Background: Within the field of plastic surgery, clinical photography is an essential tool. ‘Smart phones’ are increasingly being used for photography in medical settings. Objective: To determine the prevalence of smart phone use for clinical photography among plastic surgeons and plastic surgery residents in Canada. Methods: In 2014, a survey was distributed to all members of the Canadian Society of Plastic Surgeons. The questions encompassed four main categories: smart phone use for clinical photos; storage of photos; consent process; and privacy issues. The survey participation rate was 27% (147 of 545) with 103 surgeons and 44 residents. In total, 89.1% (131 of 147) of respondents have taken photographs of patients using smart phones and 57% (74 of 130) store these photos on their phones. In addition, 73% (74 of 102) of respondents store these photos among personal photos. The majority of respondents (75% [106 of 142]) believe obtaining verbal consent before taking clinical photographs is sufficient to ensure privacy is respected. Written consent is not commonly obtained, but 83% (116 of 140) would obtain it, if it could be done more efficiently. Twenty-six percent (31 of 119) of respondents have accidentally shown a clinical photograph on their phone to friends or family. A smart phone application that incorporates a written consent process, and allows photos to be immediately stored externally, is perceived by 59% (83 of 140) to be a possible way to address these issues. Conclusion: Smart phones are commonly used to obtain clinical photographs in plastic surgery. There are issues around consent process, storage of photos and privacy that need to be addressed.

Objective: To examine treatment indications, efficacy and side effects of oral beta-blockers for the treatment of problematic hemangiomas. Methods: A retrospective review of patients with hemangiomas presenting to the Alberta Children's Hospital Vascular Birthmark Clinic (Calgary, Alberta) between 2009 and 2011 was conducted. The subset of patients treated with oral beta-blockers was further characterized, investigating indication for treatment, response to treatment, time to resolution of indication, duration of treatment, occurrence of rebound growth and side effects of therapy. Results: Between 2009 and 2011, 311 new patients with hemangiomas were seen, of whom 105 were treated with oral beta-blockers. Forty-five patients completed beta-blocker treatment while the remainder continue to receive therapy. Indications for treatment were either functional concerns (68.6%) or disfigurement (31.4%). Functional concerns included ulceration (29.5%), periocular location with potential for visual interference (28.6%), airway interference (4.8%), PHACES syndrome (3.8%), auditory interference (0.95%) and visceral location with congestive heart failure (0.95%). The median age at beta-blocker initiation was 3.3 months; median duration of therapy was 10.6 months; and median maximal treatment dose was 1.5 mg/kg/day for propranolol and 1.6 mg/kg/day for atenolol. Ninety-nine patients (94.3%) responded to therapy with size reduction, colour changes, softened texture and/or healing of ulceration. Rebound growth requiring an additional course of therapy was observed in 23 patients. Side effects from beta-blockers included cool extremities (26.7%), irritability (17.1%), lower gastrointestinal upset (14.3%), emesis (11.4%), hypotension (10.5%), poor feeding (7.6%), lethargy (4.8%), bronchospasm (0.95%) and rash (0.95%). Side effects did not result in complete discontinuation of beta-blocker treatment in any case; however, they prompted a switch to a different beta-blocker preparation in some cases. Resolution of the primary indication, requiring a median time of three months, occurred in 87 individuals (82.9%). Conclusions: Treatment of infantile hemangiomas with oral beta-blocker therapy is highly effective and well tolerated, with more than 94% of patients demonstrating a response to treatment and 90% showing resolution of the primary functional indication for treatment.

