Management of flexor tendon injuries in the digits: an update.

Currently used techniques of flexor tendon repair and methods of postoperative rehabilitation differ significantly from those used still 10-15 years ago. Techniques of the repair evolved from 2-strand sutures (the Kessler suture) in the direction of much stronger 4-strand and 6-strand sutures (the Adelaide and Savage sutures), what reduced the risk of failure of the repair and made possible more intensive rehabilitation. Also rehabilitation regimes changed on more comfortable for patients than older protocols and allowed to achieve better functional outcomes of the treatment. This study presents updated trends in management of flexor tendon injuries in the digits, with regard to operative technique and postoperative rehabilitation protocols.

Difficult iatrogenic bile duct injuries following different types of upper abdominal surgery: report of three cases and review of literature.

BACKGROUND: Iatrogenic bile duct injuries (BDIs) are mostly associated with laparoscopic cholecystectomy but may also occur following gastroduodenal surgery or liver resection. Delayed diagnosis of type of injury with an ongoing biliary leak as well as the management in a non-specialized general surgical units are still the main factors affecting the outcome. CASE PRESENTATION: Herein we present three types of BDIs (Bismuth type I, IV and V) following three different types of upper abdominal surgery, ie. Billroth II gastric resection, laparoscopic cholecystectomy and left hepatectomy. All of them were complex injuries with complete bile duct transections necessitating surgical treatment. All were also very difficult to treat mainly because of a delayed diagnosis of type of injury, associated biliary leak and as a consequence severe inflammatory changes within the liver hilum. The treatment was carried out in our specialist hepatobiliary unit and first focused on infection and inflammation control with adequate biliary drainage. This was followed by a delayed surgical repair with the technique which had to be tailored to the type of injury in each case. CONCLUSION: We emphasize that staged and individualized treatment strategy is often necessary in case of a delayed diagnosis of complex BDIs presenting with a biliary leak, inflammatory intraabdominal changes and infection. Referral of such patients to expert hepatobiliary centres is crucial for the outcome.

Acute liver injury, acute liver failure and acute on chronic liver failure: A clinical spectrum of poisoning due to Gyromitra esculenta.

Gyromitra esculenta, also known as "false morel" is one of the most poisonous mushrooms. This species is found all over the world, growing in coniferous forest in early spring time. Common manifestation of poisoning includes gastrointestinal symptoms which include varied degrees of liver impairment. We describe three cases: acute liver injury, acute liver failure and acute-on-chronic liver failure due to G. esculenta poisoning. At admission patients presented with encephalopathy and features of liver failure. Two of them recovered completely following supportive management while the remaining patient who also had preexisting liver disease developed multiorgan failure and subsequently died. Although a rare occurrence, G. esculenta poisoning should be considered in the differential diagnosis of acute liver failure.

[Is computed tomography scanning necessary in every case of minor head trauma? Clinical and tomographic analysis of a cohort of patients]. / Czy badanie tomografii komputerowej jest konieczne w kazdym przypadku lekkiego urazu glowy? Analiza materiatu klinicznego i radiologicznego grupy chorych.

INTRODUCTION: The objective of the study was an assessment of the occurrence of traumatic cerebral lesions and skull fractures in patients with mild head trauma. A total of 171 patients' notes, 89 male (52%) and 82 female (48%), mean age 48 years, were subjected to analysis. RESULTS: Of the 171 patients, in 58 (34%) CT scanning of the head was not performed for various reasons, and these patients were discharged home. Of the remaining 113 persons, who had head CT performed, in 99 (88%) no abnormalities were found; in 10 (9%) CT scans revealed pathological findings unrelated to the trauma: most frequently cortical-subcortical atrophy followed by old post-stroke foci, and in 4 patients (3%) post-traumatic pathologies: skull fractures in 2 and facial bone fractures in 2. Diagnosis of these fractures did not change the conservative treatment of these patients, but only prolonged in-patient stay for 2-3 days. All skull and facial bone fractures occurred in patients who were alcohol intoxicated, were lying, could not maintain vertical position, or who had the "racoon eyes" sign. CONCLUSIONS: The results of our study show that lack of abnormalities in neurological examination in patients after mild head injury is a reliable indicator for omitting CT scanning, because the risk of overlooking brain injuries in these patients is minimal. However, patients who are intoxicated, have problems with maintaining a vertical position and have the "racoon eyes" sign, are likely to have skull or facial fractures, and CT scanning is therefore justified. Considering these precursors (guidelines) and the use of clinical decision rules described in the article may reduce the number of head CT scans performed "just in a case".

[Bi-compartmental gall bladder with the distal part filled with stones and inflamed, and the proximal part not involved ­ a case report].

Anatomical anomalies of extra-hepatical biliary ducts are fairly common, occurring in about 16% of patients. The most common anomaly is an atypical course of the cystic duct and its outlet to the common hepatic duct. Anomalies of the gall bladder are less common and rarely presented, due to their minor clinical relevance. The paper presents the case of a female patient with a two- -compartment gall bladder, the distal part of which was filled with biliary stones and in􀏐lamed, whereas the proximal part contained no stones and was not involved. The operation, although difficult because of the atypical anatomy and inflammatory infiltration, was uneventful, and the patient eventually recovered.

Distal radioulnar joint instability: a review of literature.

Distal radioulnar joint instability most commonly accompanies fractures of the distal radius and is directly caused by lesion of the triangular fibrocartilage complex, which is the major structure responsible for congruity of the distal radioulnar joint. Acute instability accompanying fractures of the distal radius usually does not require separate management, if the fracture itself is firmly fixated. Chronic instabilities causing persistent pain and wrist dysfunction are treated by arthroscopic reinsertion of the torn attachments of the triangular fibrocartilage. If not possible, radioulnar functional tenodesis is performed using palmaris longus tendon graft, thus restoring joint stability.

