Boris Fung

A case of disseminated Mycobacterium marinum infection following systemic steroid therapy.

We describe the dissemination of Mycobacterium marinum infection from the right middle finger to the whole extremity and two legs, with the involvement of tendons and joints, in a patient who was treated with a steroid when Mycobacterium marinum infection was not suspected. The patient was successfully treated with a combined surgical and medical approach.We describe the dissemination of Mycobacterium marinum infection from the right middle finger to the whole extremity and two legs, with the involvement of tendons and joints, in a patient who was treated with a steroid when Mycobacterium marinum infection was not suspected. The patient was successfully treated with a combined surgical and medical approach.

Mycobacterium marinum infection of the hand and wrist

Purpose. To review records of 166 patients who underwent treatment for Mycobacterium marinum tenosynovitis of the hand and wrist to identify factors associated with functional outcome. Methods. Records of 97 men and 69 women aged 13 to 85 (mean, 50) years who underwent treatment for suspected M marinum tenosynovitis of the hand and wrist were retrospectively reviewed. All underwent open biopsy; synovectomy was performed when florid synovitis was present. Rifampicin and ethambutol were usually prescribed. Clarithromycin, minocycline and/or levofloxacin were used as adjuvants if there was drug intolerance, allergy, or relapse. The duration of antibiotic treatment depended on the clinical recovery. Patients were followed up for one year after completion of drug treatment. Functional outcome was considered excellent for those with >195° total active motion (TAM) and >75% return of motion, good for those with 130° to 195° TAM and 50 to 75% return of motion, fair for those with 65° to 129° TAM and 25 to 49% return of motion, and poor for those with <65° TAM and <25% return of motion. Results. The mean delay in presentation was 4.9 (0.3–120) months. 93 of the patients presented with disabilities (fexion deformity or reduced range of motion), 64 of whom presented one month after injury. 37 (22%) of the patients had received intralesional steroids prior to admission, 30 of whom presented one month after injury. 32 (19%) patients were treated with antibiotics alone, whereas 134 (81%) patients underwent debridement in addition to antibiotic treatment. The mean duration of antibiotic treatment was 7.2 (range, 0–29) months. Of the 156 patients who completed the follow-up, functional outcome was satisfactory in 128 (82%) and unsatisfactory in 28 (17%). Steroid injections and late presentation led to worse functional outcome. Patients with unsatisfactory outcome were more likely to have received intralesional steroid injections (43% [16/37] vs. 10% [12/118], p<0.001, Pearson Chi squared test), have presented >2 months after injury (27% [21/79] vs. 9% [7/77], p=0.004, Pearson Chi squared test), and have undergone synovectomy (23% [28/124]) vs. 0% [0/32], p=0.001, Fishers exact test). Worse functional outcome correlated with late presentation (r=0.218) and the greater number of debridement procedures (r=0.453). Conclusion. Delayed antibiotic treatment of M marinum infections and steroid injections were associated with unsatisfactory outcome. Clinicians must have a high index of suspicion for this condition and avoid inappropriate management such as intralesional steroid injections. Public awareness to this condition should be raised.

Review Article: Mycobacterium Marinum Infection of the Hand and Wrist

Misdiagnosis and delayed treatment of Mycobacterium marinum infection is common because of its diverse manifestations. This leads to inappropriate use of antimicrobials, extension of the infection from the skin to the tenosynovium, and a poor prognosis (loss of tendons and prolonged immobilisation, secondary to multiple debridements and joint contractures). Clinicians should be aware of this type of infection, especially in subjects at risk (fishermen and aquarium enthusiasts), and those with a history of trauma coupled with exposure to water or marine life. A proactive approach to obtain a biopsy for histopathological and microbiological diagnosis is advised. Anti-mycobacterial treatment should be started promptly. The combined use of rifampicin, ethambutol, and clarithromycin appears to be effective, and debridement is indicated in patients with deep-seated infections.

