Ulnar nerve compression secondary to migration of pyrocarbon implant following right wrist arthroplasty.

A 50-year-old, right-hand dominant woman presented with a seven-month history of stiffness, pain and swelling on the ulnar side of her right wrist. She had undergone right wrist arthroplasty with a Pyrocarbon Amandys implant seven months previously for post-traumatic degenerative arthritis. She had an uneventful initial recovery until developing carpal tunnel syndrome, for which she underwent carpal tunnel release 5 months after her arthroplasty. Examination revealed a painful and limited range of movement in the affected wrist, with weakness of the first dorsal interosseous muscle and altered sensation in the ring finger. A hard swelling was visible and palpable on the palmar-ulnar aspect of the wrist. X-rays showed that the swelling was due to the dislocated Amandys implant (which was thought to be causing compression neuropathy of the ulnar nerve). The patient underwent removal of the pyrocarbon implant (through a palmar approach) and total wrist fusion one month later, following which the wrist successfully united and all symptoms of ulnar nerve compression resolved. Although some studies have reported migration of pyrocarbon implant following total wrist arthroplasty, to our knowledge, this is the first reported case of ulnar compression neuropathy from a migrated pyrocarbon wrist implant.

Infection Rates for Open Distal Phalangeal Fractures Treated with Kirschner Wire: A UK Regional Hand Centre Experience.

Background: Phalangeal fractures are common in hand injuries which: comprising of 23% of all hand and forearm fractures. The current consensus is that focus of treatment should be on prompt irrigation and debridement to reduce infection risk. These infections are significant as they can lead to serious sequelae including osteomyelitis. The aim of this study was to determine the incidence of infection amongst patients with open fracture of distal phalanx who had been treated with K-wire fixation and the timing of their operative management compared to the UK national guideline. Methods: We performed a retrospective case-note analysis of the patients treated for open distal phalangeal fractures at a regional hands centre over the period of 12 months, and compared with the national guidelines. Data collected included patient demographics, mechanism of injury, length of time taken from injury to first washout, length of time K-wire remains in situ, and infection rate. Results: Half of the patients (n = 19) met the guideline and were treated with washout within the first 24 hours. Infection rates in this group was 11%. This compared with 26% in those patients that did not receive washout within 24 hours. Conclusions: This study demonstrates the difficulty in always meeting national guidelines and suggests key reasons for this. The authors propose a set of local, easily-achieved interventions to raise awareness and compliance with the national guidelines and reduce infection. Furthermore, it highlights the importance of carefully selecting cases that required percutaneous K-wire fixation.

Small Finger Abduction Test to Evaluate the Flexor Carpi Ulnaris Tendon.

We describe a simple and effective method to assess the integrity of the flexor carpi ulnaris muscle and tendon. This method is called the Small Finger Abduction Test. The study also evaluates the efficacy and practicality of the test.Level of Evidence: Level II.

Outcomes of the glove-gauze regimen for managing burn injuries of the hand.

We studied the efficacy of the glove-gauze regimen in treating superficial, partial-thickness and small full-thickness hand burns. Outcome measures included healing time, need for surgical intervention, need for formal physical therapy, restoration of range of motion, return to function and incidence of infection. All patients (n = 123) successfully completed the regimen with an average healing time of 3.7 weeks. None required surgical debridement and seven (6%) required formal physical therapy. One hundred and eighteen patients (96%) regained full range of motion and 122 (99%) returned to their previous level of work. We believe that the glove-gauze regimen provides a simplified and effective means of managing hand burns. We conclude from our patients that the glove-gauze regimen is an effective treatment that can ensure uneventful healing of superficial, partial-thickness and small full-thickness burns. A majority of our patients healed with full range of motion and function without formal physical therapy.Level of evidence: IV.

Total laparoscopic repair of sigmoid foreign body perforation.

We describe the case of a 43-year-old male who presented with lower abdominal pain following rectal foreign body introduction and self-removal. Clinical examination revealed generalized peritonitis with pneumoperitoneum on Erect Chest X-ray. At laparoscopy a perforation in the sigmoid colon was found and successfully repaired. In view of contamination, the bowel proximal to the perforation was exteriorized as a loop colostomy without conversion to open laparotomy. The patient was discharged home four days later: He subsequently underwent successful reversal of his colostomy at four months. Herein we present to the best of our knowledge the first case in the literature of a successful total laparoscopic repair of sigmoid perforation resulting from transanal foreign body abuse.

