Management of a Dehisced Hand Wound Using Hydrogen Peroxide, Electrical Stimulation, Silver-containing Dressings, and Compression: A Case Study.

Wound dehiscence is the separation of a wound along surgical sutures. A 57-year-old, otherwise healthy mechanic presented with a large open wound of >1 month duration on his left hand. His wound had dehisced after treatment that involved cleansing, surgical sutures, and oral antibiotics. He presented with a 5.0 cmx0.7 cmx0.3 cm lesion through the palmar creases of the hand with edema around the fourth and fifth digits and a callous formation around the distal portion of the wound. The wound had scant serosanguinous drainage and some induration at the periwound area, as well as a moderate foul odor. Tendons were not affected, but function was limited, the hand was painful, and the patient had been unable to work. Treatment was initiated with twice-a-week immersion of the hand in hydrogen peroxide diluted with water subjected to high-voltage pulsed current electric stimulation (HVPC). The wound was dressed with silver-containing dressings secured with stretch gauze and a compression garment. The wound was completely closed after 9 visits (35 days). No functional limitations of the hand or fingers, no cosmetic defect, and no wound recurrence were noted 9 months after healing. Although uncommon, dehisced wounds, especially in certain anatomical locations such as the hand, can be difficult to heal and may cause long-term problems with functioning. The treatment combination facilitated expedient healing of this dehisced hand wound. Research is needed to help elucidate the observations from this case study.

Hand surgery using local anesthesia.

Most hand traumas and elective surgical disorders of the hand can be treated quickly, easily, inexpensively, and effectively in an outpatient clinic. Although many surgeons prefer general anesthesia, the senior author routinely uses local anesthesia without sedation almost exclusively for carpal and cubital tunnel release, fasciectomy, arthrodesis, arthroplasty, synovectomy, and trauma, including the repair of tendons, nerves, ligaments, fractures, and soft tissue defects. After completing more than 10,000 procedures, the authors have found great benefits through the use of local anesthesia, which are detailed in the article.

Utilidad del sulfato cálcico e hidroxiapatita con antibióticos en las osteomielitis de la mano, a propósito de 2 casos clínicos / Use of calcium sulfate and hydroxyapatite with antibiotics in osteomyelitis of the hand: Two clinical cases

Las osteomielitis representan entre el 1-6% de las infecciones de la mano, cuya etiología fundamental es el Staphilococcus aureus. Presentamos 2 casos tratados eficazmente mediante legrado de la lesión y relleno con sulfato cálcico e hidroxiapatita (PerOssal®) impregnado con antibióticos, valorando el tipo de lesión, aspectos analíticos, y radiológicos. Nuestro objetivo es la revisión de esta patología, así como subrayar la utilidad de este nuevo biomaterial en la cirugía de la mano (AU)

Osteomyelitis accounts for 1-6% of all infections of the hand, the main causal agent being Staphylococcus aureus. We present two cases successfully treated with lesion curettage and filling with calcium sulfate and hydroxyapatite (PerOssal®) impregnated with antibiotics, evaluating the type of lesion, laboratory test parameters and radiological data. Our aim is to offer a review of this condition, and to underscore the usefulness of this new biomaterial in surgery of the hand (AU)

[Generalized tetanus complicating a traditional medicine applied for snakebite]. / Tétanos généralisé compliquant un traitement traditionnel instauré après une morsure de serpent.

In many of Africa's rural areas, snakebite victims often resort to traditional healers for first line treatment. This may be source of infectious complications. We report a case of generalized tetanus which occured after 15 days in a 13-years old boy who had applied a traditional, plant-based concoction on a snake bite. He presented with trismus, generalized contractures and fever extended musculo-aponevrotic necrosis of the right upper limb, without loss of consciousness. The only accompanying biological sign was an increased leukocyte count (11,200/mm3) with a predominance of neutrophils (84%). Platelets count, creatinin and AST/ALT titers and haemostasis were all normal, as was the radiogram of the right hand. The clinical outcome was favourable after 3 weeks hopital care (antibiotic, muscle relaxants, antitetanus serotherapy and local wounds care). This clinical observation shows that traditional care for snake bite wounds can be an entry point for tetanus. Appropriate treatment of snake bites in a hospital setting is of the utmost importance, in addition to vaccination against tetanus, in order to reduce the incidence of tetanus in African countries.

Management of metallic mercury injection in the hand.

This case report discusses a patient who injected 20 mL of metallic mercury subcutaneously in his left hand during an attempted suicide. The blood mercury level was 118 microg/L and the urinary mercury level was 43 microg/L, which confirmed the diagnosis of metallic mercury poisoning. A good result was obtained in this patient and the local and systemic toxicity and its management are discussed. A chelation therapy with dimercaprol and early surgical excision of injected material are recommended because this treatment effectively lowers mercury blood levels and controls the local inflammatory reaction. Intraoperative fluoroscopy is useful to confirm the extent of removal.

