Stephen B. Schnall

Negative pressure dressings as an alternative technique for the treatment of infected wounds.

Coverage of wounds caused by infection and subsequent treatment often are variable because of the location of the wound and wound size. Although much research has been done to expand the indications of negative pressure wound treatment systems, little investigation has been done to quantify the reduction of wound size for vacuum-assisted closure treatment in the presence of infection. In this series, 14 patients who had wounds caused by infections were treated with the vacuum-assisted wound closure system. All wounds were greater than 20 cm2. The duration of treatment averaged 10 days (range, 2–27 days), and the initial wound size averaged 70 cm2 (range, 22.5–288 cm2). After the course of treatment, the final wound size averaged 39 cm2 (range, 10–147 cm2). The average wound size reduction was 43%. This method seems to enhance the rapidity of wound reduction, and because it is a closed system of treatment, it has the added benefit of minimizing exposure of staff and other patients to communicable diseases. Vacuum-assisted wound closure systems add another option in the care of musculoskeletal infections.

Trans-Scaphoid, Transtriquetral, Volar Lunate Fracture-Dislocation of the Wrist. A Case Report*

Fracture-dislocations of the carpus represent a spectrum of complex injuries1-3,5-12,14. Accurate description of a specific injury may be difficult because of the number of skeletal and ligamentous structures involved. Some authors have suggested that these injuries represent so-called perilunate injuries, as the mechanism of injury has been noted to follow a pattern about the lunate5,9,10. Moneim described greater arc injuries as those including trans-scaphoid, transcapitate, trans-hamate, and transtriquetral perilunate fracture-dislocations. When the lunate itself is dislocated, the injury is more extensive and classification is more difficult. We report the case of a patient who had an unusual fracture-dislocation of the wrist. The lunate was displaced volarly in conjunction with displaced fractures of the adjacent scaphoid and triquetrum. A twenty-six-year-old, female, right-hand-dominant law student fell from a height of approximately twenty-four feet (7.3 meters). She could not recall the position of the upper extremity at the time of the impact. On examination, the right wrist was markedly swollen and any attempt at motion produced pain. Sensibility was diminished in the distribution of the median nerve and, although deep-pressure sensation was present, light-touch sensation was absent. Circulation to the hand was intact. The only associated injury was a compression fracture of the second lumbar vertebra without neurological deficit. Radiographs of the right wrist showed displaced fractures of the scaphoid and triquetrum as well as volar dislocation of the lunate (Figs. 1-A, 1-B, 1-C, 2-A through 2-B). Fig. 1-A Posteroanterior, oblique, and lateral radiographs showing the trans-scaphoid, transtriquetral, volar lunate fracture-dislocation. Fig. 1-B Posteroanterior, oblique, and lateral …

TISSUE PRESSURES IN PYOGENIC FLEXOR TENOSYNOVITIS OF THE FINGER

We investigated 14 patients with pyogenic flexor tenosynovitis for increased tissue pressures in involved digits. All showed raised pressures, in eight to 30 mmHg or more. These levels are consistent with a compartment syndrome. We describe the results of a modified operative technique which includes irrigation of the sheath and the leaving open of a lateral incision. This also allows early active mobilisation of the finger and has given satisfactory early results.

Unusual capitate fracture: A case report*

Fractures of the capitate without associated carpal bone injuries are rare. Rand et al. reported 13 capitate fractures out of 978 carpal injuries) Only 3 of the 13 were capitate fractures without involvement of other carpal bones and none of those had a 180 ~ fracture displacement. A 180 ~ displaced fracture of the capitate with an associated scaphoid fracture has been documented previously. 2 To our knowledge, there has been no report in the literature of an isolated capitate fracture with 180 ~ displacement.

Abscesses secondary to parenteral abuse of drugs. A study of demographic and bacteriological characteristics.

