Are the palmar cutaneous nerves safe during standard carpal tunnel release?

An incision in the axis of the ring finger is thought to be the safest for carpal tunnel release based on cadaveric studies that suggest that the palmar cutaneous nerves do not cross into this area. Despite the use of this incision, persistent postoperative scar tenderness has been reported in up to 36% of patients following standard carpal tunnel release. For this reason, an investigation was undertaken to determine the presence of palmar cutaneous nerves in this incision. Random biopsies of transversely oriented fibrous bands in the subcutaneous tissue were taken during 15 open carpal tunnel releases. In every patient, at least one biopsy was positive for peripheral nerve tissue. These findings, combined with previous cadaveric studies, suggest that a "safe" palmar incision that will avoid injury to palmar cutaneous nerves does not exist. Carpal tunnel release techniques that avoid a palmar incision may lessen postoperative morbidity by avoiding injury to these small cutaneous nerves.

Is training in endoscopic carpal tunnel release appropriate for residents?

Based on the relatively high incidence of complications for surgeons initially learning the technique, endoscopic carpal tunnel release is thought to have a steep learning curve. To determine if endoscopic carpal tunnel release can be safely performed by trainees, the outcomes of 84 patients who underwent endoscopic carpal tunnel release performed by a chief resident or hand fellow in a supervised setting were reviewed. All but 1 patient had uneventful procedures and complete resolution of preoperative symptoms. One patient with persistent symptoms represented the only complication. At reexploration through a standard palmar incision, the transverse carpal ligament was found to have been completely divided and fulminant tenosynovitis surrounding the nerve and flexor tendons was presumed to be the cause of his persistent symptoms. It appears that endoscopic carpal tunnel release can be safely performed by chief residents in a supervised clinical setting. Given that this procedure has a high learning curve, repeated exposure during a residency training program may offer significant advantages over the current approach of training surgeons during a single cadaveric instructional course.

Selective fecal diversion in complex open pelvic fractures from blunt trauma.

OBJECTIVE: To review the outcomes of patients with open pelvic fractures. DESIGN: Retrospective review of medical records. SETTING: Patients admitted from the injury scene or transferred within 24 hours to a level 1 trauma center. PATIENTS: Thirty-three patients sustaining blunt trauma had pelvic fractures and adjacent wounding. INTERVENTIONS: Treatment protocol that included selective fecal diversion, measures to arrest hemorrhage and prevent wound sepsis, manage associated pelvic injuries, and provide optimal orthopedic outcomes. MAIN OUTCOME MEASURES: Death and sepsis. RESULTS: Exsanguination occurred in one patient and death owing to head injuries occurred in five patients. Wound sepsis occurred in 31% of patients with colostomy and 19% without colostomy. CONCLUSIONS: Management of open pelvic fractures requires a well-coordinated group using several techniques. Selected patients with open pelvic fractures do not require fecal diversion. Incisions for orthopedic surgery should be considered when decisions are made regarding fecal diversion.

Blood component supplementation during massive transfusion of AS-1 red cells in trauma patients.

Coagulation component transfusions in trauma patients given more than 10 units of AS-1 red cells during the first 24 hours after injury were studied. Serial coagulation tests were obtained to direct component therapy. Coagulopathy developed in more than 70% of patients. Patients with blunt or penetrating trauma had similar coagulation abnormalities during massive transfusions. More than 40% of patients with either exsanguinating hemorrhage from penetrating trauma or blunt trauma with associated brain injuries had abnormal coagulation tests on admission. In contrast, patients with blunt trauma, but without brain injury, did not have coagulopathy on admission. Patients received an average of 25 units (range, 10-77) of AS-1 red cells and were exposed to an average of 80 (range, 11-252) donors. Exsanguination and brain injuries primarily caused death in 57%. Abnormal coagulation tests will be frequent and profound during a massive transfusion with AS-1 red cells. Serial coagulation testing is recommended.