Juvenile xanthogranuloma of the finger.

We present an unusual instance of juvenile xanthogranuloma occurring in the hand. A 23-month-old girl had a mass on the radial aspect of the right third finger at the distal interphalangeal joint that extended to the collateral ligament. The lesion was histologically diagnosed as a juvenile xanthogranuloma after resection of the mass. Juvenile xanthogranuloma is uncommon in the hand, and only three patients with this condition occurring in the digits have been reported in the English language literature. The clinical presentation, diagnosis, and treatment are discussed.

Hand infections: basic principles and management.

BACKGROUND: An untreated hand infection can lead rapidly to tissue destruction and permanent disability. METHODS: Review of the pertinent English literature. RESULTS: Early diagnosis and timely, effective intervention is crucial to treatment. Anatomically, the hand consists of multiple potential spaces and tissue planes that can become infected with a wide variety of organisms. Thus, a working knowledge of hand anatomy as well as pharmalogical therapies is imperative for successful management. CONCLUSIONS: Knowledge of the basic principles of hand care, relevant anatomy, infectious organisms, and clinical signs of an unusually aggressive infection greatly improves treatment efficacy.

Forearm compartment syndrome: anatomical analysis of surgical approaches to the deep space.

Forearm compartment syndrome is a surgical emergency that usually requires release of the superficial muscle compartments. In some clinical situations it is imperative to also explore the deep muscle compartments. There are no anatomical guides for surgical exploration of the deep compartments that would minimize collateral damage to surrounding vessels, nerves, and muscles. Surgical injury in the setting of ischemia, especially vascular injury, compounds the tissue damage that has already occurred. The authors evaluated four surgical approaches (three volar and one dorsal) to the deep forearm by performing detailed anatomical dissections on 10 embalmed and plastinated cadavers. They used a scoring system to rate the approaches for their ability to visualize the deep space without causing iatrogenic injury to superficial muscles, arteries, and nerves. In the volar forearm, an ulnar approach to the deep space is simple, causes the least iatrogenic surgical injury, and provides access to the deep volar forearm structures. The plane of dissection is between the flexor carpi ulnaris and the flexor digitorum superficialis. Dividing one or two distal segmental branches of the ulnar artery to the distal flexor digitorum superficialis exposes the pronator quadratus. Lifting the ulnar neurovascular bundle with the flexor digitorum superficialis in the middle third of the forearm exposes the flexor digitorum profundus and the flexor pollicis longus. This approach to the deep space requires no sharp dissection. In the dorsal forearm, a midline approach between the extensor digitorum communis and the extensor carpi radialis brevis is simple and safe.

Botox and collagen for glabellar furrows: advantages of combination therapy.

Plastic surgeons frequently administer botulinum toxin A (Botox) or collagen as monotherapy to treat glabellar furrows. This study evaluates the possible advantages of combination therapy. Sixty-five patients with moderate to severe glabellar rhytids were prospectively randomized to receive standard injections of Botox, Zyderm II collagen, or a combination. Improvement in rhytids was assessed over 3 months using patient satisfaction scores and an independent physician evaluation. Baseline wrinkle severity was similar in all 3 groups. By 1 month posttreatment, the combination arm showed significantly greater improvement in furrows (79% compared with only 56% and 50% in the Botox and Zyderm arms, respectively; P < 0.05). At 3 months postinjection, the dual-therapy arm maintained better improvement (57% versus 33% and 27% in the monotherapy arms; P < 0.05). Patient satisfaction further highlighted the superiority of the combination approach. By simultaneously addressing the static and dynamic aspects of glabellar furrows, dual therapy provides optimal treatment of this problem.

COX-2 up-regulation in idiopathic carpal tunnel syndrome.

The objective of this study was to determine whether cyclooxygenase-2 (COX-2) is up-regulated in the synovium of patients with carpal tunnel syndrome. Twenty patients were enrolled: 16 consecutive patients with carpal tunnel syndrome and four control patients (exploration for non-carpal tunnel syndrome-related wrist or forearm pathology). Clinical data (demographics, pertinent history, symptomatology) were obtained preoperatively. Flexor tenosynovial tissue was isolated from all patients and clinically graded as thin, intermediate, or thick. Histologic evaluation was conducted to rule out the presence of inflammatory cells. Immunohistochemical staining for COX-2 was performed. The immunohistochemical data were confirmed by reverse transcriptase-polymerase chain reaction analysis of COX-2 mRNA. Results showed that the majority of carpal tunnel syndrome specimens (88 percent) showed synovial hypertrophy compared with 0 percent of the controls (p < 0.05). Also, 69 percent of carpal tunnel syndrome specimens (11 of 16) versus 0 percent of controls (zero of four) stained positively for COX-2 (p < 0.05). Of the carpal tunnel syndrome patients, 91 percent of thick specimens versus 33 percent of intermediate specimens versus 0 percent of thin specimens showed COX-2 staining. The authors conclude that synovial hypertrophy is a prominent finding in carpal tunnel syndrome. COX-2 is up-regulated in the tenosynovium of patients with carpal tunnel syndrome, and this upregulation may correlate with the clinical grade of the tenosynovium. The role of COX-2 in carpal tunnel syndrome may be to mediate remodeling of pathologic tissue. To this end, it may be a potential therapeutic target for specific inhibition.

Management strategy for compartment syndrome of the upper extremity arising during anticoagulation or thrombolytic therapy: an increasingly common surgical dilemma.

Compartment syndrome is a documented and potentially lethal complication of thrombolytic therapy. With the increasing use of catheter-directed thrombolytic therapy, a high index of suspicion for the potential occurrence of this surgical emergency must be maintained. Errors of omission in the diagnosis of compartment syndrome, even for a few hours, may lead rapidly to limb loss, renal failure, and possibly death. The authors present a case of compartment syndrome arising in the forearm of a patient being treated with continuous catheter-directed thrombolytic therapy for an occluded arterial bypass graft associated with an ischemic lower extremity. Specific to this presentation is their management of compartment syndrome during thrombolytic therapy as well as previously unreported use of a homograft (cadaveric skin) to control ongoing blood loss from a fasciotomy site in this fully anticoagulated patient. The authors think their management in this case may help to provide direction to others faced with a similar, increasingly common, surgical dilemma.