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Purpose: Carpal tunnel syndrome (CTS) is commonly encountered in clinical practice. Diagnostic tools that currently exist include painful provocative maneuvers, invasive nerve conduction studies and the use of tests that require physician's direct participation in an era of sanitary crisis and virtual consultations. Therefore, having an easily accessible, reliable and practical tool for diagnosing CTS would be highly beneficial. Herein, we investigated the diagnostic value of the "pronation compensation sign" that we described for diagnosing CTS. Patients and Methods: We included 18 hands with and 18 hands without CTS (age: CTS hands = 52.5 ± 13.8 years, non-CTS hands = 43.2 ± 12.3 years; sex ratio: CTS hands = 12:8, non-CTS hands = 9:9). The presence of the "pronation compensation sign" was evaluated in each included hand. The presence of the "pronation compensation sign" were compared between CTS and non-CTS hands using the chi-squared test. Statistical significance was set at p < 0.05. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated of the "pronation compensation sign" for CTS. Results: All 18 hands with CTS showed a positive "pronation compensation sign", while those without CTS were negative. All 18 hands that were positive for the "pronation compensation sign" were hands with CTS, while those that were negative were hands without CTS. The sensitivity and specificity of the "pronation compensation sign" for diagnosing CTS were both 100%. The PPV and NPV of the "pronation compensation sign" for CTS were both 1.000. The rates of the presence of the "pronation compensation sign" were significantly different between hands with and without CTS (p < 0.001). Conclusion: The "pronation compensation sign" seems a useful tool for diagnosing CTS. We believe that the "pronation compensation sign" will help clinicians diagnose CTS with high diagnostic accuracy.
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BACKGROUND: Trigger finger is one of the most frequent causes of hand pain and disability. Recently, an endoscopic trigger finger release technique was developed, but outcomes have rarely been reported. Here, we present the outcomes of 2154 endoscopic trigger finger release procedures in a single center. METHODS: In this retrospective study, 2154 endoscopic trigger finger release procedures were performed on 2034 patients. Outcome assessment at 90 days after surgery was classified as excellent, good, fair or poor according to a combination of patient satisfaction with the scar and pain at rest or under load on a numeric rating scale. RESULTS: The therapeutic outcomes were: 1027 excellent, 607 good, 400 fair, and none poor. No major surgical complications were observed. Minor complications occurred in 231 fingers (10.7%). CONCLUSIONS: All patients were satisfied with their outcome after endoscopic trigger finger release. Endoscopic release can be an effective and efficient therapeutic method for the treatment of trigger finger.
Subject(s)
Endoscopy , Patient Satisfaction , Trigger Finger Disorder , Humans , Trigger Finger Disorder/surgery , Retrospective Studies , Male , Female , Middle Aged , Adult , Aged , Aged, 80 and over , Young AdultABSTRACT
OBJECTIVE: Many clinicians are unfamiliar with a diagnosis of lacertus syndrome (LS). We investigated the value of the lacertus notch sign in diagnosing LS. METHODS: We included 56 consecutive patients (112 upper extremities) who had neuropathic pain and neurological symptoms of the hand. The presence of LS and the lacertus notch sign in each upper extremity was assessed. RESULTS: Of the 83 upper extremities with LS, 54 (65.1%) had a lacertus notch sign, whereas 29 (34.9%) did not. Of the 29 upper extremities without LS, 9 (31.0%) and 20 (69.0%) had and did not have a lacertus notch sign, respectively. The rates of lacertus notch presence in upper extremities with and without LS were significantly different. Of the 63 upper extremities with a lacertus notch sign, 54 (85.7%) were diagnosed with LS, whereas 9 (14.3%) were not. Of the 49 upper extremities without a lacertus notch sign, 20 (40.8%) were diagnosed with LS, and 29 (59.2%) were not. We observed significant differences in the rates of LS in upper extremities with and without lacertus notch. CONCLUSIONS: The presence of the lacertus notch sign is useful for diagnosing LS. When patients with neuropathic pain and neurological symptoms present with a lacertus notch sign, clinicians should consider the possibility of LS.
