Vascular Problems in Elite Throwing Athletes.

There are approximately 880 and 3,600 major league baseball and minor league baseball players who currently are active in their respective leagues, with thousands of players in the collegiate, high school, and little league ranks. Although relatively uncommon, vascular injuries, such as thoracic outlet syndrome, axillary artery compression, quadrilateral space syndrome, and direct vascular trauma, can afflict these players. These career- and limb-threatening injuries can mimic often seen muscular sprains and strains in their early stages with nonspecific symptoms, such as exertional fatigue, which can delay diagnosis with disastrous sequelae, including thrombus propagation, aneurysm rupture, and ischemia from distal embolization. The goal of this review is to discuss the pathophysiology, diagnosis, and treatment of these injuries to increase awareness of sport-related vascular phenomena among the hand and upper-extremity surgery community because these players typically are seen first in the training room or a hand specialist's office.

Outcomes of periarterial sympathectomy in patients with digital ischemia.

INTRODUCTION: Digital ischemia with subsequent severe pain and tissue loss is often difficult to treat, with no obvious guidelines or strong evidence in the literature to support a specific treatment modality. Patients who fail medical treatment remain with very limited surgical options due to the difficulty of any intervention in this "no man's land" area of the hand, as described since 1918. Extended distal periarterial sympathectomy is reported as an effective treatment option since the eighties of last century. The procedure entails large incisions and major technical difficulties. In this study, we describe a less invasive approach with very promising results and equally high success rates. MATERIALS AND METHODS: This was a prospective study. All patients with severe digital ischemia manifesting with bluish discoloration, ulceration, and/or dry gangrene who failed medical treatment underwent distal periarterial sympathectomy for the radial and ulnar arteries, with added digital sympathectomy in very severe cases. Primary endpoints were ulcer healing and improvement in pain scores assessed by Visual Analog Scale pain scoring system. Secondary endpoints included complications and amputation rates. RESULTS: This study recruited 17 patients between January 2019 and January 2020. The mean follow-up was 14.6 months. The mean age was 33.71 (±SD 13.14) years. 41% were males. 59% suffered from vasculitis, 35% of patients had dry gangrene, and 71% had ulcers. Periarterial radial and ulnar sympathectomy was performed for all cases, with digital sympathectomy for 12 fingers. We had 50% complete ulcer healing within 1 month (p = 0.031), and 100% were completely healed at 6 months (p < 0.001). Pain scores showed significant reductions at 1 (p = 0.001) and 6 months (p < 0.001) of follow-up. CONCLUSION: Distal periarterial sympathectomy demonstrates high success rates in terms of pain relief and ulcer healing in severe digital ischemia.

Case series of: Iatrogenic digital compression ischaemic injury in the emergency department.

This brief report is a retrospective review of three cases of iatrogenic digital ischemia and clinical outcome at six months. Hand injuries are one of the most common injuries that occur in the working population. Iatrogenic digital ischemia is a rare condition that can be avoided by proper wound management. After the correct initial treatment is provided, it is important to apply the wound dressing correctly to avoid iatrogenic trauma or ischemia. Currently, there is no consensus regarding the best treatment for these injuries. Our aim is to remind clinicians of this rare condition, and to highlight prevention and treatment strategies.

Digital ischemia in Behçet's disease: case-based review.

Behçet's disease is a rare chronic autoimmune disease affecting primarily Middle and East Asian populations between the ages of 20 and 40 years. Behçet's disease manifests with oral and genital mucocutaneous lesions, ocular disease, venous thrombosis, and central nervous system degradation. Treatment can be challenging and may require immunosuppressive agents and/or topical wound-care. While larger vascular involvement has been reported, digital ischemia due to small-vessel involvement has not been well described in the literature. Based on a systematic literature review, we were only able to find seven published cases of limb ischemia, none of which reported digital involvement. We present a unique case of Behçet's disease with severe digital ischemia and ulceration caused by small-vessel involvement. The patient was managed successfully with antiplatelet, immunosuppressants, and anti-inflammatories with complete resolution of the ischemic symptoms. By focusing on small-vessel involvement and digital ischemia, we provide insight into clinical presentation and treatment for this very rare vascular manifestation of Behçet's disease.

Digital Ischemia in COVID-19 Patients: Case Report.

