Radial nerve entrapment in the upper arm as a cause of lateral arm pain: a report of four cases.

Four patients with no history of trauma presented with lateral arm pain, local tenderness, and a tingling sensation at the distal end of the arm when the radial nerve was percussed in the mid-third of the upper arm (Tinel's sign), but no clinical or subjective signs of muscular weakness. They were treated by decompression of the radial nerve in the fibrous canal proximal to the lateral intermuscular septum. Three of the patients had a complete or pronounced reduction in pain, while the fourth had only a slight improvement. Non-traumatic radial nerve entrapment in the upper arm may be the cause of lateral arm pain without clinical signs of muscular weakness.

Is there a need for antithrombin III substitution early after burn injury?

The changes in antithrombin III (AT-III) levels in the blood and restitution in coagulation parameters between patients receiving and not receiving AT-III substitution were examined early after burn injury. The study was divided into two parts with a total of 14 consecutive patients (per cent total body surface area (TBSA) > or = 20 per cent). The first six patients were given AT-III substitution when AT-III levels fell below 50 per cent. The second part examined the restitution of the coagulation parameters when the patients (n = 8) obtained AT-III substitution only at extremely low values of AT-III. The decline in AT-III observed occurred in parallel to the permeability changes and the haemodilution normally seen secondarily to the initial fluid rescucitation. The observed changes in the coagulation parameters were modest and no hepatic dysfunction was noted. In addition, no differences of the restitution in these coagulation parameters were noted between the substituted and non-substituted groups. These results suggest that changes in AT-III early after burn injury depend mainly on factors other than an ongoing disseminated coagulation process. Probable causes are increased capillary leak and haemodilution. Our results suggest that substitution of AT-III in the early postburn period, on the assumption that low levels alone indicate ongoing coagulation, is not warranted.

Clinical experiences of the pedicled extensor digitorum brevis flap.

The extensor digitorum brevis muscle of the dorsum of the foot is well suited both anatomically and from the point of functional deficit to use as a pedicled muscle flap in the lower parts of the leg. We demonstrate the extensive anatomical reach of the flap and our results in a series of 16 patients who required reconstruction, in 15 of whom the flap survived successfully. Even the flap that failed partly achieved its goal in that its application induced enough granulations on the exposed anterior tibial tendon for a skin graft to take.

Extradural catheter-related infections in patients with infected cutaneous wounds.

We report three previously healthy individuals, aged 19-40 yr, with co-existing infected lower limb cutaneous wounds, who developed, in all probability, spinal space infections complicating continuous extradural analgesia. As the number of patients with extradural catheters and large cutaneous wounds represents a small fraction of the total number of patients with extradural catheters, three cases of presumed spinal space infection over a 4-yr period suggests that extradural analgesia with a catheter technique in this clinical situation is unsafe.

Psoralens used for cosmetic sun tanning: an unusual cause of extensive burn injury.

Psoralen combined with long-wave ultraviolt radiation (UV-A) has become a standard method of psoriasis treatment. A well-known and often appreciated 'side-effect' is the hyperpigmentation caused by this treatment. Three patients demonstrating a novel cause of severe skin loss, 'psoralen burn', are presented. No patient was afflicted by psoriasis and all three had used psoralen and ultraviolet exposure with the intent to enhance sun tanning. In the case histories presented, it is notable that two of the patients share an alarmingly extensive skin injury (90-95 per cent body surface area), while the third had an extensive but rather superficial injury. In addition, a very similar time-table for the development of the injury could be observed, with a maximum distribution of skin loss not reached until 7 or 8 days after exposure. Psorelen-UV-A can cause life-threatening skin losses when used in an erratic manner. Early recognition of the nature and knowledge of the time-course in the development of these lesions is necessary for optimal treatment. Some principles of treatment are discussed. Dermatologists prescribing PUVA treatment should further increase their warnings of uncontrolled use of psoralens in non-psoriatrics.

Endotoxemia and complement activation after severe burn injuries--effects on leukocytes, soluble selectins, and inflammatory cytokines.

In this study we followed the development of an inflammatory response in a group of patients the first week after a burn injury. We detected elevated plasma endotoxin levels, on at least one occasion, in 6 of 8 patients. No endotoxin was detected in the two patients with the lowest total burned surface area (< or = 30%). We found evidence of complement activation as increased C3a levels, in parallel with a production of inflammatory cytokines (TNF-alpha, IL-6). The TNF-alpha levels increased significantly during the observation period, while the IL-6 levels were elevated already at admission, and remained so. Elevated levels of soluble E-selectin were detected, indicating endothelial cell activation. Despite the inflammatory response and a loss of inflammatory cells during the first days of the monitoring period, we found no evidence of cellular activation measured as increased expression of beta 2 integrin CD11b, nor increased plasma levels of soluble L-selectin.

