John A. Boswick

Empirical Selection of Antibiotics for Hand Infections

Bacterial cultures and antibiotic sensitivity tests in a series of recent infections of the hand and forearm were analyzed. Staphylococci (58.6 per cent), beta hemolytic streptococci (12.1 per cent), and Escherichia coli (8.3 per cent) were the organisms most frequently isolated. Knowledge of the gram stain property of organism aids considerably in the empirical selection of antibiotics while awaiting positive identification and sensitivity reports. The possibility of encountering gram positive and gram negative organisms together in an acute infection is extremely small. More than 98 per cent of all gram positive organisms were sensitive to lincomycin, chloramphenicol, and methicillin. Empirical selections of antibiotics for unidentified gram negative organisms are less certain, but kanamycin showed statistical superiority (85.6 per cent). Penicillin for gram positive organisms and streptomycin for gram negative organisms had the highest rates of resistance.

Systemic corticosteroid therapy for high-pressure injection injuries of the hand.

Two cases of high-pressure injection injuries of the hand have benefited from early administration of high doses of systemic corticosteroids. The pathophysiology of these injuries relates to: 1) Local mechanical tissue destruction from the injection; 2) Deleterious tissue responses to the injectant; and 3) Sequelae of secondary bacterial infection. Steroids have been shown experimentally to play a beneficial role in the second group of factors without increasing the incidence of secondary infection. The rapid favorable response to steroids demonstrated in the two reported cases suggests further use and investigation of this treatment modality is warranted.

Isolated injury to the median nerve above the elbow. A review of thirteen cases.

Isolated median-nerve injuries above the elbow are uncommon and are usually associated with injury to the brachial artery. The typical findings in the thirteen patients studied were loss of sensation in the distribution of the nerve and atrophy of the forearm flexors and thenar muscles in all patients. The only consistent motor loss was lack of flexion of the interphalangeal joints of the thumb and index finger. Inability to rotate the thumb occurred in five of the thirteen patients. Forearm pronation was weakened but was never completely lost. Suture of the brachial artery restored the radial pulse in all patients but not always immediately. Both primary and secondary nerve suture resulted in an excellent return of protective sensation. In two young patients with primary nerve repair sudomotor activity returned twenty-three and twenty-six months, respectively, after injury. Action of the digital flexors returned clinically and electromyographically in all patients. In four patients an abnormal grasp developed and they had to relearn thumb and index finger flexion. During the time required for nerve regeneration, burns of the hand were a significant complication for five of the thirteen patients. Loss of thumb rotation, which occurred in five of the thirteen patients, appeared to be the most serious disability. Nerve suture was effective in restoring this function in only one of the five patients. Tendon transfer to restore thumb rotation was performed in the remaining four patients. This procedure was reserved for patients who have reinnervation of the forearm muscles, a return of protective sensation to the hand, and joints that have been kept supple by exercising and splinting.

The role of soft tissue reconstruction in flexible implant arthroplasty of the metacarpophalangeal joint.

In 116 hand metacarpophalangeal joint arthroplasties of the flexible type, the operative technique did not include reconstruction of capsular or ligamentous structures, but employed meticulous relocation of the common extensor tendons, and a modification of the metacarpal osteotomy plane and shape. A closely supervised program of splintage and therapy was instituted postoperatively. This series does not vary significantly with respect to range of motion or recurrence of ulnar drift (seen only when patients failed to wear splints as directed) in comparison to other reports. The results, therefore, fail to support the concept that radial capsular and ligamentous reconstruction is an essential part of this procedure.

Microsurgical repair of peripheral nerve injuries in the upper extremity.

Microsurgical techniques have been used for peripheral nerve repair at the University of Colorado since 1975. The authors prefer a modified fascicular repair. The rationale is discussed, surgical technique described, and a preliminary review of functional results presented

Common Problems in Clinical Replantation and Revascularization in the Upper Extremity

The restoration of viability to damaged or amputated tissues may be associated with a variety of unique situational and technical problems. The replantation surgeon must be aware of the many pitfalls which can occur in the care of these serious injuries in order to make appropriate decisions and execute the techniques of microsurgery effectively. The care of these patients begins with an accurate assessment of the injury and the potential functional restoration which can be achieved. It ends following a long rehabilitative and reconstructive effort to maximize ultimate function. All phases of this care are the responsibility of the replantation surgeon who must identify and attempt to solve these unique problems as they arise.

Staged reconstruction of flexor tendons with a silicone rod and a "pedicled" sublimis transfer.

We report the results in 11 cases of secondary flexor tendon reconstruction, employing a silicone rubber rod and a sublimis/profundus tenorrhaphy in the first stage, then hinging out the sublimis tendon on the profundus motor at the second stage. Achievement of a healed proximal tenorrhaphy before the second stage allows (1) inspection of the proximal tenorrhaphy (with assessment of its location, apperance, and strength) and (2) early postoperative motion in a controlled range (with greater confidence in the proximal tenorrhaphy, as rupture after free tendon grafting is not uncommon. The functional results attained were comparable to those in other series of secondary flexor tendon reconstructions.

Complications in hand surgery

Describes the complications and conditions that may develop as a result of injury, disease, or surgery in the upper extremity. Written by an international group of contributors.