Invasive infections with community-associated methicillin-resistant Staphylococcus aureus after kidney transplantation.

We report two cases of invasive infections caused by Panton-Valentine leukocidin-positive, community-associated, methicillin-resistant Staphylococcus aureus (CA-MRSA) after kidney transplantation. This report emphasizes the clinical importance of considering CA-MRSA as a causative agent in the differential diagnosis of infections of the skin and soft tissues in organ transplant recipients.

Carpal tunnel syndrome.

Carpal tunnel syndrome is the most common compressive neuropathy of the upper extremity. As a result of median nerve compression, the patient reports pain, weakness, and paresthesias in the hand and digits. The etiology of this condition is multifactorial; anatomic, systemic, and occupational factors have all been implicated. The diagnosis is based on the patient history and physical examination and is confirmed by electrodiagnostic testing. Treatment methods range from observation and splinting, to cortisone injection and splinting, to surgical intervention. Both nonsurgical and surgical management provide symptom relief in most patients. The results of open and endoscopic surgery essentially are equivalent at 3 months; the superiority of one technique over the other has yet to be established.

Mannitol extravasation during partial nephrectomy leading to forearm compartment syndrome.

We present the first known complication of forearm compartment syndrome after mannitol infusion during partial nephrectomy. We stress the importance of excellent intravenous catheter access and constant visual monitoring of the intravenous catheter site during and after mannitol infusion as ways to prevent this complication. Prompt recognition of compartment syndrome with appropriate intervention can prevent long-term sequelae.

Mannitol extravasation during partial nephrectomy leading to forearm compartment syndrome

We present the first known complication of forearm compartment syndrome after mannitol infusion during partial nephrectomy. We stress the importance of excellent intravenous catheter access and constant visual monitoring of the intravenous catheter site during and after mannitol infusion as ways to prevent this complication. Prompt recognition of compartment syndrome with appropriate intervention can prevent long-term sequelae.

Kaplan's cardinal line.

PURPOSE: To determine if a consensus definition exists in the literature and among hand surgeons for Kaplan's cardinal line (KCL) and to determine the relationship of the various descriptions to deep structures. METHODS: The literature contains 4 different descriptions of KCL. Members of the American Society for Surgery of the Hand were surveyed to determine which line they understand to be the correct description of KCL. The 4 variations of KCL were marked on cadavers and the lines' precision in identifying deep structures was measured. RESULTS: Our survey showed that there is no consensus regarding the definition of KCL. Fifty percent of the surgeons surveyed use KCL as a surgical landmark. A line extended along the abducted thumb and a line from the apex of the interdigital fold between the thumb and the index finger to the hook of hamate most closely reproduce the location of deep structures of the hand and are the farthest from and always proximal to the superficial palmar arch. The line from the apex of the interdigital fold between the thumb and the index finger parallel to the middle crease of the palm and the line from the apex of the interdigital fold between the thumb and the index finger to a point 2 cm distal to the pisiform are the farthest from the motor branch of the median nerve and are markedly closer to the superficial palmar arch. All lines are radial and distal to the motor branch of the median nerve. CONCLUSIONS: Ambiguity exists regarding the definition of KCL among hand surgeons and in the literature. Although no single line is ideal for locating all deep structures, line C is the safest line to identify hand anatomy. Kaplan's cardinal line does not locate the deep structures of the hand accurately but may assist in making palmar incisions.

Mallet finger.

Mallet finger involves loss of continuity of the extensor tendon over the distal interphalangeal joint. This common hand injury results in a flexion deformity of the distal finger joint and may lead to an imbalance between flexion and extension forces more proximally in the digit. Mallet injuries can be classified into four types, based on skin integrity and the presence or absence of bony involvement. Although various treatment protocols have been proposed, splinting of the distal interphalangeal joint for 6 to 8 weeks has yielded good results while minimizing morbidity in the majority of patients. Surgical management may be considered for acute and chronic mallet lesions in patients who have failed nonsurgical treatment, are unable to work with the splint in position, or have a fracture involving more than one third of the joint surface.

Use of bone graft substitutes and bioactive materials in treatment of distal radius fractures.

Although autogenous bone graft has been shown to be useful in the treatment of distal radius fractures, the role of bone graft substitutes and the optimal replacement material remains unclear. Several products are commercially available, each with differing osteoconductive, osteoinductive, and structural properties. Indications and choice of graft substitute should be based on the needs of the individual case with regard to need for structural support, gap filling, or bone healing stimulation. Further comparative research will help clarify the indications and most appropriate material for a given fracture and clinical situation.

Nonsurgical treatment of closed mallet finger fractures.

PURPOSE: Surgical repair of closed mallet finger fractures has been favored for displaced injuries involving more than one third of the articular surface and for injuries with palmar subluxation of the distal phalanx. This study analyzed the results of nonsurgical treatment for closed and displaced mallet finger fractures with greater than one-third articular surface damage, comparing cases with and without concomitant terminal joint subluxation. METHODS: Twenty-two closed mallet finger fractures in 21 patients who were treated nonsurgically and involving more than one third of the articular surface were reviewed retrospectively. The patients were treated by continuous extension splinting of the distal interphalangeal joint for a mean of 5.5 weeks. The average patient age at the time of injury was 35.2 years, with a mean delay to treatment of 21 days. Nine cases showed a reduced distal interphalangeal joint at presentation (type IB) and 13 cases showed palmar subluxation of the distal phalanx (type IIB). Complications from splinting were limited to 2 cases of transient skin irritation. All patients returned for new finger radiographs and completed a survey to assess pain, function, and satisfaction at an average of 24.5 months after injury. RESULTS: Patients expressed negligible pain, minimal difficulties with activities of daily living and work, relatively high satisfaction with finger function and treatment outcome, but only marginal satisfaction with finger appearance. The differences between type IB and type IIB cases were not significant. The resultant terminal joint extensor lag improved in both groups. Moderate and large joint prominences, swan-neck deformities, and moderate arthritis were seen more commonly in type IIB cases but the differences between groups were not significant. CONCLUSIONS: This study supports the rationale for nonsurgical treatment of closed and displaced mallet finger fractures with greater than one-third articular surface involvement. Pain likely will be negligible and patient satisfaction with finger function and treatment outcome is projected to be relatively high at 2-year follow-up evaluation. A dorsal joint prominence, terminal joint extensor lag, swan-neck deformity, and degenerative joint changes, however, may develop, particularly in cases with palmar subluxation of the distal phalanx.

Bicycling-induced ulnar tunnel syndrome.

Symptoms of ulnar tunnel syndrome are commonly experienced by avid bicyclists. Previous orthopedic and hand surgery publications have rarely included bicycling as a causative factor for this condition. We present the case of a 41-year-old man who developed bilateral ulnar tunnel syndrome during a week-long mountain bicycling tour. His symptoms gradually improved with nonoperative treatment measures, including rest, splinting, and nonsteroidal anti-inflammatory medication.