Isolated Dorsoradial Capsular Tear of the Thumb Metacarpophalangeal Joint: Missed Diagnosis and the Management of Delayed Presentation.

Isolated dorsoradial capsule injuries of the thumb metacarpophalangeal joint are different from those associated with collateral ligament disruption. Early suspicion of this rare injury is important because, if overlooked, ulnarward subluxation of extensor pollicis longus tendon can develop. Functionally, active thumb extension becomes impaired, and over the long term, a thumb Boutonniere's deformity becomes established. Joint hypermobility/instability may predispose to this injury. The 2 cases presented illustrate this through anatomic differences. At the time of acute injury, 3 presenting clinical features should raise suspicion of dorsoradial capsular rupture: a history of isolated hyperflexion injury to the thumb, stable collateral ligaments on examination, and x-ray evidence of palmar subluxation of the proximal phalanx on the metacarpal. Ulnarward subluxation of the extensor pollicis longus is a delayed sign. Diagnostic imaging, beyond x-ray studies, may not be helpful in defining the injury. Early exploration and repair of this injury give the best long-term outcome. Postrepair, metacarpophalangeal joint range of motion may not be fully restored, but stability and a preinjury level of hand function can usually be reestablished.

Multifocal necrotising fasciitis: an overlooked entity?

OBJECTIVE: The aim of the study is to report a case of multi-focal necrotising fasciitis, review research on this subject to identify common aetiological factors and highlight suggestions to improve management. CONTEXT: Necrotising fasciitis is a severe, life-threatening soft tissue infection that typically arises from a single area, usually secondary to a minor penetrating injury. Multi-focal necrotising fasciitis, where there is more than one non-contiguous area of necrosis, is much less commonly reported. There are no guidelines specific to the management of multi-focal necrotising fasciitis, and its under-reporting may lead to missed management opportunities. DESIGN: A systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. DATA SOURCES: A search of MEDLINE, OLD MEDLINE and the Cochrane Collaboration was performed from 1966 to March 2011 using 16 search terms. DATA EXTRACTION: All articles were screened for genuine non-contiguous multi-focal necrotising fasciitis. Of the papers that met this criterion, data on patient demographics, likely inciting injury, presentation time-line, microbial agents, sites affected, objective assessment scores, treatment and outcome were extracted. DATA SYNTHESIS: A total of 31 studies met our inclusion criteria and 33 individual cases of multi-focal necrotising fasciitis were included in the quantitative analysis. About half (52%) of cases were type II necrotising fasciitis; 42% of cases had identifiable inciting injuries; 21% of cases developed multi-focal lesions non-synchronously, of which 86% were type II. Nearly all (94%) of cases had incomplete objective assessment scores. One case identified inflammatory imaging findings prior to clinical necrosis. CONCLUSIONS: Multifocality in necrotising fasciitis is likely to be associated with type II disease. We postulate that validated objective tools will aid necrotising fasciitis management pathways that will identify high-risk groups for multifocality and advise early pre-emptive imaging. We recommend the adoption of regional multi-focal necrotising fasciitis registers.