ITEMS IN AFP WITH MESH TERM:
Fishhook Removal - Article
ABSTRACT: Fishing is a common recreational sport. While serious injuries are uncommon, penetrating tissue trauma involving fishhooks frequently occurs. Most of these injuries are minor and can be treated in the office without difficulty. All fishhook injuries require careful evaluation of surrounding tissue before attempting removal. Ocular involvement should prompt immediate referral to an ophthalmologist. The four most common techniques of fishhook removal and injury management are described in this article. The choice of the method for fishhook removal depends on the type of fishhook embedded, the location of the injury and the depth of tissue penetration. Occasionally, more than one removal technique may be required for removal of the fishhook. The retrograde technique is the simplest but least successful removal method, while the traditional advance and cut method is most effective for removing fishhooks that are embedded close to the skin surface. The advance and cut technique is almost always successful, even for removal of large fishhooks. The string-yank method can be used in the field and can often be performed without anesthesia. Wound care following successful removal involves extraction of foreign bodies from the wound and the application of a simple dressing. Prophylactic antibiotics are generally not indicated. Tetanus status should be assessed and toxoid administered if needed.
ABSTRACT: The interrupted vertical and horizontal mattress suture techniques are two of the most commonly used skin closure methods. These mattress sutures promote wound edge eversion and less prominent scarring. Vertical and horizontal mattress sutures allow for skin edges to be closed under tension when wound edges have to be brought together over a distance. The corner stitch, a variation of the horizontal mattress suture, is commonly used for closure of angled skin flaps or wounds. Although mattress sutures can produce surface scarring or "railroad marks," early removal of these sutures can limit this damage.
Splinter Removal - Article
ABSTRACT: Splinter injuries are common, but larger and deeper splinters are often difficult and painful to remove at home. These splinters often present as a foreign body embedded in the superficial or subcutaneous soft tissues. Whenever possible, reactive objects like wood, thorns, spines, and vegetative material should be removed immediately, before inflammation or infection occurs. Superficial horizontal splinters are generally visible on inspection or easily palpated. A horizontal splinter is exposed completely by incising the skin over the length of the long axis of the splinter, and removed by lifting it out with forceps. A subungual splinter may be removed by cutting out a V-shaped piece of the nail. The point of the V is at the proximal tip of the splinter, which is grasped and removed, taking particular care not to push the splinter further into the nail bed. Removal of an elusive splinter can be challenging and may require the use of imaging modalities for better localization. Deeper splinters, especially those close to important structures such as nerves, tendons, blood vessels, or vital organs, should be referred for removal.
Management of Corneal Abrasions - Article
ABSTRACT: Corneal abrasions result from cutting, scratching, or abrading the thin, protective, clear coat of the exposed anterior portion of the ocular epithelium. These injuries cause pain, tearing, photophobia, foreign body sensation, and a gritty feeling. Symptoms can be worsened by exposure to light, blinking, and rubbing the injured surface against the inside of the eyelid. Visualizing the cornea under cobalt-blue filtered light after the application of fluorescein can confirm the diagnosis. Most corneal abrasions heal in 24 to 72 hours and rarely progress to corneal erosion or infection. Although eye patching traditionally has been recommended in the treatment of corneal abrasions, multiple well-designed studies show that patching does not help and may hinder healing. Topical mydriatics also are not beneficial. Initial treatment should be symptomatic, consisting of foreign body removal and analgesia with topical nonsteroidal anti-inflammatory drugs or oral analgesics; topical antibiotics also may be used. Corneal abrasions can be avoided through the use of protective eyewear.
ABSTRACT: A pressure ulcer is a localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of unrelieved pressure. Predisposing factors are classified as intrinsic (e.g., limited mobility, poor nutrition, comorbidities, aging skin) or extrinsic (e.g., pressure, friction, shear, moisture). Prevention includes identifying at-risk persons and implementing specific prevention measures, such as following a patient repositioning schedule; keeping the head of the bed at the lowest safe elevation to prevent shear; using pressure-reducing surfaces; and assessing nutrition and providing supplementation, if needed. When an ulcer occurs, documentation of each ulcer (i.e., size, location, eschar and granulation tissue, exudate, odor, sinus tracts, undermining, and infection) and appropriate staging (I through IV) are essential to the wound assessment. Treatment involves management of local and distant infections, removal of necrotic tissue, maintenance of a moist environment for wound healing, and possibly surgery. Debridement is indicated when necrotic tissue is present. Urgent sharp debridement should be performed if advancing cellulitis or sepsis occurs. Mechanical, enzymatic, and autolytic debridement methods are nonurgent treatments. Wound cleansing, preferably with normal saline and appropriate dressings, is a mainstay of treatment for clean ulcers and after debridement. Bacterial load can be managed with cleansing. Topical antibiotics should be considered if there is no improvement in healing after 14 days. Systemic antibiotics are used in patients with advancing cellulitis, osteomyelitis, or systemic infection.
