruction are variable and routine exploration may be detrimental. The Brooks classification is reviewed.

Subcutaneous emphysema from an axillary wound that resulted in pneumomediastinum and bilateral pneumothorax in a horse

A 5-year-old Thoroughbred gelding was examined because of a small axillary wound sustained 5 days earlier and had resulted in extensive subcutaneous emphysema. Three days after admission, the horse's respiratory rate had increased to 72 breaths/min, and the horse appeared anxious and distressed. Thoracic radiography revealed pneumomediastinum and severe bilateral pneumothorax. Tube thoracostomy was performed on both hemithoraxes. The drains were connected to one-way suction valves and suction devices to decompress the thorax. A nasopharyngeal catheter was inserted, and oxygen insufflation was started. Cross ties were placed on the horse to limit movement, and the wound was packed. The horse improved within 30 minutes after initiating treatment. The horse was released 15 days after the development of pneumothorax, at which time the pneumothorax had resolved, the wound was no longer open, and the subcutaneous emphysema had greatly decreased. Although subcutaneous emphysema is usually regarded as a temporary cosmetic disfigurement, it can lead to serious complications such as pneumothorax. This case demonstrates that subcutaneous emphysema can lead to a life-threatening pneumothorax if the pressure is great enough to migrate through the mediastinum and into the pleural cavity. Horses with subcutaneous emphysema should be kept in confinement and monitored for the development of pneumothorax.