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Subcutaneous Fat Necrosis

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821. Distal Humerus Fractures (Treatment)

and distally to the cubital tunnel to allow the nerve to lie within the subcutaneous tissues anteromedially to the cubital tunnel (transposition). [ , , ] Careful attention should be paid to the release of the medial intermuscular septum and distal dissection of the nerve within the flexor carpi ulnaris (FCU). A triceps-splitting approach is most commonly used for exposure of the distal humerus. This technique involves deep dissection down the middle of the arm over the olecranon, along with fascial (...) and lateral ligamentous attachments typically remain preserved, lending stability to the elbow after operative stabilization. Avascular necrosis (AVN) is extremely rare after distal humerus fractures. Isolated studies have reported an increased risk of AVN of the free-floating fragment after H-type intra-articular distal humerus fractures. The most common nerve injuries that are associated with ORIF of distal humerus fractures are ulnar nerve injuries. Ulnar neuropathy has been reported to occur in 7-15

2014 eMedicine Surgery

822. Decubitus Ulcers (Treatment)

, ointments, creams, solutions, dressings, ultrasonography, ultraviolet heat lamps, sugar, and surgery. In choosing a treatment strategy, consideration should be given to the stage of the wound and the purpose of the treatment (eg, protection, moisture, or removal of necrotic tissue). An algorithm for assessment and treatment is available. [ , , ] General principles of wound assessment and treatment are as follows: Wound care may be broadly divided into nonoperative and operative methods For stage 1 and 2 (...) medical management of pressure ulcers relies on the following key principles: Reduction of pressure Adequate débridement of necrotic and devitalized tissue Control of infection Meticulous wound care If surgical reconstruction of a pressure injury is indicated, it cannot be emphasized too strongly that medical management must be optimized before reconstruction is attempted; otherwise, reconstruction is doomed to failure. That is, spasticity must be controlled, nutritional status must be optimized

2014 eMedicine Surgery

823. Diaphyseal Femur Fractures (Treatment)

of the femoral neck is important to avoid the devastating complication of avascular necrosis (AVN). Some reports give the neck priority and recommend treating the neck separately with screws or a screw-plate device and the shaft with compression plating or retrograde nailing. If the neck fracture is discovered after an antegrade nail is placed, supplemental screws are placed anterior to the nail into the neck. If anatomic reduction cannot be achieved, the hardware should be removed and revised as previously (...) and is superficial with skin penetration (mortality, 0%) Type I occurs at greater than 12 m and penetrates only subcutaneous and deep fascia (mortality, 0-5%) Type II occurs at 5-12 m and penetrates beyond deep fascia (mortality, 15-20%) Type III occurs at less than 5 m and causes extensive tissue damage (mortality, 85-90%) Children Femoral-shaft fractures in children are associated with many of the same concerns as those in adults. [ , ] Again, the level of injury sustained by the patient is of great importance

2014 eMedicine Surgery

824. Wound Care (Overview)

parathyroid hormone level. Skin biopsy reveals calcification of the arterial media and luminal stricture of small-to-medium blood vessels in the subcutaneous fat. Muscle biopsy shows patchy necrosis and atrophy. [ ] Necrobiosis lipoidica Necrobiosis lipoidica, a necrotizing skin lesion characterized by collagen degeneration and a granulomatous response, usually involves the anterior tibial areas, though it can also occur in the face, arms, and chest. Patients present with well-circumscribed, shiny (...) result is the inhibition of regeneration of skin cells from dividing basal cells. This may cause recalcitrant, painful skin ulcers. The surrounding skin is atrophic, with atrophy of hair follicles and a paucity subcutaneous fat. Ultraviolet radiation exposure, particularly ultraviolet B, causes sunburn initially and subsequently conveys a continuing risk of skin malignancy (eg, , , ). Excessive exposure to infrared radiation, which induces repeated or persistent skin hyperthermia of 43-47°C, may