Flexor carpi ulnaris herniation after cubital tunnel release: A case report.

Muscle herniation in the upper extremity is a rare but recognized phenomenon with a paucity of reports in the current literature. In the majority of cases, the herniation is secondary to trauma, with some of the cases due to muscle hypertrophy and increased intra-compartmental pressure from the forced exertion. Treatment for this condition ranges from nonsurgical, repair, or reconstruction to fasciotomy of the flexor carpi ulnaris fascia. Here, we present a case of flexor carpi ulnaris herniation after an open in situ cubital tunnel release in a 57-year-old male 6 years after initial surgery. The patient's symptoms did not improve with conservative management, and the patient subsequently underwent endoscopic fasciotomy with resolution of his symptoms and maintenance of his wrist and grip strength. The rationale for the treatment chosen is discussed.

A case of traumatic rupture of the distal oesophagus: the importance of early diagnosis.

We present a case of blunt traumatic rupture of the distal oesophagus successfully managed following early diagnosis and treatment. This is a rare cause of oesophageal perforation. We present the evidence that early diagnosis of ruptured oesophagus leads to reduced mortality and fewer complications. Our report reminds colleagues to consider this unusual and potentially fatal condition in cases of blunt chest trauma.

Antiseptic Efficacy of Povidone Iodine and Chlorhexidine Gluconate Skin Preparation Solutions Used in Burns Surgery.

The authors devised a comparative prospective study to determine the in vitro microbicidal efficacy of skin preparation solutions in the concentrations and temperatures used in the burns theatre against common bacterial and fungal microorganisms. A panel of 10 microorganisms Staphylococcus aureus, streptococcus pyogenes, enterococcus faecalis, escherichia coli, pseudomonas aeruginosa, candida albicans, bacillus cereus were assembled comprising 8 common strains of S. aureus (including methicillin resistant staphylococcus aureus (MRSA)), S. pyogenes, E. faecalis, E. coli, P. aeruginosa, C. albicans, B. cereus, and multi-drug resistant Klebsiella and Acinetobacter. These were cultured in the following formulations: 1) povidone iodine (PVP-iodine) 10% stored at room temperature (250C), 2) PVP-iodine stored at 40 to 420C, 3) chlorhexidine digluconate stored at room temperature diluted with warmed saline to concentrations of 4%, 2%, 1%, 0.8%, and 0.5%. All 3 formulations met DIN EN (Deutsches Institut für Normung) (European Standards) requirements for antiseptics. Both antiseptics showed the same high bactericidal and fungicidal efficacy (P = < 0.05). For chlorhexidine, all minimum inhibitory concentrations at both 24 and 48 hours were very low (< 0.5mg/L), but for PVP-iodine the minimum inhibitory concentrations were much higher and ranged from 64 to 512 mg/L. All concentrations of chlorhexidine tested were superior to PVP-iodine with no bacterial growth. There was a small amount of growth in some of the PVP-iodine treated groups, but this was not clinically significant.

In patients with post-sternotomy mediastinitis is vacuum-assisted closure superior to conventional therapy?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether vacuum-assisted closure therapy (VAC) is superior to conventional therapy for treating post-sternotomy mediastinitis. Altogether >261 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Several studies indicate that VAC therapy is associated with shorter lengths of intensive care and in-hospital stay as well as faster rates of wound healing and fewer dressing changes. It has also been shown that VAC therapy is correlated with a statistically significant reduction in reinfection rates, particularly those that occur in the early postoperative period (at the 1-week follow-up). Patients can be discharged with the dressing in situ and managed in the community with a view to delayed closure or reconstruction. However, the studies comparing VAC with conventional therapy are all retrospective in nature and reinforce the need for randomized controlled trials in order to more accurately establish differences in outcomes between VAC and conventional therapy. Additionally, owing tlo the variability of treatment protocols within the non-VAC arm, it is more challenging to draw definitive conclusions regarding the superiority of VAC therapy to every modality that is considered conventional treatment. We conclude that VAC therapy is a portable and an increasingly economical option for the treatment of post sternotomy mediastinitis. Although reductions in mortality rates were not reproduced in all studies, evidence suggests that VAC should still be considered as a first-line therapy for post-sternotomy mediastinitis and as a bridge therapy to musculocutaneous reconstruction or primary closure.