Reducing patient discomfort during digital blockade: The subcutaneous single injection digital block - A simple, safe and fast procedure.

BACKGROUND: Regional anesthesia of a single finger is commonly achieved by the traditional ring block, which requires at least two painful injections in the digit. Single injection digital block techniques have been described to avoid this problem. Among these, the subcutaneous technique described by Harbison appears to be safe and to allow most procedures to be carried out with good tolerance. OBJECTIVES: A prospective study was designed to evaluate the results of the subcutaneous technique in terms of patient tolerance, distribution of anesthesia and efficiency. METHODS: All blocks were performed by a single investigator. A visual analog scale was used to evaluate pain associated with the injection. Prick testing was used to evaluate the quality of anesthesia at the volar and dorsal aspects of the phalanxes. Tolerance to the surgical procedure and the need for additional injections were also recorded. RESULTS: This technique allowed surgery to be performed without complementary injection most of the time and was very well tolerated. The dorsum of the proximal phalanx, however, was unpredictably included in the anesthetized territory. CONCLUSION: The subcutaneous single injection digital block is safe, efficient and easy to perform. It allows the treatment of all conditions on the volar aspect of the finger and on the dorsal aspect of the distal and middle phalanxes. For surgery on the dorsal aspect of the proximal phalanx, a combined single injection technique or a supplementary dorsal block should be used.

CONTEXTE: L'anesthésie régionale d'un seul doigt se réalise généralement par le traditionnel bloc en bague, qui exige au moins deux injections douloureuses. Il semblerait que les techniques d'anesthésie à une seule injection résoudrait le problème. Parmi celles-ci, la technique d'injection sous-cutanée décrite par Harbison serait sûre tout en permettant à la plupart des interventions d'être bien tolérées. OBJECTIF: Étude prospective visant à évaluer les résultats de la technique d'injection sous-cutanée au regard de la tolérance, de l'étendue de l'anesthésie et de son efficacité. MÉTHODE: Toutes les anesthésies en bloc ont été effectuées par le même chercheur. L'intensité de la douleur associée à l'injection a été évaluée à l'aide d'une échelle visuelle analogue. Un test par piqûre a servi à évaluer la qualité de l'anesthésie sur les faces antérieure et postérieure des phalanges. La tolérance à l'intervention chirurgicale et le besoin d'injections supplémentaires ont également été notés. RÉSULTATS: Dans la plupart des cas, l'intervention a été très bien tolérée, sans recours à une injection supplémentaire d'anesthésique. Toutefois, le dos de la phalange proximale était compris de façon imprévisible dans le territoire anesthésié. CONCLUSION: L'anesthésie du doigt par une seule injection sous-cutanée s'avère simple, sûre et efficace. Elle permet de traiter tous les troubles sur la face antérieure du doigt ou sur la face postérieure des phalanges médianes et distales. Quant aux interventions pratiquées sur la face postérieure des phalanges proximales, il faudrait recourir à une technique mixte à une seule injection ou à une anesthésie complémentaire du dos du doigt.

Single injection digital block: comparison between three techniques.

INTRODUCTION: Regional anesthesia of a single finger is commonly achieved by the traditional ring block. The major drawback of this technique is the need for at least two painful injections in the digit. Single injection techniques have been described. A comparison of their results could help health professionals select the most appropriate technique. MATERIAL AND METHODS: A prospective randomized study was designed to compare three techniques in term of patient tolerance, distribution of anesthesia and efficiency: the modified transthecal digital block, the subcutaneous digital block and a combination of the two. Digits were randomized in three groups (n = 30). Blocks were performed by a single investigator. A visual analogic scale was used to evaluate pain associated with the injection. Prick-testing was used to evaluate anesthesia at the volar and dorsal aspects of the phalanxes. Statistical analysis of the results was performed. RESULTS: All techniques allowed surgery to be performed without complementary injection most of the time (25/30). The dorsum of the proximal phalanx, however, was unpredictably included in the anesthetized territory. The highest rate of full digital block was achieved with the combined technique. DISCUSSION: The least invasive of equally effective techniques should be considered as the first choice. The subcutaneous single injection digital block is safe, efficient and easy to perform. It allows treatment of all conditions on the volar aspect of the finger and on the dorsal aspect of the distal and middle phalanxes. For surgery on the dorsal aspect of the proximal phalanx, a supplementary dorsal block should be used.

Percutaneous Herbert screw fixation for fractures of the scaphoid: review of 30 cases.