As coronavirus 2019 (COVID-19) continues to cause an immense burden on the global health care systems, it is crucial to understand the breadth of this disease process. Recent reports identified hypercoagulability in a subset of critically ill patients and extremity ischemia in an even smaller cohort. Because abnormal coagulation parameters and extremity ischemia have been shown to correlate with poor disease prognosis, understanding how to treat these patients is crucial. To better describe the identification and management of this phenomenon, we present 2 cases of critically ill patients with COVID-19 who developed fingertip ischemia while in the intensive care unit.

Peripheral vascular manifestation in patients receiving an amphetamine analog: A case series.

Amphetamine and its related derivatives and analogues (ADRA) are highly addictive central nervous system stimulants that are used commonly in the treatment of attention-deficit/hyperactivity disorder and narcolepsy. These medications are associated with many side effects but reports of peripheral arterial manifestations associated with ADRA usage are scarce. We retrospectively reviewed the records of 16 patients (median age 37 years (IQR 31-47), 13 females) referred to a single tertiary referral service while receiving ADRA. Follow-up was available for a median of 3 years (IQR 3-4.5). The most common presentation (62.5%) was mild vasospastic symptoms involving the upper, lower or both extremities. Six patients developed severe manifestations including tissue loss and the need for lower extremity amputation. Most patients (75%) refused to stop the medication during follow-up. Underlying rheumatologic disorders were found in 25% of the patients, and the presence of rheumatologic disease seemed to be associated with more severe vascular manifestations. In conclusion, it is important to search for ADRA usage as part of the differential diagnosis of digital ischemia.

Paraneoplastic acral vascular syndrome in a patient with metastatic melanoma under immune checkpoint blockade.

BACKGROUND: Paraneoplastic acral vascular syndrome (PAVS) is a rare phenomenon which is observed in patients with adenocarcinomas and other malignancies. Various potential pathogenic mechanisms such as tumour invasion of sympathetic nerves, hyperviscosity, hypercoagulability, vasoactive tumour-secreted substances, and immunological mechanisms have been suggested. CASE PRESENTATION: We report a 60-year-old Caucasian male attended our hospital with a bulky lymph node mass in the right axilla. Extirpation of a lymph node conglomerate revealed 5 melanoma lymph node metastases. Computed tomography showed a liver metastasis (diameter: 3.8 cm), several retroperitoneal metastases, bilateral metastases in the lung hilus, and prepectoral subcutaneous metastases (Stage IV; pTx, N3, M1c). Lactate dehydrogenase and S100B were slightly elevated. Combination therapy of nivolumab (1 mg/kg BW) and ipilimumab (3 mg/kg BW) was started. Three weeks after the first combination therapy he developed progressive erythema, paraesthesia and pain on the fingertips of both hands. Both cold and warmth was not well tolerated by the patient. Complete work-up excluded associated conditions or factors such as haematological disorders, rheumatologic disorders, hypertension, diabetes or smoking. Treatment was initiated with prostacyclin 20 µg twice daily and oral prednisolone 50 mg in tapering dosage. However, prostacyclin was stopped after the first applications because the pain increased during infusion. The second course of nivolumab and ipilimumab was administered. About 2 weeks later, the patient presented with increased pain and small subungual necrosis. We treated the patient with oral analgetics and intravenous prednisolone 500 mg in tapering dosage. On digital substraction angiography occlusion of all arteries of the fingers was demonstrated. Further rheologic and anti-melanoma treatments were refused by the patient. About 2 months after the second course of nivolumab and ipilimumab combination therapy several fingers showed severe gangrene which finally led to amputations of end phalanges of several fingers. Histopathology did not reveal evidence for vasculitis or other primary vascular pathologies. During the following 2 months the patient experienced dramatic progress of his metastatic disease and finally died at multi-organ failure. CONCLUSION: Presence of rapidly progressive digital ischemia in an elderly patient with cancer should always raise clinical suspicion of a paraneoplastic phenomenon when other possible causes have been excluded. In patients treated with immune checkpoint inhibitors such as CTLA-4 and PD-L1 blockers PVAS-like events have not been reported so far. However, it is debatable whether immune checkpoint blockade may play a pathogenetic role in the development of PAVS in patients with malignancies.

Delayed-Onset Digital Ischemia After Local Anesthetic With Epinephrine Injection Requiring Phentolamine Reversal.

The use of low-dose epinephrine in hand surgery has made it possible to perform a wide range of surgical procedures in the office setting. Low-dose epinephrine use is safe, and its vasoconstrictive effects are reversible with phentolamine. In this report, we present late-onset finger ischemia beginning 3 hours after an ipsilateral carpal tunnel and A1 pulley release of the middle finger anesthetized with local anesthetic and low-dose epinephrine (1:100,000). Finger ischemia lasted 14 hours until rescued with phentolamine injection.

