Python bite: an unusual cause of hand injury.

We report a patient that sustained a severe hand injury following a python bite. Python bite injuries are rare and we were unable to find guidelines in literature regarding the management of this injury. This report details our experience in managing this case and summarizes the available literature.

Effect of negative-pressure wound therapy on open fractures of the lower limb.

INTRODUCTION: Early debridement and coverage has long been regarded as the standard of care for open fractures of the lower limb, as infection is a serious complication. However, the best time for wound closure remains controversial. Negative-pressure wound therapy (NPWT) is thought to result in reduced flap infection and failure. To determine the effect of NPWT, we reviewed patients with open fractures of the lower limb and compared the rates of infection and flap failure in two time-based cohorts. METHODS: Two cohorts of patients (periods 2003-2004 and 2008-2009) with Gustilo type IIIB open tibial fractures were recruited and their outcomes were compared. In the 2003-2004 cohort, wounds were dressed with occlusive dressing. In the 2008-2009 cohort, all patients underwent NPWT. Data was retrospectively analysed with regard to infection, failure, age, type of flap, comorbidities and defect size. The incidences of infection and flap failure were further analysed for any statistical difference between the different treatment protocols. RESULTS: In the 2003-2004 cohort, 33% of patients developed infection and 11% had flap failure. However, in the 2008-2009 cohort, 10% of patients developed infection and 6% had flap failure. The difference in the incidence of infection was statistically significant between the two cohorts (p = 0.029). CONCLUSION: Patients in the 2008-2009 cohort had better outcomes, and we are of the opinion that performing NPWT may have contributed to this result.

Fitting very short finger stumps with silicone prosthesis: a nonsurgical method.

BACKGROUND AND AIM: The fitting of short finger stumps with silicone prosthesis is a challenge because of the suboptimal finger-prosthesis contact due to length and distal tapering of digital stumps. The purpose of this report was to describe and evaluate the Micropore(™)-polyvinyl chloride tube technique for fitting short finger stumps. TECHNIQUE: For a total of 10 patients, short finger stumps were fitted using the technique. A short length of polyvinyl chloride tube, trimmed and contoured to fit, was secured on the distal stump tip with Micropore tape. The prosthesis was worn over the polyvinyl chloride tube extension. Three different fitting methods were evaluated: fitting with and without the Micropore-polyvinyl chloride tube technique, and with the use of skin adhesive on the stump. DISCUSSION: All patients achieved a very secure prosthetic fit with the Micropore-polyvinyl chloride tube technique. No incidences of prosthesis slippage were reported at the longest follow-up of 30 months. The Micropore-polyvinyl chloride tube technique is an effective method for fitting short finger stumps.

Spare-part surgery.

The authors discuss the use of scavenged tissue for reconstruction of an injured limb, also referred to as "spare-part surgery." It forms an important part of overall reconstructive strategy. Though some principles can be laid down, there is no "textbook" method for the surgeon to follow. Successful application of this strategy requires understanding of the concept, accurate judgment, and the ability to plan "on-the-spot," as well as knowledge and skill to improvise composite flaps from nonsalvageable parts. Requirements for limb reconstruction vary from simple solutions such as tissue coverage, which include skin grafts or flaps to more complex planning as in functional reconstruction of the hand, where the functional importance of individual digits as well as the overall prehensile function of the hand needs to be addressed right from the time of primary surgery. The incorporation of the concept of spare-part surgery allows the surgeon to carry out primary reconstruction of the limb without resorting to harvest tissue from other regions of the body.

Use of a hand drill to remove particulate contamination within a traumatic bone tunnel.

We report a novel method of debridement for penetrating trauma to the hand involving bone using a sterile hand drill. This provides a means for adequate clearance of debris which may otherwise be left in-situ due to poor access to the contaminants when conventional techniques of debridement are used.

Carpal tunnel syndrome caused by gouty tophus of the flexor tendons of the fingers: sonographic features.

We report the case of a 23-year-old male presenting with carpal tunnel syndrome and a swelling over the flexor surface of the wrist. MRI findings were initially suggestive of a median nerve schwannoma but sonography (US) showed a heterogenous mass infiltrating the flexor tendons of the fingers and displacing the median nerve in the carpal tunnel. US findings were confirmed by surgical exploration, which revealed a gouty tophus of the flexor tendons of the fingers at the wrist with secondary median nerve displacement and compression.

Rice bodies, millet seeds, and melon seeds in tuberculous tenosynovitis of the hand and wrist.