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The gold-standard for bone, ligament and joint surgery in the wrist is locoregional anesthesia in most countries. Wide-Awake Local Anesthesia No Tourniquet (WALANT) is commonly used for simple soft-tissue hand surgery procedures such as carpal tunnel or trigger finger release, and can now also be safely used in procedures such as proximal row carpectomy, scapholunate ligament repair or partial wrist fusion, to name but a few. This article describes the use of WALANT for complex surgery in the wrist. WALANT surgery offers many known benefits, such as enhanced patient safety and comfort, simplified perioperative process and avoidance of anesthesia-related risks, and also allows the surgeon to perform intraoperative testing of the repaired structures. Thus, the surgeon can tailor the rehabilitation program and shorten recovery time. We describe detailed guidelines for performing WALANT procedures safely and effectively, making it a favorable option for complex surgeries in the wrist.
Subject(s)
Anesthesia, Local , Carpal Tunnel Syndrome , Humans , Anesthesia, Local/methods , Wrist , Carpal Tunnel Syndrome/surgery , Wrist Joint/surgery , Ligaments, Articular/surgeryABSTRACT
Fasciectomy for Dupuytren disease is a common procedure traditionally performed with a tourniquet under general or regional anesthesia. Since the year 2001, the wide-awake local anesthesia no tourniquet (WALANT) approach has been applied successfully to Dupuytren surgery, with current excellent surgeon and patient satisfaction. However, using WALANT for Dupuytren surgery may be intimidating for hand surgeons who want to begin using this method. The purpose of this article is to offer a series of tips and tricks the authors have learned after having performed hundreds of WALANT fasciectomies, to make this technique easier for surgeons and a more pleasurable experience for patients.
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OBJECTIVE: We report a rare case of flexor tenosynovial fistula secondary to endoscopic release of the A1 pulley for treatment of trigger finger. CASE PRESENTATION: A 72-year-old woman underwent endoscopic release of the A1 pulleys of her left ring and right middle fingers. Nine days after surgery, the wound at the base of the proximal phalanx of the ring finger (distal portal) remained open and a clear liquid discharge was seen. The volume of discharge increased with active finger motion. However, there was no evidence of infection. The patient was diagnosed with tenosynovial fistula as a complication of endoscopic release of the A1 pulley. At day 30, the fistula and drainage persisted and the condition was managed by surgical excision of the fistula and primary closure. The wound then healed completely. CONCLUSION: Our report alerts hand surgeons to the potential development of flexor tenosynovial fistula as a very rare complication following endoscopic release of the A1 pulley for the treatment of trigger finger.
Subject(s)
Fistula , Trigger Finger Disorder , Humans , Female , Aged , Trigger Finger Disorder/etiology , Trigger Finger Disorder/surgery , Fingers , Endoscopy/adverse effects , Fistula/etiology , Fistula/surgeryABSTRACT
OBJECTIVE: Pilonidal sinus of the hand is an occupational hazard for barbers, cow milkers, sheep shearers and dog groomers. Here, we report on a dog groomer who had four pilonidal sinuses. CASE PRESENTATION: A 49-year-old woman working as a dog groomer complained of multiple non-erythematous and fluctuant nodules on both hands, associated with pain, which had been identified five years previously. On the skin of her right hand, three nodules were observed on the volar (diameter: 1.5â¯cm) and medial (diameter: 1.4â¯cm) sides of fifth metacarpophalangeal joint and the volar aspect of the distal phalanx of the small finger (diameter: 0.7â¯cm). On the left hand, a 2-cm diameter nodule was identified on the volar side of the fifth metacarpophalangeal joint region. The nodules were excised surgically. A 5-mm long hair was removed from one nodule. Histopathology confirmed pilonidal sinus, treated by excision. One month postoperatively, the wound had healed uneventfully. CONCLUSION: When nodules are found in dog groomers, clinicians should consider the possibility of pilonidal sinus disease.