Hypothenar hammer syndrome: long-term results of vascular reconstruction.

PURPOSE: To evaluate long-term patency rates and related outcomes after vascular reconstruction of hypothenar hammer syndrome and identify patient- or treatment-related factors that may contribute to differences in outcome. METHODS: We used color flow ultrasound to determine the patency of 18 vein graft reconstructions of the ulnar artery at the wrist in 16 patients. Validated questionnaires evaluated patients' functional disability with the Disabilities of the Arm, Shoulder, and Hand score, pain with the visual analog scale, and cold intolerance with the Cold Intolerance Symptom Severity survey. Patient demographics, clinical data, and surgical factors were analyzed for association with graft failure. Patients were asked to grade the result of treatment on a scale of 0 to 10. RESULTS: Of 18 grafts, 14 (78%) were occluded at a mean of 118 months postoperatively. Patients with patent grafts had significantly less disability related to cold intolerance according to the Cold Intolerance Symptom Severity survey in addition to significantly less pain on the visual analog scale. There was no statistical difference in Disabilities of the Arm, Shoulder, and Hand scores between patients with patent or occluded grafts. Patients graded the result significantly higher in patent reconstructions. CONCLUSIONS: We noted a higher incidence of graft occlusion than previously reported at a mean follow-up of 9.8 years, which represents a long-duration follow-up study of surgical treatment of hypothenar hammer syndrome. Despite a high percentage of occlusion, overall, patients remained satisfied with low functional disability and all would recommend surgical reconstruction. This study suggests that improved outcomes may result from patent grafts in the long term. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Risk factors associated with self-reported symptoms of digital ischemia in elite male volleyball players in the Netherlands.

One in every four elite male volleyball players in the Netherlands reported blue or pale digits in the dominant hand. Little is known about risk factors. To assess whether personal-, sports-, and work-related risk factors are associated with these symptoms in these volleyball players, a survey was performed among elite male volleyball players in the Dutch national top league and in the Dutch beach volleyball team. The questionnaire assessed the presence of symptoms and risk factors. Binary logistic regression was performed to calculate odds ratios (ORs). A total of 99 of the 107 athletes participated - a response rate of 93%. Two sports-related risk factors were associated with symptoms of blue or pale digits: 18-30 years playing volleyball [OR = 6.70; 95% confidence interval (CI) 1.12-29.54] and often/always performing weight training to increase dominant limb strength (OR = 2.70; 95% CI 1.05-6.92). No significant other sports-, personal-, or work-related risk factors were found. Playing volleyball for more than 17 years and often/always performing weight training to increase dominant limb strength were independently associated with an increased risk on ischemia-related complaints of the dominant hand in elite male volleyball players.

Antineutrophil Cytoplasmic Autoantibody-negative Pauci-immune Necrotizing Glomerulonephritis with Plasma Cell-rich Tubulointerstitial Nephritis Complicated with Pleuritis and Digital Ischemia.

Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) predominantly affects small vessels. Almost all AAV patients are positive for myeloperoxidase- or proteinase 3-ANCA, and ANCA plays a crucial role in the pathogenesis of AAV. We herein report an ANCA-negative AAV patient with pauci-immune necrotizing glomerulonephritis and plasma cell-rich tubulointerstitial nephritis who was complicated with pleuritis and digital ischemia. ANCA-negative AAV is a rare clinical entity that is difficult to diagnose, and pleuritis and digital ischemia are rare manifestations of AAV. An early diagnosis and appropriate treatment are important, as any delay in the diagnosis may worsen the prognosis.

Primary antiphospholipid syndrome in a male presents with acute digital ischemia: Dramatic response to glucocorticoid.

We present a rare case of primary antiphospholipid syndrome in a 38-year-old male who presented with painful digital ischemia. Early initiation of anticoagulation and addition of glucocorticoid led to a significant improvement in the patient.

Fingertip ischemia following intralesional injection of Candida albicans antigen for treatment of a subungual wart.