Diagnosis, characterisation and evaluation of treatment response of frostbite using pertechnetate scintigraphy: a prospective study.

No large prospective study is available on use of a radionuclide method to assess frostbite and its response to conservative treatment. Recently, a large retrospective study using two-phase bone scintigraphy suggested that non-uptake (or low uptake) in frostbite lesions in the blood pool or bone phase had a strong correlation with the subsequent need for amputation. In the present study, we performed early blood pool scintigraphy with technetium-99m pertechnetate in 20 patients (10-180 days after frostbite injury; 71 clinical lesions) referred for a topical treatment protocol for mild to moderately severe frostbite, and in 22 asymptomatic controls. The aims of the study were to define the "normal" microcirculation of the hands and feet, to characterise the appearances of frostbite lesions on scintigraphy and correlate these with the clinical presentation, and to evaluate the usefulness of scintigraphy for assessing the treatment response. Six patients were "fresh", 12 had been undergoing conservative treatment (topical homeopathic) for several weeks and two had permanent fibrotic hand phalanges. Nine patients on treatment underwent serial scintigraphy a total of 22 times. Eleven patients were imaged only once, including the two with permanent fixed defects. Three distinct physiological microcirculation patterns were evident in control hands or feet: right- or left-handedness (seven subjects), subclinical inflammatory foci correlating with callosity or pressure points (36 lesions) and distinctly increased pooling of radiotracer at the thenar or hypothenar region (eight subjects). In frostbite patients, 128 lesions (48 inflammatory, 80 ischaemic) were seen on the scan. This number included all 71 lesions identified clinically, the rest being subclinical. Subclinical frostbite lesion as an entity has not been described previously. Microvasculature of normal muscle groups (in the hands, elbow or feet) was shown on scintigraphy to improve after topical treatment. The treatment resulted in improved or normalised perfusion scan in 25 of 45 ischaemic segments with matching clinical improvement, and reduction or normalisation of uptake in inflammatory lesions (n=30). The data confirm the vasodilator and anti-inflammatory action of the topical preparation, and the sensitivity of the radionuclide method in monitoring treatment response. In contrast to the previous findings that non-uptake on a scan performed 2 or more weeks after exposure correlates with the need for amputation, none of the 80 ischaemic lesions in our series required amputation while 60% showed improvement or normalisation in microvascular blood flow even though they were 10-180 days old. Our findings suggest that moderate to severe frostbite lesion can be classified as having infarcted, ischaemic or hibernating (viable) tissue, similar to the classification employed when using myocardial scintigraphy. Absence of uptake even after the initial 10 days does not necessarily indicate infarction and the need for amputation as many such lesions retain potential for vasodilation and recovery.

[The Marjolin's ulcer": a malignant and rarely complication after burn trauma of the upper extremity - a case report]. / Das maligne "Marjolin Ulcus" als seltene Komplikation eines thermischen Traumas an der oberen Extremität. Fallbericht.

The,Marjolin's ulcer" is a malignant lesion which is developed especially at chronic wounds after burn trauma. The latency from primary trauma to the malignant transformation is about 30 years. The lesion is more aggressive than other squamous cell carcinomas. We report on the combined radiation and surgical therapy of an 65-year-old patient with this lesion on the right hand and regional lymph node metastases. The extensive tissue defect after wide excision was reconstructed with a reversal radial forearm flap.

[Microsurgery: indications and organization]. / Mikrochirurgie: Indikationen und Organisation.

Microsurgery is an important, but purely technical advancement. It would be a serious error for medicine and patient care to accept the concept of a "microsurgeon" rather than recognizing the necessity for surgical specialists working in many anatomical regions to learn microsurgery techniques as related to comprehensive care of their area. In hand surgery it is already clear that the duration of procedures and the exhaustion associated especially with reattachment surgery demands care by a team rather than by a single individual. Decision making and over all responsibility for performance of that team must, however, rest clearly with a primary surgeon. The institution of an emergency service for microsurgical cases represents a heavy burden to the infrastructure of a hospital. Therefore it seems reasonable to institute in each country an appropriate number of replantation centers to which the cases can be referred. The indications for reattachment surgery must be carefully evaluated and well balanced against traditional possibilities of treatment. The dramatic achievements of reattachment surgery and composite tissue transfers are illustrated by a few examples.

Jelly fish sting with serious hand complications.

The consequences of a jelly fish sting on the arm are described. The effects of the venom and inadequate early treatment resulted in vascular spasm in the forearm and necrosis of the digits. The toxicological properties of jelly fish venom are briefly described.