Mycobacterium chelonae infection of the hand presenting as a collar-button abscess.

Mycobacterial infections of the hand are extremely rare, with Mycobacterium chelonae being an especially uncommon source of infection. The following is a report of such an infection presenting as a collar-button abscess. The difficulty of isolating the organism, in addition to a low index of suspicion for it, resulted in a significant delay in appropriate treatment. The patient demonstrated an indolent course of infection and unresponsiveness to traditional treatments, both red flags that should raise concern for a mycobacterial cause. Eventually, repeated irrigation and debridement and a prolonged course of antibiotics resulted in the resolution of the patient's symptoms.

Current treatment concepts for "terrible triad" injuries of the elbow.

Elbow fracture-dislocations destabilize the elbow, preventing functional rehabilitation. If left untreated, they commonly result in functional compromise and poor outcomes. The "terrible triad" injury is classically described as a combination of a coronoid process and radial head fractures, as well as a posterolateral elbow dislocation. Surgical treatment to restore stable elbow range of motion has evolved in the past few decades based on increased understanding of elbow biomechanics and the anatomy of these injuries. This article highlights current concepts in the treatment of these complicated injuries.

Use of emergency department services for hand, wrist, and forearm fractures in the United States in 2008.

The objective of this study was to determine demographic characteristics and epidemiology of hand, wrist, and forearm fracture patients treated in the emergency departments (EDs) to identify the at-risk populations. The Nationwide Emergency Department Sample database collected by the Agency for Healthcare Research and Quality was used to estimate ED visits for hand, wrist, and forearm fractures during 2008. The overall rate of ED visits for these injuries was 54 per 10,000 population. Children aged 6 to 15 had the highest rate of ED visits at 124 per 10,000. A secondary increase in ED visits occurred at age 50 and rose with age. Metacarpals were the most common fracture location in adults aged 16 to 25, while radius and ulna were the most common fracture location in all other age groups. Demographic analysis identified children, adult males aged 16 to 25, and the elderly as target populations for preventive interventions.

Current indications for and the technique of wrist arthroscopy.

Since its introduction more than 30 years ago, wrist arthroscopy has become an essential diagnostic and therapeutic tool in hand surgery. This procedure minimizes exposures and allows access to otherwise remotely located anatomic regions with minimal morbidity. Advances in anatomic understanding and wrist scope technology have standardized the procedure and expanded indications. Current applications are diagnostic staging of various wrist pathologies where arthroscopy allows for a direct, magnified, and tactile-assisted examination. This includes injuries to the triangular fibrocartilage complex (TFCC), osteochondral lesion of the carpus, and dynamic assessment of carpal instability and radiocarpal arthritis. Therapeutic applications have continued to expand and include arthroscopic-assisted fracture reductions, treatment of radiocarpal synovitis and arthritis, TFCC repairs, and arthroscopic management of soft tissue pathologies such as ganglion excisions and release of contractures.

Current concepts in the treatment of distal radial fractures.

Distal radial fractures are among the most commonly encountered traumatic fractures of the upper extremity. Initial trauma mechanism, fracture pattern, associated injuries, and patient age influence treatment and outcome. Although stable fractures are commonly treated conservatively, the past decade has seen changes in surgical practice and techniques. Indications for surgery have been extended and refined based on new insight into the pathophysiology of the distal end of the forearm and technological advances in implant design. Despite the frequency of this fracture, only limited higher-level evidence exists to guide practitioners in decision making for this injury. This article highlights key concepts in the treatment of distal radial fractures and summarizes current evidence.

Current surgical instrument labeling techniques may increase the risk of unintentionally retained foreign objects: a hypothesis.

BACKGROUND: Marking of surgical instruments is essential to ensure their proper identification after sterile processing. The National Quality Forum defines unintentionally retained foreign objects in a surgical patient as a serious reportable event also called "never event." PRESENTATION OF THE HYPOTHESIS: We hypothesize that established practices of surgical instrument identification using unkempt tape labels and plastic tags may expose patients to "never events" from retained disintegrating labels. TESTING OF THE HYPOTHESIS: We demonstrate the near miss of a "never event" during a surgical case in which the breakage of an instrument label remained initially unwitnessed. A fragment of the plastic label was accidentally found in the wound upon closing. Further clinical testing of the occurrence of this "never event" appears not feasible. As the name implies a patient should never be exposed to the risk of fragmenting labels. IMPLICATION OF THE HYPOTHESIS: Current practice does not mandate verifying intact instrument markers as part of the instrument count. The clinical confirmation of our hypothesis mandates a change in perioperative practice: Mechanical labels need to undergo routine inspection and maintenance. The perioperative count must not only verify the quantity of surgical instruments but also the intactness of labels to ensure that no part of an instrument is left behind. Proactive maintenance of taped and dipped labels should be performed routinely. The implementation of newer labeling technologies - such as laser engraved codes - appears to eliminate risks seen in traditional mechanical labels.This article reviews current instrument marking technologies, highlights shortcomings and recommends safe instrument handling and marking practices implementing newer available technologies.

Retained palmar foreign body presenting as a late hand infection: proposed diagnostic algorithm to detect radiolucent objects.

BACKGROUND: Penetrating injuries to the hand can compromise important anatomic structures, and persisting foreign objects may become a source of infection. Foreign body intrusions into the hand are among the most common injuries to the upper extremity seen in the Emergency Department. Radiolucent organic objects, as well as a few higher density inorganic materials such as plastic, present a diagnostic challenge and are routinely missed using standard radiography. While the literature describes the use of high-frequency ultrasound as an adjunct to conventional diagnostics, to our knowledge, no formal algorithm has been published. CASE PRESENTATION: We describe a case of incomplete wooden splinter removal, presenting as a late midpalmar abscess five months after the initial injury, and requiring two subsequent surgical explorations for definitive treatment. This case has led us to implement a formal diagnostic pathway including high-frequency ultrasound at our institution. We contrast this presentation with a subsequent case involving a much smaller wooden palmar foreign body that was easily identified under ultrasound and removed without sequelae. CONCLUSION: Many hand injuries are caused by low density, radiolucent foreign bodies. These objects can easily escape traditional evaluation in the emergency room including standard radiography. We present an algorithm implementing high frequency ultrasound to minimize the risk of missing radiolucent penetrating foreign objects in the hand.

Skin grafts provide durable end-bearing coverage for lower-extremity amputations with critical soft tissue loss.

Lower-extremity amputations in the presence of soft tissue loss represent an unresolved conundrum because surgeons must consider sacrificing bone length to obtain adequate soft tissue coverage. Local flaps and microvascular soft tissue transfers are established strategies for maintaining residual limb length. However, the use of skin grafts remains controversial due to the presumed inferiority compared with flaps with regard to enabling prosthetic fitting and full weight bearing. The current study was designed to test the hypothesis that split-thickness skin grafts represent a safe and feasible option to preserve bone length in lower-extremity amputations with critical soft tissue loss.