Tuberculosis (TB) is still endemic in many developed countries. Involvement of the hand and wrist at presentation is extremely rare, and the diagnosis is often missed. Operative findings of "rice bodies, millet seeds, or melon seeds" are highly suggestive of tuberculous tenosynovitis. Six patients with TB of the hand and wrist at various stages of disease with characteristic operative findings are reviewed. Four patients had underlying immunosuppression. One patient had previous pulmonary TB, whereas 3 patients had radiographic evidence of previously undiagnosed pulmonary TB. The interval to presentation ranged from 1 week to 2 years. Two patients had median nerve irritation, 3 patients had osteomyelitis, and 1 patient had flexor tendon rupture. Mycobacterial cultures were positive in 4 patients; acid-fast bacilli stain, and polymerase chain reaction were positive in remaining 1 patient; and both stain and culture were negative in the last patient who had history of pulmonary TB. All 6 patients were managed with combination therapy comprising antituberculous chemotherapy and at least 1 debulking tenosynovectomy. Two patients had 2 debridements. Of these 2 patients, 1 underwent wrist arthrodesis during the second procedure. Mean follow-up was 4 years. There were no recurrences after the most recent debridement. The diagnosis of TB of the hand and wrist is often missed. The surgeon has to be aware of the significance of loose bodies when performing routine excision of innocuous looking wrist ganglia. Combination therapy comprising thorough excisional debridement and antituberculous chemotherapy will minimize recurrence of this difficult-to-treat disease.

Dermal pocketing following distal finger replantation.

Replantation is an ideal technique for reconstruction following fingertip amputation as it provides 'like for like' total reconstruction of the nail complex, bone pulp tissue and skin with no donor-site morbidity. However, fingertips are often not replanted because veins cannot be found or are thought to be too small to repair. Attempts at 'cap-plasty' or pocketing of replanted tips with and without microvascular anastomosis have been done in the past with varying degrees of success. We prospectively followed up a group of patients who underwent digital replantation and dermal pocketing in the palm to evaluate the outcome of this procedure. There were 10 patients with 14 amputated digits (two thumbs, five index, four middle, two ring and one little) who underwent dermal pocketing of the amputated digit following replantation. Among the 14 digits that were treated with dermal pocketing, 11 survived completely, one had partial atrophy and two were completely lost. Complications encountered included finger stiffness (two patients) and infection of the replanted fingertip with osteomyelitis of the distal phalanx (one patient). We believe that this technique can help increase the chance of survival for distal replantation with an acceptable salvage rate of 85% in our series.

Heterodigital vascular island flap for simultaneous resurfacing and revascularization of digits.

Devascularized digits with segmental skin and vessel loss require revascularization and resurfacing. This can be addressed by using a heterodigital vascular island flap. This flap brings with it an appropriately sized pristine artery of optimal length for revascularization and provides simultaneous skin cover. We describe 3 cases. Primary wound healing was achieved in all patients with good functional recovery and acceptable donor site morbidity. We compare the options available for reconstructing such defects and discuss other possible surgical indications for this flap.

"Palmar pivot flap" for resurfacing palmar lateral defects of the fingers.

PURPOSE: Soft tissue defects on the lateral borders of the digits are difficult to reconstruct using local or local-regional flaps. We describe a "palmar pivot flap" to resurface an adjacent defect on the palmar-lateral aspect of the digit. METHODS: The surgical technique is described. This flap is an axial pattern flap based on the subcutaneous transverse branches of the digital artery. The flap is pivoted up to 90 degrees on the neurovascular bundle in its base, into an adjacent defect. The flap can be raised from either the proximal or the middle phalangeal segments. It can cover defects sited from the level of the proximal interphalangeal joint up to the fingertip. The donor defect is limited to the same digit and is covered with a full-thickness skin graft. RESULTS: We have used this flap on 3 patients with defects at the middle phalangeal segment, the distal interphalangeal joint, and the fingertip. All healed primarily. One patient had a mild flexion contracture of the proximal interphalangeal joint, whereas the other 2 had no complications. The patients with distal interphalangeal joint and fingertip defects had excellent sensation in the flap (2-point discrimination of 5-6 mm). CONCLUSIONS: The palmar pivot flap is useful for resurfacing otherwise difficult defects on the lateral borders of the digits around and distal to the proximal interphalangeal joint, including those at the fingertip. It provides sensate, glabrous skin. The donor defect is on the same digit and is well hidden, producing an aesthetic and functional reconstruction.

Reverse anterior tibial artery flap for reconstruction of foot donor site.

The foot offers numerous useful options for hand reconstruction. Hallux transfer, dorsalis pedis flap, second toe transfers, and toe joint transfers offer good functional results in reconstructed hands. However, when the donor site is repaired with skin grafts, delayed wound healing, scarring, and contractures often result. Poor cosmesis of the donor site and altered gait are the main drawbacks of the procedures. The authors propose a new concept of primary reconstruction of the donor foot using a reverse-flow anterior tibial flap from the same leg. Two flaps are raised from the same anterior tibial vessel system in continuity as a distal free flap for hand reconstruction and as a proximal reverse-flow pedicled flap to resurface the donor defect. This technique allows good flap reconstruction of the foot donor site, reducing morbidity and limiting the operation to the same limb. The authors report their experience of 33 cases. There were no failures. Primary wound healing was achieved in the foot donor site, with acceptable cosmesis and satisfactory function.