Aug 21, 2008


A lipoma is a growth of fat cells in a thin, fibrous capsule usually found just below the skin. Lipomas are found most often on the torso, neck, upper thighs, upper arms, and armpits, but they can occur almost anywhere in the body. One or more lipomas may be present at the same time. Lipomas are the most common noncancerous soft tissue growth.

A lipoma may be surgically removed if symptoms develop, such as if the lipoma:

  • Becomes painful or tender.
  • Becomes infected or inflamed repeatedly.
  • Drains foul-smelling discharge.
  • Interferes with movement or function.
  • Increases in size.
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Jun 11, 2008


One of the common birth defects is syndactyly, in which two or more fingers are fused together. Surgical correction involves cutting the tissue that connects the fingers, then grafting skin from another part of the body. (The procedure is more complicated if bones are also fused.) Surgery can usually provide a full range of motion and a fairly normal appearance, although the color of the grafted skin may be slightly different from the rest of the hand. Other common congenital defects include short, missing, or deformed fingers, immobile tendons, and abnormal nerves or blood vessels. In most cases, these defects can be treated surgically and significant improvement can be expected.

Medical therapy

Syndactyly requires surgical intervention. Full-term infants can be scheduled for elective surgical procedures as early as 5 or 6 months of age. Surgery before this age can increase anesthetic risks. Prior to that time, there is generally no intervention necessary if there are no problems. If there is an associated paronychia which can occur with complex syndactyly, the parents are given instructions to wash the child's hands thoroughly with soap and water and toa apply a topical antibacterial solution or ointment. Oral antibiotics are given when indicated.

Surgical therapy

The timing of surgery is variable. However, if more fingers are involved and the syndactyly is more complex, release should be performed earlier. Early release can prevent the malrotation and angulation that develops from differential growth rates of the involved fingers.

In persons with complex syndactyly, the author performs the first release of the border digits when the individual is approximately 6 months old. This approach is used because differential growth rates are observed, particularly between the small finger and ring finger or between the thumb and index finger. Prolonged syndactyly between these digits can cause permanent deformities. If more than one syndactyly is present in the same hand, simultaneous surgical release can be performed, provided only one side of the involved fingers is released. For example, in a 4-finger syndactyly involving the index, long, ring, and small fingers, the index finger can be released from the long finger, and the small finger can be released from the ring finger, leaving a central syndactyly involving the long and ring fingers (see Images 27-28). If both hands are involved, bilateral releases can be performed at one operative setting.

Perform bilateral releases whenever feasible to reduce the number of surgeries and the associated risks. Postoperative bilateral immobilization of the upper extremities is well tolerated in the child who is younger than 18 months. The increasingly active child who is older than 18 months has a difficult time with bilateral immobilization. Therefore, in children older than 18 months, any procedures must be staged unilaterally. The remaining syndactyly between the long finger and ring finger can be released approximately 6 months later (see Images 29-30). In an individual with isolated central syndactyly between the long finger and ring finger, the release need not be accomplished until the second year of life because of similar growth rates between the long finger and ring finger. It is preferable to complete all major reconstructions before a child is school age.

However, even if the child is older than the ideal age (which is usually before school age for functional, developmental, and psychological reasons), it is not too late to release the central rays (long and ring fingers) at a later age, as they have similar growth rates. For example, a 5° flexion contracture could eventually improve once the fingers are released. In children, unlike in adults, persistent flexion contractures are rare. The technical details of syndactyly release are similar to the release performed in infants. In older patients, splints are still applied but can be removed earlier, at about 7-10 days, because the patients are more compliant with activity and with dressing changes after the splint is removed

Jun 9, 2008


Neurofibromatosis is a genetically-transmitted disease in which nerve cells (Schwann cells) grow tumors (neurofibromas) that may be harmless or may cause serious damage by compressing nerves and other tissues.

Neurofibromatosis is inherited through a dominant gene. That means that if a child gets one gene for neurofibromatosis from one parent, and a normal gene from the other parent, that child will have neurofibromatosis. Therefore, if only one parent has neurofibromatosis, his or her children have a 50% chance of developing the condition as well. Disease severity in affected individuals, however, can vary (this is called incomplete penetrance).