2014 eMedicine Surgery

825. Fournier Gangrene (Diagnosis)

. Skin and superficial fascia Because Fournier gangrene is predominately an infectious process of the superficial and deep fascial planes, understanding the anatomic relationship of the skin and subcutaneous structures of the perineum and abdominal wall is important. The skin cephalad to the inguinal ligament is backed by Camper fascia, which is a layer of fat-containing tissue of varying thickness and the superficial vessels to the skin that run through it. Scarpa fascia forms another distinct layer (...) . Ultimately, an obliterative endarteritis develops, and the ensuing cutaneous and subcutaneous vascular necrosis leads to localized ischemia and further bacterial proliferation. Rates of fascial destruction as high as 2-3 cm/h have been described. Infection of superficial perineal fascia (Colles fascia) may spread to the penis and scrotum via Buck and Dartos fascia, or to the anterior abdominal wall via Scarpa fascia, or vice versa. Colles fascia is attached to the perineal body and urogenital diaphragm

2014 eMedicine Emergency Medicine

826. Pediatrics, Sickle Cell Disease (Follow-up)

initiation of opioids for the treatment of severe pain associated with a vasoocclusive crisis Use of analgesics and physical therapy for the treatment of avascular necrosis In July 2017, the US Food & Drug Administration (FDA) approved L-glutamine oral powder (Endari) for patients age 5 years and older to reduce severe complications of SCD. [ , ] L-glutamine increases the proportion of the reduced form of nicotinamide adenine dinucleotides in sickle cell erythrocytes; this probably reduces oxidative (...) , and deferiprone. Deferoxamine is an efficient iron chelator. It is administered as a prolonged infusion intravenously or subcutaneously for 5-7 days a week. Although effective, there are significant challenges associated with its use that can result in non-compliance. [ ] Deferiprone and deferasirox, oral iron chelators, are effective for iron overload treatment and have differences (eg, different pharmacokinetics and adverse effect profiles). Deferasirox has a capacity similar to deferoxamine in chelating

2014 eMedicine Emergency Medicine

827. Plantar Fasciitis (Follow-up)

the superficial layers of the subcutaneous tissue, because corticosteroid injection into the superficial fat pad can cause fat necrosis and atrophy, which reduce the shock-absorbing capacity of the plantar heel Studies have reported success rates of 70% or better. [ , ] Corticosteroid injections have been shown to improve symptoms at 1 month but not at 6 months. It is recommended not to give more than 3 steroid injections within a year. A randomized, controlled study demonstrated that intralesional (...) corticosteroids. [ ] Potential risks of corticosteroid injection include plantar fascia rupture, which was found in almost 10% of patients after plantar fascia injection in one case series, [ ] and fat pad atrophy. [ , ] Long-term sequelae were found in approximately 50% of patients with plantar fascia rupture. [ ] Improper placement of a corticosteroid injection for plantar fasciitis can result in necrosis and atrophy of the plantar fat pad at the heel. This complication may result in significant pain

2014 eMedicine Emergency Medicine

828. Myocardial Infarction (Follow-up)

variability and narrow therapeutic window. Low molecular weight heparin (LMWH) Enoxaparin is given at a dose of 1 mg/kg subcutaneously (SC) every 12 hours. It should be continued for the duration of hospitalization or until PCI is performed. A dose reduction is required for patients with impaired kidney function. Enoxaparin results in a more predictable and efficient anticoagulation compared to unfractionated heparin, leading to reduction in recurrent MI events [ , ] ; however, there is possibly a higher (...) bleeding risk in patients undergoing PCI. [ ] These findings were demonstrated in the Efficacy and Safety of Subcutaneous Enoxaparin in Non–Q wave Coronary Events (ESSENCE) trial. [ , , ] Bivalirudin Bivalirudin is direct thrombin inhibitor that is given as 0.1 mg/kg loading dose, followed by 0.25 mg/kg per hour only in patients managed with an early invasive strategy. This regimen is continued until diagnostic angiography or PCI. [ ] In the Acute Catheterization and Urgent Intervention Triage Strategy

