Cephalosporin therapy in intraabdominal infections. A multicenter randomized, comparative study of cefotetan, moxalactam, and cefoxitin.

Three broad-spectrum cephalosporins (cefotetan, moxalactam, and cefoxitin) proved effective in this randomized, prospective trial for treatment of 303 surgical patients with moderately severe regional peritonitis.

Comprehensive rehabilitation after burn injury.

Comprehensive rehabilitation of patients after burn injury requires the organized application of sound, recognized principles. The basic concerns are the prevention of loss of joint motion, loss of muscle mass, and the prevention of anatomic deformities. Important considerations are starting the rehabilitative program as early as possible after injury and avoiding techniques that unduly immobilize the patient or parts of the body. The use of early active motion to the patient and all movable joints, along with appropriate positioning while at rest, is crucial to a successful program. Passive exercising along with the use of restraints and splints is necessary in certain patients.

Topical cerium nitrate prevents postburn immunosuppression.

Suppression of cell-mediated immunity (CMI) follows a major thermal injury and is associated with an increased incidence of serious infections. Adult female CF-1 mice received a 20% full-thickness steam burn and were then treated with various topical antimicrobial creams in an attempt to alter the course of postburn immunosuppression. Topical agents included cerium nitrate (CE), silver sulfadiazine (SSD), mafenide (SML), silver nitrate (AG), and a mixture of CE and SSD (CE-SSD). CMI was determined in vivo by measuring ear swelling in response to 2,4-dinitrofluorobenzene (DNFB) challenge in previously sensitized mice. The usual nadir in CMI (ear swelling) when mice were sensitized at day 14 postburn did not occur in burned mice treated with CE or CE-SSD, AG was only modestly effective, and SML or SSD failed to restore CMI. These studies suggest that topical CE may have potential as an immunomodulator in the treatment of burns.

Identification and antibiotic susceptibility of bacterial isolates from burned patients.

We retrieved bacterial blood isolates from 397 adult burned patients admitted over a 7-year period. Sixty-two patients (15.6 per cent) developed true-positive bacterial blood cultures (judged non-contaminants), and of these 30 (48.4 per cent) expired. Pseudomonas aeruginosa (24 isolates), Staphylococcus aureus (19) and Klebsiella pneumoniae (19) were the most frequent isolates. In vitro susceptibilities of 149 isolates were determined to 12 antibiotics (gentamicin, amikacin, ticarcillin, piperacillin, mezlocillin, azlocillin, cefazolin, cefotaxime, ceftazidime, cefoperazone, thienamycin and ticarcillin-clavulinic acid) using agar diffusion assay. Thienamycin proved the most active agent (97 per cent of isolates susceptible). Cefoperazone was the most active cephalosporin (95 per cent susceptible). Twenty-eight organisms demonstrated multiple drug resistance; patients with such organisms had a 71 per cent mortality. Thienamycin was the most active agent against such isolates (27/28 susceptible). Susceptibilities of all 149 isolates to combinations of antibiotics were calculated, assuming no synergism or antagonism; some combinations of third-generation cephalosporins with the newer penicillins may prove to be as effective as combinations including aminoglycosides.

Isolated high median nerve injuries.

High median nerve injuries are commonly associated with injury to the brachial artery and decreased sensibility typical for the pattern of innervation. Loss of motor function is to the interphalangeal joint of the thumb and index finger. Nerve suture was always successful in restoring some degree of sensibility. The return of action to the forearm flexors occurred in a predictable fashion 6-13 months after nerve suture.

Rehabilitation after burn injury.

Optimal rehabilitation of patients after burn injury requires the organised application of sound, recognised principles. The basic concerns are the prevention of loss of joint motion, loss of muscle mass, and the prevention of anatomical deformities. Important considerations are starting the rehabilitative programme as early as possible after injury and avoiding techniques which unduly immobilise the patient or parts of the body. The use of early active motion to the patient and all movable joints, along with appropriate positioning while at rest, is crucial to a successful programme. Passive exercising along with the use of restraints and splints are necessary in certain patients.

Palmar arthroplasty for the treatment of the stiff swan-neck deformity.

Palmar arthroplasty for the treatment of the stiff swan-neck deformity in rheumatoid arthritis is designed to correct the mechanical block to flexion that is caused by palmar plate adhesions (which obliterate the retrocondylar recess) and by collateral ligament contracture and adhesions. This procedure can be performed at the same time as correction of the primary cause of proximal interphalangeal joint (PIP) hyperextension (e.g., intrinsic tightness or flexor tenosynovitis) and can also be supplemented with superficialis tenodesis to minimize recurrent hyperextension. Postoperative flexor dynamic traction, which is started at 24 to 48 hours and continued for a minimum of 3 to 4 weeks, is critical to the maintenance of motion. Arthroplasty in 47 PIP joints in 14 hands of 9 patients demonstrate an increase in motion from +20 degrees hyperextension and 9.5 degrees flexion to -7 degrees extension and 72 degrees flexion postoperatively.

Neuroma formation following digital amputations.

One hundred consecutive patients with 144 digital amputations performed at the University of Colorado Health Sciences Center between 1978 and 1980 were retrospectively reviewed. In this group, four patients demonstrated painful amputation stumps. Two of these were treated by surgical excision of neuromas and two patients, who had more vague complaints, were treated by desensitization which decreased the sensitivity of their stumps and allowed them to return to work. It is felt that this low incidence of painful neuromas and amputation stumps is due to the positive postoperative effort to send patients back to work as soon as possible, allowing them to perform their own therapy and thereby minimizing their disability and tendency to develop pain problems.

Rehabilitation following electrical injury to the upper extremity.