Subject(s)
Pilonidal Sinus , Humans , Female , Cattle , Dogs , Animals , Sheep , Middle Aged , Pilonidal Sinus/surgery , Pilonidal Sinus/etiology , Pilonidal Sinus/pathology , Hand , Metacarpophalangeal JointABSTRACT
Little is known about tremors caused by peripheral nerve entrapment. We report two cases of tremors caused by peripheral nerve compressions. Two patients presented with intentional tremors combined with peripheral nerve compression symptoms on their affected hand. Based on the clinical findings and evaluations, the first patient was diagnosed with double-crush compression of the ulnar nerve at the cubital tunnel and Guyon canal, and the second patient was diagnosed with lacertus syndrome. The first patient underwent surgical release of the cubital tunnel and Guyon canal in two stages. The second patient underwent release of the lacertus fibrosus. At the 1-month follow-up after surgery, the tremors had completely resolved, and neurological symptoms improved. Peripheral nerve entrapment should be considered a potential cause of tremors in patients with tremors combined with symptoms of peripheral neuropathy. Surgical release can be curative.
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OBJECTIVE: The double crush syndrome describes a condition characterized by multifocal entrapment of a nerve. In the upper limb, the high prevalence of carpal tunnel syndrome makes it a common diagnosis of assumption in the setting of median neuropathy. More proximal compressions may tend to be overlooked, under-diagnosed and under-treated in the population. This study aims to map the prevalence of peripheral upper limb nerve compressions among patients undergoing peripheral nerve decompression. METHODS: A prospective case series was conducted on 183 patients undergoing peripheral nerve decompression in a private hand surgery clinic. Level(s) of nerve compression in the median, ulnar and radial nerves were determined by history and physical examination. The prevalence of each nerve compression syndrome or combination of syndromes was analyzed. RESULTS: A total of 320 upper limbs in 183 patients were analyzed. A double crush of the median nerve at the levels of the lacertus fibrosus and carpal tunnel was identified in 78% of upper limbs with median neuropathy, whereas isolated lacertus syndrome and carpal tunnel syndrome were present in only 5% and 17% of affected limbs respectively. Cubital tunnel syndrome affected 12.5% of upper limbs, and 80% of these had concomitant lacertus and carpal tunnel syndromes, compared to only 7.5% with isolated cubital tunnel syndrome. CONCLUSION: A high prevalence should prompt clinicians towards more routine assessment for double crush syndrome to avoid misdiagnosis, inadequate treatment, recurrence, and revision surgeries.
Subject(s)
Carpal Tunnel Syndrome , Crush Syndrome , Cubital Tunnel Syndrome , Median Neuropathy , Humans , Carpal Tunnel Syndrome/epidemiology , Carpal Tunnel Syndrome/surgery , Cubital Tunnel Syndrome/surgery , Prevalence , Crush Syndrome/epidemiology , Crush Syndrome/surgery , Crush Syndrome/complications , Median Nerve , WristABSTRACT
This article provides practical tips that surgeons can use to improve their patient experience with wide awake local anesthesia no tourniquet hand surgery. The difference between patient satisfaction and patient experience is explained. Delivering a superior patient experience leads to better outcomes for patients, less postoperative complications, and a better quality of life and practice for the surgeon. Practical tips are presented, broken down into the preoperative, operative, and postoperative phases. Surgeons who commit to improving their patient experience will enjoy superior outcomes, patient loyalty, more fulfillment, and a rejuvenated sense of purpose.
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BACKGROUND: There is level II evidence that volunteers prefer the single subcutaneous injection in the midline of the proximal phalanx with lidocaine and epinephrine (SIMPLE) finger block over the classic two dorsal injection block technique. The purpose of this study was to possibly further decrease the pain of digital block injection by examining the effect of the duration of injection on the pain felt by volunteers receiving the SIMPLE block at two different injection rates. METHODS: Forty healthy blinded volunteers were injected 2 mL of lidocaine 1 % and epinephrine 1/100,000 in the digital palmar crease of both long fingers, one at a time. Two different rates of injection were used: 8 and 60 s. Pain scores were measured using a visual analogue scale and the volunteers were asked which of injection techniques they preferred. RESULTS: The visual analogue scale results revealed less pain with the slow injection (p < 0.001). Thirty three out of 40 volunteers preferred the slow injection rate. No difference could be attributed to sex of participants or to the first hand injected. CONCLUSION: Blinded volunteers preferred digital blocks injected over 60 s to the more rapid 8 s. Decreasing the pain of injection only takes a minute of our valuable time for finger blocks.