2014 eMedicine Emergency Medicine

829. Gout and Pseudogout (Diagnosis)

are as follows: Avoidance or restricted consumption of high-purine foods Avoidance of excess ingestion of alcoholic drinks, particularly beer Avoidance of sodas and other beverages or foods sweetened with high-fructose corn syrup Limited use of naturally sweet fruit juices, table sugar, and sweetened beverages and desserts, as well as table salt Maintenance of a high level of hydration with water (≥8 glasses of liquids daily) A low-cholesterol, low-fat diet, if such a diet is otherwise appropriate (...) chemotactic factors, and tumor necrosis factor (TNF)-α. [ , ] Neutrophil phagocytosis leads to another burst of inflammatory mediator production. Chatfield et al reported that the interaction of urate crystals with lysosomes results in the formation of web-like chromatin structures known as neutrophil extracellular traps (NETs) and subsequent cell death (NETosis), via a mechanism independent of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase. The urate crystal–induced NETs are enriched

2014 eMedicine Emergency Medicine

830. Hernias (Diagnosis)

rotation, adduction, or extension at the hip Sciatic hernia - Tender mass in the gluteal area that is increasing in size; sciatic neuropathy and symptoms of intestinal or ureteral obstruction can also occur Perineal hernias - Perineal mass with discomfort on sitting and occasionally obstructive symptoms with incarceration Umbilical hernia - Central, midabdominal bulge Epigastric hernia - Small lumps along the linea alba reflecting openings through which preperitoneal fat can protrude; may be adjacent (...) approaches to other hernia types may vary, as follows: Umbilical hernia - After exposure of the umbilical sac, a plane is created to encircle the sac at the level of the fascial ring, and the defect is closed transversely with interrupted sutures; if the defect is very large (>2 cm), mesh may be required Epigastric hernia - A small vertical incision directly over the defect is carried to the linea alba, and incarcerated preperitoneal fat is either excised or returned to the properitoneum; the defect

2014 eMedicine Emergency Medicine

831. Burns, Chemical (Diagnosis)

as liquefaction necrosis. This involves denaturing of proteins as well as saponification of fats, which does not limit tissue penetration. Hydrofluoric acid is somewhat different from other acids in that it produces a liquefaction necrosis. The severity of the burn is related to a number of factors, including the pH of the agent, the concentration of the agent, the length of the contact time, the volume of the offending agent, and the physical form of the agent. The ingestion of solid pellets of alkaline (...) it gives up the proton; the strength of a base is determined by how avidly it binds the proton. The strength of acids and bases is defined by using the pH scale, which ranges from 1-14 and is logarithmic. A strong acid has a pH of 1, and a strong base has a pH of 14. A pH of 7 is neutral. Next: Pathophysiology Most acids produce a coagulation necrosis by denaturing proteins, forming a coagulum (eg, eschar) that limits the penetration of the acid. Bases typically produce a more severe injury known

2014 eMedicine Emergency Medicine

832. Cellulitis (Diagnosis)

, the tissue is hemorrhagic and necrotic. Hematoxylin and eosin (H&E) stain, high power. This image shows deeper subcutaneous tissue involved in a case of cellulitis, with acute inflammatory cells and fat necrosis. Hematoxylin and eosin (H&E) stain, high power. This image shows cellulitis caused by herpes simplex virus, with the multinucleated organism in the center of the picture. of 14 Tables Table 1. Empiric Antibiotic Therapy for Cellulitis by Etiology and Anatomic Location Location Likely Organisms (...) E Herchline, MD; Chief Editor: Michael Stuart Bronze, MD Share Email Print Feedback Close Sections Sections Cellulitis Overview Practice Essentials The term cellulitis is commonly used to indicate a nonnecrotizing inflammation of the skin and subcutaneous tissues, usually from acute infection (see the image below). Cellulitis usually follows a breach in the skin, although a portal of entry may not be obvious; the breach may involve microscopic skin changes or invasive qualities of certain

