Intravenous Foreign Body at the Hand: Case Report.

Intravenous foreign bodies following trauma to the hand are relatively uncommon with sparse reports of this condition being published in the literature. They have been reported to migrate as far as the thoracic cavity and the heart. In the following case report, we describe a case of an intravenous foreign body following hand trauma, and the treatment and potential complications are also discussed.

One-stage Distal Interphalangeal Joint Fusion With External Fixator for the Treatment of Septic Joint Arthritis.

Septic joint arthritis in the small joints of the hand can be caused by penetrating trauma, ruptured ganglion cysts, or open joint dislocations, among others. The use of external fixation for the treatment of this condition has been reported in the past as a means of temporary joint distraction, or for secondary fusion procedures. In the present article, the authors describe a surgical technique involving the use of a low-cost external fixator for the primary arthrodesis of infected distal interphalangeal joints of the hand. The external fixator is fabricated with simple materials, threaded Kirshner wires, bone cement, and an insulin syringe, which the authors have used to fuse the distal interphalangeal joint primarily when destroyed by septic arthritis.

Intramedullary Screws versus Kirschner Wires for Metacarpal Fixation, Functional, and Patient-Related Outcomes.

Purpose The purpose of our study is to compare the intramedullary fixation of metacarpal fractures with cannulated headless screws and antegrade Kirschner wires in terms of final total active motion, grip strength, patient-related outcomes, need for casting, and return to work times. Methods The authors performed a retrospective review of the hospital records. Thirty fractures were included in the study, 19 in the screw fixation group, and 11 in the Kirschner wire group. Grip strength, and total active motion, was measured at the latest follow-up for both the injured and contralateral hand. Pain was measured on the visual analog scale. Patients were requested to fill a Quick disabilities of the arm and hand score (DASH) questionnaire at the latest follow-up. Satisfaction was measured on a scale from 0 to 10. The time to return to work was quantified from the accident to the point when the patient was back to active duty. Postoperative casting time was also quantified. Results The authors did not find any differences between the two groups in total active motion, grip strength, pain, satisfaction, or Quick DASH scores. We did find a difference in the return to work and casting times; these appeared to be shorter in the screw group. Conclusion Due to the small number of cases, we have been unable to clearly conclude that there were any benefits in the application of one particular technique when compared with the other.

The Bilobed Racquet Flap or Extended Seagull Flap for Thumb Reconstruction: A Case Report.

The treatment of extensive soft tissue defects in the thumb with dorsal metacarpal artery flaps has been previously reported in the literature. Island flaps from the dorsum of the index and long fingers have been the subject of many reports and studies. However, when the defect involves the whole thumb, a 360° circumferential defect, standard first or second dorsal metacarpal artery flaps are usually insufficient. There are fewer reports on the use of bilobed flaps for this application and we have found no reports on the use of bilobed racquet flaps or extended seagull flaps as treatment for this condition. We report the salvage of a thumb degloving injury with use of a bilobed racquet flap.

Atypical fibroxanthoma developing on a pacemaker pocket mimicking a pyogenic granuloma.

Malignant tumors at the site of implantation of a pacemaker generator, although rare, have been reported in the literature. We present a case of an 89-year-old man with atypical fibroxanthoma in a pacemaker pocket. The device had been implanted for more than 4 years. An exophytic tumor had developed in this place and was clinically interpreted as a pyogenic granuloma. An excisional biopsy revealed the nature of the tumor. To our knowledge, the association of atypical fibroxanthoma arising from a pacemaker pocket has not been previously reported. A review of the literature has revealed four malignant soft tissue tumors previously reported at the pacemaker site. Routine examination in all patients with implanted pacemaker generators should be practiced at follow-up visits. This would allow an early diagnosis of a malignant associated neoplasm. Pathologists should become familiar with this type of devices and their potential neoplastic complications.

Late salvage of the ischemic finger after crush injury using flow-through flaps: case report.

The progressive evolution and late salvage of a posttraumatic digit with poor vascularization has not been discussed in the literature. We report the cases of 3 patients whose fingers were rescued at referral 5 to 16 days after the traumatic event by restoring the arterial inflow by means of flow-through free flaps. All 3 fingers were compromised vascularly with patchy necrosis and absence of Doppler signal distal to the injury. All were salvaged. In our experience, in the setting of a posttraumatic digit with poor vascularization, it is possible to reverse impending necrosis by late revascularization. Frank infection or mummification is considered an irreversible state and a contraindication to salvage.

Ischemic toe encountered during harvesting: report of 6 cases.

Local vessel disease causing lack of arterial inflow at the time of toe harvesting represents a surgical emergency. In a personal experience of 194 toe transfers to the hand, 6 cases (in 4 patients) were found to have diseased vessels at the first web to the point that acute ischemia of the toe occurred when the tourniquet was released at the lower limb. We report our experience in these 6 cases.

