Envenomation by an opisthoglyphous snake, Erythrolamprus aesculapii (Dipsadidae), in southeastern Brazil

Abstract Snakebites by aglyphous or opisthoglyphous snakes are common in Brazil. We report a case of snakebite by the opisthoglyphous Erythrolamprus aesculapii. The victim presented with pain, edema, and bleeding at the bite site, along with erythema, similar to a Bothrops envenomation. In this type of snakebite, if the snake is not brought to the hospital, the victim may receive unnecessary serum therapy, with the risk of adverse reactions to the antivenom. The possibility of reducing after-effects with anti-inflammatory drugs and early antibiotic therapy for secondary infection need to be further investigated, preferably in multicenter studies, while observing good clinical practice.

Effects of lubricant and autologous bone marrow stromal cell augmentation on immobilized flexor tendon repairs.

The purpose of the study was to test a novel treatment that carbodiimide-derivatized-hyaluronic acid-lubricin (cd-HA-lubricin) combined cell-based therapy in an immobilized flexor tendon repair in a canine model. Seventy-eight flexor tendons from 39 dogs were transected. One tendon was treated with cd-HA-lubricin plus an interpositional graft of 8 × 10(5) BMSCs and GDF-5. The other tendon was repaired without treatment. After 21 day of immobilization, 19 dogs were sacrificed; the remaining 20 dogs underwent a 21-day rehabilitation protocol before euthanasia. The work of flexion, tendon gliding resistance, and adhesion score in treated tendons were significantly less than the untreated tendons (p < 0.05). The failure strength of the untreated tendons was higher than the treated tendons at 21 and 42 days (p < 0.05). However, there is no significant difference in stiffness between two groups at day 42. Histologic analysis of treated tendons showed a smooth surface and viable transplanted cells 42 days after the repair, whereas untreated tendons showed severe adhesion formation around the repair site. The combination of lubricant and cell treatment resulted in significantly improved digit function, reduced adhesion formation. This novel treatment can address the unmet needs of patients who are unable to commence an early mobilization protocol after flexor tendon repair.

[Hydrofluoric acid burns of the hands in the home environment: correct therapeutic approach]. / Le ustioni delle mani da acido fluoridrico in ambiente domestico: corretto approccio terapeutico.

The broad market penetration of products with components used primarily in the industrial sector requires the precise knowledge of their mechanism of action in order to perform a correct therapeutic approach. The article reports on three cases of domestic hydrofluoric acid burn that came to our Plastic Surgery Unit over the last three years. The treatment options are discussed in detail with emphasis on the importance of a constant update about such emerging diseases.

Hypothenar hammer syndrome from ice hockey stick-handling.

Ulnar artery thrombosis and hypothenar hammer syndrome are rare vascular complications that could potentially occur with repeated blows or trauma to the hand. Although initially reported as an occupational hazard among laborers and craftsmen, it has been observed more recently among recreationalists and athletes. Until now, it has never been reported as a complication in ice hockey players. In this case report, a 26-year-old Canadian professional ice hockey player presented with acute dominant right hand paleness, coolness, and pain with hand use. The patient used a wooden hockey stick with a large knob of tape at the end of the handle, which he regularly gripped in the palm of his right hand to help with face-offs and general stick-handling. Sonographic evaluation demonstrated no arterial flow in the distal right ulnar artery distribution, and ulnar artery occlusion with no aneurysmal degeneration was confirmed by magnetic resonance angiogram. Intraarterial thrombolytic therapy was initiated, and subsequent serial angiograms demonstrated significant improvement in distal ulnar artery flow as well as recanalization of right hand deep palmar arch and digital arteries. The patient's symptoms resolved, and he was maintained on therapeutic anticoagulation for 3 months prior to returning to playing ice hockey professionally, but with a padded glove and no tape knob at the handle tip. This case highlights a unique presentation of hockey stick-handling causing ulnar artery thrombosis that was likely from repeated palmar hypothenar trauma. Appropriate diagnostic imaging, early intraarterial thrombolysis, and postoperative surveillance and follow-up were crucial for the successful outcome in this patient.

Use of bone morphogenetic protein-2 (rh-BMP-2) in treatment of wrist and hand nonunion with comparison to historical control groups.

The purpose of this study is to report the percentage of patients achieving union, time to union, and complications with the use of bone morphogenetic protein-2 (rh-BMP-2) in surgical repair of established nonunion in the hand and wrist. Twenty-seven patients with nonunion of the hand and wrist were treated between 2005 and 2011 with surgical repair and augmentation using 4.2 mg of rh-BMP-2. Sites of nonunion included the phalanx (seven), carpus (nine), distal radius (five), and distal ulna (six). Radiographic union and complications were the primary and secondary outcomes, respectively. Eighty-nine percent (24/27) of patients achieved union within an average of 4.3 ± 2.8 months of surgery. There were no direct complications from administration of rh-BMP-2. Radiographic union was consistent with published rates for nonunion repair of scaphoid, phalanx, and distal radius fractures. Rh-BMP-2 did not produce superior rates of union in the patients with wrist and hand nonunion.