2014 eMedicine Emergency Medicine

833. Burns, Thermal (Diagnosis)

go completely through the eschar. The subcutaneous fat will appear to bubble up into the escharotomy wound. Bleeding is minimal and is easily controlled by pressure. Upon completion of the escharotomy, a dressing with antibiotics is placed on the wound, and the extremity is elevated to help maintain homeostasis. If the chest is involved and the eschar compromises ventilatory motion, perform an escharotomy involving the anterior chest. Incisions are made along the costal margin, along the anterior (...) be debrided (see the image below); the intact skin serves as a hermetic barrier, although the blister fluid can serve as an excellent medium for bacterial growth. Another argument for debridement is that removal of the blister roof allows topical agents to reach burn tissue. Blisters that are intact but are located in areas that have a high likelihood of rupture may be sharply debrided. The World Health Organization (WHO) recommends debridement of all bullae and excision of all adherent necrotic tissue

2014 eMedicine Emergency Medicine

834. White Blood Cell Function (Overview)

, differentiation, activation and apoptosis of the cells of the immune system. Some ILs, including IL2, also have antiviral and antitumoral functions. Interferons (-a, -b, -g) are involved in the regulation of immune responses and promote the activation and differentiation of the cells of the immune system. Interferons also possess antiviral and antitumoral properties. Tumor necrosis factor (TNF)-a and TNF-b have proinflammatory properties as well as antitumoral functions. Hematopoietic growth and survival (...) and severe immunopathologic conditions. Most parenchymal cells express IL-17 receptors; signaling through these receptors induces the target cells to produce proinflammatory factors, such as IL-6, IL-1, tumor necrosis (TNF), IL-8, and matrix metalloproteinases. [ ] Most cytotoxic T lymphocytes express CD8 and recognize endogenously derived antigens in the context of MHC class I molecules. They are critical in mediating allograft rejection, tumor surveillance, and destruction of intracellular pathogens

2014 eMedicine Pediatrics

835. Sickle Cell Anemia (Follow-up)

for the treatment of severe pain associated with a vasoocclusive crisis Use of analgesics and physical therapy for the treatment of avascular necrosis In July 2017, the US Food & Drug Administration (FDA) approved L-glutamine oral powder (Endari) for patients age 5 years and older to reduce severe complications of SCD. [ , ] L-glutamine increases the proportion of the reduced form of nicotinamide adenine dinucleotides in sickle cell erythrocytes; this probably reduces oxidative stress, which contributes (...) is an efficient iron chelator. It is administered as a prolonged infusion intravenously or subcutaneously for 5-7 days a week. Although effective, there are significant challenges associated with its use that can result in non-compliance. [ ] Deferiprone and deferasirox, oral iron chelators, are effective for iron overload treatment and have differences (eg, different pharmacokinetics and adverse effect profiles). Deferasirox has a capacity similar to deferoxamine in chelating iron, but it is administered

2014 eMedicine Pediatrics

836. Weber-Christian Disease (Diagnosis)

: A, ×20; B, ×200.) Histopathologic features of subcutaneous fat necrosis of the newborn. (A) Scanning power shows a mostly lobular panniculitis (arrow indicates area enlarged in B). (B) Higher magnification demonstrated narrow needle-shaped clefts radially arranged and surrounded by histiocytes. (A and B, hematoxylin-eosin stain; original magnifications: A, X 20; B, X 200). Histopathologic features of lipoatrophy secondary to subcutaneous injections of corticosteroids. (A) Low-power view showed small (...) Updated: Aug 28, 2018 Author: Eyal Muscal, MD, MS; Chief Editor: Lawrence K Jung, MD Share Email Print Feedback Close Sections Sections Weber-Christian Disease Overview Background Panniculitis refers to a broad spectrum of diseases that involve inflammation of the subcutaneous fat layer of the skin. Weber-Christian disease is an eponym for a form of panniculitis, idiopathic nodular panniculitis, which is characterized by subcutaneous nodules, inflammatory cells in the fat lobules, and systemic

