The effect of dobutamine treatment on salvage of digital replantation and revascularization.

PURPOSE: One of the most common causes of a failure after replantation and revascularization surgeries is 'no reflow' from proximal artery that occurs, especially following crush and avulsion injuries. In this study, we aimed to evaluate the effect of dobutamine treatment on salvage of replanted and revascularized digits. METHODS: The patients with no reflow phenomenon detected in the salvage operations of replanted/revascularized digits between the years 2017 and 2020 were included in the study. Dobutamine treatment was infused at a rate of 4 µg·kg-1·min-1 intraoperatively and of 2 µg·kg-1 min-1 postoperatively. Demographic data (age, sex), digit survival rate, ischemia time, and level of injury were retrospectively analysed. Pre-infusion, intraoperative and postoperative values of cardiac index (CI), mean arterial pressure (MAP), and heart rate (HR) were recorded. RESULTS: The phenomenon of 'no reflow' was encountered in 35 digits of 22 patients who underwent salvage surgery due to vascular compromise. The survival rate in the revascularization group was 75%, while it was 42.1% in the replanted digits. Metaphysis level of proximal phalanx was the most common localization for 'no reflow' phenomenon. The least values of CI, MAP and HR to obtain sufficient perfusion in salvaged digits were as follows: 4.2 l.min-1.m-2, 76 mm Hg, and 83 beat·min-1, respectively. CONCLUSIONS: It was demonstrated that dobutamine infusion at a rate of 4 µg·kg-1·min-1 intraoperatively and at 2 µg·kg-1·min-1 postoperatively has favorable effects on the vascular compromise derived from no reflow of proximal artery.

Tratamiento combinado de Espongostan® y Mepitel® en heridas con pérdida de sustancia y abundante sangrado / Combined treatment of Espongostan® and Mepitel® in wounds with loss of substance and abundant bleeding: a case series

Objetivo: Las heridas por pérdida de sustancia en las yemas de los dedos son dolorosas, incapacitantes y sangran abundantemente. El tratamiento recomendado es a base de Espongostan®, aunque este producto puede combinarse con Mepitel®. La combinación de ambos tratamientos podría reducir el dolor y minimizar el sangrado en curas sucesivas. El objetivo de este estudio es describir la aplicación del tratamiento combinado de Espongostan® y Mepitel®. Además, se describirá la evolución del dolor y el sangrado en estos pacientes. Descripción del caso: Se aplicó el tratamiento combinado a 6 pacientes con heridas de pérdida de sustancia en las yemas de los dedos. Resultados: La escala EVA se mantuvo en valores moderados o se redujo a leve en curas sucesivas. Los pacientes no describen signos de dolor destacables al retirar el Espongostan®. Por otro lado, el sangrado remitió antes de 8 días. La tasa promedio de remisión del sangrado se situó en 1 caso por 4 días. Conclusión: La cura combinada es altamente positiva para minimizar el dolor y el sangrado, reduciendo por consiguiente las molestias derivadas sobre los pacientes. (AU)

Objective: Loss of substance wounds on the pads of the fingers are painful, disabling, and have profuse bleeding. The recommended treatment is based on Espongostan®, although this product may be combined with Mepitel ®. The combination of both treatments could reduce pain and minimize bleeding in successive cures. The objective of this study is to describe the application of the combined treatment of Espongostan® and Mepitel®. In addition, the evolution of pain and bleeding in these patients will be described. Description of the case: We applied the combined treatment to 6 patients with loss of substance wounds on the pads of the fingers. Results: The VAS scale remained at moderate values or was reduced to mild in successive cures. Patients do not describe noticeable signs of pain when removing the Espongostan®. Bleeding subsided before 8 days. The average bleeding remission rate was 1 case per 4 days. Conclusion: The combined cure is highly positive for minimizing pain, bleeding and reducing discomfort caused to patients. (AU)

Úlceras cutáneas en paciente con dermatomiositis amiopática anti-MDA5 positivo / Cutaneous ulceration in a patient with amyophatic dermatomyositis anti-MDA5 antibody positive

No disponible

Multiple Beneficial Effects of High-dose BoNT-A Injection to Improve Wound Healing and Spasticity in a Patient With Hypoxic Encephalopathy Due to High-voltage Electrical Injury.