REVIEW ON MALLET FINGER TREATMENT

Mallet finger is a common injury involving either an extensor tendon rupture at its insertion or an avulsion fracture involving the insertion of the terminal extensor tendon. It is usually caused by a forceful blow to the tip of the finger causing sudden flexion or a hyperextension injury. Fracture at the dorsal aspect of the base of the distal phalanx is commonly associated with palmar subluxation of the distal phalanx. Most mallet finger injuries are recommended to be treated with immobilisation of the distal interphalangeal joint in extension by splints. There is no consensus on the type of splint and the duration of use. Most studies have shown comparable results with different splints. Surgical fixation is still indicated in certain conditions such as open injuries, avulsion fracture involving at least one third of the articular surface with or without palmar subluxation of the distal phalanx and also failed splinting treatment.

STUDY OF WRIST POSTURE, LOADING AND REPETITIVE MOTION AS RISK FACTORS FOR DEVELOPING CARPAL TUNNEL SYNDROME

Occupational risk factors of carpal tunnel syndrome (CTS) are popular current research targets, with main emphasis put on wrist posture and dynamics. In this study, we do not intend to pinpoint individual occupations, but aim to identify high risk wrist postures and actions which may occur across various occupations. It is hoped that prevention can thus be instituted in a general population by directing at the particular causative wrist actions rather than exclusively targeting isolated occupations. We performed a case-control study with 166 cases and 111 controls recruited from different hospitals in Hong Kong in 2004. All cases and controls completed the survey on their general health condition, smoking status, wrist posture and motion as well as psychosocial status at the time of diagnosis of CTS. Frequent flexion OR = 4.436 (95% CI: 1.833-10.734), frequent extension OR = 2.691 (95% CI: 1.106-6.547) of the wrist were found to be associated with CTS. Frequent sustained forceful motion of the wrist OR = 2.588 (95% CI: 1.144-5.851) was also found to be associated with CTS. Neutral wrist position and repetitive wrist motion were not associated with CTS. Adjustment was made for age, sex, BMI, smoking and psychosocial stress. Our study confirms that frequent flexion, extension and sustained force of the wrist increase the risk of developing CTS.

The versatile reverse flow sural artery neurocutaneous flap: A case series and review of literature

BackgroundReverse flow sural neurocutaneous flap has been utilized more frequently during the past decade to cover vital structures around the foot and ankle area. The potential advantages are the relatively constant blood supply, ease of elevation and preservation of major vascular trunks in the leg. The potential disadvantages remain venous congestion, donor site morbidity and lack of sensation.MethodsThis descriptive case series was conducted at Queen Mary Hospital, Hong Kong, from 1997 to 2003. Ten patients having undergone reverse flow sural neurocutaneous flap were identified through medical records. There were six females (60%) and four males (40%), with an average age of 59.8 years. The defects occurred as a result of trauma in five patients (50%), diabetic ulcers in four (40%) and decubitus ulcer in one (10%) paraplegic patient. The defect site included non weight bearing heel in four (40%), tendo Achilles in two (20%), distal tibia in two (20%), lateral malleolus in one (10%) and medial aspect of the midfoot in one patient (10%). The maximum flap size harvested was 14 × 6 cm. Preoperative doppler evaluation was performed in all patients to identify perforators and modified plaster of paris boot was used in the post operative period. A detailed questionnaire was developed addressing variables of interest.ResultsThere was no flap failure. Venous congestion was encountered in one case. The donor site was relatively unsightly but acceptable to all patients. The loss of sensation in the sural nerve distribution was transient in all patients.ConclusionReverse sural artery flap remains to be the workhorse flap to resurface the soft tissue defects of the foot and ankle. Anastomosis of the sural nerve to the digital plantar nerve can potentially solve the issue of lack of sensation in the flap especially when used for weight bearing heel.

HAND INFECTION IN DIABETIC PATIENTS

The diabetic hand infection is less reported in the literature. Therefore, it is easily ignored and underestimated resulting in increased morbidity among the diabetic population. Diabetic hand is a rapid in progression, extensive and severe tissue destruction. We analyze the clinical course and outcome of hand infection in diabetic patients. We reviewed all the admissions with hand infection from January 2006-April 2010. Thirty-seven patients were found with associated diabetes mellitus. The demographic data, culture report, number of operations and management, hospital stay and outcome-like amputation were recorded. The average age was 62 years. Pain and swelling were the chief complaints. The cause of infection was varied. The infection was superficial in 13 and deep in 24 patients. Forty-one percent of culture report revealed polymicrobial organism. The increased length of hospital stay, reoperations and amputation were associated with deep infection and polymicrobial organism. Prompt medical and surgical attentions are the most important factors. A proper glycemic control, elevation of the affected extremity, thorough and adequate surgical debridement and appropriate antibiotics are the important considerations when dealing with diabetic hand infection.