Aseptic tissue necrosis and chronic inflammation after irrigation of penetrating hand wounds using Octenisept®.

Penetrating hand wounds are common and these are managed by thorough debridement. However, stab wounds without evidence of divided structures are often treated with irrigation using antiseptic substances, antibiotic therapy, and immobilization. Octenisept® (Schülke & Mayr Ltd) is a widely used antiseptic agent for disinfection of acute or chronic wounds. It has a broad spectrum of antiseptic efficacy and has become an antiseptic of first choice in many hospitals. Within a few months, four patients presented to us with chronic inflammation and severe tissue necrosis after irrigation of penetrating hand wounds with Octenisept®. Repeated surgery and debridement was required in all patients. Wound healing was prolonged and patients had persisting oedema. Penetrating hand wounds must not be irrigated with Octenisept®.

[Severe side effects after Octenisept irrigation of penetrating wounds in children]. / Schwere Nebenwirkungen nach Octenisept-Spülung von Perforationswunden im Kindesalter.

BACKGROUND: Deep penetrating wounds in children's hands are repeatedly treated in emergency wards conservatively through irrigation, antibiotic therapy and splint immobilisation. After we had seen severest phlegmonous reactions after irrigation with Octenisept followed by long troublesome histories we would like to warn against using this antiseptic agent for irrigation of wounds. We give an overview about the significance of antiseptics and the use of antibiotics in the treatment of deeper contaminated wounds. PATIENTS AND METHODS: Between 2003 and 2007, 5 children (aged 2 to 8 years) were treated for sequelae of local wound irrigation with Octenisept in perforating hand injuries. We describe the early and medium-term aspects after irrigation, the further development, therapeutic measures, long-term damages and necessary reconstructions. We present the results of bacteriological smear tests, laboratory reports and histological examinations as well as allergy tests. RESULTS: All children showed more or less identical hand appearances. Hands were swollen caused by an interstitial oedema, compartment pressures were increased and hand function was completely suspended. The oedemas persisted for weeks and were hardly controllable. Especially serious were injuries at thenar level and in the first web space. Long-term sequelae were contractures caused by fibrotic muscle changes. Neither through bacteriological nor histological analysis were hints of bacterial or viral infections found. An allergic reaction to Octenisept could be excluded in the 3 most heavily affected children by an ROAT test. CONCLUSION: To prevent damage, contaminated wounds should be operatively debrided and not be irrigated with an antiseptic liquid. Octenisept seems to have a toxic effect in non-distinguished tissue. Because of a slow resorption it remains for a long time in the tissue. For therapy we recommend fasciotomy of the mid-hand and probably finger compartments, followed by compression treatment, physiotherapy with lymphatic drainage, dynamic and static splints.

Inusual caso de fusión carpo-metacarpiana de origen congénito / Unusual case of carpometacarpial fusion of congenital origin

Se presenta un paciente que acude al cuerpo de guardia de Ortopedia, por haber sufrió un trauma en la mano derecha cuando realizaba labores agrícolas. Se diagnóstico sinostosis total del carpo fusionada con el segundo y tercer metacarpianos, unilateral. El diagnóstico fue casual. Se realizó una revisión de la literatura científica sobre esta entidad y no se encontró caso similar

This paper presented a patient who went to the Emergency Orthopedic Service for a trauma in his right hand that occurred while he was working in farming. The diagnosis was total unilateral synostosis of the carpus fused with the second and third metacarpals. The diagnosis was made by chance. A scientific literature review was made but no other similar case was found

Un patient allant au Service des urgences en orthopédie dû à un traumatisme de la main droite est présenté. Une synostose totale du carpe par soudure unilatérale du deuxième et le troisième métacarpien est diagnostiqué. Le diagnostic est fortuit. Une revue bibliographique sur cette entité a été faite, mais on n'a pas trouvé un cas pareil

Non-infective subcutaneous emphysema of the hand secondary to a minor webspace injury.

Subcutaneous emphysema in the hand is commonly associated with infection or high-pressure injection injuries, with other non-infectious causes being reported as rarities in the literature. We describe an unusual case of minor injury to the first webspace resulting in significant subcutaneous emphysema.

Effectiveness of therapy with iloprost in hand-arm vibration syndrome.