This review emphasizes two of the difficult problems associated with electrical injury to the hand and forearm. Early wound closure to preserve important vascular, nerve, and tendon structures in the hand must be considered, recognizing the tendency for continued necrosis of tissue in this type of injury. Tissue fibrosis, even in areas of the hand not grossly injured, may develop, progressively compromising function. Five patients are presented to illustrate the early care and rehabilitation of these patients.

Volar fracture-dislocation of the carpometacarpal joint of the index finger treated by delayed open reduction.

Isolated volar fracture dislocation of the carpometacarpal joint of the index finger is a rare injury and has apparently not previously been reported. We are presenting a case treated by delayed open reduction and internal fixation. Satisfactory but not anatomic reduction was obtained. The literature and anatomic factors are discussed.

Hemophilus influenzae cellulitis of the hand.

Hemophilus influenzae type b cellulitis of the hand is a rare infection presenting mainly in the 2-month to 3-year age group. Three proven cases and one clinical case are reported, and the bacteriology and management are discussed. Most of these infections respond to ampicillin and/or chloramphenicol. One must include H. influenzae type b in the differential diagnosis of cellulitis of the hand in this age group and specify this possibility on all cultures so that appropriate identification of the organism can be made.

Recovery of function following replantation and revascularization of amputated hand parts.

One hundred patients with replantation or revascularization of 149 hand units were studied with respect to return of function. Criteria for assessment included level and mechanism of injury, age, active range of motion, two-point discrimination sensibility ratings, grip and pinch strength, cold intolerance, and return to previous employment. Survival rate for replantation was 79% and for revascularization 97%. In the 38 replantation patients 80% underwent secondary operations, the most common being flexor tendon reconstruction. Most digits regained two-point discrimination of better than 10 mm; normal two-point discrimination was achieved in 40% of digits in this group; total active motion of 84% of fingers was rated poor. In the 62 revascularizations motion of 28% was rated poor, of 29% rated excellent. Restoration of tendon and joint function was aided by early and aggressive flexor tendon reconstruction and early digital motion; selected patients had primary insertion of silastic rods when there was expectation of a poor result due to tendon or soft-tissue damage. Isolated index amputations should not be replanted except in children or young adults. Revascularization should rarely be used when there is index tendon and bone involvement.

The effects of perfusion on an amputated extremity.

The amputated hindquarters of adult female rats were infused with solutions of lactated Ringer's, Collins hypertonic renal perfusate, and dextran-dextrose on a washout and continuous basis. The perfusate was analyzed for energy compounds and breakdown products and the muscle tissue examined histologically. Intermittent perfusion or injection under pressure led to marked edema in a 4-hour period and was abandoned in favor of a system that perfused the part at 120 to 150 cm H2O. The model perfused with Collins gained an average of 1.35 gm, that with lactated Ringer's 2.35 gm, and that with dextran-dextrose lost 2.35 gm. Pressure graphs of the various solutions indicated that the vascular bed reacts more physiologically to Collins solution and dextran-dextrose than to lactated Ringer's. Histologic sections of the muscle biopsies confirmed this. The release of ATP and hypoxanthine with lactated Ringer's suggests that it is the most damaging of the perfusates. These findings support the results of the pressure graphs and histologic studies. A potential for replantation of amputated limbs that contain muscle when the cold ischemia time may exceed 6 hours is suggested by the data presented.

Wounds of the hand contaminated by human or animal saliva.

A prospective and retrospective evaluation of 75 patients with hand wounds contaminated by human saliva (35) or animal saliva (40) demonstrates that a program of outpatient management can be sufficient for optimal care in many patients. This series challenges the proposition that hospitalization, radiographs, and surgical debridement are necessary for most such wounds. Sixty-seven per cent did not have surgical intervention and no complications resulted. Ninety-two per cent received antibiotics. Radiographs were obtained only when bony injury or entry into a joint was suspected. Delay in seeking treatment until obvious signs of infection or pain are present is common. Literature review details the anatomic factors important in the natural history and control of these infections, and the changes with respect to modes of treatment for these potentially dangerous wounds. The injury is caused by bites with the hand extended or, in fight-bite wounds, with the metacarpal-phalangeal and interphalangeal joints flexed, allowing deeper penetration and then sealing of the wound when the first is opened. Staphylococcus and Streptococcus are the organisms most frequently found in human bites, and in animal bites; Pasteurella multocida should be considered in dog and cat bites.

High-pressure injection injuries of the hand.

One hundred twenty-seven case reports of high-pressure injection injuries have been analyzed, and five patients of our own are reported. The injury usually occurs to young, working males, most often to their nondominant index finger. Without proper surgical intervention, the injected part often progresses to necrosis, debilitating fibrosis, and stiffness. The pathology is that of inflammation and foreign body granulomatous formation. Damage results from impact, ischemia resulting from vascular compression, chemical inflammation, and secondary infection. Recommended treatment has traditionally been early surgical decompression, removal of injected material, and antibiotics. There is some evidence that anti-inflammatory medication is of value. In the patients treated early with steroids and proper antibiotics, infection has not been a problem. We feel that treatment of these injuries should include: 1) Immediate, high-dose, parenteral steroids followed by high-dose oral steroids in tapered doses. Our present regimen consists of initial doses of hydrocortisone sodium succinate 100 mg intravenously every 6 hours until it appears that swelling and erythema have maximized and begun to diminish, then changing to oral prednisone 25 mg twice daily. Prednisone is then slowly tapered in 5- to 10-mg increments per day until stopped. If swelling, pain, and erythema begin to worsen, high-dose steroids are resumed and tapered again. 2) Extensive and complete surgical decompression and drainage of the injured part. 3) Appropriate broad-spectrum antibiotic coverage.