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INTRODUCTION: Studies on dressings frequently measure wound healing to demonstrate performance. Knowledge of existing methodologies available for wound healing assessment, including their advantages and limitations, is paramount when evaluating the literature on dressings. METHODOLOGY: Medline and Cochrane databases were searched for wound healing assessment methodologies used in research or in clinical practice. RESULTS: Twenty-nine methodologies were identified and classified into 8 categories: scales (n = 4), one-dimensional measurements (n = 2), area measurements (n = 4), volume measurements (n = 6), 3-dimensional wound reproduction systems (n = 5), methodologies based on wound physical characteristics (n = 3), rates and surrogates end point calculated from variation in wound dimensions (n = 4), and time to wound healing (n = 1). The main problems encountered during wound healing assessment include the following: boundary definition, assessor's contact with the wound, irregular wound shape, and difficulty in evaluating early healing. CONCLUSION: At this time, an ideal methodology does not exist. Research in this area is lacking and should be the focus in wound healing evaluation.
Subject(s)
Research Design , Wound Healing , Bandages , Humans , Imaging, Three-Dimensional , Outcome Assessment, Health Care , Time Factors , Wound Healing/physiology , Wounds and Injuries/pathologyABSTRACT
BACKGROUND: The purpose of this study was to evaluate the correlation between plastic surgery education received through residency in Canadian programs and perceived preparedness for independent clinical practice among recently graduated plastic surgeons. METHODS: All practicing plastic surgeons having graduated from a Canadian program between 1996 and 2006 were surveyed. An itemized Web-based questionnaire was designed and distributed by e-mail with the assistance of all program directors. RESULTS: Eighty (52 percent) of the 155 recent graduates from Canadian plastic surgery programs with valid contact information responded to the survey. The majority of respondents were satisfied with most aspects of their training. Only 22 percent of respondents had done part of their training in a foreign center, but all of them agreed that it was beneficial to their training. Clinical research was encouraged in 92 percent of the respondents' programs, but dedicated time was only allocated in 29 percent of these. At the beginning of their practice, the majority of respondents felt comfortable or very comfortable in all subspecialties with the exception of pediatric plastic surgery and ancillary procedures. CONCLUSIONS: The authors' results describe the tendencies in type and duration of the training that Canadian graduates had over the last 10 years. The majority of respondents were satisfied with most aspects of their residency programs and felt comfortable practicing different subspecialties early in their careers. Expectations during residency and the resources made available to meet these expectations are also revealed. This study will help improve residency programs by identifying existing gaps in the preparedness of surgeons.
Subject(s)
Surgery, Plastic/education , Canada , Clinical Competence , Fellowships and Scholarships/statistics & numerical data , Female , Humans , Internship and Residency , Male , Surveys and QuestionnairesABSTRACT
Numerous complications have been reported following abdominoplasty. In this report, the case of a 48-year-old woman who developed an esophageal stricture, and subsequently Barrett's esophagus, secondary to increased intra-abdominal pressure following abdominoplasty is presented.
Subject(s)
Abdominal Wall/surgery , Esophageal Stenosis/etiology , Esophagus/pathology , Plastic Surgery Procedures/methods , Postoperative Complications , Barrett Esophagus/etiology , Female , Hernia, Hiatal/etiology , Humans , Metaplasia/pathology , Middle AgedSubject(s)
Herpes Zoster/diagnosis , Median Nerve/virology , Aged , Electromyography , Female , Hand Strength , Herpes Zoster/drug therapy , Humans , Pain MeasurementSubject(s)
Fractures, Bone/diagnostic imaging , Joint Dislocations/diagnostic imaging , Scaphoid Bone/diagnostic imaging , Scaphoid Bone/injuries , Trapezoid Bone/diagnostic imaging , Trapezoid Bone/injuries , Wrist Injuries/diagnostic imaging , Diagnostic Errors , Fractures, Bone/surgery , Humans , Joint Dislocations/surgery , Male , Middle Aged , Scaphoid Bone/surgery , Tomography, X-Ray Computed , Trapezoid Bone/surgery , Wrist Injuries/surgeryABSTRACT