INTRODUCTION: High-voltage electrical injuries remain a difficult challenge for physicians. The survivors often have complicated wounds over the trunk or extremities, and some of them may develop hypoxic encephalopathy. The emergence of spasticity following hypoxic encephalopathy may further interfere with the healing of wounds. CASE REPORT: The authors report the case of a 17-year-old male with strong spasticity of finger flexors graded 4 by the Modified Ashworth Scale (0-5) after electric shock. He also had a nonhealing wound on the flexor side of the left index finger after 6 weeks of standard wound care. The wound measured 0.3 cm × 0.3 cm × 0.2 cm in size. The authors hypothesized that wound healing was negatively affected by spasticity and expected the wound might heal gradually after reducing the strong spasticity of the index finger. The authors employed electrical stimulator for guidance and injected high-dose (50 units/muscle) botulinum toxin type A into the flexor digitorum superficialis and the flexor digitorum profundus of his left index finger. At 7 days following administration, focal spasticity of these muscles in the left index finger decreased from 4 to 1 on the Modified Ashworth Scale. At 21 days post administration, the wound healed completely. CONCLUSIONS: For patients with hypoxic encephalopathy due to high-voltage electrical injury, botulinum toxin type A injection may be an option of therapeutic approach for both reduction of spasticity and facilitation of wound healing.

Botulinum Toxin A Salvage of Ischemic Hand Trauma.

Posttraumatic hand injuries from crush injury, infusion, or iatrogenic vascular cannulation can cause ischemic finger damage that can progress to necrosis and digital amputation. Botulinum toxin type A (Botox) improves blood flow in chronic vasospastic disorders of the hand. Botox's efficacy in salvaging ischemic loss in digits in acute traumatic and iatrogenic injury has not been previously reported. From February of 2015 to December of 2016, 11 patients at a Level I trauma center (West Virginia University) presented to the hand surgery service with early ischemic injury and vascular compromise to hand and fingers as a result of crush, direct drug injection, or proximal arterial injury from drug injection or catheterization. Before 2015, all patients with vascular compromise were treated with standard protocol. After January of 2016, patients were treated with additional injection of 80 to 100 U of Botox into the palm and wrist. Before administration of Botox, six patients with vascular compromise of one or more fingers were treated with a conservative protocol and 83 percent had amputation of necrotic digits. After January of 2016, five patients with ischemia were treated with Botox into the palm and proximal arteries. All Botox-treated digits were preserved (100 percent salvage). Pain scores were lower in Botox-treated fingers. We conclude that (1) in the acute traumatic vascular hand injury, early Botox injection markedly increases digital salvage; (2) direct nerve effects after Botox injections improve postinjury pain scores; and (3) early use of Botox in finger injuries is our standard approach to impending ischemia in the hand.

Efficacy of corticosteroid injection in rock climber's tenosynovitis.

While many finger conditions in climbers have been studied extensively, no data exist on the treatment of rock climber's finger flexor tenosynovitis. The purpose of this study was to evaluate the outcomes after corticosteroid injection. The study included rock climbing athletes suffering from chronic (longer than 6 weeks) finger flexor tenosynovitis who were seen at our clinic in 2017. All 42 patients received two corticosteroid injections within a 7-10 day period. Thirty-one climbers (73.8%) were pain free after the second injection and a mean of 20.9±23.1 days. The climbers reported an 84.2% decrease in pain level and no complications. The positive outcome after corticosteroid injection therapy and the absence of complications justifies this invasive approach in rock climbing athletes.

Anaphylaxis after treatment with recombinant factor VIII: investigation and therapeutic challenge.

We report a 10-year-old patient with haemophilia A developing anaphylaxis to recombinant factor VIII (octocog alfa). Allergic reactions, and especially anaphylactic events, are rare in patients with haemophilia A. The nature of these reactions is not fully understood. Here, we demonstrate a type I hypersensitivity reaction using sodium dodecyl sulfate-polyacrylamide gel electrophoresis immunoblotting assay. This test revealed itself as an essential diagnostic tool, as it allowed us to choose an alternative treatment (moroctocog alfa). Its safety was later confirmed by an uneventful challenge test.

[Cold and White - Hypothenar Hammer Syndrome]. / Kalt und weiss ­ Hypothenar-Hammer-Syndrom.

Cold and White - Hypothenar Hammer Syndrome Abstract. Hypothenar hammer syndrome (HHS) is a condition caused by digital ischemia as a result of repeated trauma to the little finger. Routine diagnosis should include a detailed medical history and a physical examination including Allen's test. Imaging of vascular lesions can be done initially by acral plethysmography and duplex sonography, or directly in the context of angiography (gold standard). Early diagnosis enables effective therapeutic strategies and preventing permanent sequelae. The optimal treatment options are selected depending on the intensity of symptoms, ranging from conservative methods, secondary prevention, through a local thrombolysis up to operational measures.

Pitch Ointment: Applications in Scar and Wound Management.

There is a high incidence of household knife-related injuries requiring emergency department treatment in the U.S. The Pitch Ointment, a named formula developed by a compounding pharmacist, was used separately by two patients who suffered a knife injury in a finger and a foot. This formula combines Pinene (L-Alpha) 0.5% and Canada Balsam 5% in PracaSil-Plus, special ingredients with applications in scar and wound healing. The patients' level of satisfaction with the Pitch Ointment was very high since all 4 treatment satisfaction domains by the Treatment Satisfaction Questionnaire for Medication (effectiveness, side effects, convenience, global satisfaction) were rated over 85. These results are consistent with the clinical improvements observed in the before and after treatment photographs. The success of these case reports is evidence to suggest that the Pitch Ointment may be recommended by compounding pharmacists as a viable treatment option in scar and wound management.