AIM: To evaluate the efficacy and tolerance of therapy with iloprost in hand-arm vibration syndrome. METHODS: We describe a clinical case of a male aged 53 years, who was a heavy smoker for 30 years and a mason working with vibrating tools since 1962. He presented with a history of 10 years of attacks of vasospasm, functional impairment and digital ulceration. He was diagnosed as having hand-arm vibration syndrome vascular stage 4 on the Stockholm Workshop 1986 Scale. Besides suspension from work and abstention from smoking, we began intravenous infusion of iloprost for 6 h in cycles of 3-6 consecutive days, arriving at a dose of 1.5-2.0 ng/kg/min. RESULTS: After eight cycles, he reported significant symptomatic and functional improvement. Iloprost was seen to be efficacious: the trophic skin lesions disappeared and his microcirculatory perfusion tests improved. There were no significant side effects. CONCLUSIONS: We suggest that the use of iloprost in the treatment of the most advanced stages of vascular hand-arm vibration syndrome warrants further study

[Atypical HHS-syndrome--a rare differential diagnosis of circulatory disorders of the hand]. / Das atypische Hypothenar-Hammer-Syndrom--eine seltene Differenzialdiagnose der akralen Durchblutungsstörung der Hand.

We report on an acral circulatory disorder of the hand, representing a Hypothenar-Hammer-Syndrome (HHS) with atypical symptoms. The patient suffered from a radial circulatory disorder of his right hand, clinically representing a secondary M. Raynaud. The symptoms occurred after a single severe trauma of the right hand and after using both hands like a hammer. Angiography showed a cork-screw sign of the A. ulnaris at the typical area and an open Arcus palmaris superficialis as well as occlusions of multiple finger arteries. Symptoms improved significantly after lysis. The most important differential diagnosis is endangiitis obliterans according to angiography. If symptoms occur again, histology is recommended to exclude vasculitis. Surgery should be discussed if the HHS is confirmed, since a cork-screw morphology of the A. ulnaris exists as well as perfusion of the fingers mainly via the A. ulnaris. Also a radial circulatory disorder of the hand combined with typical anamnesis may represent a HHS.

Bullous pemphigoid induced by cephalexin.

Two young men developed severe bullous eruptions with a distinctive clinical picture of severe flexural involvement and extensive mucosal ulceration. Biopsies showed subepidermal bullae and associated inflammation consisted of predominantly neutrophils. Both had IgG and C3 staining of the dermal-epidermal junction on direct immunofluorescence. Bullous pemphigoid was diagnosed on the basis of clinical, histopathological and immunofluorescence findings. Both cases occurred after recent ingestion of cephalexin. We believe they represent the first reported cases of bullous pemphigoid induced by cephalexin.

Two case reports of vinorelbine extravasation: management and review of the literature.

Vinorelbine tartrate (Navelbine, Burroughs Wellcome Company, Research Triangle Park, NC, USA) is a semisynthetic vinca alkaloid approved in many countries for the first-line treatment of patients with advanced non-small-cell lung cancer. It is also used in the treatment of advanced breast and ovarian cancers and lymphoma. Like other vinca alkaloids, Navelbine can cause skin necrosis as a consequence of inadvertent extravasation in surrounding tissues during intravenous administration. In such cases, early treatment is strongly advocated. There is no documented case of vinorelbine extravasation in the literature. The authors herein report two cases successfully treated with hyaluronidase injections plus saline flushout under local anesthesia.

Community acquired methicillin-resistant Staphylococcus aureus hand infections: case reports and clinical implications.

We report a series of 4 cases of community acquired methicillin-resistant Staphylococcus aureus hand infections in patients without risk factors. Methicillin-resistant S aureus infections commonly involve the skin and soft tissue; therefore, hand infections may become more common as the prevalence of this pathogen increases. Hand surgeons must be aware of this emerging pathogen and obtain appropriate tissue cultures to diagnose and effectively treat this infection.

Expanded profile of the SHAFT syndrome.

The SHAFT syndrome is a factitious disorder in which a patient manipulates the surgeon to perform operations to fulfill his or her psychological needs. The acronym describes patients who are sad, hostile, anxious, frustrating, and tenacious. A chart review from January 1990 to June 1996 was undertaken to provide a profile to aid in the recognition and diagnosis of the SHAFT syndrome. An analysis of 28 patients revealed characteristics supporting a definitive SHAFT profile. Patients with SHAFT syndrome seek physicians to perform invasive procedures. Their typical complaint is pain, usually without objective physical findings that would support a more definitive diagnosis. Such patients tend to be women, cry with pain, describe symptoms out of proportion to objective findings, and have a history of psychiatric care.