Outcome of treatment of complex, perilunate fracture-dislocation of the wrist: a case report.

Complex, perilunate fracture-dislocations of the wrist comprise severe and challenging injuries, characterised by a total loss of contact between the lunate bone and the head of the capitate as well as fracture of one, or more bones surrounding lunate bone. The principle of treatment of such injuries involves stable fixation of fractures, anatomical reduction of the displaced carpal bones with temporary arthrodesis wit K-wires to maintain their position. We present a patient who sustained a complex, perilunate fracture-dislocation of the wrist with fractures of the scaphoid, hamate and base of the IV metacarpal bone, as a result of a blast. Assessment at one year after the surgery showed satisfactory result: mean range of motion in the wrist was 50-60% of the healthy side, grip strength was 55%, DASH score of 36 and Mayo score of 65.

Analysis of the reliability of clinical examination in predicting traumatic cerebral lesions and skull fractures in patients with mild and moderate head trauma.

UNLABELLED: The aim of the study was to assess the reliability of neurological examination and other factors in predicting traumatic cerebral lesions and skull fractures in patients with mild and moderate head trauma (GCS 10-15). MATERIAL AND METHODS: Over a one-year period, 227 patients: 145 male and 82 female, aged a mean of 51 years who sustained mild or moderate head trauma (GSC 10-15) were examined neurologically and had performed head CT scans. The neurological examination as a whole and each finding of the neurological examination were tested as predictors of the presence of traumatic abnormalities in the head CT scan. RESULTS: Post-traumatic lesions in head CT scan were found in 109 patients (48%): skull fractures in 66 of these and brain injuries in 94; fifty-eight patients had skull fracture combined with brain injury. Seventeen patients required neurosurgical intervention (hematoma evacuation). Abnormal neurological examination showed the highest reliability in identifying patients with brain injuries in CT (sensitivity 87%, specificity 79%). Of single findings, gait abnormalities and consciousness disturbances, present in sober patients, were the strongest predictors of cerebral lesions. Likewise, abnormal neurological examination was the best indicator of skull fractures (sensitivity 77%, specificity 63%). Gait abnormalities and "raccoon eyes" present in alcohol intoxicated patients were the strongest individual predictors of skull fractures. CONCLUSION: Results of our study show neurological abnormalities as the most reliable (although not 100% accurate) in identifying patients who are likely to have brain injuries and/or skull fracture following head trauma. Use of clinical decision rules may reduce the number of head CT scans performed "just in case".

The management of scapholunate wrist instability: a review.

An injury to the ligament linking the scaphoid with the lunate is the most common and and budrened with the most negative sequelae cause of the carpal instability. It occurs most frequently as an associated injury at fractures of the distal radius. A review of methods of treatment of the pathology is provided, according to clinical advancement, duration form original trauma and condition of articular structures. Technical complexity of methods is directly related to severity of intrarticular changes. In early, dynamic instabilities, a simple, temporary scapholunate arthrodesis with K-wires is is an useful procedure, preventing further development of chronic instsbility. In later stages. The treatment is technically more demanding, considering re-alignment of carpal anatomy with ligaments or tendons (capsulodesis or tenodesis). An usefulness of arthroscopy in diagnostics and management at any stage of this pathology was emphasized.

[Scapholunate instability of the wrist--a review]. / Niestabilnosc lódeczkowo-ksiezycowata nadgarstka--przeglad pismiennictwa.

Injury to the scapholunate ligament is considered the most common and burdened with the most negative squeals cause of the carpal instability. The article provides information on the functional anatomy of the scapholunate complex and the consequences of the tear of the ligament that joints these bones. Rupture of this ligament, associated with tear of extrinsic (secondary) stabilizers of the wrist leads on to dislocation of the carpal bones one against another and, finally, results in carpal instability. Classifications of the severity of the instability based on radiological and arthroscopic grounds were presented. Clinical symptoms and signs of the condition were described as well as imaging techniques helpful in its diagnosing. The usefulness of arthroscopy was emphasised in diagnosing of scapholunate complex disturbances, particularly those which are negative radiologically and present with no typical symptoms.

[Use of questionnaires in outcome measurement in hand surgery]. / Zastosowanie kwestionariuszy w ocenie wyników leczenia w chirurgii reki.

An assessment of outcomes of the treatment of the diseases and injuries to the hand should include both objective parameters, i.e. range of motion or grip strength, and subjective parameters i.e. intensity of complaints or dexterity of the hand in various tasks of daily activity. Questionnaires were developed to evaluate subjective parameters in objective and systematic manner. They indeed allow us to better apprehend what is important from our patients' perspective. Questionnaire (called also form or test) is a list of queries concerning the issue being a subject of the assessment. The queries are designed in the way allowing answers to imply an important and possible objective information on the problem of interest. The objective of this article was to attract notice on the problems associated with the use of questionnaires in a research, with particular attention on hand surgery. Authors referred to the parameters which characterise these instruments: responsiveness, validity and reliability. Brief descriptions of most commonly used forms were provided, including DASH, Levine, PEM, Michigan and CISS. Shortcomings and pitfalls associated with the use of questionnaires and possible sources of bias were emphasised, e.g. difficulties in precise assignation of scores, answering some particular questions and accuracy of the completion of the form. Attention was paid on the choice of the questionnaire to be well-matched for an aim of a given research project both in substantial and formal manner. An opinion was supported that modem research projects measuring outcomes in hand surgery must include questionnaires as an obligatory component of a complex assessment.