Continuous peripheral nerve block in replantation and revascularization.

Continuous infusion of a local anesthetic by means of a percutaneous forearm catheter and an infusion pump was studied for its utility in achieving sympathetic blockade following replantation and revascularization of the digits. The efficacy of the technique was demonstrated by cold stress testing. When the technique was used in 55 patients who underwent digital replantation or revascularization, 53 of 57 replanted digits (93 percent) and 25 of 26 revascularized digits (96 percent) survived. The analgesia obtained from the nerve block benefited patient comfort during hospitalization, and normal sensibility in the uninjured digits returned promptly after discontinuing the anesthetic in all but one patient. The reported study indicates that continuous peripheral nerve block by means of an indwelling forearm catheter is a safe and effective adjunct in preventing neurogenically-mediated vasospasm.

Acquisition and functional use of voice output communication by persons with profound multiple disabilities.

The acquisition and subsequent functional use of communication skills by persons with profound mental and physical impairment using a voice output communication aid (VOCA) was evaluated. Initially, a graduated guidance and time delay procedure was used to teach three individuals to use a VOCA in response to a trainer's specific request. Results indicated that all participants increased their correct VOCA activations in response to specific requests following training. Probes also indicated that participants effectively used the VOCA after training to request preferred items in a variety of settings. The functional utility of VOCA skills was supported by a survey of individuals unfamiliar with the participants. This survey indicated that those surveyed could better understand the participants when they used a VOCA. Results are discussed as to potential advantages of VOCAs relative to other augmentative communication options for persons with multiple disabilities. Future research directions are discussed, focusing on strategies for promoting a broader set of communicative interactions using VOCAs.

Left-hand dominance and hand trauma.

To investigate the relationship between hand dominance and the risk of major hand injury, the case records of 125 patients who had been treated for digital amputation were retrospectively reviewed. A second group of 116 patients treated for minor hand trauma was similarly evaluated. The incidence of left-hand dominance among the digital amputation group was 35%, and among the minor trauma group the incidence was 11%. The left-handed were more likely to have an amputating injury of their dominant hand than were the right-handed (70% compared with 51%, respectively). The most common mechanism of amputating injury was by power saw. The present data suggest that left-handed individuals have a relative risk of sustaining an amputating injury that is 4.9 times greater than the right-handed individuals, while minor hand trauma occurs at rates proportional to the distribution of left handedness within the population. Additional safety measures and the redesigning of tools, assembly lines, and workstations are recommended to help decrease the incidence of serious hand injury among left-handed individuals.

Acute dislocation of the carpometacarpal joint of the thumb: an anatomic and cadaver study.

An anatomic study was undertaken to provide an understanding of the ligamentous disruption that occurs during acute dislocation of the thumb carpometacarpal joint. Thirty-eight cadaver thumbs were dissected free of soft tissue, with the ligaments preserved. The dorsoradial, posterior oblique, anterior oblique, and intermetacarpal ligaments were identified in all specimens. A dorsal dislocating force was applied to the base of the thumb metacarpal to recreate the mechanism of clinical dislocation. Serial sectioning of the ligaments was performed with the metacarpal in neutral, flexion, and extension. The primary restraint to dorsal dislocation was found to be the dorsoradial ligament, with the anterior oblique ligament allowing dislocation by subperiosteal stripping from the base of the first metacarpal. After reduction, the joint was most stable in pronation and extension, which tightened the anterior oblique ligament. We conclude that the dorsoradial ligament is the primary restraining force with respect to acute dorsal dislocation of the thumb carpometacarpal joint.

Distal humeral replacement after failed continuous passive motion in a T-condylar fracture.

Comminuted osteoporotic intercondylar fractures of the distal humerus are a treatment dilemma. We report the case of an elderly patient with a type C3 T-condylar fracture initially treated with continuous passive motion. This treatment resulted in a loss of medial stability. Pain relief and adequate function were achieved with a custom distal humeral replacement and repair of the medial collateral ligament.

Perioperative red blood cell salvage in spine surgery. A prospective analysis.

Reinfusion of perioperative blood loss was studied in 150 spinal surgery patients to evaluate its efficacy in reducing transfusion requirements. Three groups of 50 consecutive patients were observed. Group A had no blood salvage and served as a control group, Group B used Cell Saver for intraoperative blood salvage, and Group C used Cell Saver intraoperatively and Solcotrans postoperatively for salvage of postoperative drainage. The three groups had similar demographics, preoperative hematocrits (HCT), operative blood loss, and postoperative drainage. Serial HCTs through the fifth postoperative day showed no significant difference between groups. Total transfusion requirements of homologous and prebanked autologous blood were reduced 35% in Group B and 68% in Group C when compared to control group A. These differences are statistically significant. The combination of intraoperative and postoperative blood salvage was highly effective in reducing the need for transfused blood.

Intraoperative and postoperative red blood cell salvage.

The risks associated with homologous blood transfusions include hepatitis, transfusion reactions, and AIDS. Intraoperative and postoperative red blood cell salvage and reinfusion are techniques available to decrease the need for homologous transfusions. In this article the techniques of red blood cell salvage are described and the benefits and potential risks of these methods are discussed.

Fracture of the medial condyle of the humerus in an elderly patient.

Isolated fractures of the medial condyle of the humerus are rare in any age group and have not been previously reported in the elderly. The case of an 82-year-old who sustained such a fracture is reported. The patient was successfully treated by anatomic reduction and rigid internal fixation. Treatment guidelines and relevant literature are reviewed.