Where is the Lesion? Glomus Tumours of the Hand

Glomus tumours are vascular hamartomas that are commonly found in the hand, particularly the subungual region. They appear as solitary or multiple tumours, and often present as a bluish discoloration of the nail plate. Different diagnostic tests are outlined, as well as imaging studies such as magnetic resonance imaging and ultrasound. Misdiagnosis and delayed diagnosis of these tumours are common, while a familial tendency is a potential risk factor but not yet proven. Complete surgical excision often results in complete symptomatic relief, while recurrences are largely due to incomplete excision or the growth of a new glomus tumour. This article aims to review the key aspects of glomus tumours and provide a diagnostic algorithm so that the lesion can be recognized and treated earlier.

Schwannoma in the Upper Limbs

Schwannomas are the commonest tumours of peripheral nerves. Despite the classical description that schwannomas are well encapsulated and can be completely enucleated during excision, a portion of them have fascicular involvement and could not be completely shelled out. A retrospective review for 8 patients was carried out over 10 years. 75% of schwannoma occurred over the distal region of upper limb (at elbow or distal to it). It occurs more in the mixed nerve instead of pure sensory or motor nerve. 50% of patients had mixed nerve involvement. Fascicular involvement was very common in schwannoma (75% of patients). Removal of the tumour with fascicles can cause functional deficit. At present, there is no method (including preoperative MRI) which can predict the occurrence of fascicular involvement; the authors therefore proposed a new system to stratify patients who may benefit from interfascicular nerve grafts. In this group of patients, the authors strongly recommend that the possibility and option of nerve graft should be discussed with patients prior to schwannoma excision, so that nerve grafting could be directly proceeded with patient consent in case there is fascicular involvement of tumour found intraoperatively.

LONG TERM RESULTS OF MATCHED HEMIRESECTION INTERPOSITION ARTHROPLASTY FOR DRUJ ARTHRITIS IN RHEUMATOID PATIENTS

INTRODUCTION The distal radioulnar joint (DRUJ) is commonly affected in rheumatoid arthritis and is associated with significant functional morbidity. The aim of our study is to review our results with matched hemi-resection interposition arthroplasty in patients with DRUJ arthritis. METHODS This was a retrospective study of 39 patients with 51 wrists that were treated at Queen Mary Hospital in Hong Kong from 1989 to 2007. All patients underwent matched hemi-resection interposition arthroplasty and dorsal wrist synovectomy. Long arm hinged elbow brace was used for three weeks followed by intensive rehabilitation up to twelve weeks. The indicators of outcome included range of motion assessment, pain, wrist stiffness, grip of strength and need for revision assessed during follow-up. Statistical analysis was performed with student t-test. RESULTS The average age of patients was 50.5 years (25 to 77 years) and there was a 35:4 female to male ratio. The average follow up was 4.5 years ranging from 1 to 18 years. Associated extensor tendon ruptures were found in 31.4% patients. The average increase in supination was from 73 degrees preoperatively to 81 degrees at long term follow up (p = 0.10 at 1 year and 0.13 at long term follow-up). The average increase in pronation was from 68 degrees preoperatively to 74 degrees on long term follow up (p = 0.57 at 1 year and 0.02 at long term follow-up). There was evidence of painless, relatively stiff but functional wrist in 37.25% of patients. There was an increase in grip strength from an average of 6.1 kilogram force preoperatively to an average of 11.5 kilogram force at follow-up (p = 0.004 at 1 year and 0.15 at long term follow-up). Complete relief of ulnar sided pain was seen in 43 wrists (84%), partial relief was seen in 7 wrists (13.7%) and no relief was found in one wrist (1.9%). CONCLUSIONS DRUJ arthroplasty is a rewarding procedure and most of the patients obtain pain free movement.