A Zone-II Flexor Tendon Injury Secondary to a Catfish Spine: A Case Report.

CASE: We present the case of a 17-year-old man who sustained a delayed rupture of a zone-II flexor tendon injury in the long finger from a catfish spine, which caused local envenomization and a likely secondary bacterial infection. He underwent surgical exploration and irrigation and debridement of the finger. The flexor digitorum profundus tendon was found to be lacerated and was primarily repaired. CONCLUSION: Catfish spines can cause traumatic disruption of anatomic structures and can envenomate the area of injury, which can lead to a secondary bacterial infection. We review the literature regarding catfish spine injuries and describe a basic treatment algorithm for patients who are injured by catfish spines.

Antithrombotic Therapies in Digit Replantation with Papaverine Administration: A Prospective, Observational Study.

BACKGROUND: The primary objective of this study was to investigate whether the application of antithrombotic therapies affects the success rate of digit replantation. METHODS: A total 477 digits of 319 patients who received dextran with low-molecular-weight heparin, dextran with prostaglandin E1, or no antithrombotic therapy after replantation of complete amputated digits from January 1, 2012, to January 1, 2016, were included in this study. Papaverine was given by intramuscular injection to all patients at a dosage of 90 mg/day postoperatively. RESULTS: There was no significant difference in any of the potential risk factors, including age, smoking, Tamai level of amputation, causes of injury, and warm ischemia time among groups. The survival rates of digits from patients who received dextran with low-molecular-weight heparin, dextran with prostaglandin E1, or no antithrombotic therapy were not significantly different. CONCLUSION: Antithrombotic therapies showed no significant benefit for digit replantation in patients receiving papaverine. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Cutaneous Tuberculosis Occurring After a Skin Cut in a Child.

BACKGROUND: Tuberculosis is a common problem in Turkey, and cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis. Herein, the authors describe a case of cutaneous tuberculosis (lupus vulgaris) occurring after contact with a sheep. CASE: A 15-year-old boy was admitted to Marmara University School of Medicine Pendik Training and Research Hospital (Istanbul, Turkey) with delayed wound healing on the left index finger and left axillary lymphadenopathy. His medical history was unremarkable except for a wound incurred when he slaughtered a sheep 3 months before. One month after this injury, the patient developed enlargement of the left axillary lymph node on the side of the wounded extremity, and the wound turned a dark black color. The biopsy specimens obtained from the wounded skin and lymph nodes showed granulomatous reaction, but acid-fast bacilli (AFB) could not be shown with Ehrlich-Ziehl Neelsen staining. The patient tested positive in an interferon-gamma release assay. Computerized tomography scans of the thorax were normal, and early morning gastric lavage specimen was negative for AFB. The wound and axillary lymphadenopathy disappeared after institution of anti-tuberculosis therapy. CONCLUSION: Tuberculosis infection must be considered in chronic skin lesions with granulomatous reaction occurring in countries with high prevalence of tuberculosis.

Traumatic Amputation of Finger From an Alligator Snapping Turtle Bite.

Legend states that the alligator snapping turtle (Macrochelys temminckii) should be handled with extreme caution as it has jaw strength powerful enough to bite a wooden broomstick in half. Tales of bite injuries from what is the largest freshwater turtle in North America exist anecdotally, yet there are few descriptions of medical encounters for such. The risk of infection from reptilian bites to the hand in an aquatic environment warrants thorough antibiotic treatment in conjunction with hand surgery consultation. We present the first case report of a near total amputation of an index finger in an adolescent boy who had been bitten by a wild "gator snapper."

Postoperative care in finger replantation: our case-load and review of the literature.

OBJECTIVE: Technical success of a finger replantation depends on several factors such as surgical procedure, type of injury, number of segments amputated, amputation level and individual patient factors. Among early complications that can occur in this type of surgery the onset of venous or arterial thrombosis is the most dreaded. Local irrigating solutions, oral and intravenous anticoagulants, thrombolytic agents, plasma expanders, vasodilating, and antiaggregant drugs are routinely used in patients undergoing microvascular procedures, but currently there is only a non-standardized practice based on anecdotal personal experience. MATERIALS AND METHODS: The aim of our study is to review selected literature relating to perioperative therapy in microsurgical digital replantation. We also report our case-load of 16 patients with finger avulsion describing our particular protocol for postoperative anticoagulation and restoration of fluid and electrolyte balance. RESULTS: Following our daily pharmacological protocol, the postoperative course of the replanted fingers was uneventful. The survival rate for finger replantations performed was 100% (n = 16) with no need for surgical revisions. CONCLUSIONS: The association Dextran-40/Heparin/fluids in the proposed standardized pro-weight pharmacological protocol is an optimal postoperative prophylactic/therapeutic plan to reduce the incidence of endovascular thrombosis after replantation, so ensuring high rate of success in microvascular surgery.