Patching for Corneal Abrasions? - Cochrane for Clinicians
Effectiveness of Dressings for Healing Venous Leg Ulcers - Cochrane for Clinicians
ABSTRACT: Keloids and hypertrophic scars represent an exuberant healing response that poses a challenge for physicians. Patients at high risk of keloids are usually younger than 30 years and have darker skin. Sternal skin, shoulders and upper arms, earlobes, and cheeks are most susceptible to developing keloids and hypertrophic scars. High-risk trauma includes burns, ear piercing, and any factor that prolongs wound healing. Keloid formation often can be prevented if anticipated with immediate silicone elastomer sheeting, taping to reduce skin tension, or corticosteroid injections. Once established, however, keloids are difficult to treat, with a high recurrence rate regardless of therapy. Evidence supports silicone sheeting, pressure dressings, and corticosteroid injections as first-line treatments. Cryotherapy may be useful, but should be reserved for smaller lesions. Surgical removal of keloids poses a high recurrence risk unless combined with one or several of these standard therapies. Alternative postsurgical options for refractory scars include pulsed dye laser, radiation, and possibly imiquimod cream. Intralesional verapamil, fluorouracil, bleomycin, and interferon alfa-2b injections appear to be beneficial for treatment of established keloids. Despite the popularity of over-the-counter herb-based creams, the evidence for their use is mixed, and there is little evidence that vitamin E is helpful.
ABSTRACT: Chronic critical limb ischemia is manifested by pain at rest, nonhealing wounds and gangrene. Ischemic rest pain is typically described as a burning pain in the arch or distal foot that occurs while the patient is recumbent but is relieved when the patient returns to a position in which the feet are dependent. Objective hemodynamic parameters that support the diagnosis of critical limb ischemia include an ankle-brachial index of 0.4 or less, an ankle systolic pressure of 50 mm Hg or less, or a toe systolic pressure of 30 mm Hg or less. Intervention may include conservative therapy, revascularization or amputation. Progressive gangrene, rapidly enlarging wounds or continuous ischemic rest pain can signify a threat to the limb and suggest the need for revascularization in patients without prohibitive operative risks. Bypass grafts are usually required because of the multilevel and distal nature of the arterial narrowing in critical limb ischemia. Patients with diabetes are more likely than other patients to have distal disease that is less amenable to bypass grafting. Compared with amputation, revascularization is more cost-effective and is associated with better perioperative morbidity and mortality. Limb preservation should be the goal in most patients with critical limb ischemia.
Cutaneous Cryosurgery - Article
ABSTRACT: Cutaneous cryosurgery refers to localized application of freezing temperatures to achieve destruction of skin lesions. It can be used to treat a broad range of benign and premalignant skin conditions, and certain malignant skin conditions, with high cure rates. Cellular destruction is accomplished by delivery of the cryogen via dipstick, probe, or spray techniques. It is widely used in primary care because of its safety, effectiveness, low cost, ease of use, good cosmetic results, and lack of need for anesthesia. Cryosurgery is as effective as alternative therapies for most cases of molluscum contagiosum, dermatofibromas, keloids, and plantar or genital warts. It is a more effective cure for common warts than salicylic acid or observation. Cryosurgery is generally the treatment of choice for actinic keratosis. Contraindications to cryosurgery include cryofibrinogenemia, cryoglobulinemia, Raynaud disease, agammaglobulinemia, and multiple myeloma. Complications from cryosurgery include hypopigmentation and alopecia, and can be avoided by limiting freeze times to less than 30 seconds. Referral to a dermatologist should be considered in cases of diagnostic uncertainty or for treatment of skin cancer, which requires larger amounts of tissue destruction, resulting in higher complication rates.