599 Intramammary Melanoma Micrometastasis Within A Silicone Implanted Breast

Case Summary

Melanoma of the abdominal wall is not uncommon, and sentinel lymph nodes are usually located in the lymphatic drainage basins of the axilla or inguinal region. Less frequently, interval sentinel lymph nodes can be found along the lymphatic vessels between the primary cancer and nearest basin.

We present the case of a 53-year-old female with silicone breast implants who underwent scar excision and sentinel lymph node biopsy for a 1mm Breslow thickness superficial spreading melanoma of the abdomen. Two lymph nodes were excised; both lying in the subcutaneous fat at the lateral aspect of the right breast capsule. Lymph node histology revealed a subcapsular melanoma deposit along with silicone lymphadenopathy in the sentinel node, and silicone lymphadenopathy in the second node. Whole body positron emission tomography (PET/CT) and magnetic resonance imaging (MRI) of the brain showed no evidence of metastases or implant rupture. Subsequent MRI breast revealed likely intracapsular implant rupture. The patient was offered removal of implants and remains under follow-up.

The unusual location of the sentinel node in our patient highlights the possibility that previous breast augmentation may have altered the pattern of lymphatic drainage to the axilla. In addition, to our knowledge, this is the first reported case of silicone and melanoma deposits in a single sentinel node.

598 Burns Management at A UK Major Trauma Centre During The COVID-19 Lockdown

Aim

The COVID-19 pandemic forced huge changes in healthcare delivery in the UK within a matter of weeks. We report our experience of managing burns presenting to a UK Major Trauma Centre during the COVID-19 lockdown period.

Method

Retrospective patient data was collected on aetiology, severity and management of burns during the first six weeks of the government-enforced lockdown. Data was compared with patients presenting with burns during the same period in 2019 (control) and statistical analysis was performed.

Results

Fifteen patients were treated during the COVID-19 lockdown and fourteen in the control group. Adults treated during the COVID-19 lockdown had a greater total body surface area (TBSA) (9% vs. 2.9%, p 0.035) and were more likely to suffer full thickness burns (40% vs. 0%). In the COVID-19 group all patients that did not require resuscitation, seven of whom met criteria for referral to burns services, were managed locally by the plastic surgery department with good outcomes.

Conclusions

Despite the increase in severity of adult burns seen during the COVID-19 lockdown period, local plastic surgery units have been able to adapt their practice and successfully manage more complex burns. This adaptability will be key as we move through the pandemic.

540 Point of Care Testing for Tetanus Immunity: A Systematic Review

Introduction

All patients presenting to emergency departments (EDs) with traumatic injuries require tetanus immunity assessments. Inaccurate tetanus vaccination history based on patient recall incurs unnecessary costs on the NHS. Point-of-care immunochromatographic tests (Tetanus Quick Sticks [TQS]) quickly identify tetanus immunity status. We aim to evaluate the diagnostic accuracy and cost-efficacy of TQS to assess their relevance in emergency care.

Method

The systematic review followed PRISMA guidelines. A retrospective search of MEDLINE, Embase, Global Health, HMIC and The Cochrane Library was conducted. Studies were eligible if sensitivity, specificity, or cost-efficacy of TQS were reported. At least two authors independently analysed the data from each study.

Results

12 studies were suitable for inclusion (n = 1,662,865 participants): one retrospective and 11 prospective observational cohort studies. Eight studies assessed diagnostic accuracy with the median sensitivity at 86% (55-100) and the median specificity at 97.5% (1-100). All six studies investigating cost-efficacy reported greater savings when using TQS instead of using vaccination history, due to a decrease in unnecessary tetanus vaccine and immunoglobulin administration.

Conclusions

TQS is a safe diagnostic tool, especially when used by trained operators. TQS widely reduces costs in comparison to traditional vaccination history. We recommend the use of TQS in Emergency Departments throughout the NHS.

The COVID-19 Pandemic: The effect on open lower limb fractures in a London major trauma centre - a plastic surgery perspective

BACKGROUND

COVID-19 has created huge pressures on healthcare systems. The ongoing provision of major trauma services during this time has proved challenging. We report our experience of managing open lower limb fractures (oLLFs) during the pandemic in a London major trauma centre (MTC).

METHODS

This was a prospective study of all open lower limb fractures presenting to our unit over the initial 48 days of UK government lockdown - 24th March till 10th May 2020. Results were compared to the same time period in 2019 retrospectively. Epidemiological data, mechanism, Gustilo-Anderson (G-A) severity grading, time to initial debridement and definitive coverage were analysed.

RESULTS

There was a 64% reduction in emergency department (ED) attendances (25,264 vs 9042). There was an 18% reduction in oLLFs (22 vs 18). Approximately three-quarters of injuries were in males across both cohorts (77% vs 78%) and tended to occur in younger patients (median age, 37 vs 35). Road-traffic-accidents (RTAs) were the most common injury mechanism in both 2019 and lockdown, but a rise in jumpers from height was seen in the latter. A similar pattern of G-A severities were seen, however only 3 injuries during lockdown required major soft tissue reconstruction. There was no significant difference in times taken for initial debridement (p = 0.72786) or definitive wound coverage (p = 0.16152). A greater proportion of independent operating was seen during lockdown between orthopaedics and plastic surgery.

CONCLUSIONS

Despite government lockdown measures, oLLFs still placed significant burden on our MTC. Notwithstanding significant staffing alterations and theatre pressures, we have been able to ensure these lower limb emergencies remain a surgical priority and have managed to utilise resources appropriately.

Management of amputated digits

Traumatic digit amputations account for 1% of all trauma admissions and are an important cause of morbidity in young, working people. It is essential that patients are worked up appropriately and referred promptly to a specialist unit for consideration of replantation. This review summarises the acute management of a patient presenting to the emergency department with an amputated digit. It discusses the assessment, initial management in the emergency department, how to make the decision to replant and operative steps.