OBJECTIVES: The use of antimicrobial prophylaxis against surgical site infection (SSI) is widespread in plastic surgery, while results from prospective randomised controlled trials in guiding antibiotic use are lacking. The purpose of this study was to identify the incidence and risk factors for SSI in plastic surgery, and to evaluate the appropriateness of prophylactic antibiotic prescribing habits in a tertiary university centre. METHODS: A retrospective chart review was conducted over a 6-month period. Co-morbidities, types of procedure, prophylactic antimicrobial administration, SSI rates, and clinical outcomes were evaluated. RESULTS: The incidence of SSI was 9.3% for 335 procedures. The cumulative incidence of SSI for breast surgery (n=80) was 16.3%, with a 78.8% prescription rate. For head and neck procedures (n=68), the incidence of SSI was 10.3%, with 80.9% of patients receiving antibiotic prophylaxis. For hand and upper limb procedures (n=170), 70.6% of patients received antimicrobial prophylaxis, with a 4.7% SSI incidence. According to category A prophylaxis guidelines published in the plastic surgery literature, over prescribing was identified in 27.5% of breast, 61.8% of head and neck, and 19.4% of hand and upper limb procedures. CONCLUSIONS: This is the first study evaluating appropriateness of antimicrobial prophylaxis use by plastic surgeons. Despite widespread use of prophylactic antibiotics, significant SSI rates were still present and frequently responsible for re-hospitalisations and re-interventions. The appropriateness of administration and indications for perioperative prophylactic antibiotic use must be evaluated.
Subject(s)
Antibiotic Prophylaxis , Plastic Surgery Procedures , Surgical Wound Infection/prevention & control , Adolescent , Adult , Aged , Aged, 80 and over , Female , Head and Neck Neoplasms/surgery , Humans , Male , Mammaplasty , Middle Aged , Patient Readmission , Postoperative Complications , Practice Patterns, Physicians' , Reoperation , Retrospective Studies , Risk Factors , Upper Extremity/surgeryABSTRACT
BACKGROUND: Flap failure is a major complication in reconstructive plastic surgery. One of the most frequent etiologies of flap failure is venous thrombosis. However, infrequent causes also need to be explored, especially when faced with recurrent thrombosis. Heparin is frequently used in the prevention of venous thrombosis; however, the use of the medication itself may cause a serious thromboembolic state via an immune-related pathophysiological process. This adverse reaction to heparin may be life threatening. CASE PRESENTATION: We present two cases, one pedicled and one free flap, with venous congestion concomitant to heparin-induced thrombocytopenia syndrome, in conjunction with severe life-threatening sequelae. CONCLUSIONS: Heparin-induced thrombocytopenia syndrome can be the cause of postoperative venous congestion. It is necessary to be alert for this syndrome in the presence of recurrent unexplained venous thrombosis or thrombocytopenia in patients receiving anticoagulation therapy.
Subject(s)
Anticoagulants/adverse effects , Graft Rejection/chemically induced , Heparin/adverse effects , Surgical Flaps/pathology , Thrombocytopenia/chemically induced , Aged , Carcinoma, Squamous Cell/surgery , Female , Humans , Male , Mammaplasty/methods , Middle Aged , Mouth Neoplasms/surgery , Postoperative Care/adverse effects , Surgical Flaps/blood supply , Venous Thrombosis/chemically inducedABSTRACT
PURPOSE: Infection rates following median sternotomy vary between 0.2% and 10%. These cases are associated with morbidity and mortality rates between 10% and 25% and 5% and 20%, respectively. The purpose of this study was to evaluate patient outcomes following plastic surgery correction of sternotomy dehiscence (SD). METHODS: All patients operated on for an SD following coronary artery bypass graft surgery (CABG), between 1995 and 2005, with 1 or more flaps, were included. RESULTS: Eighty cases were identified over a 10-year period. The mean age was 64 (+/-9.1) years. Two or more procedures were required in 17.5% of patients, and the mortality rate within 30 days was 12.5%. Significant variability was revealed between the cumulative mortality rates of plastic surgeons, from 0.0% to 50.0%. Multiple associations were identified for poor outcome, including chronic renal insufficiency and early mortality, and obesity with risk of reintervention. CONCLUSION: Although patients who undergo surgical correction of a deep sternal infection usually tolerate their intervention well, the mortality within 30 days remains high. This study has identified several factors explaining morbidity and mortality in this patient population.