Background: Pediatric hand fractures are common and approximately 10% require surgery. Methods: This retrospective cohort study reports on hand fractures in a large pediatric population and identifies the characteristics and patterns of fractures that required surgical correction. A χ² analysis was done to evaluate the association between individual fracture variables and surgery. The STROBE checklist was applied. Results: One thousand one-hundred seventy-three hand fractures were reviewed. Peak age was 16 years for boys and 14 years for girls. Most fractures were closed (96.0%) and nonrotated (91.3%), and had no concomitant soft tissue injury (72.7%). More than half (56.3%) were nonepiphyseal plate fractures; yet as a single diagnosis, Salter–Harris II fractures were most common (30.2%). The following variables were significantly associated with surgery: open fractures, rotational deformity, distal phalangeal fracture location, multiple fractures, oblique pattern, comminution, displacement >2 mm, intra-articular involvement, and angulation >15°. Most fractures required only immobilization and early range of motion (64.3%). Closed reduction was required in 22.7%. Minor surgery by the primary provider was performed in 3.2% of fractures. Surgery by a hand surgeon was performed in 9.8%. The most common patterns requiring surgery were proximal or middle phalanx head or neck fractures (38.2%) and metacarpal midshaft fractures (20.9%). The most common operation was open reduction internal fixation (52.2%). Conclusions: Pediatric hand fractures are common, but 90.2% do not require surgery and, as such, primary providers play a key role in management. Certain fracture variables and patterns are more likely to lead to surgery.

To evaluate the development process and clinical impact of implementing a standardized perioperative clinical care pathway for cleft palate repair. Medical records of patients undergoing primary cleft palate repair prior to pathway implementation were retrospectively reviewed as a historical control group (N = 40). The historical cohort was compared to a prospectively collected group of patients who were treated according to the pathway (N = 40). Healthy, nonsyndromic infants undergoing primary cleft palate repair at a tertiary care pediatric hospital. A novel, standardized pathway was created through an iterative process, combining literature review with expert opinion and discussions with institutional stakeholders. The pathway integrated multimodal analgesia throughout the perioperative course and included intraoperative bilateral maxillary nerve blocks. Perioperative protocols for preoperative fasting, case timing, antiemetics, intravenous fluid management, and postoperative diet advancement were standardized. Primary outcomes include: (1) length of hospital stay, (2) cumulative opioid consumption, (3) oral intake postoperatively. Patients treated according to the pathway had shorter mean length of stay (31 vs 57 hours, P < .001), decreased cumulative morphine consumption (77 vs 727 μg/kg, P < .001), shorter time to initiate oral intake (9.3 vs 22 hours, P = .01), and greater volume of oral intake in first 24 hours postoperatively (379 vs 171 mL, P < .001). There were no differences in total anesthesia time, total surgical time, or complication rates between the control and treatment groups. Implementation of a standardized perioperative clinical care pathway for primary cleft palate repair is safe, feasible, and associated with reduced length of stay, reduced opioid consumption, and improved oral intake postoperatively.

Background: The Vascular Birthmark (VBM) Clinic at the Alberta Children's Hospital (Calgary, Alberta) is a multidisciplinary clinic dedicated to the evaluation of children with vascular anomalies. Objective: To review the characteristics of patients seen at the VBM Clinic. Method: A retrospective data analysis of all pediatric patients presenting to the VBM Clinic between 1998 and 2009 was performed. Data including demographic, referring, diagnostic and treatment information were obtained from the clinic's database. Results: Of 932 patients, 621 with hemangiomas and 311 patients with vascular malformations were found in the database. Hemangiomas were more commonly found in girls (68.5%), and most commonly located on the head and neck (54%), with most patients (72.6%) having only one lesion. Of the patients with hemangiomas, 14.7% underwent diagnostic imaging investigation and 23.7% received treatment including medications, surgery, pulsed-dye laser or dressings. The sex distribution among the 311 patients with vascular malformations was almost equal. Venous malformations accounted for 38.9% of patients, isolated capillary malformations for 31.5%, lymphatic malformations for 11.6%, mixed low-flow malformations for 14.8% and arteriovenous malformations for 2.9%. Overall, 37.9% of patients underwent diagnostic imaging investigation and 42.4% received treatment – either pulsed-dye laser, surgical excision, sclerotherapy or other treatment. Conclusions: Hemangiomas and vascular malformations can occur at any anatomical site. There is a large variation in clinical presentation necessitating expertise in a variety of diagnostic approaches and treatment modalities. Vascular anomalies are best managed in a multidisciplinary setting.