Clostridium myonecrosis - a rare and underdiagnosed condition in the elderly: a case with severe skipping lesions and an overview of treatment guidelines.

We present an unusual and severe case of spontaneous clostridial myonecrosis (SCM) in an elderly patient, with severe skipping lesions spread throughout the body. CT imaging, combined with postmortem available blood cultures, confirmed the diagnosis. We noted an underrepresentation of SCM in the cohort of elderly patients (≥ 85 years), upon a review of case reports in the literature over the last decade. Given the worldwide demographic change resulting in an increase in the number of visits to emergency departments for this age group, it is likely that SCM is underdiagnosed in these elderly patients. This case report aims to increase awareness among emergency physicians to recognize the disease as well as to provide a treatment guideline, in order to provide better care and outcome.

The vascularized groin lymph node flap (VGLN): Anatomical study and flap planning using multi-detector CT scanner. The golden triangle for flap harvesting.

INTRODUCTION: A growing number of surgeons perform lymph node transfers for the treatment of lymphedema. When harvesting a vascularized lymph node groin flap (VGLNF) one of the major concerns is the potential risk of iatrogenic lymphedema of the donor-site. This article helps understanding of the lymph node distribution of the groin in order to minimize this risk. MATERIALS AND METHODS: Fifty consecutive patients undergoing abdominal mapping by multi-detector CT scanner were included and 100 groins analyzed. The groin was divided in three zones (of which zone II is the safe zone) and lymph nodes were counted and mapped with their distances to anatomic landmarks. Further node units were plotted and counted. RESULTS: The average age was 48 years. A mean number of nodes of 6.5/groin was found. In zone II, which is our zone of interest a mean of 3.1 nodes were counted with a mean size of 7.8 mm. In three patients no nodes were found in zone II. In five patients nodes were seen in zone II but were not sufficient in size or number to be considered a lymph node unit. On average the lymph node unit in zone II was found to be 48.3 mm from the pubic tubercle when projected on a line from the pubic tubercle to the anterior superior iliac spine, 16.0 mm caudal to this line, and 20.4 mm above the groin crease. On average the lymph node unit was a mean of 41.7 mm lateral to the SCIV-SIEV confluence. CONCLUSION: This study provides increased understanding of the lymphatic anatomy in zone II of the groin flap and suggests a refined technique for designing the VGLNF. As with any flap there is a degree of individual patient variability. However, having information on the most common anatomy and flap design is of great value.

Thickness of extensor tendons at the proximal intersection: sonographic measurements in asymptomatic volunteers.

OBJECTIVES: An important sign of proximal intersection syndrome is thickening of the tendons at the area where the first extensor compartment tendons cross over the second compartment. Normal values for the thickness of the tendons have not been reported. Our purpose was to measure the thickness of the tendons with sonography at the level of the intersection in healthy volunteers and assess differences between men and women, dominant and nondominant sides, and different tendons. METHODS: Forty-one asymptomatic volunteers (25 women and 16 men) were examined by 2 radiologists experienced in musculoskeletal sonography. The thickness of the tendons in the first and second compartments was measured at their intersection at standardized proximal and distal levels. Descriptive statistics were obtained. Differences between men and women, dominant and nondominant sides, and different tendons were evaluated by a Student t test. RESULTS: The 95% confidence intervals for measurements of superimposed tendon groups varied between 0.30 and 0.40 cm in women and between 0.36 and 0.48 cm in men. There were no statistically significant differences in comparisons of the different tendon groups (P > .05). There were statistically significant differences (P < .05) between tendon thickness in men and women except for the right extensor carpi radialis longus + abductor pollicis longus (proximal measurement) and extensor carpi radialis brevis + extensor pollicis brevis (distal measurement). On comparison of dominant and nondominant sides, there were no statistically significant differences. CONCLUSIONS: Normal tendon thickness should be between 0.30 and 0.40 cm in women and 0.36 and 0.48 cm in men. A comparison between asymptomatic and symptomatic sides and proximal and distal measurements is recommended.

Ultrasound of the sural nerve: normal anatomy on cadaveric dissection and case series.

The sural nerve is a small sensory nerve innervating the lateral aspect of the ankle and foot. Clinical symptoms of pathology may present as atypical sensory changes in this region. We present the normal anatomy and ultrasound technique for examination of the sural nerve based on an anatomical dissection, as well as imaging in a normal volunteer. We also present a case series (n=10) of different conditions of the sural nerve that we encountered based on a review of interesting cases from 4 institutions. The pathological conditions included neuropathy related to stripping or venous laser surgery, compression by abscess, Lyme disease, nerve tumors, traumatic transsection, and encasement by fibrous plaque and edema. Ultrasound with its exquisite resolution is the preferred imaging method for examining the sural nerve in patients with unexplained sensory changes at the lateral aspect of the ankle and foot.

Ultrasound findings in injuries of dorsal extensor hood: correlation with MR and follow-up findings.