Diagnosis and Treatment

Neurofibromatosis is usually diagnosed based on a combination of findings. A child must have at least two of the following signs to be diagnosed with NF1:

  • cafĂ©-au-lait spots of a certain number, size, and location
  • the appearance of two or more neurofibromas (often resembling pea-sized bumps on the skin)
  • Lisch nodules on the irises
  • an optic glioma (tumor along the main nerve of the eye that is responsible for sight)
  • certain skeletal abnormalities
  • a family member with NF1
  • freckling under the arms or in the groin

Tests like magnetic resonance imaging (MRI) and X-rays may be used to screen for tumors or evidence of skeletal problems. A child's head circumference will be measured because children with symptoms of NF can have a larger than normal head circumference for a given age. Blood pressure will be monitored. Doctors will also take a detailed personal history, looking for signs of learning difficulties at home or at school.

To diagnose NF2, doctors will check for any evidence of hearing loss. They'll order audiometry (hearing tests) as well as imaging tests to look for tumors in the nerves of the ears, spinal cord, or brain. They'll also determine if there's a family history of NF2.

Genetic testing is now available for people with a family history of either NF1 or NF2, though such testing is still not 100% sensitive. Amniocentesis can sometimes determine if a woman's unborn child has the condition.

Treatment for NF1 includes removal of the neurofibromas for cosmetic purposes, treating the complications (see below), and getting intervention for children with learning disabilities. Kids will be referred to appropriate medical specialists to monitor and treat any complications from the disease

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Benign prostatic hyperplasia (BPH) is not simply a case of too many prostate cells. Prostate growth involves hormones, occurs in different types of tissue (e.g., muscular, glandular), and affects men differently.

Jun 7, 2008

Decubitus Ulcers

The terms decubitus ulcer and pressure sore often are used interchangeably in the medical community. Decubitus, from the Latin decumbere, means "to lie down." Decubitus ulcer, therefore, does not adequately describe ulceration that occurs in other positions, such as prolonged sitting (eg, the commonly encountered ischial tuberosity ulcer). Because the common denominator of all such ulcerations is pressure, pressure sore is the better term to describe this condition.

Many factors contribute to the development of pressure sores, but pressure leading to ischemia is the final common pathway. Tissues are capable of withstanding enormous pressures when brief in duration, but prolonged exposure to pressures slightly above capillary filling pressure initiates a downward spiral towards ulceration.

Impaired mobility is an important contributing factor. Patients who are neurologically impaired, heavily sedated, restrained, or demented are incapable of assuming the responsibility of altering their position to relieve pressure. Moreover, this paralysis leads to muscle and soft tissue atrophy, decreasing the bulk over which these bony prominences are supported.

Contractures and spasticity often contribute by repeatedly exposing tissues to pressure through flexion of a joint. Contractures rigidly hold a joint in flexion, while spasticity subjects tissues to considerable repeated friction and shear forces.

Sensory loss also contributes to ulceration by removing one of the most important warning signals, pain.

Paralysis and insensibility also lead to atrophy of the skin with thinning of this protective barrier. The skin becomes more susceptible to minor traumatic forces, such as friction and shear forces, exerted during the moving of a patient. Trauma causing deepithelialization leads to transdermal water loss, creating maceration and adherence of the skin to clothing and bedding, which raises the coefficient of friction for further insult.

Malnutrition, hypoproteinemia, and anemia reflect the overall status of the patient and can contribute to vulnerability of tissue and delays in wound healing. Poor nutritional status certainly contributes to the chronicity often observed with these lesions. Anemia indicates poor oxygen-carrying capacity of the blood. Vascular disease also may impair blood flow to the region of ulceration.

Bacterial contamination from improper skin care or urinary or fecal incontinence, while not truly an etiological factor, is an important factor to consider in the treatment of pressure sores and can delay wound healing.

The first step in resolution is to reduce or eliminate the cause, that is, pressure.
Regardless of the choice of support surface, turning and repositioning the patient remain the cornerstones of prevention and treatment. This should be performed every 2 hours, even in the presence of a specialty surface or bed.
Even with optimal medical management, many patients require a trip to the operating room for debridement, diversion of urinary or fecal stream, release of flexion contractures, wound closure, or amputation.