Subungual or periungual cutaneous warts are caused by the human papillomavirus (HPV). These lesions can be refractory to destructive therapy, necessitating the use of intralesional immunotherapies such as Candida albicans antigen. In this case report, we present a 23-year-old female who sustained distal fingertip soft tissue necrosis following intralesional injection of Candida albicans antigen for the treatment of a refractory subungual wart. While this patient recovered appropriately with conservative bedside debridement and local wound care, intralesional injections to the digit, or hand are not without sequela. It's important to inject intradermally while avoiding the digital vasculature underneath. In this case, the radial digital vessels were traumatized upon injection, leading to digital ischemia and soft tissue necrosis. While isolated soft tissue ischemia without compromised perfusion can be treated conservatively, these injuries should be evaluated by a hand surgeon to determine the need for emergent revascularization, or future soft tissue reconstruction.

Under 2$ hand anesthesia? Our first 800 cases with Wide-Awake Local Anesthesia No Tourniquet (WALANT) in hand surgery.

INTRODUCTION: The Wide-Awake-Local-Anesthesia-No-Tourniquet (WALANT) technique is being used progressively more and more in hand surgery as it avoids tourniquet-related complications and saves money. MATERIALS AND METHODS: In the present study, we analyzed our cases of carpal tunnel syndrome or trigger finger operated upon with this technique from January 1, 2018 to December 31, 2022. RESULTS: We obtained 822 cases (426 carpal tunnel syndrome, 396 trigger finger) with an overall anesthesiologic efficacy (no need of additional anesthetic) of 97.8%. Patients were satisfied or very satisfied with the anesthetic choice in 99.8% of cases. CONCLUSIONS: We believe WALANT to be a safe and effective technique that every hand surgeon should have in his/her repertoire.

Distal periarterial sympathectomy surgery for chronic digital ischemia: A systematic review of the literature.

Objective: This study assesses the efficacy of distal periarterial sympathectomy in treating chronic digital ischemia by evaluating clinical outcomes of surgery. Methods: A systematic literature review of distal sympathectomy for chronic digital ischemia was conducted. Data extracted included study design, patient statistics, aetiology, follow-up duration, sympathectomy level, and surgical outcomes. Results: 21 studies were analysed, containing a total of 337 patients, 324 hands, and 398 digits. Patient age ranged from 23.2 to 56.6 years. Causes of ischemia included Scleroderma, Raynaud's disease, atherosclerosis/Buerger's disease, systemic lupus erythematosus/discoid lupus, undifferentiated rheumatic disorder/mixed connective tissue disease, CREST syndrome, trauma and unknown diagnoses. Common digital artery sympathectomy was mostly performed. Follow-up spanned 12-120 months. Outcomes: Distal sympathectomy led to reduced pain in 94.7 % patients. Complete resolution of ulceration was seen in 73 % patients. Subsequent amputation was required in 28 % patients. Other complications were reported in 24.1 % patients. Conclusions: This study indicates that distal periarterial sympathectomy may effectively treat chronic digital ischemia, offering pain relief and resolution of digital ulceration. However, risks of complications and amputation persist. Further research is required to inform patient selection and establish the optimal technique and extent of distal sympathectomy surgery, before it can be considered a valid treatment option.

Black Digits Matter: A Multispecialty Enigma.

Introduction Digital ischemia is alike any other visceral ischemic event leading to severe tissue damage ultimately causing necrosis of the involved extremity. It's like a preview of the upcoming systemic disorder and can present itself in any specialty and hence everyone, be it a physician or a surgeon must be primed toward how to proceed with a case of digital ischemia. In this case series, we present six such cases that presented with digital ischemic events either as a sole presentation or were followed by other systemic manifestations that led to their evaluation and ultimately the etiology behind it. Material and method Patients visiting Rheumatology OPD with complaints suggestive of digital ischemia were included in this study. All patients underwent thorough history taking and clinical examination to establish the cause of digital ischemia. Patients with probable infective, trauma, cardiac, and drug-induced causes and malignancies were excluded. As per probable autoimmune causes, patients underwent evaluation via antinuclear antibodies by immunofluorescence (ANA by IF), antiphospholipid antibodies like lupus anticoagulant (LAC), anticardiolipin antibodies (AcL) and anti Beta2GP1 antibodies, extractable nuclear antigens (ENA) and in cases of suspected vasculitis doppler ultrasound and angiography.  Results Six patients were identified as cases primarily presenting with digital ischemia or with a prior history of digital ischemia. Two patients were of the pediatric age group, one 16-year-old male presenting with acute arthritis and a history of digital ischemia one year back, and the other was a 12-year-old female with blackening of the second toe in her left foot with a history of similar complaints in the left great toe for which she underwent amputation of that toe. Other four cases were of the adult age group, with two cases of scleroderma, one with systemic lupus erythematosus, and one with Takayasu arteritis. All of these patients primarily presented to departments other than rheumatology. Conclusion Digital ischemia is a pan-specialty problem with the etiologies spreading across a vast spectrum of rheumatological disorders, many of which may present to different specialties initially, later discovered to be part of the systemic manifestation of autoimmune diseases. Hence, it becomes imperative to have a rheumatological perspective in these cases of digital ischemia which all specialities should be aware of, and timely referral may prevent permanent loss of the digits and in some cases the entire limb.

