Immediate tissue transplantation in upper limb trauma: spare parts reconstruction.

The management of mutilated upper extremity wounds offers challenges for all hand surgeons. Loss of composite tissues usually requires grafts or flaps to gain coverage and restore function. Nonsalvagable digits or amputated parts are a source of spare tissues that can be used for reconstruction of the hand or limb. Immediate tissue transplantation is a resourceful technique for hand surgeons to limit donor morbidity while making the most out of a terrible injury to the hand or upper extremity. This article reviews the various methods by which immediate tissue transplantation can be employed in hand trauma.

Non-surgical management of metacarpal fractures.

Metacarpal fractures are among the most common fractures of the upper extremity. Surgical management is generally offered for unstable or significantly displaced fractures. A more conservative, nonsurgical approach, however, may provide safe, rapid recovery while maintaining normal active range of motion. This article reviews the nonsurgical approach, protocols, and outcomes of metacarpal fractures.

Minimally invasive treatment of Raynaud phenomenon: the role of botulinum type A.

Although the mechanism is unknown, Btx-A injection may be an effective, localized, nonsurgical treatment option without addictive properties or systemic side effects for the treatment of ischemic digits. Clinical research supports the safety and efficacy of injection of Btx-A for the treatment of Raynaud phenomenon.

Botox therapy for ischemic digits.

BACKGROUND: Treating patients with Raynaud's phenomenon who have chronic pain and ulcerations is extremely challenging. Unrelenting pain can lead to dysfunction and disuse, rendering the patient debilitated and/or chronically depressed. Pharmacologic vasodilators and surgical sympathectomies offer variable benefits. Outcomes of symptomatic patients treated with botulinum toxin type A (Botox) injections for Raynaud's phenomenon are presented. METHODS: A retrospective study focused on patient outcomes was performed on 19 patients diagnosed with Raynaud's phenomenon. Patients suffered from chronic ischemic hand pain. All patients had vascular studies to rule out occlusive disease. Fifty to 100 units of Botox were injected into the palm around each involved neurovascular bundle. Preinjection and postinjection laser Doppler scanning was performed on most patients to measure blood flow. RESULTS: Sixteen of 19 patients (84 percent) reported pain reduction at rest. Thirteen patients reported immediate relief; three reported more gradual pain reduction over 1 to 2 months. Three patients had no or minimal pain relief. Tissue perfusion results demonstrated a marked change in blood flow (-48.15 percent to 425 percent) to the digits. All patients with chronic finger ulcers healed within 60 days. Most patients [n = 12 (63 percent)] remained pain-free (13 to 59 months) with a single-injection schedule. Four patients (21 percent) required repeated injections because of recurrent pain. CONCLUSIONS: Vascular function is abnormal in patients with Raynaud's phenomenon. Although its mechanism is unknown, Botox yielded a distinct improvement in perfusion and reduction in pain in patients failing conservative management. Continued research may lead to more specific and reliable treatment for Raynaud's patients.

Long-term results and quality-of-life measures in the management of hyperhidrosis.

Primary focal hyperhidrosis has a significant, negative impact on quality of life, causing impairments in social, physical, leisure, and occupational activities. The outcome of different surgical and medical treatment modalities is best assessed by using a combination of tools. Quantitative tools include gravimetry, evaporimetry, and Minor's starch and iodine test. Qualitative assessment tools include general health surveys and hyperhidrosis-specific surveys. Of these, the HDSS has been found to have a good correlation to other assessment tools and to be practical in the clinical setting. The surgical literature has primarily used qualitative tools to assess outcomes and many of these tools are investigator-developed, rather than standardized surveys, which may be partly because of the largely retrospective nature of these studies. A surgical investigator's goal tends to be focused on obtaining specific postoperative information regarding symptom improvement and potential surgical complications. The VATS can have a major positive impact on the quality of life of patients who have hyperhidrosis. The impairment that this disorder causes is often underappreciated by the medical community.

Tissue eosinophilia as an indicator of drug-induced cutaneous small-vessel vasculitis.

OBJECTIVE: To determine whether tissue eosinophilia is a reliable indicator of a drug-induced etiology in biopsy samples demonstrating leukocytoclastic vasculitis. DESIGN: Retrospective medical record review with concurrent histopathologic analysis. SETTING: University-affiliated dermatology practice. PATIENTS: Sixty-three patients with cutaneous small-vessel vasculitis meeting specific inclusion criteria were divided into drug-induced (n = 16) and non-drug-induced (n = 47) groups. MAIN OUTCOME MEASURES: Corresponding histopathologic material was reviewed by a dermatopathologist masked to the etiologic associations. An eosinophil ratio was calculated for each patient, derived from the mean eosinophil score (averaging eosinophil counts from 10 high-power histologic fields), and expressed in relation to the intensity of inflammation in the histopathologic slides examined. Eosinophilia ratios were compared for both groups using the Mann-Whitney test. RESULTS: A significant difference was found in mean eosinophil ratios in the drug-induced vs non-drug-induced groups (5.20 vs 1.05; P = .01). Vascular fibrin deposition was present in both groups and was not found to be significantly different (P = .78). Clinical evidence of systemic vasculitis was present in 2 patients (13%) in the drug-induced group vs 15 (32%) in the non-drug-induced group. Fourteen patients (88%) in the drug-induced group had a short-term disease course vs 27 (57%) in the non-drug-induced group. CONCLUSIONS: Tissue eosinophilia is established as a reliable indicator of drug induction in cutaneous small vessel vasculitis. Drug-induced small-vessel vasculitis generally follows a short-term disease course without development of systemic involvement. This information may be useful for guiding management decisions, especially when the etiology is unclear.

Occupational allergic contact dermatitis to nitromethane.

Nitromethane has wide industrial and commercial application as a polar solvent for adhesives and acrylics as well as explosive fuel. Allergic contact dermatitis to this chemical has not been described previously. The authors documented allergic contact hand dermatitis in 4 coworkers who similarly handled an adhesive solvent containing nitromethane. All 4 cases were confirmed by patch testing and resolved after allergen avoidance.