Marjolin's ulcer arising at the elbow: a case report and literature review.

Marjolin's ulcer is a squamous cell carcinoma that develops in posttraumatic scars and chronic wounds. It was first noted to be associated with chronic osteomyelitis in 1835 and is usually described occurring in lower extremity wounds. Suspicion of such lesions should be raised in chronic wounds demonstrating characteristic changes. Impaired immunologic activity in chronic wounds has also been shown to contribute to the pathologic process. Definitive treatment in the past has been amputation proximal to the tumor, however; recently, wide resection and radiation therapy have been used. According to Lifeso et al., wide local excision is unreliable and they recommend amputation in grade II or III disease and wide local excision in very small lesions that can be radically excised or in grade I lesions. We report a case of a Marjolin ulcer that developed at the elbow. Physicians should have a high index of suspicion in chronic wounds that are recalcitrant to therapy and should remember to biopsy all suspected lesions. Early recognition and definitive treatment are the mainstays ensuring the best prognosis.

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.

High-pressure injection injuries to the hand.

High-pressure injection injuries of the hand can lead to devastating outcomes. Amputation rates as high as 48% have been reported. The authors review the history of high-pressure injection injuries, with attention to the materials injected, the clinical presentation of these injuries, emergency room and subsequent definitive surgical management of these injuries, the bacteriology and recommendations for antibiotic use in these injuries, and postoperative management.

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 examiner's 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.

Latissimus dorsi pedicle flap for coverage of soft tissue defects about the elbow.

Sixteen consecutive patients who were treated with a pedicled latissimus dorsi flap for complex soft tissue defects about the elbow were reviewed. The average defect size was 100 cm2. Thirteen of the 16 patients achieved stable wound healing with a single procedure. Three patients had partial necrosis of the latissimus and required additional coverage procedures. We recommend that the latissimus dorsi flap should not be routinely used to cover defects more than 8 cm distal to the olecranon. The flap should be closely monitored in the first 48 hours, drains should be routinely used at the recipient and donor sites, and the elbow should be maintained in an extended position for the first 5 days after the procedure. The latissimus dorsi flap may also have a prophylactic role in selected patients with compromised soft tissue coverage about the elbow. The pedicled latissimus flap can be performed under loupe magnification and requires no microsurgical skills or equipment.

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.

Delayed primary wound closure in upper extremity soft tissue infections.

Health care costs for inpatient care have been escalating. Homeless and indigent patients may be unable to have access to clean toilet facilities to perform adequate wound care. Evaluation of delayed primary closure of upper extremity soft tissue infections after incision and drainage in 34 patients was done. Patients were discharged at an average of 8.3 days (range, 5-21 days). This is 11 days less than the reported average granulation time for wounds to heal. No patient required readmission for surgery, wound care, or intravenous antibiotics. The authors' institution charges a rate of $2800 per patient day. A potential savings of $1,047,200 was realized.

Tissue pressures in pyogenic flexor tenosynovitis of the finger. Compartment syndrome and its management.

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.

Efficacy of immediate postirrigation culture in the treatment of upper-extremity abscesses.

A retrospective chart review of 192 patients of the musculoskeletal infection ward at the authors' facility was performed to assess the value of immediate postirrigation cultures in the treatment of acute soft tissue infections of the upper extremity. Twenty-two patients (11.5%) had postirrigation cultures with an organism that was not present in the preirrigation cultures. All of those organisms not previously found were gram-positive organisms, and no changes were necessary in the initial antibiotic regimes. Immediate postirrigation cultures did not prove to be effective in the information they provided related to treatment of acute soft tissue infections of the upper extremity.

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.

Compartment syndrome associated with infection of the upper extremity.

Compartment syndrome is a potentially devastating entity associated with a great variety of injuries, but to the authors' knowledge there are no known reports of infection documented as a cause. A retrospective review of 263 patients with upper extremity infections admitted to the orthopaedic infection ward during 1992 was conducted to identify patients with compartment syndrome directly associated with infection. Four patients' clinical presentations fulfilled the criteria: two presented with infection and compartment syndrome, and two developed compartment syndrome 2-12 hours after admission. All four had beta-hemolytic streptococci on initial culture; three of four grew Group A streptococcus. Fasciotomies and serial debridements were necessary. One patient ultimately underwent amputation through the elbow.

Old displaced fracture of the scaphoid. An unusual cause of carpal tunnel syndrome.

The case of a 37-year-old man with carpal tunnel syndrome and a palpable mass in the proximal wrist is reported. Roentgenograms revealed an old middle-third scaphoid fracture with the proximal pole displaced into the proximal carpal tunnel. Excision of this mass led to a complete resolution of the patient's carpal tunnel problem.

Disappearing bone disease of the upper extremity.

Disappearing bone disease (Gorham's disease) is a rare clinical problem. The extensive bone loss seen with this entity makes it a difficult therapeutic problem, especially if contiguous bones are involved, which is a highly unusual occurrence. We report a case of disappearing bone disease involving the upper extremity and review the relevant literature.

Congenital pseudarthrosis of the clavicle: a review of the literature and surgical results of six cases.

This article is a retrospective review of six symptomatic patients who, when treated surgically, all healed with excision of pseudarthrosis, bone grafting, and plating. We discuss congenital pseudarthrosis of the clavicle with emphasis on etiologies, clinical presentation, differential diagnosis, and method of treatment. Our patients' chief complaints were cosmesis, pain, or shoulder deformity.