OBJECTIVE: The aim of this study was to use ultrasound to examine the dorsal hood in nine patients with a clinical suspicion of dorsal hood injuries. MATERIAL AND METHODS: Clinical and imaging files from interesting case logbooks of nine patients were reviewed. Ultrasound was performed by one of the three radiologists experienced in musculoskeletal ultrasound. The examinations were also performed in flexion and in flexion with resistance. MR correlation was obtained in six patients. One patient underwent surgery. To obtain anatomical correlation of the normal dorsal hood 2 embalmed hand specimens were dissected. RESULTS: The sagittal bands were easily depicted in the transverse plane on ultrasound images and presented as hypoechoic bands on both sides of the extensor communis tendons. Injuries of the sagittal bands were seen on ultrasound as hypoechoic thickening of the sagittal bands at the side of the extensor tendons. The normal shape of the sagittal bands was also no longer recognizable. Subluxations or dislocations of the extensor tendons were also seen. When the injuries were located in the fibrous slips between the extensor indicis and the extensor communis of the second finger, subluxations with an increased distance between these 2 tendons were seen, especially in flexion, or in flexion with resistance. CONCLUSION: Ultrasound is a valuable tool for the assessment of the injuries of the dorsal hood and is an easily available method for the diagnosis of the fine soft tissue components of the dorsal hood region.

The thickness of the sagittal bands in volunteers: high resolution ultrasound of the fingers.

PURPOSE: A sign of injury of the sagittal bands is thickening. The normal values for the thickness of the sagittal bands has not been described before. Our purpose was to measure the thickness of the sagittal bands with ultrasound in normal volunteers and compare differences between radial and ulnar band, dominant and non-dominant hand, different fingers, and men and women. MATERIALS AND METHODS: In 21 volunteers (10 men, 11 women), high resolution ultrasound imaging of the fingers was performed by two radiologists. The index, mid finger, ring finger and little finger were analyzed. The mean values were obtained for each finger. Statistical differences were calculated with a two-tailed Student's t test. RESULTS: The thickness of the sagittal bands showed a wide range of variations. Statistically significant differences were not found between the radial and ulnar band, dominant and non-dominant hand, and different fingers. Between men and women a significant difference was found for the ulnar band of index and ring finger of the dominant hand. CONCLUSION: The measurements of the sagittal bands show a wide range of values. Statistically significant differences for the means were only found for the ulnar band of index and ring finger of the dominant hand between men and women.

Functional anatomy of the dorsal hood or the hand: correlation of ultrasound and MR findings with cadaveric dissection.

The main aim of this study was to provide an overview of the anatomy of the dorsal hood (DH) based on the dissection of sixteen cadaver hands, correlated with magnetic resonance (MR) and ultrasound findings. A secondary aim was to assess the function of components of the DH. Sixteen embalmed hands were evaluated by MRI and ultrasound before being dissected. Each hand was photographed during each stage of dissection. Secondly we evaluated the role of the different structures of the DH in the stability of the extensor tendon by transection of the different components alternatively at the ulnar and radial sides. MR, ultrasound, and dissection showed that the extensor tendon (ET) is stabilized by the sagittal band (SB) at the level of the metacarpophalangeal (MCP) joint and more distally by the transverse and the oblique bands, respectively. Transection of the radial SB of the second finger leads systematically to ulnar dislocation of the ET. The transection of the ulnar DH does not lead to instability of the ET. The SB is the most important structure of the DH in the stability of the ET at the MCP level. Rupture of the radial SB of the second finger leads systematically to ulnar dislocation of the ET.

Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT.

BACKGROUND: Pedicled superior epigastric artery perforator (SEAP) flaps can be raised to cover challenging thoracic defects. We present an anatomical study based on multidetector computerized tomography (MDCT) scan findings of the SEA perforators in addition to the first reported clinical series of SEAP flaps in anterior chest wall reconstruction. MATERIAL AND METHODS: (a) In the CT scan study, images of a group of 20 patients who underwent MDCT scan analysis were used to visualise bilaterally the location of musculocutaneous SEAP. X- and Y-axes were used as landmarks to localise the perforators. The X-axis is a horizontal line at the junction of sternum and xyphoid (JCX) and the Y-axis is at the midline. (b) In the clinical study, seven pedicled SEAP flaps were performed in another group of patients. RESULTS: MDCT images revealed totally 157 perforators with a mean of 7.85 perforators per patient. The dominant perforators (137 perforators) were mainly localised in an area between 1.5 and 6.5 cm from the X-axis on both sides and between 3 and 16 cm below the Y-axis. The calibre of these dominant perforators was judged as 'good' to 'very good' in 82.5% of the cases. The average dimension of the flap was 21.7x6.7 cm. All flaps were based on one perforator. Mean harvesting time was 110 min. There were no flap losses. Minor tip necrosis occurred in two flaps. One of them was treated with excision and primary closure. CONCLUSION: Our clinical experience indicates that the SEAP flap provides a novel and useful approach for reconstruction of anterior chest wall defects. CT-based imaging allows for anatomical assessment of the perforators of the superior epigastric artery (SEA).