INTRODUCTION: The purpose of this study was to evaluate the results of percutaneous fixation of undisplaced or minimally displaced fractures of the scaphoid using the first generation Herbert screw in terms of union, functional results and scaphoid mobility. METHODS: 30 of the 50 patients operated on in our department between 1995 and 2000 were available for evaluation by an independent observer. Wrist mobility, grip strength and key pinch were measured. Scaphoid mobility was evaluated by measuring radioscaphoid angles in flexed and extended positions on dynamic X-rays. RESULTS: The union rate was comparable to that achieved by non-operative management (90%). Resumption of professional activities was possible long before bony union because immobilization was short. Grip strength, wrist and scaphoid mobilities were comparable to the controlateral sides except for scaphoid flexion. Persistent symptoms were found in 30% of the patients despite union of their fracture. DISCUSSION: Our results demonstrate that percutaneous stabilization of undisplaced or minimally displaced fractures of the scaphoid preserves the mobility of the wrist and minimally alters the normal dynamics of the carpus. The duration of work inability is short.

Atypical mycobacterial infections of the hand: report of eight cases and literature review.

INTRODUCTION: Atypical mycobacteria are an uncommon cause of hand infections in immunocompetent patients. Diagnosis is often delayed, with consequent increased morbidity. Better awareness would allow earlier diagnosis and treatment. MATERIAL AND METHODS: Eight patients with atypical mycobacterial hand infections treated in our department over a 21 year period have been retrospectively identified. Their charts have been searched for the general characteristics of these infections, treatment and outcome. Our findings have been compared to the data collected from a literature review. RESULTS: These pathogens have caused soft tissue infections in otherwise healthy patients. Clinical signs were those of chronic finger or wrist synovitis or skin granulomas. Carpal tunnel syndrome was a common finding. Diagnosis relied on surgical biopsy. Germ identification required specific incubation temperature and media. Antibiotics and synovectomy have been the mainstay of therapy. DISCUSSION: In a patient with achronic, relapsing, superficial or deep skin infection or tenosynovitis, aquatic and farm exposures are important anamnestic keys to diagnosis. Extensive synovectomy is both diagnostic and therapeutic. Specific cultures should be ordered without delay. Oral pharmacotherapy should be initiated upon clinical suspicion.

[Linburg-Comstock syndrome. Epidemiologic and anatomic study, clinical applications]. / Syndrome de Linburg-Comstock. Etude épidémiologique et anatomique, application clinique.

The Linburg-Comstock (LC) syndrome is distinguished by the inability to actively flex the interphalangeal (IP) joint of the thumb without simultaneously flexing the distal IP joint of the index finger. Any resistance to this 'parasitic' reaction causes pain on the palmar side of the wrist or in the distal part of the forearm; this is due to an anomalous tendinous connection between the flexor pollicus longus (FPL) and the flexor digitorum profundus (FDP). An epidemiological study was carried out on 264 individuals (a total of 528 hands were examined), and the LC syndrome was found in 98 subjects (37%); women were more frequently affected than men, and bilaterally rather than unilaterally. In addition, we dissected 26 fresh cadaver upper limbs, and in seven cases found an anomalous connection between FPL and FDP. We also examined the case of a young violinist with bilateral LC syndrome, who complained of pain in the distal part of the left forearm after prolonged musical exercises. Surgical investigation determined a complete fusion between FPL and FDP of the index with a common tendon. Treatment consisted of splitting this common tendon to form two separate tendons, thereby permitting a certain degree of independence between the thumb and index finger, and which considerably improved the violinist's musical performance. A review of the literature showed that there was a large quantity of anatomical descriptions available on these types of connection. Certain publications also provide an extremely precise report on the anthropological significance of these anomalies.

Acute anterior forearm compartment syndrome following wrist arthrodesis.

The authors report a case of anterior compartment syndrome in the forearm following total wrist arthrodesis via a dorsal approach. As far as they know this is the second case reported.

Closed rupture of both flexor tendons of the fifth finger due to a calcium hydroxyapatite deposit in the carpal tunnel.

A closed rupture of both flexor tendons of the fifth finger is reported. The most probable cause was an amorphous deposit of calcium hydroxyapatite between the hamulus of the hamate bone and the pisiform bone. The flexor apparatus was reconstructed with a reinforced superficialis flexor tendon from the ring finger.

[Intestinal bypass in the treatment of obesity. Results of 14 cases (author's transl)]. / Les courts-circuits jéjuno-iléaux dans le traitement de l'obésité. 14 observations personnelles.

Fourteen women with severe obesity resistant to previous dietetic measures underwent intestinal bypass using Scott's method. Weight loss ranged from 1-2 kg to 50 kg (mean = 25 kg) but weas unpredictable and varied from patient to patient; most remained obese. The other results of the operation were similar to those already reported. There was a decrease in total plasma cholesterol, while HDL cholesterol remained normal. Calcaemia was in the lower range of normal values; one patient developed severe hypokaliaemia (1.8 mEq); low blood magnesium levels and steatorrhoea were common. Fibrosis of the liver was observed in one patient and probably in another. Five patients were re-operated upon for incisional hernia or intestinal occlusion. Other complications reported in the literature (pulmonary embolism, arthralgias, kidney stones and gall stones) did not occur in this series. Because of these complications we decided to stop using intestinal bypass for the treatment of severe obesity. However, in view of the potential dangers of severe obesity we feel that other surgical techniques, such as Mason's gastric bypass, should be considered in some patients.