Hypothenar hammer syndrome: an uncommon and correctable cause of digital ischemia.

Hypothenar hammer syndrome (HHS) is the rare entity of finger ischemia secondary to embolic occlusion of the digital arteries as a result of repetitive trauma to the palmar ulnar artery. We report the case of a young man found to have digital embolic complications from an ulnar artery aneurysm. This is thought to have developed as a result of palmar trauma experienced during military rifle drill exercises.

The impact of pre-existing end-stage renal disease on survival in acutely injured trauma patients.

End-stage renal disease and associated dialysis procedures alter homeostatic mechanisms and adversely affect the respiratory, cardiac, and central nervous systems. Currently outcomes research in acutely injured trauma patients utilizes Trauma and Injury Severity Score methodology with the Injury Severity Score and Revised Trauma Score, which do not account for comorbidities. Literature has yet to emerge that analyzes the effects of end-stage renal disease on acutely injured trauma patients. A retrospective review at an urban Level I trauma center was performed of all end-stage renal disease patients' medical records who were admitted for acute traumatic injury from 1994 through 1997. The charts were abstracted for age, sex, race, method of dialysis, specific injury, need for operation, etiology of trauma, length of stay, disposition from hospital, morbidity, and mortality. The Injury Severity Score; probability of survival; and W, M, and Z statistics were then calculated. The data collected were then compared with the overall data for the trauma center including patients with and those without end-stage renal disease during this time period. Mortality for patients with end-stage renal disease after suffering an acute traumatic injury is 2.45 that of the general population. Increased mortality was most prevalent in operative patients and those with Injury Severity Score >15. The average length of stay in the hospital was 55.3 per cent longer for patients with end-stage renal disease. Pre-existing end-stage renal disease negatively impacts survival after traumatic injury. A prospective multicentered study comparing renal patients with nonrenal patients is warranted. This would confirm the need for databases to account for the increased morbidity and mortality associated with end-stage renal disease when calculating probability of survival values for acutely injured trauma patients. Similarly future studies analyzing the affects of other comorbidities such as diabetes, chronic obstructive pulmonary disease, and hypertension on acutely injured trauma patients would help develop a more accurate method of predicting outcomes.

Drug-induced methemoglobinemia during thoracoscopic lung biopsy.

Acquired methemoglobinemia occurs rarely in clinical practice. We present a case of a 57-year-old man who developed severe drug-induced methemoglobinemia after exposure to benzocaine spray and lidocaine jelly during intubation for an elective thoracoscopic lung biopsy. Information regarding the classifications, pathophysiology, diagnosis, and treatment of this entity is reviewed.

Physical examination plus chest radiography in penetrating periclavicular trauma: the appropriate trigger for angiography.

BACKGROUND: To determine the role of physical examination, chest radiography, and angiography in the management of periclavicular penetrating trauma. METHODS: A retrospective review of the last 100 patients who suffered periclavicular penetrating trauma was performed. Patients with hard signs of vascular injury went either directly to the operating room or first to the angiography suite depending on their hemodynamic stability. All others underwent angiography and subsequent intervention if needed. The results were examined to determine the role of arteriography in the absence of hard signs of vascular injury. RESULTS: Of the 100 patients in the study, there were 81 without hard signs of vascular injury. All underwent angiography, with 11 "occult" injuries discovered. Each of these patients exhibited some physical examination or chest radiographic finding that may have predicted the presence of vascular injury. Using clinical criteria, physical examination was found to have a sensitivity of 82%, a specificity of 91%, a positive predictive value of 60%, and a negative predictive value of 96%. When coupled with the chest radiographic findings, these numbers were 100%, 80%, 44%, and 100%, respectively. Using these criteria would have eliminated the need for angiography in 56 (69%) patients and would not have missed any injuries. CONCLUSIONS: In patients with periclavicular penetrating trauma, a normal physical examination and chest radiographic excludes vascular injury. Proximity alone does not warrant angiography, although the test may be useful for therapeutic interventions or to plan operative approaches. A prospective study is essential to validate these findings.