Philippe Vostrel

Non-tuberculous mycobacterial infections of the hand

UNLABELLED Non-tuberculous mycobacterial infections of the hand are difficult to treat and require a long time before remission. But how long should we wait to see an improvement? To answer this question, the published scientific literature was reviewed in English, French and German. Tuberculosis, arthritis and osteomyelitis cases were excluded. A total of 241 non-tuberculous mycobacterial hand infections in 38 scientific publications were retrieved. Most were case reports or series. The median age of the patients was 58years and one third was female. Patients were immunocompromised in 17 episodes. The most common species were Mycobacterium marinum in 198 episodes (82%), followed by M. chelonae in 13 cases (5%). There were no cases of mixed infection. Most infections were aquatic in origin and community-acquired, and were treated with a combination of surgical debridement and long-duration systemic combination antibiotic therapy (14 different regimens; no local antibiotics) for a median duration of 6months. The median number of surgical procedures was 2.5 (range 1-5). Clinical success was not immediate: a median period of 3months (range 2-6) was necessary before the first signs of improvement were observed. The majority (173 cases; 76%) remained entirely cured after a median follow-up time of 1.7years (range, 1-6). Only two microbiological recurrences occurred (1%). However, 49 patients (21%) had long-term sequelae such as pain, stiffness and swelling. The approach of long-duration antibiotic treatment in combination with repeated surgery for mycobacterial soft tissue infections of the hand leads to few recurrences. However, clinical success is not immediate and may take up to 3months. TYPE OF STUDY Therapeutic study: systematic review of level III studies. LEVEL OF EVIDENCE III.

Third degree formic acid chemical burn in the treatment of a hand wart: a case report and review of the literature

ObjectiveCutaneous warts are very common and a large variety of topical treatments and drugs can be employed to cure these skin injuries that can arise on any part of the body. But are these products really safe?MethodWe performed a case description and PubMed literature review using key words “wart,” “chemical burn,” and “formic acid.” All articles in English and French were selected.ResultsThis is the first report of a chemical burn by formic acid in the treatment of warts. Numerous topical treatments for cutaneous warts are available with many new drugs appearing every year. However, only a few treatments have proven their effectiveness, such as salicylic acid or cryotherapy with liquid nitrogen that are commonly used. Moreover, most cutaneous warts will resolve spontaneously without any treatment and several products, including topical acids and cryotherapy devices, presented adverse effects such as chemical burns or frostbites so demonstrating that even frequently used treatments can be harmful.ConclusionTopical treatments used for wart removal are not without risk even if some products are sold without prescription. For self-treatment products, we recommend enhanced warning by the pharmacist about the risks involved.

Dorsal approach and internal fixation of impacted intra-articular distal radius fractures with 2.4 mm locking plates

The treatment of impacted distal radius fractures is complex. Internal fixation by a dorsal approach with arthrotomy should be considered, particularly when the fractures are dorsally comminuted. This was a retrospective, observational study of 26 patients operated between 2008 and 2012 who were reviewed in September 2013. In the surgical procedure, a single dorsal incision was made over the distal radius and arthrotomy performed; the fracture site was stabilized with two 2.4mm locking plates. The average follow-up was 39months. All fractures were type 23C in the AO classification. All patients were assessed with the QuickDASH and Mayo Wrist scores. Total range of motion was 82% of the contralateral side. Grip strength was 30kg in average. The mean radial sagittal tilt was +6° postoperatively. No plate movement or intra-articular screws were present. Four patients developed symptomatic early osteoarthritis. Thirteen patients had the plate removed due to discomfort. No tendon ruptures were observed. The dorsal approach remains a treatment option for specific intra-articular fractures. It offers direct intra-articular congruency control, along with a stable buttress and locking fixation for early mobilization. Our results are comparable to those using other surgical techniques for this type of high-energy fracture.

Accuracy of High-Resolution Ultrasound for Evaluating Soft Tissue Tumours of the Hand and Wrist

Abstract Objectives: High resolution ultrasound (HRUS) is increasingly popular in the assessment of soft tissue tumours. This retrospective study evaluates the reliability of HRUS in diagnosing soft tissue tumours of the hand and wrist, compared to clinical evaluation, intraoperative findings and histological examination. Methods: Sixty-three patients with soft tissue tumours of the hand and wrist were first evaluated clinically investigated. HRUS was then performed using a 5-17 MHz broadband linear probe, with the radiologist blinded to the clinical interpretation. The patient was scheduled for operation depending upon suspected pathology. Histological examination was routinely obtained during surgery. Results: Thirty-one patients underwent surgery. Of the 16 solid lesions HRUS was right in 15 cases (94%). Only nine of these 16 lesions (56%) were correctly diagnosed on clinical examination (p= 0.041). All 15 cysts were correctly diagnosed by HRUS, whereas clinical examination alone correctly diagnosed a cyst in 14 patients (not significant). Conclusion: No significant difference was found in the differentiation of cystic and solid lesions comparing HRUS and clinical examination. HRUS is significantly better than clinical diagnosis alone in distinguishing the type of solid lesions. Further benefits of HRUS include the identification of atypically localised cysts and improved preoperative planning.