Seventy-seven patients (eighty-six lesions) who had been seen over a fifteen-month period because of an abscess at the site of injection due to parenteral abuse of drugs were identified in a retrospective review. Forty-one patients (forty-five abscesses) had had cultures before antibiotic therapy. Thirty (73 per cent) of the forty-one patients had isolation of a streptococcal species on culture, with microaerophilic streptococci identified in sixteen. Twenty (49 per cent) of the forty-one patients had isolation of a staphylococcal species. Four of the staphylococcal organisms were identified as oxacillin-resistant Staphylococcus aureus. Two patients who had three abscesses each had different organisms in each abscess. Gram-negative bacilli were identified in the cultures of ten (24 per cent) of the forty-one patients; patients who were forty years old or more had a sixfold greater risk of having gram-negative bacilli. Specimens of the abscess had been obtained from thirty-six patients for culture from twelve to seventy-two hours after the first dose of antibiotics had been given. The microbiological findings in these cultures were similar to those in the cultures of specimens obtained from patients before antibiotics had been given. Five (14 per cent) of thirty-five patients who had been tested for the human immunodeficiency virus had a positive result. This finding emphasizes the importance of surveillance for and precautions against the human immunodeficiency virus in people who abuse drugs parenterally.

The role of prophylactic antibiotics in elective hand surgery.

The current literature has poorly defined the role of antibiotic agents in elective hand surgery. The reason for this may be due to a small number of well-designed studies specifically addressing the efficacy of antibiotics in hand surgery. Our purpose is to critically review the current literature in an attempt to more precisely define the role of prophylactic antibiotics in elective hand surgery.

Culture Results and Amputation Rates in High-Pressure Paint Gun Injuries of the Hand

High-pressure paint gun injuries have been well described in the literature, and the use of antibiotics is recommended as part of their management. However, there is no scientific evidence to support the use of antibiotics. In addition, the type of paint injected (water- versus oil-based) has never been investigated to determine the extent of morbidity resulting from these injuries. This study examines the organisms cultured in wounds resulting from these injuries and whether the type of paint injected had an influence on amputation rates. Charts of 35 patients with high-pressure paint gun injuries to their hands were reviewed. The amputation rate was 50% with oil-based paints and 0% with water-based paints. Forty-seven percent of wound cultures were positive, with gram-negative bacteria found in 58% of isolates. Our findings support the use of antibiotics, which should cover both gram-positive and gram-negative organisms.

Scaphocapitate syndrome in a child associated with a distal radius and ulna fracture.

A case is presented of scaphocapitate fracture syndrome associated with a Salter-Harris type II fracture of the distal radius and ulna occurring in an 11-year-old girl. The proximal fragment of the fractured capitate was rotated 180 degrees. The injury was treated by open reduction and internal fixation. One year after the injury, radiographs showed that fractures were united with no signs of avascular necrosis of the capitate. The patient had a full range of motion of the wrist, as well as full pronation and supination of the forearm. An awareness of this fracture entity is necessary to correctly diagnose this injury in a child.

Accuracy of the preoperative examination in Zone 5 wrist lacerations

Fifty patients were studied to determine the accuracy of the preoperative physical examination in flexor tendon Zone 5 wrist lacerations. Initially, a retrospective review of the charts of 33 patients who were examined by a second- or third-year postgraduate physician was done. An average of three errors per examination was found. Then a prospective study of 17 patients was performed to see if an examiners level of training in hand surgery influenced the accuracy of the examination. Error rates improved slightly with experience. Ninety-seven examinations were performed in the combined prospective and retrospective studies, and only 13 were completely correct. Nearly 1/2 of all examinations had three or more errors. If a structure had been lacerated, the injury was not detected 33% of the time on the preoperative examination. The size and mechanism of injury of the skin laceration did not correlate with the number of structures that were cut.

New onset diabetes mellitus in patients presenting with extremity infections.

Although a relationship between diabetes and extremity infections has been established, the current literature notes little regarding the initial diagnosis of a patient’s diabetic condition being made at the time of presentation with an extremity infection. The current study is an analysis of patients with extremity infections being diagnosed with diabetes for the first time. A chart review of 1166 patients who were admitted to the orthopaedic infection service revealed 385 patients with an admission glucose of 120 mg/dL or greater. One hundred seventy-four of these patients (45%) were diagnosed with diabetes. Thirty of these 174 patients (17.2%) previously had not been diagnosed with diabetes.