2014 eMedicine Pediatrics

837. White Blood Cell Function (Follow-up)

, differentiation, activation and apoptosis of the cells of the immune system. Some ILs, including IL2, also have antiviral and antitumoral functions. Interferons (-a, -b, -g) are involved in the regulation of immune responses and promote the activation and differentiation of the cells of the immune system. Interferons also possess antiviral and antitumoral properties. Tumor necrosis factor (TNF)-a and TNF-b have proinflammatory properties as well as antitumoral functions. Hematopoietic growth and survival (...) and severe immunopathologic conditions. Most parenchymal cells express IL-17 receptors; signaling through these receptors induces the target cells to produce proinflammatory factors, such as IL-6, IL-1, tumor necrosis (TNF), IL-8, and matrix metalloproteinases. [ ] Most cytotoxic T lymphocytes express CD8 and recognize endogenously derived antigens in the context of MHC class I molecules. They are critical in mediating allograft rejection, tumor surveillance, and destruction of intracellular pathogens

2014 eMedicine Pediatrics

838. Xenotransplantation (Diagnosis)

endothelial cells (pECs) and promote intravascular coagulation. After contact with human/primate blood, clots quickly develop in pECs. The increased clot formation may be immunologically mediated, or may be the result of specific hormone regulators. Lee et al. recently examined this question. [ ] Incubation of pECs with human tumor necrosis factor alpha (TNF-α) or interleukin-1α (IL-1α) caused an increase in porcine tissue factor (TF) activity and mRNA; however, those changes were not seen when (...) alginate macroencapsulation devices. [ ] Adult pig islet cells were encapsulated in microcapsules implanted in the kidney or in a subcutaneous macrodevice in streptozocin-treated cynomolgus monkeys; in the latter group, diabetes was controlled for 6 months without immune suppression. This remarkable advance could pave the way for a variety of future human trials. The regulation of T-regulatory cells Still another approach involves inducing host immune tolerance and tissue accommodation; if the host

2014 eMedicine Pediatrics

839. White Blood Cell Function (Diagnosis)

, differentiation, activation and apoptosis of the cells of the immune system. Some ILs, including IL2, also have antiviral and antitumoral functions. Interferons (-a, -b, -g) are involved in the regulation of immune responses and promote the activation and differentiation of the cells of the immune system. Interferons also possess antiviral and antitumoral properties. Tumor necrosis factor (TNF)-a and TNF-b have proinflammatory properties as well as antitumoral functions. Hematopoietic growth and survival (...) and severe immunopathologic conditions. Most parenchymal cells express IL-17 receptors; signaling through these receptors induces the target cells to produce proinflammatory factors, such as IL-6, IL-1, tumor necrosis (TNF), IL-8, and matrix metalloproteinases. [ ] Most cytotoxic T lymphocytes express CD8 and recognize endogenously derived antigens in the context of MHC class I molecules. They are critical in mediating allograft rejection, tumor surveillance, and destruction of intracellular pathogens

2014 eMedicine Pediatrics

840. Weber-Christian Disease (Follow-up)

.) Histopathologic features of subcutaneous fat necrosis of the newborn. (A) Scanning power shows a mostly lobular panniculitis (arrow indicates area enlarged in B). (B) Higher magnification demonstrated narrow needle-shaped clefts radially arranged and surrounded by histiocytes. (A and B, hematoxylin-eosin stain; original magnifications: A, X 20; B, X 200). Histopathologic features of lipoatrophy secondary to subcutaneous injections of corticosteroids. (A) Low-power view showed small fat lobules (arrow (...) with minimal systemic complaints for several years before the disorder resolves. Patients with severe visceral inflammation of the heart, lungs, intestines, spleen, kidney, or adrenal glands may not survive. Previous Next: Patient Education Inform patients of the risks and adverse effects of various treatment options. Select different treatment modalities on an individual basis. Previous References Lazarus GS. Panniculitis and Disorders of the Subcutaneous Fat. . Weber EP. A case or relapsing

2014 eMedicine Pediatrics

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