Super-thinned iliac flap for major defects on the elbow and wrist flexion creases.

Four free iliac flaps were used to treat or prevent flexion contracture at the elbow or wrist flexion crease. Flap size ranged from 13 x 6 cm to 18 x 8 cm. Two flaps were used for primary coverage, and the other 2 flaps were used to treat established flexion contractures. All flaps survived without vascular complications. Full range of motion was obtained at the elbow and 40 degrees of active extension was obtained at the wrist. The flap has a very thin dermis with minimal panniculus that can be thinned as required, making it ideal to cover flexion creases. Despite the fact that anatomic variations are common in the inguinal region, the flap can be expeditiously and safely elevated. If needed, pedicle length can be up to 8 to 10 cm. The donor site is comparable with that of a full-thickness skin graft harvested from the groin. The donor artery, however, can be very small.

A technique to improve foot appearance after trimmed toe or hallux harvesting.

We describe a technique to improve the appearance of the donor site after hallux harvesting. The surgery has been used in 6 consecutive patients having a trimmed-toe-type transfer. Instead of the classic stump closure advised by Wei, the following steps were performed on the donor site: (1) removal en bloc of the second metatarsal and transposition of the second toe on top of the proximal phalanx of the hallux, (2) interposition of a tibial (medial) glabrous flap from the tibial aspect of the hallux onto the tibial side of the second toe to increase its size, and (3) eponichial flap to increase the nail show on the second toe. Fixation of the toe was achieved with K-wires and cerclage wire. Crossed K-wires stabilized the first to the third metatarsals for 4 to 6 weeks. Ambulation with a stiff sole was allowed a few days after surgery. The main advantage of this technique is the improved donor site appearance. As a bonus, the amount of skin that can be harvested with the trimmed toe is slightly increased. The main drawback is that the number of toes is reduced to 4.

The tibial second toe vascularized neurocutaneous free flap for major digital nerve defects.

PURPOSE: Most digital nerve defects can be reconstructed by means of nonvascularized nerve grafts or artificial tubes, for example. When the bed is poor, the defect is long, or there is a concomitant soft-tissue loss; however, a vascularized nerve graft may be a better option. Our purpose is to introduce a method of 1-stage reconstruction of complex neurocutaneous defects in the fingers and to report the results and clinical effectiveness at a minimum 1-year follow-up period. METHODS: From 1997 to 2005 there were 6 consecutive patients who had a combined soft-tissue and digital nerve defect reconstructed by a vascularized neurocutaneous flap from the tibial (medial) side of the second toe. Three were acute and 3 were chronic cases. One flap was used for the ulnar side of the thumb, 2 for the radial aspect of the index finger, 1 for the radial of the small finger, and 2 for the ulnar side of the small finger. The nerve gap averaged 4.2 cm, and the flap size averaged 3.2 x 2.1 cm. The flaps were revascularized with standard microsurgical techniques to local vessels in the fingers. The nerves were sutured with epineural stitches. A split-thickness skin graft was used to close the donor site of the toe. RESULTS: All flaps survived without complications. At the latest follow-up evaluation static two-point discrimination (s2PD) averaged 8 mm on the pulp. Three patients had normal sensation when tested with Semmes-Weinstein filaments. Subjective feeling was 78% of that of the normal side. Five patients rated their feeling as excellent on a subjective scale. The Disabilities of the Arm, Shoulder, and Hand questionnaire score averaged 5. CONCLUSIONS: The tibial neurocutaneous second toe free flap is suitable for reconstructing a missing nerve and soft-tissue defect in the finger. We found good functional recovery and high satisfaction in this group of patients. The donor site morbidity has been minimal, although delayed healing is common. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Dry arthroscopy of the wrist: surgical technique.

PURPOSE: To present a method to perform arthroscopic exploration and instrumentation without infusing any fluid. METHODS: The hand is suspended from a bow, with traction on all fingers. Portals are developed as in the classic (wet) wrist arthroscopic procedure except that no water is infused to distend the joint and create the optic cavity. For this procedure the joint must be dried; we use suction through the synoviotomes and neurosurgical patties to accomplish this. RESULTS: We have performed more than 100 wrist arthroscopies using the dry technique without any undue difficulty. CONCLUSIONS: The dry technique is as effective as the classic procedure, without the cumbersome leakage of water or the risk of compartment syndrome. It allows some sophisticated arthroscopic procedures to be performed that would be impracticable with water. In addition from these benefits, if open surgery is performed after the arthroscopic exploration then the tissue planes are dry, making surgery much easier. The technique is believed to be inappropriate if thermal probes are used. A learning curve exists.