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Jun 5, 2008


A keloid is a type of scar which results in an overgrowth of tissue at the site of a healed skin injury. Keloids are firm, rubbery lesions or shiny, fibrous nodules, and can vary from pink to flesh-colored or red to dark brown in color. A keloid scar is benign, non-contagious, and usually accompanied by severe itchiness, sharp pains, and changes in texture. In severe cases, it can affect movement of skin. Keloids should not be confused with hypertrophic scars, which are raised scars that do not grow beyond the boundaries of the original wound and may reduce over time.

Keloids are mostly found on earlobes, the sternum, shoulders, the upper back and any place where abrasion has occurred. These are usually the result of pimples, insect bites, scratching, burns, or other skin trauma. Certain procedures are known to cause keloid formation such as within post-operative surgical scars or on earlobes following piercing and behind the ears after otoplasty

People of all ages can develop a keloid. Children under 11 are less likely to develop keloids, even when they get their ears pierced. Keloids may also develop from pseudofoliculitis barbae, continued shaving when one has razor bumps will cause irritation to the bumps, infection and over time keloids will form. It would thus be wise for a man with razor bumps to stop shaving for a while and have the skin repair itself first before undertaking any form of hair removal.

No treatment for keloids is considered to be 100% effective. Some of the treatments that are currently available are described below. These treatments have varying degrees of effectiveness. All the invasive methods of treatment like surgery carry a serious risk of the keloid recurring and becoming bigger than it previously was.

  • Tea Tree Oil.
  • Crushed Aspirin Paste.
  • Surgery — Surgery requires great care during and after the operation. Keloids that return after being excised may be larger than the original. There is a 50% chance of recurrence after surgical removal. However, keloids are less likely to return if surgical removal is combined with other treatments. Surgical or laser excision may be followed by intralesional injections of a corticosteroid. Plastic closure of the skin including techniques such as v-plasty or w-plasty to reduce skin tension are known to reduce recurrence of keloids following excision.
  • Dressings
  • Steroid injections — Steroid injections are best used as the scar begins to thicken or if the person is a known keloid former. A series of injections with triamcinolone acetonide or another corticosteroid may reduce keloid size and irritation. However, injections are often uncomfortable and in large and/or hard scars can be difficult to perform, requiring local anesthetic for people over 16, and full anesthetic for people under. The treatment area can become very painful as the anesthetic wears off.
  • Compression — Compression bandages applied to the site over several months, sometimes for as long as six to twelve months, may lead to a reduction in the size of the keloid. This is the best treatment for preventing new scars.
  • Cryosurgery

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Fibroadenomas are benign tumors that represent a hyperplastic or proliferative process in a single terminal ductal unit; their development is considered to be an aberration of normal development. The cause of these tumors is unknown. Approximately 10% of fibroadenomas disappear spontaneously each year, and most stop growing after they reach 2-3 cm.

Fibroadenomas may involute in postmenopausal women, and coarse calcifications may develop. Conversely, fibroadenomas may grow rapidly during pregnancy, during hormone replacement therapy, or during immunosuppression, in which case they can simulate malignancy. In immunosuppressed patients, the etiology of multiple or growing fibroadenomas appears to be related to Epstein-Barr virus infection.

On clinical examination, fibroadenomas are oval, freely mobile, rubbery masses that may be nonpalpable or palpable. Their size varies from smaller than 1 cm in diameter to as large as 15 cm in diameter in the giant forms. Most commonly, the tumors are removed surgically when they are 2-4 cm in diameter. In young women, the tumors are usually palpable. In older women, the tumors typically appear as a mass on mammograms and may be palpable or nonpalpable.

In approximately 50% of women who receive cyclosporine after renal transplantation, fibroadenomas develop, and these tumors are often multiple and bilateral. The size of fibroadenomas also can vary during the menstrual cycle and during pregnancy. During postmenopause, tumors regress and often develop calcifications. Cancer may arise in a fibroadenoma, occurring in about 2.9% of cases; an increase in size, a change or irregularity in the margin, the development of small pleomorphic calcifications, and the presence of cystic spaces all suggest a developing malignancy.

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