From a fish tank injury to hospital haemodialysis: the serious consequences of drug interactions.

We present the case of a 68-year-old man admitted to hospital with severe acute kidney injury secondary to statin-induced rhabdomyolysis. Five weeks previously, the patient started a course of clarithromycin for infection of a finger wound with Mycobacterium marinum. His current medications included simvastatin, which he continued along with clarithromycin. The severity of the acute kidney injury necessitated initial continuous venovenous haemofiltration followed by 12 haemodialysis sessions before a spontaneous improvement in renal function occurred. Statins are widely prescribed and we report this case to encourage increased vigilance in avoiding drug interactions known to increase the risk of statin-induced myopathy, including macrolide antibiotics, calcium channel antagonists and amiodarone. The authors would also like to highlight recent guidance on atorvastatin as the statin of choice in patients with chronic kidney disease, and of the need for dose adjustment in those with an estimated glomerular filtration rate less than 30 mLs/min/1.73 m².

PXL01 in sodium hyaluronate for improvement of hand recovery after flexor tendon repair surgery: randomized controlled trial.

BACKGROUND: Postoperative adhesions constitute a substantial clinical problem in hand surgery. Fexor tendon injury and repair result in adhesion formation around the tendon, which restricts the gliding function of the tendon, leading to decreased digit mobility and impaired hand recovery. This study evaluated the efficacy and safety of the peptide PXL01 in preventing adhesions, and correspondingly improving hand function, in flexor tendon repair surgery. METHODS: This prospective, randomised, double-blind trial included 138 patients admitted for flexor tendon repair surgery. PXL01 in carrier sodium hyaluronate or placebo was administered around the repaired tendon. Efficacy was assessed by total active motion of the injured finger, tip-to-crease distance, sensory function, tenolysis rate and grip strength, and safety parameters were followed, for 12 months post-surgery. RESULTS: The most pronounced difference between the treatment groups was observed at 6 months post-surgery. At this timepoint, the total active motion of the distal finger joint was improved in the PXL01 group (60 vs. 41 degrees for PXL01 vs. placebo group, p = 0.016 in PPAS). The proportion of patients with excellent/good digit mobility was higher in the PXL01 group (61% vs. 38%, p = 0.0499 in PPAS). Consistently, the PXL01 group presented improved tip-to-crease distance (5.0 vs. 15.5 mm for PXL01 vs. placebo group, p = 0.048 in PPAS). Sensory evaluation showed that more patients in the PXL01 group felt the thinnest monofilaments (FAS: 74% vs. 35%, p = 0.021; PPAS: 76% vs. 35%, p = 0.016). At 12 months post-surgery, more patients in the placebo group were considered to benefit from tenolysis (30% vs. 12%, p = 0.086 in PPAS). The treatment was safe, well tolerated, and did not increase the rate of tendon rupture. CONCLUSIONS: Treatment with PXL01 in sodium hyaluronate improves hand recovery after flexor tendon repair surgery. Further clinical trials are warranted to determine the most efficient dose and health economic benefits. TRIAL REGISTRATION: ClinicalTrials.gov NCT01022242; EU Clinical Trials 2009-012703-25.

[Case of continuous trans-arterial calcium gluconate infusion using a direct arterial sphygmomanometry line that exhibited dramatic improvement of chemical burns on the fingers caused by hydrofluoric acid].

Hydrofluoric acid (HFA) is commonly used and many injuries occur on the upper extremities following exposure to HFA. The use of calcium gluconate (CG) -containing gel or local injections of CG are widely used for the initial treatment of HFA exposure. However, severe pain continues in some cases despite the treatment. There was a report that trans-arterial CG infusion could improve HFA burns, however, such treatment is not an established clinical procedure. A 30-year-old male presented at our hospital with severe pain in his left thumb. He had been cleaning tiles with an HFA-containing detergent. We diagnosed him with a chemical burn due to HFA exposure. Local CG injections were tried several times, but his terrible pain continued. Therefore, a direct arterial sphygmomanometry line was inserted from the left radial artery, and continuous transarterial CG injection was performed. His terrible pain dramatically improved. Direct arterial sphygmomanometry systems are widely used in the critical care field to monitor the hemodynamics and ICU staffs are used to dealing with it. Moreover, continuous saline infusion prevents the tube obstruction. Continuous CG infusion from a direct arterial sphygmomanometry line is simple and safe way to administer CG in HFA burns.