Case report of streptococcal infection as a potential precipitating factor in cutaneous polyarteritis nodosa in pediatric patients.

Key Clinical Message: This pediatric case report underscores the importance of maintaining a high clinical suspicion for polyarteritis nodosa (PAN) in patients presenting with atypical features, such as migratory arthritis and subcutaneous nodules. Importantly, it highlights the focus on the potential relationship between streptococcal infection and cutaneous PAN. Early recognition and prompt, aggressive treatment is critical, as PAN can be a life-threatening condition if left unmanaged. This case emphasizes the need for a multidisciplinary approach to effectively identify and manage this rare vasculitis disorder in the pediatric population. Abstract: Polyarteritis nodosa (PAN) is a rare and life-threatening vasculitis with diverse clinical presentations, posing a diagnostic challenge. Early recognition and prompt intervention are crucial to prevent organ damage. We present the case of an 8-year-old boy who exhibited atypical symptoms including migratory arthritis, myalgia, digital discoloration and ischemic changes, and subcutaneous nodules. Initial concerns for septic arthritis were ruled out. A comprehensive evaluation revealed elevated inflammatory markers and a confirmatory skin biopsy demonstrating active leukocytoclastic vasculitis, are highly suggestive of a diagnosis of PAN. Notably, elevated ASO titers suggested a possible concurrent streptococcal infection. The aggressive treatment approach with high-dose aspirin, steroids, methotrexate, and tocilizumab is justified given the severity of the patient's symptoms and the nature of the disease process. This case underscores the importance of considering PAN in the differential diagnosis for children presenting with atypical features. Early diagnosis and prompt intervention, including addressing potential infectious triggers, are crucial for optimal outcomes in pediatric PAN.

Worsening of Primary Raynaud's Phenomenon During Episodes of Pyrexia and Rigors in SARS-CoV-2 Infection.

Acute SARS-CoV-2 infection is associated with several cutaneous manifestations, including vasculitic digital ischemia. The reversal of digital ischemia in the primary Raynaud phenomenon (RP) arises from endothelial hypersensitivity to circulating adrenaline and noradrenaline and diminished vasodilatory innervation. SARS-CoV-2 can infect endothelial cells and be associated with raised adrenaline levels, reduced microvascular dilatory responses, and exaggerated clotting mechanisms. We report worsened RP in a patient with previously mild winter-time primary RP during the periods of fever and rigors from an acute SARS-CoV-2 infection contracted in a warm summer period. This reverted to the mild phenotype after recovery, and we discussed possible mechanisms for the brief exacerbation.

[Livid Fingers after Respiratory Infection]. / Blaue Finger nach respiratorischem Infekt.

Livid Fingers after Respiratory Infection Abstract. A 53-year-old patient fell ill with SARS-CoV-2. She suffered from cough, headache and slight exertional dyspnoea. She was hospitalized for a short time as the dyspnoea increased. Two weeks after the first respiratory symptoms, the patient developed painful livid discoloration of the left terminal phalanges I-III. An occlusion of the arteria princeps pollicis and the arteria digitalis communis/propria of the left fingers II and III could be documented in the angiography. In addition to short-term lysis therapy with alteplase, the patient was therapeutically anticoagulated and received aspirin. An ilomedin (iloprost) therapy was carried out.

A Case of Thenar Hammer Syndrome.

Thenar hammer syndrome (THS) is characterized by vascular injury and subsequent digital ischemia from acute high-energy trauma or repetitive low-energy trauma to the thenar eminence of the palm. Here, we report the case of a 41-year-old male construction worker who presented with unilateral, cold, painful, and blue-colored fingertips in his left hand. Angiography of his left upper extremity showed abrupt occlusion of the radial artery at the level of the radial styloid process with a poorly developed but patent deep palmar arch, consistent with THS. The ulnar artery and superficial palmar arch were both patent. He had moderate symptomatic relief with administration of low-dose endovascular fibrinolytics, anticoagulation therapy, and a calcium channel blocker during his stay in the hospital and was discharged home on dual antiplatelet therapy.