Magnetic resonance imaging: a new diagnostic aid in the care of high-voltage electrical burns.

Magnetic resonance imaging (MRI) can detect and delineate alterations in the hydration properties of tissues such as oedema and necrosis. The distinction between living tissue oedema and frank necrosis is also possible with MRI, by use of a spin-echo (SE) sequence and a fast spin-echo (FSE) sequence with a 1.5 T imager. With this background, the aim of this study was to examine the ability of MRI for early detection of concealed tissue injuries caused by high-voltage electrical burns, an entity not previously explored. Clinical use of MRI examinations in patients with high-voltage injuries admitted to the Burn Unit at Linköping University Hospital, has resulted in the significant elucidation of the deeper tissue injuries that occur. The T2-weighted images provided substantial information about the localization and amount of muscle necrosis, thus enabling increased surgical precision in the treatment of these high-voltage injury victims. FSE sequences produce T2-weighted images with increased speed of acquisition and/or increased image resolution compared to conventional SE sequence. Two illustrative examples are provided.

Transient endotoxemia during burn wound revision causes leukocyte beta 2 integrin up-regulation and cytokine release.

After severe burns, a wound revision is often done to remove devitalized tissue and minimize bacterial growth. After such revision, the patient may show signs of sepsis. In a group of burned patients we found a transient endotoxemia, and a subsequent leukocyte activation, monitored as increased expression of the beta 2-integrin CD11b, after such wound revision. In most patients we could detect elevated levels of plasma TNF-alpha before the operation, with no increases in these levels after the operation. Plasma levels of IL-6 were elevated in all patients and increased after the wound revision in all patients. They also had elevated plasma levels of soluble E-selectin, indicating systemic inflammation. The close relation between endotoxin levels and CD11b expression, and lack of evidence for additional production of TNF-alpha, suggests that up-regulation of the beta 2 adhesion protein during wound revision is mainly caused by endotoxin interaction with the leukocyte.

Team approach to tibial fracture. 37 consecutive type III cases reviewed after 2-10 years.

During a 10-year period, we managed 35 patients with 37 cases of Type III open tibial fractures, 15 cases within 1 week and 22 as late referrals. In all cases, simultaneous assessment and management by a microvascular and an orthopedic surgeon were mandatory throughout the treatment period. 6 of the 15 acute cases had a primary amputation. Of the remaining 31 cases, limb salvage was possible in 27. 31 flaps, pedicle and microvascular free flaps were used. Major complications occurred in 6 cases, but in 27 cases infection-free solid union was obtained. At long-term follow-up, average 5 years, the function was good or acceptable in 23 cases. We conclude that: (1) patients with Type III tibial injuries should preferably be transferred within a week after injury to a hospital where major reconstructive procedures are commonly performed, (2) early soft tissue coverage is essential in the management of these injuries, (3) unilateral external fixation should be the preferred technique of stabilization, and, finally, (4) plastic surgery expertise is important in management of severe tibial fractures.

Pain relief after free flap reconstruction in adriamycin necrosis on the dorsum of the hand. A case report.

A free flap transfer in a case of Adriamycin necrosis on the dorsum of the hand is reported. The advantages of this method of reconstruction are discussed.

Reconstruction of soft tissue defects including the Achilles tendon with free neurovascular tensor fascia lata flap and fascia lata. Case report.

The combined loss of the Achilles tendon and the overlying soft tissue in the young ambulant patient with expectations of a normal life is a challenge. These patients need not only skin coverage but also dynamic, functioning repair. Two cases of major defects after tumour resection are presented. In each case the tendon was reconstructed using the remaining gastrocnemius aponeurosis reinforced with fascia lata. This was covered by a free tensor fascia lata (TFL) flap. In one of the cases the flap was transferred as a neurovascular free flap.

Heterotopic microvascular growth plate transplantation of the proximal fibula: an experimental canine model.

The reconstructive potential of microvascular transplantation of skeletal growth plates was investigated through heterotopic transfers. The distal radius was resected in two series of puppies of a known large breed and substituted with a microsurgically revascularized transplant from the proximal fibula. Evaluation was conducted through serial roentgenograms, goniometric registration of joint mobility, volume measurements, histology, and fluorescent bone labeling. In the first series, development of neuropathic-like destruction of the weight-bearing graft ensued in the majority of the animals. In the second series, prolonged protection from weight bearing inhibited this destruction and resulted in hypertrophy of the revascularized epiphyseal end of the transplant but clearly reduced longitudinal growth, with only one transplant exhibiting longitudinal growth that exceeded 50 percent of the value for the control. This experiment demonstrates that skeletal growth plates possess a capacity for hypertrophy under the influence of increased loads. Whether this adaptability is sufficient to allow microvascular transplantation of growth plates to become a clinically useful procedure in children remains unclear. Further laboratory investigations are mandatory prior to clinical application of microvascular transfers of epiphyseal growth plates.